Vestibular fold configuration during phonation in adults with and without dysphonia

The real participation of the vestibular folds during phonation mechanism is unknown. How vestibular folds change their configuration during phonation is still unclear. Learning about these changes in the functional mechanism of vestibular fold would be helpful for the evaluation of pathological conditions.

Aim

The objective of the present study was to analyze the configuration of laryngeal vestibular folds during phonation (sustained emission of vowel/μ/) by comparing exams of individuals without vocal complaints (the normal voice group) with those with vocal complaints.

Study design

Transversal simple study.

Material and Method

120 images of larynges were analyzed, 60 of normal voice individuals and 60 of dysphonic subjects, with equal gender distribution. The position of the free margin of the vestibular fold was identified in relation to a straight line that brought together the anterior and posterior insertions. Regarding this position, three types of configurations were described: concave, when it was in a lateral position, convex when it was in a medial position, and linear when it overlapped.

Results

Out of the 240 vestibular folds, 158 were concave, 41 convex and 31 linear. The concave form was predominant in both groups in relation to the other two forms, although the number of convex and linear forms increased in the dysphonic group. Analyzing the behavior of these forms in each gender we noticed that among women, the linear form was significantly increased in the dysphonic group, whereas among men there was significant increase in convex form.

Conclusion

We concluded that there were differences in behavior of vestibular folds in the dysphonic group in relation to the normal voice group, and that the differences occurred differently in both gender groups.

[Vocal fold superficial layer of lamina propria histology after the position of mucosa pediculated flap: canine experimental study]

Many techniques were applied to treat patients with sulcus vocalis and scarred vocal folds. Their results were not good enough. In the Technique of Vocal Fold Pediculated Mucosa Flap, an anterior pediculated flap of vocal fold is positioned on the superficial layer of the lamina propria, below the free margin.

AIM

To describe histological postoperative findings on the superficial layer of lamina propria during the application of the technique Vocal Fold Pediculated Mucosa Flap. The following parameters were compared between tested and control groups: total, type I and type III collagen and number of cellular nucleus.

STUDY DESIGN

experimental.

MATERIAL AND METHOD

Fifteen dogs were used. One vocal fold was submitted to the intervention and the other was left as control. Each group of three dogs was sacrificed on 10, 30, 90, 180 and 360 days after the experimental surgery. Hematoxylin and eosin (H.E.) and Syrius Red were the staining techniques used.

RESULTS

Type I and total collagen suggested increased results in the tested group on postoperative days 90 and 180, nevertheless there was statistical significance only on postoperative day 180 (p<0.05). Type III collagen group area was less significant than the control group on postoperative day 180 (p<0.05). The number of cellular nucleus was increased on the 10th postoperative day, but decreased after the 30th day.

DISCUSSION

The findings about total and type I collagen and the amount of cellular nucleus on the superficial layer of lamina propria were similar to laryngeal postoperative studies in dogs. More complex studies would contribute with new data about the present subject.

The utility of the fiberoptic endoscopic evaluation of swallowing (FEES) in diagnosing and treating children with Type I laryngeal clefts

This case series of three young children with type I laryngeal clefts is presented to demonstrate the utility of fiberoptic endoscopic evaluation of swallowing (FEES) in managing these patients. FEES revealed laryngeal penetration in a posterior to anterior direction in two patients and penetration from lateral to medial in the third patient. The type of laryngeal penetration helped in making the diagnosis of a type I cleft in two children and helped establish a safe feeding regiment in the third child. Patients with type I laryngeal clefts are often misdiagnosed, most likely resulting from the complex presentation of signs/symptoms and the difficulty of detecting small clefts with currently available tests. The pattern of laryngeal aspiration seen with FEES can help in diagnosis and management in this patient population.

Laryngeal examination is superior to endoscopy in the diagnosis of the laryngopharyngeal form of gastroesophageal reflux disease

OBJECTIVE

The laryngopharyngeal form of gastroesophageal reflux disease (LF GERD) is a frequent manifestation of supraesophageal GERD. Diagnosis of LF GERD is difficult: most of the common diagnostic methods of GERD have insufficient accuracy in establishing LF GERD. The purpose of this study was to evaluate the role of endoscopic and laryngologic examination in the diagnosis of LF GERD and to create a laryngoscopic reflux index (LRI).

