Usefulness of Intraoperative Narrow-Band Imaging in the Site Diagnosis of Respiratory Papillomatosis.

OBJECTIVE: Narrow-band imaging (NBI) is considered useful for detecting respiratory papillomatosis. However, the choice between preoperative and intraoperative NBI depends on the facility. We investigated the usefulness of NBI and determined whether preoperative NBI can replace intraoperative NBI with a comparable detection rate. METHODS: In this retrospective cohort study conducted at single a tertiary care center, patients with respiratory papillomatosis treated between 2017 and 2022 were enrolled. We systematically compared preoperative white light imaging (WLI) with preoperative and intraoperative NBI. The primary endpoints were the papilloma detection rate and lesion site assessed by the Derkay scoring system. The secondary endpoints were the risk factors for increased Derkay scores. RESULTS: The study included 127 patients with papilloma. Intraoperative NBI yielded significantly higher Derkay scores than preoperative WLI (p < 0.001) and preoperative NBI (p = 0.004). The papilloma detection rates of preoperative WLI and preoperative NBI were not significantly different. Intraoperative NBI detected more lesions than preoperative NBI in 37 of 127 (29%) patients; the overall number of additional lesions was 47 of 279 (17%). Compared with preoperative NBI, intraoperative NBI yielded significantly higher scores for the vocal cords (p = 0.005), false vocal cords (p = 0.010), and ventricle of the larynx (p < 0.001). Elevated Derkay scores were significantly associated with male sex (p = 0.012) and alcohol consumption (p = 0.007). CONCLUSION: Intraoperative NBI is more accurate in detecting papillomatous lesions, and preoperative NBI cannot replace intraoperative NBI. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1820-1824, 2024.

Tracheostoma Closure Technique Using Three Local Flaps.

When a tracheostoma is no longer needed, the opening normally closes spontaneously after cannula removal, but some cases require tracheostoma closure. This procedure has been well described, but must be performed in such a way as to minimize its invasiveness and complications while securing a high closure rate. Our procedure for conducting tracheostoma closure technique involves the creation of two hinge flaps and one cover flap to close the tracheostomy opening. We reviewed the medical records of 23 patients (12 men, 11 women; mean age 60.0 SD19.7 years) who underwent tracheostoma closure technique between 2001 and 2019. Surgery was indicated for patients in whom closure had not occurred after conservative monitoring for ≥ 2 months following cannula removal. The surgical procedure began by raising two hinge flaps on either side of the tracheostomy opening, turning the skin surface to the luminal side to form the anterior tracheal wall. Rather than a single layer of skin, multiple skin layers were sutured together to prevent air leakage from between hinge flaps. A further cover flap was produced to cover the anterior tracheal wall, closing the tracheostomy opening. Postoperatively, the tracheal lumen was observed via fiberscopy. No stenosis of the tracheal lumen occurred in any patients, and the tracheocutaneous fistula was successfully closed in all cases. Tracheostoma closure technique using hinge flaps to reconstruct the anterior tracheal wall and a cover flap as a skin flap to cover the skin defect appears useful for patients with failure of spontaneous tracheocutaneous fistula closure.

Repeated Surgery in a Case of Epithelial-Myoepithelial Carcinoma of the Parotid Gland that was Difficult to Distinguish from Pleomorphic Adenoma.

Epithelial-myoepithelial carcinoma (EMC) of the parotid gland is a comparatively rare tumor that accounts for less than 1% of all salivary gland tumors. A patient with EMC of the parotid gland that was initially diagnosed as pleomorphic adenoma and that recurred locally during the watchful waiting period but was controlled by surgery under local anesthesia is reported. An 80-year-old man had noticed a swelling in the left infra aural region. A left parotid gland tumor was suspected, and he was referred to our department. Magnetic resonance imaging (MRI) and fine-needle aspiration cytology findings were suggestive of pleomorphic adenoma of the superficial lobe of the parotid gland, and this was therefore resected under general anesthesia. Postoperative histopathological examination, immunostaining, and genetic tests resulted in a diagnosis of EMC. Postoperative pathological review showed that part of the resection margin was positive. The possibility of recurrence was explained to the patient, and additional treatment was recommended, but since the patient did not desire this, a policy of watchful waiting was adopted. Signs of cutaneous metastasis in the left infra aural region were detected at 13 months postoperatively, and this metastasis was excised under local anesthesia. The resection margin was negative, and the patient's course remains uneventful. EMC is classified as a low-grade malignant tumor, but it requires stringent monitoring because of its frequent local recurrence. Since local control can usually be achieved by surgical treatment alone, and postoperative adjuvant therapy may not necessarily warranted.

