The butterfly procedure: a new technique and review of the literature for treating anterior laryngeal webs

Case Report: Ultrasound Guided Mucosal Fold Lateralization for Laryngeal Webs

The surgical management of Laryngeal webs is challenging and is associated with a high recurrence rate due the presence of opposing raw mucosal surfaces of the vocal cords, especially near the anterior commissure which causes re-scarring. We describe an endoscopic technique of mucosal flap lateralization (MFL) with ultrasound guidance, which prevents the apposition of the anterior raw surfaces of the vocal cords after web incision, thus avoiding recurrence.

Subglottic Mucosal Flap: Endoscopic Single-Stage Reconstruction for Anterior Glottic Stenosis

OBJECTIVES/HYPOTHESIS

Anterior glottic stenosis (AGS) results from surgical intervention, carcinoma, papillomatosis, congenital, or idiopathic causes. It may be present as elastic web or fibrotic scar. It impairs vocal function and glottic airway. Reconstructive options include resection and placement of a keel or glottic web-based mucosal flaps to prevent restenosis. These methods may not be sufficient for reconstructing a thick anterior scar and may require multiple interventions. The aim of the study was to describe the anterior subglottic mucosal flap (ASGMF), a one-stage, keel-free technique for AGS repair.

STUDY DESIGN

A retrospective cohort.

METHODS

Patients with AGS were operated using the ASGMF between 2017 and 2020. The stenotic segment was excised, and then an ASGMF was developed. A unilateral oblique incision was performed to allow rotation and advancement of the flap toward the contralateral vocal fold. The flap was sutured to the mucosal edge of the vocal fold to create mucosal continuity and prevent restenosis. Vocal fold length ratio (VFLR), which is between the free part and the total vocal fold length, as well as stroboscopic measures, were calculated before and after surgery.

RESULTS

Twelve patients were enrolled. Etiologies were iatrogenic, dysplasia, papillomatosis, carcinoma, and congenital. Average VFLR improved from 0.33 to 0.87 (P-value < .0001). Median amplitude and mucosal wave propagation improved from 12.3% and 9.5% to 28.6% and 22.7%, respectively (P-values = .0278, .0385). Phase symmetry improved from 24.5% to 60.9% (P-value = .0413). No complications were encountered.

CONCLUSIONS

ASGMF for AGS is an effective surgical procedure, allowing for one stage, keel-free reconstruction of the anterior commissure. ASGMF can significantly elongate the free portion of the vocal folds and improve vibratory function.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Congenital laryngeal webs: from diagnosis to surgical outcomes

Introduction

Congenital laryngeal webs are rare, may be associated with other airway abnormalities and be one of many features of microdeletion 22q11. Meticulous evaluation is imperative when deciding which surgical technique to use. The choice of appropriate stenting may be decisive to avoid persistent anterior commissure synechia and poor voice results.

Objective

To report outcomes for endoscopic and open surgical approaches in the treatment of congenital laryngeal webs and the challenges one may encounter while applying the current classification and deciding for the best treatment option.

Methods

Retrospective review of medical and surgical charts for congenital laryngeal webs treated in two tertiary university centers.

Results

Seven patients were included; following Cohen’s classification there were: three type II webs, one of them with an atypical posterior synechia, two type III webs and two type IV webs. Six patients were submitted to laryngotracheal reconstruction and one was treated with an endoscopic approach. Description of precise glottic and subglottic involvement and tailored surgical options are presented. The LT mold® stent was used for long-term stenting that varied between 40 to 60 days. All patients were successfully decannulated with good voice quality and after follow-up of over one year, there were no complications associated with the surgeries.

Conclusion

Congenital laryngeal webs should be suspected and thoroughly evaluated in the presence of neonatal dysphonia and early onset of laryngitis. Otolaryngologists must be familiar with associated lesions and genetic conditions that may be associated to congenital laryngeal webs. Congenital laryngeal webs may be successfully treated at an early age. The correct choice of surgical technique after meticulous evaluation of glottic and subglottic components of the web, presence of concomitant lesions and appropriate stenting, is imperative to avoid persistent scarring and poor voice quality.

