Laryngeal cancer after topical mitomycin C application

Effect of Bilateral Vocal Fold Microsuturing on Voice Quality Improvement in Patients With Anterior Glottic Webs: A Retrospective Observational Study

PURPOSE

This study was performed to introduce a modified procedure involving a combination of bilateral vocal fold mucosal flaps and microsurgical sutures for the management of anterior glottic webs and to study its efficacy in decreasing the recurrence rate and improving voice quality.

METHODS

We retrospectively reviewed 102 patients with anterior glottic webs who underwent surgical treatment by a carbon dioxide laser incision with or without microsurgical suturing in our hospital from May 2014 to April 2021. We focused on the reoperation rate and the voice outcomes based on the 30-item Voice Handicap Index.

RESULTS

This study included 102 patients with anterior glottic webs, which were caused by papilloma excision and endoscopic laryngocarcinoma resection in 97 (95.1%) of the 102 patients; less common causes were infection and traumatic injury. All incisions were performed along the midline with a carbon dioxide laser under microscopy and a self-retaining laryngoscope; 37 (36.3%) patients underwent microsurgical suturing and 65 (63.7%) patients did not. The microsuture group had a lower reoperation rate (χ2= 7.069, P = 0.0078) and higher voice quality (t = 2.054, P = 0.0462) than the non-microsuture group.

CONCLUSIONS

We introduced a modified procedure that can both decrease the recurrence rate and improve the voice quality in patients with anterior glottic webs. Hence, this combination therapy involving bilateral vocal fold mucosal flaps and microsurgical sutures is worthy of clinical application and promotion.

Use of Steroid-Eluting Stents after Endoscopic Repair of Choanal Atresia: A Case Series with Review

OBJECTIVE(S)

To describe a single institution's experience with the use of steroid-eluting stents after endoscopic transnasal repair of choanal atresia.

METHODS

A case series with review of children who underwent choanal atresia repair at a tertiary children's hospital from June 2017 to January 2018 was performed. Those who had a mometasone drug-eluting stent (Propel^® Mini, Intersect ENT Inc., Palo Alto, CA) placed after primary or secondary choanal atresia repair at our institution were included. The primary outcome measure was need for revision surgery due to stenosis. Postoperative regimens, duration of stenting, and need for return to the operating room (OR) were also assessed.

RESULTS

Five patients with a median age of 22 months at the time of repair met inclusion criteria. Two (40%) had bilateral atresia and 3 (60%) had confirmed CHARGE syndrome. A total of 6 mometasone drug-eluting stents were used in the 5 cases. Three patients were reassessed at least once in the OR; however, the majority (57.1%) of postoperative evaluations were able to be performed in the office or bedside setting. The first and last evaluations occurred a mean of 14 and 124 days after surgery, respectively. There were no instances of restenosis, repeat surgical interventions, or stent-related complications noted.

CONCLUSION

Placement of a mometasone drug-eluting stent is a promising method to improve postoperative results and management of choanal atresia repair by limiting the need for repeat anesthetics and OR procedures, as well as the complications of traditional stents.

Idiopathic subglottic stenosis: a review

Idiopathic subglottic stenosis (iSGS) is a fibrotic disease of unclear etiology that produces obstruction of the central airway in the anatomic region under the glottis. The diagnosis of this entity is difficult, usually delayed and confounded with other common respiratory diseases. No apparent etiology is identified even after a comprehensive workup that includes a complete history, physical examination, pulmonary function testing, auto-antibodies, imaging studies, and endoscopic procedures. This approach, however, helps to exclude other conditions such as granulomatosis with polyangiitis (GPA). It is also helpful to characterize the lesion and outline management strategies. Therapeutic endoscopic procedures and surgery are the most common management modalities, but medical therapy can also play a significant role in preventing or delaying recurrence. In this review, we describe the morphology, pathophysiology, clinical presentation, evaluation, management, and prognosis of iSGS.

Efficacy and Safety of the Local Application of Mitomycin C to Recurrent Esophageal Strictures in Children

OBJECTIVES

Research on long-term use of mitomycin C (MC) for recurrent esophageal stenoses is limited. We assessed the long-term efficacy and safety of local application of MC for recurrent esophageal stenoses in children.

