[Repairing partial suprahyoid epiglottis-preserved circumferential defect in near total laryngectomy with anterior medial thigh flap in advanced laryngeal cancer]

Objective

To explore the feasibility to restore pronunciation function by repairing partial suprahyoid epiglottis-preserved circumferential defect in near total laryngectomy with anterior medial thigh flap in advanced laryngeal cancer.

Methods

A retrospective study of 5 male patients with advanced laryngeal cancer between August 2019 and October 2022, aged 56-73 years, with an average age of 65 years were reviewed. The disease duration ranged from 3 to 24 months, with an average of 8 months. Tumor classification by location: 2 cases of glottic type, 2 cases of supraglottic type, and 1 case of subglottic type; TNM staging: 3 cases of T 4N 0M 0 stage, 1 case of T 4N 1M 0 stage, and 1 case of T 4N 2M 0 stage; American Joint Committee on Cancer (AJCC) staging (2017): stage Ⅳ. Near total laryngectomy with partial suprahyoid epiglottis-preserved and selective bilateral neck dissection were performed before the anterior medial thigh flap was used to repair the circumferential defects. The flap size ranged from 6 cm×5 cm to 8 cm×6 cm. Four patients underwent adjuvant radiotherapy and chemotherapy after operation, while 1 patient did not receive any other adjuvant treatment such as radiochemotherapy.

Results

The flaps of all 5 patients survived without obvious neck infection. One patient developed a slight pharyngeal fistula after oral feeding at 1 month after operation, which healed after another week of gastric feeding. Primary healing also achieved in the thigh donor area. One patient had bilateral cervical lymph node metastasis, and 1 patient had lymph node metastasis on one side. The remaining 3 patients had no cervical nodes metastasis on both sides. All 5 patients were followed up 12-36 months, with an average of 27.6 months. Four patients had clear, audible, and hoarse voice while 1 patient (case 3) had pronunciation similar to whispering. Laryngoscopy showed that the reconstructed laryngeal inlet was fissure-shape and the reconstructed laryngo-trachea canal below the laryngeal inlet was gradually enlarged. At 1 month after operation, the gastric tube was withdrawn and the food was taken orally. There was no obvious aspiration pneumonia. The tracheostomy tube could be blocked in 4 patients for from 30 seconds to 3 minutes. Among them, 3 patients were able to make a noticeable pronunciation even when the tube was not blocked, and they were able to engage in barrier-free language communication; the tracheostomy tube could not be blocked in 1 patient who had a pronunciation similar to whispering. Preliminary voice analysis showed that the patients have a relaxed and natural pronunciation, without obvious breath-holding or air-swallowing movement, compared to patients with esophageal pronunciation. Decannulation did not achieved until the last follow-up in all 5 patients.

Conclusion

The anterior medial thigh flap can repair circumferential defects after near total laryngectomy in advanced laryngeal cancer patients and achieve satisfactory pronunciation, thus can serve as an effective pronunciation rehabilitation method. The preserved part of epiglottis may play a role to prevent postoperative aspiration.

Epiglottopexy in Infants Younger Than 6 Months Old: A Case Series

BACKGROUND

Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia.

METHODS

A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children's hospital.

RESULTS

13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities.

CONCLUSION

Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities.

Videofluoroscopic Measures of Swallowing After Partial Epiglottidectomy for Dysphagia

OBJECTIVE

Partial epiglottidectomy has a role in improving dysphagia due to epiglottic obstruction. This study evaluates objective parameters of swallow function in patients who underwent partial epiglottidectomy.

STUDY DESIGN

Retrospective study design.

SETTING

Tertiary Care University Academic Medical Center.

METHODS

A review was performed of patients who underwent CO2 laser partial epiglottidectomy for the treatment of dysphagia at a single tertiary care academic center over a 4-year period. Objective swallowing parameters were evaluated from pre- and postoperative modified barium swallow studies using SwallowTail Advanced Measurement software using blinded reviewers. The postswallow pharyngeal residue (bolus clearance ratio or BCR), spatiotemporal swallowing variables (oropharyngeal [OPT], hypopharyngeal [HPT], and total pharyngeal transit times [TPT]), and airway protection (Penetration-Aspiration Scale [PAS]) were analyzed. Student paired t test was used to determine significant changes in outcome parameters pre- and postsurgery.

RESULTS

Forty-three patients (age range 45-92 years, median 70) met the inclusion criteria. A majority (69.8%) had a history of external beam radiation therapy for head and neck cancer. BCR decreased significantly from a mean of 31.7% presurgery to 24.2% (p = .01) postsurgery. OPT, HPT, and TPT did not differ significantly postsurgery. The mean Eating Assessment Tool-10 score improved from 25.1 to 20.2 after treatment (p = .03). PAS score improved by 15.4% and remained stable at 66.2% after surgery.

CONCLUSION

Partial epiglottidectomy improves pharyngeal bolus clearance in properly selected patients with dysphagia due to epiglottic obstruction. Patients demonstrated stable swallow function with the benefit of reduced postswallow residue following surgical intervention.

New approach to establish a surgical planning in infantile vallecular cyst synchronous with laryngomalacia based on aerodynamic analysis

BACKGROUND AND OBJECTIVES

A large proportion of infants with vallecular cyst (VC) have coexisting laryngomalacia (LM). Feeding difficulties, regurgitation, occasional cough, and sleep-disordered breathing are the common symptoms in moderate to severe cases. The surgical management of these cases is more challenging and remains controversial. The purpose of this study is to help surgeons select the effective surgical strategies by computer-aided design (CAD) and computational fluid dynamics (CFD) simulations of the upper airway flow characteristics.

METHODS

The three dimensional (3D) geometric model of the upper airway was reconstructed based on two dimensional (2D) medical images of the patient with VC accompanied with LM. Virtual surgeries were carried out preoperatively to simulate three possible post-operative states in silico. The different outcomes of virtual surgical strategies were predicted based on computational evaluations of airway fluid dynamics including pressure, resistance, velocity, and wall shear stress (WSS).

RESULTS

The CFD results of this study suggested the importance of the angle between the rim of epiglottis and arytenoid epiglottic (AE) fold. There was a small impact on the upper airway flow field while the VC was removed and the angle of epiglottis was unchanged. The partial lifting of epiglottis can further improve the flow field. With performing supraglottoplasty (SGP) and the marsupialization of VC, epiglottis was completely recovered, and the flow field was significantly improved. The clinical symptoms of this patient improved greatly after surgeries and no recurrence or growth retardation were noted during 1-year follow-up. The clinical prognosis was consistent with the prediction of the CFD results.

