Endolaryngeal posterior mucosal flap for surgical repair of posterior glottic stenosis

Dilation, Steroid Injection, and Cough Exercise for Correction of Posterior Glottic Stenosis

OBJECTIVE

To describe the DISCO protocol (Dilation, Steroid injection, and post-operative Cough Exercise); a novel treatment for posterior glottic stenosis (PGS). Restoring glottic mobility in PGS is a major challenge. In orthopedic and plastic surgery, post-operative physical therapy is associated with improved motion range and flexibility; yet, this principle was never applied to laryngeal surgery.

METHODS

A retrospective cohort of PGS adult patients, treated by the DISCO protocol during 2018-2020. DISCO involves the following: scar release, glottic dilation, and steroid injection, followed by post-operative cough as glottic physical therapy. Maximal glottic opening angle (MGOA), relative glottic opening area (RGOA), and relative glottic insufficiency area (RGIA) were calculated before and post-operatively.

RESULTS

Seventeen patients were included; PGS etiology was post-intubation (n = 10), post-irradiation (n = 3), both (n = 1) and joint sclerosis (n = 3). Six patients also had additional airway disorders. Sixteen patients were tracheostomy-dependent. 2 (12%), 8 (47%) and 7 (41%) patients had type II, III and IV stenosis, respectively. Surgery included scar release, dilation and steroid injection alone in 7 patients; and additional unilateral sub-mucosal arytenoidectomy in 10. The mean follow-up was 17.5 months. There were no major complications. Successful outcomes (e.g., decannulation or permanent capping) were achieved in 14 (82%) patients with some restoration of joint movement. None had a persistent voice or swallowing complaints. Both MGOA and RGOA increased in all patients (p < 0.001). RGIA remained unchanged (p = 0.878).

CONCLUSIONS

The DISCO protocol is a novel, effective and safe approach for PGS correction that can be easily applied. It can restore vocal fold mobility and may expand the glottic airway without causing glottic insufficiency.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:883-889, 2023.

Meta-Analysis of Low Temperature Plasma Radiofrequency Ablation and CO2 Laser Surgery on Early Glottic Laryngeal Carcinoma

Objective

Meta-analysis is used to analyze the treatment of early glottic laryngeal carcinoma by cryogenic plasma radiofrequency ablation combined with CO₂ laser surgery.

Methods

Retrieval of PubMed, Embase, Medline, VIP, Wanfang, and CNKI databases using a computer. The retrieval period is from the creation of the database until August 31, 2021. References to the included literature were also searched at the same time. According to the inclusion and exclusion criteria, literatures are screened independently, relevant data were extracted, and meta-analysis was conducted.

Results

Recurrence rates are reported in seven literatures. In interstudy heterogeneity test: P = 0.624, I² = 0%, fixed effect model analysis shows that there is no significant difference in recurrence rate between low temperature plasma radiofrequency ablation and CO₂ laser ablation (OR = 0.80, 95% CI (0.35, 1.29), P = 0.371). Intraoperative blood loss is reported in 5 literatures, and heterogeneity test of each study is as follows: P = 0.03, I² = 67%. Low temperature plasma radiofrequency ablation results in more intraoperative blood loss than CO₂ laser ablation (SMD = −0.71, 95% CI (0.08, 0.82), P = 0.01). There are five reports on postoperative pain in two treatments: P = 0.04, I² = 64%. There is no significant difference in postoperative pain between low temperature plasma radiofrequency ablation and CO₂ laser ablation (SMD = −0.21, 95% CI (-0.44, 0.10), P = 0.134). Operative time is reported in nine articles: P < 0.01, I² = 95%. The operative time of low temperature plasma radiofrequency ablation is significantly shorter than CO₂ laser ablation (SMD = −2.38, 95% CI (-3.91, -1.62), P < 0.01). There are two reports on postoperative mucosal recovery: P = 0.328, I² = 2%. Low temperature plasma radiofrequency ablation was significantly better than CO₂ laser ablation in postoperative mucosal recovery (OR = 5.49, 95% CI (2.36, 10.18), P < 0.01).

Conclusion

Low temperature plasma radiofrequency ablation is superior to CO₂ laser surgery in the treatment of early glottic laryngeal carcinoma in terms of operative time and postoperative mucosal recovery. Low-temperature plasma radiofrequency ablation, on the other hand, results in higher intraoperative blood loss, with no discernible difference in recurrence rate or postoperative pain severity between the two treatments.

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.

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.

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.

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.