Laryngeal amyloidosis: An uncommon cause of dysphonia

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G. Quiñonez-Olivas, I. M. Rivera-Morales, C. Sánchez-Martínez, H. R. Ibarra-Sifuentes, R. O. Flores-Pérez, J. A. Cárdenas-de la Garza" "autores" => array:6 [ 0 => array:2 [ "Iniciales" => "C. G." "apellidos" => "Quiñonez-Olivas" ] 1 => array:2 [ "Iniciales" => "I. M." "apellidos" => "Rivera-Morales" ] 2 => array:2 [ "Iniciales" => "C." "apellidos" => "Sánchez-Martínez" ] 3 => array:2 [ "Iniciales" => "H. R." "apellidos" => "Ibarra-Sifuentes" ] 4 => array:2 [ "Iniciales" => "R. O." "apellidos" => "Flores-Pérez" ] 5 => array:2 [ "Iniciales" => "J. A." "apellidos" => "Cárdenas-de la Garza" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1665579614675896?idApp=UINPBA00004N" "url" => "/16655796/0000001600000064/v0_201607061456/X1665579614675896/v0_201607061459/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Laryngeal amyloidosis: An uncommon cause of dysphonia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "129" "paginaFinal" => "132" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "V. J. Villagómez-Ortiz, M. Villegas-González, J. L. Treviño-González, R. Santos-Lartigue, B. González-Andrade, N. Montemayor-Peña" "autores" => array:6 [ 0 => array:3 [ "Iniciales" => "V. J." "apellidos" => "Villagómez-Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "M." "apellidos" => "Villegas-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "J. L." "apellidos" => "Treviño-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "R." "apellidos" => "Santos-Lartigue" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "B." "apellidos" => "González-Andrade" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 5 => array:3 [ "Iniciales" => "N." "apellidos" => "Montemayor-Peña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Otolaryngology and Head and Neck Surgery Departament, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey, N.L., Mexico " "etiqueta" => "a" "identificador" => "affa" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "304v16n64-90367590fig1.jpg" "Alto" => 900 "Ancho" => 1025 "Tamanyo" => 42624 ] ] "descripcion" => array:1 [ "en" => "Patient 1, first visit. An increase in submucus volume can be observed in the photograph, altering the anatomy of the false vocal cords at the supraglottic level." ] ] ] "textoCompleto" => "Introduction Amyloidosis is used to describe a range of disorders defined by extracellular deposition of abnormal protein fibrils. Amyloid deposits were first described by Von Rokitansky in 1842, and the term amyloid was first used by Virchow in 1851 to describe the reaction of this tissue to iodine and sulfate.1 Borrow and Neuman (1873) were the first to report laryngeal amyloidosis. Over 300 cases have been reported since then.2 Current classifications of amyloidosis are based on the biochemical nature of the protein subunit (Chastonay, Hurliman in 1986 and Lewis et al. in 1992). AL amyloidosis (derived from light immunoglobulin chains) is associated with systemic amyloidosis. Fibrillar proteins have a characteristic pattern when observed under an electronic microscope after Congo red staining, displaying apple-green birefringence when examined with polarized light.3 The larynx is the most common site of localized amyloidosis in the head and neck region and constitutes less than 1% of benign laryngeal lesions.4 Hoarseness is the most common symptom. The male-female ratio is 3:1, with an age range between 8 and 80 years old, and a peak incidence occurring in the 5th decade of life.5-7 There are different treatments and resection methods for these lesions, though a few stand out, such as resection with a CO2 laser and cold technique. Radiotherapy has recently been described in cases where the lesions cannot be completely resected. Follow up is important in the long term, because these lesions have a high recurrence rate.3,4,8,9 Methods Presented are 4 cases of patients with localized laryngeal amyloidosis who were treated at the Otolaryngology and Head and Neck Surgery Service at the “Dr. José Eleuterio González” University Hospital in Monterrey, Mexico. A flexible nasal fiber laryngoscopy was performed on all of the patients. Lab studies were ordered to rule out the presence of a systemic disease: a complete blood count (CBC) and basic metabolic panel, urinalysis, hepatic function test, thoracic X-rays, and a full physical examination was performed, all of which were reported to be within normal parameters. Rectal or bone marrow biopsies were not performed. Maximum phonation time, voice handicap index, reflux