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Richard K, Gelbard A, Daniero J, Wootten CT. A Single Center Description of Adult and Pediatric Endoscopic Posterior Costal Cartilage Grafting. Otolaryngol Head Neck Surg 2024; 170:1117-1123. [PMID: 38234280 DOI: 10.1002/ohn.620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/26/2023] [Accepted: 12/02/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Posterior glottis impairment alters breathing, voicing, and swallowing. Bilateral vocal fold movement impairment (BVFMI) occurs when the vocal cords are fixed/remain midline. Studies inadequately assessed endoscopic posterior costal cartilage grafting (enPCCG) for BVFMI across broad ages. We aim to assess decannulation and prosthesis free airway in children and adults who have undergone enPCCG. STUDY DESIGN Retrospective cohort. SETTING Referral center. METHODS This study included adults and children who received enPCCG for BVFMI (2010-2018) and were followed for 35 months on average. The main outcome was successful decannulation of patients, or airway improvement in those without tracheostomy. Data on comorbidities, surgical complications, and interventions following surgery were collected. RESULTS Ten children and 11 adults underwent enPCCG for BVFMI. Eighty-one percent of patients had a tracheostomy at surgery; adults were more likely to have a tracheostomy at surgery (P = 0.035), and to undergo double-staged procedure (P = 0.035) and stent (P = 0.008). Average stent duration was 29.7 days. Overall decannulation rate was 76% (90% for children; 70% for adults). Children were more likely to receive postoperative intensive care unit care (P = 0.004). Adults had mean 4.4 post-enPCCG interventions per patient compared to children's mean 3.91 interventions. The most common interventions were steroid injection (17.6%) and balloon dilation (16%). Preliminary analysis suggests postoperative dysphonia was reported in 66.7% of patients; postoperative dysphagia was rare. CONCLUSION EnPCCG was more successful at achieving decannulation in children. Adults required additional interventions. A double-staged operation with prolonged stenting is recommended for adult patients. A majority of patients were decannulated at last follow-up.
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Affiliation(s)
- Kelsey Richard
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - James Daniero
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher T Wootten
- Vanderbilt Children's Hospital Pediatric Otolaryngology-Head and Neck Surgery, Nashville, Tennessee, USA
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2
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Shoffel-Havakuk H, Lahav Y, Shopen Y, Reuven Y, Bachar G, Hamzany Y. Dilation, Steroid Injection, and Cough Exercise for Correction of Posterior Glottic Stenosis. Laryngoscope 2023; 133:883-889. [PMID: 35815928 DOI: 10.1002/lary.30293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/14/2022] [Accepted: 06/14/2022] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Hagit Shoffel-Havakuk
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Lahav
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yoni Shopen
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Reuven
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaniv Hamzany
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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So RJ, Kavookjian H, Ben Or E, Snow GE, Akst LM, Hillel AT, Best SRA. Posterior Glottic Injury Following Prolonged Intubation in COVID-19 Patients. Otolaryngol Head Neck Surg 2023; 168:372-376. [PMID: 35998042 PMCID: PMC9947184 DOI: 10.1177/01945998221120005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/13/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to characterize the risk factors for posterior glottic injury (PGI) in patients with coronavirus disease 2019 (COVID-19) who underwent prolonged intubation. STUDY DESIGN This was a case-control study designed to assess the risk factors associated with development of PGI in COVID-19 patients who underwent prolonged intubation. SETTING This single-center study was conducted at a tertiary care academic hospital in a metropolitan area. METHODS We retrospectively reviewed patients who underwent prolonged intubation (≥7 days) for COVID-19 and compared those with PGI to those without. Patient demographics, comorbidities, and intubation characteristics were compared. Factors associated with PGI development among COVID-19 patients were assessed using multivariate regression. RESULTS We identified 56 patients who presented with PGI following prolonged intubation for COVID-19 and 60 control patients who underwent prolonged intubation for COVID-19 but did not develop PGI. On univariate analyses, the number of reintubations due to failed extubation efforts was significantly associated with development of PGI (odds ratio [OR], 2.9; 95% CI, 1.4-6.2). On multivariate analyses, patients with cardiovascular disease (OR, 3.3; 95% CI, 1.2-9.0); non-COVID-19 respiratory illnesses, which included obstructive sleep apnea and asthma (OR, 5.9; 95% CI, 2.0-17.8); and diabetes mellitus (OR, 11.6; 95% CI, 3.7-36.6) were more likely to develop PGI. CONCLUSION Our results represent the largest case-control study investigating risk factors for PGI in the setting of prolonged intubation specific to COVID-19. Our study suggests a significant role of comorbidities associated with poor wound healing with development of PGI.