METHODS

This was a retrospective study of 39 patients (17 girls) with a median age of 19.5 months (range: 2.4-196.0) at the time of MC application. The etiologies of stenosis were esophageal atresia (n = 25), caustic ingestion (n = 9), congenital esophageal stenosis (n = 3), and other causes (n = 2). Stenosis was single in 35 (90%) patients and multiple in 4 (10%). Before MC, patients underwent multiple repeated dilations (median: 3 dilations per child [range: 2-26]) over a median period of 7 months (range: 2.6-49.3). Treatment success was defined a priori as a reduction in the number of dilations over the same period from before to after the application of MC.

RESULTS

For 26 (67%) patients, the application of MC was considered a success: 102 versus 17 dilatations (P < 0.0001). Sixteen (41%) patients never required additional dilation during the follow-up after MC application (median: 3.1 years [range: 0.6-8.5]). No complication related to MC was observed. Biopsies at the site of MC application were performed at maximal follow-up in 16 patients and revealed no dysplasia. Three factors were associated with success of MC: single stenosis, short stenosis, and esophageal atresia type III.

CONCLUSIONS

This study is the largest series reported showing that topical application of MC is an efficient and safe treatment for recurrent esophageal stenosis in children.

Surgical management of acquired anterior glottic web: a systematic review

Background

Acquired anterior glottic web poses a significant challenge to laryngologists given its propensity to recur following treatment, and there are a wide variety of described techniques.

Methods

A systematic review of the medical literature was undertaken in order to identify all articles pertaining to the management of acquired anterior glottic web.

Results

Thirteen studies meeting the inclusion criteria were identified and analysed. All were retrospective series, with varying surgical techniques and outcome measures. Only two studies reported on the use of topical mitomycin C.

Conclusion

Mucosal graft techniques and keel placement appear to improve success rates, but both carry risks and disadvantages. Based on the available evidence, the use of topical agents such as mitomycin C cannot be recommended in the management of acquired anterior glottic web.

Novel Application of Steroid Eluting Stents in Choanal Atresia Repair: A Case Series

PURPOSE

To describe the application of mometasone furoate eluting sinus stent technology in the treatment of choanal atresia (CA) in the hopes of preventing postsurgical stenosis.

METHODS

We analyzed 3 consecutive patients aged 4 days to 16 years undergoing repair of CA at a tertiary pediatric hospital. Mometasone furoate eluting sinus stents were placed intraoperatively. Postoperative need for revision surgery as well as routine surveillance endoscopy were used to determine success of surgery.

RESULTS

Three patients of varying age and etiology underwent successful repair of choanal atresia/stenosis. The steroid eluting sinus stent was deployed successfully in all 3 cases. There was no identifiable restenosis in any of the 3 patients with 12-month follow-up. There were no complications noted throughout the follow-up period.

CONCLUSIONS

Choanal atresia is a rare disorder that can prove difficult in postsurgical management. In our case series, mometasone furoate eluting stents were effective and safe for the management of this disease process. Further prospective studies are needed to determine the exact safety profile, long-term consequences, and efficacy of steroid eluting sinus stents in the pediatric population.

Current Updates on Choanal Atresia

Choanal atresia (CA) is a relatively uncommon but well-recognized condition characterized by the anatomical closure of the posterior choanae in the nasal cavity. Since the original description back in the early eighteenth century, there have been controversies regarding its exact pathogenesis, the optimal surgical approach, and the use of adjunct treatments such as post-surgical stenting and anti-neoplastic agents, despite of abundant literature available. The emergence and development of new technologies play a significant role in the management of this condition. This review provides a comprehensive clinical update on CA and identifies areas for future study based on the existing available literature.

Morbidity and mortality associated with subglottic laryngotracheal stenosis in granulomatosis with polyangiitis (Wegener's granulomatosis): a single-centre experience in the United Kingdom

OBJECTIVES

We aimed to determine the prevalence of symptomatic subglottic laryngotracheal stenosis in patients with granulomatosis with polyangiitis (Wegener's granulomatosis); we also wanted to characterise the clinical outcomes and surgical interventions required, and the relapse rate in our cohort.

METHODS

We undertook a retrospective clinical review of all granulomatosis with polyangiitis patients with symptomatic subglottic laryngotracheal stenosis attending St Thomas' Hospital, London, United Kingdom.

RESULTS

Symptomatic subglottic laryngotracheal stenosis developed in 16 per cent of granulomatosis with polyangiitis patients attending our clinic. The median age of patients at diagnosis was 44 years (range: 34-81 years); 78 per cent of those presenting with subglottic laryngotracheal stenosis were women and 22 per cent were men. All patients were white; 67 per cent of patients were proteinase 3-antineutrophil cytoplasmic antibody-positive and 67 per cent developed relapsing disease requiring repeated surgical intervention. Subglottic laryngotracheal stenosis relapse was not associated with active systemic vasculitis elsewhere.