CONCLUSIONS

The state of epiglottis needs to be carefully checked to evaluate the necessity of performing further SGP in the patients with VC accompanied with LM. CFD and CAD could be developed as a new approach to help surgeons predict the post-operative outcomes through quantification of the airflow dynamics, and make the optimal and individualized surgical approaches for patients with airway obstruction.

[The one-stage technology of epiglottis function and voice reconstruction after total laryngectomy with the sternohyoid myocutaneous flap]

Objective:To investigate the clinical effect of one-stage sternohyoid musculocutaneous flap after total laryngectomy for reconstruction of epiglottis function and vocalization. Methods:A retrospective analysis of 8 patients who underwent total laryngectomy from November 2019 to September 2020. The sternohyoid myocutaneous flap was designed after total laryngectomy. The lower edge of the flap was sewed with the posterior upper edge of the tracheostomy opening, and the lateral and medial edges of the flap were anastomosed to create a vocal tube. The lateral edge of the upper end of tube was sutured with the anterolateral wall of the hypopharynx, then made full use of residual epiglottis and tongue root tissue to reconstruct epiglottis function. Results:None of the 8 patients had serious complications after total laryngectomies. Fifteen months after operation,the vocal tube flaps survived and had intact structure under fiberoptic laryngoscope. All patients could speak clearly and forcefully, and the swallowing function was intact. Conclusion:The use of adjacent myocutaneous flap to construct the vocal canal and reconstruct the epiglottis function is a simple and effective technique that can be completed in one stage and improve the voicing of patients undergoing total laryngectomy.

Treatment of primary epiglottis collapse in OSA in adults with glossoepiglottopexy: a 5-year experience

Objective

To review our 5-year experience with a modified version of glossoepiglottopexy for treatment of obstructive sleep apnoea syndrome (OSA) in two hospitals.

Methods

A retrospective analysis was carried out on a cohort of adult patients affected by OSA suffering from primary collapse of the epiglottis who underwent a modified glossoepiglottopexy. All patients underwent drug-induced sleep endoscopy, polysomnographic and swallowing evaluation, and assessment with the Epworth Sleepiness Scale (ESS).

Results

Forty-nine patients were retrospectively evaluated. Both the apnoea-hypopnoea index (AHI) (median AHI_post-AHI_pre = -22.4 events/h; p < 0.001) and oxygen desaturation index (ODI) showed a significant postoperative decrease (median ODI_post-ODI_pre = -18 events/h; p < 0.001), as did hypoxaemia index (median T_{90% post}-T_{90% pre} = -5%; p < 0.001). The ESS questionnaire revealed a significant decrease in postoperative scores (median ESS_post-ESS_pre =- 9; p < 0.001). None of the patients developed postoperative dysphagia.

Conclusions

Our 5-year experience demonstrates that modified glossoepiglottopexy is a safe and reliable surgical technique for treatment of primary epiglottic collapse in OSA patients.

A Retrospective Case Series of Anesthetic Patients With Epiglottic Cysts

Previously undiagnosed or asymptomatic epiglottic cysts may be coincidentally detected during intubation. This retrospective case series identified undiagnosed epiglottic cysts that were discovered during intubation in 4 patients who underwent oral surgery under general anesthesia at our hospital during a 6-year period. Including 2 additional cases, 1 previously diagnosed and 1 detected during preoperative imaging, epiglottic cysts were observed in 6 of 1112 cases (0.54%) total. Among the undiagnosed epiglottic cyst cases, mild dyspnea on effort or snoring was reported in 2 patients, but all others were asymptomatic. Upon discovering previously undiagnosed epiglottic cysts during intubation, it is essential to proceed cautiously, remain alert for potential airway management difficulties, and avoid injuring or rupturing the cysts. In addition, any available preoperative imaging should be reviewed as information pertinent to the airway and any abnormalities may be useful. This report discusses the anesthetic care of 6 patients with epiglottic cysts that were previously known or initially discovered during intubation.

Surgical approach of laryngofissure combined with epiglottis valley in treating locally-advanced pyriform sinus carcinoma

OBJECTIVES

To evaluate feasibility and efficacy of surgical approach of laryngofissure combined with epiglottis valley in treating locally-advanced pyriform sinus carcinoma.

METHODS

Clinical data of 216 patients with T3 and T4a pyriform sinus carcinoma, who came from the Department of Otorhinolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University between January 2013 and December 2019, were retrospectively analyzed. Three different types of surgery were used in these patients. Seventy-three patients were performed by approach of laryngofissure combined with epiglottis valley for partial laryngopharyngectomy (Group I); 75 patients were performed by approach of lateral pharynx for piriform fossa resection (Group II); 68 patients were performed by total laryngopharyngectomy (Group III). All patients were treated with radiotherapy and followed up regularly after operation. Kaplan-Meier regression model was used to analyze the overall survival rate. EAT-10 swallowing scale was utilized to evaluate the postoperative swallowing function, while the rate of tracheal tube extubation and the incidence of postoperative complications in each group were compared.

RESULTS

There were 76.7% patients with T3 stage in Group I, 100% patients with T3 stage in Group II, and 64.7% patients with T4a stage in Group III. There was significant difference between them (P<0.01). Clinical stage IV patients in the Group I, Group II, and Group III were 74.0%, 54.7%, and 89.7%, respectively, with significant difference (P<0.01). The 3-year overall survival (OS) rate in Group I, Group II, and Group III were 69.9%, 53.3%, and 58.8%, respectively. Patients in the Group I had a better survival outcome than that in the Group II (P<0.05). The median score of EAT-10 swallowing scale was 12.0 in the Group I, 8.0 in Group II, and 5.0 in Group III, with significant difference (P<0.01). There was no significant difference in the rate of tracheal tube extubation and the incidence of complication among the 3 groups (both P>0.05).

CONCLUSIONS

Surgical approach of laryngofissure combined with epiglottis valley in the treating locally-advanced piriform sinus carcinoma presents favorable outcome in terms of survival rate and laryngeal function preservation, which deserves to be promoted.

