Laryngospasm during transtracheal high frequency jet ventilation

A 74-year-old woman developed severe cardiovascular depression during percutaneous transtracheal high frequency jet ventilation for laser surgery of the epiglottis. This was found to be caused by acute airway obstruction secondary to severe laryngospasm. We recommend profound neuromuscular blockade during percutaneous transtracheal jet ventilation, in order to prevent this complication.

Surgical treatment of large epiglottic cysts with a side-opened direct laryngoscope and snare

Two cases of large epiglottic cysts are reported. Histopathological examination revealed a retention cyst in one case and an epidermoid cyst in the other. We designed a side-opened direct larngoscope and snare for treating epiglottic cysts. This direct laryngoscope is characterized by an opening from the anterior tip to the posterior end of the right side. The removal of the cysts was accomplished by using this direct laryngoscope and a snare under inhalation anesthesia by fiber optic guided endotracheal intubation. The side-opened direct laryngoscope enabled easy insertion of the snare through the right side opening.

[Subglosso-epiglottectomy: carcinologic and functional results]

The authors report on 26 cases of patients treated by subglosso-epiglottectomy from 1978 to 1989. Whilst as far as survival and local oncological control are concerned the results are encouraging, the functional results are disappointing.

Laryngotracheal reconstruction. Extended vertical partial laryngectomy: reconstruction combining epiglottoplasty and the rotary door flap

This article explores various surgical techniques for vertical, partial laryngectomy in the treatment of laryngeal cancer. Potential for reconstruction and broader indications for such surgical procedures may be achieved by combining laryngeal epiglottoplasty with the rotary door sternohyoid myocutaneous flap.

Standing endoscopic electrosurgery

Common equine upper respiratory conditions are diagnosed via endoscopy. Endoscopic surgery facilitates correction of many conditions without general anesthesia or laryngotomy, reducing the morbidity and cost of the procedures. Modalities of endoscopic surgery include the Nd-YAG laser or electrosurgery, which may be complementary. The least expensive method is electrosurgery, and instruments are available that can be passed through the biopsy channel of the endoscope. Conditions amenable to such procedures include entrapped epiglottis, rostral displacement of the palatopharyngeal arch, pharyngeal cysts or polyps, retropharyngeal abscesses within the guttural pouch, guttural pouch tympany, and ethmoid hematoma.

Evaluation of epiglottic augmentation by use of polytetrafluoroethylene paste in horses

Epiglottic augmentation was evaluated in 7 horses, using 7 ml of polytetrafluoroethylene (polytef) paste injected submucosally on the ventral surface of the epiglottis. In 6 horses, an Arnold-Bruning intracordal injection syringe, specifically designed to inject polytef into paralyzed vocal folds in human beings, was used. At necropsy 60 days after surgery, group mean thickness measurement 20 mm from the epiglottic tip was 40% greater (P less than 0.01) and, at the epiglottic attachment of the aryepiglottic fold, was 29% greater (P less than 0.01) in the 6 polytef-augmented horses than in clinically normal nonsurgically treated controls. At necropsy, extensive epiglottic thickening was seen. This thickening was exclusively attributable to distention of submucosal areas in the ventral aspect of the epiglottis, with foreign body granulomata surrounded by fibrous connective tissue. In 1 horse, polytef paste was injected by use of a disposable syringe and needle. Excess ventral epiglottic swelling and exposed epiglottic cartilage was seen during subsequent endoscopy. At necropsy 60 days after surgery, the epiglottic contour remained deformed and a large deep mucosal ulcer was observed at the injection site. Histologic examination revealed necrotizing suppurative inflammation that extended into the epiglottic cartilage. Surgery was not technically difficult to perform through a laryngotomy, and all horses tolerated the procedure without apparent discomfort. Endoscopy performed after surgery revealed unremarkable and uniform response to the polytef paste in 4 horses, and in 3 horses, revealed excess swelling and inflammation of the ventral epiglottic tissue that resolved over time.(ABSTRACT TRUNCATED AT 250 WORDS)

Subtotal laryngectomy with crico-hyoido-epiglotto-pexy for the treatment of extended glottic carcinomas

