Epiglottopexy with or without aryepiglottic fold division: Comparing outcomes in the treatment of pediatric obstructive sleep apnea.

OBJECTIVE: To determine the success of epiglottopexy with or without aryepiglottic fold division for treatment of patients with obstructive sleep apnea (OSA) with epiglottic obstruction. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic hospital. METHODS: Children with sleep study proven OSA who underwent epiglottopexy with or without aryepiglottic fold division from January 2013 to June 2017 were included. The epiglottis contributed to airway obstruction in all patients. Pre- and post-operative apnea-hypopnea index (AHI) were compared. Age, sex, body mass index (BMI) z-score and post-operative complications were also evaluated. Success was defined by post-operative AHI < 5.0 with resolution of OSA symptoms or AHI ≤ 1.0 events per hour. RESULTS: Twenty-eight children (age 2-17 years) underwent either epiglottopexy with division of aryepiglottic folds (N = 18) or epiglottopexy alone (N = 10). There was no difference in preoperative age, AHI, or BMI between the groups. Post-operative AHI was lower in the group undergoing epiglottopexy alone (AHI 1.50) versus with aryepiglottic fold division (AHI 3.17) (P < 0.05). No difference was found in mean AHI improvement between the two groups. For the entire cohort, success criteria were met by 53.6% of patients for AHI < 5.0 without symptoms and 25.0% of patients for AHI ≤ 1.0, with no difference in surgical success between procedures (P > 0.05). CONCLUSIONS: Children undergoing epiglottopexy with division of aryepiglottic folds for laryngeal collapse were as likely to have improved OSA symptoms as children undergoing epiglottopexy alone.

[Complex fracture of the larynx caused by a horse kick]. / Komplexe Larynxverletzung durch Pferdetrittverletzung.

Every blunt laryngeal trauma requires examination by an ENT physician and may necessitate observation for a number of hours. The literature shows a heterogeneous picture regarding airway management (tracheotomy vs. intubation). Extremely violence forces such as horse kicks require a tracheotomy, as demonstrated by case studies. In such cases, a high level of responsibility lies with the emergency physician providing the initial treatment. We present the case of a 37-year-old horse trainer, who suffered a horse kick to the larynx with a complex laryngeal fracture. Intubation of the patient by the emergency physician would most probably have led to incorrect placement of the tube or complete displacement of larynx and trachea. In addition to securing a vital airway by tracheotomy, a timely reconstruction of the airways, where necessary by employing the temporary insertion of a tracheal stent, is the treatment of choice. The latter therapy should be applied within the first 6 hours following the accident.

[Case of urgent surgical cricothyrotomy in CICV situation during induction of anesthesia for hemostasis after tonsillectomy].

A 38-year-old man (BMI 31) underwent bilateral tonsillectomy for sleep apnea syndrome under general anesthesia without any airway difficulty. On the fifth post-operative day excessive bleeding occurred suddenly. Emergency tracheostomy was planned, not under local anesthesia but general anesthesia in the presence of otolaryngologists for urgent tracheostomy, since the patient could not lie in the supine position. Tracheal intubation was tried using rapid sequence technique. However, excessive bleeding in the oral cavity did not allow successful direct laryngoscopy, resulting in CICV situation. When CICV situation was con- firmed associated with SpO2 91%, surgical cricothyrotomy was started by otolaryngologists. SpO2 decreased to 13% associated with heart rate of 38 beats · min-1 immediately before restoration of ventilation and oxygenation. After hemostasis, he showed uneventful post-operative course. On the occasion of airway management for excessive laryngopharyngeal bleeding, emergency surgical crycothyrotomy should be performed immediately before the fall of oxygen tension, if rapid sequence tracheal intubation had failed.

Supracricoid laryngectomy with cricohyoidopexy: oncological results.

