Review of Critical Care Medicine

26. Subglottic Hemangioma:-Although rare in adults, subglottic hemangioma is the most common laryngeal and upper tracheal neoplasm in the newborn and infant. The lesion typically appears as a well-defined mass in the posterior or lateral portion of the subglottic airway ( Fig. 99–11 ). [127] [138] Although the subglottic narrowing is usually eccentric, circumferential narrowing suggestive of croup may be seen. Hemangiomas may occur on the skin or elsewhere in the body.

“Squamous papillomas, the most frequent laryngeal tumors in children, have also been reported in adults.”

Current management options that have been reported include tracheotomy, laser partial excision, open surgical resection, systemic or intralesional steroids, and systemic interferon alfa-2A

Infantile subglottic hemangiomas occur in children a few months of age and present as a lateral subglottic submucosal bluish mass, causing respiratory symptoms. These lesions, if mildly symptomatic, are managed conservatively with corticosteroids and observation. They usually involute spontaneously with time; however, a tracheotomy is occasionally needed when severe airway compromise is present. Healy and others[3] reported the use of the carbon dioxide laser for the management of this condition.[3] The carbon dioxide laser is used to vaporize the tumor until an adequate airway is achieved.
The Nd:YAG laser, although ideal for low-flow venous malformations, is not recommended for subglottic hemangiomas because these lesions are more compact capillary-type vascular lesions. The depth of penetration of the Nd:YAG laser presents a serious risk to the infant’s larynx and trachea, with potential stricture formation or tracheal perforation, and is not recommended for the management of these lesions.

27. Management Of early Glottic Cancer:- Recent advances in microlaryngeal laser excision (laser microscopic excision, LME) of early glottic lesions and in laryngeal reconstruction after vertical partial laryngectomy (VPL) have enhanced the quality of life for patients cured of their cancer.

Curative radiotherapy is reserved for early lesions which neither impair cord mobility nor invade cartilage or cervical nodes. Cancer of the vocal cord without impairment of its mobility gives a 90% cure rate after irradiation and has the advantage of preservation of voice. Superficial exophytic lesions, especially of the rip of epiglottis, and aryepiglottic folds give 70-90% cure rate. Radiotherapy does not give good results in lesions with fixed cords, subglottic extension, cartilage invasion, and nodal metastases. These lesions require surgery.

The anterior commissure has been considered as a barrier to tumor spread or as an early pathway for cancer extension into the laryngeal framework.[29] Shvero and others[55] related that surgical treatment is preferred for cancers arising in this region because of a higher local recurrence rate and an increased risk for distant metastasis. They contend that the behavior of small cancers in this location is much different from that of other early glottic cancers.[56] Other investigators have attributed the higher rates of failure after radiotherapy for anterior commissure lesions to problems with adequate dosing.[31] [71] The distance from the anterior commissure to the skin varies greatly among patients. This variability and the thick overlying thyroid cartilage have been cited as impediments to consistent dosing of radiation to this region. Some investigators relate that modern radiotherapy techniques with improved dosimetry have adequately addressed these concerns.Radiotherapy more frequently fails to control the cancer when there is involvement of the anterior commissure, impaired vocal cord mobility, or subglottic extension.

Indications for Vertical Partial Laryngectomy and Laryngoplasty ; VPL and laryngoplasty are anterior commissure involvement, extension to the vocal process of the arytenoid, selected superficial transglottic lesions, and recurrent cancer after radiation therapy. Partial laryngectomy for recurrent cancer after radiation therapy must meet the following criteria: (a) lesion limited to one cord (may involve the anterior commissure); (b) body of arytenoid free of tumor; (c) subglottic extension no more than 5 mm; (d) mobile cord; (e) no cartilage invasion; (f) recurrence correlating with initial tumor; and (g) early complications after partial laryngectomy, including subcutaneous emphysema, bleeding, and tracheotomy tube occlusion.

Early glottic carcinoma limited to the membranous portion of the vocal fold can be cured using endoscopic surgical excision, thyrotomy with cordectomy, hemilaryngectomy, VPL with laryngoplasty, and/or radiation therapy.

About one in six patients with severe dysplasia or carcinoma in situ will develop invasive carcinoma if the only therapy used is a single vocal cord stripping or biopsy.

Microinvasive carcinoma of the true vocal fold can be managed by sequential endoscopic excisional biopsy, endoscopic laser excision, or radiation therapy

The management issues in glottic carcinoma are local control, effective management of suspected or known metastatic cervical lymph nodes, patient education concerning carcinogenic substances (usually smoking cessation therapy), and patient follow-up for the possibility of residual laryngeal cancer or second primary lesions. Tumors arising on the arytenoid, in the subglottic region, or in the supraglottic portion of the larynx do not cause hoarseness and often are diagnosed at a later stage. They have a lower cure rate because delayed diagnosis is associated with diminished therapeutic effectiveness of surgery or radiation therapy.

In general, early glottic carcinoma can be managed without total laryngectomy and without the procedures that limit vocal quality or rely on radiation therapy with its inherent problems. A broad surgical armamentarium now includes endoscopic excision, laser resection, and surgical excision, with a number of reconstructive/rehabilitative techniques to enhance postoperative function.

