Idiopathic central vocal fold adhesion

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safe, complete endoscopic resection. However, lesions with obvious extranasal extension should not be approached endoscopitally, because margins would be difficult to obtain. Cases suitable for endoscopic resection must be carefully selected to maximize the surgical advantages of the endoscope while avoiding the potential difficulties of bleeding and inadequate margins. Because these tumors are indolent and often asymptomatic during early recurrence, the endoscope should be routinely used during the follow-up. Life-long follow-up should be observed given the potential for recurrence even at 25 years2 The potential for earlier detection of recurrence with the endoscope may be of clinical benefit. CONCLUSION Endoscopic excision of sinonasal HPC should be considered in selected cases. The tendency for benign behavior coupled with the potential for late recurrence makes the endoscopic approach feasible for resection and helpful for surveillance. Safe, effective endoscopic excision of selected cases of sinonasal HPC can be performed in experienced hands, and may offer both a technical advantage and decreased morbidity. As with any rare tumor, additional cases with further follow-up will be required to confirm the success of this approach.

BHAlTACHARYYA,

SHAPIRO,

AND

METSON

REFERENCES 1. El-Naggar AK, Batsakis JG, Garcia GM, et al: Sinonasal hemangiopericytomas. Arch Otolaryngol Head Neck Surg118:134-137,1992 2. Enzinger FM, Smith BH: Hemangiopericytomas: An analysis of 106 Cases. Hum Path01 7:61-82,1976 3. Walike JW, Bailey BJ: Head and neck hemangiopericytomas. Arch Otolaryngol Head Neck Surg 93:345-353, 1971 4. Eichhorn JH, Dickersin GR, Bhan AK, Goodman ML: Sinonasal hemangiopericytoma: A reassessment with electron microscopy, immunohistochemistry, and long term follow-up. Am J Surg Path01 14:856-866,199O 5. Millman B, Brett D, Vrabec DP: Sinonasal hemagniopericytoma. Ear Nose Throat J 73:680-687,1994 6. Cross DL, Mixon C: Temporal bone hemangiopericytoma. Otolaryngol Head Neck Surg 114:631-633,1996 7. Staples JJ, Robinson RA, Wen BC, Hussey DH: Hemangiopericytoma: The role of radiation therapy. Int J Radiat Oncol Biol Phys 19:445-451,1990 8. Delupehe KG, Jorissen M, Sciot R, et al: Hemangiopericytoma of the head and neck: A report of four cases and a literature review. Acta Otorhinolaryngol Belg 46:421427,1992 9. Waitz G, Wigand ME: Results of endoscopic sinus surgery for the treatment of inverted papillomas. Laryngoscope 102:917-922,1992 10. McCary WS, Gross CW, Reibel JF, Cantrell RW: Preliminary report: Endoscopic versus external surgery in the management of inverting papilloma. Laryngoscope 104:415-419,1994 11. Menezes CA, Davidson TM: Endoscopic resection of a sphenoetbmoid osteoma: A case report. Ear Nose Throat J 73:598-600,1994 12. Isenberg SF: Endoscopic removal of chondromyxoid fibroma of the ethmoid sinus. Am J Otolaryngol 16:205-208,1995 13. Lesperance MM, Esclamado RM: Squamous cell carcinoma arising in inverted papilloma. Laryngoscope 105:178-183,1995 14. Abdel-Fattah HM, Adams GL, Wick MD: Hemangiopericytoma of the maxillary sinus and skull base. Head Neck 12:77-83, 1990

Idiopathic Masahiro

(Editorial of adhesion in a patient tation.)

