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Management of tracheobronchial disease requires careful preoperative evaluation and close cooperation between anesthesiologic and surgical procedures. Techniques are available to resect and reconstruct most benign and malignant diseases of the tracheobronchial tree. Good surgical results depend on proper selection of patients, precise surgical technique, and careful attention to postoperative care.

We describe the reconstruction of an anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap. This procedure is safer, more easily carried out, a more reliable means of creating an anterior mediastinal tracheostomy and is better suited for chest wound healing than previous methods. In addition, the appearance of the patient's chest after operation is cosmetically excellent.

Purpose: The use of a Montgomery T-tube as a palliative measure in the treatment of patients with respiratory obstruction due to cancer is described., Patients and Method: Six patients with terminal malignant disease presented with airway obstruction caused by direct infiltration of the trachea by tumor. The primary carcinoma originated in the esophagus in five cases, whereas one patient had metastatic carcinoma of the breast. In each case, the airway was initially secured using a rigid ventilating bronchoscope that was advanced past the area of tracheal obstruction. Tumor was removed from the lumen of the bronchoscope with suction and cup forceps. Anesthesia was continued through the bronchoscope while the trachea was exposed through a cervical incision and a window cut in the anterior tracheal wall. A Montgomery T-tube was inserted as the bronchoscope was withdrawn., Results: This technique allowed dramatic relief of airway obstruction in all cases. The tube relieves the obstruction by stenting the airway and permits speech in most patients. The authors stress the need for frank discussion with patients and family when considering the appropriateness for this form of palliation.

Controversy remains over the comparative efficacy and subsequent prognosis of resections for carcinomas of the esophagus involving the trachea, bronchus, and/or aorta. Results of a multi-variate analysis are reported using clinical data from 103 cases from 1981 to 1987. Based on the survival-rate curves according to the Kaplan-Meier method, resection was superior to non-resection. However, when other prognostic factors were adjusted using Cox's proportional hazards linear model, there was no significant difference between the resection and non-resection groups. This analysis indicates that esophagectomy is not necessarily the best approach for carcinoma of the esophagus involving these adjacent organs, although it must be remembered that resection provides excellent palliation.

The results of interferon therapy of 32 children with severe forms of laryngeal, tracheal, and bronchial papillomatosis are very encouraging. Clinical recovery (no relapses during 3 years or longer) was observed in 8 patients, improvement (no relapses during less than 3 years or 2-3-fold prolongation of no-relapse periods) was seen in 12 patients, no changes were recorded in 10 children; data on 2 other patients were too limited or lacking at all. The efficacy of interferon therapy of airways papillomatosis can be further increased, if doses are selected on an individual basis.

A 48 year old white male presented to our office with a piece of tissue which he had coughed up earlier. Histopathology proved it to be a clear cell carcinoma. Bronchoscopy demonstrated the stump of a lesion in the distal trachea. Renal arteriogram confirmed a large renal cell carcinoma of the upper pole of the right kidney.

The patient was a 58-year-old male with tracheostomal recurrence after surgery for laryngeal carcinoma. After median sternotomy, half of the bilateral clavicula, the anterior portion of the bilateral 1st ribs, and the upper portion of the sternum were resected. The tumor was resected with the muscle layer of the esophagus and the left internal jugular vein. A left internal jugular vein was reconstructed from the major saphenous vein. The trachea was resected at a position of 5 rings from the carina, and then a tracheostoma was made. At an early stage after surgery, there was no problem associated with the tracheostoma. Three months after surgery, stenosis of stoma occurred, but temporary intubation of the trachea released the stenosis completely. From this result, we concluded that when anterior mediastinal tracheostomy is performed for tracheostomal recurrence with invasion to the major vessels, addition of a median sternotomy is a safe and beneficial procedure.