symptoms (described by Belafsky et al.), and glottic function and features in all patients were measured. A resection by microlaryngoscopy with cold technique on all the lesions was performed. Congo red stains were applied to all surgical specimens. The approval of the ethics Committee of the “Dr. José Eleuterio González” University Hospital was obtained, as well as signed informed consents from all the patients.Cases presentation A laryngeal amyloidosis diagnosis was performed on 3 men and one woman, whose ages ranged from 14 to 67 years. The most common symptoms are: hoarseness, pharyngodynia, vocal pauses, and vocal fatigue. The duration of the symptoms before diagnosis was between 2 and 12 years. Diagnosis and treatment were implemented to rule out systemic involvement; the results were negative in all patients. Resections of the lesions by microlaryngoscopy with cold technique were executed, and samples were sent out for histopathology analysis. Congo red staining was used, where we were able to observe green birefringence through the use of the electronic microscope. The results of the questionnaires conducted before and after the surgical procedure were documented. With the use of this technique we were able to observe favorable results in the subjective symptoms as well as in the maximum phonation time. Case 1 A 67-year-old male, came to the Voice Clinic for the first time presenting hoarseness with an evolution of 10 years, progressive, vocal fatigue, glottic leak and inability to reach high notes. He denies any systemic diseases or smoking. He scored a glottic closure force index of 9, reflux index of 8 and quality of life index of 3. At the physical examination: Maximum phonation time was 17 seconds, S:Z ratio of 25:27. The videolaryngoscopy displayed an elevated lump towards the right false vocal cord and anterior commissure (Fig. 1).<img alt="Figure 1 Patient 1, first visit. An increase in submucus volume can be observed in the photograph, altering the anatomy of the false vocal cords at the supraglottic level." src="304v16n64-90367590fig1.jpg"></img>Figure 1 Patient 1, first visit. An increase in submucus volume can be observed in the photograph, altering the anatomy of the false vocal cords at the supraglottic level. Case 2 A 52-year-old female, teacher, came to the Voice Clinic as a result of hoarseness with a 3-year evolution, accompanied by vocal fatigue, vocal pauses and inability to reach high notes. She did not improve by resting her voice. She denies smoking or ethilism. She previously received steroids and antibiotics without improvement. Her glottic closure force index was 12, reflux index of 17 and quality of life index of 7. Her maximum phonation time was 7 seconds, S:Z ratio of 5:3. We were able to observe a major glottis edema with the videolaryngoscopy (Fig. 2). A phonomicrosurgery with cold technique was performed, and the sample was sent for histopathological analysis with an amyloidosis report.<img alt="Figure 2 Patient 2, first visit. An increase in volume is observed in the left lower lip of the true vocal cord, creating premature contact upon glottal closure." src="304v16n64-90367590fig2.jpg"></img>Figure 2 Patient 2, first visit. An increase in volume is observed in the left lower lip of the true vocal cord, creating premature contact upon glottal closure. Post-surgically, she showed an improvement in her maximum phonation time to 12 seconds, a glottic force closure rate index to 4, reflux index to 4, and a quality of life index of 3 (Fig. 3).<img alt="Figure 3 Patient 2, one month post-surgery. A lessening of the increase in volume can be observed at the true vocal cords. There is now no premature contact upon glottal closure." src="304v16n64-90367590fig4.jpg"></img>Figure 3 Patient 2, one month post-surgery. A lessening of the increase in volume can be observed at the true vocal cords. There is now no premature contact upon glottal closure. Case 3 A 33-year-old male, presenting hoarseness with an evolution of 3 years, accompanied by vocal fatigue, vocal pauses and inability to reach high notes, occasional ethilism and denied smoking. At physical examination: Glottic leak, a glottic force closure rate index of 19, reflux index of 25, and a quality of life index of 18, maximum phonation time was 9 seconds, S:Z ratio of 32:8. The videolaryngoscopy displayed an elevated lump towards the right false vocal cord which impedes glottic closure, with a wide glottal gap (Fig. 4). A resection using the cold technique was performed, and we confirmed a diagnosis of amyloidosis. Post-surgical data: Glottic force closure rate index of 10, reflux index of 5, quality of life index of 9, and maximum phonation time of 16 seconds (Fig. 5).