This study assessed the oncological results in patients undergoing supracricoid laryngectomy with cricohyoidopexy. A cohort of 44 patients surgically treated using supracricoid laryngectomy with cricohyoidopexy between June 2001 and December 2009 was retrospectively analyzed. The mean follow-up period was 53.2 (±24.7) months. The Kaplan-Meier method was used to analyze overall survival and disease-specific survival, as well as survival according to T2 and T3 subgroups. Overall survival rates at 3 and 5 years were 90.5 and 84.1%, respectively. The 3- and 5-year disease-specific survival rates were 95.4 and 92.5%, respectively. Overall survival for patients with T2 disease was 87.5% at 3 years and 80.8% at 5 years. For T3, the corresponding rates were 91.8 and 87.0%. Disease-specific survival for patients with T2 disease was 93.3% at 3 years and the same at 5 years; the corresponding rates for T3 were 96.4 and 91.4%. The differences between T2 and T3 patients at 3 and 5 years with respect to overall and disease-specific survival were not statistically significant (P = 0.903 and P = 0.863, respectively). Recurrence was local in one patient (2.2%) and regional in three (6.8%). There were three distant metastases (6.8%) and one second primary carcinoma (2.2%). These findings support the use of supracricoid laryngectomy with cricohyoidopexy as an oncologically safe technique in properly selected patients with laryngeal carcinoma.

The Healing Effect of Amniotic Membrane in Laryngeal Defects in Rabbit Model.

OBJECTIVE: Fibrosis and scar formation following laryngeal repairing is a major concern. This study evaluated the efficacy of applying amniotic membrane (AM) as a biologic dressing to reduce fibrosis and inflammation and promote cartilage repair. STUDY DESIGN: Experimental animal study. METHODS: Nine male white Dutch rabbits were selected. A standard defect (5 mm) was created in right and left thyroid lamina. In the right side, two layers of AM were applied while the left side was kept intact for future comparison. Histologic examination with criteria of inflammation, fibrosis, and cartilage regeneration was performed 2, 4, and 6 weeks following AM application. All procedures were done according to animal ethics rules. RESULTS: Histologic and gross examination showed that AM application was able to reduce inflammation and fibrosis and improve cartilage regeneration significantly. CONCLUSION: As a useful intervention, AM application can reduce inflammation and fibrosis and enhance cartilage regeneration, following laryngeal defect repair. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E527-E533, 2021.

Clinicopathologic characteristics of laryngeal chondrosarcoma: An analysis of the National Cancer Database.

OBJECTIVES: Laryngeal Chondrosarcoma (LC) is a rare malignancy with limited studies documenting its clinicopathologic characteristics and treatment options. This study reports demographic and clinical determinants of outcomes for this rare tumor. METHODS: The National Cancer Database (NCDB) was queried for cases of LC reported from 2004-2016. 274 cases that met inclusion criteria were analyzed for demographic and clinicopathologic characteristics. Kaplan-Meier (KM) and Cox proportional hazard analyses were conducted to identify variables that impacted the overall survival of these patients. RESULTS: LC was found to be more common in males (74.8%). The mean age of patients was 61.8 years and 92.3% of the patients were white. 91.3% of patients were treated with only surgical resection, most commonly: partial laryngectomy (31.6%), total laryngectomy (25.7%), and local resection (22.4%). 98.8% of patients had no evidence of nodal disease and 99.6% of patients did not have distant metastasis at presentation. KM analysis revealed a 5-year overall survival (5YOS) of 89.0%. Age, insurance status, facility type, and surgery type were significant predictors of 5YOS (p<0.05). On Cox Proportional Hazard analysis, private insurance significantly improved survival (HR 0.21; p = 0.048) while increasing age was a poor prognostic indicator (HR 1.10; p = 0.004). CONCLUSION: The majority of LC patients present with no nodal involvement or distant metastasis at diagnosis, and overall this tumor has a favorable prognosis. Increasing age was found to be a poor prognostic factor while private insurance status was associated with improved survival.

Scarless Neck Feminization: Transoral Transvestibular Approach Chondrolaryngoplasty.

