Endoscopic management of adult subglottic stenosis: an alternative to open surgery.

PURPOSE: Various surgical techniques could be used to treat subglottic stenosis (SGS). The aim of this study is to present our experience in endoscopic management of SGS and show the impact of symptoms' evaluation, clinical examination and spirometry in the therapeutic decision. METHODS: Endoscopic treatment was performed in patients referred for SGS and consisted of CO2 scar lysis associated with balloon dilation and concomitant steroids' injection for patients with grade II or higher on the mMRC (modified Medical Research Council) dyspnea scale associated with a DI (Dyspnea Index) score higher than 10/40 and objective stenosis equal or higher than grade II. The preoperative DI score, EDI (expiratory disproportion index) and voice parameters were compared to postoperative results. The mean interval between endoscopic procedures (IEP) was calculated and we looked for the evolution of the IEP during repeated procedures. RESULTS: Nineteen patients were included. 35 dilations were performed. The mean IEP was 86 weeks. There was a significant decrease of the postoperative DI scores by 18.6 points ± 11 (SD). An important difference of 20.1 ± 13.5 (SD) was identified between the pre and postoperative EDI. Minimal changes occured in voice parameters. CONCLUSIONS: Endoscopic treatment with CO2 scar lysis associated with balloon dilation and concomitant steroids' injection is a safe, reliable and minimally invasive endoscopic procedure to treat SGS. Decision to treat has to be on an individual basis taking into account subjective symptoms including Dyspnea Index score and objective laryngoscopic findings and spirometry.

Evaluation of percutaneous dilatational tracheostomy under laryngosuspension.

PURPOSE: To describe the technique and outcomes of percutaneous tracheostomy under laryngosuspension. METHODS: A consecutive series of patients who underwent percutaneous tracheostomy under laryngosuspension were reviewed for outcomes. The procedure is performed under general anesthesia and laryngosuspension. An 8.5 oral endotracheal tube is inserted and the cuff is inflated in the supraglottis, allowing access to the whole trachea and subglottis. The tube is taped to the laryngoscope. A rigid endoscope is inserted in the endotracheal tube through a swivel connector connected to the tube and the ventilation circuit. Percutaneous tracheostomy kit is used to perform dilatational tracheostomy at the desired level of the trachea under direct visual endoscopic control. RESULTS: Forty-eight patients underwent percutaneous tracheostomy under laryngosuspension. Thirty-two cases were performed in an emergency after securing the airway with endotracheal intubation. In all other cases, tracheostomy was performed as a part of an elective procedure affecting the airway or in patients requiring prolonged ventilation. More than half of patients were considered high risk by virtue of one or more of the following: morbid obesity, prior neck surgery, prior neck radiotherapy, progressive head and neck cancer, or laryngotracheal stenosis. Complications occurred in seven cases. CONCLUSION: Percutaneous tracheostomy under laryngosuspension has the advantage of optimal control of patient ventilation and hemostasis throughout the procedure. High-quality endoscopic vision and easy access to the airway under laryngosuspension allow tracheostomy to be performed with maximum safety.

Glottic configuration changes and outcomes of endoscopic arytenoid abduction lateropexy.

INTRODUCTION: Endoscopic arytenoid abduction lateropexy (EAAL) is an effective glottis enlarging procedure for the treatment of bilateral vocal cord palsy (BVCP). The postoperative glottic configuration changes can be evaluated by modern, high-resolution, 3D image reconstructions. Functional results are described by spirometry as well as objective and subjective phoniatric tests. METHODS: Unilateral EAAL was performed in ten malignant thyroid gland tumor patients (eight women, two men), who had BVCP after thyroid surgery. Slicer 3D® software was used for morphometric analysis. Pre- and postoperative peak inspiratory flow (PIF) and standard phoniatric parameters were compared. RESULTS: The glottic gap improved significantly (+ 60%). Significant improvement of PIF was found in all cases. Phoniatric tests revealed better quality of voice and patient satisfaction. Their voices changed from a severely impaired to a socially acceptable, almost normal, quality. CONCLUSION: The results support our clinical observations that the ideal position of the lateralization sutures is the one which provides a physiological abduction position of the arytenoid cartilage. Considering these good results, the surgical indications for minimally invasive endoscopic arytenoid lateropexy may be extended.

