Diagnosis and endoscopic treatment of blunt laryngeal trauma with arytenoid injury / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the clinical characteristics, diagnosis, endoscopic surgical procedures, and therapeutic effect of blunt laryngeal trauma with arytenoid injury. Methods: We retrospectively reviewed 12 patients who suffered blunt laryngeal trauma with laryngeal mucosa avulsion and arytenoid region injury at the Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital from April 2007 to December 2018. Among the 12 patients, 10 were males, 2 were females, aged from 7 to 48 years old, with a median age of 21 years old. All patients were performed with transoral endoscopic laryngeal microsurgery under general anesthesia. Clinical characteristics, laryngoscopic signs, laryngeal CT, endoscopic surgical findings and procedures, and therapeutic effect were analyzed. The subjective and objective parameters of the voice quality of patients before and after surgery were compared using SPSS 22.0 statistical software by paired T test. Results: All patients had a history of obvious dysphonia immediately after trauma, accompanied by throat pain and hemoptysis without obvious dyspnea and dysphagia. Slight subcutaneous emphysema was found in 3 patients by physical examination. Laryngoscope revealed that 14 sides of vocal folds immobilized, arytenoid and/or ventricular region and posterior glottis mucosa were avulsed in 4 patients within 48 h of injury, and arytenoid cartilage was exposed in 4 sides. The arytenoid and ventricular regions were covered with thick pseudo-membrane or granulation, with abnormal structure in 8 patients with damage of more than 48 h. Intraoperative exploration revealed that there were 17 sides of arytenoid region (bilateral 5 cases, unilateral 7 cases) with varying degrees of injury. There was only limited laceration on three sides of the vocal folds. The lateral ventricular and vocal fold mucosae were avulsed vertically from the arytenoid region and arytenoid cartilage was exposed in 14 sides, among which 6 sides had abnormal arytenoid cartilage morphology and 8 sides had fracture displacement. Laryngeal CT showed irregular thickening of lateral glottis and/or supratroglottic structures in patients with vocal folds immobility, among which asymmetry of arytenoid cartilage structure on both sides in 3 cases and displacement in 2 cases were found. Restoration and microsuture of the fractured arytenoid, perichondrium and avulsion laryngeal mucosa under the direct laryngoscope were performed. The degree of dysphonia was significantly improved immediately after laryngeal microsurgery, the voice significantly improved in G, R, B, A, jitter, shimmer, NHR, and MPT three months after surgery(t=12.792, 12.792, 10.340, 3.276, 2.865, 3.781, 3.173, 3.090, respectively, P<0.05). Except for 1 patient with scar on vocal fold, all the other patients had normal laryngeal morphology and normal vocal fold movement. No laryngeal stenosis was found during the follow-up period. Conclusions: For patients with blunt laryngeal trauma, the injury of arytenoid region and arytenoid cartilage should be evaluated if there is obvious hoarseness, vocal fold immobility, avulsion of ventricular/vocal folds mucosa, or structural abnormality of arytenoid region under laryngoscopic examination. For highly suspected cases, microrphonosurgery under the direct laryngoscope should be performed as soon as possible, which can effectively reduce the occurrence of vocal fold movement disorders and laryngeal scar/stenosis, reconstruct the normal laryngeal structure, and restore the vocal function.

Clinical outcomes of vocal fold immobility after tracheal intubation / 北京大学学报(医学版)

OBJECTIVE@#To assess the incidence of postoperative vocal cord immobility in patients following endotracheal intubation underwent general anesthesia.@*METHODS@#We retrospectively enrolled patients who underwent surgical procedures with endotracheal intubation under general anesthesia from January 2014 to December 2018 in Peking University First Hospital. Demographic and treatment data were obtained for patients with hoarseness and vocal cord fixation. The incidence of postoperative hoarseness and vocal cord fixation were presented and clinical outcomes were further analyzed.@*RESULTS@#A total of 85 998 patients following tracheal intubation and general anesthesia were enrolled in this study. Hoarseness was observed in 222 (0.26%) patients postoperatively. Sixteen patients (73%) were accomplished with symptoms of choking on water, dysphonia and sore throat. Twenty-nine patients with persistent hoarseness on the third postoperative day needed further treatment by otolaryngologists. Among them, seven patients had pharyngolaryngitis and twenty-two patients (0.026%) were demonstrated postoperative vocal cord immobility. There were seventeen patients (77%) with left-side vocal cord fixation and five patients (23%) with right-side vocal cord fixation. Nine patients were identified with arytenoid dislocation. Seven patients had left vocal cord fixation and two patients had right-side vocal cord fixation. Seven patients were intubated under the guidance of visual laryngoscope. One patient was confirmed difficult airway and intubated with light wand. One patient was inserted with laryngeal mask airway. One patient was suspected to have hoarseness caused by gastric tube before anesthesia. One patient showed simultaneously left recurrent laryngeal nerve abnormality on laryngeal electromyography result. The symptom of hoarseness ranged between 6 and 31 days. Three patients underwent closed reduction under local anesthesia and one patient demonstrated spontaneous recovery. Among the remaining thirteen patients with vocal cord immobility, two patients were demonstrated vocal cord paralysis. Eleven patients underwent neck surgery, thyroid surgery and cardiothoracic surgery and further examinations including laryn-geal electromyography and computed tomography help to determine the diagnosis were not performed. All patients were treated with inhaled corticosteroid conservatively. Five patients had significant improvement of symptom and almost regained normal voice. One patient had slight improvement and sixteen patients were not relieved before discharge.@*CONCLUSION@#Patients with hoarseness and vocal fold immobility after endotracheal intubation should be treated properly and immediately.

