Anatomical bases of glottic widening surgery related to arytenoidectomy

Subtotal Carbon Dioxide Laser Arytenoidectomy for the Treatment of Bilateral Vocal Fold Immobility: Long-Term Results

Sixty-nine patients underwent subtotal carbon dioxide laser arytenoidectomy for treatment of bilateral vocal fold immobility between 1985 and 2000. The population included 69 patients whose mean age was 56 years (SD, 16 years; range, 11 to 82 years). The mean follow-up was 50 months (SD, 44 months; range, 1 to 181 months). The overall postoperative peak expiratory/peak inspiratory flow ratio (normal value, 1) significantly improved (closer to 1; p = .0036). Voice analyses were also undertaken for 27 patients, almost exclusively after operation, given the context of initial emergency. The maximum phonation time averaged 6.57 seconds (median, 6 seconds). The phonation quotient remained high, with a mean of 503 (median, 440), and the mean conversational voice intensity remained around 59 dB. The median frequency analysis type was 3. The advantage of subtotal arytenoidectomy lies in the fact that it maintains a certain degree of rigidity along the posterior limit of the arytenoid frame, preventing inward collapse of the mucosa and thus lowering the risk of aspiration.

Partial Laser Arytenoidectomy in the Management of Bilateral Vocal Fold Immobility: A Modification Based on Functional Anatomical Study of the Cricoarytenoid Joint

OBJECTIVE: To establish the anatomical relationships between the arytenoid and cricoid cartilages and apply these findings to design an arytenoidectomy based on a sound anatomical basis.

STUDY DESIGN: In 50 patients the length of the vocal process and the distance between vocal process tip and upper border of the cricoid cartilage were endoscopically measured. Twenty-five total laryngectomy specimens were sagittally and axially sectioned to verify the position of the arytenoids and their relation to the cricoid. The anatomical findings led to the design of laser partial arytenoidectomy and cordotomy (L-PAC), which was used in 45 patients with bilateral cord paralysis in adduction.

RESULTS: The anatomical findings showed that the cricoarytenoid joint did not contribute to the airway in any of the measured specimens. Using L-PAC, 100% of the patients were decannulated and no patient needed a postoperative tracheostomy at any time. Only 3 patients experienced minimal postoperative aspiration to liquids (6.7%). Reasonable phonation was achieved as regarded by a speech analysis battery. Three patients (6.7%) needed a contralateral L-PAC.

CONCLUSIONS: The shape of the cricoid and the location of its axis of maximum width ought to dictate the technique of glottic widening to be used in bilateral cord immobility in adduction. The present extra-articular technique, L-PAC, showed its versatility in providing an effective balance between the protective, the respiratory, and to lesser extent the phoniatory functions.

EBM rating: C-4

The glottis and subglottis: an otolaryngologist's perspective

The complexity of the glottic and subglottic region in terms of anatomy and function make this region challenging in evaluation and treatment. A thorough understanding of the complex anatomy is necessary for the management of patients who have dysphonia, vocal fold paralysis, glottic or subglottic stenosis, or complications, which may present after prolonged intubation or surgical interventions in the upper airway and the thorax.

Embryological study of the glottic site and clinical implications

The development of the glottic site, in particular of its ventral area, was studied to better understand the spreading pathways of T1, T2 cancer. Serial sections of larynges from human embryos, fetuses and adults were observed. A dorsal, a ventral and an intermediate compartment were found on the basis of their maturation schedule. A commissure muscle which develops in the anterior one third of the glottic site and wraps the connection system of vocal ligaments was recognized. The inferior paraglottic space, the compartment structures and the localization of superficial and deep blood vessels and of glands in the ventral compartment and the components of Broyles ligament were studied during ontogenesis. The compartments identified here have clinical and oncological relevance. Their detailed knowledge offers a prerequisite for planning and performing compartment conservative surgery in T1, T2 cancer, based on their spreading pathways.