Friday, May 12, 2017

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General Considerations

  • Definitions
    • "Posterior glottis" (1):
      • Posterior 1/3 of vocal cords (cartilaginous)
      • posterior commissure with interarytenoid muscle
      • cricoid lamina
      • crico-artyenoid joints
      • arytenoids
      • overlying mucosa
    • "Posterior glottic scarring"
      • Total or partial fixation of the vocal cords from fibrosis
    • Bogdasarian Classification
      • Type I involves an interarytenoid scar band between the vocal folds that is anterior and separate from the posterior interarytenoid mucosa
      • Type II stenosis involves scarring of the mucosa or musculature of the posterior interarytenoid area
      • Types III unilateral cricoarytenoid joint fixation
      • Type IV involves bilateral cricoarytenoid joint fixation
  • Differential Diagnosis
    • Bilateral vocal cord paralysis
    • Crico-arytenoid arthritis
  • Etiology
    • Endotracheal intubation
    • External trauma
    • Laryngopharygneal Reflux (LPR)
    • Inhalation Injury
    • Caustic ingestion
    • Foreign body ingestion
    • Tuberculosis
    • Diphtheria
  • Indications for surgical intervention
    • Airway obstruction

Preoperative Preparation

  • Evaluation
    • Transnasal fiberoptic laryngoscopy and, if tracheotomy present, then also perform transtracheal exam of subglottis with removal of tracheotomy tube (if it can be done safely) - view of undersurface of the vocal cords is facilitated by instillation of topical anesthetic - this 'view from below' helps in discriminating between bilateral vocal cord paralysis and interarytenoid scarring (fixation).
  • Consent
  • Counseling
    • Management Options
      • Tracheotomy - Tracheostomy
      • Dilation
        • Ancillary measures: mitomycin, steroid injection
      • Laryngofissure or transoral approach to remove scar and widen posterior glottis
      • Scar removal, grafting (buccal mucosa, cartilage)
      • Stent (Montgomery stent)
      • Arytenoidectomy or posterior cordotomy
      • EPAF = endoscopic postcricoid advancement flap (Damrose 2016)

Nursing Considerations

  1. Room Setup
  2. Instrumentation and Equipment
    • Special
      • Tracheotomy Tray (if tracheotomy done before procedure)
      • Sterile anesthesia breathing circuit, adult
      • Halsted micro-line artery forceps, curved, 5 in
      • Rousch Laryngoflex 7 mm endotracheal tube
  3. Medications (specific to nursing)
    • Antibiotic ointment
  4. Prep and Drape
    • Standard prep, 10% providone iodine
    • Drape
  5. Drains and Dressings
    • Antibiotic ointment to suture line
    • Passive Penrose drains
  6. Special Considerations
    • Confirm if the Tracheotomy will be done first, as a separate procedure, or as part of the procedure

Anesthetic Considerations

  1. Induction
    • Systemic medications
      • Antibiotics
      • Consider Decadron 8 to 10 mg to diminish postoperative edema

Operative Procedures

  • Initially most common (Gadkaree 2018): endoscopic posterior cordotomy, arytenoidectomy or suture lateralization
  • When above fails, posterior cricoid split, laryngoplasty or maintenance of a tracheostomy

References

Bogdasarian RS and Olson NR: Posterior Glottic Laryngeal Stenosis. Otolaryngol head Neck Surg 88:765-772 (Nov-Dec) 1980

Gallivan GJ: Bilateral vocal fold posterior glottic/subglottic stenotic web resected with contact tip Nd-YAG laser (J Voice) 2002 Sep;16(3):415-21.

Glendon M. Gardner, MD POSTERIOR GLOTTICSTENOSIS AND BILATERALVOCAL FOLD IMMOBILITYDiagnosis and TreatmentOTOLARYNGOLOGIC CLINICS OF NORTH AMERICAOTOLARYNGOLOGIC CLINICS OF NORTH AMERICAVOLUME 33 NLTMBER 4 AUGUST 200033 NLTMBER 4 AUGUST 2000  pp 855-877

Damrose EJ and Beswick DM: Repair of Posterior Glottic Stenosis with the Modified Endoscopic Postcricoid Advancement Flap  Otolaryngol Head Neck Surg. 2016 Mar;154(3):568-71 Epub 2016 Feb 9

Gadkaree SK, Gelbard A, Best SR, Akst LM, Brodsky M and Hillel AT: Outcomes in Bilateral Vocal Fold Immobility: A Retrospective Cohort Analysis. Otolaryngology -Head and Neck Surgery 2018, Vol. 159(6) 1020-1027

Benninger MS, Xiao R, Osborne K and Bryson PC: Outcomes Following Cordotomy by Coblation for Bilateral Vocal Fold Immobility. JAMA Otolaryngol Head Neck Surg. 2018 Feb;144(2):149-155

Pinto JA, Godoy LB de M, Marquis VWP, Sonego TB, Leal C de FA. Bilateral vocal fold immobility: diagnosis and treatment. Braz J Otorhinolaryngol. 2011;77(5):594-599.

Hillel AD, Benninger M, Blitzer A, et al. Evaluation and management of bilateral vocal cord immobility. Otolaryngol Head Neck Surg. 1999;121(6):760-765.

Özdemir S, Tuncer Ü, Tarkan Ö, Kara K, Sürmelioğlu Ö. Carbon dioxide laser endoscopic posterior cordotomy technique for bilateral abductor vocal cord paralysis: a 15-year experience. JAMA Otolaryngol Head Neck Surg. 2013;139(4):401-404