We first described subtotal laryngectomy with crico-hyoido-epiglotto-pexy in 1974. This procedure is a modification of Majer's operation and results in the complete resection of the intact thyroid cartilage. The epiglottic petiole, the false cords, the true cords, and one arytenoid are also excised, along with the paraglottic space. The pharynx is closed by suturing the cricoid to the epiglottis and the hyoid bone. The neoglottis is occluded during deglutition by the epiglottis and the base of tongue, which come into contact with the remaining arytenoid. Postoperative hospitalization lasts approximately 3 weeks, and patients have a strong but deep voice. Between 1972 and 1985, we treated 104 patients with stage T2 and T3 lesions of the glottis using this method. A retrospective analysis showed that the overall survival rate of patients was 86% at 3 years and 75% at 5 years. Five patients experienced local recurrence. Seven patients had recurrences in the neck, and eight developed second primaries. Thirteen patients were lost to follow-up or developed intercurrent disease. Patients with T3NO lesions were treated with unilateral prophylactic neck dissection, and positive nodes were found in 23% of cases. We believe that the high proportion of positive nodes justifies routine prophylactic neck dissection in these patients. Because our operation is associated with good local control (5% recurrence rate), we propose that, for the treatment of extended glottic cancers, it replace transcartilaginous procedures that are associated with much higher recurrence rates.

Amelanotic melanoma metastatic to the epiglottis

Metastasis of melanoma in the head and neck region is often reported but the report of amelanotic melanoma metastatic to the epiglottis is an extremely rare entity. This paper describes a patients previously treated for cutaneous amelanotic melanoma who developed metastatic tumour involving his epiglottis. This legion was successfully excised by a intra-oral approach combined with KTP/532 laser surgery. The paper also describes the diagnostic evaluation, management, operative technique and DNA analysis of this rare case.

The current status of corrective surgery for laryngomalacia

When the airway obstruction related to laryngomalacia becomes significant, surgical correction of the underlying laryngeal deformity is indicated. The three elements of the supraglottic soft tissue that prolapses, namely, the corniculate mounds on the arytenoid cartilages, the shortened ary-epiglottic folds, and the omega shaped epiglottis, can all be appropriately "trimmed" using either conventional instruments or the surgical laser. Relief of symptoms is dramatic and, provided surgery is performed precisely and not during episodes of infection, complications should not occur. The aid of specialized, skillful anesthesia is required for this type of surgery. We present a series of 40 children with significant obstruction: 30% had neuromuscular disorders, 68% had an infantile epiglottis, seven required airway support prior to surgery, all had laser "supraglottic trimming," and 13 required airway support after surgery. Relief of stridor and airway obstruction was generally rapid. There was only one complication: croup developing 4 days after surgery.

Epiglottoplasty for reconstruction of posttraumatic laryngeal stenosis

Laryngeal stenosis secondary to blunt laryngeal trauma is mostly localized at the supraglottic and glottic levels. The epiglottis is ideally suited to reconstruct the defect after excision of supraglottic and glottic scar tissue and anterior thyroid cartilage. It is the conclusion of the authors that epiglottic reconstruction is an effective procedure for repair of laryngeal stenosis at the supracricoid level. Two case reports are given.

Use of transendoscopic contact neodymium:yttrium aluminum garnet laser to drain dorsal epiglottic abscesses in two horses

A submucosal abscess, located on the dorsal surface of the epiglottis, was diagnosed in 2 Thoroughbred racehorses by use of endoscopy. Both horses had exercise intolerance. One horse had intermittent dorsal displacement of the soft palate, coughed while eating and galloping, and made an abnormal respiratory noise. Both abscesses were drained transendoscopically by use of a contact neodymium:yttrium aluminum garnet laser. Eleven days after surgery, the surgical sites appeared to have healed. Clinical signs resolved permanently, and both horses returned to successful racing careers.

A precision technique for suprahyoid pharyngotomy

This technique of suprahyoid pharyngotomy is very useful for excision of selected laryngeal and pharyngeal neoplasms. By identifying and following the hyoepiglottic ligament, precise entry into the pharynx is accomplished easily and rapidly at the median glossoepiglottic fold.

