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Patients with esophageal stricture being treated with dilatation, who developed esophageal perforation or local peritonitis and subsequent central nervous system infection, are reviewed. It is suggested that the vertebral venous system may be the route by which the metastatic infection is carried. Physicians caring for patients with esophageal stricture, who are receiving dilatation, should be aware of the possible intracranial complications and should be alert to the first sign of central nervous system abnormality.

Fifty-one patients underwent 71 carbon dioxide laser procedures under general anesthesia for various intralaryngeal pathology. Anesthesia was induced with thiopental sodium followed by succinylcholine to facilitate endotracheal intubation. For maintenance of anesthesia, 70 percent nitrous oxide was supplemented with halothane, enflurane or small doses of fentanyl. Succinylcholine, d-tubocurare or pancuronium were used to maintain muscular relaxation of jaw, pharyngeal and laryngeal muscles for a smooth lasing procedure. Small diameter (16–22 Fr.), red rubber, cuffed endotracheal tubes provided maximum working space, facilitated the controlled ventilation and reduced the explosion hazard of the anesthetic gases. Safely eyeglasses were used by all the personnel in the operating room against accidental injury to the cornea by the laser beam. Anesthetic management provided excellent operative conditions with maximum safety to the patient and the personnel in the operating room.

This report describes 21 infants and children with bilateral abductor vocal cord paralysis and associated meningomyelocele, Arnold-Chiari malformation, and hydrocephalus. Two life-threatening forms of respiratory distress are distinguished: (1) upper airway obstruction due to bilateral abductor cord paralysis and (2) apnea. Clinically significant episodes of apnea were documented in 13 infants. Ten infants had evidence of aspiration and dysphagia. Vocal cord paralysis, apnea, aspiration, and dysphagia were frequently temporally related to increased intracranial pressure.

The symptoms, endoscopic findings, treatment and results of 46 patients with laryngoceles and saccular cysts are presented. Thirty-four were adults; 12 were infants and children under three years of age. Twenty-two adults had anterior saccular cysts, nine had lateral saccular cysts; three had laryngoceles. Ten infants and children had saccular cysts; two had laryngoceles. A laryngocele is an abnormal dilatation of the saccule which communicates with the lumen of the larynx, fills with air but on occasion may be temporarily distended with mucus; laryngoceles may be congenital or acquired. A saccular cyst is a mucus-filled dilatation of the saccule which does not communicate with the laryngeal lumen; saccular cysts are classified as lateral or anterior. Laryngoceles and saccular cysts represent abnormalities of the laryngeal saccule; a developmental spectrum exists among the normal saccule, large saccule, laryngocele and saccular cyst. The treatment of saccular cysts in infants and children is primarily repeated aspiration. In adults, symptomatic laryngoceles and large lateral saccular cysts are treated by an external approach; endoscopic aspiration and unroofing of small lateral saccular cysts is sometimes adequate and is attempted first. Anterior saccular cysts are treated by endoscopic excision biopsy. Carcinoma of the larynx may be found in association with a laryngocele or saccular cyst and must be diligently searched for by biopsies in the region of the saccular orifice. A smooth mass involving the area of the false vocal cord and aryepiglottic fold cannot be assumed to be a lateral saccular cyst; biopsies of the ventricle and saccule and deep incisional biopsies of the mass are indicated to rule out a carcinoma originating in the ventricle or saccule.

The etiology of 389 cases of partial or complete bilateral abductor vocal cord paralysis has been determined and classified. One hundred and forty-nine were infants and children 12 years of age and under; 240 were adults, age 13 and older. In the infants and children the paralyses were congenital in 82 cases, of which 43 were associated with other congenital anomalies, and 39 were without associated anomalies. Fifty-nine cases were considered acquired, most being secondary to underlying congenital anomalies, particularly the associated findings of meningomyelocele, Arnold-Chiari malformation, and hydrocephalus. Eight cases of paralysis in this age group were of undetermined etiology. Of the 240 adult cases of bilateral vocal cord paralysis, 138 followed thyroidectomy. Fifty-two cases were associated with various neurologic disorders, including poliomyelitis, Parkinson's disease, cerebrovascular accident, Guillain-Barré syndrome, multiple sclerosis, neoplasm, and other miscellaneous neurologic conditions. Sixteen cases were due to malignant neoplasms of the neck and mediastinum. The remaining 34 cases constitute a miscellaneous group which includes foreign bodies, bilateral neck dissection, infection, congenital lesions, trauma, and idiopathic paralyses. The characteristic symptoms of bilateral abductor vocal cord paralysis include normal or near normal phonation with inspiratory stridor which may progress to complete respiratory obstruction. These symptoms are due to the stationary but flaccid midline position of the vocal cords which places them in a phonating position, where they both obstruct the airway and produce a fairly clear voice or cry. This paradoxical combination of symptoms was frequently found to be responsible for a failure or delay in diagnosis.