A new bronchial applicator for afterloading irradiation is introduced which can be positioned to the center of the tracheobronchial lumen. The central position in the lumen leads to a clear improvement of dose distribution. The applicator is built on the principle of a coaxial tube. Parts of the outer cover can be expanded to baskets and effect a distance of the radiation source from the bronchial mucosa or tumor surface, and at the same time, expend a relief of extreme contact doses. No obstruction of the respiratory system through the positioning device will be caused. The positionable bronchial applicator seems to be suitable for reducing complications caused through high contact doses and irregular dose distributions and may be able to improve the results of endoluminal radiotherapy.

Eight cell lines derived from human non-small cell lung carcinomas were used to compare their in vivo invasiveness, in vitro chemoinvasive abilities and type IV collagenase activity. For the evaluation of the in vivo invasive potential, the tumor cells were seeded into deepithelialized rat tracheas and transplanted subcutaneously into nude mice. The invasive behavior of the cells was observed at 4, 8 and 12 weeks and assessed histologically by determination of the levels of penetration of tumor cells into the different layers of the tracheal wall. Except for two cell lines that did not grow at all in vivo, there was a very good correspondence between the levels of in vivo tracheal wall penetration and the in vitro chemoinvasion assay using fibronectin as chemoattractant and Matrigel as barrier. This also correlated very well with the capacity of the cells to secrete type IV collagenase. The in vivo evaluation of invasion using tracheal transplants, although requiring several weeks of experimentation, proved to be very reliable, yielding homogeneous results with little internal variation, and is proposed as a dependable in vivo invasion assay that closely mimics the in vivo human conditions in which most carcinomas develop and eventually invade neighboring tissues.

Secondary tumors of the trachea are exceedingly rare, only 14 cases having been reported in the literature. Moreover, metastatic involvement of naso-paranasal cavities can be considered quite unusual. Approximately 150 cases have been drawn from the literature, most of which presented a metastatic deposit from a renal adenocarcinoma. Report is then made of a case of cutaneous melanoma metastatic to the trachea and nasal cavity. The tracheal lesion was repeatedly treated with Nd Yag laser, whereas no treatment was considered eligible for nasal metastasis. The patient succumbed to the tumor 16 months after diagnosis of tracheal involvement had been made. The tendency for malignant melanomas to metastasize to distant organs via the bloodstream is well known, yet trachea and nasoparanasal involvement by metastatic melanoma has been reported, respectively, in only three and six cases, including the present one. Prognosis is unfavorable due to the unusual coexistence of metastases to other organs and the lack of an adequate treatment.

Flexible Nd:YAG endoscopic laser surgery may become an effective new modality for palliation in patients with obstructive endotracheal metastatic malignancies. We report the results of the treatment of two patients with severely obstructing intraluminal tracheal metastatic melanoma and medullary thyroid carcinoma, using the neodymium-YAG laser via the flexible fiberoptic bronchoscope. Both patients complained of significant dyspnea, orthopnea, cough, and hemoptysis and were not candidates for rigid bronchoscopy because of underlying medical contraindications and anatomical problems. Multiple treatment sessions were used with treatment intervals of 1 to 2 weeks. All treatments were performed in the operating room under sedation, without intubation, with topical lidocaine and standard superior laryngeal nerve block. Successful relief of airway obstruction with complete regression of the endotracheal masses was achieved and no recurrences were seen after 9 months' follow-up. Flexible Nd:YAG laser bronchoscopy offered an alternative for the relief of obstructing endotracheal or bronchial malignancies in patients in whom the rigid bronchoscope could not be passed. it seemed to prolong survival in selected cases, and provided definite improvement in quality of life.

A rare case of tracheopathia osteochondroplastica complicated with malignancy is reported. Further examination of hemosputum following thyroid cancer operation revealed an abnormal finding of the trachea, suggesting the recurrence of thyroid cancer. However, the serum level of thyroglobulin was within the normal range. In contrast, the findings of bronchofiberscopy and the histological analysis confirmed the presence of tracheopathia osteochondroplastica. Therefore, measurement of serum thyroglobulin level and the bronchofiberscopy procedure were valuable for the differential diagnosis of metastasis of thyroid cancer in this case. Additionally, case reports of tracheopathia osteochondroplastica in Japan are summarized.