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Affiliation(s)
- Raymond J So
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hannah Kavookjian
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Esther Ben Or
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Grace E Snow
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lee M Akst
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Simon R A Best
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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4
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Functional outcomes after transoral CO 2 laser treatment for posterior glottic stenosis: a bicentric case series. Eur Arch Otorhinolaryngol 2023; 280:249-257. [PMID: 35819506 DOI: 10.1007/s00405-022-07516-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/14/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE The aim of this study is to evaluate functional outcomes in terms of decannulation rate and quality of life of patients affected by PGS (Grades I-IV) treated only by transoral CO2 laser microsurgery (TOLMS) in two tertiary centers. METHODS An observational retrospective study was carried out, enrolling 22 patients affected by PGS who were treated by a transoral approach at two tertiary referral centers. Surgical treatment included TOLMS with tailored laser resection of the scar tissue combined with posterior cordotomy, resurfacing of the raw area with mucosal microflap, or placement of a Montgomery T-tube or Keel stent. All patients were evaluated and staged preoperatively and postoperatively, at least 6 months after the surgery. Functional outcomes were objectively evaluated by the Airway-Dysphonia-Voice-Swallowing (ADVS) staging system, Voice Handicap Index-30 (VHI-30), and Eating Assessment Tool-10 (EAT-10) questionnaires. RESULTS Quality of life significantly improved as measured by the VHI-30 questionnaire with a median variation of - 31.0 (p = 0.003), the EAT-10 with a median variation of - 4.0 (p = 0.042), and the ADVS with a median variation of - 3.5 (p < 0.001). No significant changes were observed in swallowing scores. We were able to decannulate 7 of 9 patients (almost 80%) with previous tracheotomy. CONCLUSION In conclusion, even if there is still no general agreement on an exact therapeutic algorithm to treat PGS, our results confirm that transoral surgery, in terms of scar tissue removal, combined in selected patients with posterior cordotomy and pedicled local flaps and/or placement of stents, represents a safe and effective surgical approach even for more severe PGS.
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Melley LE, Alnouri G, Sataloff RT. A Novel Surgical Technique for Posterior Glottic Stenosis Using a Silastic Implant. J Voice 2023; 37:110-116. [PMID: 33358410 DOI: 10.1016/j.jvoice.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/28/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To introduce a novel surgical technique for the management of posterior glottic stenosis (PGS). METHODS Literature review (PubMed 1973-2020) and case example of a patient treated with novel technique by principal investigator (R.T.S.) RESULTS: Numerous techniques for the treatment of PGS have had varying success. Our patient, a 67-year-old male with a 2-year history of posterior glottic stenosis secondary to multiple, prolonged intubations previously had been treated with several surgical and medical interventions. Three weeks following an additional endotracheal intubation, he presented to our office with PGS recurrence, exhibiting hoarseness, and shortness of breath with any physical activity. He was treated with a silastic sheet placed through a tunnel in the stenosis and sutured posteriorly as a stent. The stent was removed 3 weeks later and the remaining stenosis was divided, successfully treating our patient's PGS with long-term improvement in both respiratory and voice complaints. This led to the design of a stent to be used for this purpose. CONCLUSIONS This new surgical technique addresses a complex clinical problem and provides otolaryngologists with a minimally invasive option for the surgical treatment of PGS that offers advantages over existing techniques. The two-stage procedure should reduce the risk of recurrence, but more experience is needed. This novel implant may be a valuable tool in the treatment of select patients with mild-moderate PGS.
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Affiliation(s)
- Lauren E Melley
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, and Lankenau Institute for Medical Research, Philadelphia, Pennsylvania
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, and Lankenau Institute for Medical Research, Philadelphia, Pennsylvania.