Correlation of performance with endoscopic and radiographic assessment of epiglottic hypoplasia in racehorses with epiglottic entrapment corrected by use of contact neodymium:yttrium aluminum garnet laser

Epiglottic entrapment in 35 Thoroughbred and 44 Standardbred horses was corrected transendoscopically by use of a neodymium:yttrium aluminum garnet laser. Before surgery, the entrapped epiglottis was classified as hypoplastic or normal in each horse on the basis of endoscopic appearance alone. Using a digitizer, thyroepiglottic length was determined from lateral-view laryngeal radiographs. For 78 racehorses, earnings (less than $5,000 or greater than $5,000) were compared before and after surgery. Earnings category and racing performance after surgery were tested for association with endoscopically determined epiglottic hypoplasia and radiographically determined thyroepiglottic length. Endoscopy and radiography were useful methods of evaluating the epiglottis in horses with epiglottic entrapment. Mean (+/- SD) thyroepiglottic length for both breeds of horses with epiglottic entrapment was significantly (P = 0.0001) smaller (Thoroughbreds, 7.28 +/- 0.67 cm; Standardbreds, 7.21 +/- 0.62 cm), compared with thyroepiglottic length measured from control groups composed of clinically normal Thoroughbred (8.56 +/- 0.29 cm) and Standardbred (8.74 +/- 0.38 cm) racehorses. Both breeds of horses with epiglottic entrapment that had endoscopically apparent hypoplastic epiglottis had significantly (P less than 0.0001) smaller thyroepiglottic length (Thoroughbreds, 6.64 +/- 0.60 cm; Standardbred, 6.93 +/- 0.72 cm) than did horses with epiglottic entrapment that had endoscopically normal epiglottis (Throughbreds, 7.57 +/- 0.47 cm, Standardbreds, 7.36 +/- 0.50 cm). Significant difference was not detected in endoscopic appearance of the epiglottis among age, gender, or breed distributions.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of epiglottoplasty as treatment for severe laryngomalacia

Six patients with severe laryngomalacia underwent epiglottoplasty. Four of these patients had life-threatening episodes of airway obstruction before surgery; of these, two had required tracheal intubation and one had required cardiopulmonary resuscitation. Two patients had failure to thrive and two had cor pulmonale. Patients had required a mean of two hospitalizations related to upper airway obstruction. We performed polysomnography during a daytime nap, both before and after epiglottoplasty, in all patients. Respiratory effort, arterial oxygen saturation, and end-tidal carbon dioxide pressure were monitored with continuous electrocardiograms and electrooculograms. All patients had abnormal polysomnograms preoperatively. Six patients had obstructive apnea, four had hypoxemia (arterial oxygen saturation less than 90% while breathing room air), and four had hypoventilation (end-tidal carbon dioxide pressure greater than 45 mm Hg) before epiglottoplasty. Mean age (+/- SEM) at epiglottoplasty was 10.3 +/- 5.3 months. No patients had surgical complications. An endotracheal tube was in place for 25 +/- 7 hours postoperatively, and patients were discharged 4 +/- 1 days postoperatively. Polysomnography performed 2.8 +/- 1.0 months after surgery showed that all patients had improved. Two patients had residual, mild episodes of obstructive apnea, and one patient had mild hypoventilation and desaturation. No patient had further life-threatening events or required further hospitalizations after epiglottoplasty. We conclude that epiglottoplasty is an effective and safe treatment for a selected group of patients with severe laryngomalacia.

Laser epiglottectomy: endoscopic technique and indications

Endoscopic epiglottectomy (epiglottidectomy) may be performed with relative ease and minimal morbidity by using standard microlaryngoscopy techniques and the CO2 laser. Depending on the indications, the removal may be partial or complete. Indications for 51 epiglottectomies included treatment of supraglottic airway obstruction--30 cases; discovery of benign or malignant neoplasm (diagnosis and staging)--20 cases; treatment of malignant neoplasm--7 cases; glottic visualization--4 cases; and treatment of chronic inflammatory conditions--1 case. It is not unusual for a patient to have more than one indication for this procedure. Some epiglottic cancers invade the pre-epiglottic space. This crucial information may not be detectable by MRI or CT scanning techniques. Laser epiglottectomy provides a method to explore and perform a biopsy of the pre-epiglottic space and thereby stage these lesions accurately. There are no significant problems with postoperative alimentation, airway, or voice. Any form of primary or adjuvant therapy can be started without delay.