Amyloidosis is the deposition into tissues of a substance which Virchow called amyloid because of its resemblance to starch. It is a mucopolysaccharide-protein complex which changes the color of iodine as starch changes it, and it is specific in its absorption of Congo red and methyl violet. According to Peters,1the substance is deposited in extracellular spaces, forming on tissues as a product of a disturbed protein metabolism of the cellular membranes. Larsen2has suggested that amyloid forms on tissues because of a change in the capillary permeability not associated with any alteration of tissues. Many theories have been developed in an attempt to determine the etiology of amyloidosis. Amyloid deposits have been considered the product of a disturbance of protein metabolism, the result of an antigen-antibody reaction, and the consequence of a reticuloendothelial disturbance, and, in those cases associated with multiple myeloma, it has been suggested that

1. Electron microscopic studies have failed to demonstrate virus particles in papillomas of four patients with laryngeal papilloma and one patient from whom the entire base of the papilloma was evulsed and excised from the tracheal wall.2. No growth was obtained at the site of inoculation of the larynx of three female Rhesus monkeys whose true and false cords were inoculated unilaterally with 0.5 ml of a suspension made from papilloma removed from two children and one adult.3. It was not possible to duplicate work reported previously which had indicated the presence of a species-specific virus capable of producing growth of tissue cultures with regrowth after blind serial tissue culture passes.4. Blood samples were collected before and after vaccine therapy in patients with laryngeal papillomas so that in case a virus was isolated, the viral agent could be used as the antigen in a serological reaction; since the virus could not be isolated, there could be no serological evaluation of vaccine therapy.5. Th...

A case of primary fibrosarcoma of the bronchus in a five and one half boy is presented. It is the ninth case reported in the literature and with Donohue's patient, the youngest. The diagnosis was established by bronchoscopic biopsy and the tumor successfully removed by lobectomy of the right lower and right middle lobes of the lung. The incidence, symptomatology, diagnosis, therapy and prognosis of fibrosarcoma of the bronchus are discussed.

Summary Lobar emphysema secondary to bronchial cartilage abnormalities, intrathoracic vascular abnormalities, and unknown causes is reported in five infants and children. The incidence, diagnosis, etiology, and treatment are considered.

This report describes the unusual association of bilateral abductor vocal cord paralysis (BAbVCP) and Charcot-Marie-Tooth disease in a boy and his natural mother who have been followed for eight years. The boy initially presented with life-threatening respiratory distress at age ten years; BAbVCP was documented by direct laryngoscopy. Mirror laryngoscopy confirmed BAbVCP in the mother. Neurological diagnosis was made by history, physical examination, electromyography, and nerve conduction velocity studies. The BAbVCP may represent an additional genetic marker within the spectrum of heredodegenerative disorders. Of clinical importance is examination of voice and respiratory symptomatology of patients with heredodegenerative diseases and neurological work-up of patients with familial vocal cord paralysis. Further genetic and clinical studies of X cranial nerve involvement in heredodegenerative disorders are warranted.

• The nature and cause of psychiatric symptoms associated with the postthyroidectomy bilateral abductor vocal cord paralysis (BAVCP) syndrome are analyzed. The postthyroidectomy BAVCP syndrome is characterized by normal voice, airway obstruction, hypothyroidism, hypoparathyroidism, and psychiatric manifestations. Forty-five (35.2%) of 128 patients with postthyroidectomy BAVCP syndrome had psychiatric manifestations of some kind. The following four categories of psychiatric problems were found: (1) preexisting psychiatric symptoms exacerbated by the postthyroidectomy BAVCP syndrome, (2) psychiatric symptoms initiated by the syndrome, (3) psychiatric symptoms that were etiologically distinct from the syndrome, and (4) misdiagnosis. The variety of psychiatric symptoms, as well as the difficulty in determining the cause of the symptoms, makes it essential that surgeons, internists, and psychiatrists cooperate in the treatment of patients with the postthyroidectomy BAVCP syndrome. ( Arch Otolaryngol 107:33-36, 1981)

Four children with foreign bodies found outside the lumen of the upper food and air passages are presented. The diagnostic difficulty of such extraluminal foreign bodies and the importance of accurate localization by endoscopy and radiologic examination prior to external surgical removal are discussed.

Of 158 cases of subglottic stenosis 115 were congenital and 43 acquired. Current follow-up has been obtained in 146 (92%) which constitutes the determinate group. Although stridor was the most common presenting symptom of the congenital group, 34% presented with recurrent or prolonged episodes of croup. Tracheotomy was required in 47 of the 107 determinate cases (44%). Further management of the congenital cases was based on the experience that children outgrow this disorder; periodic dilatation may augment the natural process. Of those infants and children tracheotomized, all but five have been decannulated, and there was one death — a mortality rate of 2.1%. Acquired subglottic stenosis proved to be a more difficult management problem. Tracheotomy was necessary in 38 of the 39 determinate cases (97%). Repeated active dilatations for prolonged periods were usually required as well as endoscopic removal of granulation tissue. Of those infants and children tracheotomized, all but eight have been decannulated. There were nine deaths; five were due to unrelated underlying disease; four were attributable to complications of long-term tracheostomy. Thus, in the entire series, 85 infants and children required tracheotomy and five deaths may be attributable to long-term tracheostomy complications — a mortality rate of 5.9%.