<img alt="Figure 4 Patient 3, first visit. Increased exophytic volume can be seen, at the right level of the false vocal cords, which does not obstruct the glottal light. And a plain deformity of the right true vocal cord with premature contact and alteration of the chordal wave vibration." src="304v16n64-90367590fig3.jpg"></img>Figure 4 Patient 3, first visit. Increased exophytic volume can be seen, at the right level of the false vocal cords, which does not obstruct the glottal light. And a plain deformity of the right true vocal cord with premature contact and alteration of the chordal wave vibration.<img alt="Figure 5 Patient 3, one month post-surgery. There is no evidence of supraglottic lesions, or obstruction of glottic light." src="304v16n64-90367590fig5.jpg"></img>Figure 5 Patient 3, one month post-surgery. There is no evidence of supraglottic lesions, or obstruction of glottic light. Case 4 A 14-year-old male with hoarseness, with a 2-year evolution, progressive, with vocal fatigue and vocal pauses during conversation. A videolaryngoscopy was performed, where we were able to observe a lump which deformed both false and true vocal cords, thus conditioning a premature glottic closure (Fig. 6).<img alt="Figure 6 Patient 4, first visit. Submucous lesions at the left false vocal cord level can be observed." src="304v16n64-90367590fig6.jpg"></img>Figure 6 Patient 4, first visit. Submucous lesions at the left false vocal cord level can be observed. Glottic force closure rate index of 13, reflux index of 10, and a quality of life index of 6, maximum phonation time was 12 seconds, S:Z ratio of 17:12 seconds. The same surgical procedure was executed, and we sent a sample for histopathological analysis. Post-surgical data: Maximum phonation time of 21 seconds, glottic force closure rate index of 4, reflux index of 2, quality of life index of 5 (Fig. 7).<img alt="Figure 7 Patient 4, post-surgery. No evidence of lesions at the supraglotic or glotic level." src="304v16n64-90367590fig7.jpg"></img>Figure 7 Patient 4, post-surgery. No evidence of lesions at the supraglotic or glotic level.Discussion The larynx is the most common site for primary amyloidosis in the head and neck region. The male-female ratio in our patients was the same as the one reported in medical literature, with a variation in age range. In order of frequency, lesions were most commonly found in the ventricle, vestibular folds, vocal folds, epiglottis, and aryepiglottic folds. In our patients the most common was the involvement of false vocal cords. In general, the symptoms of this pathology are specific and do not lead to diagnosis, thus requiring a high level of suspicion, because they will appear depending on the size and site of the lesion. The most common reported symptom in our patients was hoarseness and vocal fatigue. It is important to rule out the involvement of a systemic disease in patients with this pathology. It is worth noting the fact that in order to obtain our diagnosis, we did not perform any invasive procedures in our patients (i. E. Rectal or bone marrow biopsies). The treatment for these patients is surgical, and a complete resection is essential to avoid recurrence; however, there are few comparative studies between lesion resection with cold technique and laser to estimate their recurrence. Studies have suggested the use of radiotherapy combined with surgery in those lesions where complete resection is not possible.7 Conclusions Laryngeal amyloidosis is a rare disease with a rate of 8 in 1,000,000 and a higher incidence during the 5th decade of life. Diagnosis is confirmed by Congo red staining observing an apple-green birefringence under an electronic microscope. Resection with cold technique is an adequate method to remove lesions with positive subjective and objective results. It is important to rule out a systemic involvement in these patients.Conflicts of interest The authors have no conflicts of interest to declare.Funding No financial support was provided.<hr></hr> Received: November 2013; Accepted: January 2014 * Corresponding author: Otolaryngology and Head and Neck Surgery Departament, “Dr. José Eleuterio González” University Hospital. Francisco I. Madero and Gonzalitos Avenue, Mitras Centro, Monterrey, N.L., Mexico. Telephone: (81) 8333 2917. E-mail address: <a href="mailto:vicentevilla@yahoo.com" class="elsevierStyleCrossRefs">vicentevilla@yahoo.com</a> (V. J. Villagómez-Ortiz)." 