The clinical, histopathologic, immunohistochemical, and electron microscopic findings of two cases of poorly differentiated ("insular") thyroid carcinoma are reported and compared with the 25 cases previously described in the literature. These 27 cases occurred in eight men and 19 women, aged from 34 to 77 years. All but 2 presented with a thyroid mass. Eleven (41%) of the 27 patients experienced local recurrences following surgery, 17 (63%) had development of cervical lymph node metastases, 5 (19%) had development of mediastinal lymph node metastases, 11 (41%) had pulmonary metastases, and 9 (33%) had bone metastases, and 9 (33%) had bone metastases. At least 15 patients (56%) are known to have died of their disease, usually within 8 years of diagnosis. Pathologically, the tumors are distinctive and grow as solid islands (insulae) of small cells separated by artifactually created clefts. In some instances, small follicles are also noted within the insulae. All tumors were positive on immunostaining for thyroglobulin. In view of the propensity for local recurrences and lymphatic and hematogenous dissemination, a total thyroidectomy and neck dissection would seem advisable. Additionally, adjuvant external beam irradiation, systemic chemotherapy, and/or radioactive iodine therapy should also be considered.

Forty-five patients with papillary or follicular thyroid carcinomas with tracheal infiltration were examined by clinical, histologic, and morphometric analyses. Twenty-four patients with completely encapsulated carcinomas (encapsulated cases) and 26 patients with carcinomas confining within the thyroid capsule (nonencapsulated cases) were examined as controls. Patients with tracheal infiltration were significantly more often male and older than the patients without (P less than 0.01 and P less than 0.05, respectively). The histologic grade of differentiation did not correlate with tracheal infiltration. The nuclear area of tumor cells was significantly larger in the cases with tracheal infiltration than in the cases without (P less than 0.01). In 12 recurrent cases with tracheal infiltration, the nuclear area of recurrent tumors was significantly larger than those of their own primary tumors (P less than 0.01). These results confirm that thyroid carcinomas with tracheal infiltration were more frequent in male and older patients and had more significant nuclear atypia than the tumors without tracheal infiltration.

Thyroid carcinoma that invades the airway can, in most cases, be treated by partial laryngectomy or partial tracheal resection. Total laryngectomy or circumferential tracheal reconstruction may be required in patients with extensive disease. Closure of subglottic and tracheal defects can be accomplished with the sternocleidomastoid myoperiosteal flap in a simple, single-staged procedure. Patterns of invasion and appropriate reconstruction are described.

Ten cases of laryngotracheal invasion by well-differentiated thyroid cancer are described. All the patients were over 40 years of age, with a male preponderance of 4:1. A mass in the neck, stridor, and hemoptysis was the common symptom. Bronchoscopy done in six of ten patients revealed an intraluminal tumour in all. Radiographs of the neck showed invasion of the trachea in six patients. Surgery consisted of tracheostomy alone (three of ten), total thyroidectomy with laryngectomy (one of ten), circumferential resection of trachea (one of ten), and total thyroidectomy with tracheotomy and "shaving" of the intraluminal disease in five of ten patients. Adjuvant external radiation, radioiodine, or laser therapy was given when indicated. Of the ten patients, three died and seven survived. Five of seven were alive without disease for 2.5 years or more, and one had skull metastasis 2 years later but no local disease.