Central

Vocal Fold Adhesion

Kawaida, MD, Hiroyuki

Fukuda, MD, and Naoyuki Kohno, MD

Comment: These authors report a case of the central third of the true vocal fold with no history of laryngeal instrumen-

Adhesive lesions in the bilateral sides of the glottic space usually consist of glottic webs, in which a considerable amount of the anterior part of the membranous portion of the vocal folds adhere to each other, and posterior glottic adhesions, in which the vocal process or arytenoid areas adhere to each other. With the exception of congenital adhesions, the majority of these lesions can be traced to laryngeal trauma or damage to the vocal folds associated with endotracheal intubation. Severe dysphonia is noted in glottic webs, whereas dyspnea is the chief complaint with posterior glottic adhesion. Intermediate lesions between the glottic web and posterior glottic adhesion, in which only the central part of the membranous portion of the vocal folds adhere, are characterized as central vocal fold adhesions and are extremely rare. A search of the literature indicated only a single report of central vocal fold adhesion that had developed after endotracheal intubati0n.l A case of idiopathic central vocal fold adhesion in which the lesion developed in the absence of any predisposing factors, such as endotracheal intubation or laryngeal surgery, is reported in this article.

CASE REPORT Clinical

Course

A 68-year-old man was examined in our clinic in September 1994 complaining of continuous hoarseFrom the Departments of Otolaryngology, Tokyo Metrooolitan Ohtsuka HosDital. Keio Universitv School of ‘Medicine, and Juntendo University School ‘of Medicine, Tokyo, Japan. Address reprint requests to Masahiro Kawaida. MD. Department of Otolaryngology, Tokyo Metropolitan Ohtsuka Hospital, 2-8-1, Minamiohtsuka, Toshima-ku, Tokyo 170, Japan Copyright 0 1997 by W.B. Saunders Company 0196-0709/97/l 805-0011$5.00/O American Journal of Otolaryngology,

ness for 6 months after a sudden onset that had immediately followed an outburst of loud talking in March 19%. The patient’s medical history and familial history were unremarkable. He had no history of endotracheal intubation, laryngeal surgery, or trauma. The patient had smoked 60 cigarettes a day for 35 years but had not smoked for the previous 2 years. Endoscopic examination with a rigid laryngotelescope and an ordinary light source showed complete adhesion between the bilateral free edges of the membranous portion of the vocal folds extenting from the anterior to the central portion on inspiration (Fig 1A). Subsequent laryngostroboscopic examination with a rigid laryngotelescope during phonation indicated that only the area around the central membranous portion of the vocal folds was adherent. While the wave motion of the mucous membrane was absent in the adherent portion, it was relatively good in the membranous portion of the vocal folds both anterior and posterior to the site of adhesion (Fig 1B). Examination of the nasal cavity, oral cavity, and pharynx failed to show any abnormalities. There were no abnormal findings detected on general physical examination, and serum biochemical laboratory data were normal. The patient was admitted in November 1884, and endolaryngeal microscopic lasersurgery using a direct laryngoscope was performed under inhalation anesthesia by endotracheal intubation. Cicatrical adhesion approximately s-mm long was observed in the center of the membranous portion of the vocal folds (Fig 2A). However, the cicatrix was localized to the adherent area alone, and there were no abnormal findings at any other sites in the vocal folds or any evidence of a tumorous lesion. The adherent area alone was vaporized and detached with SW-output continuous mode noncontact irradiation from a carbon dioxide laser (Fig 2B). The operation was concluded after the removal of a very small amount of mucosal epithelium from the vocal folds in the detached area with forceps. Histopathological examination of the specimen obtained showed stratified squamous epithelium of the vocal folds with mild inflammatory change, and there was no evidence of carcinoma or dysplasia. The patient was instructed to refrain from phonating for 7 days postoperatively. Endoscopic examination with a rigid laryngotelescope on postoperative day 8 indicated that the adherent area of the membranous portion of the vocal folds was separated (Fig 3). When the patient was then given permission to phonate, the dysphonia was both subjectively and objectively evaluated

Vol 18, No 5 (September-October),

1997: pp 345-348

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346

KAWAIDA,

FUKUDA,

AND

KOHNO

(APQ) was 2.63%, and the normalized noise energy for 0 to 4 kHz (NNEa) was -2.9 dB. One month postoperatively, MPT was 14 seconds, MFRc 150 mL/s, FO 170 Hz, FO range 120 to 450 Hz (22 semitones), SPL range 68.0 to 90.0 dB (22 dB), PPQ 0.22%, APQ 1.32%, and NNEa -8.0 dB. The SPL range was almost unchanged and FO was slightly lower, whereas MPT and FO range had increased after the operation, indicating improvement of dysphonia. The PPQ, APQ, and NNEa decreased following the operation indicating that vocal fold vibrations had become more periodic and turbulent noise had reduced. Subjectively, the natient’n I--------

-

vnire .-_--

was ..-I

imnrnvfd ----I---.