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Chen LW, Lina I, Motz K, Berges AJ, Ospino R, Seo P, Hillel AT. Factors Affecting Dilation Interval in Patients With Granulomatosis With Polyangiitis-Associated Subglottic and Glottic Stenosis. Otolaryngol Head Neck Surg 2021; 165:845-853. [PMID: 33845664 DOI: 10.1177/01945998211004264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Subglottic stenosis (SGS) is a known complication of granulomatosis with polyangiitis (GPA). We investigated the impact of medical and surgical interventions on the surgical dilation interval and characterized patients with glottic involvement. STUDY DESIGN A retrospective chart review of patients with GPA-associated SGS was performed from 2010 to 2019. SETTING Tertiary academic medical center. METHODS The impact of medical and surgical interventions on dilation interval was assessed. The prevalence of glottic involvement was assessed, and clinical characteristics and outcomes were compared with patients without glottic involvement. RESULTS A total of 39 patients with GPA-associated SGS were analyzed. Dilation intervals in patients receiving leflunomide (n = 4; median, 484 days; 95% CI, 405-1099) were greater than in those not receiving leflunomide (median, 155 days; 95% CI, 48-305; P = .033). The surgical technique used did not affect dilation interval. Patients with glottic involvement (n = 13) had a greater incidence of dysphonia (13/13 vs 15/26 [58%], P = .007) and a shorter dilation interval with involvement (median, 91 days; interquartile range, 70-277) versus without involvement (median, 377 days; interquartile range, 175-1148; hazard ratio, 3.38; 95% CI, 2.26-5.05; P < .001). Of 13 patients, 8 (62%) did not have glottic involvement on first presentation. CONCLUSION Although GPA is classically thought to affect the subglottis, it also involves the glottis in a subset of patients. These patients have greater complaints of dysphonia and require more frequent surgery. Systemic therapy may increase dilation intervals. In this preliminary study, patients taking leflunomide demonstrated an improvement, highlighting the need for further study of immunosuppression regimens in the treatment of GPA-associated SGS.
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Affiliation(s)
- Lena W Chen
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ioan Lina
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kevin Motz
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexandra J Berges
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rafael Ospino
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip Seo
- The Johns Hopkins Vasculitis Center, Department of Rheumatology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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7
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Kremer C, Jiang R, Singh A, Sukys J, Brackett A, Kohli N. Factors Affecting Posterior Glottic Stenosis Surgery Outcomes: Systematic Review and Meta-analysis. Ann Otol Rhinol Laryngol 2021; 130:1156-1163. [PMID: 33641352 DOI: 10.1177/0003489421997278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Candice Kremer
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Roy Jiang
- Yale University School of Medicine, New Haven, CT, USA
| | - Amrita Singh
- Yale University School of Medicine, New Haven, CT, USA
| | - Jordan Sukys
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Nikita Kohli
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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8
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Ghodke A, Tracy LF, Hollis A, Adams K, Shah RN, Buckmire RA. Combined Transverse Cordotomy- Anteromedial Arytenoidectomy for Isolated Glottic Stenosis. Laryngoscope 2021; 131:2305-2311. [PMID: 33577090 DOI: 10.1002/lary.29438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Glottic stenosis is a discrete cause of airway compromise. We aimed to determine the surgical outcomes of transverse cordotomy with anteromedial arytenoidectomy (TCAMA), performed in the setting of isolated glottic stenosis resulting from two discrete etiologies: bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS). STUDY DESIGN Retrospective, analytic cohort study. METHODS Twenty-six patients with isolated glottic stenosis were treated with TCAMA between 2006 and 2019. A retrospective analysis determined decannulation rates and intervals, voice outcomes, swallowing outcomes, and reoperation rates postoperatively. Outcomes between the two etiologic cohorts were compared. RESULTS Of the 26 patients, 16/26 patients were diagnosed with PGS and 10/26 with BVFP. Eighteen patients required tracheotomies during their clinical course (11/16 PGS, and 7/10 BVFP), and 100% were ultimately decannulated. The PGS cohort required two-sided interventions more frequently than the BVFP cohort (45.5% vs. 0%, P = .066). Trach-dependent PGS patients required a longer time to achieve decannulation than BVFP patients by a factor of 2.38, although the difference was not statistically significant (102.3 days vs. 42.9 days, respectively, P = .113). Patients demonstrated a significant change in maximum phonation time but no statistically significant differences with preoperative versus postoperative voice outcomes like voice-related quality of life. All patients ultimately returned to their baseline swallow function postoperatively. CONCLUSION TCAMA is an effective treatment for surgical rehabilitation of glottic stenosis caused by both BVFP and PGS. Patient-reported outcomes of postoperative vocal function remain consistent following surgical intervention. Additional, prospective studies with greater power are warranted to validate the contrasting outcomes observed when applying this discrete surgical technique across two distinct diagnostic cohorts in this retrospective study. LEVEL OF EVIDENCE 4. Laryngoscope, 2021.
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Affiliation(s)
- Ameer Ghodke
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Lauren F Tracy
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts, U.S.A
| | - Alison Hollis
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Katherine Adams
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Rupali N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Robert A Buckmire
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
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Vahidi N, Wang L, Moore J. Posterior Glottic Stenosis Type I: Clinical Presentation and Postoperative Course. EAR, NOSE & THROAT JOURNAL 2020; 100:801S-804S. [PMID: 32141317 DOI: 10.1177/0145561320908482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Posterior glottic stenosis (PGS) is a process that results in partial or total fixation of the vocal folds. Type I PGS (PGS-1) is an uncommon clinical entity that results from an interarytenoid adhesion/scar band that is separate from the posterior interarytenoid mucosa. We present a case series of patients with PGS-1 treated at our institution to contribute to the understanding of this complex clinical entity.