Inferior Surface Leukoplakia of Vocal Folds: Risk of Recurrence: A Preliminary Study.

OBJECTIVES: This study aimed to identify vocal fold leukoplakia (VFL) lesions on the inferior surface as a risk factor for recurrence. METHODS: This was a retrospective study with data collected from 2001 to 2018. The study comprised 37 patients with VFL, divided into the nonrecurrent and recurrent groups. We examined the clinicopathological characteristics and the surgical procedures performed in each patient. RESULTS: Among the 37 patients, 15 (40.5%) had residual (3) or recurrent (12) VFL. Of those patients with and without recurrence, 8 of 12 (66.7%) and 6 of 22 (27.3%), respectively, had inferior surface lesions of the vocal fold at the initial operation (P = .036). Recurrences were significantly higher in patients with inferior surface lesions. Other evaluated factors did not show significance for recurrence. CONCLUSION: The presence of VFL lesions on the inferior surface is a significant risk factor for recurrence.

Effect of a Single Injection of Basic Fibroblast Growth Factor into the Vocal Folds: A 36-Month Clinical Study.

OBJECTIVE: A single injection of basic fibroblast growth factor (bFGF) into the vocal folds of patients with glottal insufficiency has been shown to be effective for a few years. However, the long-term therapeutic effect of a single injection of bFGF into the vocal folds has yet to be demonstrated. In this study, the therapeutic effect of a single injection of bFGF into the vocal folds was investigated over several years by monitoring patients for 36 months following this treatment. METHODS: Nineteen patients with glottal insufficiency received injections of bFGF diluted to 20 µg/mL in the superficial layer of the lamina propria of the bilateral vocal folds. The following parameters were evaluated at preinjection baseline and 6, 12, 18, 24, and 36 months later, and statistical comparisons were performed. The parameters evaluated were: the Grade, Rough, Breathy, Asthenic, and Strained (GRBAS) scale score; maximum phonation time; acoustic analysis; and glottal wave analysis (GWA) and kymograph edge analysis (KEA) using high-speed digital imaging (HSDI). The amplitude perturbation quotient (APQ) and period perturbation quotient (PPQ) were measured by acoustic analysis. The mean minimum glottal area during vocalization and mean minimum distance between the vocal folds were measured by GWA. The amplitudes of the bilateral vocal folds were measured by KEA. RESULTS: Postinjection, the GRBAS scale score decreased from 6 months after injection, and maximum phonation time was prolonged. The mean minimum glottal area during vocalization and the mean minimum distance between the vocal folds calculated by GWA of HSDI decreased significantly after 6 months. These effects persisted until 36 months postinjection. APQ and PPQ derived from acoustic analysis tended to decrease, but not significantly. There was no clear change in the amplitudes of the bilateral vocal folds calculated by KEA of HSDI before and after injection. CONCLUSIONS: These results suggest that the effects of a single injection of bFGF into the vocal folds persist for 36 months.

Posterior Cervical Intramuscular Schwannoma Within the Trapezius Muscle: A Case Report.

Schwannomas are benign soft tissue tumors derived from the Schwann cells of the peripheral nerves. An intramuscular schwannoma arising within the trapezius muscle in the posterior neck is rare. We report a case of a 31-year-old woman with an intramuscular schwannoma in the trapezius muscle. A painless and smooth-surfaced mass from 10 years ago was evident on palpation in the right posterior neck. Ultrasonography revealed an oval mass with clear borders and slight internal blood flow. No continuous hypoechoic lesions were noted at the tip of the mass. Magnetic resonance imaging of the neck revealed a mass in the right posterior cervical trapezius muscle with isointensity on T1-weighted imaging and heterointensity on T2-weighted imaging. Based on these findings, a schwannoma was suspected. Ultrasonography guided fine needle aspiration cytology revealed no significant findings. During surgery, a white-colored, encapsulated-tumor mass was found in the trapezius muscle. Histopathologically, hypocellular and hypercellular areas of fusiform cells were conspicuous, and nuclear palisading was observed in a part of the hypercellular region, confirming the diagnosis of schwannoma. To our knowledge, this is an extremely rare report of an intramuscular schwannoma within the trapezius muscle; herein, we report its clinical, radiological, and pathological features.

The predominant site of pharyngeal lesions in patients with recurrent respiratory papillomatosis.