Dorsal Displacement of the Soft Palate Secondary to Persistent Frenulum of the Epiglottis in Neonatal Foal

Dorsal displacement of the soft palate (DDSP) usually occurs in athletic adult horses. Congenital DDSP in foals secondary to the persistent frenulum of the epiglottis is rarely observed. The aim of this report was to describe a case of a seven-day-old female neonate Quarter Horse presenting dysphagia, milk reflux through the nostrils and mouth, and expiratory dyspnea since 4 days. Thoracic auscultation was indicative of aspiration pneumonia. Diagnosis of DDSP associated with local inflammation was made after endoscopic examination of upper respiratory tract. Radiographic examination was performed to rule out hypoplasia of the epiglottis. No clinical improvement was observed after anti-inflammatory treatment with flunixin meglumine. Oral endoscopy under general anesthesia revealed that the displacement of the soft palate was caused by a persistent frenulum of the epiglottis. Using a 30° rigid endoscope and a curved laparoscopic scissors, the frenulum was transected. After surgery, no dysphagia or dyspnea at rest was observed. However, discreet respiratory noise persisted during exercise for 5 days postoperatively. After discharge, the owner reported that the animal was completely normal during exercise. The animal is currently 3 years old and is developing a normal athletic performance. Persistent frenulum of the epiglottis should be considered while examining neonates with nasal milk reflux associated with expiratory dyspnea. This case report emphasizes the importance of the differential diagnosis for DDSP and for DDSP secondary to the persistent frenulum of the epiglottis in neonatal foals. It also underlines the importance of oral endoscopic examination for diagnosis.

Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions

OBJECTIVE

The fiber-guided carbon dioxide (CO₂) laser is a useful device for laryngopharyngeal surgery. The flexible CO₂ wave-guide laser has been developed and commercially available for several years. However, the transnasal use of CO₂ flexible wave-guided laser surgery through the instrument channel of a flexible endoscope (CO₂ TNFLS) is not permitted in Japan. This feasibility study aimed to assess the value and the safety of an in-office CO₂ TNFLS procedure.

METHODS

Patients with small laryngopharyngeal diseases were enrolled from June 2015. Eligible patients had indications with lesions generally localized superficial lesions such as the benign tumor, leukoplakia, and premalignant lesion-like carcinoma in situ (CIS). Patients were locally well anesthetized using xylocaine. After removing as much of the lesion(s) as possible with flexible forceps, the remainder of the lesions were evaporated using CO₂ TNFLS through the instrument channel of a flexible endoscope under local anesthesia.

RESULTS

Eighteen surgeries involving 13 patients, including 9 papilloma (7 recurrent respiratory papilloma [RRP]), 2 carcinoma in situ, 1 leukoplakia, and 1 large epiglottic cyst), were performed. Four patients with RRP required multiple surgeries. Except for 3 patients with RRP, all patients achieved disease control without additional intervention. All procedures were completed with no severe adverse events.

CONCLUSION

Office-based CO₂ TNFLS is safe and feasible for patients with laryngopharyngeal pathologies. It is especially valuable for RRP patients with small lesions to avoid surgery under general anesthesia.

Supraglottoplasty in neonates and infants: A radiofrequency ablation approach

BACKGROUND

Supraglottoplasty is the mainstay of surgical treatment for laryngomalacia. A novel supraglottoplasty surgical technique is needed to achieve better efficacy. The purpose of this study was to introduce modified microscopic radiofrequency ablation supraglottoplasty (MMRAS) for the treatment of congenital laryngomalacia and to evaluate the outcome and effectiveness of this novel approach.

METHODS

Seventeen children with severe laryngomalacia who underwent MMRAS were studied retrospectively. Supraglottoplasty of type III laryngomalacia was different from classical method. All the patients were kept intubated for 5 days after surgery to achieve a better epiglottal position and to avoid reconglutination of aryepiglottic folds. The patients' demographic information, symptoms, comorbidities, type of laryngomalacia, synchronous airway lesions and final outcomes were examined.

RESULTS

The median age at the time of surgery was 3.36 months (3 months 10 days). Operative indications included feeding difficulties, noisy breathing or respiratory distress (or both), and sleep-related symptoms. The MMRAS success rate was 82.4%. Most patients were extubated successfully on postoperative day 5. The major postoperative complication was pulmonary infection which occurred in 3 cases (17.6%) and required anti-infective therapy. No perioperative deaths and no long-term complications occurred. Failures were observed in 3 (17.6%) of 17 cases, 2 patients presented with a neurological disease and required tracheostomy, 1 patient relapsed because of postoperative adhesions and later underwent revision supraglottoplasty.

CONCLUSIONS

From these results, we conclude that MMRAS is an effective and safe treatment for symptomatic laryngomalacia and has the potential to provide better breathing, feeding, and sleeping outcomes in children with severe laryngomalacia. Postoperative intubation for 5 days may result in better therapeutic outcomes. Multicenter cooperative studies of comparison between MMRAS and conventional approaches would lend further evidence-based support for this surgical method.

Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy for Recurrent Laryngeal Cancer

Objectives:

Recurrent laryngeal cancer can be treated either with total laryngectomy or in selected cases with supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP). We performed a retrospective study to analyze the functional and oncological results of supracricoid laryngectomy with CHEP.

Methods:

Fourteen patients were treated with supracricoid laryngectomy with CHEP. In 8 patients, flexible endoscopic evaluation of swallowing was performed. Preoperative and postoperative voice evaluation was performed in 5 patients. Oncological and functional follow-up, postoperative complications, and data concerning rehabilitation were recorded on standard forms.

Results:

After the supracricoid laryngectomy with CHEP, 11 of the 14 patients were alive and disease-free. No local recurrences were found, but 2 patients had regional recurrences. The voice was worse after the operation; however, most patients were satisfied. Swallowing was uncompromised.

Conclusions:

Supracricoid laryngectomy with CHEP for recurrent glottic laryngeal cancer after radiotherapy appears to be oncologically safe and functional.

[Utility of McGRATH MAC for a Patient with a Large Epiglottic Cyst]

A 76-year-old man with an epiglottic cyst was scheduled for transoral rigid endoscopic epiglottic cystectomy under general anesthesia. The epiglottic cyst was found accidentally when he had an operation of radical cystectomy 2 weeks before. When he had the radical cystectomy, the ventilation through a mask was easy. He had no subjective respiratory symptoms. We chose rapid induction with propofol, remifentanl, and rocuronium. When we inserted the McGRATH MAC laryngoscope, we could only see a big epiglottic cyst not vocal cord but the pressure on the neck enabled the laryngologist to see the vocal cord. We could identify the space through which we could insert tracheal tube without touching the cyst. After the operation, his trachea was extubed.