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Clinical cases: Presented are 4 cases of patients with localized laryngeal amyloidosis who were treated at the Otolaryngology and Head and Neck Surgery Department at the “Dr. José Eleuterio González” University Hospital in Monterrey, Mexico. Three patients underwent phonomicrosurgery by direct microlaryngoscopy with the removal of the amyloid implantation using a cold knife excision with great results. In each patient the major site of involvement was the supraglottis with a small focus on the false vocal cord. A medical work-up, including a complete blood count (CBC), a basic metabolic panel, urinalysis, liver function test, chest X-ray and physical examination were performed to rule out the presence of systemic disease; no amyloidosis or signs of systemic disease were found. Congo red staining confirms the diagnosis of amyloidosis in all surgical specimens. Conclusions: In laryngeal amyloidosis, the treatment should be directed toward the improvement of the voice and the maintenance of the airway." ] ] "multimedia" => array:14 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "304v16n64-90367590fig1.jpg" "Alto" => 900 "Ancho" => 1025 "Tamanyo" => 42624 ] ] "descripcion" => array:1 [ "en" => "Patient 1, first visit. An increase in submucus volume can be observed in the photograph, altering the anatomy of the false vocal cords at the supraglottic level." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "304v16n64-90367590fig2.jpg" "Alto" => 745 "Ancho" => 1033 "Tamanyo" => 38994 ] ] "descripcion" => array:1 [ "en" => "Patient 2, first visit. 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And a plain deformity of the right true vocal cord with premature contact and alteration of the chordal wave vibration." ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "304v16n64-90367590fig4.jpg" "Alto" => 754 "Ancho" => 1020 "Tamanyo" => 42571 ] ] "descripcion" => array:1 [ "en" => "Patient 2, one month post-surgery. A lessening of the increase in volume can be observed at the true vocal cords. There is now no premature contact upon glottal closure." ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "304v16n64-90367590fig5.jpg" "Alto" => 687 "Ancho" => 1033 "Tamanyo" => 51938 ] ] "descripcion" => array:1 [ "en" => "Patient 3, one month post-surgery. There is no evidence of supraglottic lesions, or obstruction of glottic light." ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "304v16n64-90367590fig6.jpg" "Alto" => 775 "Ancho" => 1029 "Tamanyo" => 48828 ] ] "descripcion" => array:1 [ "en" => "Patient 4, first visit. Submucous lesions at the left false vocal cord level can be observed." ] ] 6 => array:8 [ "identificador" => "fig7" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "304v16n64-90367590fig7.jpg" "Alto" => 770 "Ancho" => 1029 "Tamanyo" => 66399 ] ] "descripcion" => array:1 [ "en" => "Patient 4, post-surgery. No evidence of lesions at the supraglotic or glotic level." ] ] 7 => array:7 [ "identificador" => "fig8" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Patient 1, first visit. An increase in submucus volume can be observed in the photograph, altering the anatomy of the false vocal cords at the supraglottic level." ] ] 8 => array:7 [ "identificador" => "fig9" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Patient 2, first visit. An increase in volume is observed in the left lower lip of the true vocal cord, creating premature contact upon glottal closure." ] ] 9 => array:7 [ "identificador" => "fig10" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Patient 2, one month post-surgery. A lessening of the increase in volume can be observed at the true vocal cords. 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V. J.. Villagómez-Ortiza, M.. Villegas-Gonzáleza, J. L.. Treviño-Gonzáleza, R.. Santos-Lartiguea, B.. González-Andradea, N.. Montemayor-Peñaa

a Otolaryngology and Head and Neck Surgery Departament, Dr. José Eleuterio González University Hospital, Universidad Autónoma de Nuevo León, Monterrey, N.L., Mexico

