Abstract
Herpes simplex virus infection of the larynx is an exceedingly rare clinical entity, most frequently reported in the pediatric population or in immunocompromised adults. We present a 62-year-old woman presented with neck pain, hoarseness, crepitus over the larynx, and what appeared to be a necrotic mass of the right true vocal cord on laryngoscopy. Due to near-complete destruction of the cartilaginous framework of the larynx, a total laryngectomy was performed. The final pathology report showed squamous mucosal changes consistent with herpes simplex infection, confirmed by immunohistochemical staining. Though herpes simplex laryngitis is uncommon, this case shows the potential for herpes simplex to cause extensive damage and compromise airway patency when left untreated.
1
Introduction
Herpes simplex virus (HSV) is a relatively common viral pathogen. In fact, a cross-sectional survey of over 11,000 people between the ages of 14 and 49 found an overall seroprevalence of 57.7% and 17.2% for HSV-1 and HSV-2 respectively . While most HSV infections are subclinical, both subtypes can present clinically with pathology at numerous sites on the body. HSV most commonly infects the lips and oral cavity as a gingivostomatitis, though it is also known to frequently cause lesions in the anogenital region. Laryngeal infection with HSV is very rare and is most commonly reported in the pediatric population as an acute laryngotracheitis, also referred to as herpetic croup . HSV laryngitis has less frequently been found in adults, commonly in the setting of immunocompromised hosts . On exam, HSV infiltration of the larynx can present as white plaques , mucosal ulceration , mucosal thickening , or even as a discrete mass . To the best of our knowledge, this is the first report of HSV laryngitis presenting with extensive cartilage destruction requiring a laryngectomy.
2
Case report
A 62-year-old Caucasian woman presented to the emergency department with shortness of breath, neck pain, hoarseness, difficulty swallowing, and crepitus over the larynx. She had a history of laryngeal cancer successfully treated with radiation therapy 15 years previously. The hoarseness and difficulty swallowing had been progressively getting worse for the past few weeks, and 1 week prior to presentation she had been hospitalized and treated for presumed aspiration pneumonia. She had also noted anterior neck pain that had first started approximately 3 weeks prior to presentation. Her past medical history was significant for COPD treated with oral prednisone (20 mg per day), hypertension, and coronary artery disease with a myocardial infarct 2 years prior. She also had a long history of tobacco use, though she had quit smoking at the time of presentation.
On physical exam, the patient was afebrile with stable vitals. Mild inspiratory stridor was noted, though the patient had adequate oxygen saturation on room air. The head and neck exam was significant for a tender 3 cm × 2 cm area of swelling and erythema just anterior to the thyroid cartilage in the neck, as well as, a 2 cm area of cartilage defect with crepitus. Flexible laryngoscopy was performed and showed a necrotic mass of the right true vocal cord extending across the anterior commissure and involving approximately one-third of the left true vocal cord. This mass appeared to be eroding through the thyroid cartilage anteriorly. A computed-tomography (CT) scan supported physical exam findings showing thickening in the anterior glottis with erosion of the thyroid cartilage and subcutaneous free air. These findings were highly suspicious for recurrent laryngeal cancer and the patient was scheduled for a diagnostic laryngoscopy with biopsy and possible total laryngectomy a few days later.
On the day of her surgery, the larynx was reexamined under general anesthesia and multiple biopsies were taken of the lesion. Frozen sections of the biopsies were sent to the pathology lab and all of them were negative for malignancy. Despite this, we proceeded with surgery due to the amount of cartilage destruction seen on exam. Directly below the skin and subcutaneous tissues, a large defect was found that was in communication with the anterior larynx. In addition to this, extensive necrosis and near complete destruction of all thyroid cartilage were found. Some anterior strap muscles were also involved, showing necrosis. More frozen sections were sent for pathologic examination, and they also returned negative for malignancy. A total laryngectomy was subsequently performed, and a deltopectoral flap was used to fill in the resulting defect. Following surgery, the patient recovered well and was discharged on postoperative day 8.
Approximately 3 days after discharge from the hospital, the patient presented to an outside hospital in respiratory distress due to a large amount of crust and debris blocking her tracheostomy tube. After stabilization of her airway, she followed up in the otolaryngology clinic on the same day. In the clinic, some necrosis was found along the superior aspect of her stoma. The final surgical pathology report was available at this time, which showed squamous mucosa with changes consistent with herpes simplex virus (HSV), confirmed by immunohistochemical studies (see Figs. 1 and 2 ). She was then admitted to the hospital from clinic and started on intravenous acyclovir (5 mg/kg every 8 hours). She remained hospitalized on this regiment for 13 days and gradually improved. She was subsequently discharged with 8 days worth of oral valacyclovir (1 g every 12 hours).