In most instances, the prognosis of well-differentiated thyroid carcinoma is generally favorable and adequately controlled by surgery alone. In some cases, however, in which the tumor has remained or in recurrent cases, infiltrates surrounding the skin or trachea can result in uncontrollable hemorrhage which cannot be treated with conventional medical or surgical therapy. We present our attempts at hemostatic procedures in such cases. When a thyroid cancer for which radical surgery is not indicated invades the skin with hemorrhage, we remove the ulcerated skin area with as much of underlying cancerous tissue as possible, and cover the defect skin area with a Bakamjian's deltopectoral flap or a musculocutaneous flap. In the 4 cases we have experienced, there had been no ulceration of the flap skin or recurrent. When a thyroid cancer invades the tracheal wall resulting in an intratracheal tumor accompanied by hemoptysis, we attempt to perform bronchoscopic cauterization using Nd-YAG Laser. Cauterization is repeatedly performed weekly, up to five times in one series. In all cases, radioiodine therapy is used before or after treatment. In all 4 cases we have experienced, hemostasis and shrinkage of the tumor was achieved. No complication such as ulcer formation or perforation was noted.

Tracheal invasion may occur by direct extension of thyroid carcinoma. Follicular, papillary, mixed follicular and papillary, and poorly differentiated cell types have all been found to cause tracheal invasion. Two cases of tracheal invasion by thyroid carcinomas prompted us to review the literature, although our review revealed little current data on tracheal invasion. We reviewed the records of all patients surgically treated for thyroid carcinoma at the University of Nebraska Medical Center from 1976 through 1987. The results of this review and our review of the literature on tracheal invasion are reported here. We conclude that thyroid carcinomas behave most aggressively in men and older patients. The more poorly differentiated follicular thyroid carcinomas have also been found to behave aggressively. Our findings show that en bloc resections are indicated in certain patients with tracheal invasion.

Tracheal or endobronchial metastases from distant primary malignancies are rare. Hemoptysis, dyspnea and cough are common nonspecific presenting symptoms. Renal, breast, thyroid and colon cancers are the most common malignancies associated with tracheobronchial metastases. Since 1979, five patients with tracheobronchial metastases from distant sites have been treated by the otolaryngology service at the Boston University Medical Center. Patients with advanced tumors previously treated by conventional modalities were referred for palliation of airway obstruction. Satisfactory palliation without significant morbidity was achieved in four out of five patients utilizing a CO2 surgical laser through a rigid bronchoscope system. Four patients died from advanced cancer, 1 to 18 months after laser surgery. Although tracheobronchial metastasis from extrathoracic malignancy is associated with a poor prognosis, palliation of airway obstruction can be achieved in most patients with endobronchial or tracheal tumor.

Endoscopic Nd-YAG laser treatment and adjuvant therapy were performed in 44 cases with metastatic lesions of airway. The best results were obtained in 31 cases (93.9%) out of 33 cases complaining of ventilatory disturbance in which endoscopic Nd-YAG laser treatment was indicated as an emergency procedure. In most of these cases with metastatic lesions of airway consisted of respiratory tract invasion from mediastinal lymph nodes in cases of esophageal cancer or lung cancer. In these cases, after laser treatment for ventilatory disturbance, the patients condition improved to the extent that adjuvant therapy could be performed. Adjuvant therapy was performed in 38 cases, there were 7 cases treated surgically (resection of the metastatic lesions of airway in 3 cases, tracheal tube stent operation in 4 cases 0, 28 radiotherapy in 28 cases (Linac irradiation in 24 cases, 60Co intraluminal irradiation of the trachea in 4 cases 0, and 32 cases were treated with chemotherapy. Tracheal tube stent operation was useful for maintenance of the tracheal lumen following laser treatment, and 60Co intraluminal irradiation was effective for the residual intratracheal tumor. The 1-year survival rate of 44 cases with metastatic lesions of airway was 42% and the 2-year survival rate was 22%, so this result suggested endoscopic Nd-YAG laser treatment and adjuvant therapy for metastatic lesions of airway was useful to prolong survival time. However the main value of this modality is for the rapid relief of severe ventilatory disturbance due to obstructive airway lesions.

