Postcricoid Cushion” Observations on the Vascular Anatomy of the Posterior Cricoid Region
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ORIGINAL ARTICLE The “Postcricoid Cushion” Observations on the Vascular Anatomy of the Posterior Cricoid Region Stephen R. Hoff, MD; Peter J. Koltai, MD Objective: To describe the cyclical vascular enlarge- months had presence of a cushion compared with only ment that occurs in the postcricoid region during the ex- 38% of children 24 months or older (PϽ.001). Twenty- piratory phase on an infant’s cry, and to consider the ana- five percent of the cushions had violaceous discolor- tomic, physiologic, and clinical implications of this ation that resembled a vascular malformation. phenomenon, which we term the “postcricoid cushion.” Conclusions: Anatomic studies have demonstrated a rich Design: A total of 125 consecutive office fiber-optic la- venous plexus in the postcricoid region of the larynx. Dur- ryngoscopic examinations in children and infants were ing the expiratory phase of an infant’s cry, there is a cy- reviewed for engorgement and vascular discoloration of clical engorgement, occasionally with vascular discolor- the postcricoid region. Presence of a postcricoid cush- ation, in the postcricoid region at the same level of the ion in relation to patient age was reviewed. A compre- venous plexus—the “postcricoid cushion.” We propose hensive literature review was also performed. that during crying, with acute elevation in intrathoracic pressure, there is a filling of the plexus, causing apposi- Setting: Tertiary care pediatric hospital. tion of the postcricoid cushion against the posterior pha- ryngeal wall, which may serve as a protective barrier to Patients: Patients from newborns to 17 years old un- dergoing laryngoscopy for any reason. emesis in infants. Our observations relate and differen- tiate this normal physiologic phenomenon from the rare Results: Sixty-one percent of the videos showed a post- cases of postcricoid vascular anomalies. cricoid cushion with cyclical enlargement during cry- ing. Eighty-eight percent of children younger than 24 Arch Otolaryngol Head Neck Surg. 2012;138(6):562-571 E BECAME AWARE nounced and most regularly observed in of the vascular newborns and infants. We term this en- anatomy of the largement the “postcricoid cushion.” postcricoid region by a cluster of 4 Videos available online at children seen from 1998 through 2002 W 1 www.archoto.com who had “postcricoid hemangiomas” (Figure 1). Informal analysis of find- Further insight into the morphologic ings from subsequent office fiber-optic la- significance of the postcricoid cushion ryngoscopies suggested that a violaceous occurred serendipitously during review bulge, which at times appeared much like Author Affiliations: Division of of a French anatomy text from 1854 by a postcricoid hemangioma, was more fre- Bourgery and Jacob12 in which there is Pediatric Otolaryngology, quently seen in this region than would be Children’s Memorial Hospital, a beautiful color illustration of the post- Chicago, Illinois (Dr Hoff); expected, given the rarity of these vascu- cricoid region, demonstrating a rich 2-11 Department of lar anomalies (Video 1; http://www vascular plexus at this site (Figure 2). Otolaryngology–Head and Neck .archoto.com). In looking for postcricoid Subsequent historical searches of the Surgery, Feinberg School of vascular coloration, we became con- anatomical literature confirmed that this Medicine, Northwestern scious of a consistent phenomenon not, plexus of veins has been extensively University, Chicago (Dr Hoff); to our knowledge, previously appreci- studied.13-24 The plexus is relatively more and Division of Pediatric ated: a cyclical engorgement of the post- prominent in fetal dissections than in Otolaryngology, Department of cricoid mucosa that was coincidental with Otolaryngology–Head and Neck adult ones. Surgery, Stanford University the expiratory phase of the infant’s cry Our hypothesis is that these observa- School of Medicine and Lucile (Video 2). Interestingly, the prominence tions are related and can be woven into a Packard Children’s Hospital, of these tissues, which occasionally has rational narrative that is anatomically, Stanford, California (Dr Koltai). vascular coloration, seems to be most pro- physiologically, and clinically consis- ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 138 (NO. 6), JUNE 2012 WWW.ARCHOTO.COM 562 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 A B C D E F Figure 1. Illustration of 3 cases of postcricoid hemangioma reprinted from Discolo and Koltai.1 A and B, Case 1. C and D, Case 2. E and F, Case 3. tent. To test this premise, we analyzed a random selec- viewer’s ratings were different, the video was replayed until a tion of findings from office fiber-optic laryngoscopies of consensus was reached. infants and children to see if the presence of the cush- Guided by the consistent findings in the anatomical litera- ion