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displaying apple-green birefringence when examined with polarized light&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"> The larynx is the most common site of localized amyloidosis in the head and neck region and constitutes less than 1&#37; of benign laryngeal lesions&#46;<span class="elsevierStyleSup">4</span> Hoarseness is the most common symptom&#46; The male-female ratio is 3&#58;1&#44; with an age range between 8 and 80 years old&#44; and a peak incidence occurring in the 5<span class="elsevierStyleSup">th</span> decade of life&#46;<span class="elsevierStyleSup">5-7</span></p><p class="elsevierStylePara"> There are different treatments and resection methods for these lesions&#44; though a few stand out&#44; such as resection with a CO<span class="elsevierStyleInf">2</span> laser and cold technique&#46; Radiotherapy has recently been described in cases where the lesions cannot be completely resected&#46; Follow up is important in the long term&#44; because these lesions have a high recurrence rate&#46;<span class="elsevierStyleSup">3&#44;4&#44;8&#44;9 </span></p><p class="elsevierStylePara"> Methods</p><p class="elsevierStylePara"> Presented are 4 cases of patients with localized laryngeal amyloidosis who were treated at the Otolaryngology and Head and Neck Surgery Service at the <span class="elsevierStyleItalic">&#8220;Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#8221; </span>University Hospital in Monterrey&#44; Mexico&#46;</p><p class="elsevierStylePara"> A flexible nasal fiber laryngoscopy was performed on all of the patients&#46; Lab studies were ordered to rule out the presence of a systemic disease&#58; a complete blood count &#40;CBC&#41; and basic metabolic panel&#44; urinalysis&#44; hepatic function test&#44; thoracic X-rays&#44; and a full physical examination was performed&#44; all of which were reported to be within normal parameters&#46; Rectal or bone marrow biopsies were not performed&#46; Maximum phonation time&#44; voice handicap index&#44; reflux symptoms &#40;described by Belafsky et al&#46;&#41;&#44; and glottic function and features in all patients were measured&#46;</p><p class="elsevierStylePara"> A resection by microlaryngoscopy with cold technique on all the lesions was performed&#46; Congo red stains were applied to all surgical specimens&#46;</p><p class="elsevierStylePara"> The approval of the ethics Committee of the <span class="elsevierStyleItalic">&#8220;Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#8221;</span> University Hospital was obtained&#44; as well as signed informed consents from all the patients&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Cases presentation </span></p><p class="elsevierStylePara"> A laryngeal amyloidosis diagnosis was performed on 3 men and one woman&#44; whose ages ranged from 14 to 67 years&#46; The most common symptoms are&#58; hoarseness&#44; pharyngodynia&#44; vocal pauses&#44; and vocal fatigue&#46; The duration of the symptoms before diagnosis was between 2 and 12 years&#46;</p><p class="elsevierStylePara"> Diagnosis and treatment were implemented to rule out systemic involvement&#59; the results were negative in all patients&#46;</p><p class="elsevierStylePara"> Resections of the lesions by microlaryngoscopy with cold technique were executed&#44; and samples were sent out for histopathology analysis&#46; Congo red staining was used&#44; where we were able to observe green birefringence through the use of the electronic microscope&#46;</p><p class="elsevierStylePara"> The results of the questionnaires conducted before and after the surgical procedure were documented&#46; With the use of this technique we were able to observe favorable results in the subjective symptoms as well as in the maximum phonation time&#46;</p><p class="elsevierStylePara"> Case 1</p><p class="elsevierStylePara"> A 67-year-old male&#44; came to the Voice Clinic for the first time presenting hoarseness with an evolution of 10 years&#44; progressive&#44; vocal fatigue&#44; glottic leak and inability to reach high notes&#46; He denies any systemic diseases or smoking&#46; He scored a glottic closure force index of 9&#44; reflux index of 8 and quality of life index of 3&#46;</p><p class="elsevierStylePara"> At the physical examination&#58; Maximum phonation time was 17 seconds&#44; S&#58;Z ratio of 25&#58;27&#46; The videolaryngoscopy displayed an elevated lump towards the right false vocal cord and anterior commissure &#40;Fig&#46; 1&#41;&#46;</p><p class="elsevierStylePara"><img alt="Figure 1 Patient 1&#44; first visit&#46; An increase in submucus volume can be observed in the photograph&#44; altering the anatomy of the false vocal cords at the supraglottic level&#46;" src="304v16n64-90367590fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1 </span>Patient 1&#44; first visit&#46; An increase in submucus volume can be observed in the photograph&#44; altering the anatomy of the false vocal cords at the supraglottic level&#46;</p><p class="elsevierStylePara"> Case 2</p><p class="elsevierStylePara"> A 52-year-old female&#44; teacher&#44; came to the Voice Clinic as a result of hoarseness with a 3-year evolution&#44; accompanied