Plexiform Neurofibroma of the Larynx in Children

[PDF] Plexiform Neurofibroma of the Larynx in Children: About an Unusual Case Report

R Mahdoufi, I Barhmi, N Tazi, R Sami, R Abada - Arch Otolaryngol Rhinol 2 (1): 035 …, 2016

Archives of Otolaryngology and Rhinology Citation: Mahdoufi R, Barhmi I, Tazi N, Sami R, Abada R, et al. (2016) Plexiform Neurofibroma of the Larynx in Children: About an Unusual Case Report. Arch Otolaryngol Rhinol 2(1): 035-037. DOI: 10.17352/2455-1759.000020 035 Abstract Introduction: The plexiform neurofibroma is a rare benign tumor which is often associated to type 1 neurofibromatosis or Von Recklinghausen’s disease. The laryngeal involvement in neurofibromatosis is extremely rare. The objective of our report is the consideration of laryngeal neurofibromatosis in the differential diagnosis of dyspnea in infants and children. Summary of the clinical case: We report the case of a 4 year-old child who presented with inspiratory dyspnea. Laryngoscopy revealed a mass obstructing completely the laryngeal vestibule. Pathological examination of the resected tissue revealed a plexiform neurofibroma after immunohistochemical examination. The patient had regular follow up and she remained symptom free. Discussion: There is an association between neurofibromatosis type 1 and plexiform neurofibromas of the larynx. Analysis of the margins of neurofibromas of the larynx associated with neurofibromatosis type 1 may help predict clinical behavior. Abbreviations NF: Neurofibroma; CT: Computed Tomography; MRI: Magnetic Resonance Imaging Introduction The plexiform neurofibroma is a benign tumor of the peripheral nerves, made at the expense of the connective cells perineurium, often considered pathognomonic of neurofibromatosis type 1. The patient can develop tumors of neural origin at any age and at any location. However, laryngeal involvement in neurofibromatosis remains rare, and is usually manifested by obstructive airway symptoms. Because its rarity and our inexperience, it is often misdiagnosed. In this review we discuss the pertinent clinical findings of this rare lesion and review the literature relative to laryngeal neurofibroma. Case Report A 4 year-old-girl was admitted to our department with obstructive respiratory symptoms. She had a history of laryngeal stridor since birth, more intense during physical activity and screams, associated with progressive dyspnea and nocturnal snoring; there was no history of previous intubation or foreign body ingestion. The physical exam showed a substernal draw with flaring nose. And found many café-au-lait spots over the trunk and limbs Figure 1. Fiberoptic laryngoscopy revealed a mass obstructing the laryngeal vestibule. A tracheotomy was indicated to improve respiratory function Figure 2. Case Report Plexiform Neurofibroma of the Larynx in Children: About an Unusual Case Report R Mahdoufi*, I Barhmi, N Tazi, R Sami, R Abada, M Roubal and M Mahtar ENT-Neck and Face Surgery, Hospital August 20, 1953, University Hospital IBN ROCHD, Casablanca, Morocco Dates: Received: 24 June, 2016; Accepted: 01 July, 2016; Published: 04 July, 2016 *Corresponding author: R Mahdoufi, ENT-Neck and Face Surgery, Hospital August 20, 1953, University Hospital IBN ROCHD, Casablanca, App. H1, Résidence Mawlid IX, Rue Brahim Nakhaii, Maarif, Casablanca, Morocco, Tel: +212663466994; +212617173539; E-mail: www.peertechz.com ISSN: 2455-1759 Keywords: Larynx; Plexiforme; Neurofibroma; Child The CT scan showed a mass hypodense endolaryngeal behind the epiglottis. The laryngeal cartilages are individualized Figure 3. Modified supraglottic laryngectomy, included the resection of epiglottis, aryepiglottic folds and incomplete false vocal folds resection was indicated because the tumor infiltrating the larynx was Figure 1: multiple cafe-au-lait spots over the trunk and limbs. Figure 2: mass at the laryngeal surface of the epiglottis. Citation: Mahdoufi R, Barhmi I, Tazi N, Sami R, Abada R, et al. (2016) Plexiform Neurofibroma of the Larynx in Children: About an Unusual Case Report. Arch Otolaryngol Rhinol 2(1): 035-037. DOI: 10.17352/2455-1759.000020 Mahdoufi et al. (2016) 036 large. Nevertheless a partial approach was decided for two raisons: young age of a patient and because the tumor was benign Figure 4. Immediate postoperative course was uneventful. Histopathological examination with immuno-histochimical exam showed a plexiforme neurofibroma. The evolution was marked by the improvement of respiratory signs. The patient was asymptomatic for almost 4 years and had not yet received another surgical intervention. Discussion Neurogenic laryngeal tumor is rare. Neurofibromas are not encapsulated and are often associated with NF-1. Still, they can occur sporadically. Laryngeal involvement of neurofibroma in NF-1 is uncommon. Up to 1996 there were only 35 cases reported, of which 19 were in pediatric patients [1]. The clinical symptoms of the disease are those usually associated with a slow growing lesion of