| A large number of diseases may present with respiratory distress. In adults, upper airway obstruction (UAO) is relatively rare. Consequently, UAO may initially be overlooked in the differential diagnosis of the dyspneic patient. Because it may progress rapidly, delays or errors in diagnosis can be critical. During an eight-month period in one emergency department, seven adult patients with potentially life-threatening diseases of the upper airway were seen. To reacquaint physicians with the syndrome of mechanical obstruction of large airways, several illustrative cases are presented and the syndrome is discussed. ( info) |
| A case of life-threatening laryngo-epiglottitis is reported, caused by ampicillin-resistant haemophilus paraphrophilus. Clinicians and microbiologists should be aware of a beta-lactamase-mediated resistance among Haemophilus species other than H. influenzae. ( info) |
3/186. A pilot study of autofluorescent endoscopy for the in vivo detection of laryngeal cancer. OBJECTIVES: To determine the advantage of autofluorescent endoscopy for the identification of laryngeal cancer. STUDY DESIGN: This is a prospective, multicenter clinical study. We investigated whether autofluorescent endoscopy using the lung Imaging Fluorescent endoscopy (life)-lung System (Xillix, Olympus) is capable of identifying early cancer of the larynx, especially in comparison with conventional white-light endoscopy and microscopic laryngoscopy. Benign lesions as well as microinvasive and invasive squamous cell carcinoma of the larynx were investigated. For logistic reasons and because of the pilot character of this study, the number of patients was limited. methods: Sixteen patients having 24 laryngeal lesions of both benign or malignant character were subsequently examined by autofluorescent endoscopy, white-light endoscopy, and microscopic laryngoscopy. Based on optical appearance, and for each method separately, the lesions were classified as malignant or not. The visual results were documented and histologically verified. RESULTS: The sensitivity of autofluorescent endoscopy for laryngeal cancer detection was more than 90% and therefore higher than that of white-light endoscopy and microscopic laryngoscopy. However, as far as laryngeal cancer is concerned, the specificity of autofluorescent endoscopy was very low. Many of the false-positive results were due to inflammation, hypervascularization, and edema. CONCLUSION: Autofluorescent endoscopy is advantageous only in the hands of an experienced ENT specialist. Although it does not replace the combination of white-light endoscopy and a critical evaluation of the clinical symptoms of the individual disease, it can profitably complement them. Autofluorescent endoscopy can help in determining whether microscopic laryngoscopy performed with general anesthesia should be recommended urgently to the patient. Microscopic laryngoscopy remains the best method for the identification of malignant lesions, if it is combined with obtaining taking multiple biopsy specimens. Confirmation of the results of this pilot study with a larger series of patients is desirable. ( info) |
| blastomycosis is a relatively uncommon fungal disease that most commonly affects the lungs. Other organs may be involved, usually secondary to dissemination of the organism. Laryngeal blastomycosis may occur in isolation from active pulmonary disease. The signs, symptoms, clinical features, and pathological findings of laryngeal blastomycosis mimic those of squamous cell carcinoma. Misdiagnosis may result in inappropriate treatment with potential morbidity. Proper understanding of the clinical presentation and familiarity with the histopathologic features of this disease are therefore imperative. In this paper, we report 2 cases of laryngeal blastomycosis, 1 of which was misdiagnosed as squamous cell carcinoma, clinically and microscopically, with consequent radiotherapy and laryngectomy. In the other case, a clinical diagnosis of glottic squamous cell carcinoma was rendered. However, blastomycosis was identified in a biopsy specimen. We also review cases of isolated laryngeal blastomycosis that have been reported in the English-language literature during the last 80 years. A number of those cases were misdiagnosed clinically and microscopically as squamous cell carcinoma. ( info) |
| Rarely, adult herpetic laryngitis without involvement of the oropharynx has been reported. However, to our knowledge, laryngitis caused by herpes simplex virus with coexisting candida albicans has not been reported. We report what we believe to be the first case of localized herpetic laryngitis superimposed by laryngeal Candida species infection in an immunosuppressed patient. This diagnosis was made on the basis of the findings of a laryngeal mucosal biopsy and ancillary testing using fungal stains and immunohistochemical stains for herpetic antigens. We also review the literature and discuss the clinical and diagnostic presentations, including potential pitfalls in the diagnosis. ( info) |
