Endoscopic Z-plasty for Treatment of Supraglottic Stenosis: Experience on Nine Patients

OBJECTIVES

Supraglottic stenosis is a rare type of laryngeal stenosis that is caused by congenital laryngotracheal anomalies, iatrogenic instrumentation injuries, autoimmune disorders, infection, irradiation, chemical or thermal burns, and external blunt or penetrating trauma. The author presents his experience on nine patients using this new endoscopic surgical technique for treatment of supraglottic stenosis.

STUDY DESIGN

Individual retrospective cohort study, tertiary referral center, university hospital.

METHODS

All cases of supraglottic laryngeal stenosis treated during a 10-year period at a tertiary academic medical center were reviewed. Nine patients with supraglottic stenosis treated with endoscopic uni- or bilateral z-plasty technique were determined and presented. The etiology of stenosis was iatrogenic surgical trauma in seven patients, laryngeal fracture in one patient, and systemic lupus erythematosus in the other patient. Main outcome measures were respiratory function test results, absence of dyspnea on exertion, and decannulation if tracheotomy was present preoperatively.

RESULTS

Seven patients with tracheotomy were decannulated 1 month after surgery. All nine patients had adequate airway and were dyspnea-free. Their preop respiratory function test results improved significantly postoperatively (P < .05).

CONCLUSION

For supraglottic stenosis endoscopic surgery using mucosal flaps in the form of z-plasty should be considered within the available surgical techniques. Although this type of surgery is highly successful, it is technically difficult to apply.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E534-E539, 2021.

Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review

OBJECTIVES

To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection.

METHODS

A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker's diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded.

RESULTS

An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death.

CONCLUSIONS

The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.

Surgical Management of Supraglottic Stenosis Using Intubationless Optiflow

Objective:

Airway management during endoscopic surgical treatment of supraglottic and pharyngeal stenosis is often challenging and can be accomplished by various means, including tracheostomy, jet ventilation, or direct laryngoscopy. We describe CO2 laser excision of supraglottic-pharyngeal stenosis using intubationless Optiflow high-flow nasal cannula (HFNC).

Methods:

A 55-year-old male presented with dyspnea and dysphagia secondary to severe supraglottic-pharyngeal stenosis in the setting of previous chemoradiation for a T0N2aM0 squamous cell carcinoma. Laryngoscopy revealed severe supraglottic-pharyngeal stenosis with tethering of the epiglottis to the lateral pharyngeal walls. Optiflow HFNC was used to deliver 70 L/min of oxygen. After anesthetic induction, CO2 laser microlaryngoscopy was utilized to release scar tissue along the lateral epiglottic border, opening up the supraglottic airway sufficiently for endotracheal intubation and further laser resection.

Results:

Airway management with Optiflow HFNC allowed initial endoscopic surgical access, partial stenotic release, and intubation. From anesthetic induction to intubation, the patient remained apneic for 26 minutes. The patient’s stenosis was successfully addressed, and 10-month follow-up demonstrated stable patency of the airway.

Conclusion:

Optiflow is an important new tool in the management of severe supraglottic stenosis. It provides sufficient oxygenation to perform extended apneic surgery and improves endoscopic surgical access in a limited airway.

Management of supraglottic stenosis using a novel stent design

OBJECTIVES

To present a novel design for a stent for management of a traumatic supraglottic web.

METHODS

Case report and literature review (PubMed 1964-2013).

RESULTS

A 48-year-old man was presented after penetrating laryngeal trauma. He had severe dysphonia and was tracheotomy dependent. He had been treated previously with open reduction and fixation of laryngeal fracture. On examination, we identified an avulsed left vocal fold and a supraglottic web. He initially underwent reapproximation of the avulsed left vocal fold, and subsequently, the supraglottic web was treated using a stent designed by the senior author (R.T.S.). In addition, he underwent later resection of scar tissue to improve dysphonia and then he was decanulated.

CONCLUSIONS

There are a few techniques presented in the literature and mostly are adaptations of subglottic stenosis management techniques. Individualized treatment is needed for these difficult cases. We present our experience with supraglottic web treatment to expand the literature on this uncommon disorder.