Reconstructive transoral laser microsurgery for posterior glottic web with stenosis

Surgical margins in head and neck squamous cell carcinoma: A narrative review

Head and neck squamous cell carcinoma (HNSCC), a prevalent and frequently recurring malignancy, often necessitates surgical intervention. The surgical margin (SM) plays a pivotal role in determining the postoperative treatment strategy and prognostic evaluation of HNSCC. Nonetheless, the process of clinical appraisal and assessment of the SMs remains a complex and indeterminate endeavor, thereby leading to potential difficulties for surgeons in defining the extent of resection. In this regard, we undertake a comprehensive review of the suggested surgical distance in varying circumstances, diverse methods of margin evaluation, and the delicate balance that must be maintained between tissue resection and preservation in head and neck surgical procedures. This review is intended to provide surgeons with pragmatic guidance in selecting the most suitable resection techniques, and in improving patients' quality of life by achieving optimal functional and aesthetic restoration.

Scoping Review of Surgical Rehabilitation of Post Intubation Phonatory Insufficiency

OBJECTIVES

Post intubation phonatory insufficiency (PIPI) or posterior glottic diastasis describes posterior glottic insufficiency (PGI) caused by prolonged intubation causing medial arytenoid ulceration, mucosal scarring, and incomplete cricoarytenoid joint adduction. The purpose of this review is to showcase diagnostic findings, surgical rehabilitation, and gaps in our treatment algorithm of PIPI.

DATA SOURCES

Embase, PubMed, Scopus, Web of Science.

REVIEW METHODS

Two independent reviewers completed a systematic search of the literature studying PIPI. Reported intubation history, laryngeal defect, clinical symptoms, surgical intervention, and outcomes were gathered from included studies.

RESULTS

Nine studies met our inclusion criteria for full review, (45 patients) all of which were case reports/series. All patients had posterior glottic defects, most commonly loss of medial arytenoid tissue, causing varying degrees of PGI. Eleven patients had vocal fold (VF) immobility or hypomobility. Treatment interventions were observation (1), speech therapy (2), VF or posterior glottic injection augmentation (15), medialization laryngoplasty (4), arytenoid repositioning (6), endoscopic (19) or open (3) posterior cricoid reduction, local mucosal rotation flap (11), or free mucosal graft (2) to fill the glottic defect. Observation, voice therapy, and augmentation or type 1 laryngoplasty failed to improve symptoms. Other surgical techniques improved symptoms with varying outcomes.

CONCLUSION

PIPI is a difficult injury to diagnosis and treat. Conservative measures and augmentation/laryngoplasty often fail to fix the PGI. Our review supports symptom improvement with reconstruction of the posterior glottic defect with cricoid reduction or mucosal grafts. Future investigation is needed to better define the diagnosis and successful treatment algorithm. Laryngoscope, 134:2048-2058, 2024.

Partial arytenoidectomy with transoral vocal fold lateralisation in treating airway obstruction secondary to bilateral vocal fold immobility

OBJECTIVE

To report the outcome of 18 patients with a tracheostomy secondary to bilateral vocal fold immobility, who were managed using reconstructive transoral laser microsurgical techniques.

METHODS

A retrospective review was conducted of the surgical outcome of 18 patients with bilateral vocal fold immobility and a tracheostomy resulting from different aetiologies. Follow-up duration ranged from one to five years.

RESULTS

A total of 18 patients had a tracheostomy at presentation because of bilateral true vocal fold immobility and stridor. All cases were treated using reconstructive transoral laser microsurgery with arytenoidectomy and vocal fold lateralisation. All patients were successfully decannulated by eight weeks after surgery.

CONCLUSION

Reconstructive transoral laser microsurgery using partial arytenoidectomy with vocal fold lateralisation is minimally invasive, feasible, safe and effective for airway reconstruction in patients who present with stridor due to bilateral true vocal fold immobility.

The Management in Patients With Bilateral Vocal Fold Immobility: 15 Years' Experience at a Tertiary Centre

OBJECTIVE

In order to correct the varying vocal fold positions to meet the various clinical requirements in patients with bilateral vocal fold immobility, we present pertinent surgical methods to treat them.

MATERIALS AND METHODS

From 2005 to 2020, 115 patients diagnosed with bilateral vocal fold immobility were addressed for ventilation in 89 patients and for phonation in 26 patients. In the ventilation surgery group, all the neurogenic subjects received mere suture lateralization (SL) procedures and the mechanical ones underwent arytenoid release (AR) plus SL procedures if the cricoarytenoid joint fixation (CAJF) could be confirmed before operation. In the phonation group, neurogenic subjects received nonsurgical treatment and the mechanical ones underwent AR plus arytenoid adduction (AA) procedure. The decannulation rate and respiratory comfort rate for each subgroup will be calculated and the phonatory tests were conducted.

