Lysis of interarytenoid synechia (Type I posterior glottic stenosis): Vocal fold mobility and airway results

A Single Center Description of Adult and Pediatric Endoscopic Posterior Costal Cartilage Grafting

OBJECTIVE

Posterior glottis impairment alters breathing, voicing, and swallowing. Bilateral vocal fold movement impairment (BVFMI) occurs when the vocal cords are fixed/remain midline. Studies inadequately assessed endoscopic posterior costal cartilage grafting (enPCCG) for BVFMI across broad ages. We aim to assess decannulation and prosthesis free airway in children and adults who have undergone enPCCG.

STUDY DESIGN

Retrospective cohort.

SETTING

Referral center.

METHODS

This study included adults and children who received enPCCG for BVFMI (2010-2018) and were followed for 35 months on average. The main outcome was successful decannulation of patients, or airway improvement in those without tracheostomy. Data on comorbidities, surgical complications, and interventions following surgery were collected.

RESULTS

Ten children and 11 adults underwent enPCCG for BVFMI. Eighty-one percent of patients had a tracheostomy at surgery; adults were more likely to have a tracheostomy at surgery (P = 0.035), and to undergo double-staged procedure (P = 0.035) and stent (P = 0.008). Average stent duration was 29.7 days. Overall decannulation rate was 76% (90% for children; 70% for adults). Children were more likely to receive postoperative intensive care unit care (P = 0.004). Adults had mean 4.4 post-enPCCG interventions per patient compared to children's mean 3.91 interventions. The most common interventions were steroid injection (17.6%) and balloon dilation (16%). Preliminary analysis suggests postoperative dysphonia was reported in 66.7% of patients; postoperative dysphagia was rare.

CONCLUSION

EnPCCG was more successful at achieving decannulation in children. Adults required additional interventions. A double-staged operation with prolonged stenting is recommended for adult patients. A majority of patients were decannulated at last follow-up.

Interventions and Outcomes in Glottic Versus Multi-level Airway Stenosis: A Multi-institutional Review

OBJECTIVE

Airway stenosis-particularly multi-level-presents complex management challenges. This study assessed rates of tracheostomy, decannulation, and the number of surgeries required in patients with posterior glottic stenosis (PGS), multi-level airway stenosis (MLAS), and bilateral vocal fold paralysis (BVFP).

METHODS

Airway stenosis patients treated between 2016 and 2021 at three tertiary medical centers were identified. Demographics, etiology of stenosis, medical comorbidities, and patient-reported outcome measures (PROMs) were collected.

RESULTS

158 patients (84 women, mean age 56.98 ± 15.5 years) were identified (54 PGS, 38 MLAS, and 66 BVFP). 72.3% required tracheostomy, including 72.2%, 86.8%, and 63.6% in these groups, respectively. Decannulation rates were 43.6%, 21.2%, and 32.5% in these groups, respectively. Patients with MLAS had higher rates of tracheostomy than BVFP (p < 0.05). However, decannulation rates were not different between groups (p > 0.05). MLAS required more surgeries (mean 4.0 ± 3.9) than PGS (2.4 ± 2.2, p = 0.02) or BVFP (1.0 ± 1.8, p < 0.0001). Mean PROMs scores at the latest follow-up were abnormal: 15.4 ± 12.2 (Dyspnea Index), 19.9 ± 12.2 (Voice Handicap Index-10), and 9.67 ± 11.1 (Eating Assessment Tool-10). Co-morbidities present included body mass index >30 (41.4%), diabetes (31.8%), pulmonary disease (50.7%), gastroesophageal reflux disease (39.4%), autoimmune disease (22.9%), and tobacco use history (55.2%).

CONCLUSIONS

Airway stenosis is a challenging clinical problem that negatively impacts patients' quality of life and often requires numerous surgeries. PGS more frequently requires tracheostomy compared to BVFP, but patients can often decannulate successfully. Patients with multi-level stenosis have lower decannulation rates and require more surgeries than glottic stenosis alone; these patients may benefit from earlier and/or more aggressive intervention.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:528-534, 2023.

A Novel Surgical Technique for Posterior Glottic Stenosis Using a Silastic Implant

OBJECTIVES

To introduce a novel surgical technique for the management of posterior glottic stenosis (PGS).

METHODS

Literature review (PubMed 1973-2020) and case example of a patient treated with novel technique by principal investigator (R.T.S.) RESULTS: Numerous techniques for the treatment of PGS have had varying success. Our patient, a 67-year-old male with a 2-year history of posterior glottic stenosis secondary to multiple, prolonged intubations previously had been treated with several surgical and medical interventions. Three weeks following an additional endotracheal intubation, he presented to our office with PGS recurrence, exhibiting hoarseness, and shortness of breath with any physical activity. He was treated with a silastic sheet placed through a tunnel in the stenosis and sutured posteriorly as a stent. The stent was removed 3 weeks later and the remaining stenosis was divided, successfully treating our patient's PGS with long-term improvement in both respiratory and voice complaints. This led to the design of a stent to be used for this purpose.