MATERIAL AND METHODS

A total of 108 LF GERD patients and 90 controls were investigated. The criteria for LF GERD were: complaints, reflux-laryngitis, and esophagitis (endoscopically or histologically proven). Lesions in four laryngeal regions were evaluated: arytenoids (A), intraarytenoid notch (IAN), vestibular folds (VF), and vocal cords (VC). Three types of mucosal lesions were evaluated on a points basis: alterations of the epithelium, erythema, and edema. Total LRI was calculated by summing-up the indices in the separate laryngeal areas.

RESULTS

The LRI mean value (11.48+/-3.78 points) of LF GERD patients was statistically significantly greater than that (1.64+/-1.93 points) of the controls. The most significant laryngoscopic changes of LF GERD were: mucosal lesions of IAN, mucosal lesions of VC, and edema of VC. A combination of these three findings reliably distinguishes the LF GERD patients from controls in 95.9% of cases. The mucosal lesions of IAN have the greatest importance in diagnosing LF GERD: the odds ratio to LF GERD - 21.32, p<0.001. Endoscopic esophagitis was established in 36 (33.3%) cases. The severity of esophagitis did not correlate with the severity of the laryngeal findings.

CONCLUSIONS

Laryngoscopy is superior to endoscopy in diagnosing LF GERD. Endoscopy has limited value in the diagnosis of LF GERD. Establishing the LRI could be helpful in the differential diagnosis of the disease in the everyday clinical practice.

Use of condoms as blade covers during laryngoscopy, a method to reduce possible cross infection among patients

OBJECTIVES

Laryngoscope blades are in close contact with mucous membranes and can possibly contaminated with virulent or readily transmissible organisms. As laryngoscopy is often required during endotracheal intubation, proper cleaning and sterilization of the laryngoscope blade is crucial to prevent cross-contamination among patients.

METHODS

We tested the effectiveness of latex condom using as a laryngoscope blade cover during endotracheal intubation. Both control (no condom) and study group blades were rinsed with sterile saline after intubation. The rinse was sent for bacteria culture, and appearance of bacterial colonization was counted as positive. A water leak test (WLT) was performed on used condoms to verify their integrity.

RESULTS

There were total 162 laryngoscopes studied with 83 (51.2%) scopes in the study group and 79 (48.8%) in the control group. Rate of positive bacterial culture were 13.3% and 88.6% in the study and control group, respectively. Although WLT (+) rate of 41% was found in the study group, a high negative culture rate (71.6%) was also noted among the WLT (+) group.

CONCLUSIONS

Condom when using as a blade cover during laryngoscopy is a simple, inexpansive and effective way in reducing cross contamination among patients.

Charcot-Marie-Tooth Disease type 1 and pediatric true vocal fold paralysis

A case study of a child with Charcot-Marie-Tooth type 1 (CMT1) that presented with bilateral vocal fold paralysis. This is the first case of bilateral vocal fold paralysis in a child with CMT1 and it is the first case to be managed endoscopically. The surgical decision making process is discussed, and in particular the role of fiberoptic endoscopic evaluation of swallowing (FEES) in determining what surgical options should be entertained. In children with bilateral vocal fold paralysis who also have other neurologic abnormalities, the clinician should consider the possibility of CMT as the cause.

Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible laryngoscope)

OBJECTIVES

The objectives of this study were to 1) determine the prevalence of ENT findings in the normal asymptomatic population and 2) to compare findings between flexible and rigid laryngoscopes in an attempt to increase specificity of diagnosis of reflux in endoscopic laryngeal examinations.

STUDY DESIGN

Prospective study.

METHODS

Fifty-two nonsmoker volunteers (24 male, 28 female), mean age of 42.7 years, with no history of ENT abnormalities or gastroesophageal reflux disease, underwent both rigid and flexible videolaryngologic examinations with a digital endoscopic unit. A group of three expert judges reviewed the oral and transnasal examinations blindly and independently for physical signs of irritation/inflammation commonly associated with reflux.

RESULTS

Atleast one sign of tissue irritation was detected in 93% and 83% of the population when using a flexible and a rigid laryngoscope, respectively. Results showed a high incidence of posterior commissure bar (53.2% and 51.9%), arytenoid complex edema/erythema (76.3% and 53.2%), and pseudosulcus (37.2% and 7.7%). Most signs were more frequently detected on flexible transasal examinations than with rigid transoral examinations: posterior pharyngeal wall (<0.01), interarytenoid irritation (<0.01), arytenoids complex irritation (<0.01), ventricular obliteration (<0.01), and pseudosulcus (<0.01).