Two patients with malignant airway obstruction and acute respiratory insufficiency were given emergency treatment with yttrium aluminum garnet (YAG) laser tissue vaporization under local anesthesia only. A mixture of oxygen and helium was administered to reduce the respiratory distress. This case emphasizes the rapidity and effectiveness of YAG laser treatment via fiberoptic bronchoscopy under local anesthesia in the management of acute malignant airway obstructions.

A clinicopathologic study of 14 cases of thyroid carcinoma with tracheal infiltration and 70 control cases of thyroid carcinoma without tracheal infiltration was performed. The cases with tracheal infiltration were classified into well differentiated carcinoma in 5 cases, poorly differentiated carcinoma in 6, undifferentiated in 2, and squamous cell carcinoma in one, thus showing a higher frequency (54.5%) of poorly differentiated carcinoma than that (11.4%) in the control cases. A comparative study of biological behavior between well differentiated and poorly differentiated carcinomas revealed that the latter was more aggressive, and the lymphnode metastatic rate of which was higher. The prognosis of poorly differentiated carcinoma was poorer than that of well differentiated carcinoma. Selective en bloc resection of the tumor including the larynx and trachea was followed by the improved prognosis of advanced thyroid carcinoma with tracheal infiltration.

An occasional patient with metastatic or recurrent malignant disease develops intraluminal masses in the trachea and/or the main bronchi. The accuracy of the application, absence of bleeding, slight reaction, and rapid healing make the CO2 laser applied through the open bronchoscope a valuable palliative treatment for the relief of obstructive dyspnea. This patient is reported because he demonstrated the reduced bleeding which occurred with the bronchoscopic CO2 lasing as compared to bronchoscopic forceps removal.

The authors discuss different variants of resection of the trachea and adjacent organs in relation to the localization and character of the disease, the variants being used in 212 patients. Special attention is given to problems of plastic repair of the trachea defects after resection. Under analysis are specific features of the combined treatment of malignant tumors of the trachea, surgical treatment of trachea-pleural and trachea-esophageal fistulas. Complications took place in 26.4%, postoperative lethality was 10.5%.

A 34 year-old female was admitted because of anemia and leukopenia. Her bone marrow contained abundant blastic cells, which were histochemically positive for peroxidase and alpha-naphthyl butyrate esterase, but negative for ASD chloroacetate esterase. She was diagnosed as acute monocytic leukemia (FAB, M5a). Complete remission was achieved after the administration of BHAC, daunorubicin, 6MP and prednisolone, and she was discharged after consolidation therapies. But shortly later, she noticed hoarseness and erythematous nodules on her breast and abdomen. Though the examinations of peripheral blood and bone marrow did not show any abnormality, hoarseness rapidly worsened and she complained of dyspnea. X-ray and CT scan demonstrated narrowing of the trachea under the cricoid cartilage, and trans-tracheal biopsy revealed leukemic involvement. In addition, erythematous skin lesion showed the infiltration of leukemic cells by biopsy. Although radiation and chemotherapy was initiated, she died of pneumonia. We tried to discuss the laryngo-tracheal and skin involvement of acute monocytic leukemia as early symptoms of relapse.

Thyroid tumors may involve the airway. Eight patients with such invasion are reported; five with invasion of the larynx and three of the trachea. The symptoms varied: five of the eight patients had stridor and hemoptysis, one had hoarseness, and two had no symptoms at all. Endoscopic and radiologic examinations were performed in all patients including computed tomography in six. Six patients underwent total thyroidectomy and two patients, one with paraganglioma and one with hemangiopericytoma, had a hemithyroidectomy. Three patients had a total laryngectomy, one a partial laryngectomy and one a laryngofissure procedure. Tracheal resection was performed in two patients and one had laser excision of the endotracheal tumor involvement. Three patients received postoperative external irradiation. Six of the eight patients are alive with follow-up of 39 to 85 months.