One-phase management of severe obstructive sleep apnea: Tongue base reduction with hyoepiglottoplasty plus uvulopalatopharyngoplasty

OBJECTIVES: To describe the results of a 1 phase surgical procedure for the treatment of severe obstructive sleep apnea (OSA) attributable to tongue base obstruction.

STUDY DESIGN AND SETTING: A retrospective nonrandomized study at S Orsola Malpighi University Hospital of Bologna, Italy.

METHODS: Ten male patients affected by severe OSA (mean apnea/hypopnea index [AHI] of 54.7), underwent uvulopalatopharyngoplasty (UPPP) associated with tongue base reduction and hyoepiglottoplasty (TBRHE). The indications to this surgical procedure were based on the presence of hyolingual abnormalities and absence of craniofacial deficiencies determined by preoperative assessment.

RESULTS: Mean AHI decreased from 54.7 + 11.5 to 9.4 + 5.4 whereas the mean low SaO2 value went from 77% + 6.2 to 90.7% + 3 and the time of sleep with SaO2 < 90% improved from 53% + 17.2 to 7.3% + 8. The overall success rate was 100%.

CONCLUSIONS AND SIGNIFICANCE: TBRHE is an effective and safe treatment in patients with severe OSA attributable to tongue base obstruction and in absence of craniofacial deficiencies.

Partial Epiglottoplasty for Pharyngeal Dysphagia due to Cervical Spine Pathology

OBJECTIVE

To examine the role of epiglottoplasty in patients with pharyngeal dysphagia due to pharyngeal crowding from cervical spine pathology and to assess swallowing outcomes following epiglottoplasty.

STUDY DESIGN

Retrospective case series.

SETTING

Academic tertiary care medical center.

SUBJECTS AND METHODS

Dysphagia can occur in patients with cervical spine pathology because of hypopharyngeal crowding. Swallowing studies, such as modified barium swallow study and fiberoptic endoscopic evaluation of swallowing, may demonstrate a nonretroflexing epiglottis owing to cervical spine osteophytes or hardware, thus impeding pharyngeal bolus transit. We performed partial epiglottoplasties in a series of these patients. A retrospective review of swallowing outcomes was performed to assess the efficacy of this surgery in this patient population.

RESULTS

Epiglottic dysfunction causing dysphagia due to cervical spine pathology was diagnosed by modified barium swallow study and/or fiberoptic endoscopic evaluation of swallowing in 12 patients. Findings included hypopharyngeal crowding because of cervical osteophytes (n = 8) or cervical hardware (n = 4) associated with absent epiglottic retroflexion and retained vallecular residue. Partial epiglottoplasty resulted in significant reduction of vallecular residue and a significant increase in functional swallow outcomes without an increase in swallow morbidity.

CONCLUSION

There is a role for partial epiglottoplasty in patients with dysphagia attributed to hypopharyngeal crowding from cervical spine pathology. Surgery enables reduced vallecular residue and improved functional swallowing outcomes.

Post-surgical and oncologic outcomes of frontal anterior laryngectomy with epiglottic reconstruction: a review of 68 cases

OBJECTIVE

To report post-surgical and oncological outcomes of 68 patients treated with frontal anterior laryngectomy with epiglottic reconstruction.

STUDY DESIGN

Demographic data and all information regarding histopathological grade, initial tumor stage and neck status, follow up time, postoperative complications, nasogastric tube removal time, decannulation time and recurrences were collected from the database and follow-up forms.

SETTING

All patients between 1994 and 2014 who were treated with frontal anterior laryngectomy with epiglottic reconstruction for early glottic carcinoma at Ege University Otolaryngology Clinic were included in the study.

SUBJECTS AND METHODS

Sixty-six of the patients were male and 2 were female with a median age of 57.5 years (IQR 53-63.75, range 44-75). Four patients had a tumor stage of T1a, 43 had T1b and 21 had T2. Median nasogastric tube removal time, decannulation time, overall and disease free survival rates were calculated.

RESULTS

Median nasogastric tube removal time was 10 days. Median decannulation time was 12 days. Median N/G tube removal and decannulation times were higher in T2 patients but this did not reach statistical significance (p>0.05). Median follow-up time was 68.5 months (6-222 months). Five year disease free survival was 93.5%. There were 6 oncologic failures which were salvaged with total laryngectomy, neck dissection and adjuvant radiotherapy.

CONCLUSION

According to our results, which is one of the largest reported FAL with epiglottic reconstruction series in the English literature, this procedure's local control and survival rates are high with good functional results.

Epiglottic hypoplasia: a natural model for supraglottic laryngoplasty

Non-syndromic hypoplasia of the epiglottis presenting without symptoms at middle age is an extremely rare entity. We report a 50 years female who presented with oral ulcers and incidentally was found to have an asymptomatic rudimentary epiglottis and thickened bilateral aryepiglottic folds forming an inverted funnel shaped supraglottis protecting the airway from any aspiration. This case demonstrated a functional model of natural supraglottic laryngoplasty which can be used in treating intractable aspiration, similar to the Steam boat modification of Biller's technique of supraglottic laryngoplasty. This natural example can be used to design or scrutinize the existing models of supraglottic laryngoplasty in the treatment of intractable aspiration.

Technical refinements to the minithyrotomy procedure

OBJECTIVES/HYPOTHESIS

Although the minithyrotomy (MT) procedure was introduced in 1999, it has not been widely used for voice restoration. Its limited dissemination is due in part to lack of appropriate implants and in part due to technical challenges. The 2011 introduction of the composite thyroid ala perichondrium flap (CTAP) into a vocal fold through an MT was designed to supply an appropriate implanted tissue. However, technical difficulties persisted. Noted impediments have included limited surgical access, potential CTAP pedicle constriction during healing, lack of specialized surgical instrumentation, and potential retraction or extrusion of CTAPs. This study was performed to address these technical challenges with or without the use of CTAP reconstruction.

STUDY DESIGN

Experimental. Cadaveric and in vivo canine model.