RESULTS

In the ventilation group, 55% (49/89) of subjects received related surgeries. Mere SL offered 40 successful decannulation or respiratory comfort in 42 neurogenic subjects (95.2%). The single episode rate was high as 95%. An AR plus SL procedure also obtained 100% of decannulation or respiratory comfort with a single episode of surgical procedure if the CAJF could be confirmed preoperatively. In the phonation group, 15% (4/26) of subjects received appropriate surgeries. Single AR plus AA procedures also led to 100% (4/4) of the appropriate candidates serviceable sound.

CONCLUSION

SL procedure keeping intact laryngeal mucosa usually offered permanent glottis enlarging effect or decannulation with a single episode of procedure. The use of arytenoid release for CAJF has led to remarkable advances in the ultimate surgical outcomes of both the ventilation and phonation in terms of decreasing revision surgeries.

LEVELS OF EVIDENCE

level 4.

Decannulation of Tracheostomy-Dependent Patients: Results and Review of Techniques of Reconstructive Transoral Laser Microsurgery

OBJECTIVES

This study aims to demonstrate the benefit of reconstructive transoral laser microsurgery (R-TLM) in decannulation of tracheostomy-dependent patients with airway obstruction.

METHODS

A consecutive series of tracheostomy-dependent patients who underwent R-TLM using multiple techniques described in our previous works, were reviewed for outcomes especially for decannulation. Full airway examination was essential to determine the anatomical and functional sites of obstruction to establish the surgical plan including R-TLM techniques needed to improve airway prior to permanent decannulation.

RESULTS

Twenty-two patients were treated. Eighteen subjects were successfully decannulated. Single or multiple R-TLM surgical technique(s) was/were performed during the same surgery to treat upper airway stenosis at the level of the hypopharynx, larynx, and trachea. The mean number of surgeries per patient was 2.1. Patients were followed up for at least 12 months.

CONCLUSION

R-TLM combines different surgical techniques which can be used individually or combined in a stepwise surgical plan for permanent decannulation of tracheostomy-dependent patients with a previous history of decannulation failure secondary to airway obstruction. Accurate preoperative examination gives valuable information about airway and allows establishing a stepwise surgical plan that may need multiple surgeries for full permanent decannulation of these patients.

Augmentation-lateralization for Unilateral Vocal Fold Palsy With Airway Obstruction: A New Concept in Laryngology

OBJECTIVES

This study presents an efficient, safe, effective, and novel technique of reconstructive transoral laser microsurgery (R-TLM) for the treatment of unilateral vocal fold paralysis (UVFP) with airway obstruction. It is based on the augmentation of the immobile and potentially flaccid and atrophic side while lateralizing the arytenoid and posterior part of the vocal fold, thus improving breathing without sacrificing phonation and commonly improving it.

STUDY DESIGN

Retrospective cohort study through data from medical records and operative notes.

METHODS

Patients with UVFP with exertional dyspnea with or without dysphonia were included in this report. The vocal fold is augmented by harvesting the aryepiglottic fold soft tissues and the upper part of the arytenoid and placing them into the paraglottic space as a pedicled microflap, thus augmenting the anterior two thirds of the vocal fold while lateralizing the remaining arytenoid and posterior third of the vocal fold by an internal traction suture to improve airway. Postoperative breathing, phonation and swallowing were assessed.

RESULTS

Twenty two cases are reported in the study. Follow-up evaluations ranged from 6 to 12 months. All cases showed successful and durable improvement of breathing and phonation. None required tracheostomy or gastrostomy pre- or postoperatively.

CONCLUSIONS

Augmentation-lateralization is a novel, safe, and effective minimally invasive technique that allows airway improvement with good results on phonation in patients with challenging UVFP with airway obstruction.

Functional outcomes after transoral CO2 laser treatment for posterior glottic stenosis: a bicentric case series

PURPOSE

The aim of this study is to evaluate functional outcomes in terms of decannulation rate and quality of life of patients affected by PGS (Grades I-IV) treated only by transoral CO₂ laser microsurgery (TOLMS) in two tertiary centers.

METHODS

An observational retrospective study was carried out, enrolling 22 patients affected by PGS who were treated by a transoral approach at two tertiary referral centers. Surgical treatment included TOLMS with tailored laser resection of the scar tissue combined with posterior cordotomy, resurfacing of the raw area with mucosal microflap, or placement of a Montgomery T-tube or Keel stent. All patients were evaluated and staged preoperatively and postoperatively, at least 6 months after the surgery. Functional outcomes were objectively evaluated by the Airway-Dysphonia-Voice-Swallowing (ADVS) staging system, Voice Handicap Index-30 (VHI-30), and Eating Assessment Tool-10 (EAT-10) questionnaires.

RESULTS

Quality of life significantly improved as measured by the VHI-30 questionnaire with a median variation of - 31.0 (p = 0.003), the EAT-10 with a median variation of - 4.0 (p = 0.042), and the ADVS with a median variation of - 3.5 (p < 0.001). No significant changes were observed in swallowing scores. We were able to decannulate 7 of 9 patients (almost 80%) with previous tracheotomy.