A CO2 laser rigid bronchoscope system has been used to palliate symptoms of a malignancy obstructing the tracheobronchial airway. Fifty-nine endoscopic laser operations (34 patients) were done between 1975 and 1981. Severe dyspnea and obstructive atelectasis were the most common indications for treatment. Contraindications for treatment included extrinsic tracheobronchial compression, widespread distant metastases, rapidly progressing tumors, and highly vascular neoplasms. There were nine primary tracheal malignancies, five metastases from distant sites, and 20 primary lung cancers with tracheobronchial obstructions. Most patients were previously treated with one or more standard modalities (radiation therapy, surgery, and chemotherapy). Removal of airway obstruction was occasionally indicated prior to radiation therapy to facilitate treatment. There were seven instances of complications in this group of patients and one mortality. Most patients (23 of 34) have died from their malignancy. The best palliation was achieved in proximal (tracheal and main stem bronchial), slower growing tumors.

The computed tomographic (CT) findings in 52 patients with histologically proved esophageal carcinoma were reviewed. In 30 of these patients, the CT findings were correlated with findings at surgery or autopsy. CT was found to be highly accurate in predicting tumor size and assessing invasion of the tracheobronchial tree and spread to the liver, adrenals, and celiac and left gastric nodes. By quantifying the contact between the tumor and aorta, it was found that the CT appearance correctly predicted the presence or absence of aortic invasion in 24 of 25 cases (five cases were indeterminate). CT was insensitive in detecting metastatic spread to local periesophageal nodes; in these cases the tumor tended to involve the nodes without enlarging them. CT is an accurate method for assessing the spread of esophageal carcinoma. Its use can prevent unnecessary surgery in patients with inoperable tumors.

We have had experience with 31 tracheoplastic procedures. Underlying diseases consisted of primary tumor, cancer invasion from carcinoma of the thyroid gland and the esophagus, traumatic rupture and post-tracheostomy and tuberculous stenoses. During operation, respiratory support has been satisfactorily established by using the intubation method via the operative field and/or high frequency ventilation instrument. Furthermore, development of absorbable suture material like Dexon and Vicryl benefited by minimizing granulation stenosis at anastomosis due to less foreign body reaction. The prognosis for carcinomatous involvement from surrounding organs was much worse according to advanced cancer stages. However, surgical outcome of this procedure was satisfactory in terms of relieving respiratory distress.

Intraluminal involvement of larynx or trachea in thyroid cancer causes extraordinary therapeutical problems. Surgical or medical treatment fails in most of these advanced tumours. Only carcinomas of low-grade malignancy--especially follicular and papillary type--can be cured by operation if involved parts of larynx or trachea are resected with the tumour. Surveying 85 cases reported in literature and 9 observations of our own we present the clinical, diagnostical and therapeutical aspects of this disease.

Lymphoma of the thyroid gland is usually seen as a rapidly enlarging goiter in older persons, and is associated frequently with dysphagia, hoarseness, and choking. There is infrequent vocal cord paralysis. Three patients with malignant lymphoma seen in a two-year period were hoarse without vocal cord paralysis. Two of them had biopsy-proven lymphoma from within the subglottic trachea.

A 10-year old Nigerian boy was admitted to hospital with a history of swelling in the neck, change of voice, dysphagia and dyspnoea of 2 weeks duration. He died on the 2nd day of admission. Autopsy revealed a thymoma infiltrating the thyroid, trachea and neck muscles and transforming the tracheal lumen into a slit like space. The condition is considered worthy of record on account of its rarity and of the short clinical course terminating in death. The authors feel that the most important factor in determining the prognosis of thymoma is the presence or absence of gross invasion.

Involvement of the tracheobronchial tree, as observed through the bronchoscope, was in the form of impingement or invasion. Bronchoscopy was performed on 525 patients with carcinoma of the esophagus. Impingement was found in 91 patients and invasion in 87 patients. Forty-eight of the 63 patients with impingement and 7 of the 51 patients with invasion were found to have resectable tumors. Bypass operations were performed on the rest of the patients. The operative mortality was high for both bypass and resection procedures. The median survival for bypassed patients and resected patients were 4 months and 9 months, respectively. Four resected patients survived 3 years or more, 2 of whom had no evidence of recurrence. Most patients with impingement have resectable tumors and long-term survival is possible if the tumor can be resected.