METHODS

Experimentation on canine cadaveric larynges yielded MT and CTAP alterations, instrument creation, and implant affixation procedures. These refinements were applied in vivo using canine subjects. Two weeks post-CTAP repair, subjects were humanely euthanized, followed by laryngeal harvest and histologic analysis of the vocal folds.

RESULTS

Refinements to CTAP modification, MT, instrumentation, and CTAP affixation are successful in vivo, just as in preliminary cadaveric trials.

CONCLUSIONS

The proposed refinements were designed to improve the outcomes achieved via a CTAP specifically but have utility for any MT approach. Continued improvements to specialized instrumentation are necessary. Enhanced affixation of a CTAP, with improved accuracy and easier deployment are also essential. Further refinements should allow more reliable implementation of the MT by a growing number of laryngeal surgeons.

[Application of electric coagulation treatment via bronchoscopy in the management of congenital vallecular cyst in children]

OBJECTIVE

To discuss the effect of electric coagulation through bronchoscopy in diagnosis and treatment of congenital vallecular cyst in children.

METHOD

Ten cases of congenital vallecular cyst in the study with age ranged from 21 days to 4 years and 10 months were treated with electric coagulation through bronchoscopy. The therapeutic effect was evaluated by endoscopic and clinical manifestation. And all the patients were followed-up for 6-12 months.

RESULT

All the patients obtained 3-5 times electric coagulation. After the operation, the cyst decreased in size, epiglottis softening was subsided, uplift uncompression, dyspnea and laryngeal stridor were improved obviously. After follow-up periods of 6-12 months, no capsule wall were left, and the activity of the epiglottis resumed.No severe complication was found in any patient.

CONCLUSION

Electric coagulation through bronchoscopy is a simple, effective and safe method to treat congenital vallecular cyst in children.

[Transoral CO2 laser epiglottectomy for early epiglottic carcinomas]

OBJECTIVE

To compare the functional results of transoral CO2 laser epiglottectomy with transcervical supraglottic laryngectomy and to find the landmarks for CO2 laser surgery.

METHODS

Forty-nine preoperatively untreated patients diagnosed as clinical T1-2N0M0 epiglottic carcinomas enrolled from June 1, 2006, to November 1, 2009 in the Second Affiliated Hospital of Harbin Medical University were studied retrospectively. Seventeen cases were treated by CO2 laser whereas 32 by open surgeries. The upper edge of thyroid cartilage and mucosal recess infra epiglottic tubercle could be used as intraoperation landmarks for transoral CO2 laser surgery. Optional neck dissections (II, III) were performed for 34 patients with tumors on laryngeal face, but not for 15 with tumors on the edges of epiglottis or small laryngeal face tumors.

RESULTS

The follow-up for this study covers a period ranging from 3 to 6 years postoperatively. Four local recurrences were found for this study, 2 for laser surgery who underwent additional repeated exisions and 2 for conventional techniques, one received radiotherapy (60 Gy) and another with total laryngectomy. The incidence of lymph node metastasis was 10.2% (5/49) in all cases. Time of naso-feeding or hospitalisation was significantly shorter for CO2 laser treated patients than that for open techniques. Overall 3 year's survival rates were 100% and 90.6% for CO2 laser and the open techniques respectively.

CONCLUSIONS

Compared to the open technique, transoral CO2 laser epiglottectomy is a well-tolerated and promising resection technique with low morbidity for early epiglottic carcinomas, and the identification of landmarks is useful for entire resection of epiglottis.

Misguidance of peroral rigid laryngoscopy in assessment of difficult airway: two comparable cases in microlaryngeal surgery

We describe two patients with laryngeal cyst who underwent microlaryngeal surgery. Peroral rigid laryngoscopy, as an indirect endoscopy, performed via the transoral route, was evaluated as a routine screening tool of the difficult airway in patients with laryngeal neoplasm, in our hospital preoperatively. Peroral rigid laryngoscopy had led to two different procedures: One patient was misdiagnosed as having a difficult airway by the ear, nose and throat surgeon resulting in an unnecessary awake tracheotomy. The other patient was found to be with an unanticipated difficult intubation following routine anaesthesia, successful on the third attempt. As we saw in these two cases, endoscopic examination alone was inadequate for the assessment of a difficult airway, which may also lack the predictive sensitivity or may cause a high false positive. Usage of video laryngoscopy combined with intubating stylet will improve the intubation success in patients with huge epiglottic cyst.

Surgical treatment of larynx T1N0M0 cancer - partial laryngectomy modified Majer-Piquet's intervention

The increase of general radiation background in Georgia and some national characteristics such as spicy dishes, high level of alcohol and cigarette consumption, emotional, loud way of speaking result in a high percentage of people suffering from larynx malignant tumor. As generally known, the majority of larynx cancer cases represent surgical indications and only a small percentage submit to radio or chemotherapy. Since the beginning of the previous century, laryngologists have been intensely thinking about maintaining the larynx itself when giving surgical treatment. With this article we aim to introduce you to one of surgical techniques often applied in France. The method is Pr. B. Guerrier's modification of Majer-Piquet's cricohyoidoepiglotopexy, which is very popular in Europe. This consists in reconstructive operation maintaining cricoid cartilage and epiglottis with larynx's pexy when resecting partially. In cases of exact indications the, Majet-Piquet's modified operation provides a perfect: opportunity both to achieve the desirable outcome and maintain the main functions of larynx vocal, swallowing and breathing with a relatively less invasive surgical interference.

Long-term outcomes of supracricoid partial laryngectomy with cricohyoidoepiglottopexy and its modified version

OBJECTIVE

To investigate the long-term outcomes of supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP) and its modified version, in which we reserve the poster inferior borders of both thyroid cartilage laminas to protect swallowing function.

METHODS

This retrospective survival analysis was performed in 86 patients, wherein 46 undergoing CHEP and 40 undergoing modified CHEP. Their decannulation data were reviewed. We used swallowing quality-of-life questionnaire to measure the quality-of-life in 53 of the 65 survivals at the end of the follow-up period in 2011. Of the 53 patients, 24 underwent CHEP, while the remaining by modified CHEP.

RESULTS

The log rank test showed no significant difference in survival distributions of 2 the groups (p=0.92). The decannulation rate was 93.5% in CHEP and 100% in modified CHEP, showing no significant difference. The time span of decannulation in CHEP was 19.0+/-4.6 days, significantly longer than (14.0+/-2.3 days) the modified CHEP (p=0.000). As to quality-of life data, one-way multivariate analysis of variance, revealed a significant multivariate main effect for groups (p=0.001), and significant univariate main effects in 5 scales out of 11 (p<0.05), which showed a better swallowing life quality in modified CHEP.