Chemodectoma of the larynx

Chemodectomas of the larynx are rare tumors. Only 35 cases were reported in the literature prior to the publication of this paper. We report a further case and discuss the problems associated with hemorrhage during surgery.

Transendoscopic Nd:YAG laser surgery for treatment of epiglottal entrapment and dorsal displacement of the soft palate in the horse

Transendoscopic neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was used to treat 12 standing horses with epiglottic entrapment (EE) or dorsal displacement of the soft palate (DDSP), or both. In four horses, transendoscopic laser staphylectomy was performed. The most common presenting complaints were respiratory stridor, cough, and exercise intolerance. Ten horses with EE healed without epiglottic complications; in one horse, partial adhesion of the aryepiglottic fold to one side of the epiglottis was corrected surgically through a laryngotomy incision. One horse with DDSP had no further signs, one continued to have continual DDSP, and two had induced DDSP. Transendoscopic Nd:YAG laser proved to be a feasible means of correcting EE and selected cases of DDSP.

Aryepiglottic fold excision for the treatment of severe laryngomalacia

Laryngomalacia is the most common laryngeal anomaly. Clinical presentation is most often associated with stridor, which usually resolves spontaneously by the second year of life. Infrequently, laryngomalacia can be severe and cause dyspnea and feeding difficulties. These children require surgical treatment, including tracheostomy. A new procedure has been recently described for the endoscopic excision of the aryepiglottic folds. The authors report results in 39 patients who have been treated with this procedure. One failure required tracheostomy. No recurrence of dyspnea was noticed in the other children. Gastroesophageal reflux, associated with 50% of our cases, was also noted in our only failure. We advocate endoscopic treatment in children with severe laryngomalacia.

Transendoscopic contact neodymium:yttrium aluminum garnet laser correction of epiglottic entrapment in standing horses

Fifty-seven Standardbred and 44 Thoroughbred racehorses and 1 Thoroughbred polo mare with primary clinical signs of exercise intolerance or respiratory tract noise or combined exercise intolerance and respiratory tract noise were referred for laser correction of epiglottic entrapment. Significantly (P less than 0.001) more Standardbred than Thoroughbred racehorses were affected, compared with the observed hospital population during the same period. At referral, 14 horses did not have evident epiglottic entrapment and were returned to exercise without development of entrapment after treatment, which consisted of 1 week of rest and administration of anti-inflammatory medication. In 88 standing horses under sedation and topical anesthesia, epiglottic entrapment was corrected transendoscopically by use of a contact neodymium:yttrium aluminum garnet laser. In these 88 horses, 98% of entrapments were persistent, 92% were thick, 97% were wide, and 45% were ulcerated. Thirty-one percent of the horses had endoscopic evidence of epiglottic hypoplasia, and 8% had deviated epiglottic axis. Complete correction was achieved in 97% of the horses, Persistent dorsal displacement of the soft palate in 1 horse and severe epiglottic hypoplasia with thick, chronic entrapping membranes in 2 horses precluded successful transendoscopic correction with the horses in standing position. Most horses were treated on an outpatient basis, and all were able to be returned to exercise after 7 to 14 days of rest and treatment with anti-inflammatory medication. Entrapment recurred in 4 horses (5%), 3 of which had hypoplastic epiglottis. Dorsal displacement of the soft palate developed after surgery in 9 horses (10%) and continued in 4 horses (5%) that had displaced soft palate before surgery. All these horses had epiglottic hypoplasia. Laser correction of epiglottic entrapment in standing horses was safe, well tolerated, and effective. Laser surgery was an alternative to conventional surgery, and eliminated the need for general anesthesia and laryngotomy. It also reduced convalescence and postoperative complications.