the larynx: the patient gradually develops hoarseness, globus sensation, dysphagia, inspiratory dyspnea on exertion, sometimes biphasic stridor [2,3]. Some patients complain about dyspnea in the supine position which seems to be associated with the location of the lesion [3,4]. Most laryngeal lesions would produce stridor during the inspiratory phase. The first diagnosis would be laryngomalacia [5]. Other common etiologies in pediatric respiratory distress include vocal paralysis, subglottic stensosis, and vascular anomaly. When swallowing difficulty is encountered, supraglottic tumor should also be considered [6]. The diagnostic workup should include indirect and fiberoptic laryngoscopy, computed tomography (CT) and magnetic resonance imaging (MRI) aid the differential diagnosis possible. Definitive diagnosis can only be made histologically [7]. Surgery is the choice of treatment and depends on the location and the size of the tumor. Most authors favor external approaches with alternative airway provisions such as a preliminary tracheotomy in larger tumors. Median or lateral thyrotomy or median or lateral pharyngotomy are recommended [1,8-12]. In smaller tumors, endoscopic (laser-assisted) resection of the tumor can be a reasonable treatment option [1,13]. Due to the relative big sized tumor of our case, external approach would guarantee a wider exposure [2,5,7]. Surgical morbidity includes hemorrhage, scarring with or without laryngeal stenosis, vocal paralysis, and postoperative pulmonary edema [7]. Nevertheless, long-term follow up is necessary and a second operation will be necessary if the symptoms recurred again. Conclusion The association between laryngeal plexiforme neurofibroma in children and neurofibromatosis is very rare, revealed by respiratory signs such as dyspnea and stridor. The imaging including CT and / or MRI is a valuable aid to the diagnosis and assessment of extension of the lesion. The treatment is based on a conservative cervical surgery or endoscopy. Consent to publish Written informed consent was obtained from the parent of the patient for publication of this case report and accompanying image. References 1. Weiss SW, Goldbum JR (2008) editors. Enzinger and weiss’s soft tissue tumors.5th ed, Elseiver 827-828. 2. Friedman J, Birch P (1997) Type 1 neurofibromatosis: a descriptive analysis of the disorder in 1,728 patients. Am J Med Genet 70: 138-143. 3. Huson SM, Harper PS, Compston DA (1988) Von Recklinghausen neurofibromatosis. A clinical and population study in south-east Wales. Brain 111: 1355-1381. 4. Lin VY, Daniel SJ, Papsin BC (2004) Button batteries in the ear, nose and upper aerodigestive tract. Int J Pediatr Otorhinolaryngol 68: 473-479. 5. Pinson S, Wolkenstein P (2005) [Neurofibromatosis type 1 or Von Recklinghausen’s disease]. Rev Med Interne 26: 196-215. 6. Heuze Y, Piot B, Mercier J (2002) [Difficult surgical management of facial neurofibromatosis type I or von Recklinghausen disease in children]. Rev Stomatol Chir Maxillofac 103: 105-113. 7. Chang-Lo M (1977) Laryngeal involvement in Von Recklinghausen’s disease: a case report and review of the literature. Laryngoscope 87: 435-442. 8. Meric F, Arslan A, Cüreoglu S, Nazaroglu H (2000) Schwannoma of the larynx: case report. Eur Arch Otorhinolaryngol 257: 555-557. Figure 3: Axial CT with coronal view scan shows a 20 × 30 × 25 mm mass, large hypodense mass slightly less dense than the muscle, obliterating the laryngeal vestibule and invading the larynx. Figure 4: Contrast-enhanced axial CT scan at 4-year postsurgical follow-up shows a small of residual disease. Citation: Mahdoufi R, Barhmi I, Tazi N, Sami R, Abada R, et al. (2016) Plexiform Neurofibroma of the Larynx in Children: About an Unusual Case Report. Arch Otolaryngol Rhinol 2(1): 035-037. DOI: 10.17352/2455-1759.000020 Mahdoufi et al. (2016) 037 Copyright: © 2016 Mahdoufi R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 9. Ho WK, Lo SD, Ng RW (2005) Schwannoma of the larynx. Ear Nose Throat J 84: 554-555. 10. Lo S, Ho WK (2004) Schwannoma of the larynx-an uncommon cause of vocal cord immobility. Hong Kong Med J 10: 131-133. 11. Elias MM, Balm AJ, Peterse JL, Keus RB, Hilgers FJ (1993) Malignant schwannoma of the parapharyngeal space in von Recklinghausen’s disease: a case report and review of the literature. J Laryngol Otol 107: 848-852. 12. Syeda F, Hussain A (2005) Schwannoma of the larynx: a case report. Ear Nose Throat J 84: 732-734. 13. Cihangiroglu M, Yilmaz S, Topsakal C, Gok U, Altinsoy B, et al. (2002) Laryngeal neurofibroma associated with neurofibromatosis type 2. AJNR Am J Neuroradiol 23: 1637-1369. 14. Peltonen J, Jaakkola S, Lebwohl M, Renvall S, Risteli L, et al. (1988) Cellular differentiation and expression of matrix genes in type 1 neurofibromatosis. Lab Invest 59: 760-771. 15. Masip MJ, Esteban E, Alberto C, Menor F, Cortina H (1996) Laryngeal involvement in pediatric neurofibromatosis: a case report and review of the literature. Pediatr Radiol 26: 488-492.