CONCLUSION

There was no significant difference in survival rate between the 2 surgeries. The modified CHEP succeeded in earlier decannulation and better long-term swallowing life quality. Thus, modified CHEP is worth promoting, as long as indications were strictly conformed.

Bullet in the pharynx: endoscopic management

Gunshot wounds of the neck are diagnostically and therapeutically challenging cases and treatment should be individualized and multidisciplinary. We present an unusual case of bullet injury to the neck. A fourteen year old male patient sustained an accidental bullet injury to the submental area of the neck, with no serious injuries to the vital structures. The bullet was found close to the epiglottis, embedded in the pharynx between the base of the tongue and the lower pole of the left tonsil. The patient underwent successful endoscopic removal with no serious postoperative complications. In this paper, this case is discussed, its presentation and management, together with literature review.

Recent Developments in the Treatment of Obstructive Sleep Apnea

Modern sleep medicine has been in existence for only 20 years and therefore has to be regarded as a comparatively recent field of specialization. For this reason it is not surprising that there are numerous new trends and developments concerning the treatment of sleep-related breathing disorders. This review focuses on developments in the treatment of obstructive sleep apnea (OSA) over the last 5 years.The review is based on a Medline bibliographic search using the key words 'treatment', 'obstructive sleep apnea' and 'sleep-related breathing disorders' and covers papers published since 1997, including references in these articles. In respect to conservative treatments the following important developments were found. Oral devices were shown to be effective in about 50-70% of patients with OSA, but at this stage it is not possible to predict in which patients successful treatment can be expected. As subjective compliance averages only about 50%, thermoplastic devices used as trial devices provide a reasonable alternative to reduce costs. Automatic continuous positive airway pressure (CPAP) units have been shown to cut costs when used for pressure titration in severe sleep apneics during the day or when used in so-called split-night procedures in appropriate cases. Nasal CPAP has proven to be effective in children, showing higher compliance rates than in adults. The development of mouth-pieces provides the possibility of using CPAP orally, e.g. after nasal surgery. Electrical stimulation of the tongue muscles shows promising preliminary results. Nevertheless, further research in this field is necessary. In the field of surgery, the most valuable development has been tissue reduction using radiofrequency energy, which has been shown to be effective and minimally invasive. Other fundamentally new surgical techniques have not been attempted within the last 5 years; instead, development in this area appears to be defined by a combination of previously known methods (so-called multilevel surgery) and optimized methods of patient selection. Such combined surgical procedures has achieved success rates of about 70%. Taking all these developments into account, CPAP therapy remains the gold standard for treatment of patients with OSA; yet the low long-term compliance rates of 60-70% have to be regarded as a major challenge warranting further effort.

[Application of minimally invasive technique of coblation in 30 infants with epiglottic cyst]

OBJECTIVE

To present the efficacy of minimally invasive technology of coblation in the treatment of infant epiglottic cyst.

METHODS

The clinical data of 30 infants with epiglottic cyst treated between January 2008 and January 2011 were reviewed retrospectively. All infants with epiglottic cyst were treated with the ArthroCare ENT Coblator II Surgery System after being checked completely.

RESULTS

All 30 patients were successfully operated. The blood loss was less than 2 ml during the surgery. The infants recovered without any complications and were discharged from hospital in 10 days after surgery. The clinical symptoms improved significantly or disappeared. No patients showed recurrence during followed-up over 6 months.

CONCLUSION

The advantage of the minimally invasive technology of coblation in infant epiglottic cyst was less bleeding, little injury and postoperative organization reaction.

Analogy between laryngeal gesture in Mongolian Long Song and supracricoid partial laryngectomy

This article reports the results of a multiparametrical analysis of Mongolian Long Song, characterised by multiple ornamentation and shows the similarities between the laryngeal behaviour observed during these ornamentations and the compensatory gesture produced by patients after supracricoid partial laryngectomy. This study includes (1) a physiological analysis of videofiberscopic laryngeal data from a healthy Mongolian singer and from three non-singer French-speaking clinical patients; and (2) an acoustical analysis (fundamental frequency and intensity). For the singer, the fiberoptic analysis showed two main laryngeal behaviours in producing ornamentations: (1) 'lyrical' vibratos mobilising the entire laryngeal block; (2) 'Mongolian' trills with essentially supraglottic movements, the arytenoids being mobilised independently of the rest of the laryngeal block. Patients demonstrated similar aryepiglottic trilling to fulfil a function of voicing. The acoustic analysis showed that the fundamental frequency and the intensity were in phase for vibrato, contrary to the 'Mongolian' trills which were in opposite phase, underlying a change of laryngeal vibratory mechanisms.

[Long-term treatment outcome in patients undergoing cricohyoidoepiglottopexy for glottic carcinoma]

OBJECTIVE

To investigate the long-term results of cricohyoidoepiglottopexy(CHEP) in the treatment of glottic carcinoma.

METHODS

A retrospective chart review of 92 consecutive patients who underwent CHEP in the selected institut from January 1990 to December 2008. Of the 92 cases, 41 cases of stage I, 39 cases of stage II, 12 cases of stage III. The time for the decannulation and the removal of the nasal feeding and quality of phonation were used for evaluating postoperative functional rehabilitation. The estimated long-term survival rates were calculated by Kaplan-Meier method.

RESULTS

Among 92 patients, 26 cases (27 sides) received neck dissection and lymph nodes were pathologically positive in 3 patients (11.1%). All final surgical margins were negative for tumor invasion. Seven patients had postoperative radiotherapy and one had chemoradiation. Thirteen patients (14.1%) were found local recurrence and nine patients (9.8%) had postoperative metastases. Overall 3-, 5- and 10-year survival rates were 90.0%, 84.5% and 67.0% respectively. Cox multivariate analysis showed that the recurrence had significant influences on the overall survival rate.

CONCLUSION

CHEP not only is relatively easy to master, but also effective in the treatment of glottic carcinoma.