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Affiliation(s)
- Nima Vahidi
- Department of Otolaryngology-Head and Neck Surgery, 72054Virginia Commonwealth University, Richmond, VA, USA
| | - Lexie Wang
- Department of Otolaryngology-Head and Neck Surgery, 72054Virginia Commonwealth University, Richmond, VA, USA
| | - Jaime Moore
- Department of Otolaryngology-Head and Neck Surgery, 72054Virginia Commonwealth University, Richmond, VA, USA
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10
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Silva Merea V, Sadoughi B. Type I Posterior Glottic Stenosis: Natural History and In-Office Management. Ann Otol Rhinol Laryngol 2019; 128:1073-1077. [DOI: 10.1177/0003489419854777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Valeria Silva Merea
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak Sadoughi
- Sean Parker Institute for the Voice, Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA
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11
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Atallah I, MK M, Al Omari A, Righini CA, Castellanos PF. Cricoarytenoid Joint Ankylosis: Classification and Transoral Laser Microsurgical Treatment. J Voice 2019; 33:375-380. [DOI: 10.1016/j.jvoice.2017.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/23/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
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12
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Cates DJ, Magnetta MJ, Smith LJ, Rosen CA. Novel, anatomically appropriate balloon dilation technique of the glottis to treat posterior glottic stenosis in a 3D‐printed model. Laryngoscope 2019; 129:2239-2243. [DOI: 10.1002/lary.27524] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Daniel J. Cates
- Department of OtolaryngologyUniversity of Pittsburgh Pittsburgh Pennsylvania U.S.A
| | - Michael J. Magnetta
- Department of RadiologyUniversity of Pittsburgh Pittsburgh Pennsylvania U.S.A
| | - Libby J. Smith
- Department of OtolaryngologyUniversity of Pittsburgh Pittsburgh Pennsylvania U.S.A
| | - Clark A. Rosen
- Department of OtolaryngologyUniversity of Pittsburgh Pittsburgh Pennsylvania U.S.A
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Szabó D, Kovács D, Endrész V, Igaz N, Jenovai K, Spengler G, Tiszlavicz L, Molnár J, Burián K, Kiricsi M, Rovó L. Antifibrotic effect of mitomycin-C on human vocal cord fibroblasts. Laryngoscope 2019; 129:E255-E262. [PMID: 30618152 DOI: 10.1002/lary.27657] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/05/2018] [Accepted: 10/10/2018] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Diána Szabó
- Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Szeged, Hungary
| | - Dávid Kovács
- Department of Biochemistry and Molecular Biology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Valéria Endrész
- Department of Medical Microbiology and Immunobiology, Szeged, Hungary
| | - Nóra Igaz
- Department of Biochemistry and Molecular Biology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Kitti Jenovai
- Department of Biochemistry and Molecular Biology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | | | | | - József Molnár
- Department of Medical Microbiology and Immunobiology, Szeged, Hungary
| | - Katalin Burián
- Department of Medical Microbiology and Immunobiology, Szeged, Hungary
| | - Mónika Kiricsi
- Department of Biochemistry and Molecular Biology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - László Rovó
- Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Szeged, Hungary
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Atallah I, Manjunath MK, Omari AA, Righini CA, Castellanos PF. Reconstructive transoral laser microsurgery for posterior glottic web with stenosis. Laryngoscope 2016; 127:685-690. [DOI: 10.1002/lary.26212] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/10/2016] [Accepted: 06/27/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Ihab Atallah
- Division of Otolaryngology, Department of Surgery; University of Alabama at Birmingham; Birmingham Alabama U.S.A
- Otolaryngology-Head and Neck Surgery Department; Grenoble University Hospital; Grenoble France
| | - M. Krishniah Manjunath
- Division of Otolaryngology, Department of Surgery; University of Alabama at Birmingham; Birmingham Alabama U.S.A
- Department of Surgery; Colombia Asia Referral Hospital; Yeshwanthpur Bangalore India
| | - Ahmad Al Omari
- Division of Otolaryngology, Department of Surgery; University of Alabama at Birmingham; Birmingham Alabama U.S.A
- Division of Otolaryngology, Department of Special Surgery, Faculty of Medicine; Jordan University of Science and Technology; Irbid Jordan
| | | | - Paul F. Castellanos
- Division of Otolaryngology, Department of Surgery; University of Alabama at Birmingham; Birmingham Alabama U.S.A