CONCLUSIONS

Several signs of posterior laryngeal irritation (e.g., interarytenoid bar, erythema of the medial wall of the arytenoids), which are generally considered to be signs of laryngopharyngeal reflux, are present in a high percentage of nonsymptomatic individuals, raising question about their diagnostic specificity. In addition, these signs were more often detected with flexible than with rigid laryngoscopes, suggesting that flexible laryngoscopy is more sensitive but less specific in identifying laryngeal tissue irritation.

Lateral Thyrotomy for Excision of Laryngeal Paragangliomas

Laryngeal paragangliomas, although rare, are lesions that warrant appropriate diagnosis and treatment secondary to their location and high risk of bleeding when violated. This article describes a method to workup patients with solid submucosal lesions of the larynx to diagnose a paraganglioma without a biopsy. When recognized preoperatively, a lateral approach to removal can be performed, decreasing the risk of significant bleeding and the need for tracheotomy or permanent laryngostoma. This article also adds two more cases to the reported literature of 75.

Squamous cell carcinoma of the subglottis

STUDY DESIGN

A retrospective study over a 25-year period of patients with laryngeal carcinoma treated by the Department of Otolaryngology at Wake Forest University.

METHODS

The boundaries of the subglottis were defined as 5 mm below the free edge of the true vocal folds extending to the inferior border of the cricoid cartilage. All were staged according to American Joint Committee on Cancer: stages I and II were considered early and stages III and IV as late. Patients were grouped by treatment modality of surgery alone, surgery and radiotherapy, radiotherapy alone, and radiotherapy with surgical salvage.

RESULTS

Fifteen patients represented 1.4% (15/1098) of laryngeal cancers diagnosed within that period. All patients had squamous cell carcinoma of the subglottis of which 20% (3/15) had early-stage disease (T1-T2) and 80% (12/15) had late-stage disease (T3-T4). Overall 3-year survival was low (25%) and is attributed to a high incidence of advanced-stage disease with a high rate of extralaryngeal spread and/or metastasis, especially to the lungs and paratracheal nodes.

CONCLUSIONS

To improve earlier detection by primary care physicians and otolaryngologists and to improve treatment outcome, awareness of subglottic carcinoma and its appropriate evaluation is critical in the patient presenting with hoarseness and/or stridor. Radiation therapy treatment to include the low and upper mediastinal compartments to cover local/regional extralaryngeal involvement is advocated as well as paratracheal lymphatic neck dissection and thyroidectomy in surgically treated lesions.

Comparison of two endoscopic examination methods, the Muller maneuver and fiberoptic pharyngoscopy during sleep, in patients with obstructive sleep apnea

OBJECTIVES

This study was designed to compare two endoscopic examination methods, the Muller maneuver (MM) and fiberoptic pharyngoscopy during sleep, both of which are used to detect obstructed segments in patients with obstructive sleep apnea.

PATIENTS AND METHODS

The study included 28 patients (23 males, 5 females; mean age 44.6 years; range 28 to 59 years) who underwent uvulopalatopharyngoplasty (UPPP) for snoring or obstructive sleep apnea. Obstruction was examined both at the level of the soft palate and tongue base while the patients were awake and asleep and was scored. The Muller maneuver was performed in the sitting and supine positions. In addition, fiberoptic pharyngoscopy was performed right after induction of anesthesia. The results of the two methods were compared.

RESULTS

Changes in body position were not associated with significant differences in the results of MM. The two methods were found to be highly discordant, in that a greater degree of obstruction was noted especially at the level of the soft palate by fiberoptic pharyngoscopy.

CONCLUSION

It was concluded that the degree of obstruction might be underestimated by MM.

