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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.

SUMMARY 1. One hundred and forty-six infants with congenital esophageal atresia, tracheoesophageal fistula, or both, were observed on the endoscopic service of The Children's Memorial Hospital between 1947 and 1964. One hundred and twenty-three, or 84.2 per cent, were Type III, 12 were Type IV (“H”), and 10 were Type I with both segments blind. One had an esophageal atresia with both upper and lower segments entering the trachea. 2. Laryngeal problems included congenital anomalies, paralyses, and postoperative edema. Twelve infants had laryngeal paralyses: 6 bilateral, 2 right and 4 left cord paralysis. Laryngeal paralysis invariably increased the respiratory and deglutition difficulties of the postoperative period. 3. Tracheal problems included congenital tracheomalacia and stenoses. The most serious post-surgical complications occur at the site of the fistula leading to the lower esophageal segment. Obstruction due to inversion of the edges, granulomas, and too tight a closure were present in 14 infants. Diverticula, consisting of a residual piece of the lower esophageal segment not completely removed, were found in 11 infants. There were 12 recurrent tracheoesophageal fistulas. 4. Bronchial secretions, chemical bronchitis, and atelectasis constitute the principal bronchopulmonary complications. These appear to increase in severity with delay in closure of the tracheoesophageal fistula. The alteration of respiratory physiology associated with resection of portions of several ribs may play a part in increasing the severity of the bronchopulmonary problems. 5. Esophageal strictures were present in 103 of the 146 infants; 93 at the site of a direct end-to-end anastomosis, 8 at the esophagogastric, -colic, or -jejunal site, and 2 at the cologastric site. Early recognition and treatment of the narrowing lumen in the immediate postoperative period is stressed. Swallowing function is usually normal until semisolids are added to the infant diet, at which time the anastomosis stricture is already firm and tough. Techniques of bougienage in the early postoperative period and management of the late fibrous strictures are outlined. 6. Reanastomosis was necessary in 6 infants because of inability to reestablish a lumen endoscopically. All were dilated early in the postoperative period following the revision and have attained a normal swallowing function.

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

Malignant tumors of the larynx rarely occur in infants. They are of interest to the pediatrician and to the laryngologist alike because of the rapidity with which they may produce laryngeal obstruction. The following case is worthy of note because of the age of the infant, the type of tumor and its point of origin. REPORT OF A CASE R. E., a 17 day old white boy, was admitted to the Children's Memorial Hospital, Chicago, on June 23, 1941, because of a loud inspiratory crow and "blue" spells which had been present since birth. Oxygen had been administered at frequent intervals when the inspiratory crow persisted or was associated with the "blue" spells. These attacks occurred repeatedly when the infant cried or exerted himself. Roentgen treatments had been given for suspected enlargement of the thymus, but no improvement was observed. Physical examination revealed that the infant was well developed and

The incidence of tracheotomy in infants under one year of age is increasing due to a broadening of indications, greater acceptance of tracheotomy as an adjunct to other therapy and a lower mortality through improvements in surgical technic and in the postoperative care of tracheotomized infants. Tracheotomy for inflammatory lesions is decreasing, but the incidence of tracheotomy for congenital and miscellaneous lesions is increasing. Of 62 infants under one year of age who required tracheotomy, congenital lesions were considered the cause of the respiratory obstruction in 32 cases (15 males and 17 females) and acquired lesions in 30 (21 males and 9 females). In 8 of the 30 infants in the "acquired" group congenital anomalies were indirectly responsible for the tracheotomy, since it was necessitated following extensive surgical procedures performed in an attempt to correct gross anomalies of organs other than those of the respiratory system. There were 17 deaths in the series of 62 cases. Eight occurred in the miscellaneous group, principally those operated on for gross anomalies of other organs, 3 in the group of 17 congenital laryngeal anomalies, 4 in the group of 18 inflammatory lesions and 2 in the group of 8 neoplasms. Tracheotomy is generally looked upon as an emergency life-saving procedure. However, in most cases it can be a planned, careful operation, preceded by the establishment of an airway to avoid cerebral and surgical trauma. The post-tracheotomy period is the critical period during infancy.

