Endoscopic Arytenoid Lateropexy for Isolated Posterior Glottic Stenosis:

Subtotal Submucosal Arytenoidectomy with Lateralization Sutures (SMALS) Covered by a Mucosal Flap

OBJECTIVE

Glottic airway stenosis (GAWS) may result from bilateral paralysis (BVFP) or posterior glottic stenosis (PGS). Since the glottis is the principal airway sphincter, surgeons shift on the balance between airway, aspirations, and voice. We aim to describe our surgical technique and outcome of the SMALS procedure for GAWS correction.

METHODS

A retrospective cohort of patients who underwent SMALS for PGS between 2018 and 2021. SMALS involves: endoscopic submucosal subtotal arytenoidectmy (preserving medial mucosal flap) and lateralization sutures. The sutures lateralize the mucosal flap to cover the arytenoidectomy bed without lateralization of the membranous vocal fold; expanding the posterior glottis, while preserving a relatively good voice. Covering the arytenoidectomy bed enhances healing. Medical and surgical data, airway, voice, and swallowing symptoms were collected. Relative glottic opening area (RGOA) and relative glottic insufficiency area (RGIA) were calculated.

RESULTS

Eleven PGS patients who underwent 15 SMALS were included (4 bilateral), all patients had post-intubation PGS, 1 patient also had prior radiation to the larynx. All patients were tracheostomy-dependent. There were no major complications. No granulation or retracting scar was observed at follow-up. None had a persistent voice or swallowing disability. Successful outcome (decannulation) was achieved in 8 (73%); RGOA increased in all (Δ = 0.37; p = 0.003), while RGIA remained relatively stable (Δ = 0.02; p = 0.055).

CONCLUSIONS

SMALS is a safe and effective, novel modification of the classic arytenoidectomy, for GAWS correction that can be easily applied and may expand the airway without significant glottic insufficiency symptoms.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:353-360, 2024.

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.

Active and Passive Bioimplants for Vocal Fold Paralysis

Vocal fold paralysis is one of the diseases that particularly affect quality of life. While unilateral paralysis leads to glottis closure insufficiency and hoarseness, bilateral paralysis compromises respiration and limits the exercise tolerance. Bioimplants have been used to treat persistent paralysis for over 100 years. The spectrum ranges from autologous tissue transfer and resorbable or permanent injection materials to composite thyroplasty implants and active electrical implants for neurostimulation of the larynx. If bioimplants are used in accordance with the recommendations, the quality of life of affected patients can be significantly improved today.

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.

Association Between Red Blood Cell Distribution Width and Outcomes of Open Airway Reconstruction Surgery in Adults

Importance

Airway reconstruction for adults with laryngotracheal stenosis (LTS) is directed toward improving airway caliber to mitigate the patient's dyspnea and achieve prosthesis-free breathing (ie, without tracheostomy, intraluminal stent, or T-tube). Despite the importance of preoperative risk stratification to minimize postoperative complications, consensus on an objective predictive algorithm for open airway reconstruction is lacking.

Objective

To determine whether the ability to achieve a prosthesis-free airway in adults after open airway reconstruction is associated with red blood cell distribution width (RDW) at the time of surgery.

Design, Setting, and Participants

Case series study investigating 92 consecutive patients 18 years and older with laryngotracheal stenosis who underwent open airway reconstruction at a US tertiary care hospital from January 1, 2006, to January 1, 2017.

Main Outcomes and Measures

The main outcome was a prosthesis-free airway (absence of tracheostomy, intraluminal stent, or T-tubes) at last follow-up. Multivariate logistic regression modeling was used to identify independent factors associated with this outcome.

Results

Of the 92 patients who met inclusion criteria, the median (interquartile range) age was 44 (33.0-60.3) years; 50 (53%) were female, and 82 (89%) were white. In all, 74 patients (80%) were prosthesis free at the last follow-up (mean, 833 days; 95% CI, 10-4229 days). In multivariate analyses, airway decannulation was significantly correlated with reduced RDW (odds ratio [OR], 0.40; 95% CI, 0.19-0.84) and the absence of posterior glottic stenosis (OR, 0.12; 95% CI, 0.04-0.37).

Conclusions and Relevance

These data suggest that surgical success in open airway reconstruction is significantly associated with RDW and whether the patient had posterior glottic stenosis. The RDW is a routine laboratory parameter that may provide some insight to the preoperative probability of prosthesis removal, facilitate risk stratification, promote informed patient decision making, and optimize health care resource management.

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.