Modified single-stage segmental cricotracheal resection.

The objective of our work is to demonstrate in a large cohort of patients with cricotracheal stenosis that resection of long airway segments could be performed with no increased risk of postoperative complications. A consecutive series of patients getting cervical segmental cricotracheal resection (CTR) were reviewed. The typical segmental tracheal resection technique has been modified to accommodate long segment removal. Modifications include using trachea to enable the reconstruction of the larynx itself as well as the placement of a "laryngosternopexy" stitch between the thyroid lamina and the sternoclavicular ligament designed to take all of the tension off the anastomosis and to prevent inadvertent head extension. Anastomosis was performed by using continuous barbed sutures that allowed gradual approximation of the proximal and distal segments even in the presence of a large segmental airway resection defect that could involve as much as half of the tracheal length. Thirty-eight patients were treated. Primary etiologies of cricotracheal stenosis were prolonged intubation and tracheostomy. All had Grade III-IV stenosis. Only one patient had postoperative revision surgery for anastomosis-based disease. All patients with tracheostomy (n = 29) were successfully decannulated. Complications occurred in five patients. These included acute airway obstruction requiring emergency tracheostomy through the anastomosis, a tracheal dehiscence, laryngeal edema with airway obstruction, superficial wound infections, neck abscesses, and transient vocal cord immobility. Modified cricotracheal resection has comparable results to traditional techniques and may offer advantages such as resection of long tracheal segments without any increase in the risk of post-anastomosis airway leak.

The vagal nerve stimulation outcome, and laryngeal effect: Otolaryngologists roles and perspective.

INTRODUCTION: Epilepsy is one of the most common neurologic disorders. Vagus nerve stimulation (VNS), first investigated in 1938 and subsequently studied as a potential therapy for epilepsy. The FDA approved the use of VNS in 1997 as an adjunctive non-pharmacologic symptomatic treatment option for refractory epilepsy for adults and adolescents over 12years. VNS can cause laryngeal and voice side effects that can be managed by otolaryngologists safely and effectively. OBJECTIVES: This study is to review the outcomes of vagal nerve stimulator (VNS) implantation in terms of the surgical procedures, complications, seizure frequency, and the clinical effect on larynx and vocal folds motion. METHODS: Series of thirty consecutive patients who had VNS implantation between 2007 and 2014 were recruited. Seizure-frequency outcome, surgical complications and device adverse effects of VNS were retrospectively reviewed. Additional evaluation included use of the Voice Handicap Index and Maximum Phonation Time (MPT) were conducted before and after the implantation. Videolaryngoscopy was used to evaluate the vocal fold mobility before and after the VNS implantation. RESULTS: Seizure frequency reduction over a minimum of 2years of follow up demonstrated: 100% in seizure frequency reduction in 1 patient, drastic reduction in seizure frequency (70-90%) in 9 patients, a good reduction in terms of seizure frequency (50%) in 8 patients, a 30% reduction in 5 patients, no response in 6 patients, and 1 patient had increased frequency. The most commonly reported adverse effects after VNS activation were coughing and voice changes with pitch breaks, as well as mild intermittent shortness of breath in 33% of patients. For those patients secondary supraglottic muscle tension and hyper function with reduced left vocal fold mobility were noticed on videolaryngoscopy, though none had aspiration problems. Surgical complications included a wound dehiscence in one patient (3%) which was surgically managed, minor intra-operative bleeding 3%; a superficial wound infection in one patient (3%) which was treated conservatively, none of the complications necessitated VNS removal. CONCLUSIONS: VNS appears to be an effective non-pharmacologic adjuvant therapy in patients with medically refractory seizures. With the favorable adverse-effect profile previously described, VNS is generally well tolerated and of a great benefit to such patients. Laryngeal side effects, of which hoarseness being of the greatest repetition, are the most common after the VNS implantation. VNS can affect the voice and reduced vocal cord motion on the implantation side with secondary supraglottic muscle tension. Otolaryngologists are not only capable of performing VNS implantation, but can also manage surgical complications, assess laryngeal side effects and treat them as needed.