CONCLUSION

Subglottic laryngotracheal stenosis is an uncommon but significant complication of granulomatosis with polyangiitis. Management of subglottic laryngotracheal stenosis requires a multi-disciplinary approach, with both rheumatological and otolaryngological expertise involved, given the relapsing nature of the disease.

Dose-dependent effect of mitomycin C on human vocal fold fibroblasts

BACKGROUND

The purpose of this study was to evaluate in vitro cytotoxicity and antifibrotic effects of mitomycin C on normal and scarred human vocal fold fibroblasts.

METHODS

Fibroblasts were subjected to mitomycin C treatment at 0.2, 0.5, or 1 mg/mL, or serum control. Cytotoxicity, immunocytochemistry, and Western blot for collagen I/III were performed at days 0, 1, 3, and 5.

RESULTS

Significant decreases in live cells were measured for mitomycin C-treated cells on days 3 and 5 for all doses. Extracellular staining of collagen I/III was observed in mitomycin C-treated cells across all doses and times. Extracellular staining suggests apoptosis with necrosis, compromising the integrity of cell membranes and release of cytosolic proteins into the extracellular environment. Western blot indicates inhibition of collagen at all doses except 0.2 mg/mL at day 1.

CONCLUSION

A total of 0.2 mg/mL mitomycin C may provide initial and transient stimulation of collagen for necessary repair to damaged tissue without the long-term risk of fibrosis.

Idiopathic acquired supraglottic web: a case report

We report a case of an idiopathic acquired supraglottic web in an 83-year-old man. The web was managed with a combination of dilation and unilateral CO(2) laser excision. Subsequent to removal, the web recurred three times; it was removed in the same fashion twice and left alone once. To the best of our knowledge, this is the first reported case of a truly idiopathic acquired laryngeal web.

Surgery for congenital choanal atresia

BACKGROUND

Congenital choanal atresia is a rare abnormality characterized by unilateral or bilateral lack of patency of the posterior end of the nasal cavity. With an incidence of 1:5000 to 1:8000 births, it is twice as prevalent in females as it is in males. Surgical procedures aim to provide adequate functional choanal patency and a low rate of restenosis, avoid harm to any structure in development, enable shorter surgery and hospitalization times, and minimize morbidity and mortality.

OBJECTIVES

To evaluate the effectiveness and safety of the available surgical techniques for the treatment of congenital choanal atresia in patients with unilateral and bilateral atresia.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the search was 31 January 2011.

SELECTION CRITERIA

We planned to include parallel randomized or quasi-randomized controlled trials testing surgical approaches for the treatment of congenital atresia (irrespective of gender and age) that evaluated normal/adequate respiratory function (self reported or preserved nasal airway) and restenosis as the main primary outcomes. We did not consider reoperation and non-congenital atresia (e.g. traumatic, iatrogenic atresias) for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the titles and abstracts of the identified articles to determine potential relevance. For dichotomous and continuous variables, we planned to calculate risk ratios (relative risks; RR) and mean differences (MD) with 95% confidence intervals (CI), respectively. We planned to use the random-effects model since we were expecting substantial clinical and methodological heterogeneity.

MAIN RESULTS

No randomized controlled trials were identified. From the 120 reports retrieved using our search strategy, 46 primary studies had the potential to be included since they had tested surgical approaches for choanal atresia. However, we excluded all of them during the final selection process because their study designs did not meet our inclusion criteria.

AUTHORS' CONCLUSIONS

There is no definitive evidence, based on randomized controlled trials, to demonstrate the potential advantages and disadvantages of any specific surgical technique for patients with choanal atresia. Specialists should unify their efforts in multicenter randomized controlled trials that test the effectiveness and safety of different surgical techniques in patients with choanal atresia.