CONCLUSIONS

This new surgical technique addresses a complex clinical problem and provides otolaryngologists with a minimally invasive option for the surgical treatment of PGS that offers advantages over existing techniques. The two-stage procedure should reduce the risk of recurrence, but more experience is needed. This novel implant may be a valuable tool in the treatment of select patients with mild-moderate PGS.

"Quality, Readability, and Understandability of Online Posterior Glottic Stenosis Information"

OBJECTIVES

To assess the quality, readability, and understandability of posterior glottic stenosis (PGS) information available to patients online.

METHODS

The top 50 Google search results for "posterior glottic stenosis" were categorized based on website affiliation and target audience (patient or provider). Readability was assessed using the Flesch-Kincaid Grade Level (FKGL) and the Flesch Reading Ease (FRE) scores. The DISCERN tool was used to assess quality and the Patient Education Assessment Tool for Printed Materials (PEMAT-P) was used to assess understandability and actionability. Simple descriptive statistics were used to analyze the data.

RESULTS

36 of the top 50 results were eligible for scoring. 17% (6 of 36) were classified as patient-focused while 83% (30 of 36) were provider-focused. Patient-focused materials had a higher mean FRE score (36.9) than provider-focused materials (15.5) (P < 0.001). Patient-focused materials had an average reading level of 12.5 compared to 15.8 for provider-focused materials (P < 0.001). There was a significant correlation between overall PEMAT-P and DISCERN (r = 0.63, P < 0.001), PEMAT-P understandability and DISCERN (r = 0.63, P < 0.001) and FRES and FKGL (r = -0.67, P < 0.001). From this, we can infer that higher quality sites are easier to understand but not necessarily tailored to a certain reading level.

CONCLUSIONS

Shared decision making in PGS management is crucial as patients must be aware of how treatment modalities affect airway, voice, and swallowing. However, this study shows that patient targeted PGS information is limited, and the readability, quality, and understandability is generally low. We suggest the development of web pages with PGS information tailored for patient education and search optimization to make this information appear earlier in Google search results. Furthermore, future studies should seek to characterize the link between online health information and socioeconomic-based health disparities.

Factors Affecting Posterior Glottic Stenosis Surgery Outcomes: Systematic Review and Meta-analysis

OBJECTIVES

To investigate surgical adjuncts (stents) and previous surgeries on outcomes from posterior glottic stenosis (PGS).

METHODS

PubMED/Medline, CINAHL, EMBASE, and Web of Science were searched for publications on adult patients undergoing surgery for PGS. Decannulation and need for additional surgeries were evaluated as outcomes. Linear mixed-effects (with random effects and fixed effects) models were used for multivariate testing.

RESULTS

In total, 516 abstracts were reviewed and 26 articles were considered for systematic review. Of these, 19 articles with 140 pooled patient cases were extracted for meta-analysis. On multivariate meta-analysis analysis accounting for study-specific variation and use of open procedures, prior surgeries were associated with additional surgeries (RR = 3.76 [1.39-3.86], P = .038) and the use of a stent was associated with a lower likelihood of decannulation (RR = 0.42 [0.09-0.98], P = .044).

CONCLUSION

Minimizing repeat surgery is a predictor for avoiding additional future surgeries and use of a stent was correlated with poor outcomes. These 2 findings may assist providers in patient counseling regarding the need for further surgical interventions. Further, this study is the first to compare the efficacy of surgical approaches for the resolution of PGS, and highlights the importance of avoiding repeat procedures and stents for the management of PGS.

Posterior glottic stenosis: management and outcomes

PURPOSE OF REVIEW

Pediatric posterior glottic stenosis (PGS) is a challenging clinical entity with multiple treatment options. This review describes the evaluation of patients with PGS and discusses existing surgical techniques.

RECENT FINDINGS

PGS secondary to a distinct scar band between the vocal folds can often be effectively managed with endoscopic division and surveillance. More advanced glottic scarring that also involves the interarytenoid mucosa, cricoarytenoid joints, or subglottis merits a more thorough investigation and repair. A postcricoid mucosal advancement flap can be employed in select adolescent or adult PGS, but long-term cricoarytenoid joint mobility is difficult to restore once it has been fixed. Younger pediatric patients have smaller airways and frequent concurrent subglottic stenosis which is better addressed with cartilage grafting.