Epiglottic augmentation in the horse

Epiglottic augmentation with injectable bovine collagen or an autogenous or allogenous auricular cartilage graft was performed in 12 horses with endoscopically and radiographically normal epiglottises. The grafting procedures were easy to perform and did not cause apparent discomfort. Cartilage graft extrusion or resorption may have occurred, but was not seen by endoscopy and lateral laryngeal radiography. Only collagen implants remained evident endoscopically, as smooth round submucosal bulges ventral to the epiglottic cartilage. Two horses with collagen implants, and all horses with cartilage autografts and allografts, were euthanatized at week 16. One horse with a collagen implant was euthanatized at week 4 and one at week 6. The epiglottis appeared thickened in three horses with collagen implants, two horses with autogenous grafts, and three horses with allogenous grafts. Pharyngeal lymphoid tissue was hyperplastic in two horses with autografts and three horses with allografts, but not in horses with collagen implants. Collagen grafts persisted as one or two smooth bulges 8 mm in diameter. Collagen incited a brisk foreign body reaction that was surrounded by a fibrous connective tissue capsule. Epiglottises of the horses with collagen implants were significantly thicker 20 mm from the tip than those of normal horses and horses with allografts. Cartilage graft incorporation was not evident grossly and was seen on microscopic examination in only one autograft. Thickening was caused by submucosal fibrosis.

The "second" side of the neck in supraglottic cancer

The purpose of this study was to assess the impact of decisions made at operation for primary neck tumor on survival and cause of death-specifically, whether bilateral dissection, unilateral dissection, or delayed dissection influences eventual outcome. Of 244 patients with primary cancer of the supraglottis who were treated surgically, 22 (9%) had no neck treatment, 188 (77%) had unilateral neck dissection, and 34 (14%) had bilateral simultaneous neck dissection. Dissection on one or both sides of the neck was required later in 6 (27%) of the 22 patients with no neck treatment and in 32 (17%) of the 188 patients who had unilateral dissection. There were no differences among the treatment groups in the incidence of death from any cause or in the incidence of death from cancer, although neck stage did differ from group to group. The influence of delayed metastasis on survival was analyzed to explain these findings. Multivariate analysis demonstrated that death occurred at a rate 1.81 times higher in a person with a positive neck stage than in a person of the same age who had a negative stage. Also, death occurred at a rate 1.5 times higher for a person 10 years older than for a person with the same stage of disease. The influence of stage on the probability of need for a second dissection indicated that a patient with a positive neck stage had a 6.3 times greater likelihood of requiring a subsequent neck dissection than a person with a negative neck stage.

Cancer of the tongue base treated by a transpharyngeal approach

Tongue base resection plays an important role in the management of the patient with cancer of the posterior tongue. The considerable morbidity resulting from loss of functional tongue includes compromised deglutition, chronic aspiration, and altered speech articulation. The particular operative approach used dictates additional secondary morbidity, which may include cosmetic and functional defects of the mandibular arch, malocclusion, lip and chin scars, and postoperative changes in the oral cavity. Our recent experience with a transpharyngeal approach in 13 patients with tongue base cancer is reviewed. Adequate operative exposure was obtained in all cases. Persistent aspiration was not a problem, and all patients learned to swallow effectively. The transpharyngeal approach avoids unnecessary surgical trauma to the mandible and anterior oral cavity and minimizes cosmetic deformity. Our early experience with this approach is encouraging.

Surgery of the upper respiratory tract in the racehorse

The authors discuss the surgical treatment of selected diseases of the upper airway of the racehorse. Although most of these conditions occur commonly and are easily diagnosed, their surgical management is often less straight-forward and may be surprisingly controversial. The authors' intent is to provide an overview of these problems and give some information regarding current treatment options.