by vocal fatigue&#44; vocal pauses and inability to reach high notes&#46; She did not improve by resting her voice&#46; She denies smoking or ethilism&#46; She previously received steroids and antibiotics without improvement&#46;</p><p class="elsevierStylePara"> Her glottic closure force index was 12&#44; reflux index of 17 and quality of life index of 7&#46; Her maximum phonation time was 7 seconds&#44; S&#58;Z ratio of 5&#58;3&#46; We were able to observe a major glottis edema with the videolaryngoscopy &#40;Fig&#46; 2&#41;&#46; A phonomicrosurgery with cold technique was performed&#44; and the sample was sent for histopathological analysis with an amyloidosis report&#46;</p><p class="elsevierStylePara"><img alt="Figure 2 Patient 2&#44; first visit&#46; An increase in volume is observed in the left lower lip of the true vocal cord&#44; creating premature contact upon glottal closure&#46;" src="304v16n64-90367590fig2.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2 </span>Patient 2&#44; first visit&#46; An increase in volume is observed in the left lower lip of the true vocal cord&#44; creating premature contact upon glottal closure&#46;</p><p class="elsevierStylePara"> Post-surgically&#44; she showed an improvement in her maximum phonation time to 12 seconds&#44; a glottic force closure rate index to 4&#44; reflux index to 4&#44; and a quality of life index of 3 &#40;Fig&#46; 3&#41;&#46;</p><p class="elsevierStylePara"><img alt="Figure 3 Patient 2&#44; one month post-surgery&#46; A lessening of the increase in volume can be observed at the true vocal cords&#46; There is now no premature contact upon glottal closure&#46;" src="304v16n64-90367590fig4.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 3 </span>Patient 2&#44; one month post-surgery&#46; A lessening of the increase in volume can be observed at the true vocal cords&#46; There is now no premature contact upon glottal closure&#46;</p><p class="elsevierStylePara"> Case 3</p><p class="elsevierStylePara"> A 33-year-old male&#44; presenting hoarseness with an evolution of 3 years&#44; accompanied by vocal fatigue&#44; vocal pauses and inability to reach high notes&#44; occasional ethilism and denied smoking&#46;</p><p class="elsevierStylePara"> At physical examination&#58; Glottic leak&#44; a glottic force closure rate index of 19&#44; reflux index of 25&#44; and a quality of life index of 18&#44; maximum phonation time was 9 seconds&#44; S&#58;Z ratio of 32&#58;8&#46; The videolaryngoscopy displayed an elevated lump towards the right false vocal cord which impedes glottic closure&#44; with a wide glottal gap &#40;Fig&#46; 4&#41;&#46; A resection using the cold technique was performed&#44; and we confirmed a diagnosis of amyloidosis&#46; Post-surgical data&#58; Glottic force closure rate index of 10&#44; reflux index of 5&#44; quality of life index of 9&#44; and maximum phonation time of 16 seconds &#40;Fig&#46; 5&#41;&#46;</p><p class="elsevierStylePara"><img alt="Figure 4 Patient 3&#44; first visit&#46; Increased exophytic volume can be seen&#44; at the right level of the false vocal cords&#44; which does not obstruct the glottal light&#46; And a plain deformity of the right true vocal cord with premature contact and alteration of the chordal wave vibration&#46;" src="304v16n64-90367590fig3.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 4 </span>Patient 3&#44; first visit&#46; Increased exophytic volume can be seen&#44; at the right level of the false vocal cords&#44; which does not obstruct the glottal light&#46; And a plain deformity of the right true vocal cord with premature contact and alteration of the chordal wave vibration&#46;</p><p class="elsevierStylePara"><img alt="Figure 5 Patient 3&#44; one month post-surgery&#46; There is no evidence of supraglottic lesions&#44; or obstruction of glottic light&#46;" src="304v16n64-90367590fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 5 </span>Patient 3&#44; one month post-surgery&#46; There is no evidence of supraglottic lesions&#44; or obstruction of glottic light&#46;</p><p class="elsevierStylePara"> Case 4</p><p class="elsevierStylePara"> A 14-year-old male with hoarseness&#44; with a 2-year evolution&#44; progressive&#44; with vocal fatigue and vocal pauses during conversation&#46;</p><p class="elsevierStylePara"> A videolaryngoscopy was performed&#44; where we were able to observe a lump which deformed both false and true vocal cords&#44; thus conditioning a premature glottic closure &#40;Fig&#46; 6&#41;&#46;</p><p class="elsevierStylePara"><img alt="Figure 6 Patient 4&#44; first visit&#46; Submucous lesions