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Cohen SM, Garrett CG, Netterville JL, Courey MS. Laryngoscopy in Bilateral Vocal Fold Immobility: Can You Make a Diagnosis? Ann Otol Rhinol Laryngol 2016; 115:439-43. [PMID: 16805375 DOI: 10.1177/000348940611500607] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: This study explores whether videoendoscopic findings and patient history help make the diagnosis in bilateral vocal fold immobility (BVFI). Methods: Medical records from 1995 to 2003 were searched to identify patients with posterior glottic stenosis (PGS) and bilateral vocal fold paralysis (BVFP) who also had videoendoscopic examinations. Videoendoscopic examination findings that could help differentiate PGS from BVFP were identified a priori. A weighted scoring index, based on the adjusted odds ratios of significant examination findings on multiple logistic regression, was derived. Associations between the weighted scoring index, patient history, and diagnosis were then evaluated. Results: Twenty-six patients with BVFP and 28 patients with PGS were identified. Posterior glottic scar (weight = 2), medial arytenoid erosion with a widened posterior glottis (weight =1), and appropriate vocal fold motion (weight = 1) were significant variables (p ≤ .05, multiple logistic regression) and constituted the weighted scoring index. A weighted scoring index of ≥ 2 and a history of prolonged intubation predicted PGS in 95.2% of cases. A weighted scoring index of ≤ 1 and a history of neck surgery predicted BVFP in 95.0% of cases. Conclusions: The weighted scoring index with the patient history provides an objective tool for diagnosing BVFI.
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Affiliation(s)
- Seth M Cohen
- Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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16
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Abstract
Objectives: Posterior glottic stenosis (PGS) is a disabling disease commonly induced by endolaryngeal injury from intubation or surgery. Few experiments on PGS prevention, however, have been performed. The purpose of this study was to investigate the preventive effect of mitomycin C (MMC) on PGS in a randomized, controlled animal study. Methods: Twenty-six rabbits underwent laser injury of 6 W, continuous-focus mode on the posterior glottis. There were 6 uninjured controls. Thirteen animals were treated by a single topical use of 0.4 mg/mL MMC solution on the injured posterior glottis for 5 minutes, and 13 were sham-treated controls. The posterior glottis of all groups was blindly evaluated by telescopic examination under direct laryngoscopy 2 months after injury and was harvested for histologic analyses. Results: Scar, granulation tissue, and synechia formation of the posterior glottis were clearly induced by laser injury. Microscopic examination showed increased collagen content and fibroblast proliferation in the region. The use of MMC significantly decreased the incidence of such gross and microscopic changes of the posterior glottis (p < .05). Conclusions: This study suggests that topical MMC can be helpful in preventing the progression of PGS from mucosal injury of the posterior glottis.
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Affiliation(s)
- Jong-Lyel Roh
- Department of Otolaryngology-Head and Neck Surgery, Cancer Research Institute, Chungnam National University College of Medicine, Daejeon, South Korea
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17
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Damrose EJ, Beswick DM. Repair of Posterior Glottic Stenosis with the Modified Endoscopic Postcricoid Advancement Flap. Otolaryngol Head Neck Surg 2016; 154:568-71. [DOI: 10.1177/0194599815622626] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 11/25/2015] [Indexed: 11/15/2022]
Abstract
Posterior glottic stenosis is a difficult clinical problem that frequently results in bilateral vocal fold immobility, dyspnea, and tracheostomy dependence. Charts were reviewed of all patients undergoing a modified endoscopic postcricoid advancement flap procedure for posterior glottic stenosis between October 1, 2003, and June 30, 2015. Age, sex, operative findings, complications, and outcomes were noted. Follow-up was available in 10 of 11 patients, 10 of whom were successfully decannulated. There were no complications. Regular diet was maintained in all patients. In patients with bilateral vocal fold immobility secondary to posterior glottis stenosis, endoscopic repair via endoscopic postcricoid advancement flap can restore full vocal fold motion and allow decannulation. In select patients with posterior glottic stenosis, repair via endoscopic postcricoid advancement flap should be considered in lieu of ablative methods, such as cordotomy, cordectomy, or arytenoidectomy.
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Affiliation(s)
- Edward J. Damrose
- Division of Laryngology, Department of Otolaryngology/Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel M. Beswick
- Division of Laryngology, Department of Otolaryngology/Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
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Acquired Glottic Stenosis-The Ongoing Challenge: A Review of Etiology, Pathogenesis, and Surgical Management. J Voice 2015; 29:646.e1-646.e10. [PMID: 25795359 DOI: 10.1016/j.jvoice.2014.10.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/22/2014] [Indexed: 11/21/2022]
Abstract
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.