--.

The MPT, MFRc, FO, and SPL range were measured with the use of the RION SH-01 (Rion Co Ltd, Tokyo, Japan), an apparatus for simultaneous recordings of FO, SPL, and airflow rate. The voice analyzer RION SH-10 (Rion Co Ltd) was used for acoustic analysis to determine PPQ, APQ, and NNEa. The values

Fig 1. Endoscopic findings at the time of initial examination. (A) Endoscopic examination showed complete adhesion of the vocal folds on inspiration. (B) Laryngostroboscopic examination during phonation showed that only the area around the center of the vocal folds was adherent.

to have markedly improved. No signs of recurrence have been detected during 20 months of postoperative follow-up.

Evaluation

of Vocal Function

Vocal function was evaluated at the time of initial examination and 1 month postoperatively (Table 1). At the time of initial examination, the maximum phonation time (MPT) was 7 seconds, and the mean airflow rate during phonation (MFRc) was 180 mL/s. The speaking fundamental frequency (FO) was 190 Hz, and the fundamental frequency range of phonation (FO range) was 140 to 370 Hz (15 semitones). The sound nressure level range of phonation (SPL range) &as 74.0 to 90.0 dB (16 dB), the pitch perturbation quotient (PPQ) was 0.58%, the amplitude perturbation quotient

I; Fig 2. Microscopic laryngeal findings surgky. (A) Cicatrical adhesion wasaround the center in the membranous vocal folds. (6) The adhesion has been detached with a CO2 laser.

at the time of observed only portion of the vaporized and

VOCAL

FOLD

347

ADHESION

Fig 3. The site of the adhesion was clearly separated upon laryngoendoscopic examination on postoperative day 8.

of the normal border for the seven objective variables were used from previous report.2 The lower borderline of MPT for normal subjects is 10 seconds, the upper limit of MFRc for normal population is 200 mL/s, the lower border of FO range for normal population is 18 semitones, the lower borderline of SPL range for normal population is 24 dB, the critical region of PPQ for normal subjects is 0.43%, the critical region of APQ for normal subjects is 1.71%, and the upper borderline of NNEa for normal subjects is -20.4 dB. DISCUSSION Glottic web, in which the anterior portion of the vocal folds adhere to each other near the anterior commissure, and posterior glottic adTABLE 1. Before

Values of Vocal Function and After the Operation

Values MPT MFRc FO FO range SPL range PPQ APQ NNEa

Preoperative 7s 180 mUs 190 Hz 140 to 370Hz (15 semitones) 74.0 to 90.0 dB (16 dB) 0.58% 2.63% -2.9 dB

Test of the Patient

Postoperative 14s 150 mUs 170Hz 120 to 450 Hz (22 semitones) 68.0 to 90.0 dB (22 dB) 0.22% 1.32% -8.0 dB

hesion, in which the vocal processes or arytenoid areas adhere to each other, are both well known laryngeal lesions.3-6 In general, the majority of glottic webs develop as sequela of open or closed laryngeal trauma, except when of congenital origin. Glottic webs may also develop postoperatively as a result of inadequate surgical maneuvers during endolaryngeal microsurgery to resect benign lesions arising in the vocal folds.3 Posterior glottic adhesions often develop as a sequela of laryngeal trauma and endotracheal intubation.3-5 Posterior glottic adhesions caused by endotracheal intubation can be classified into two types of lesions: one in which the arytenoid areas on either side have adhered with scarring in the interarytenoid space, and a second in which bridge-like fibrous band forms between the vocal processes of the arytenoid cartilages.4 In addition to endotracheal intubation, laryngeal trauma, and inadequate laryngosurgery, laryngeal stenosis with vocal fold adhesion may be caused by diseases that develop mucosal ulcerative or granulomatous lesions of the aerodigestive tract such as pemphigus vulgaris, benign mucous membrane pemphigoid, tuberculosis, and Wegener’s granulomatosis 7-10 Glottic webs and posterior glottic adhesions are the most common form of adhesion of the