at the left false vocal cord level can be observed&#46;" src="304v16n64-90367590fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 6 </span>Patient 4&#44; first visit&#46; Submucous lesions at the left false vocal cord level can be observed&#46;</p><p class="elsevierStylePara"> Glottic force closure rate index of 13&#44; reflux index of 10&#44; and a quality of life index of 6&#44; maximum phonation time was 12 seconds&#44; S&#58;Z ratio of 17&#58;12 seconds&#46;</p><p class="elsevierStylePara"> The same surgical procedure was executed&#44; and we sent a sample for histopathological analysis&#46; Post-surgical data&#58; Maximum phonation time of 21 seconds&#44; glottic force closure rate index of 4&#44; reflux index of 2&#44; quality of life index of 5 &#40;Fig&#46; 7&#41;&#46;</p><p class="elsevierStylePara"><img alt="Figure 7 Patient 4&#44; post-surgery&#46; No evidence of lesions at the supraglotic or glotic level&#46;" src="304v16n64-90367590fig7.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 7 </span>Patient 4&#44; post-surgery&#46; No evidence of lesions at the supraglotic or glotic level&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara"> The larynx is the most common site for primary amyloidosis in the head and neck region&#46; The male-female ratio in our patients was the same as the one reported in medical literature&#44; with a variation in age range&#46;</p><p class="elsevierStylePara"> In order of frequency&#44; lesions were most commonly found in the ventricle&#44; vestibular folds&#44; vocal folds&#44; epiglottis&#44; and aryepiglottic folds&#46; In our patients the most common was the involvement of false vocal cords&#46;</p><p class="elsevierStylePara"> In general&#44; the symptoms of this pathology are specific and do not lead to diagnosis&#44; thus requiring a high level of suspicion&#44; because they will appear depending on the size and site of the lesion&#46; The most common reported symptom in our patients was hoarseness and vocal fatigue&#46;</p><p class="elsevierStylePara"> It is important to rule out the involvement of a systemic disease in patients with this pathology&#46; It is worth noting the fact that in order to obtain our diagnosis&#44; we did not perform any invasive procedures in our patients &#40;i&#46; E&#46; Rectal or bone marrow biopsies&#41;&#46;</p><p class="elsevierStylePara"> The treatment for these patients is surgical&#44; and a complete resection is essential to avoid recurrence&#59; however&#44; there are few comparative studies between lesion resection with cold technique and laser to estimate their recurrence&#46; Studies have suggested the use of radiotherapy combined with surgery in those lesions where complete resection is not possible&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions </span></p><p class="elsevierStylePara"> Laryngeal amyloidosis is a rare disease with a rate of 8 in 1&#44;000&#44;000 and a higher incidence during the 5<span class="elsevierStyleSup">th</span> decade of life&#46; Diagnosis is confirmed by Congo red staining observing an apple-green birefringence under an electronic microscope&#46; Resection with cold technique is an adequate method to remove lesions with positive subjective and objective results&#46; It is important to rule out a systemic involvement in these patients&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest </span></p><p class="elsevierStylePara"> The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Funding </span></p><p class="elsevierStylePara"> No financial support was provided&#46;</p><hr></hr><p class="elsevierStylePara"> Received&#58; November 2013&#59; <br></br> Accepted&#58; January 2014</p><p class="elsevierStylePara"> &#42; Corresponding author&#58; <br></br> Otolaryngology and Head and Neck Surgery Departament&#44; <br></br><span class="elsevierStyleItalic">&#8220;Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#8221;</span> University Hospital&#46; <br></br> Francisco I&#46; Madero and Gonzalitos Avenue&#44; <br></br> Mitras Centro&#44; Monterrey&#44; N&#46;L&#46;&#44; Mexico&#46; <br></br> Telephone&#58; &#40;81&#41; 8333 2917&#46; <br></br><span class="elsevierStyleItalic">E-mail address</span>&#58; <a href="mailto&#58;vicentevilla&#64;yahoo&#46;com" class="elsevierStyleCrossRefs">vicentevilla&#64;yahoo&#46;com</a> &#40;V&#46; J&#46; Villag&#243;mez-Ortiz&#41;&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> <span class="elsevierStyleItalic">Introduction</span>&#58; Amyloidosis is used to describe a range of disorders defined by extracellular deposition of abnormal protein fibrils&#46; The larynx