Laser excision of a typical carcinoid tumor of the larynx: a case report

Neuroendocrine carcinomas of the larynx include a range of rare tumors which have variable biologic behavior, affecting treatment and prognosis. Among these, typical carcinoid tumors are the least common type. Prognosis of typical carcinoid tumor is better than atypical carcinoid tumor and small cell carcinoma of the larynx. Conservation surgery is the preferred treatment modality. Transoral CO2 laser surgery can be a good alternative for appropriate cases because of the functional results and less morbidity. In this article, a 71-year-old female presented with complaints of feeling a mass during swallowing. Fiberoptic examination of the larynx revealed a mass located on the right aryepiglottic fold and biopsy revealed the tumor as a typical carcinoid tumor. We describe CO2 laser excision of a typical carcinoid tumor of the larynx in this case report.

Epiglottoplasty for reconstruction of defects after laryngectomy with partial pharyngectomy

OBJECTIVES

We present a novel use of sliding epiglottoplasty as an alternative method for closing mucosal defects in selected laryngectomies with partial pharyngectomy.

METHODS

Sliding epiglottoplasty as described and advocated by Sedlacek, Bouche, Kambic, and Tucker for reconstruction in partial laryngectomies was used to close the defects after laryngectomy with partial pharyngectomy in 17 patients with advanced hypopharyngeal cancers as primary therapy (16 patients) and as post-radiochemotherapy therapy (1 patient).

RESULTS

All reconstructions were successful. Primary closures were achieved without additional morbidity, there were no pharyngocutaneous fistulas, and all patients resumed deglutition. Ten patients acquired esophageal speech, speech valves were inserted in 5 cases, and 2 patients required the use of an electrolarynx.

CONCLUSIONS

If the oncological circumstances allow its preservation in laryngectomy with partial pharyngectomy, the epiglottis is an ideal structure for closing the defect; it is a local tissue with shape, thickness, rigidity, and borders that match the recipient site. In comparison to distant pedicled or free microvascular flaps, the epiglottoplasty is a shorter procedure, requires a smaller surgical team, results in less trauma, has a lower incidence of complications, and enables faster recovery. It is surprising that this elegant, successful, and generally accepted larynx preservation procedure has not been recognized as useful for larger reconstructions.

Assessment of the efficacy of composite surgery for the treatment of dorsal displacement of the soft palate in a group of 53 racing Thoroughbreds (1990-1996)

REASONS FOR PERFORMING STUDY

There has been no objectively assessed case-control study of the efficacy of surgery to correct dorsal displacement of the soft palate (DDSP) previously reported.

HYPOTHESIS

Composite surgery has a beneficial result on racing performance in horses affected with DDSP as compared to a matched control population.

METHODS

Race records were obtained for 53 racing Thoroughbreds which underwent composite staphylectomy, sternothyrohyoideus myectomy and ventriculectomy for correction of idiopathic DDSP at the University of Bristol between 1990 and 1996. Each surgical case was matched for age, sex and training yard with 2 control horses. The racing performance, based on prize money won, of surgical cases and control horses were compared for 3 races run before and after the date of surgery.

RESULTS

Ninety-two percent of the surgical cases returned to racing after surgery. There was a significant increase in earnings of the surgical group before and after surgery (P = 0.011), but there was no significant difference in earnings of the control group before and after the date of surgery (P = 0335). Sixty percent of the surgical group had higher earnings after surgery than before, compared to 40% of controls. When horses which underwent surgery were ranked relative to their 2 matched controls, surgical cases did not significantly change in rank (P = 033), whereas control horses significantly decreased in rank (P = 0.012). Additionally, horses within the surgical group were more likely (P < 0.01) to start in 3 post operative races than those in the control group.

CONCLUSIONS AND POTENTIAL RELEVANCE

Composite surgery had a beneficial effect on racing performance of horses afflicted with idiopathic DDSP, and further studies to evaluate objectively the usefulness of other surgical techniques are warranted.

Voice and swallowing disorders: functional results and quality of life following supracricoid laryngectomy with cricohyoidoepiglottopexy

We conducted a prospective study of 11 patients with laryngeal cancer who underwent supracricoid laryngectomy with cricohyoidoepiglottopexy. Our goal was to evaluate their postoperative voice and swallowing function and to ascertain the impact that surgery had on patient-perceived quality of life. Postoperative assessments were made by auditory perception analyses, objective voice analyses, the Voice Handicap Index questionnaire, the Quality of Life in Swallowing Disorders questionnaire, and videofluoroscopy. Following surgery, 8 patients experienced severe dysphonia and 3 experienced moderate dysphonia. Also, 5 patients experienced mild to severe dysphagia whereas 6 patients experienced normal or near-normal swallowing function. Postoperative acoustic measurements were higher than expected, and spectrographic evaluation revealed the presence of high-grade noise without predominant concentration over the spectrum. Some association with the grade of dysphonia and self-perception of voice handicap was observed. With regard to swallowing, 5 patients (45.5%) showed a decrease in laryngeal remnant elevation and a slight or moderate degree of stasis in the oropharynx. Overall, patients reported good quality of life regarding both voice and swallowing. No relationship between the functional swallowing and the number of preserved arytenoid cartilages was observed.

[Application of the displacement of the ventricular bands-epiglottis mucosal flap in the surgical management of glottis carcinoma]

OBJECTIVE

To investigate the plastic method of glottis carcinoma in surgery.

METHOD

Retrospective analyzed 29 patients with T2, T3 glottis carcinoma who admitted in our department From 1996 to 2004. All of them were treated with the displacement of ventricular bands-epiglottis mucosal flap in the surgical management of glottis carcinoma. The tumour was primarily from vocal cords, and not exceeded 2 cm.

RESULT

All cases were successfully renovated laryngeal cavity with the displacement of ventricular bands-epiglottis mucosal flap and followed up for 5 years after operation. Three years survival rate was 86.2%, 5 years survival rate was 78.9%, and tube drawing rate was 100%.

CONCLUSION

With this method, surgery would be simplified and the patients would keep the voiced function and swallowing function.

[Combined use of the airway scope and fiberoptic bronchoscopy for tracheal intubation in a patient with a large epiglottic cyst]

A 26-year-old man was scheduled for surgical extraction of a large epiglottic cyst. Mask ventilation was possible under propofol anesthesia without muscle relaxant. It was difficult to see the glottis using either a Macintosh laryngoscope or by fiberoptic bronchoscopy. When the AWS laryngoscope (Hoya, Tokyo Japan) with a part of the blade removed, was inserted orally, it became possible to see the glottis with a part of the epiglottic cyst. A reinforced tube was inserted nasally, and a fiberoptic bronchoscope was passed through the tube into the trachea. The tube was then passed over the fiberscope into the trachea. We believe that the Pentax AWS laryngoscope may lift the epiglottis and its cyst atraumatically, and may facilitate nasal fiberoptic intubation in a patient with a large epiglottic cyst.

