Cricoarytenoid Joint Ankylosis: Classification and Transoral Laser Microsurgical Treatment

Open laryngotracheal reconstruction for iatrogenic posterior glottic stenosis in adults: international multicenter experience

OBJECTIVE

Posterior glottic stenosis (PGS) has a significant impact on breathing and quality of life, and remains a challenging condition to manage. Literature does not provide a single optimal approach. In this study we aim to assess post-operative outcomes of adult patients with acquired PGS treated with open laryngotracheal reconstruction (LTR) with autologous or cadaveric rib grafting.

METHODS

This multicenter retrospective cohort study included adults who underwent open LTR for iatrogenic PGS (2015-2023) and were followed for 26 months on average. Data on comorbidities, surgical complications, and interventions following surgery were collected.

RESULTS

Forty-three adult patients were included. Decannulation was successful in 76.7%, and 53.5% of patients required an endoscopic or open revision procedure for recurrent stenosis during the mean post-operative follow-up of 26 months. Patients with severe obesity (BMI ≥ 35), moderate to severe co-morbidity (ASA ≥ 3) or Chronic Kidney Disease were significantly more likely to fail decannulation after LTR. Diabetes Mellitus and ASA ≥ 3 were significant negative predictors for intervention-free survival. There were no significant differences in decannulation rate or intervention free survival between patients that had LTR with autologous (n = 26) versus cadaveric (n = 17) cartilaginous grafting.

CONCLUSION

This study describes the largest consecutive multicenter cohort of adult PGS patients treated with open LTR. This technique significantly improves breathing outcomes in PGS, with minimal complications in selected patients with a healthy weight and few comorbidities. Patients with a BMI ≥ 35, ASA ≥ 3, Diabetes Mellitus or renal failure have less favorable outcomes, with respect to decannulation rates and intervention-free survival.

The role of cricoarytenoid joint ankylosis in bilateral vocal cord immobility

OBJECTIVES

To stratify the severity of cricoarytenoid joint fixation (CAJF) by surgery and understand the role of it played in the bilateral vocal fold immobility (BVFI). The second objective emphasizes on the significance of the preoperative differential diagnosis from neurogenic immobility with medical history and endoscopic findings.

METHODS

A retrospective review was conducted of 74 patients between 2005 and 2022. Careful medical history inquiry, and videolaryngoscopy are conducted to recruit the appropriate surgical candidates. All patients underwent arytenoid remobilization (AR) followed by vocal fold medialization with arytenoid adduction (AA) or lateralization with suture lateralization (SL). The severity of CAJF is graded during the operation or inferred based on the period from operation to recurrence.

RESULT

A total of 18 patients, aged between 18 and 76 years, were analyzed. Among them, 14 cases were classified as the adducted type with ventilation problems, with three presenting with dyspnea, and 11 requiring artificial airways. Additionally, four patients presented with the abducted type, characterized by aphonia. Meanwhile, two additional cases were considered for comparison but were not included in this cohort of 18 subjects due to incorrect diagnosis and inappropriate management. Using AR procedure, the AA procedure offered three aphonia subjects a voiced sound without airway impairment and the SL procedure decannulated 100% (11/11) of the artificial airways and improved the airway patency in 100% (3/3) of the non-tracheostomized subjects despite the severity of CAJF. The severity of joint ankylosis was distributed as follows: In the aphonia group, there were three subjects with grade I, one subject with grade II, and 0 subjects with grade III. In the ventilation group, there was one subject with grade I, seven subjects with grade II, and six subjects with grade III. In contrast, the two cases used for comparison experienced recurrent dyspnea and failed decannulation because the AR procedure was not performed. The follow-up period was averaged in 58 and 14 months at least.

CONCLUSION

From this experience, it is the accurate preoperative diagnosis instead of the severity of CAJF that determines the successful rate in airway patency and voiced phonation if the AR procedure is utilized. Careful medical history inquiry and videolaryngoscopic examination can correctly differentiate the mechanical from neurogenic origin without the help of EMG. Evidence of level: 4.

Strategies for CO2 Laser Use in Laryngeal Microsurgery: A Systematic Review

OBJECTIVE

We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety.

DATA SOURCES

A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted.

REVIEW METHODS

Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software.

RESULTS

Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up).

CONCLUSION

The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.

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.

Disruption of BMP4 signaling is associated with laryngeal birth defects in a mouse model

Laryngeal birth defects are considered rare, but they can be life-threatening conditions. The BMP4 gene plays an important role in organ development and tissue remodeling throughout life. Here we examined its role in laryngeal development complementing similar efforts for the lung, pharynx, and cranial base. Our goal was to determine how different imaging techniques contribute to a better understanding of the embryonic anatomy of the normal and diseased larynx in small specimens. Contrast-enhanced micro CT images of embryonic larynx tissue from a mouse model with Bmp4 deletion informed by histology and whole-mount immunofluorescence were used to reconstruct the laryngeal cartilaginous framework in three dimensions. Laryngeal defects included laryngeal cleft, laryngeal asymmetry, ankylosis and atresia. Results implicate BMP4 in laryngeal development and show that the 3D reconstruction of laryngeal elements provides a powerful approach to visualize laryngeal defects and thereby overcoming shortcomings of 2D histological sectioning and whole mount immunofluorescence.

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.

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.

Bilateral vocal fold immobility: Clinical findings of ten cases and suggested treatment options

OBJECTIVE

To present the clinical findings of 10 cases of bilateral vocal fold immobility (adducted type) and suggest potential treatment options.

METHODS

This retrospective study included 10 patients who underwent tracheostomy for restricted airway due to bilateral vocal fold immobility of the adducted type during the period from 2007 to 2017. All 10 patients underwent unilateral laterofixation surgery with or without additional arytenoidectomy using a CO₂ laser. The effect of laterofixation surgery for decannulation was evaluated. Statistical analysis was performed to assess the effects of laterofixation based on the results of preoperative and intraoperative examinations including endoscopic examinations, electromyography, and the intraoperative traction-mobility test.

RESULTS

Initial laterofixation surgery for decannulation was effective in 6 cases. In the 4 cases that exhibited laterofixation failure, additional endoscopic subtotal arytenoidectomy was performed. Statistical analysis of the effects of laterofixation revealed that, in cases with bilateral preserved muscle tone, unilateral simple laterofixation surgery was unable to achieve a significantly effective glottal airway. Additional subtotal arytenoidectomy was also ineffective in a case with bilateral ankylosis.

CONCLUSION

Based on the clinical findings in these 10 cases of bilateral vocal fold immobility of the adducted type, treatment options are suggested and a severity classification system of bilateral vocal fold immobility is proposed that focuses mainly on electromyography results for assessment of dynamic restenosis and traction-mobility test results for assessment of static restenosis. Validation of the classification system is needed in a larger cohort of cases of bilateral vocal fold immobility.