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Posterior Glottic Stenosis in Adults

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Posterior Glottic Stenosis in Adults Original Articles Posterior Glottic Stenosis in Adults Michael Wolf MD, Adi Primov-Fever MD, Yoav P. Talmi MD FACS and Jona Kronenberg MD Department of Otorhinolaryngology & Head Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Key words: larynx, vocal cords, stenosis, fixation, laryngoplasty Abstract entiation between vocal cord paralysis and fixation [3,4], although Background: Posterior glottic stenosis is a complication of some patients survived complex central nervous system and prolonged intubation, manifesting as airway stenosis that may mimic peripheral organ injuries, long courses of mechanical ventilation, bilateral vocal cord paralysis. It presents a variety of features that oral or nasal intubation, and nasogastric tubing. These may result mandate specific surgical interventions. in combined pathologies of both paralysis and fixation, or they Objectives: To summarize our experience with PSG and its working diagnosis. may mask the alleged simplicity of making a diagnosis based Methods: We conducted a retrospective review of a cohort of solely on clinical grounds. The extent of scarring dictates the adult patients with PGS operated at the Sheba Medical Center extent of surgical intervention. While endoscopic lysis of the scar between 1994 and 2006. is appropriate for grade 1, complex laryngoplasty procedures are Results: Ten patients were diagnosed with PGS, 6 of whom mandated for grades 2 to 4 [3]. also had stenosis at other sites of the larynx and trachea. Since 2000, all patients underwent laryngeal electromyographic studies Surgical interventions are based on removal of the posterior and direct laryngoscopy prior to surgery. Surgical interventions segment of the glottis (i.e., arytenoidectomy and cordotomy) [5], included endoscopic laser procedures (in 2 patients), laryngo fissure separating the two arytenoids via scar incision and tissue inter- and scar incision (in 1), laryngofissure with buccal mucosa grafting position (i.e., mucosal flap advancement) [6], or costal cartilage (in 3) or with costal cartilage grafting (in 1) and laryngo fissure graft – extensively described among children [7,8]. with posterior cricoid split and stenting (in 1); one patient was not suitable for surgery. Postoperative follow-up included periodic This report summarizes our experience with PGS in adults and fiberoptic endoscopies. Voice analysis was evaluated by the GRBAS emphasizes the establishment of a working diagnosis. grading. Seven patients were successfully decannulated within one to three procedures. Voice quality was defined as good in 7 Patients and Methods patients, serviceable in 2 and aphonic in 1. We retrospectively reviewed a cohort of all adult patients under- Conclusions: Posterior glottic stenosis may be isolated or part of complex laryngotracheal pathologies. Electromyographic going surgical intervention for posterior glottic stenosis at our studies and direct laryngoscopy must be included in the diagnostic center. Preoperative evaluation included laryngeal electromyogra- workup. Costal cartilage or buccal mucosa grafts are reliable, safe phy performed in the neurological rehabilitation outpatient clinic and successful with respect to graft incorporation and subglottic (since 2000) and direct laryngoscopy (under general anesthesia) remodeling. in all patients. IMAJ 2007;9:597–599 The planned surgical intervention was endoscopic CO2 laser incision of the interarytenoid scar for grade 1, buccal mucosa Posterior glottic stenosis is defined as a narrowing or fixation grafting for grade 2, and cricoid split with costal cartilage of the larynx. Laryngoscopy reveals bilateral impaired vocal cord grafting for grades 3-4. All grafting procedures were performed mobility in a median or paramedian position with limited glottic via laryngofissure (open anterior laryngeal approach). Laryngeal patency [1]. PGS is a complication of prolonged intubation, oc- stents or silicone T-tubes were used in all patients undergo- curring mainly among adults, caused by scarring of the mucosa ing posterior cricoid grafting. The stents were fixed by two of the interarytenoid area, arytenoids and cricoarytenoid joints. trans-laryngeal or trans-tracheal sutures. An uncuffed trache- PGS was stratified by Bogdasarian and Olson [2] into four grades otomy tube was left in place for 2–3 weeks for mucosal grafts depending on unilaterality or bilaterality and by the involvement and 4–6 months for costal cartilage grafts. Antibiotics were of the cricoarytenoid joints: grade 1 = interaytenoid scarring given for 2 weeks after surgery. Reflux precautions, including with