Upper airway function during maximal exercise in horses with obstructive upper airway lesions. Effect of surgical treatment

Upper airway pressure was measured during maximal exercise in 10 Thoroughbred racehorses with naturally occurring upper airway obstruction. Left laryngeal hemiplegia and arytenoid chondropathy resulted in substantial increases (30-40 cm H2O) in inspiratory upper airway pressure (Pl), whereas complicated aryepiglottic entrapment and subepiglottic cysts produced only modest increases (15 cm H2O) in Pl. Uncomplicated aryepiglottic entrapment and grade IV pharyngeal lymphoid hyperplasia produced only slight increases (3-5 cm H2O). In general, surgical procedures restored airway pressures to within normal limits. Subtotal arytenoidectomy improved but did not normalize airway pressures in horses with arytenoid chondropathy. Pharyngeal lymphoid hyperplasia appeared to have little effect on upper airway function.

[Modifications of the technic of endolaryngeal extirpation. The author's own functional technic of laryngectomy]

A brief summary of the original technique will be made incorporating the following modifications and additions: glottis substituted by neoglottis muscles, sternohyoid or external perichondrium. Supraglottis substituted by remaining tissues of the epiglottis or neoepiglottis. Hypopharynx, section medium line of the pharynx constrictor. Suturing of cartilage with homologous donor cartilage. An evaluation will be made of the functional results.

Near-total laryngectomy with epiglottic reconstruction. Long-term results

A previous report reviewed the technique and indications for near-total laryngectomy with epiglottic reconstruction in the management of squamous cell carcinoma of the glottis. This approach permits removal of most of both vocal folds, with immediate reconstruction using the epiglottis without the need for stenting or multistage procedures. Forty-eight patients underwent the procedure and were followed up for at least 2 years or until death. Seventeen underwent the surgery for recurrence after failure of radiation therapy for cure. Complications included one wound infection and one laryngocutaneous fistula. All patients underwent decannulation, with little or no compromise of swallowing. All but 1 now have functional voices. Of 8 patients with recurrence, 6 have been salvaged. Two patients died of disease. The value of near-total laryngectomy with epiglottic reconstruction for management of glottic cancer is reviewed.

Lateral arm free flap in oral cavity reconstruction: a functional evaluation

By use of sophisticated techniques now available from the science of Speech Pathology, we can now document, quantify, and critically analyze the surgeon's reconstructive efforts in the oral cavity. Using these methods, we have evaluated the neurotized lateral arm free flap in six patients receiving oral reconstruction. Two of these are reported in detail. This study has provided a protocol that results in the objective analysis of swallowing, articulation, and range of tongue motion and sensation. All of these tests can be routinely performed by a speech pathologist to document both operative performance as well as patient progress in speech and swallowing. It would appear that we have quantified evidence that the neurotized lateral arm free flap may represent a significant step forward in reducing the morbidity of total and subtotal glossectomy by providing a truly functional reconstruction.

Mucoepidermoid carcinoma of the larynx in a child

Laryngeal carcinoma in childhood is rare and most commonly classified as squamous cell carcinoma. Although mucoepidermoid carcinoma of the larynx has been noted in adults, it has not previously been reported in a child. A 13-year-old boy presented to our department with an epiglottic mass which was determined histologically to be mucoepidermoid carcinoma. A total epiglottectomy was performed and one year postoperatively the child is without disease.

Endoscopic surgical management for laryngomalacia. Case report and review of the literature

Laryngomalacia is the most common of the many causes of respiratory stridor in the newborn. It may be identified by fiberoptic nasopharyngoscopy in the nursery or office. Several anatomic mechanisms of supraglottic collapse have been reported in the literature. The most common is a narrowing of the supraglottic airway with blockage of the glottic opening by the redundant tissue of the aryepiglottic folds. Although surgery rarely is indicated, severe airway obstruction, necessitating surgical intervention, can occur. Resection of supraglottic tissue should be performed only as an alternative to tracheotomy. Surgical procedures ranging from tracheotomy to epiglottidectomy have been advocated. Direct visualization of the obstructing tissue by nasopharyngoscopy allows the planning of an appropriate surgical procedure. In a patient with lateral supraglottic collapse, deep resection of the epiglottis would be expected to weaken the support of the aryepiglottic folds and aggravate the airway condition. Similarly, resection of tissue along the aryepiglottic folds will be useful only if preoperative evaluation demonstrates the obstruction to be at this location.

