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This article reports the first evidence of a larynx osteoma of the false vocal fold.
Case report and literature review.
Case report and review of previously published cases of larynx osteomas.
A 79 year-old patient was referred to our institution for dysphagia and hoarseness. Fibrolaryngoscopy showed a regular surface tumefaction of the false fold and the left ventricle, with preserved cordal motility. Patient underwent direct laryngoscopy with CO2 laser excision of the lesion. Pathologic examination of the lesion (1.6 × 1 cm) showed features consistent with an osteoma. Complete regression of symptoms was observed after surgery, with no lesions found on routine one-year follow-up.
Osteomas are benign, slow growing tumors of the craniofacial bone area, very rarely located in the larynx. Although the etiology is unknown, accepted theories point to embryologic, post-traumatic and infectious causes. Surgical excision is indicated only in symptomatic cases. This case report is the fourth evidence of laryngeal osteoma and, to our knowledge, the first finding of a false vocal fold osteoma.
Osteomas are bone tumors commonly found in long bones, in the skull or in facial bones. These slow-growing neoplasms arise from the proliferation of the cancellous or the compact bone, generally causing enlargement of the affected area with no symptoms. Excision of osteomas is often unnecessary; however surgery is needed in the presence of significant symptoms.
Osteoid osteomas and rare entities causing very troublesome symptoms and often requiring prompt surgical treatment to reduce patient’s discomfort (1). These tumors produce excess bone and secretion of pain-causing prostaglandins, resulting in intense pain, which is usually more severe at night. The pain is temporary and generally well-relieved by NSAIDs, although surgery is necessary for complete remission (2).
Most commonly osteoid osteomas occur in the craniofacial region. Previous reports have described temporal bone osteomas of the squamous portion and the mastoid bone (3,4), while osteomas of the acoustic meatus (5) and of the middle ear ossicles (6) are very rare. In addition osteomas can develop in the paranasal sinuses where lesions can more often be found in the frontal and ethmoidal sinuses rather than in the sphenoid sinus (7, 8 and 9). Rarely nasal turbinates (10, 11) or tongue (12, 13) osteomas have been described. Osseous growth within soft tissue structures of the head and neck, as the larynx, are extremely rare (13). To date three cases of larynx osteomas, arising from bone metaplasia areas in the larynx cartilages, have been reported. To our knowledge the present report is the first one describing an osteoma growing within the soft tissue structure of the larynx.
A 79-year-old male was referred to the Department of Audiology and Phoniatry of the Second University of Naples. He complained of worsening dysphonia and occasional dysphagia for solid food in the last three months. Familiar anamnesis reported that his 18-months old son died of undetermined respiratory disease. His past clinic history included a paratyphoid infection during childhood and malaria contracted at age 22. At age 55, he underwent a bilateral inguinal hernia removal, which was its only surgical procedure. The patient is a former smoker (between age 17 and 38, he used to smoke 40 cigarettes/day) currently under pharmacological treatment for type 2 diabetes mellitus and hepatitis C. Otoscopic and rinoscopic examination were unremarkable. Indirect laryngoscopy detected a left false vocal fold tumefaction, confirmed by consequent fibrolaryngoscopy (Fig. 1). Accordingly, the patient underwent a direct laryngoscopy with CO2 laser excision of the false vocal fold and ventricle.
Histological examination described a 1.6×1.0cm tissue constituted of mucosa, sub-mucosa, intrinsic striated muscle with mild limphocitary infiltrates in the corion and several calcification areas. The lesion also included a fragment of spongy bone tissue with wide trabeculae and haematopoietic medulla, demonstrating bone metaplasic areas within the laryngeal mucosa (Fig. 2, ,3,3, ,4).4). Diagnosis of an osteoma of the false vocal fold was made.
All symptoms disappeared after surgery, with no lesions found during follow-up after one year (Fig. 5).
Osteomas are usually firm, irregularly nodular or granular, bone masses, histologically characterized by trabeculae of lamellar bone; fibro-fatty and haematopoietic marrow spaces are also occasionally found. Osteomas can be more often found in the paranasal sinuses, with the frontal and ethmoidal sinuses more frequently affected than the maxillary and the sphenoidal sinuses. Osteomas of the temporal bone and the mastoid have also been reported (3, 4).
Various theories have been proposed to explain its pathogenesis: these lesions have been associated to abnormal enlargement of the embryonic tissues, previous traumas or chronic inflammatory processes. However a specific cause-effect relationship is difficult to establish (14).
An osteoma can be central, peripheral or extra-skeletal. Central osteoma arises from the endostium and peripheral osteoma from the periostium while extra skeletal osteomas usually develop within the muscle (15). Microscopically two distinct types of osteomas might be found, compact osteomas and trabecular osteomas. Compact, or “ivory”, osteomas are made of mature lamellar bones, with no harvest canals and no fibrous component. Trabecular osteomas are composed of cancellous trabecular bone with morrow surrounded by cortical bone margin. Trabecular osteomas can be found either centrally (i.e. endosteal) or peripherally (i.e. subperiosteal).
Usually only osteoid osteomas are painful, while most of other osteomas are asymptomatic. Occasionally symptoms result from the compression of contiguous anatomic structures. Therefore possible involvement of the VIII cranial nerve might be noticed, characterized vertigo and ipoacusia if the osteoma develops in the acoustic meatus, or with dysphagia and dyspnea if develops in the larynx.
In medical literature other descriptions of laryngeal tumors originating from the bone tissue (including osteosarcomas and osteomas) may be found. To date, 14 cases of primary osteosarcomas (16, 17) and three cases of osteoma of the larynx have been reported. In 2000, the first case of larynx osteoma was described by Batti JS and Abramson A (18). In that case laryngoscopic exam showed a large interarytenoid mass involving the posterior 1/3 of the vocal chords, originating from the superior face of the cricoid cartilage. Another case by Redman AG et al (19) described an osteoma originating from the thyroid cartilage. The authors describe that during excision biopsy, gross bony apical enlargement of the right superior cornu of the thyroid cartilage was observed. In 2006 Mehta RP et al. described another osteoma (20) spanning the interarytenoid region and causing impairment of vocal cord mobility with a persistent glottic gap.
In our report, a correct diagnosis was relatively simple. During indirect laryngoscopy an anomalous mass located on the false left vocal fold could be observed. Direct laryngoscopy with laser CO2 excision was therefore mandatory given patient’s discomfort, characterized by foreign body sensation and significant symptoms reported. Histological examination of the excision was conclusive. As expected, our patient presented no symptoms or pain after treatment and no relapse after one-year.
We present a case of osteoma of the left vocal fold in a 79 year-old male. The patient was referred to our institution with worsening dysphonia and occasional dysphagia for solid food. Accordingly, the patient underwent direct laryngoscopy with surgical excision of the lesion. In details, suspension laryngoscopy with CO2 laser and endoscopic excision of the osteoma were performed. This surgical approach allows to preserve laryngeal function and to shorten patient’s time-to-return-to-normal-activity. After surgery there were no symptoms. One year follow-up laryngoscopic exam showed no relapses.
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