A report on a 74-year old woman with high-grade malignant non-Hodgkin lymphoma in clinical remission, who suddenly developed episodes of severe dyspnea and wheezing. Clinical and roentgenographic investigations including tomography of the trachea failed to demonstrate any lesion. Fiberoptic bronchoscopy revealed and endotracheal, polyp-like lymphoma 3 cm above the carina, which was immediately operated. Other sites of relapse (submandibular lymph-nodes) were found 2 weeks after the operation. Second-line chemotherapy (IMVP 16) was able to induce a second remission.

A clinicopathological study of 10 cases of stomal recurrence following total laryngectomy treated at Kurume University Hospital from 1971 to 1986 was completed. The results of this study are summarized as follows: 1) The frequency of stomal recurrence was 5.8%. 2) Of these 10 cases, 3 cases were supraglottic (3%), 5 cases were glottic (7%), and 2 cases were subglottic (29%) carcinomas. The incidence of stomal recurrence was higher in subglottic carcinomas. 3) Nine cases out of 10 extend to the subglottic region. 4) The incidence of stomal recurrence was higher in emergency tracheostomy case. 5) Average of period from total laryngectomy to stomal recurrence was 9.7 months. 6) It is suggested that the cause of stomal recurrence is metastasis to the paratracheal lymphnode. 7) In order to prevent stomal recurrence, it is important to dissect paratracheal soft tissues bilaterally in high risk cases. 8) With regard to treatment, it is better to remove surgically the tumor and paratracheal soft tissues as completely as possible and to do postoperative radiation.

The presence of thyroid tissue within the tracheal lumen is an unusual cause of upper respiratory obstruction. Thyroid tissue in this location may represent true ectopic thyroid or may be caused by invasion of the trachea by a malignant process. This paper presents two patients from the same family who were found to have thyroid tissue in the trachea. The first illustrates the clinical course of a thyroid malignancy within the trachea, and the second had a true ectopic intratracheal thyroid mass. The embryology, diagnosis, and management of ectopic intratracheal thyroid are outlined.

A review of 39 laryngeal papilloma patients at The Johns Hopkins Hospital revealed an incidence of subglottic and tracheal extension much higher than previously reported. Subglottic disease was present in 69% of patients and tracheal involvement in 26%. Factors associated with distal spread were the presence of subglottic papillomas, history of tracheostomy, total number of endoscopic resections, and the duration of disease. The relationship to the presence of viral antigen was cited. Detection and elimination of all papillomas is felt to be the key for the prevention of distal spread. The strategy of management is described.

We have reported a case of severe upper airway obstruction accompanied by marked inspiratory effort which produced highly negative intrathoracic pressure, leading to a reduction in pulmonary interstitial hydrostatic pressure and impairment of left ventricular performance. Acute pulmonary edema resulted. Severe acidosis was also present and may have contributed to left ventricular dysfunction.

Between 1955-1985 515 patients with carcinoma of the thyroid have been operated. Among 170 cases with a local infiltration 69 tracheostomies were performed in 55% for lesions of both laryngeal nerves or intratracheal bleeding (absolute indication), in 45% as a prophylactic intraoperative procedure to avoid later death from asphyxiation (relative indication). In a retrospective study clinical results were analysed with special reference to the question whether patients profit by the tracheostomy. Follow-up examinations showed that tracheostomy did not influence the outcome of patients with a differentiated thyroid carcinoma while there was a remarkable difference in survival of patients with anaplastic tumors where those with a tracheostomy had a worse survival. In this group postoperative external radiotherapy often could not be administered or was delayed due to local complications of the tracheostoma.