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Hatcher JL, Dao AM, Simpson CB. Voice Outcomes After Endoscopic Treatment of Laryngotracheal Stenosis. Ann Otol Rhinol Laryngol 2014; 124:235-9. [DOI: 10.1177/0003489414551980] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: This study aimed to assess vocal disability in patients with laryngotracheal stenosis who are managed with endoscopic surgery, comparing patients with posterior glottic stenosis (PGS) to those with subglottic or tracheal stenosis (SGS/TS). Methods: Patients who underwent endoscopic treatment for laryngotracheal stenosis with voice outcomes data from 2005 to 2013 were studied. The mean Voice Handicap Index–10 (VHI-10) was compared over the study period. Of those with SGS/TS, the distance from the vocal folds to the proximal portion of the stenosis was obtained and compared to VHI-10. Results: Forty-four patients met inclusion criteria. The mean VHI-10 for all patients was 14.6. Fifty percent were dysphonic (VHI-10 > 11). The mean VHI-10 for PGS patients was 22.4, and for SGS/TS patients, 10.9 ( P = .004). Of those with PGS, 78.6% were dysphonic compared to only 36.7% of those with SGS/TS. Voice Handicap Index–10 improved from 14.1 for those with proximal stenosis to 4 for those with stenosis more than 2 cm distal to the vocal folds. Conclusion: Following endoscopic management of stenosis, those with PGS have poorer voice outcomes compared to those with SGS/TS. The majority of those with SGS/TS are not dysphonic. Vocal outcomes are greatest for those with stenosis beginning at least 2 cm distal to the vocal folds.
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Affiliation(s)
- Jeanne L. Hatcher
- University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Ashley M. Dao
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - C. Blake Simpson
- University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
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20
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Semmler M, Keck T, Reiter R, Gruen PM. Endolaryngeal posterior mucosal flap for surgical repair of posterior glottic stenosis. Auris Nasus Larynx 2011; 38:608-11. [DOI: 10.1016/j.anl.2010.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Revised: 12/27/2010] [Accepted: 12/28/2010] [Indexed: 11/24/2022]
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21
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Meyer TK, Wolf J. Lysis of interarytenoid synechia (Type I posterior glottic stenosis): Vocal fold mobility and airway results. Laryngoscope 2011; 121:2165-71. [DOI: 10.1002/lary.22036] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 05/20/2011] [Indexed: 11/11/2022]
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Post-intubation tracheoesophageal fistula with posterior glottic web. Clin Exp Otorhinolaryngol 2011; 4:105-8. [PMID: 21716949 PMCID: PMC3109326 DOI: 10.3342/ceo.2011.4.2.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 07/31/2009] [Indexed: 11/13/2022] Open
Abstract
Tracheoesophageal fistula (TEF) after prolonged intubation could present as chronic aspiration and could be mistaken as unilateral or bilateral vocal fold palsy, especially when there was combined posterior glottic synechia. We present a case of post-intubation TEF which was successfully treated with tracheal resection and anastomosis with primary esophageal closure. The accompanying posterior glottic web was treated by endoscopic technique of web lysis, with topical application of mitomycin C solution.
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George M, Jaquet Y, Ikonomidis C, Monnier P. Management of severe pediatric subglottic stenosis with glottic involvement. J Thorac Cardiovasc Surg 2010; 139:411-7. [DOI: 10.1016/j.jtcvs.2009.05.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 04/21/2009] [Accepted: 05/16/2009] [Indexed: 11/15/2022]
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Endoscopic surgical treatment of posterior glottic stenosis. The Journal of Laryngology & Otology 2010:68-71. [PMID: 19460208 DOI: 10.1017/s002221510900512x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A six-year-old girl developed posterior glottic stenosis following surgery for lateral curvature. She was post-operatively intubated for 17 days and had inspiratory stridor after extubation. Laryngoscopy revealed an adhesion at the posterior commissure which severely limited abduction of the bilateral vocal folds and arytenoids. Initially, tracheal fenestration was performed and the scar tissue of the posterior commissure was vaporised using a CO2 laser under endolaryngeal microsurgery. However, despite this procedure the stenosis reformed and an interarytenoid adhesion developed.Endolaryngeal microsurgery was performed again three months later. Using endoscopic microscissors, the posterior commissure and interarytenoid scar tissue were submucosally separated and the bilateral corniculate cartilages of the superior arytenoids were debulked using CO2 laser. A posteriorly based mucosal flap obtained from the postcricoid region was extended to approximate to the mucosa of the posterior commissure. The mucosal flap was sutured to the inferior subglottic mucosa by two 4-0 polyglactin absorbable sutures. Three months later, the patient's respiratory and phonatory function was satisfactory.Based on the successful results of the present case, the authors highly recommend the use of a posterior mucosal flap for the treatment of posterior glottic stenosis. This procedure does not require the use of either a laryngofissure or a laryngeal stent.