PURPOSE: Recurrent respiratory papillomatosis (RRP) is a disorder characterized by the frequent recurrence of benign neoplasms in the respiratory tract. Some patients with RRP develop laryngeal papilloma, while others present with extralaryngeal lesions in the nose, pharynx, and trachea. The present study aimed to determine the pharyngeal sites where RRP-related lesions develop more frequently. METHODS: We retrospectively reviewed the medical records of 127 patients treated at our department between January 2015 and December 2020. We compared the human papilloma virus (HPV) infection status and differences in tumor location between 41 patients with RRP and 86 patients with pharyngeal papilloma (PP). RESULTS: In the RRP group, extralaryngeal papillomata were observed in 10 patients, eight (19.5%) of whom presented with lesions in the inferior wall of the nasopharynx (IWoN). On the contrary, only one patient with PP (1.1%) developed papillomata in this region. IWoN papilloma was significantly more likely to arise in the RRP group than in the PP group (p = 0.0004). CONCLUSION: In RRP, pharyngeal lesions frequently arise in the IWoN, while this region remains largely unaffected in patients with PP.

Human Papillomavirus Vaccination as an Adjuvant Therapy for Recurrent Respiratory Papillomatosis: Additional Case Series.

Prevention of the recurrence of recurrent respiratory papillomatosis (RRP), a neoplasm of the respiratory tract, is a challenge. Human papillomavirus (HPV) vaccine has been expected to suppress the aggressiveness of RRP. However, there has been insufficient data to verify whether HPV vaccination can serve as an adjuvant therapy option for RRP. The aim of this study was to add our data on the efficacy of HPV vaccination for RRP to the academic discipline. Twenty-four RRP patients were treated with a combination therapy of surgery and three sessions of quadrivalent HPV vaccine. The patients' clinical courses, which were HPV infection status changes, intersurgical interval, and disease severity score (Derkay's site score), were statistically analyzed before and after combination therapy. Twelve of the 24 (52.5%) RRP patients who were HPV-DNA positive turned negative after the combination therapy. The mean of intersurgical interval was significantly extended from 6.85 ± 4.49 months to 30.5 ± 27.6 months after the therapy (P <0.01). The median of Derkay's score of the participants also significantly decreased from 7.5 (interquartile range, 5-12) to 1 (interquartile range, 0-4.25) after the therapy (P <0.01). Thus, combination therapy comprising of surgery and HPV vaccination can postpone the recurrence and lessen the severity of RRP.

Thyroid hyalinizing trabecular adenoma with a high thyroglobulin level: a case report.

Thyroid hyalinizing trabecular adenoma (HTA) is a rare and borderline tumor of follicular origin. It is characterized by a trabecular growth pattern and marked intratrabecular hyalinization. Excessively elevated thyroglobulin levels have not been reported previously in cases without bilateral lung metastases. Here, we present a case of a 54-year-old woman with chronic thyroiditis with a 50-mm tumor in the left lobe of the thyroid gland, which was observed on ultrasonography. Her thyroglobulin level was found to be elevated at 684 ng/ml. Since fine needle aspiration cytology could not exclude possible malignancy, she underwent thyroid lobectomy; the final diagnosis was thyroid HTA. Two weeks after resection, her thyroglobulin level showed negative conversion. To our knowledge, this is the first report of a patient with a thyroid HTA exhibiting a thyroglobulin level as high as that for a patient with hyalinizing trabecular carcinoma.

Functional recurrent laryngeal nerve regeneration using a silicon tube containing a collagen gel in a rat model.

In this study, we examined the effect of differing gap lengths on regeneration of transected recurrent laryngeal nerves using silicon tubes containing type I collagen gel and the ability of this regeneration to result in restoration of vocal fold movements in rats. We simulated nerve gaps in Sprague-Dawley rats by transecting the left recurrent laryngeal nerves and bridged the nerve stumps using silicon tubes containing type 1 collagen gel. Three experimental groups, in which the gap lengths between the stumps were 1, 3, or 5 mm, were compared with a control group in which the nerve was transected but was not bridged. After surgery, we observed vocal fold movements over time with a laryngoscope. At week 15, we assessed the extent of nerve regeneration in the tube, histologically and electrophysiologically. We also assessed the degree of atrophy of the thyroarytenoid muscle (T/U ratio). Restoration of vocal fold movements was observed in 9 rats in the 1-mm group, in 6 rats in the 3-mm group, and in 3 rats in the 5-mm group. However, in most rats, restoration was temporary, with only one rat demonstrating continued vocal fold movements at week 15. In electromyograph, evoked potentials were observed in rats in the 1-mm and 3-mm groups. Regenerated tissue in the tube was thickest in the 1-mm group, followed by the 3-mm and 5-mm groups. The regenerated tissue showed the presence of myelinated and unmyelinated nerve fibers. In assessment of thyroarytenoid muscle atrophy, the T/U ratio was highest in the 1-mm group, followed by the 3-mm and 5-mm groups. We successfully regenerated the nerves and produced a rat model of recurrent laryngeal nerve regeneration that demonstrated temporary recovery of vocal fold movements. This rat model could be useful for assessing novel treatments developing in the future.