Post-thyroidectomy bilateral abductor vocal cord paralysis (BAVCP) is a life-threatening syndrome characterized by serious psychiatric manifestations as well as by voice, airway, hypothyroid, and hypoparathyroid symptoms. Of the 128 patients with post thyroidectomy BAVCP syndrome, 45 (35.2 per cent) had psychiatric complications: 21 of the 128 patients (16.4 per cent) had pre-existing psychiatric symptoms exacerbated by the post-thyroidectomy BAVCP syndrome, 16 (12.5 per cent) had psychiatric symptoms initiated by the syndrome, six (4.7 per cent) had psychiatric symptoms etiologically distinct from the syndrome, and two (1.6 per cent) were misdiagnosed. The role of psychiatric treatment is described. Theoretical aspects of laryngeal dysfunctions associated with psychiatric disorders and psychotropic medications are discussed.

Esophageal dysfunction in an infant or child usually results from congenital or traumatic lesions or chemical burns. Congenital conditions include benign strictures and webs, a short esophagus and atresia. The swallowing of foreign bodies and chemicals accounts for most of the traumatic lesions. Cardiospasm and esophageal varices are relatively uncommon in children; however, esophagitis occurs frequently. The authors discuss the diagnosis and treatment of each of these conditions.

1. 1. A review of eighty-two patients who sustained external trauma to the larynx shows the commonest cause to be automobile and other vehicular accidents (forty-three cases). Other vehicular accidents involved streetcars, buses, trains, airplanes, a tractor, bicycle and sled. In the automobile accidents the laryngeal injury was usually one of multiple injuries and it occurred as frequently in females as in males. 2. 2. Next in frequency as a cause of laryngeal trauma is physical violence (twenty-nine cases), i.e. garroting, “strong arm,” blow by edge of hand, gunshot, cutthroat, boxing and being struck by a baseball or golf ball. Twenty-seven of this group were males, only two females. 3. 3. Ten patients, all men, received their laryngeal injuries in industrial accidents, being struck in the neck by a “two by four,” striking projecting machinery or falling while carrying a heavy object and striking an edge of it in the fall. Three men had put their heads through open windows or horizontal elevator doors, the doors or windows closing on the neck. 4. 4. Minimal injuries cause hoarseness, dysphonia and aphonia. The pathologic conditions included hematomas, lacerations of the cords or other soft tissues, and dislocations or fractures of laryngeal cartilages. Respiratory obstruction is evidence of more severe injury and may vary in degree from slight respiratory embarrassment to total atresia and asphyxia. 5. 5. Diagnosis is established by palpation, mirror and direct laryngoscopic examinations of the larynx and x-ray films of the neck, particularly the lateral view. 6. 6. Treatment of minimal injuries consists of hot packs, voice rest (silence) and steam inhalations, with voice rehabilitation to help restore this important laryngeal function after the acute manifestations have subsided. 7. 7. Severe injuries to the larynx require low tracheotomy to establish the airway. Then, as soon as the patient's general condition will permit, broken cartilages must be replaced and held in position by an intralaryngeal splint or mold to insure an adequate airway. If manipulation perorally cannot be accomplished because of an associated fractured jaw, this must be performed through the tracheostomy or by external, open reduction. 8. 8. Failure or inadequate early management results in chronic laryngeal stenosis and the need of a permanent tracheostomy. Treatment of this complication requires reconstruction of the laryngeal lumen through the removal of scar and deformed cartilage and the lining of the interior of the larynx with a split thickness skin graft. This long and tedious process can be avoided by early reduction and fixation of the laryngeal fractures.

ATTENTION has recently been sharply focused on congenital lesions of the esophagus. This is because of the fact that surgical repair of the atresias is now possible, whereas formerly they were invariably fatal. Congenital anomalies of the esophagus, other than complete atresia, are apparently less well known and understood, but they undoubtedly occur more frequently than is generally recognized. They manifest their presence by signs and symptoms of dysphagia, often insidious and slowly progressive but occasionally dramatically apparent as a foreign body becomes lodged in the lesion to produce sudden partial or complete esophageal obstruction. In such instances, the episode of the foreign body assumes major importance and the underlying congenital esophageal stenosis may not be recognized and its significance not understood. This paper is an analysis of cases of foreign bodies in the esophagus in which the lodgment of the foreign body was due to a congenital anomaly of

Summary The recognition of post-traumatic hypopharyngeal diverticula has been a recent clinical observation in the newborn infant. Symptoms consist of excessive salivation, choking, and cyanosis. The diagnosis is suggested by fluoroscopy during swallowing of contrast material and confirmed by hypopharyngoscopy. The favorable outcome of the two infants reported here suggests that conservative therapy with gavage or gastrostomy feedings should be considered. Blind passage of a nasogastric tube is hazardous and may make conditions worse instead of better; failure to recognize the nature of the lesion led to reinsertion of a nasogastric tube in Case 1. Healing is usually fairly rapid within several days to a month. Cervical mediastinotomy or thoracotomy drainage may be necessary if there is wide extravasation of barium or if a complicating infection fails to respond to medical management.