| The true incidence of herpetic infections of the larynx is unknown. This entity may be underreported because of the difficulty in establishing the diagnosis. This report describes an immune-competent patient in whom extubation failed because of mass lesions of the posterior glottis. A biopsy specimen of the lesions revealed herpes simplex virus. We review the clinical presentation and histopathologic findings in this patient. ( info) |
7/186. Membranous laryngotracheobronchitis (membranous croup). Membranous laryngotracheobronchitis (membranous croup), not previously described as a distinct entity, is characterized by diffuse inflammation of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes in the subglottic trachea (conus elasticus) and in the upper trachea distal to the conus elasticus. We reviewed 28 cases of membranous croup diagnosed by endoscopy and/or radiographic examination. The importance of the recognition of membranous croup as a distinct entity is discussed. The characteristic radiologic findings consist of subglottic tracheal narrowing, irregularity of contour of the proximal tracheal mucosa, and sometimes detached or partially detached proximal tracheal membranes, which can be mistaken for tracheal foreign bodies. ( info) |
8/186. role of esophageal pH recording in management of chronic laryngitis: an overview. Chronic laryngitis typically produces symptoms of frequent throat-clearing, soreness, decreased voice quality with use, nonproductive cough, globus sensation, and odynophagia. The endoscopic laryngeal examination usually demonstrates posterior glottic edema, erythema, and increased vascularity and nodularity. There is increasing support for the hypothesis that reflux of acidic gastric contents is often responsible for the symptoms and findings of chronic laryngitis. Prospective trials of acid suppression therapy demonstrate not only efficacy in symptom reduction, but also objective improvement in measurements of voice quality and mucosal erythema. Although traditionally considered the "gold standard" for diagnosis of reflux causing laryngitis, routine esophageal pH recording may result in false negatives in up to 50% of patients. This may confound the diagnosis of chronic laryngitis and delay treatment. Conversely, a positive study during comprehensive therapy may help identify patients who need additional treatment. A single distal probe is probably insufficient for evaluation of a supraesophageal disorder. Current recommendations for double-probe pH study in the evaluation of chronic laryngitis fall into 2 categories: 1) a double-probe pH study is indicated if there is ongoing moderate-to-severe laryngitis despite antireflux precautions and proton pump inhibitor treatment for at least 6 to 12 weeks; and 2) a double-probe pH study is indicated as a baseline measurement before Nissen or Toupet fundoplication. The pH study would also be indicated in patients who have symptoms after fundoplication. There is clearly much more work to be done on the technical issues of obtaining accurate objective data related to laryngeal acidification. In addition, although acid reflux appears to be causative in many cases of chronic laryngitis, further work is indicated to identify reliable testing methods that will predict treatment success. ( info) |
9/186. actinomycosis of the vocal cord: a case report. A 30-year-old Chinese lady was admitted for hoarseness of voice of one month's duration. Clinical examination revealed a granuloma of the left vocal cord while chest X-ray showed an opacity in the lower lobe of the right lung. The provisional clinical diagnosis was tuberculous laryngitis. A biopsy of the vocal cord lesion revealed inflamed tissue with actinomycotic colonies. Cultures and sputum smears did not reveal any tuberculous bacilli. The patient responded to a 6-week course of intravenous C-penicillin, regaining her voice on day 5 of commencement of antibiotics. A subsequent CT scan of the neck and thorax revealed multiple non-cavitating nodular lesions in both lung fields, felt to be indicative of resolving actinomycosis. She was discharged well after completion of treatment. It was felt that this is a case of primary actinomycosis of the vocal cord with probably secondary pulmonary actinomycosis. ( info) |
| A rare case of supraglottitis complicated by mediastinitis is presented. Despite aggressive treatment with broadspectrum intravenous antibiotics, the patient persisted to have generalized supraglottitis. Subsequent computed tomography (CT) scanning revealed that she had developed a frank fluid collection starting at the suprasternal notch, extending retrosternally into the superior mediastinum. She recovered with conservative management and did not require aggressive mediastinal drainage as advocated by the literature. ( info) |