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Abstract
In summary, long-term complications of artificial airways are rare but important sequelae of artificial airways. Many of the potential long-term complications of translaryngeal intubation and tracheotomy are similar and overlapping. Although most patients who undergo these procedures tend to tolerate them without difficulties, significant morbidity and mortality may occur. Identifying the exact cause of the complication may not be possible at times, due to the multiple risk factors involved in the pathogenesis. It is hoped that understanding these potential complications will lead to a more vigilant preventive measures during the institution of long-term artificial airways and a judicious early search for the underlying pathology when a complication is suspected.
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Affiliation(s)
- Richard D Sue
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, 37-131 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095-1690, USA
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26
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de Mello-Filho FV, Antonio SM, Carrau RL. Endoscopically placed expandable metal tracheal stents for the management of complicated tracheal stenosis. Am J Otolaryngol 2003; 24:34-40. [PMID: 12579481 DOI: 10.1053/ajot.2003.6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Metal stents have been advocated to manage complicated tracheal stenosis. OBJECTIVE The purpose of this investigation is to review the effectiveness of endoscopic placement of tracheal expandable metal stents for complicated tracheal stenosis. METHODS The charts of 6 patients who have undergone placement of metal expandable stents between 1998 and 2000 were reviewed. RESULTS Initially, all patients enjoyed immediate palliation of symptomatic tracheal stenosis. Eventually, 4 patients developed significant granulation tissue and/or recurrent stenosis, requiring intervention within 6 months after placement of the stent. One patient required the removal of the stent and placement of a T-tube silicone stent. CONCLUSIONS Metal stents provide temporary palliation for tracheal stenosis. Metal stents, however, are associated with a high incidence of obstruction with granulation tissue. Their use should be limited to a select group of patients with a short life expectancy (because of other comorbidities) or patients who are not good candidates for reconstructive surgery and/or who refuse or cannot tolerate a tracheotomy.
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Abstract
OBJECTIVES To describe a new endoscopic technique for medialization of the laterally fixed arytenoid. The surgical technique, endoscopic arytenoid repositioning, is described, and the results of a series of cases are discussed. STUDY DESIGN Retrospective chart review. METHODS Eight patients underwent the procedure. Six patients were available for long-term follow-up. Preoperative and postoperative voice ratings were compared to evaluate the success of the procedure. Follow-up ranged from 3 to 64 months (mean follow-up, 31.5 mo). RESULTS Long-term follow-up in six cases revealed that 67% (4 of 6) patients had normal or near-normal postoperative voices and one patient experienced moderate improvement. The mean preoperative voice score was 4.24, and the mean postoperative voice score was 1.83 (range, 1-5). The difference was statistically significant (P < 0.001). CONCLUSIONS Endoscopic arytenoid repositioning is a newly described procedure with a very specific indication: a unilateral, laterally fixed arytenoid complex resulting in a severely dysphonic voice. Though technically demanding, this procedure provides a promising option for medialization of the posterior glottis in a scarred larynx.
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Affiliation(s)
- M R Amin
- Department of Otolaryngology, Medical College of Pennsylvania/Hahnemann School of Medicine, Philadelphia 19103, USA
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Gardner GM. Posterior glottic stenosis and bilateral vocal fold immobility: diagnosis and treatment. Otolaryngol Clin North Am 2000; 33:855-78. [PMID: 10918665 DOI: 10.1016/s0030-6665(05)70248-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Posterior glottic stenosis and bilateral vocal fold immobility cause obstruction of the airway at the glottis. Presentation of this problem may vary according to the cause. Full evaluation of the status of the larynx is crucial with regard to the mobility of the arytenoid cartilage and innervation of the laryngeal musculature. There are many techniques for surgically treating this condition, each with advantages and disadvantages. The surgeon should be familiar with a variety of these procedures and be able to adapt to each patient's situation.
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Affiliation(s)
- G M Gardner
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan 48202, USA.