Functional outcomes of endoscopic arytenoid abduction lateropexy for unilateral vocal cord paralysis with dyspnea.

In unilateral vocal cord paralysis (UVCP), hoarseness is usually the leading symptom; however, the diminished airway might lead to breathing problems as well, especially with exertion. The application of the classic resection glottis enlarging or medialization procedures might shift the breathing and/or the voice to a worse condition. The non-destructive endoscopic arytenoid abduction lateropexy (EAAL) might be a solution for this problem. The aim of our study was to analyze the phonatory and respiratory outcomes of this treatment concept. The first year phoniatric [Jitter, Shimmer, harmonics-to-noise ratio (HNR), maximum phonation time (MPT), fundamental frequency (F 0), Voice Handicap Index (VHI), Dysphonia Severity Index (DSI), Global-Roughness-Breathiness scale (GRB)], peak inspiratory flow (PIF), and quality of life (QoL) were evaluated in ten UVCP patients treated by EAAL for dyspnea generally presented on exertion. PIF, Jitter, QoL, GRB, and VHI significantly improved. DSI, HNR, and MPT got non-significantly better. F 0 slightly increased in all patients, a mild deterioration of shimmer was observed. These results prove that improving respiratory function is not necessarily associated with a deterioration in voice quality. The EAAL provides a significant improvement in breathing and the vibratory parameters of the postoperative, more tensed and straightened vocal cords proved to be more advantageous than the original (para) median 'loose' position. The over-adduction of the contralateral side more or less compensates for the disadvantageous, more lateral position of the operated side. EAAL might be an alternative treatment for unilateral vocal cord paralysis associated with breathing problems.

Partial arytenoidectomy with transoral vocal fold lateralisation in treating airway obstruction secondary to bilateral vocal fold immobility.

OBJECTIVE: To report the outcome of 18 patients with a tracheostomy secondary to bilateral vocal fold immobility, who were managed using reconstructive transoral laser microsurgical techniques. METHODS: A retrospective review was conducted of the surgical outcome of 18 patients with bilateral vocal fold immobility and a tracheostomy resulting from different aetiologies. Follow-up duration ranged from one to five years. RESULTS: A total of 18 patients had a tracheostomy at presentation because of bilateral true vocal fold immobility and stridor. All cases were treated using reconstructive transoral laser microsurgery with arytenoidectomy and vocal fold lateralisation. All patients were successfully decannulated by eight weeks after surgery. CONCLUSION: Reconstructive transoral laser microsurgery using partial arytenoidectomy with vocal fold lateralisation is minimally invasive, feasible, safe and effective for airway reconstruction in patients who present with stridor due to bilateral true vocal fold immobility.

Decannulation of Tracheostomy-Dependent Patients: Results and Review of Techniques of Reconstructive Transoral Laser Microsurgery.

OBJECTIVES: This study aims to demonstrate the benefit of reconstructive transoral laser microsurgery (R-TLM) in decannulation of tracheostomy-dependent patients with airway obstruction. METHODS: A consecutive series of tracheostomy-dependent patients who underwent R-TLM using multiple techniques described in our previous works, were reviewed for outcomes especially for decannulation. Full airway examination was essential to determine the anatomical and functional sites of obstruction to establish the surgical plan including R-TLM techniques needed to improve airway prior to permanent decannulation. RESULTS: Twenty-two patients were treated. Eighteen subjects were successfully decannulated. Single or multiple R-TLM surgical technique(s) was/were performed during the same surgery to treat upper airway stenosis at the level of the hypopharynx, larynx, and trachea. The mean number of surgeries per patient was 2.1. Patients were followed up for at least 12 months. CONCLUSION: R-TLM combines different surgical techniques which can be used individually or combined in a stepwise surgical plan for permanent decannulation of tracheostomy-dependent patients with a previous history of decannulation failure secondary to airway obstruction. Accurate preoperative examination gives valuable information about airway and allows establishing a stepwise surgical plan that may need multiple surgeries for full permanent decannulation of these patients.

Extended partial laryngectomy with functional preservation using the rotational crico-thyrotracheopexy.