The relative contraindications for LME as anterior commissure involvement, subglottic extension, T3 glottic cancer, and posterior commissure involvemen

Indications for VPL and laryngoplasty are tumor involvement of the anterior commissure, extension to involve the vocal process of the arytenoid, selected superficial transglottic lesions, and carcinoma recurring after radiation therapy. The contraindications for any of these procedures include a fixed vocal cord, involvement of the posterior commissure, invasion of both arytenoid cartilages, bulky transglottic lesions, and lesions invading the thyroid cartilage

when a diagnosis of severe dysplasia or carcinoma in situ is made and when the site of the lesion involves the true vocal cord, microscopic suspension laryngoscopy with stripping of the epithelium and a closely monitored program of follow-up are indicated. The patient must be convinced of the necessity to discontinue smoking and ethanol intake and to maintain a schedule of regular visits for indirect laryngoscopy following a pattern of careful assessment every 2 or 3 months for at least 5 year

Microinvasive carcinoma can be managed by endoscopic excisional biopsy (vocal cord stripping), by laser excision endoscopically, or by radiation therapy. We prefer a protocol consisting of microscopic suspension laryngoscopy and sequential vocal cord stripping every 3 months until two consecutive epithelial stripping specimens can be confirmed to be free of malignant cells. We then monitor these patients with indirect laryngoscopy every 2 to 3 months. If any suspicious epithelial changes or significant voice changes are noted, we repeat the suspension microlaryngoscopy and biopsy.

Early invasive glottic carcinoma can be treated by endoscopic excision, laser excision, thyrotomy with cordectomy, hemilaryngectomy, VPL with laryngoplasty, or radiation therapy. Traditionally, radiation therapy has been offered as the preferred treatment for invasive epidermoid carcinoma involving the membranous portion of the mobile true vocal cord. Recently, some studies have challenged that approach, and endoscopic excision with or without the laser has been found to be equally safe and effective. Late recurrence of carcinoma and the development of second primary tumors are issues of great importance and mandate a pattern of close follow-up, regardless of the treatment chosen.
Radiation therapy is the primary treatment for glottic carcinoma in Northern Europe, with total or partial laryngectomy used for salvage of those patients who have recurrence of cancer. In other parts of the world, surgeons report wider use of VPL for early glottic carcinoma and for advanced T2 glottic lesions.

Ackerman’s Tumor
Verrucous carcinoma is known also as Ackerman’s tumor and can be distinguished histologically from other well-differentiated squamous cell carcinomas. This tumor is characterized by its rough, shaggy surface, a rounded, pushing margin, and no metastasis. Smaller lesions can be excised endoscopically; larger tumors are managed by partial laryngectomy. This tumor is less radiosensitive than ordinary squamous cell carcinoma, but radiation therapy is a reasonable alternative for treating larger tumors; total laryngectomy is reserved for large lesions that do not respond to radiation therapy.

28. Benign tumors and cysts of the esophagus are relatively rare, occurring less frequently than malignant tumors. Esophageal lesions can be classified as intraluminal, intramural, or extramural. Intramural tumors are usually asymptomatic until they become significantly enlarged. Because they are mucosally covered, it is uncommon for these tumors to be associated with ulceration and bleeding. Leiomyoma is the most common benign tumor of the esophagus, representing an intramural tumor arising from the muscularis mucosa (Fig. 56.7). In 90% of patients, it occurs in the middle or lower third of the esophagus. Patients usually present with dysphagia, although many leiomyomas are found radiographically in asymptomatic patients.

“Polyps are the most common intraluminal lesions, although papillomas, adenomas, and hemangiomas may occur. Fibrovascular polyps can grow to an enormous size and have been reported to prolapse into the hypopharynx, causing asphyxiation and death. Most polyps occur in the cervical esophagus, causing dysphagia and regurgitation. Barium swallow demonstrates an intraluminal, pedunculated mass. Most can be excised endoscopically by snaring the base of the polyp.”

29Scleroderma is a generalized collagen vascular disease in which 80% of patients eventually develop esophageal symptoms. Typically, scleroderma results in a motility disorder that causes progressive dysphagia for solids. There appears to be an increased incidence in those who also manifest the Raynaud phenomenon.
Pathologically, the smooth muscle in the gastrointestinal tract becomes atrophied. Manometric studies demonstrate diminished contractions in the LES and distal two thirds of the esophagus. Because the UES is composed of striated muscle, contraction pressures are usually normal. Although dysphagia occurs, heartburn is the more prominent symptom because LES tone is attenuated. With compromise of the LES, reflux esophagitis and its associated complications may develop.

30. The esophagus is a flexible, muscular tube that can be compressed or narrowed by surrounding structures at 3 locations (Fig. 3.90):

• in the posterior mediastinum at the esophageal hiatus in the diaphragm.

These constrictions have important clinical consequences. For example, a swallowed object is most likely to lodge at a constricted area. An ingested corrosive substance would move more slowly through a narrowed region, causing more damage at this site than elsewhere along the esophagus. Also, constrictions present problems during the passage of instruments.

Alpha-adrenergic neurotransmitters increase LES pressure and a-adrenergic blockers decrease it; b-adrenergic stimulation decreases LES pressure and b-adrenergic blockers increase it. Cholinergic mechanisms also exert control over resting LES pressure. Hormonal regulation has been studied extensively, and dozens of hormones and peptides have been found to influence LES pressure. Protein meals and antacids tend to increase LES pressure, whereas fatty meals, chocolate, ethanol, smoking, and caffeine are known to decrease LES pressure.