Supracricoid Laryngectomy: The Function of the Remaining Arytenoid in Voice and Swallowing

Abstract Introduction Supracricoid laryngectomy still has selected indications; there are few studies in the literature, and the case series are limited, a fact that stimulates the development of new studies to further elucidate the structural and functional aspects of the procedure. Objective To assess voice and deglutition parameters according to the number of preserved arytenoids. Methods Eleven patients who underwent subtotal laryngectomy with cricohyoidoepiglottopexy were evaluated by laryngeal nasofibroscopy, videofluoroscopy, and auditory-perceptual, acoustic, and voice pleasantness analyses, after resuming oral feeding. Results Functional abnormalities were detected in two out of the three patients who underwent arytenoidectomy, and in six patients from the remainder of the sample. Almost half of the sample presented silent laryngeal penetration and/or vallecular/ hypopharyngeal stasis on the videofluoroscopy. The mean voice analysis scores indicated moderate vocal deviation, roughness and breathiness; severe strain and loudness deviation; shorter maximum phonation time; the presence of noise; and high third and fourth formant values. The voices were rated as unpleasant. There was no difference in the number and functionality of the remaining arytenoids as prognostic factors for deglutition; however, in the qualitative analysis, favorable voice and deglutition outcomes were more common among patients who did not undergo arytenoidectomy and had normal functional conditions. Conclusion The number and functionality of the preserved arytenoidswere not found to be prognostic factors for favorable deglutition efficiency outcomes. However, the qualitative analysis showed that the preservation of both arytenoids and the absence of functional abnormalities were associated with more satisfactory voice and deglutition patterns.

Laringectomía parcial supracricoidea de rescate por recurrencia de carcinoma laríngeo tratado inicialmente con hemilaringectomía parcial vertical: informe de caso / 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.

Endoscopic correction of severe laryngomalacia.

Tracheostomy for management of severe laryngomalacia is associated with significant morbidity and mortality. Two cases are reported wherein the laryngeal abnormality was corrected by ary-epiglottic fold incision and CO2 laser supraglottoplasty. Stridor and respiratory obstruction were relieved and a long term tracheostomy avoided. Endoscopic correction of laryngomalacia offers significant benefits over conventional treatment with tracheostomy in terms of decreased morbidity and improved quality of life.

Partial laser arytenoidectomy in the management of bilateral vocal fold immobility. A modification nased on functional anatomical study of the cricoarytenoid joint

To establish the anatomical relationships of the arytenoid and cricoid cartilages and apply these findings to design an arytenoidectomy based on a sound anatomical basis. We prospectively conducted this study between 1996 and 2002 at the Main University Hospital of Alexandria, Egypt. In 50 patients, we endoscopically measured the length of the vocal process and the distance between the vocal process tip and upper border of the cricoid cartilage. We sagittally and axially sectioned 25 total laryngectomy specimens to verify the position of the arytenoids and their relation to the cricoid. The anatomical findings led to the design of a laser partial arytenoidectomy and cordotomy [L-PAC], which we used in 45 patients with bilateral cord paralysis in adduction. The anatomical findings showed that the cricoarytenoid joint did not contribute to the airway in any of the measured specimens. Using L-PAC, we decannulated 100% of the patients and no patient needed postoperative tracheostomy at any time. Only 3 patients experienced minimal postoperative aspiration to liquids [6.7%]. We achieved reasonable phonation as assessed by a speech analysis battery. However, 3 patients [6.7%] needed contralateral L-PAC. The present extra-articular technique, L-PAC, showed its superiority to previous endoscopic or transcervical complete arytenoidectomy techniques in providing an effective balance between the protective, respiratory, and to a lesser extent the phonatory functions

Resolución quirúrgica de la laringomalacia / Surgical resolution of laryngomalacia

Se presenta un caso de laringomalacia severa, con compromiso respiratorio importante, que llevaba al paciente a reiteradas hospitalizaciones, requiriendo incluso intubación. Se decide dar una solución quirúrgica a su patología, evolucionando de manera satisfactoria, con exámenes endoscópicos que demostraron su mejoría en forma inmediata. Se hizo, además una revisión del tema, sus causas, formas de presentación, diagnóstico y resolución quirúrgica de esta patología