return to: Tracheostomy and Upper Airway Management Symposium July 30 2016 IAO and SOHN Iowa City Iowa or Laryngeal Surgery (Benign Disease) Protocols

see also: Posterior Glottic Stenosis (Bogdasarian Type 1) - Scar Band in Larynx

see detailed sequence of operations for management: Case Example Posterior Glottic Stenosis (Scarring)

GENERAL CONSIDERATIONS

1. Definitions

   1. 'Posterior glottis' (1):

      1. Posterior 1/3 of vocal cords (cartilaginous)

      2. posterior commissure with interarytenoid muscle

      3. cricoid lamina

      4. crico-artyenoid joints

      5. arytenoids

      6. overlying mucosa

   2. 'Posterior glottic scarring'

      1. Total or partial fixation of the vocal cords from fibrosis

   3. Bogdasarian Classification

      1. Type I involves an interarytenoid scar band between the vocal folds that is anterior and separate from the posterior interarytenoid mucosa

      2. Type II stenosis involves scarring of the mucosa or musculature of the posterior interarytenoid area

      3. Types III unilateral cricoarytenoid joint fixation

      4. Type IV involves bilateral cricoarytenoid joint fixation

2. Differential Diagnosis

   1. Bilateral vocal cord paralysis

   2. Crico-arytenoid arthritis

3. Etiology

   1. Endotracheal intubation

   2. External trauma

   3. Laryngopharygneal Reflux (LPR)

   4. Inhalation Injury

   5. Caustic ingestion

   6. Foreign body ingestion

   7. Tuberculosis

   8. Diphtheria

4. Indications for surgical intervention

   1. Airway obstruction

PREOPERATIVE PREPARATION

1. 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).

2. Consent

3. Counseling

   1. Management Options

      1. Tracheotomy - Tracheostomy

         1. Montgomery Canula

      2. Dilation

         1. Ancillary measures: mitomycin, steroid injection

      3. Laryngofissure or transoral approach to remove scar and widen posterior glottis

      4. Scar removal, grafting (buccal mucosa, cartilage)

      5. Stent (Montgomery stent)

      6. Arytenoidectomy or posterior cordotomy

      7. EPAF = endoscopic postcricoid advancement flap (Damrose 2016)

NURSING CONSIDERATIONS

1. Room Setup

   1. See Basic Soft Tissue Room Setup

2. Instrumentation and Equipment

   1. Special

      1. Tracheotomy Tray (if tracheotomy done before procedure)

      2. Sterile anesthesia breathing circuit, adult

      3. Halsted micro-line artery forceps, curved, 5 in

      4. Rousch Laryngoflex 7 mm endotracheal tube

3. Medications (specific to nursing)

   1. Antibiotic ointment

4. Prep and Drape

   1. Standard prep, 10% providone iodine

   2. Drape

5. Drains and Dressings

   1. Antibiotic ointment to suture line

   2. Passive Penrose drains

6. Special Considerations

   1. Confirm if the Tracheotomy will be done first, as a separate procedure, or as part of the procedure

ANESTHETIC CONSIDERATIONS

1. Induction

   1. Systemic medications

      1. Antibiotics

      2. Consider Decadron 8 to 10 mg to diminish postoperative edema

2. Positioning

OPERATIVE PROCEDURES

         a. Initially most common (Gadkaree 2018): endoscopic posterior cordotomy, arytenoidectomy or suture lateralization 

         b. 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