Verrucous carcinoma is a well-differentiated squamous cell carcinoma with minimal cytologic atypia. Characteristically, the surface shows papillary fronds with prominent hyperkeratosis. Its benign appearance makes diagnosis difficult and often delays treatment. This is a review of 52 histologically confirmed cases of verrucous carcinoma of the larynx treated at the Mayo Clinic between 1960 and 1987. The follow-up ranged from 2 to 304 months. The most common primary treatment modality was surgery. Two patients died of laryngeal cancer. In both cases, the recurrence was a high-grade carcinoma histologically distinct from the original verrucous carcinoma. The T stage, clinical stage, and type of surgical excision failed to predict survival. The presence of extensive leukoplakia surrounding the exophytic tumor approached statistical significance (p = .08) in predicting recurrence. Four patients were treated with radiotherapy--in each, to control residual disease. One of these patients developed a local recurrence. None of the irradiated tumors in this series showed anaplastic dedifferentiation, and none of the irradiated patients died of uncontrolled local or regional disease. We conclude that verrucous carcinoma of the larynx should be treated by conservative surgical resection when possible. Radiotherapy can be effectively used for disease that cannot be resected with preservation of laryngeal function. Total laryngectomy should be reserved for recurrent disease or the rare case of anaplastic transformation.
Cervicomedullary compression (CMC) from traumatic, infectious, or congenital processes of the atlanto-axial joint is a known cause of vocal cord immobility. Cervicomedullary compression can also occur from destructive arthritic changes and inflammatory pannus formation at the occipito-atlanto-axial joint in patients with rheumatoid arthritis (RA). We present findings suggesting that CMC in patients with RA is an unrecognized cause of vocal cord immobility. Previously, vocal cord immobility in patients with RA has been assumed to be cricoarytenoid arthritis with joint fixation. We report 3 patients with RA and radiographically demonstrated CMC with vocal cord immobility. One patient had bilateral vocal cord immobility and airway obstruction; 2 patients had unilateral cord paralysis and contralateral paresis without airway compromise. All patients had myelopathy and neck pain in addition to brain stem symptoms. All patients underwent transoral-transpharyngeal decompression of the anterior craniocervical junction with subsequent posterior fusion. These patients demonstrated full return of vocal cord function within 3 months of decompression. We propose that CMC is a cause of vocal cord paralysis in patients with RA that may go unrecognized without appropriate imaging studies of the skull base and physician awareness of symptoms of occipito-atlanto-axial subluxation and/or basilar invagination with brain stem compression. Our results demonstrate that CMC in RA is a potentially reversible cause of vocal cord paralysis.
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