Antifibrotic effect of mitomycin-C on human vocal cord fibroblasts

OBJECTIVE

Acquired laryngotracheal stenosis is a potentially life-threatening situation and a very difficult and challenging problem in laryngology. Therefore, new trends and innovative approaches based on antifibrotic drugs and minimally invasive regimens are being developed to attenuate laryngotracheal fibrosis and scarring. The purpose of this study was to examine the efficacy of mitomycin-C (MMC) to reverse the transforming growth factor (TGF)-β-induced differentiation of MRC-5 fibroblast and human primary vocal cord fibroblasts to reveal the possible applicability of MMC to laryngotracheal fibrotic conditions.

METHODS

Human primary fibroblast cells were isolated from vocal cord specimens of patients undergoing total laryngectomy. The established primary vocal cord fibroblast cell cultures as well as the MRC-5 human fibroblast cells were treated with 5 ng/mL TGF-β alone and then with 0.5 µg/mL MMC for 24 hours. Differentiation of fibroblasts was characterized by α-smooth muscle actin (α-SMA) immunhistochemistry, Western blot analysis, and real-time polymerase chain reaction. Cell motility was assessed by wound-healing assay.

RESULTS

Elevated α-SMA mRNA and protein expression as well as increased cell motility were observed upon TGF-β exposures. However, after MMC treatments the TGF-β-induced fibroblasts exhibited a significant decrease in α-SMA expression and wound-healing activity. Therefore, TGF-β-stimulated fibroblast-myofibroblast transformation was reversed at least in part by MMC treatment. Histopathological examinations of tissue specimens of a laryngotracheal stenosis patient supported these findings.

CONCLUSION

Antifibrotic effects of MMC were demonstrated on the human MRC-5 cell line and on primary vocal cord fibroblast cultures. These results verify that MMC can be used with success to reverse upper airway stenosis by reverting the myofibroblast phenotype.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E255-E262, 2019.

Glottic configuration changes and outcomes of endoscopic arytenoid abduction lateropexy

INTRODUCTION

Endoscopic arytenoid abduction lateropexy (EAAL) is an effective glottis enlarging procedure for the treatment of bilateral vocal cord palsy (BVCP). The postoperative glottic configuration changes can be evaluated by modern, high-resolution, 3D image reconstructions. Functional results are described by spirometry as well as objective and subjective phoniatric tests.

METHODS

Unilateral EAAL was performed in ten malignant thyroid gland tumor patients (eight women, two men), who had BVCP after thyroid surgery. Slicer 3D^® software was used for morphometric analysis. Pre- and postoperative peak inspiratory flow (PIF) and standard phoniatric parameters were compared.

RESULTS

The glottic gap improved significantly (+ 60%). Significant improvement of PIF was found in all cases. Phoniatric tests revealed better quality of voice and patient satisfaction. Their voices changed from a severely impaired to a socially acceptable, almost normal, quality.

CONCLUSION

The results support our clinical observations that the ideal position of the lateralization sutures is the one which provides a physiological abduction position of the arytenoid cartilage. Considering these good results, the surgical indications for minimally invasive endoscopic arytenoid lateropexy may be extended.

Augmentation surgery on the cartilaginous portion of the vocal fold in a patient with cricoarytenoid joint ankylosis

Surgical management of cricoarytenoid joint (CAJ) ankylosis is challenging and has the risk of worsening voice quality. In the present case, augmentation surgery was performed on the cartilaginous portion of the vocal fold in a patient with CAJ ankylosis. A 24-year-old man sustained blunt trauma to the anterior neck three years prior to developing severe breathiness. Posterior glottal insufficiency resulting from lateral fixation of the right vocal fold was observed during phonation under laryngoscopy. In addition, electromyography and CT scan revealed severe ankylosis of the right CAJ. Type I thyroplasty performed on the right vocal fold did not improve postoperative vocal function. Therefore, augmentation surgery on the cartilaginous portion of the right vocal fold was performed via endolaryngeal microsurgery under general anesthesia with jet ventilation. A piece of temporalis fascia was autotransplanted into the submucosal space created at the posterior cartilaginous portion of the right vocal fold. This resulted in the narrowing of the posterior glottal gap during phonation, leading to improvement in hoarseness. Microsurgical management with autologous fascia augmentation of the cartilaginous portion of the vocal fold can be effective in patients with lateral vocal fold fixation due to CAJ ankylosis.

Minimally invasive endoscopic treatment for pediatric combined high grade stenosis as a laryngeal manifestation of epidermolysis bullosa

Epidermolysis bullosa refers to a clinically and genetically heterogeneous group of inherited mucocutaneous diseases. Laryngotracheal lesions are momentous regarding the risk of sudden airway obstruction. The traditional treatment is tracheostomy. This case report highlights the advantages of minimally invasive interventions. A successful combined endoscopic management of a life-threatening respiratory crisis is presented in a 4-year-old child. Combined commissure stenosis with supraglottic spread was treated by CO₂ laser dissection and bilateral endoscopic arytenoid abduction lateropexy, supplemented with mitomycin C application. Due to expectable less scarring, the combination of these modern methods may be an efficient solution in these vulnerable respiratory tracts.