348

glottis in laryngeal disease. Bridge-like adhesion confined to the center of the membranous portion of the vocal folds, which is reported in this article, is very rare. Only one case of central vocal fold adhesion that developed after endotracheal intubation has been reported to date. 1 A search of the literature indicated no previous reports of an idiopathic case with no history of laryngeal surgery or laryngeal trauma. Moreover, there were no abnormal findings in serum biochemical examination and no systemic diseases that might have caused mucosal ulcerative lesions in our patient. It is important to differentiate this disease from glottic cancer, which chiefly presents submucosally. In our patient, careful microscopic observation of the laryngeal cavity was performed during the operation. When the central vocal fold adhesion was detached by laser, a sample of adjacent tissue was removed and examined histopathologically. Results of the histopathological examination showed mild inflammation with no evidence of carcinoma or dysplasia. Thus, the cause of this idiopathic central vocal fold adhesion in this patient is currently unclear. Chronic corditis may have existed because the patient had been a heavy smoker up until 2 years before presentation at our clinic, causing erosion in the center of the vocal folds and resulting in adhesion. Therefore, the patient was treated with endolaryngeal microscopic laser surgery using a direct laryngoscope and the vocal folds were effectively detached. Because no adhesion was found in the anterior portion of the vocal folds, a stent was not inserted. The patient was instructed to refrain from phonating for 7 days

KAWAIDA,

FUKUDA,

AND

KOHNO

postoperatively. When he was allowed to phonate on day 8, the dysphonia was markedly improved. Moreover, when vocal function was evaluated 1 month postoperatively, results showed significant improvement. At present, 20 months postoperation, the patient’s course has been favorable without any evidence of recurrence of the adhesion. Based on this case, it is unnecessary to insert a stent after the adhesion is detached in patients where the adhesion is only between the membranous portions of the vocal folds with no adhesion at the anterior commissure. However, this should be continually assessed in subsequent cases. REFERENCES 1. Hirayama M, Shitara T, Hirose H, et al: A clinical study of vocal cord adhesion. J Jpn Bronchoesophageal Sot 45:318-322,1994 (in Japanese) 2. Hirano M, Mori K, Tanaka S, et al: Vocal function in patients with unilateral vocal fold paralysis before and after silicone injection. Acta Otolaryngol (Stockh) 115:553559,1995 3. Tucker HM: Laryngeal trauma, in Tucker HM (ed): The Larynx (ed 2). New York, NY, Thieme, 1992, pp 199-215 4. Hawkins DB: Glottic and subglottic stenosis from endotracheal intubation. Laryngoscope 87:339-346, 1977 5. Whited RR: Laryngeal dysfunction following prolonged intubation. Ann Otol Rhino1 Laryngol88:474-478, 1979 6. Nicol JW, Yardley MPJ, Bull PD: Posterior vocal cord adhesion: An unusual complication of endotracheal intubation. Br J Clin Pratt 48:278-279,1944 7. Obregon G: Pemphigus of the larynx. Ann Otol Rhino1 Laryngol66:649-655, 1957 8. Wallner LJ, Alexander RW: Pemphigus of the larynx. Laryngoscope 74:575-586,1964 9. Stell PM, Maran AGD, Stanley RR, et al: Chronic laryngeal stenosis. Ann Otol Rhino1 Laryngol 94:108-113, 1985 10. Tucker HM: Infectious and inflammatory disorders, in Tucker HM (ed): The Larynx (ed 2). New York, NY, Thieme, 1992, pp 231-244