Successful treatment of laryngeal stenosis in laryngo-onycho-cutaneous syndrome with topical mitomycin C

Laryngo-onycho-cutaneous syndrome is a very rare entity found in Punjabi families. It affects the skin, nails, and larynx. Laryngeal involvement may cause lethal airway obstruction, and has in the past proved very difficult to treat. Mitomycin C is an antibiotic that acts as an alkylating agent, inhibiting DNA synthesis. It reduces fibroblast proliferation, and has previously been used to treat choanal atresia and laryngeal stenosis. We report an 18-year-old man with complete transglottic laryngeal stenosis secondary to laryngo-onycho-cutaneous syndrome. An airway was established by dissection with a bougie and sickle knife, and was initially maintained by the upper limb of a Montgomery T-tube. Laryngeal granulation tissue present on removal of the T-tube was treated with topical mitomycin C (2 mg/mL) applied for 4 minutes on two occasions with an interval of 1 month. A year later, the airway remained patent, with no granulation tissue.

[Surgical treatment of laryngomalacia in children]

INTRODUCTION

Laryngomalacia is the most common congenital malformation of the larynx which causes stridor in newborns and infants. The stridor is inspiratory and it is first noted at birth but sometimes may not develop until 2 weeks of age. It increases in severity during crying, nursing, agitation, excitement and is made worse with head flexion or supination. Other symptoms such as supraclavicular, intraclavicular, intercostal and abdominal retractions may be associated. Boys are affected over twice as often as girls. Diagnosis of laryngomalacia is made by rigid or flexible laryngoscopy. Although this disorder is usually self-limited, in some cases the symptoms are so severe that operative intervention cannot be avoided.

MATERIAL AND METHODS

Between 2002 and 2005, 13 infants were operated for severe form of laryngomalacia in the Pediatric ENT Dept in Poznań. In all patients the rigid or flexible laryngoscopy was performed to confirm the diagnosis. Then aryepiglottoplasty or epiglottoplasty were performed in all cases. It involved excision of the redundant mucosa over the arytenoid cartilages, the offending parts of he aryepiglottic folds, and trimming the lateral edges of the epiglottis, using microlaryngeal scissors and forceps.

RESULTS

In all children symptoms such as: laryngeal stridor, feeding difficulties and dyspnea improved or completely resolved. In one case post-operative ventilation for several hours was required. All patients except one demonstrated significant airway improvement in the immediate postoperative period.

CONCLUSIONS

Direct laryngoscopy must be performed prior to the aryepiglottoplasty to decide what amount of tissue to resect. Endoscopic aryepiglottoplasty with use of microlaryngeal instruments is an effective and safe method of the treatment of severe form of laryngomalacia. It is better to perform this procedure in general anesthesia without intubation.

Thornwaldt's cyst and surgery with powered instrumentation

Thornwaldt's cyst is a relatively rare lesion located in the posterior wall of the nasopharynx. Most are small and asymptomatic whereas some cause nasal obstruction, postnasal drip, occipital headache or Eustachian tube dysfunction. Nasal endoscopy is the easiest way to visualize this during a routine ENT examination. If in any doubt, MRI is the most sensitive method for detecting and evaluating its size, its anatomic relationships and its content. When the lesion is large, symptomatic or close to the Eustachian tube torus, surgery by marsupialization is the treatment option. For small lesions, the endonasal approach is recommended but for large lesions, a transoral retrovelar approach using a 70 degree telescope is the method of choice. The powered instrumentation with a specific blade for adenoid resection permits large marsupialization with minimal trauma and bleeding and excellent postoperative results. The authors present their experience and review the relevant literature.

Cocaine toxicity after laryngoscopy in an infant

Iatrogenic cocaine toxicity was observed in a 5.5-month-old male who received intranasal cocaine as a topical anesthetic for laryngoscopy. He became agitated, diaphoretic, tachycardic, and hypertensive shortly following the procedure. To control his signs and symptoms, he required 3 doses of IV lorazepam. Systemic absorption and toxicity can vary amongst individuals, making it difficult to determine appropriate dosing. The maximum dose of 1 mg/kg in children has not been validated and toxicity may appear at a much lower dose in certain individuals. Pediatric patients receiving topical cocaine as an anesthetic must be given the lowest possible dose, and then carefully monitored for signs of systemic absorption.

Complications of Different Ventilation Strategies in Endoscopic Laryngeal Surgery

Background

Spontaneous ventilation, mechanical controlled ventilation, apneic intermittent ventilation, and jet ventilation are commonly used during interventional suspension microlaryngoscopy. The aim of this study was to investigate specific complications of each technique, with special emphasis on transtracheal and transglottal jet ventilation.