Rotational thyrotracheopexy after cricoidectomy for low-grade laryngeal chrondrosarcoma

OBJECTIVES

The complex laryngeal functions are fundamentally defined by the cricoid cartilage. Thus, lesions requiring subtotal or total resection of the cricoid cartilage commonly warrant total laryngectomy. However, from an oncological perspective, the resection of the cricoid cartilage would be an optimal solution in these cases. The poor functional results of the few reported cases of total and subtotal cricoidectomy with different reconstruction techniques confirm the need for new approaches to reconstruct the infrastructure of the larynx post cricoidectomy.

STUDY DESIGN

Retrospective case series review.

METHODS

Four consecutive patients with low-grade chondrosarcoma were treated by cricoidectomy with rotational thyrotracheopexy reconstruction to enable the functional creation of a complete cartilaginous ring that can substitute the functions of the cricoid cartilage. The glottic structures were stabilized with endoscopic arytenoid abduction lateropexy. Patients were evaluated with objective and subjective function tests.

RESULTS

Tumor-free margins were proven; patients were successfully decannulated within 3 weeks. Voice outcomes were adequate for social conversation in all cases. Oral feeding was possible in three patients.

CONCLUSION

Total and subtotal cricoidectomy can be a surgical option to avoid total laryngectomy in cases of large chondrosarcomas destroying the cricoid cartilage. The thyrotracheopexy rotational advancement technique enables the effective reconstruction of the structural deficit of the resected cricoid cartilage in cases of total and subtotal cricoidectomy. An adequate airway for breathing, swallowing, and voice production can be reconstructed with good oncological control. In cases where the pharynx is not involved, good swallowing function can also be achieved.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1109-1115, 2017.

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.

A comparison between transoral glottis-widening techniques for bilateral vocal fold immobility

OBJECTIVE

Comparison of different endoscopic glottis-widening procedures designed for bilateral vocal cord immobility (BVCI) is a challenge. This is because a statistically efficient analysis and comparable clinical series is hard to obtain considering the variable aspects of the results and the evaluation methods. This study of a large number of cadaver larynges provides comparable, objective data for the evaluation of the possible postoperative breathing and voicing function.

STUDY DESIGN

A morphometric study was performed on 50 male and 50 female larynges to compare the different suture lateralization and resection procedures.

METHODS

The postoperative characteristic of glottic configuration was evaluated following vocal cord laterofixation, endolaryngeal arytenoid abduction lateropexy (EAAL), Schobel's external lateralization procedure (SELP), transverse cordotomy (TC), and medial and total arytenoidectomies (AE). The glottic area and the parameters determining the phoniatric outcomes were assessed by a digital image analyzer program.

RESULTS

Improvement of glottic area was observed after all procedures, but arytenoid abduction procedures were significantly the most effective. However, the smallest vocal cord angles were found in TC and AE; the injury of the voicing structures results in a deterioration of vocal mechanics and can be reasonably assumed to negatively influence the voice. Endolaryngeal arytenoid abduction lateropexy and SELP may provide the best phonation closure when residual adduction regeneration can occur.

CONCLUSION

This study demonstrates the complexity of the correct surgical decision making in BVCI. Procedures that utilize physiological abduction of the arytenoid cartilage seem to be more advantageous, especially if recovery of adductor function occurs.

LEVEL OF EVIDENCE

N/A.

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.

The combined endoscopic management of congenital laryngeal web

Laryngeal web in the anterior commissure is a rare congenital anomaly often leading to severe dyspnea. Endoscopic procedures based on a simple transsection in these cases may worsen the condition because vocal folds have a tendency for fibrosis and granulation tissue formation after surgical interventions. Thus the traditional treatment of choice is the demanding, externally performed laryngotracheal reconstruction generally with a rib cartilage graft and longer period of stenting. This report presents the successful endoscopic management of a congenital laryngeal web in a 2-year-old boy, who previously underwent an uneffective scar laser transsection that led to excessive glotto-subglottic refibrosis. After the CO(2)-laser transsection the authors applied Mitomycin-C and inserted a combined silicon stent by extra-endolaryngeal technique. After the removal of the stent the patient could be decannulated and his voice improved. The application of these minimally invasive endoscopic techniques was successful, hence it may be an effective alternative treatment option for laryngeal webs.