Laryngomalacia. A review and the surgical management for severe cases

Laryngomalacia with its characteristic inspiratory collapse of lax supraglottic tissues into the laryngeal inlet may on occasion cause obstruction of such severity as to require airway intervention. The anatomy of the condition and the physiological explanation for its clinical presentation are examined and the pathological changes that precipitate a life-threatening situation discussed. Surgical correction of the abnormal tissue represents an acceptable alternative to tracheostomy in this situation. Simply 'trimming' the lax tissue over the arytenoid mounds may suffice in some cases but complications can occur and stabilisation of the epiglottis should be attempted as well. A series of 11 infants on whom such surgery was performed is presented with discussion of the surgical procedures performed and the complications experienced. The current uniformly successful surgical management of severe laryngomalacia by 'supraglottic trimming' combined with 'anterior epiglottopexy' is advocated for correction of severe laryngomalacia.

Epiglottoplasty for the treatment of laryngomalacia

Laryngomalacia is the most common congenital laryngeal anomaly. Patients present with different degrees of stridor and feeding problems that usually resolve by 18 months of age. A small number present with severe feeding problems, failure to thrive, stridor with cyanosis, and apnea, which may result in cardiopulmonary disease. These infants require surgical intervention, usually a hyomandibulopexy or tracheotomy. We present a new procedure, epiglottoplasty, that is performed endoscopically and involves excision of redundant mucosa over the lateral edges of the epiglottis, aryepiglottic folds, arytenoids, and corniculate cartilages. Ten patients have undergone this procedure with good results. Epiglottoplasty represents an alternative to tracheotomy in severe laryngomalacia. Indications, techniques, postoperative management, and complications are presented.

Epiglottopexy: a modification using additional hyoid suspension

A case of non-progressive severe laryngeal incompetence is described in which, in addition to the already established operation of epiglottopexy and cricopharyngeal myotomy, a laryngeal suspension using a carbon fibre implant is performed. This provides additional protection to the laryngeal inlet, thus obviating the need for a long-term tracheostomy.

[Therapeutic and palliative lymph drainage in therapy of edema in the face and neck]

Therapeutic drainage of lymphedema can alleviate facial and cervical edema after surgery or irradiation. It is fully justified even in a malignant tumour with a hopeless prognosis, although there is a risk of increasing the tendency to metastasis.

Epiglotto-aryepiglottopexy: a surgical procedure for severe aspiration

The loss of the protective function of the larynx is a severe complication of major ablative procedures in the upper aerodigestive tract and of certain severe neurological disorders. This may result in chronic life-threatening aspiration. Anterior pharyngotomy was used to perform epiglotto-aryepiglottopexy in four patients. The aim of this procedure is to close the laryngeal inlet and thus prevent aspiration without permanent loss of speech. In two of the patients, it was necessary to reoperate because of partial detachment of the epiglottis. This was performed successfully using the endoscopic approach. As a result, three patients have no aspiration and one has mild aspiration following epiglotto-aryepiglottopexy.

Airway interruption in encephalopathic children: a clinical and histological analysis

Severe, incessant aspiration can be a most troublesome sequel to the already tragic problem of a vegetative mental state in a previously normal child. Three patients, aged 2 to 4 years, underwent surgery to treat their aspiration. A different type of procedure was used for each patient: cord closure combined with an epiglottic flap, cord closure alone, and a laryngeal stent. Laryngeal histopathology of a case is presented for the first time; findings suggest that the theoretical reversibility of that particular type of procedure could prove formidable. Clinically, the immediate cessation of aspiration has provided all parents and health care personnel with a surprising sense of gratification and has enabled each child to be transferred to a less-costly care facility or to home.

Laser division of the aryepiglottic folds for severe laryngomalacia

Laryngomalacia is an entity of ill-defined etiology. The clinical situation is one of inspiratory stridor present at birth, or within the newborn period. The stridor may increase in severity for the first several months of life and thereafter spontaneously begins to resolve. In the majority of cases the condition resolves spontaneously by approximately two years of age. This report will present the surgical management of severe laryngomalacia in infants using the carbon dioxide laser to surgically divide the aryepiglottic fold with resolution of the laryngomalacia.