Objectives: Glottic tumors with infiltration of the anterior/posterior commissure, and lesions with subglottic, cricoid, or cricoarytenoid joint infiltration have been highly controversial in the past, from the perspective of oncological safety. Although conservation laryngeal resection options exist, most are limited by the extent of resection proscribed by the technique and the postoperative functional results. Oncologically speaking, extended vertical hemilaryngectomy is often the optimal solution. However, limited reconstruction methods often compel total laryngectomy. Methods: Eight patients with vocal fold malignancy, which infiltrated the anterior and sometimes the posterior commissure and with subglottic extension and resultant uni/bilateral vocal fold motion impairment, were treated by single stage extended vertical partial laryngectomy with rotational crico-thyrotracheopexy as a functional reconstruction of the laryngeal framework. Patients were evaluated with objective and subjective function tests. Results: Histologic examination demonstrated tumor-free margins in every case. Definitive decannulation was successful in all cases within 2 weeks. All patients had a stable and adequate airway during follow-up and reported socially acceptable voice. Oral feeding was possible in seven patients. Conclusion: Rotational crico-thyrotracheopexy, as a single stage reconstruction technique, is based on well-vascularized, readily available, appropriately shaped local tissues, without significant donor site morbidity or need for long-term stenting to reconstruct large laryngeal defects after extended vertical hemilaryngectomy for advanced unilateral glottic tumors and is applicable even with supra/subglottic invasion or infiltration of the contralateral vocal fold. An adequate airway can be achieved with socially acceptable voice and safe swallowing without compromising oncologic reliability. Level of Evidence: 4 (retrospective case series review).

Comparative Treatment Outcomes for Idiopathic Subglottic Stenosis: 5-Year Update.

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

Construction and characterization of a portable sound booth for onsite voice recording.

The negative effects of environmental noise on sound recordings are recognized in the professional literature. Sound booths and anechoic chambers are examples of controlled acoustical environments widely used in research. However, both enclosures are expensive, require substantial space, and are not portable. Our research has been directed to measuring vocal endurance and voice characteristics of singers before and after sustained voice use. Our desire to acquire high-quality onsite recordings necessitated the development of a portable recording environment. In this article, we report the design, construction, and acoustic characterization of a prototype portable sound box (PSB) to acquire high-quality voice recordings in a controlled, portable acoustical measurement. Simulations were conducted to model the intended use of the PSB by voice users, using two acoustic characterization procedures. The first method showed higher intensity variations by region and depth as frequency changed. For the modified method, intensity response was more uniform and displayed less variation with frequency change. Both methods enabled us to 1) refine the onsite recording procedure, 2) provide insight into potential sources of analysis errors, and 3) develop detailed analysis of frequency intensity response affected by equipment variability. We found that it is possible to construct a PSB for onsite high-quality voice recording.

Transoral closure of the supraglottic larynx for intractable aspiration.

The aim of this paper is to describe a novel, safe, and effective surgical technique to eliminate aspiration, that is performed entirely by reconstructive transoral laser microsurgery (R-TLM). Eleven tracheostomy-dependent patients with recurrent pneumonia secondary to intractable aspiration treated with transoral laryngeal closure were included in our study. In all cases, the supraglottic mucosa is incised in a circumferential manner. The distal tissues are sutured side-to-side longitudinally, and the superficial tissues are sutured back-to-front transversally. All patients successfully underwent transoral laryngeal closure without significant perioperative complication. Four patients resumed oral feeding for effective nutrition and two patients for pleasure. One patient developed a small fistula with a leak that warranted secondary closure by a follow-up R-TLM procedure and subsequently held to protect his airway. Complete supraglottic laryngeal closure can be performed safely and effectively using R-TLM techniques. They provide a natural-orifice alternative to open surgery in patients with intractable aspiration.

Lateralization of the Vocal Fold: Results of an Exclusive Transoral Approach.