Surgical Management of Anterior Glottic Webs

Congenital webs are rare and represent <5% of all congenital laryngeal anomalies. They are usually a partial laryngeal atresia rather than a true web, and present as a thick and fibrotic web with subglottic extension and associated subglottic stenosis. All patients with a congenital anterior glottic web should be evaluated for chromosome 22q11.2 deletion syndrome. Management strategies are mainly based on the severity of airway obstruction and the anatomical extension of the webs. Simple division of the web endoscopically may be adequate for rare thin webs, however, an open approach is usually warranted for thick glottic webs regardless of Cohen grades. Open repair can be either with keel placement or reconstruction of the anterior commissure.

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.

Surgical Treatment Modalities for Iatrogenic Anterior Glottic Stenosis

Objectives:

The aim of this study was to describe common iatrogenic causes of anterior glottic stenosis and to investigate the surgical treatment outcomes of 3 different techniques aimed at repairing stenoses and preventing web reformation.

Methods:

Clinical information regarding patient demographics, presentation, etiology, treatment, and follow-up outcomes was obtained retrospectively through a review of patients’ records between April 2010 and April 2017. Voice quality was evaluated using grade, roughness, breathiness, asthenia, and strain scale and Voice Handicap Index scores. Objective acoustic parameters were collected using the Kay Elemetrics Multi-Speech program.

Results:

Twenty patients were included in the study. Causes of glottic web formation included chemoradiation therapy and previous laryngeal surgery for polyps or malignant tumors at the anterior commissure. Web lysis with a CO2 laser, intralaryngeal suturing, and keel placement were used in surgical treatment. Satisfactory results were achieved in 19 patients, and 1 recurrence was observed. Grade, roughness, breathiness, asthenia, and strain scale and Voice Handicap Index scores and objective voice variables for patients with Cohen type I or II webs improved significantly after the surgery.

Conclusions:

Treatment modalities for anterior glottic stenosis should be carefully chosen according to the etiology of the web, as well as the length and depth of the glottis involved.

Prevention of laryngeal webs through endoscopic keel placement for bilateral vocal cord lesions

Transoral microresection for treatment of vocal cord lesions involving the anterior commissure may result in anterior glottic webs. In this study, we retrospectively reviewed 54 patients who underwent microsurgery for bilateral lesions involving the anterior commissure and categorized them into two groups. The keel placement and control groups received endoscopic keel placement and mitomycin C, respectively. During the follow-up of at least 1 year, the laryngeal web formation rate significantly decreased in the keel placement group compared with that in the control group (18.6% versus 54.5%, P < 0.05). Furthermore, the voice handicap index-10 scores for patients without web formation decreased in both the keel placement and control groups (P < 0.0001 and P < 0.001, respectively). A pseudomembrane covering the vocal cords was detected in 16.3% (7 of 43) cases after keel removal. A total of 100% (7 of 7) of these cases and 2.8% (1 of 36) of the other cases formed laryngeal webs (P < 0.0001). Endoscopic keel placement could be an effective method for preventing anterior glottic webs after surgery for bilateral vocal cord diseases involving the anterior commissure. The pseudomembrane observed at the time of keel removal may imply a high risk of web formation.

Web thickness determines the therapeutic effect of endoscopic keel placement on anterior glottic web

This work is a retrospective analysis to investigate the critical risk factor for the therapeutic effect of endoscopic keel placement on anterior glottic web. Altogether, 36 patients with anterior glottic web undergoing endoscopic lysis and silicone keel placement were enrolled. Their voice qualities were evaluated using the voice handicap index-10 (VHI-10) questionnaire, and improved significantly 3 months after surgery (21.53 ± 3.89 vs 9.81 ± 6.68, P < 0.0001). However, 10 (27.8%) cases had web recurrence during the at least 1-year follow-up. Therefore, patients were classified according to the Cohen classification or web thickness, and the recurrence rates were compared. The distribution of recurrence rates for Cohen type 1 ~ 4 were 28.6, 16.7, 33.3, and 40%, respectively. The difference was not statistically significant (P = 0.461). When classified by web thickness, only 2 of 27 (7.41%) thin type cases relapsed whereas 8 of 9 (88.9%) cases in the thick group reformed webs (P < 0.001). These results suggest that the therapeutic outcome of endoscopic keel placement mostly depends on the web thickness rather than the Cohen grades. Endoscopic lysis and keel placement is only effective for cases with thin glottic webs. Patients with thick webs should be treated by other means.