SUMMARY

Surgical success in pediatric PGS depends on careful preoperative airway assessment and the accurate characterization of airway stenosis. A surgical technique should be chosen based on the severity and extent of stenosis.

Posterior Glottic Stenosis Type I: Clinical Presentation and Postoperative Course

Posterior glottic stenosis (PGS) is a process that results in partial or total fixation of the vocal folds. Type I PGS (PGS-1) is an uncommon clinical entity that results from an interarytenoid adhesion/scar band that is separate from the posterior interarytenoid mucosa. We present a case series of patients with PGS-1 treated at our institution to contribute to the understanding of this complex clinical entity.

Type I Posterior Glottic Stenosis: Natural History and In-Office Management

Objectives:

To review the natural history of type I posterior glottic stenosis (PGS-I) and its treatment outcomes through a case presentation and demonstrate the feasibility of in-office management of PGS-I.

Methods:

The case of a middle-aged woman who developed PGS-I after prolonged intubation is presented. A review of the literature on management and treatment outcomes of PGS-I is also performed.

Results:

Initially presenting with a large granuloma that failed conservative management, the patient deferred surgical intervention and developed unilateral vocal fold hypomobility with posterior glottic synechia. The adhesion was successfully ablated in the office with potassium-titanyl-phosphate (KTP) laser; however, vocal fold hypomobility persisted after treatment.

Conclusions:

This case illustrates the natural history of the development of PGS-I, demonstrates the feasibility of office-based management of this condition, and provides further evidence that lysis of PGS-I synechia does not uniformly lead to restoration of normal laryngeal function and mobility.

Cicatricial posterior glottic stenosis. Our experience

INTRODUCTION AND OBJECTIVES

Presentation of the results obtained in the treatment of cicatricial posterior glottic stenosis.

METHODS

A retrospective study of 34 patients diagnosed and treated for cicatricial posterior glottic stenosis in our ENT Department.

RESULTS

In our series, 85.36% of our patients were decannulated. Of these, 80% of the patients with glottic stenosis were decannulated, while 92.9% of the patients with other associated laryngotracheal stenosis were paradoxically decannulated. Of all the patients, 70% required more than 1 surgical procedure, although most of these interventions were to resolve minor issues following our protocol. The number of subsequent interventions was determined by the location of the stenosis, with there being more interventions when the posterior glottic stenosis was associated with another type of laryngotracheal stenosis (p=.001).

CONCLUSIONS

The surgical results for treating cicatricial posterior glottic stenosis are quite positive. However, unlike other types of posterior glottic stenosis (such as neurogenic abductor paralysis), it requires a greater number of interventions to achieve definitive decannulation. Endoscopic procedures play an important role and represent our main tool.

Acquired Glottic Stenosis-The Ongoing Challenge: A Review of Etiology, Pathogenesis, and Surgical Management

OBJECTIVE

To review the etiology and pathogenesis of acquired glottic stenosis, as well as the workup, patient preparation, interventional options, and their changing trends, as described in the literature since the 19th century until the present day.

METHODS

Literature from the PubMed search engine and the authors' personal experience were used. The search included up to date studies and historical reports covering different aspects of glottic stenosis, such as basic science, pathogenesis, anesthesia, and surgical techniques.

RESULTS

At present, the most common etiology for acquired glottic stenosis is damage to the posterior commissure after intubation. Until less than a century ago, infectious diseases such as diphtheria and syphilis were the most prevalent etiologies. The common pathway of stenosis includes mucosal and cartilaginous ulcers, granulation formation, fibrosis, and tethering scars. Planning of surgical intervention must begin with the matching of expectations with the patient and considering voice versus airway functions. Preoperative tracheotomy should be considered for securing the airway. Anesthesia has to be carefully planned, and both the surgeon and the anesthesiologist have to be familiar with the options for tubeless jet ventilation. Surgical options include a variety of open and endoscopic resection and reconstruction procedures, which are reviewed in this article, followed by images and illustrations based on the authors' experience.

CONCLUSION

Acquired glottic stenosis compromises the breathing, voice production, and airway protection. Reconstructing the stenosed glottis is one of the major challenges facing laryngologists in this era. For this reason, the surgeon must be familiar with the variety of treatment options.

Photodocumentation of the development of type I posterior glottic stenosis after intubation injury

Bilateral vocal fold immobility may result from bilateral recurrent laryngeal nerve paralysis or physiologic insults to the airway such as glottic scars. The progression of mucosal injury to granulation tissue, and then posterior glottis stenosis, is an accepted theory but has not been photodocumented. This paper presents serial images from common postintubation injury to less common posterior glottic stenosis with interarytenoid synechia.