Methods

The authors performed a retrospective single-institution analysis of a case series of 1,093 microlaryngoscopies performed in 661 patients between January 1994 and January 2004. Data were collected from two separate prospective databases. Feasibility and complications encountered with each technique of ventilation were analyzed as main outcome measures.

Results

During 1,093 suspension microlaryngoscopies, ventilation was supplied by mechanical controlled ventilation via small endotracheal tubes (n = 200), intermittent apneic ventilation (n = 159), transtracheal jet ventilation (n = 265), or transglottal jet ventilation (n = 469). Twenty-nine minor and 4 major complications occurred. Seventy-five percent of the patients with major events had an American Society of Anesthesiologists physical status classification of III. Five laryngospasms were observed with apneic intermittent ventilation. All other 24 complications (including 7 barotrauma) occurred during jet ventilation. Transtracheal jet ventilation was associated with a significantly higher complication rate than transglottal jet ventilation (P &lt; 0.0001; odds ratio, 4.3 [95% confidence interval, 1.9-10.0]). All severe complications were related to barotraumas resulting from airway outflow obstruction during jet ventilation, most often laryngospasms.

Conclusions

The use of a transtracheal cannula was the major independent risk factor for complications during jet ventilation for interventional microlaryngoscopy. The anesthetist's vigilance in clinically detecting and preventing outflow airway obstruction remains the best prevention of barotrauma during subglottic jet ventilation.

Computed tomography virtual laryngoscopy: comparison between radiological and otolaryngological evaluations for laryngeal carcinoma

OBJECTIVES

We evaluated the utility of computed tomography virtual laryngoscopy (CTVL) in identifying endolaryngeal lesions in laryngeal tumors.

PATIENTS AND METHODS

Virtual laryngoscopic images were obtained from axial CT scans of 21 patients with known laryngeal carcinoma. Findings from rigid telescopic videolaryngoscopy (RTV) and CTVL images were evaluated and compared with reference to operative records.

RESULTS

Lesions localized in the base of the tongue, pyriform sinus, aryepiglottic folds, and arytenoids were well visualized by both RTV and CTVL. The two techniques were not found effective in identifying lesions of the ventricular bands, ventricular cavities, and the anterior commissure. Virtual laryngoscopy was superior to RTV in the visualization of the subglottic area and vocal cords.

CONCLUSION

Virtual laryngoscopy is a noninvasive and reliable technique that provides visualization of endolaryngeal surfaces and tumor extension. It may be beneficial in staging larynx carcinoma and planning the most appropriate surgical procedure.

Cricopharyngeal Myotomy Normalizes the Opening Size of the Upper Esophageal Sphincter in Cricopharyngeal Dysfunction

OBJECTIVE

The development of a cricopharyngeal dysfunction is associated with a hypertonic cricopharyngeus (CP) muscle. Therefore, CP myotomy has been advocated by some authors to be an essential part of repair of this condition. However, little objective data exists to show that there is improvement in the upper esophageal sphincter (UES) after CP myotomy. This study assesses the impact of CP myotomy on UES opening.

STUDY DESIGN

Prospective.

METHODS

Twenty patients treated at a university tertiary care center for cricopharyngeal dysfunction between 1998 and 2003 were identified. All patients underwent CP myotomy with or without Zenker's diverticulectomy. These patients had videofluoroscopic swallow studies before and after repair. The values of UES opening for 3 mL boluses from pre- and postrepair studies were compared with each other as well as with normal controls. Sixty percent (12/20) of the patients had a Zenker's diverticulum. Of these 12 patients, 5 had undergone previous attempts at surgical correction. Cricopharyngeal myotomy by way of an external approach, with or without Zenker's diverticulectomy, was performed in all patients by the senior author.

RESULTS

Before Zenker's diverticulectomy and CP myotomy, the mean UES opening (n = 20) for a 3 mL bolus was 0.30 cm +/- 0.17, which was 57% of the mean of 60 normal controls (0.52 cm +/- 0.15) (P < .001). After repair, the mean UES opening for the same bolus size improved to 0.51 cm +/- 0.16 (P < .0001). The UES opening size in patients who have undergone repair is comparable with that of the normal controls (P > .05).