An Excised Canine Model of Anterior Glottic Web and Its Acoustic, Aerodynamic, and High-speed Measurements

OBJECTIVES

This study aims to build an excised anterior glottic web (AGW) model and study the basic voice-related mechanisms of the AGW through investigating the acoustic, aerodynamic, and vibratory properties.

STUDY DESIGN AND METHODS

Overall, four conditions were tested for each of the eight canine larynges used. At baseline, 10%, 20%, and 33% occlusion (as determined by the placement of the suture), acoustic, aerodynamic, and high-speed video data were collected while each larynx was phonated in a soundproof booth.

RESULTS

The phonation threshold pressure (PTP) and the phonation threshold flow significantly increased as percent occlusion increased (P < 0.001). There were significant increases in jitter % and shimmer % from baseline group to AGW model groups at PTP, 1.25 PTP, and 1.5 PTP (P = 0.039, P < 0.001, P < 0.001, P < 0.001, P < 0.001, and P = 0.001, respectively). The fundamental frequency significantly increased as percent occlusion increased at all given pressures (P < 0.001). Correlation dimension (D2) was significantly higher in the AGW model groups than in the baseline group at PTP, 1.25 PTP, and 1.5 PTP (P = 0.002, P < 0.001, P = 0.01, respectively). High-speed videos revealed that, the left phase shift in the AGW model groups compared with the baseline at 1.25 PTP was significant (P = 0.027) and right phase shift at 1.5 PTP (P < 0.001).

CONCLUSIONS

We presented an anatomically similar model of a type 1 AGW and confirmed its validity through aerodynamic, acoustic, and high-speed video analysis in our study. We observed and investigated the glottic web movement, which may be a new explanation for the pathologic voice-related mechanism of AGW.

Type IV congenital laryngeal web: Case report and 15 year follow up

A five day old patient with mild VACTERL syndrome had repair of a type IV congenital laryngeal web with successful decannulation 76 days later. Voice and respiratory outcome is good with follow up 15 years later. This case presents a rare clinical finding of a type IV laryngeal web successfully repaired with a keel and subsequent long term follow up during an era when it was suggested that repair be delayed until 18 months of age at the earliest.

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.

Suturing silastic sheet from outside into larynx cavity: measurement of angles and clinical practice

CONCLUSION

Extra-endolaryngeal cavity puncturing with reasonable puncturing angles is an alternative method for implantation of silastic sheets when the Lichtenberger needle holder is unavailable.

OBJECTIVES

To determine reasonable extra-endolaryngeal puncturing angles for implantation of laryngeal silastic sheet and to observe the effect on treating and preventing glottic webs.

METHODS

Puncture processes were conducted via extra-endolaryngeal access. For the upper puncture, the needle was inserted into the bottom of the epiglottic petiole superior to the anterior commissure through the thyrohyoid membrane. For the lower puncture, the needle was delivered into the inferior to anterior commissure (equivalent to the inferior border of the vocal cords) through the cricothyroid membrane. The upper and lower puncture angles between puncture needles and the tangential line of the thyroid cartilage were measured in 14 cadavers. Silastic sheets were implanted into laryngeal cavities in 20 patients to treat or prevent anterior glottic webs.

RESULTS

The mean value of the upper puncture angle was 30° (range 23.5-39°) while the lower puncture angle was also 30° (24-40°). Surgery procedures for implanting silastic sheets succeeded in 20 patients by extra-endolaryngeal puncture access. The average numbers of upper and lower punctures were 2 and 1.6, respectively. At follow-up none of the 20 patients had webs or had only 1 mm adhesion area.