Importance: Chondrolaryngoplasty or reduction of laryngeal prominence is a gender affirmation surgery for transgender women, or for male patients desiring an aesthetic surgery. Several variations of the procedure were suggested, yet to date, all described chondrolaryngoplasty procedures involved a visible neck scar. Objective: To describe a novel technique for scarless chondrolaryngoplasty, transoral endoscopic vestibular approach (TOEVA)-chondrolaryngoplasty, and to report the results of first ever performed cases. Design, Setting, and Participants: This was a prospective cohort at an academic referral center. Adult transgender women, interested in chondrolaryngoplasty who never had previous surgery of their neck or vocal folds, were offered both transcervical chondrolaryngoplasty and scarless TOEVA-chondrolaryngoplasty. Four patients aged 21 to 33 years, who preferred TOEVA-chondrolaryngoplasty, were consented and recruited. Interventions: The surgical technique was successfully examined on two cadavers. Subsequently, all surgical procedures were conducted according to the described study protocol and technique, between April and June 2019. Main Outcomes: Vocal assessment was recorded preoperatively and repeated 4 to 6 weeks after surgery for comparison. Surgical documentations as well as adverse surgical events and complications were recorded. To measure outcome, 1-2 months postoperatively, all patients filled an outcome instrument for aesthetic chondrolaryngoplasty (seven questions on a 5-point Likert scale) based on previously designed questionnaires for chondrolaryngoplasty and facial plastic surgery. Results: Duration of operative time ranged from 90 to 150 min. No adverse events or complications were recorded during surgery. All patients were discharged 1 day postoperatively. A single patient had a mild temporary mental hypoesthesia that resolved 2 months after surgery, no other complications were encountered. Vocal folds' function remained unchanged in all four patients. All operated patients were highly satisfied with the surgical results as measured by the outcome instrument; three out of the four patients responded with perfect scores, and the fourth patient responded with 90% of the perfect score. Conclusions: This report is the first description of scarless chondrolaryngoplasty through TOEVA. On a series of four patients, TOEVA-chondrolaryngoplasty appeared to be safe, with no adverse events or major complication, and with extremely high patient satisfaction. Further clinical evidence is required to establish a widespread use of this surgical technique.

Postoperative race performance is not correlated with degree of surgical abduction after laryngoplasty in National Hunt Thoroughbred racehorses.

OBJECTIVES: To (1) assess the degree of arytenoid cartilage abduction lost after laryngoplasty (LP) in Thoroughbred National Hunt racehorses and (2) to correlate postoperative racing performance with degree of arytenoid abduction after LP. STUDY DESIGN: Case series. ANIMALS: National Hunt Thoroughbred racehorses (n=68). METHODS: Grade of postoperative arytenoid abduction for National Hunt racehorses that had LP with ventriculocordectomy was assessed at 1 day, 6 days, and 6 weeks after LP. Race records were analyzed to ascertain if there was correlation between the degree of arytenoid cartilage abduction and various measures of race performance (return to racing postoperatively, total earnings in 5 races immediately postoperatively, and lifetime number of starts postoperatively). RESULTS: Median postoperative arytenoid abduction was grade 2 on day 1 but had decreased to grade 3 by 6 weeks. Horses with grades 1, 2, and 3 abduction 1 day after surgery had median losses of 1, 1, and 0.5 abduction grades, respectively, at 6 weeks. Horses with grade 1 abduction on day 1 were significantly more likely to lose abduction by day 6 after surgery than horses with grade 3 abduction on day 1. There was no statistically significant correlation between the postoperative grade of arytenoid abduction at any time point and earnings in 5 races after surgery, likelihood of racing postoperatively, or total number of lifetime race starts postoperatively. CONCLUSIONS: Horses with maximal (grade 1) surgical arytenoid abduction are significantly more likely to suffer postoperative loss of abduction than those with grade 3 abduction. Postoperative grade of abduction does not appear significantly correlated with markers of racing performance in National Hunt racehorses; however, very few horses with poor (grade 4 or 5) abduction were included and thus conclusions regarding racing performance in such horses cannot be drawn from this study. CLINICAL RELEVANCE: Seemingly, most horses with grade 3 laryngeal abduction can race successfully and perhaps surgeons should not be disillusioned by the appearance of only moderate (grade 3) abduction in the long term after LP in racehorses.