could be consistently confirmed, how often it had any ture of a relatively larger plexus of vessels in fetuses and in- vascular coloration, and if it is more frequently seen in fants compared with those in older children and adults, we per- formed a logistic regression analysis on our data to determine younger compared with older children. We also per- the age at which the probability of seeing a cushion exceeds formed a search of the literature on the assumption that the probability of not seeing one. Based on this analysis, the there exists a body of knowledge in other subspecialty patients were then divided into 2 groups according to the de- fields that may provide a unified understanding of the rived age. Statistical analysis was performed using IBM SPSS postcricoid cushion. Statistics software (version 18; IBM Corp). METHODS LITERATURE REVIEW LARYNGOSCOPIC ANALYSIS A comprehensive literature review was performed, including anatomical, radiologic, and otolaryngologic publications and After institutional review board approval, we selected and re- texts. PubMed, Web of Science, and Google Scholar were que- viewed 125 consecutive flexible fiber-optic laryngoscopic (FFL) ried with the terms “postcricoid,” “postcricoid enlargement,” examinations on patients from birth to age 17 years were se- “postcricoid veins,” “postcricoid hemangioma/vascular mal- lected from our archived collection. FFL is routinely per- formation,” “cervical esophageal hemangioma,” and “pharyn- formed in our pediatric otolaryngology outpatient clinic as part geal plexus.” The references of all relevant articles were also of the workup for a variety of disorders of the pharynx and lar- obtained and reviewed, including historical texts and foreign- ynx. Videos are recorded and stored using KayPentax soft- language publications. ware and then stored on labeled CD-ROM discs (KayPentax). Videos were viewed in real time and in slow motion for the pres- RESULTS ence or absence of engorgement of the postcricoid region. If seen, we separately rated the fullness “small,” “medium,” or “large.” Any vascular-appearing violaceous discoloration of the FFL ANALYSIS postcricoid region was also looked for and was categorized as “none,” “transitional,” or “obvious.” Each video was judged in- A total of 125 videos of office-based FFL examinations dependently by each reviewer. On all videos for which the re- in pediatric patients were reviewed. Patient ages ranged ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 138 (NO. 6), JUNE 2012 WWW.ARCHOTO.COM 563 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Table 1. Primary Symptoms for Clinic Referral in 125 Patients Presenting Symptoms No. (%) Stridor 38 (31.9) Hoarseness 36 (30.3) Snoring 22 (18.5) Noisy breathing 5 (4.2) Cough 5 (4.2) Weak voice 4 (3.4) Nasal obstruction 3 (2.5) Dysphagia 3 (2.5) Dyspnea 2 (1.7) Cyanotic spells 2 (1.7) Velopharyngeal insufficiency 1 (0.8) Sore throat 1 (0.8) Recurrent pneumonia 1 (0.8) Globus sensation 1 (0.8) Failure to thrive 1 (0.8) Table 2. Final Diagnosis After Laryngoscopy in 125 Patients Diagnoses No. (%) Laryngomalacia 23 (18.4) Normal 21 (17.6) Sleep apnea 17 (14.3) Vocal cord paralysis 16 (13.4) Gastroesophageal reflux disorder 11 (9.2) Vocal cord nodule 10 (8.4) Adenoid hypertrophy 8 (6.7) Laryngeal web 4 (3.4) Episodic croup 2 (1.7) Hemangioma 2 (1.7) Papillomatosis 2 (1.7) Subglottic stenosis 2 (1.7) Caustic ingestion 1 (0.8) Epidermolysis bullosa 1 (0.8) Laryngeal cleft, type II 1 (0.8) Posterior glottic stenosis 1 (0.8) Paradoxical vocal cord movement 1 (0.8) Tracheal stenosis 1 (0.8) Figure 2. Illustration of postcricoid venous plexus from Bourgery and Vocal cord cyst 1 (0.8) Jacob,12 reproduced with permission from Taschen GmbH. from 3 weeks to 17 years, with an average age of 4.6 years and a median age of 2.3 years. The most common pre- tients with a medium (3.0%), small (3.3%), or absent (0%) senting symptom for laryngoscopy was stridor (Table 1), cushion (Figure 3). and the most common final diagnosis was laryngomala- Logistic regression demonstrated that the age at which cia (Table 2). There was no association of the present- the probability of seeing a cushion exceeds the probabil- ing symptoms or final diagnosis in clinic with the pres- ity of not seeing one is 24 months (2 years). Therefore, ence of a postcricoid cushion. patients were divided into 2 groups: those younger than Of the 125 videos, 119 had technically adequate vi- 2 years and those 2 years or older. There were 56 pa- sualization of the postcricoid region, while 6 were con- tients younger than 2 years, 49 (88%) of whom had a vis- sidered unusable owing to inability to assess the post- ible postcricoid cushion; 14% had a large cushion, 45% cricoid space. The postcricoid cushion was seen in 61.3% had a medium cushion, and 29% had a small cushion. of videos and rated as large in 8.4% of all patients, me- In this group, 13% did not have a visible cushion dium in 27.7%, and small in 25.2%.