Multi-Year Effect of Human Papillomavirus Vaccination on Recurrent Respiratory Papillomatosis.

OBJECTIVE: To examine whether human papilloma virus (HPV) vaccination in combination with surgical resection could suppress recurrence for an extended period of time in patients with recurrent respiratory papillomatosis (RRP). METHODS: In a prospective case series, data of patients who received combination therapy comprising surgery and quadrivalent HPV vaccination (Gardasil; Merck & Co., West Point, PA) were collected. Patients were followed up for RRP from March 2012 to July 2018 in an academic tertiary care center. The patients comprised 16 adults with RRP who were observed for >12 months after HPV vaccination, and whose HPV-DNA status was tested before and for >12 months after completion of combination therapy. The outcomes of this study were the severity score of larynx disease, tumor incidence rate, and relationship between this rate and HPV-DNA negative conversion after therapy. RESULTS: The severity score of laryngeal disease significantly decreased from before combination therapy to the time of final examination (P = 0.00045). The tumor incidence rate decreased to approximately 20% during the period from 12 to 47 months after HPV vaccination. Regarding HPV-DNA status in the final test results of each patient, 12 of 16 (75%) patients showed negative conversion; these 12 were significantly less likely to experience recurrence than patients who persistently tested positive for HPV-DNA during the period between 12 and 47 months after vaccination. CONCLUSION: HPV vaccination prevented recurrence associated with RRP surgery for 4 years in 80% of patients. This may be an effective adjuvant therapy, and HPV-DNA negative conversion after HPV vaccination might predict prevention of recurrence. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:442-447, 2020.

Parotid Gland Non-Sebaceous Lymphadenoma: A Case Report.

We here report a rare salivary gland tumor, a non-sebaceous lymphadenoma (NSLA), in the parotid gland with positive technetium-99m (99mTc) pertechnetate scintigraphy and cervical masses that was difficult to distinguish from malignant lymphoma preoperatively. A 65-year-old Japanese woman presented to our institution with a painless left parotid mass that had been gradually enlarging for three months. Computed tomography and magnetic resonance imaging showed a solid mass (30 mm) in the tail of the left parotid gland with three swellings (each 10 mm) on the periphery of the parotid gland. A low grade malignant lymphoma was diagnosed by fine needle aspiration cytology. Gallium-67 scintigraphy showed mild positivity. On 99mTc pertechnetate scintigraphy, the mild accumulation remained after oral stimulation with a mixture of ascorbic acid and calcium pantothenate. The patient underwent superficial parotidectomy with removal of the cervical masses. Our findings in this patient suggest that 99mTc positivity may constitute a clue to the preoperative diagnosis of NSLA that has pathologically overlapping sites with Warthin tumor.

Gardasil Vaccination for Recurrent Laryngeal Papillomatosis in Adult Men Second Report: Negative Conversion of HPV in Laryngeal Secretions.

BACKGROUND: In our first report on antibody levels in middle-aged and older men with recurrent laryngeal papillomatosis (RLP), we reported increases in human papillomavirus (HPV) antibody levels similar to those seen in adult women and young men. We posited that HPV antibodies produced in laryngeal mucus by Gardasil would prevent postoperative reinfection in patients with RLP. STUDY DESIGN: This is a case series study. PURPOSE: The purpose of this study was to examine whether Gardasil injection effectively inhibits recurrence of RLP. Specifically, in this second report, whether HPV antibodies produced in laryngeal secretions by Gardasil are capable of causing negative conversion of HPV-DNA (deoxyribonucleic acid) in laryngeal mucosa was investigated. METHODS: A total of 11 patients for whom antibodies were measured in the first report were studied. Before vaccination and after 1 year Post-vaccination, HPV screening tests were performed on laryngeal secretions, and whether HPV-DNA negative conversion had occurred was evaluated. At the time of collection of laryngeal secretions, the presence or absence of laryngeal papillomas was examined. RESULTS: Before vaccination, all patients were HPV low-risk positive on laryngeal secretion screening tests. After vaccination, three patients were positive. Laryngeal papillomas remained in five patients. CONCLUSIONS: The HPV-DNA test showed negative conversion in eight of 11 (72.7%) patients after vaccination. Residual laryngeal papillomas were found in five of 11 (45.5%) patients. The serum HPV antibody titer did not differ significantly between the group in which laryngeal secretions showed HPV negative conversion and the group in which conversion did not occur. The serum antibody titer did not differ significantly as a function of whether there were residual tumors.