OBJECTIVE: Vocal fold paralysis in adduction can result in dyspnea. The authors have previously described an original vocal fold lateralization technique performed exclusively through an endoscopic approach. In this work, we studied long and short-term results of this procedure on dyspnea, phonation, and swallowing. STUDY DESIGN: Retrospective cohort study through data from medical records and operative notes. Patients with unilateral or bilateral vocal fold paralysis in adduction who underwent transoral lateralization were included. METHODS: In all patients, under laryngosuspension, a supraglottic laryngotomy was performed with CO2 laser and a lateralization suture was passed through the thyroid cartilage to the vocal process of the vocal fold with the desired tension allowing lateralization of the arytenoid and corresponding vocal fold. We studied evolution of breathing, phonation, and swallowing in all patients who underwent lateralization suture. We tried to correlate symptoms to preoperative and postoperative glottic area, inter-arytenoid distance, and anterior glottic angle. RESULTS: Eighteen patients were included in the study. Three patients were tracheostomy-dependent and were successfully decannulated. All other cases presented short and long-term significant improvement of their dyspnea index score (P < 0.001) in correlation with glottic area enlargement (P < 0.001). There was no statistical difference between preoperative and postoperative voice and swallowing parameters. CONCLUSION: Our transoral lateralization technique allows enlargement of the glottic aperture in case of laryngeal dyspnea secondary to vocal fold paralysis in adduction. This technique optimally preserves laryngeal structures, especially the mucosa. It is reproducible and reliable for all laryngologists experienced in reconstructive transoral laser microsurgery.

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

OBJECTIVES: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. METHODS: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. RESULTS: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. CONCLUSIONS: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Clinical outcomes of bedside percutaneous dilatational tracheostomy with suspension laryngoscopy for airway control.

OBJECTIVES: We sought to describe outcomes of a new technique blending suspension laryngoscopy (SL) with percutaneous dilatational tracheostomy (PDT), addressing concerns of airway control and risks of dire complications. METHODS: A retrospective review of 67 cases included "all comers", in that if the patient could undergo any type of tracheostomy, SL-PDT was offered, and it was performed in all but 1 patient. Patient demographics, intubation time, time from consultation to procedure, and perioperative complications were reviewed. RESULTS: Sixty-six patients underwent SL-PDT; 54 procedures were performed bedside in the intensive care unit, and 12 in the operating room. Use of the operating room was due to lack of intensivist availability or possible need for an emergent surgical airway. Early in the series, 1 patient required open tracheostomy because of unfavorable anatomy. Two major complications occurred: 1 perioperative airway obstruction and 1 severe bradycardic event. The 2 patients were resuscitated without significant sequelae. Three minor complications occurred: 2 cases of endotracheal bleeding and 1 transient bradycardic event. CONCLUSIONS: Bedside SL-PDT is relatively safe and effective, and offers advantages over traditional PDT and open tracheostomy. This novel technique may encourage a concerted multidisciplinary effort, including otolaryngologists, to continue to improve bedside airway management in critically ill patients.

Transoral silastic medialization for unilateral vocal fold paralysis.

BACKGROUND: Medialization laryngoplasty has historically been performed through an external approach. The aim of our work is to demonstrate the feasibility of silastic vocal fold medialization transorally. METHODS: Patients with unilateral vocal fold paralysis requiring medialization laryngoplasty were included in this report. Silastic medialization was done through a transoral approach. A supraglottic laryngotomy is performed followed by dissection and tunneling in the paraglottic space. Silastic implant is inserted into the tunnel to medialize the vocal fold and the ipsilateral arytenoid. The laryngotomy is tightly closed by endoscopic sutures. RESULTS: A consecutive series of 22 patients are reported. All patients had dysphonia with significant glottic insufficiency. After endoscopic silastic medialization, voice and swallowing were significantly improved (P < .001). No postoperative complications or implant extrusion occurred in our series. CONCLUSION: Silastic vocal fold medialization can be safely and effectively performed through a transoral approach with good results on voice and swallowing.

Cricoarytenoid Joint Ankylosis: Classification and Transoral Laser Microsurgical Treatment.