is the most common site of localized amyloidosis in the head and neck region and constitutes less than 1&#37; of benign laryngeal lesions&#46; Hoarseness is the most common symptom&#46;</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Objective</span>&#58; Prospective clinical evaluation of patients with localized laryngeal amyloidosis&#46;</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Clinical cases</span>&#58; Presented are 4 cases of patients with localized laryngeal amyloidosis who were treated at the Otolaryngology and Head and Neck Surgery Department at the <span class="elsevierStyleItalic">&#8220;Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#8221;</span> University Hospital in Monterrey&#44; Mexico&#46; Three patients underwent phonomicrosurgery by direct microlaryngoscopy with the removal of the amyloid implantation using a cold knife excision with great results&#46; In each patient the major site of involvement was the supraglottis with a small focus on the false vocal cord&#46; A medical work-up&#44; including a complete blood count &#40;CBC&#41;&#44; a basic metabolic panel&#44; urinalysis&#44; liver function test&#44; chest X-ray and physical examination were performed to rule out the presence of systemic disease&#59; no amyloidosis or signs of systemic disease were found&#46; Congo red staining confirms the diagnosis of amyloidosis in all surgical specimens&#46;</p> <p class="elsevierStylePara"> <span class="elsevierStyleItalic">Conclusions</span>&#58; In laryngeal amyloidosis&#44; the treatment should be directed toward the improvement of the voice and the maintenance of the airway&#46;</p>"
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              "identificador" => "bib5"
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                            0 => "Elphinstone J"
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Article information

ISSN: 16655796
Original language: English

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Year/Month	Html	Pdf	Total

2024 November	53	0	53
2024 October	246	14	260
2024 September	297	12	309
2024 August	312	11	323
2024 July	293	16	309
2024 June	264	11	275
2024 May	335	11	346
2024 April	230	8	238
2024 March	279	7	286
2024 February	337	18	355
2024 January	309	9	318
2023 December	192	11	203
2023 November	260	13	273
2023 October	213	22	235
2023 September	204	11	215
2023 August	189	10	199
2023 July	154	9	163
2023 June	147	13	160
2023 May	154	9	163
2023 April	138	6	144
2023 March	110	12	122
2023 February	85	15	100
2023 January	76	0	76
2022 December	57	10	67
2022 November	75	12	87
2022 October	96	8	104
2022 September	62	10	72
2022 August	108	15	123
2022 July	112	10	122
2022 June	89	12	101
2022 May	90	11	101
2022 April	81	24	105
2022 March	111	23	134
2022 February	90	8	98
2022 January	114	9	123
2021 December	66	17	83
2021 November	113	12	125
2021 October	118	17	135
2021 September	121	20	141
2021 August	137	22	159
2021 July	103	12	115
2021 June	128	19	147
2021 May	108	12	120
2021 April	298	25	323
2021 March	131	16	147
2021 February	114	14	128
2021 January	105	16	121
2020 December	85	7	92
2020 November	68	7	75
2020 October	62	6	68
2020 September	39	9	48
2020 August	69	8	77
2020 July	57	13	70
2020 June	31	7	38
2020 May	52	11	63
2020 April	54	12	66
2020 March	54	5	59
2020 February	46	5	51
2020 January	58	13	71
2019 December	40	16	56
2019 November	40	10	50
2019 October	102	9	111
2019 September	179	4	183
2019 August	43	12	55
2019 July	35	20	55
2019 June	58	20	78
2019 May	138	8	146
2019 April	79	9	88
2019 March	11	1	12
2019 February	11	2	13
2019 January	14	0	14
2018 December	9	2	11
2018 November	13	2	15
2018 October	12	10	22
2018 September	11	5	16
2018 August	5	0	5
2018 July	12	3	15
2018 June	8	0	8
2018 May	4	1	5
2018 April	16	0	16
2018 March	21	1	22
2018 February	8	1	9
2018 January	15	0	15
2017 December	17	0	17
2017 November	6	0	6
2017 October	11	1	12
2017 September	7	0	7
2017 August	5	1	6
2017 July	9	1	10
2017 June	20	0	20
2017 May	18	1	19
2017 April	8	6	14
2017 March	16	53	69
2017 February	27	1	28
2017 January	12	0	12
2016 December	14	0	14
2016 November	23	2	25
2016 October	22	2	24
2016 September	10	2	12
2016 August	9	1	10
2016 July	12	1	13
2016 June	40	9	49
2016 May	25	7	32
2016 April	26	16	42
2016 March	33	4	37
2016 February	25	11	36
2016 January	27	9	36
2015 December	23	8	31
2015 November	24	4	28
2015 October	33	10	43
2015 September	15	5	20
2015 August	56	8	64
2015 July	85	4	89
2015 June	19	3	22
2015 May	26	4	30
2015 April	33	12	45
2015 March	43	7	50
2015 February	29	9	38
2015 January	20	4	24
2014 December	22	9	31

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