Chondrolaryngoplasty-Thyroid Cartilage Reduction.

Chondrolaryngoplasty, also known as tracheal shave, is a surgical procedure performed for a prominent Adam's apple, usually in transfeminine patients with gender dysphoria to this marker of male sex. Although laryngeal anatomy is complex, knowledge of landmarks and techniques discussed in this article results in a safe procedure with rare complications and improvement in quality of life.

Laryngeal fractures treated with titanium mesh fixation.

The larynx plays a vital role in respiration, swallowing, and vocal function. Thus, laryngeal fractures that are not appropriately managed may lead to permanent dyspnea, dysphagia, and voice disorders. In cases of laryngeal fractures, surgical repair by internal fixation has been performed with materials such as thread, steel wire, and titanium miniplates. However, thyroid and cricoid cartilage have a complicated morphology, and ossification at each site in the cartilage is not uniform; thus, in some cases it is difficult to perform internal fixation with conventional methods. In this case report, we describe two patients who underwent successful fixation of fractures in their laryngeal cartilage after trauma by using titanium mesh with thread and screws. Since optimal reduction and fixation of fractured laryngeal cartilage cannot be performed with conventional methods in patients with unossified cartilage, titanium mesh may be considered a safe and reliable alternative.

Neoplastic invasion of laryngeal cartilage: reassessment of criteria for diagnosis at MR imaging.

PURPOSE: To evaluate whether proposed diagnostic criteria applied to magnetic resonance (MR) images of patients with laryngeal and hypopharyngeal carcinoma may be used to distinguish neoplastic from inflammatory involvement of the laryngeal cartilages. MATERIALS AND METHODS: The radiologic and histopathologic data in 121 consecutive patients with primary squamous cell carcinoma of the larynx (n = 63) or hypopharynx (n = 58) who underwent MR imaging before laryngectomy formed the basis of this retrospective study. Patient consent for retrospective chart review was waived by the institutional review board. All laryngectomy specimens were processed with a dedicated histopathologic whole-organ slice technique. MR images were evaluated by two readers according to established ("old") and proposed ("new") diagnostic criteria on the basis of the signal intensity behavior of cartilage on T2-weighted images and contrast material-enhanced T1-weighted images compared with that of the adjacent tumor. Specifically, with the new criteria, T2-weighted or postcontrast T1-weighted cartilage signal intensity greater than that of the adjacent tumor was considered to indicate inflammation, and signal intensity similar to that of the adjacent tumor was considered to indicate neoplastic invasion. The results of the MR image interpretation were compared with the histologic reference standard. RESULTS: The area under the receiver operating characteristic curve for the new criteria (0.94) was nominally but significantly larger than that for the old criteria (0.92) (P = .01). Overall specificity was significantly improved (82% for new vs 74% for old criteria, P < .001) and was greatest for the thyroid cartilage (75% for new vs 54% for old criteria, P < .001) with the new criteria. The sensitivities of the established and the proposed criteria were identical. CONCLUSION: The proposed MR imaging criteria enable improved differentiation of neoplastic cartilage invasion from peritumoral inflammation.

Bilateral vocal cord paralysis in children.

Bilateral vocal cord paralysis in children with its many causes presents a challenging problem to the pediatric otolaryngologist. Traditionally, management of bilateral vocal cord paralysis includes securing the airway with a tracheotomy and waiting for spontaneous recovery. Surgeons have tried a variety of surgical procedures in lieu of or in addition to tracheotomy, but none are perfect solutions to the problem. This article reviews the current surgical procedures for bilateral vocal cord paralysis in the pediatric population with a particular focus on the senior author's experience with the endoscopic posterior costal cartilage grafting procedure.