OBJECTIVE: This study aimed to describe a graduated approach for effective transoral mobilization of cricoarytenoid joint ankylosis (CJA) in the context of the Bogdasarian system of classifying posterior glottic web-based stenosis (PGWS). STUDY DESIGN: This is a retrospective cohort study through data from medical records and operative notes. A consecutive series of 23 patients who underwent reconstructive transoral laser microsurgery for PGWS with a significant degree of CJA (Bogdasarian grade III-IV) was included in the study. METHODS: Techniques necessary to remobilize their cricoarytenoid joints were reviewed in the context of the extent of scar tissue found. RESULTS: Arytenoids with CJA were successfully mobilized by resection of the fused portion of the cricoid and arytenoid cartilages achieving respiratory improvements as well as decannulation of tracheostomy-dependent patients. The majority (83%) of patient's voices improved. All patients tolerated a full diet after the procedures. Cases with Bogdasarian grade III PGWS with minor unilateral fixation should be classified as IIIa. If the fixation is severe, the case should be classified as a grade IIIb. Grade IVa would indicate that both sides were mildly to moderately ankylosed, and grade IVb involves ankylosis of both joints with subtotal or complete fusion of at least one; it presents the greatest surgical challenge. CONCLUSION: We provided effective transoral techniques for the re-mobilization of cricoarytenoid joint, along with a classification of CJA that aims to standardize the severity of disease in the context of the existing and widely accepted Bogdasarian scale.

Isolated Recovery of Adductor Muscle Function Following Bilateral Recurrent Laryngeal Nerve Injuries.

OBJECTIVES/HYPOTHESIS: The aim of this study was to analyze the phoniatric and respiratory outcomes of a subset of bilateral vocal cord paralysis (BVCP) patients who were all treated with unilateral endoscopic arytenoid abduction lateropexy (EAAL). EAAL is a nondestructive, minimally invasive glottis widening operation, which does not damage either the surgically treated or the contralateral vocal cord. Therefore, it does not impair the regeneration potential of the recurrent laryngeal nerve. STUDY DESIGN: Case series. METHODS: Ten out of 21 BVCP patients who were treated with EAAL showed signs of isolated adduction recovery at 1 year and were chosen for this study. Functional results (objective and subjective voice analysis, spirometric measurement) and vocal cord movements were assessed preoperatively, 1 week and 1 year after EAAL. Laryngeal electromyography was performed on the 12th postoperative month. RESULTS: The volitional adductor movement seen on laryngoscopy was corroborated by laryngeal electromyography evaluation. Peak inspiratory flow increased significantly after EAAL. Quality-of-life scores also showed high patient satisfaction. Shimmer showed consistent improvement along with harmonic-to-noise ratio and average maximal phonation time in parallel with the improving vocal cord movement. Complex voice analysis and subjective self-evaluation tests also demonstrated significant improvement. CONCLUSIONS: EAAL, as a minimally invasive, nondestructive airway widening technique, does not interfere with the potential regeneration process that can still occur after BVCP, allowing for laryngeal functional recovery. It is a safe and effective treatment for BVCP that allows a simple solution with good phonatory, swallowing, and respiratory benefits by unilateral passive and reversible vocal cord lateralization. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2334-2340, 2019.

Laparoscopic Nissen fundoplication effectively relieves symptoms in patients with laryngopharyngeal reflux.

INTRODUCTION: The utility of laparoscopic Nissen fundoplication in the treatment of laryngopharyngeal reflux symptoms remains controversial. We hypothesized that a carefully selected population with these symptoms would benefit from antireflux surgery. MATERIALS AND METHODS: Sixty-one consecutive patients have undergone antireflux surgery for laryngopharyngeal reflux at a single institution. Preoperative evaluation including upper endoscopy, laryngoscopy, and 24-h ambulatory pharyngeal pH probe monitoring confirmed the diagnosis. Patients completed two validated symptom assessment instruments preoperatively and at multiple time points postoperatively. RESULTS: Patients were followed for up to 3 years with a mean follow-up of 15.2 months. A significant improvement in reflux symptom index score (preoperative= 1.5+/-7.4 vs 3 years=12.4+/-10.9, p<0.01), laryngopharyngeal reflux health-related quality of life overall score (preoperative=55.0+/-26.0 vs 3 years=11.3+/-13.9, p<0.01), and symptom domain scores (voice, cough, throat clearing, and swallowing) occurred within 1 month of surgery and remained improved over the course of the study. CONCLUSION: Laparoscopic Nissen fundoplication is effective in relieving the symptoms of laryngopharyngeal reflux in a carefully selected patient population. Benefits are seen within 1 month of surgery and persist for at least 3 years.