CONCLUSION

In conclusion, even if there is still no general agreement on an exact therapeutic algorithm to treat PGS, our results confirm that transoral surgery, in terms of scar tissue removal, combined in selected patients with posterior cordotomy and pedicled local flaps and/or placement of stents, represents a safe and effective surgical approach even for more severe PGS.

Idiopathic posterior laryngeal web on an adult patient

Posterior laryngeal webs are uncommon pathologies that are usually acquired at some point in adult life. Prior and prolonged intubation is the leading cause for developing such lesions. In certain rare cases of posterior laryngeal webs, no identifiable cause can be associated with the development of this pathology. We present a case with such an idiopathic lesion. Surgery is the treatment of choice. Several techniques and modifications can be used, to achieve maximum airway release and, at the same time, ensure that restenosis will be avoided. Our patient recurred following initial treatment and a more complex revision surgery was necessary. Special attention should be given in differentiating these lesions from abductor vocal cord paralysis. Furthermore, careful investigation of the cause and individualisation of patient treatment are crucial.

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.

Transoral closure of the supraglottic larynx for intractable aspiration

The aim of this paper is to describe a novel, safe, and effective surgical technique to eliminate aspiration, that is performed entirely by reconstructive transoral laser microsurgery (R-TLM). Eleven tracheostomy-dependent patients with recurrent pneumonia secondary to intractable aspiration treated with transoral laryngeal closure were included in our study. In all cases, the supraglottic mucosa is incised in a circumferential manner. The distal tissues are sutured side-to-side longitudinally, and the superficial tissues are sutured back-to-front transversally. All patients successfully underwent transoral laryngeal closure without significant perioperative complication. Four patients resumed oral feeding for effective nutrition and two patients for pleasure. One patient developed a small fistula with a leak that warranted secondary closure by a follow-up R-TLM procedure and subsequently held to protect his airway. Complete supraglottic laryngeal closure can be performed safely and effectively using R-TLM techniques. They provide a natural-orifice alternative to open surgery in patients with intractable aspiration.

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.

Transoral laser microsurgery for polydimethylsiloxane (VOX Implant®) explantation

INTRODUCTION

Polydimethylsiloxane (VOX Implant®) injection into the larynx is a surgical technique used to restore volume to paralysed or atrophic vocal folds. We present a case series that demonstrates the feasibility of explantation of this non-resorbable material in the event of complications secondary to this injection.

DESCRIPTION

We report four cases of VOX Implant® explantation. In every case, explantation was performed following complications such as dysphonia and/or dyspnoea secondary to injection of this material. VOX Implant® explantation was performed via cordotomy using transoral lasermicrosurgical techniques.

DISCUSSION

VOX Implant® explantation improved voice and breathing parameters in all patients. Explantation can be performed by transoral microsurgery in the presence of complications related to polydimethylsiloxane injection.

Vocal-fold leukoplakia and dysplasia. Mini-review by the French Society of Phoniatrics and Laryngology (SFPL)

Vocal-fold leukoplakia and dysplasia are together designated "epithelial hyperplastic laryngeal lesions" (EHLL). Work-up and follow-up are founded on optical examination with high-definition imaging, stroboscopy and narrow-band imaging. Diagnosis is based on pathology, using the new 2017 WHO classification, dichotomizing "low grade" and "high grade". Statistically, the risk of cancerous progression is 20% within 5 to 10 years of diagnosis, or more in over-65 year-old males; risk for any given patient, however, is unpredictable. Research focuses on the genetic criteria of the lesion and characterization of the tumoral microenvironment. Treatment is exclusively microsurgical. Resection depth is adjusted according to infiltration. EHLL is a chronic disease, necessitating long-term follow-up, which may be hampered by residual dysphonia and surgical sequelae in the vocal folds. Sequelae need to be minimized by good mastery of microsurgical technique and indications. When they occur, biomaterials such as autologous fat and hyaluronic acid can be useful. Tissue bio-engineering is a promising field.

Suture lateralisation plus arytenoid cartilage release for treating bilateral vocal fold immobility with mechanical fixation

A suture lateralisation (SL) instead of an endolaryngeal tissue ablation procedure under endoscopy has been utilised to treat bilateral vocal fold immobility (BVFI) since 1980. However, mechanical fixation (MF) of the cricoarytenoid joint (CAJ) has continually challenged the effectiveness of glottic dilatation both in the SL procedure and the tissue ablation procedure. From 2007 to 2015, a total of 38 patients with BVFI underwent 40 exo-endolaryngeal suture lateralisation (exoeSL) procedures and three were diagnosed with MF in our hospital. For these MF, we introduced an external approach method to release the CAJ followed by a similar exoeSL procedure. The CAJ release procedure enabled the preservation of the endolaryngeal mucous membrane (ELM) and consequently spared the use of laser surgery. All three CAJ release procedures led to decannulations (one patient) or improvement of dyspnoea (two patients). The difference between the exoeSL and the endo-exolaryngeal suture lateralisation (endoeSL) procedure is discussed based on their effectiveness in MF management.