Epiglottis in reconstruction of the larynx and trachea

Many methods have been proposed for reconstruction of the larynx and trachea. An ideal method would utilize tissue which is native to the area, highly viable, convenient to the surgeon, and expendable to the patient. This tissue should be composite, that is, containing both epithelium and skeletal support. This paper describes the use of epiglottis in repair of laryngeal and tracheal defects due to cancer or trauma. The methods of repair include 1) pedicled composite epiglottic flap, 2) free composite epiglottic graft, and 3) pedicled epiglottic mucosal flap. Results in 15 patients are discussed and indicate that use of the epiglottis is an effective method for one-stage laryngotracheal reconstruction.

Transendoscopic electrosurgery for epiglottal entrapment in the horse

Monopolar electrosurgical cutting was used to correct epiglottal entrapment in 5 horses. The operations were carried out in the conscious animal, using topical anesthesia. The procedure required the use of a coagulation electrode designed specifically for electrosurgery, introduced through the instrument channel of a fiberoptic endoscope. The results were satisfactory and serious complications were not encountered. In 2 horses, excessive submucosal swelling developed at the site of the surgical wound, and the tumefaction took several weeks to subside in one of these horses. In both horses, the long-term outcome was a minor degree of reentrapment. The main advantages of this technique, compared with other corrective procedures, related to the avoidance of the need for general anesthesia and laryngotomy, allowing racehorses to be treated without any major interruption in their training schedules. The surgery was simple, rapid, and bloodless, and was not followed by any dorsal displacement of the soft palate. It was suggested that transendoscopic electrosurgery has potential for use in the treatment of a number of other diseases of the respiratory tract and other systems, both in the horse and in other species. In the equine respiratory tract, the technique might usefully be applied to the treatment of guttural pouch tympany, soft palate cysts, nasopharyngeal polyps, choanal atresia, subepiglottic cysts, and tracheal granulomata. A review of 21 cases of epiglottal entrapment in horses revealed no evidence to support the suggestion that dorsal displacement of the soft palate is a cause of epiglottal entrapment or vice-versa.(ABSTRACT TRUNCATED AT 250 WORDS)

Airway-obstructing epiglottic cyst

Laryngeal cysts, particularly epiglottic cysts, are generally benign lesions which cause mild dysphagia or hoarseness. We report a case of an epiglottic cyst that caused almost complete airway obstruction. A 43-year-old man presented with progressive dysphagia, hoarseness, and airway obstruction secondary to a large cystic mass involving the entire epiglottis and filling the hypopharynx. He required emergency tracheotomy to secure the airway, and the cyst was incised and drained. Following a subsequent recurrence, laser excision of the cyst was performed and the problem resolved. The cystic mass was found to fill the valleculae, and involved the lingual and laryngeal surfaces of the epiglottis and the left false vocal cord. A review of laryngeal cysts is presented with emphasis on anatomic and embryologic considerations. The potential lethal nature of these lesions is emphasized.

Sarcoidosis of the larynx treated with CO2 laser

A case of sarcoidosis of the larynx is described. The definitive treatment consisted of transoral partial supraglottic resection using the CO2 laser. Longterm follow-up results are shown by a photograph.

Epiglottic reconstruction after supraglottic laryngectomy

It has been well established that supraglottic laryngectomy is an effective treatment of laryngeal cancer arising above the vocal cords with cure rates equaling total laryngectomy. Although there is preservation of a near normal voice after supraglottic laryngectomy, chronic aspiration occurs in some patients particularly after extended supraglottic laryngectomy or when there is associated compromised pulmonary function. During normal deglutition, the epiglottis serves to divert food to the pyriform fossae and partially covers the inlet to the airway. These important functions can be accomplished after supraglottic laryngectomy by reconstructing a neoepiglottis from an epiglottic remnant whenever one third or more of the epiglottis can be preserved which is microscopically free of tumor. Our results in 14 patients have shown no clinically significant aspiration after epiglottic reconstruction.