Cutaneous normolipemic plane xanthoma with supraglottic involvement in a patient with hand-Schüller-Christian Disease: a case report

Normolipemic plane xanthoma (NPX) is a histiocytic disorder characterized by yellow-orange plaques in the periorbital areas, neck, upper trunk, and flexural folds. Association with systemic disease or paraproteinemia has been reported previously, but rarely with Langerhans cell histiocytosis (LCH). We report a case of Hand-Schüller-Christian disease (a type of LCH) in a patient who developed NPX with supraglottic involvement. NPX developed after several courses of chemotherapy and the supraglottic xanthoma occurred about 2 years later. The coexistence of LCH and non-LCH histiocytic lesions in this patient could be a result of chemotherapy-induced changes or may be just coincidental.

[Supracricoid partial laryngectomy as salvage for recurrent carcinoma of the larynx initially treated by vertical partial hemilaryngectomy. Case report]

OBJECTIVE

We undertook this study to report the possibility of salvage of vertical partial hemilaryngectomy with imbrication laryngoplasty (PVHLIL) to supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP) in a patient with recurrent glottic carcinoma.

CLINICAL CASE

A 68-year-old patient with recurrent glottic squamous cell carcinoma (T1aN0) was treated with imbricated partial laryngectomy. Transoperative histopathological report demonstrated vocal cord free surgical margins anterior at 1 cm and 0.4 cm posterior. The patient was evaluated trimonthly and at 16-month follow-up presented with tumor activity on the posterior third of the left false vocal cord, close to the arytenoids, which still conserved mobility. Biopsy was performed and confirmed recurrence of squamous cell carcinoma. SCPL with CHEP was performed with a satisfactory postoperative evolution with tracheotomy decannulation at day 7. Physiological phonation and retirement of nasogastric tube were accomplished at day 15, as well as reinitiation of oral feeding. Histopathological report showed a moderately differentiated squamous cell carcinoma. Functional evaluation with PVHLIL is a clear voice alteration; however, patients do not require permanent tracheostomy, and a close to normal biopsicosocial integration after SCPL + CHEP is possible.

CONCLUSIONS

PVHLIL is an excellent treatment option for selected glottic tumors staged T1 or T2. Close follow-up must be given to allow the possibility of organ conservation either with radiotherapy or surgery. When recurrence occurs, SCPL + CHEP must be considered according to the established criteria for this procedure. Total laryngectomy must be considered as the last option, with the only purpose being a normal quality of life.

Supracricoid laryngectomy with cricohyoidoepiglotto-pexy or cricohyoido-pexy: Experience on 32 patients

OBJECTIVE

Supracricoid laryngectomy (SCL) with Cricohyoidoepiglotto-pexy (CHEP) or Cricohyoido-pexy (CHP) is an organ preservation surgery indicated for early and selected advanced laryngeal cancers. To verify the clinical usefulness of supracricoid laryngectomy versus total laryngectomy, a retrospective review was conducted.

METHODS

We summarized the clinical and postoperative data of 32 patients who received SCL over the past 9 years (1997-2005). Five-year survival rate of the SCL patient group (29 cases) was compared with that of the patient group receiving total laryngectomy (35 cases) within the same period.

RESULTS

Wound infection was detected in 12 patients (38%). Those with severe infection, which required surgical intervention, included two cases of ruptured pexis and two cases showing cricoid cartilage necrosis induced by Forestier disease. There were two T4 cases that resulted in extensive excision. In one case, excision involved the posterior part of the cricoid cartilage resulting in insufficient closure of the neoglottis; the patient received total laryngectomy 30 months after SCL-CHEP because of persistent aspiration of liquid diet. In the other T4 case, the tumor invaded the thyroid and arytenoid cartilages but not the cricoid cartilage. Reposition of the remaining corniculate cartilage resulted in sufficient closure of the neoglottis; this patient subsequently acquired satisfactory laryngeal function. The 5-year overall survival rate was 86% for SCL group and 61% for the total laryngectomy group (limited to Stages III and IV glottic cancers). The causes of the four deaths were distant metastasis, neck metastasis, and intercurrent disease, respectively. Two patients are alive with distant disease.

CONCLUSION

Through our experience in this series, the functional and oncological results of SCL showed certain advantages over those of total laryngectomy. Particularly, the clinical impact of SCL-CHEP was impressive; this technique needs is recommended to both head and neck surgeons and patients.

Persistent dorsal displacement of the soft palate attributable to a frenulum of the epiglottis in a racing Thoroughbred

CASE DESCRIPTION

A 7-year-old sexually intact male Thoroughbred racehorse was evaluated because of exercise intolerance, respiratory tract noise, and coughing when eating.

CLINICAL FINDINGS

A persistent dorsal displacement of the soft palate was identified during endoscopic examination of the upper portions of the respiratory tract. Radiography of the pharyngeal and laryngeal regions revealed a hypoplastic epiglottis that was ventral to, and not in contact with, the soft palate. The horse was anesthetized, and an oral endoscopic examination revealed a subepiglottic frenulum that had resulted in the dorsal displacement of the soft palate.

TREATMENT AND OUTCOME

The frenulum was transected transendoscopically by use of a diode laser. Twenty-four hours following surgery, repeat endoscopic and radiographic examinations revealed that the epiglottis had returned to its correct anatomic position in relation to the soft palate. Four weeks after surgery, endoscopy of the upper portions of the airway revealed recurrence of the dorsal displacement of the soft palate.

CLINICAL RELEVANCE

A subepiglottic frenulum should be considered as a cause of persistent dorsal displacement of the soft palate in horses. An endoscopic examination of the oropharyngeal region should be performed in horses prior to undertaking any surgical interventions to treat persistent dorsal displacement of the soft palate.

Treatment in the field of 27 horses with epiglottic entrapment

Twenty-seven horses were treated for epiglottic entrapment by using an oral, hand-assisted bistoury knife technique, under general anaesthesia; 26 of them returned successfully to racing, but one developed a permanently displaced soft palate. After the surgery 13 of the horses had an increased handicap rating and 13 had a decreased rating.