Topical use of MMC in the upper aerodigestive tract: a review on the side effects

Not much is known about the side effects of mitomycin C (MMC), an anti-fibrogenetic agent, in the upper aerodigestive tract. However, its use in ophthalmology is widely known and without quantitatively important side effects. A literature review was performed for side effects of MMC in the upper aerodigestive tract. Forty-six articles, describing the use of MMC to prevent scarring, were retracted from PubMed. Thirty-two are human studies. MMC is used in different concentrations (0.1–10 mg/ml) with different application times (2–5 min) and frequencies (up to 4 times). Five hundred and thirty-eight patients were included in those publications, of whom 19 developed side effects (3.53%). No side effects developed in studies, where post-application irrigation with saline was reported. The longest mean follow-up period is 75.5 months. Direct relations between the reported side effects and MMC seem absent in most studies. Serious complications seem to occur when MMC is used in high concentrations. Unfortunately, sometimes crucial information is lacking. One patient was described who supposedly developed laryngeal carcinoma after repeated treatment of hyperkeratosis and anterior commissure webbing. Animal studies show that excessive fibrin production can lead to acute airway obstruction. In conclusion, topical application of MMC on a wound with consecutive irrigation with saline can be performed safely to prevent scar formation in circular structures of the upper aerodigestive tract. Long-term yearly control of the application site seems advisable.

The anterior laryngeal webs

Anterior laryngeal webs can be congenital or acquired and occur secondary to a surgical procedure, intubation, or infection. Clinical presentation can include vocal and respiratory symptoms. The first step in managing a laryngeal web is performing flexible laryngoscopy, followed by a direct laryngoscopy under general anesthesia. Treatment remains a challenge. Endoscopically, the web can be incised with cold instruments or by laser, mitomycin-C can be applied, and a silastic keel can be inserted in the anterior commissure. Externally, an anterior cricothyrotomy is necessary and a silastic keel can be placed; anterior cartilage graft can be inserted in case of a thick web. Regardless of the technique used, the primary concern is recurrence.

[Adjuvants in operative laryngology: corticosteroids, fibrin adhesives, Mitomycin C]

Medicinal adjuvants are often used in operative laryngology but their value is judged very differently. The scientific evidence is unsatisfactory for most of these substances. For corticosteroids it is proven that in pediatric intensive care they reduce stridor following extubation. Routine prophylactic use for intubation does not seem to be justified and methylprednisolone and dexamethasone are the preferred preparations. Fibrin adhesives are well tolerated and low in side-effects. The indications for their use should be primarily limited due to the cost factor. Their use in laryngology remains a decision on an individual case-to-case basis. Mitomycin C is used because of its antiproliferative effect on fibroblasts in order to reduce scar tissue formation. Many positive effects have been attributed to the topical application but there are large differences in dosage and exposure time.

Comparison Between Mitomycin C and Chitosan for Prevention of Anterior Glottic Steno After CO2Laser Cordectomy in Dogs

OBJECTIVE

To compare the effectiveness of an immediate application of topical mitomycin C (MMC) with chitosan for prevention of anterior glottic stenosis (AGS) after microsurgical resecting of both vocal fold with CO2 laser, including the anterior commissure, in a canine model.

DESIGN

Prospective randomized experimental study.

METHOD

Twenty-four canine larynges were injured by a microresecting procedure of both vocal folds with a CO2 laser. The dogs were randomly divided into three groups for treatment, respectively with MMC, chitosan, or isotonic sodium chloride solution (control) for 5 minutes immediately after surgery. One week after the initial surgery, three dogs in each group were randomly selected, the ultrastructures of the fibroblasts were examined with a transmission electronic microscope, and expression of basic fibroblast growth factor (bFGF) and transforming growth factor beta1 (TGF-beta1) were evaluated by enzyme-linked immunosorbent assay (ELISA). Three weeks after surgery, the remaining dogs' glottic web were lysed and repeatedly treated with MMC, chitosan, or isotonic sodium chloride solution. The glottic wound healing and AGS formation were examined every week, and all larynges were harvested and examined histologically 6 weeks after the initial surgery.

RESULTS

Results included 1) transmission electronic microscope examination of the ultrastructures of the fibroblasts indicated that both MMC and chitosan inhibited the proliferation of fibroblast; 2) the expression of bFGF and TGF-beta1 increased both in the MMC group and the chitosan group, and the expression of bFGF in the chi-tosan group was higher than in the MMC group (P = .010), while the expression of TGF-beta1 was lower (P = .000);3) the extent of AGS formation was decreased both in the MMC group and the chitosan group, while it was less in the chitosan group than in the MMC group (P = .047); 4) the grade of collagen content between the MMC group and the chitosan group was not significantly different (P = .5).

CONCLUSION

Chitosan is more effective in preventing AGS after CO2 laser cordectomy than MMC.