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...

The indications for bronchoscopy and esophagoscopy in infants are constantly increasing. Problems associated with the examinations of the small air and food passages of patients under one year of age have become more complex, largely as the result of the spectacular advances of pediatric surgery of the heart, lungs and esophagus. Such surgery requires the most accurate diagnostic endoscopic pre-and postoperative endoscopic procedures that are of unusual interest. Using miniature lamps and light carriers, practical bronchoscopes and esophagoscopes for use in newborn infants are available. In addition, aspirators, forceps and even telescopes (optics) have been developed for special studies. No anesthesia is required or desirable for bronchoscopy, bronchography or esophagoscopy in infants; but team work to permit a rapid, thorough procedure is essential.In the immediate post-partum period, bronchoscopic problems are essentially those of differential diagnosis and relief of bronchial obstruction. The most obvious condition is that of retained mucoid secretions; however, when bronchoscopic aspiration of the newborn is requested, there is usually an additional, serious underlying condition responsible for the retained secretions. Central nervoussystem changes such as cerebral agenesis or a birth injury resulting in loss of haryngeal and cough reflexes may account for the symptoms. However, congenital anomalies such as esophageal stenosis or atresia, with or without a fistula, pulmonary agenesis, lobar emphysema, anomalous vessels obstructing the trachea or bronchi, constitute the types of congenital anomalies that require endoscopic investigation. Corrective surgery for many of these conditions necessitates further endoscopy to assist in maintaining the patency of the air and food passages. Endoscopic problems in 150 cases of congenital atresia of the esophagus with a tracheoesophageal fistula have consisted of management of the stenoses at the site of anastomosis of the esophagus, the occasional severe tracheal stenoses occurring at the site from which the lower esophageal segment had been removed, and pulmonary atelectasis, particularly of the right upper lobe.Severe respiratory and esophageal obstruction produced by anomalies of the aorta and its branches has been observed in 37 infants during the past 12 years. Diagnostic procedures have included bronchoscopy, esophagoscopy and, in some cases, bronchography. Intrabronchial support by means of polyethylene tubing following removal of the constricting vessel has been necessary. Persistance of bronchial narrowing is noted after surgery in most cases, although there is improvement in symptoms because of relief of pressure. Reduction in lumen sized is due to the pressure of the vessel on the bronchus during development.Bronchopulmonary suppuration in infants under one year of age presents a wide field for diagnostic and therapeutic bronchooscopy. Non-specific respiratory tract suppuration, the pulmonary aspects of pancreatic fibrocystic disease and specific infections such as tuberculosis have endobronchial and extra-bronchial aspects of particular bronchoscopic import. The correlation of general pediatric management with bronchial hygiene through endobronchial removal of obstructive secretions and exudates constitutes an important phase of the recognition and management bronchoscopic and esophagoscopic problems in infants.

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.

The system for classification of laryngeal cancer was revised following a field study of 19 participating cancer clinics and hospitals in the United States and the T.N.M. Committee of the U.I.C.C. Study of records of 1,645 larynx cancer patients demonstrated that the best survival was experienced by patients with in-situ carcinoma (Tis), 97%. When the tumor was limited to the region of origin (T1), survival was 94% for glottic cancers and 91% for supraglottic cases. As the tumor spread to other regions of the larynx but still confined to the larynx without fixation (T2), survival was 85%–82%; when the larynx was fixed, and tumor still confined to the larynx (T3), survival was 65%–74%, and as the tumor spread outside the larynx (T4) survival dropped to 40%–55%. When cervical lymph node metastases were not fixed, survival was ±50% (hemolateral, bilateral, or contralateral non-fixed metastases). When the regional metastases were fixed, survival dropped to 21%. There were no survivors when the metastases were bilateral and fixed. Grouping the 4 “T”, 4 “N”, and 2 “M” categories into four stages, survival progressively decreased from 94% for Stage I, 85% for Stage II, 59% for Stage III, and 9% for Stage IV for the glottic cases. Similar survival for the supraglottic group was 91%, 82%, 49%, and 9%.