Human Papillomavirus Infection Status of Various Laryngeal Diseases in Japan: A Comprehensive Study.

OBJECTIVE: The aim of our study was to clarify the human papillomavirus (HPV) infection status of various laryngeal diseases in Tokyo, Japan. STUDY DESIGN: This is a retrospective study. METHODS: A total of 144 patients who underwent surgical resection for various laryngeal lesions were enrolled in this study. These subjects were categorized into four groups based on lesion type: non-neoplastic, 44; precancerous, 29; cancer, 35; and papilloma, 36. To determine the rate of HPV infection, laryngeal secretions and resected tissue from our study participants were examined by liquid-phase hybridization (LPH) and consensus primer-directed polymerase chain reaction (PCR). RESULTS: The LPH for low-risk HPV was applied to all 144 patients, and that for high-risk HPV was additionally applied to 121 of the 144 patients. The PCR was applied to 94 of the 144 patients. The LPH detected low-risk HPV-DNA in 23 patients (1 cancer and 22 papillomas) and high-risk HPV-DNA in 3 patients (1 cancer and 2 papillomas). The PCR detected HPV-6 and HPV-11 in the papilloma group, whereas it detected HPV-31 in one patient with laryngeal cancer and one patient with precancerous lesion. Both the LPH and the PCR revealed the HPV infection rate in the non-neoplastic group to be 0%. CONCLUSIONS: Although we found no significant difference in the HPV-DNA positive rates of laryngeal cancer and precancerous lesions in the non-neoplastic group, the positive rates were significantly smaller in this group than in the papilloma group. In the Tokyo area, HPV had little or no association with laryngeal cancer, precancerous lesions, and non-neoplastic lesions in the larynx.

Gardasil Vaccination for Recurrent Laryngeal Papillomatosis in Adult Men: First Report: Changes in HPV Antibody Titer.

BACKGROUND: Patients with human papillomavirus (HPV) DNA-positive recurrent laryngeal papillomatosis commonly have repeated recurrences following surgery. The reason is suspected to be a mechanism by which latent HPV infection in the surrounding healthy mucosa reinfects the surgical site. It may be that production of HPV antibodies in the laryngeal mucosa with Gardasil injection could inhibit postoperative recurrence. STUDY DESIGN: This is a case series study. PURPOSE: The purpose of this study was to examine whether Gardasil injection effectively inhibits recurrence. However, as a first report, we describe the antibody titers before and after vaccination. METHODS: Gardasil was injected in 12 men (aged 32-74 years; mean age 47.9 years) with HPV-positive laryngeal papillomatosis. Serum antibody titers of HPV-6, -11, -16, and -18 were measured by a competitive Luminex-based immunoassay before the vaccination and 7 months after the start of the vaccination. RESULTS: Each of the antibody titers was very low before vaccination, and they rose in all patients after the vaccination. CONCLUSIONS: This finding demonstrates that antibody titers increase with Gardasil injection in post-adolescent males.

High Prevalence of Laryngopharyngeal Reflux Disease in Patients With Lumbar Kyphosis.

OBJECTIVE: To evaluate the relationship between laryngopharyngeal reflux disease and presence of lumbar kyphosis. STUDY DESIGN: A cross-sectional study. METHODS: We included 20 patients with lumbar kyphosis and 31 control subjects. A diagnosis of laryngopharyngeal reflux disease and gastroesophageal reflux disease was made if the Reflux Symptom Index score was ≥13 and if the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease was ≥8, respectively. We compared the prevalence of the two reflux diseases, frequent reflux symptoms, and demographic factors between the two groups. RESULTS: There was no significant difference in demographic factors between the two groups. Five (25%) of 20 patients with lumbar kyphosis had a Reflux Symptom Index ≥13 compared with one (3.2%) of 31 controls. Seven (35.0%) of 20 patients had a Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease ≥8 compared with three (9.7%) of 31 controls. A comparison of the prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease showed a significant difference between patients with kyphosis and controls (P value = 0.029 and 0.036, respectively). In Reflux Symptom Index, heartburn, hoarseness, and a swallowing problem were significantly frequent symptoms in the kyphosis group compared with the control group. CONCLUSIONS: The prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease was significantly higher in patients with lumbar kyphosis than in controls. Therefore, otolaryngologists and orthopedic surgeons should be aware that patients with lumbar kyphosis are likely to have gastroesophageal reflux disease and also laryngopharyngeal reflux disease.