Congenital laryngeal stenosis.

Congenital subglottic stenosis is rare and as a consequence may not be considered in children experiencing respiratory difficulty at birth. Diagnosis after a child already is intubated complicates the recognition and blurs the boundary between congenital and acquired lesions. This article discusses the anatomy of the larynx, its common anatomic variations, and its response to trauma, a thorough understanding of which is required for the accurate diagnosis and treatment of this complicated problem. The authors discuss evaluation and assessment options to guide treatment.

Single-stage and multistage pediatric laryngotracheal reconstruction.

Acquired pediatric laryngotracheal stenosis almost always results from prolonged intubation for prematurity. An understanding of the process by which this occurs helps in prevention and treatment. Before deciding to perform cartilage augmentation procedures, more limited techniques such as medical therapy or endoscopic surgery need to be considered. Careful assessment of the patient and the stenosis aid the decision-making process for the right operation at the right time. Despite this assessment, patients with a severe or complete stenosis have a poorer prognosis, and cricotracheal resection may be a better option.

Revision pediatric laryngotracheal reconstruction.

Surgeons who make airway reconstruction a major part of their practice inevitably are faced with children in whom initial surgical management fails. Searching for the possible causes of failure and determining how best to minimize the risk of repeated failure is often an exhaustive process. Establishing a framework and guidelines for approaching and managing these failures can improve the chances of success significantly. The aim of this article is to provide such a framework.

Intra-articular stabilisation of the equine cricoarytenoid joint.

REASONS FOR PERFORMING STUDY: The success of laryngoplasty is limited by abduction loss in the early post operative period. OBJECTIVE: To determine the efficacy of polymethylmethacrylate (PMMA) in stabilising the cricoarytenoid joint (CAJ) and reducing the force on the laryngoplasty suture. HYPOTHESIS: Injection into the cricoarytenoid joint resists the forces produced by physiological laryngeal air flows and pressures thereby reducing the force experienced by the laryngoplasty suture. METHODS: Ten cadaver larynges were collected at necropsy and PMMA was injected into one CAJ at selected random. Each larynx was subjected to physiological conditions with with constant (static) or cycling (dynamic) flow. The specimens were tested sequentially in each of 4 conditions: 1) bilateral full abduction (Control 1); 2) transection of the suture on the side without PMMA; 3) bilateral abduction achieved by replacing the suture (Control 2); and 4) cutting the suture on the PMMA side. Tracheal pressure and flow and pressure in the flow chamber were recorded using pressure and flow transducers. The strain experienced by each suture during bilateral abduction (Controls 1 and 2) was measured. Statistical comparison of the 4 conditions was performed using a mixed effect model with Tukey's post hoc test for multiple comparisons. The strain gauge data were analysed by paired comparison of the regression slopes. RESULTS: In the static and dynamic states, tracheal pressure increased and tracheal flow decreased when the suture on the non-cement side was cut (P < 0.05). There was no significant difference in any outcome measure between PMMA injected into the CAJ and bilaterally abducted specimens (Controls 1 and 2) for either condition. The rate of increase in strain with increasing translaryngeal pressure was significantly less on the suture with PMMA placed in the CAJ (P = 0.03). CONCLUSIONS: These data provide strong evidence that injecting PMMA into the CAJ resists the collapsing effect of physiological airflows and pressures in vitro and reduces the force experienced by the laryngoplasty suture during maximal abduction. POTENTIAL RELEVANCE: Augmentation of prosthetic laryngoplasty with this technique may reduce arytenoid abduction loss in the early post operative period.

Efficacy of total intravenous anesthesia without intubation for laryngeal framework surgery.