CONCLUSIONS

UES opening size in patients with cricopharyngeal dysfunction is 57% of the size in normal controls. CP myotomy helps to normalize the UES opening in cricopharyngeal dysfunction repair.

Effects of Lidocaine and Prednisolone on Endoscopic Rigid Laryngoscopy

OBJECTIVE/HYPOTHESIS

The aim of this study is to compare the effects of lidocaine and methylprednisolone on postoperative respiratory complications caused by short-term laryngeal surgery by way of rigid laryngoscope under general anesthesia. The effects of these drugs on recovery from anesthesia are also compared.

STUDY DESIGN

One hundred American Society of Anesthesiologists physical status I to II patients over 20 years of age admitted for laryngeal mass, nodule, or polyp were included in this prospective, placebo-controlled, randomized, and double-blinded study.

METHODS

Patients were randomly allocated to four groups; methylprednisolone 3 mg.kg-1 (group 1), 0.9% saline physiologic 5 mL (group 2), lidocaine 1.5 mg.kg-1 (group 3) intravenously, seven puffs of lidocaine aerosol 10% to oropharyngolaryngeal structures topically (group 4) sprayed. Anesthesia recovery time was calculated. Respiratory system was evaluated using a scoring table during early postoperative period.

RESULTS

Ninety-two cases were suitable for analysis. Recovery time was longer in group 1 (9.8 3+/- 3.79 minutes) than in groups 3 and 4 (7.22 +/- 2.38, 7.50 +/- 2.30 minutes, respectively) (P < .05). Postoperative respiratory complications were lower in groups 3 and 4 than group 2 (P < .05).

CONCLUSIONS

Lidocaine intravenous or topical administration was effective in reducing postoperative respiratory complications after short-term laryngeal surgery by way of rigid laryngoscope. Methylprednisolone prolonged recovery time from anesthesia.

Impact of endoscopic screening on early detection of hypopharyngeal cancer

BACKGROUND

The aim was to investigate whether periodic pharyngolaryngoscopy screening in high-risk patients with preceding carcinoma of the upper aerodigestive tract can detect early hypopharyngeal cancer and preserve the larynx.

METHODS

The records of 122 patients with hypopharyngeal cancer were retrospectively reviewed. Patients were divided into the following two groups: (1) the screening (SCR) group (n = 65), patients whose hypopharyngeal cancer was detected by pharyngolaryngoscopy screening; and (2) the symptom (SYMP) group (n = 57), patients whose cancer was discovered by any symptoms. Patients' demographics and larynx preservation were compared.

RESULTS

The number of patients with clinical stage I to IV disease at diagnosis was 44, 14, three, four for the SCR group, respectively, and six, six, 15, 30 for the SYMP group, which was significantly different (p < .0001). The rate of larynx preservation after radical treatment was 79.4% for the SCR group and 45.4% for the SYMP group (p < .001).

CONCLUSIONS

Periodic pharyngolaryngoscopy screening in high-risk patients may contribute to detecting early hypopharyngeal cancer. Early detection of hypopharyngeal cancer may enhance the rate of larynx preservation and improve the quality of life.

Videoendoscopic surgery for inaccessible glottic lesions

OBJECTIVES

Lesions in the anterior segment of the vocal fold are sometimes difficult to access by means of conventional suspension microlaryngoscopy under general anaesthesia because of anatomical factors such as short, stout and inflexible necks, reduced jaw protrusion, and long incisors. Various techniques have recently been proposed for the management of inaccessible glottic lesions, most of which are performed under general anaesthesia. The use of flexible videoendoscopic surgery under topical anaesthesia in two cases of anterior glottic lesions that could not be treated by means of conventional suspension laryngoscopy is described.

STUDY DESIGN

Case report.

METHODS

A flexible videobronchoscope with an instrument channel was inserted transnasally on an out-patient basis. While the examiner carried out the endoscopy, an assistant maneuvered the biopsy forceps through the instrument channel, and removed the lesion.

RESULTS

Both patients underwent successful removal of an anterior glottic polyp, and the one-year follow-up evaluation revealed normal anatomy of the vocal folds and normal vocal function.

CONCLUSIONS

Flexible videoendoscopic surgery under topical anaesthesia is a safe, simple and minimally invasive procedure that can be considered as an alternative to traditional endoscopic surgery for inaccessible anterior glottic lesions.