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29
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Abstract
Derived from arytenoidectomy, different surgical techniques have been developed for widening the glottis in cases of bilateral vocal cord paralysis. Their anatomical bases were reinvestigated in plastinated serial sections of 25 adult human larynges. At the anterolateral surface of the arytenoid cartilage, blood vessels crossing the crista arcuata may cause bleeding complications. The arytenoid cartilage is related to three major histologic complexes which must be taken into account during surgery. The dense connective tissue complex consists of the cricoarytenoid ligament and the conus elasticus, which are connected ventrocaudally. The cricoarytenoid ligament and the vocal cord are separated by the cartilaginous inscription of the vocal process. The muscular complex consists of the transverse arytenoid muscle, which is the posterior wall of the glottis, and the thyroarytenoid muscle, which is intimately fixed to the conus elasticus near the arytenoid cartilage. The loose connective tissue complex is represented by the vestibular fold, containing adipose tissue, mucous glands, few collagenous fiber septa, and at its posterior end, a small cranial extension of the vocal cord. For glottic widening surgery, the arytenoid cartilage must be regarded as an integrated component of an extended fibro-cartilaginous framework supporting the laryngeal airway. Shrinking processes of the dense connective tissue elements may complicate surgical interventions. Iatrogenic lesions of the posterior glottis should be avoided to prevent the development of synechia or insufficient closure of the larynx during swallowing.
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Affiliation(s)
- M M Reidenbach
- Department of Anatomy, Rheinische Friedrich-Wilhelms-Universität, Bonn, Germany
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30
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Affiliation(s)
- A N Goldberg
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, USA
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Spector JE, Werkhaven JA, Spector NC, Huang S, Page RN, Baranowski B, Luther M, McGehee B, Reinisch L. Preservation of function and histologic appearance in the injured glottis with topical mitomycin-C. Laryngoscope 1999; 109:1125-9. [PMID: 10401854 DOI: 10.1097/00005537-199907000-00022] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the functional and histological effects of a single application of topical mitomycin-C after laser injury in the posterior canine glottis. STUDY DESIGN A prospective, randomized study of 16 canines. METHODS A supersaturated (1%) solution of topical mitomycin-C was applied to a unilateral, laser-induced injury near the cricoarytenoid joint in eight dogs. The mitomycin-soaked pledget was placed immediately after induction of the injury and was left in contact with exposed cartilage for 3 minutes. The opposite side was not injured to provide an internal control. In eight additional dogs, the same laser injury was allowed to heal untreated. After 6 weeks, the animals were sacrificed and their larynges harvested. Arytenoid adduction sutures were placed bilaterally, and the force required to bring the vocal folds to midline was measured for each side using tensiometry. Gross and microscopic histological analysis was performed. Statistical analysis was accomplished using a two-tailed Student t test of unpaired samples, and the Wilcoxon Signed Rank Test where appropriate. RESULTS The mitomycin-C treated larynges demonstrated improved cricoarytenoid joint mobility (P = .007), decreased granulation tissue development (P = .03), and complete prevention of secondary "vocal granuloma" formation (P = .0004) when compared with eight dogs with identical laser injuries allowed to heal untreated. No complications were noted. CONCLUSIONS This study demonstrates functional preservation and improved histological appearance of the injured glottis after a single treatment with topical mitomycin-C. Potential applications of these findings include prophylactic use of topical mitomycin-C on glottic insults that commonly progress from granulation tissue formation to scarring and decreased vocal fold function.
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Affiliation(s)
- J E Spector
- Department of Otolaryngology, Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2559, USA
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Abstract
INTRODUCTION Synechiae formation of the posterior glottis can result in tracheostomy dependence secondary to airway obstruction. Stenosis is caused by total or partial fixation of the vocal folds in adduction resulting from scar contracture. The treatment poses a management dilemma because of recurrent scar formation, made worse by mobility of the vocal folds. Although various treatment options from conservative endoscopic repair to open procedures have been proposed, the results are not satisfactory and patients often require multiple procedures. METHODS We present the trial of a conservative approach that includes microscopic CO2 laser resection of the scar with concomitant botulinum toxin injection of the interarytenoid and thyroarytenoid muscles of the more mobile cord. This results in a temporary paresis of the adductor muscles and hence prevents overadduction in the posterior commissure during the postoperative healing period. STUDY DESIGN We present the surgical technique and results in three patients who underwent the procedure. RESULTS Treatment in all three patients was successful. CONCLUSIONS The appropriate use of botulinum toxin may help improve the treatment outcome of posterior synechiae of the larynx without sacrificing any laryngeal components.
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Affiliation(s)
- C O Nathan
- Department of Otolaryngology/Head & Neck Surgery, Louisiana State University Medical Center, Shreveport 71130, USA.
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