CONCLUSION: Total intravenous anesthesia (TIVA) without intubation has the advantages of both conventional general anesthesia and local anesthesia. It is useful in laryngeal framework surgery because intraoperative voice monitoring while the patient remains awake is required. OBJECTIVE: In laryngeal framework surgery, it is desirable to monitor the voice during surgery. However, surgery is conducted under general anesthesia, although such a procedure renders the patient unable to phonate during surgery. We conducted TIVA without intubation, allowing patients to breathe spontaneously while undergoing operation, and succeeded in intraoperative voice monitoring with satisfactory postoperative voice production. SUBJECTS AND METHODS: The subjects were 21 patients who underwent surgery. For TIVA, propofol and pentazocine were used as a sedative and analgesic, respectively. A bispectral index (BIS) monitor was used to measure the depth of the anesthesia. Before the vocal folds were to be rotated, propofol administration was interrupted to arouse and instruct the patient to phonate. Guided by the phonation, the vocal folds were correctly positioned. Then propofol administration was resumed, and the wound was closed. RESULTS: The BIS value during continued administration of propofol was around 60, but exceeded 90 in all patients within 233.6 +/- 64.5 s after cessation. They clearly remembered the conversation they had with us during surgery.

Hyaluronan-based scaffolds to tissue-engineer cartilage implants for laryngotracheal reconstruction.

OBJECTIVES: Donor site morbidity, including pneumothorax, can be a considerable problem when harvesting cartilage grafts for laryngotracheal reconstruction (LTR). Tissue-engineered cartilage may offer a solution to this problem. This study investigated the feasibility of using Hyalograft C combined with autologous chondrocytes to tissue engineer cartilage grafts for LTR in rabbits. STUDY DESIGN: Animal study. METHODS: Eighteen New Zealand white rabbits underwent LTR: 12 rabbits received autologous tissue-engineered cartilage grafts and 6 animals, serving as a positive control group, native auricular cartilage. To determine any differences in response to the site of implantation and any potential immune response to the scaffold, a second piece of engineered neocartilage and a non-cell-loaded scaffold were inserted paralaryngeally into a subset of the rabbits. The rabbits were sacrificed 3, 6, 8, 10, and 12 weeks after the LTR and their larynx examined. RESULTS: None of the 18 rabbits showed signs of respiratory distress. A smooth, noninflammatory scar was visible intraluminally. Histologically, the native auricular cartilage implants showed excellent integration without any signs of inflammation or cartilage degradation. In contrast, all tissue-engineered grafts and empty scaffolds revealed marked signs of an unspecific foreign body reaction, leading to a complete degradation of the neocartilage, whether implanted para- or intralaryngeally. CONCLUSION: In contrast to the success with which Hyalograft C has been applied in articular defect repair, our results indicate that, in rabbits, Hyalograft C initiates a foreign body reaction if implanted intra- or paralaryngeally, leading to cartilage degradation and possible graft failure. These findings suggest limitations on the environment in which Hyalograft C can be applied.

Evaluation of the efficacy of supraglottoplasty in obstructive sleep apnea syndrome associated with severe laryngomalacia.

OBJECTIVE: To evaluate the clinical and polysomnographic evolution of patients with severe laryngomalacia who underwent supraglottoplasty. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: Seven children with severe laryngomalacia. MAIN OUTCOME MEASURES: The patients were evaluated with a questionnaire given to their parents and with polysomnographic examination before and 3 months after surgery. The clinical data of respiratory and swallowing symptoms as well as the parameters of minimum oxygen saturation and respiratory disturbance index were evaluated after bilateral supraglottoplasty and compared with the preoperative data. RESULTS: Two patients had pharyngolaryngomalacia and required tracheotomy. Four patients had a marked improvement of respiratory and deglutition symptoms. Polysomnographic data showed a significant improvement in the respiratory disturbance index after surgery (P<.05) but not in the minimum oxygen saturation level. However, this improvement was only partially achieved in 3 patients, in whom there were associated airway or neurologic changes. No serious surgical complications were observed. CONCLUSION: Supraglottoplasty led to a marked improvement in all 5 patients without pharyngolaryngomalacia, but the 2 patients with pharyngolaryngomalacia required tracheotomy.