normal posterior commissure, grade 2 = interarytenoid and proton pump inhibitors, were utilized until removal of the posterior commissure scarring, grade 3 = posterior commissure stent. This was performed under general anesthesia via direct scarring involving one cricoarytenoid joint, and grade 4 = poste- laryngoscopy. rior commissure scarring involving both cricoarytenoid joints. Periodic endoscopies were performed to follow granula- In practice, one may notice impaired vocal cord mobility, tion tissue formation, mucosal coverage and scar retraction. mimicking nerve damage (i.e., paralysis). It has been assumed Decannulation was attempted 2 to 3 months after stent removal that the clinical history and physical examination enables differ- assuming that scar contracture can take 6 to 12 weeks to com- plete. Voice quality was evaluated according to the GRBAS system PSG = posterior glottic stenosis (Grade, Roughness, Breathiness, Asthenia, Strain) [9]. • Vol 9 • August 2007 Posterior Glottic Stenosis 597 Original Articles Results [Table 1]: one was operated before and developed an ossified Ten adult patients, age 25–82 years, were diagnosed with PGS cicatrix to an extent not suitable for further intervention; a and scheduled for surgery. PGS grading was defined as follows: second patient with complete subglottic obstruction underwent three patients at grade 1, three at grade 2, two at grade 3, and thyrotracheal anastomosis with posterior mucosal graft in a two at grade 4. Four patients had isolated PGS and six patients single stage. Although the subglottis is patent and enables had other pathologies including anterior glottic stenosis, subglot- vocalization, PGS was still present. A third patient, 82 years tic stenosis, supraglottic stenosis, tracheal stenosis, and complete old, underwent segmental tracheal resection and tracheo- glottic obstruction [Table 1]. All patients had a tracheostomy. esophageal fistula correction in the first stage and bilateral Four patients with grades 2, 3 and 4 failed previous endoscopic posterior cordectomy in a second stage; this patient is still CO2 laser surgery. cannulated. Electromyographic studies confirmed the diagnosis of PGS, Patients with grade 1 stenosis had near normal voice quality rather than vocal cord paralysis, in three patients. Direct laryn- (G0-1, R0-1, B0-1, A-0, S-0). The patient with costal cartilage graft goscopy revealed grade 1 scarring in two of three patients developed false cord voice and the three patients with buccal who were considered grades 2 and 3; these two patients had mucosa grafts had a clear voice with mild breathiness (G1, R1, CO2 laser vaporization. The third patient, mistakenly diagnosed B1, A1, S1). with posterior commissure scarring, was found to have grade 1 stenosis only after laryngofissure was performed. Four patients Discussion underwent laryngofissure: three with buccal mucosa and one with The extent and features of posterior glottic stenosis dictate its costal cartilage grafting. Laryngeal stents were inserted in two method of reconstruction [3]. Consequently, it is of paramount patients and a silicone tube in three other patients. importance to define precisely the characteristics of the laryngeal Two patients developed postoperative granulations that pathology. necessitated a single CO2 laser intervention in each patient. Langman et al. [10] observed that in normal larynges the pos- No complications occurred in the buccal mucosa or costal terior commissure is posterior to the anterior aspect of the body cartilage graft sites. Three patients are still stoma-dependent of the arytenoids while the posterior glottic chink was described Table 1. Characteristics of 10 patients with posterior glottic stenosis No. Pre-op diagnosis age/ gender Primary evaluation (post-EMG and DL) Operative findings Operation Results 1 VC paralysis, G2? Normal EMG, G1 G1, interarytenoid Endoscopy, Decannulated 18 / F scar CO2 laser 2 PGS, G2 Normal EMG, G1 G1, interarytenoid Endoscopy, Decannulated 41 / M scar CO2 laser 3 PGS, G3 Normal EMG, G2 G1, interarytenoid Laryngofissure, Decannulated 60 / M ossified scar scar incision 4 PGS, G2, Normal EMG G2 Laryngofissure, Decannulated 70/F Bilat VC paralysis, on Rt, PGS, G2 mucosal graft Post-Lt cordectomy 5 PGS, G2 and G2, anterior glottic and SGS, G2, anterior Posterior cricoid split, Decannulated 25 / F anterior SGS normal EMG glottic and SGS anterior CCG, stent 6 Supraglottic stenosis, Supraglottic stenosis Severe supraglottic, supraglotoplasty, Decannulated 40 /M post-multiple CO2 laser PGS, G2 laryngofissure, mucosal graft, stent 7 Tracheal stenosis, TEF, Normal EMG Rt side, Lt paralysis, PGS, G3, tracheal 1st tracheal resection, closure Still with cannula 82 / F bilat VC paralysis Lt VC dislocation (?), PGS, G2 stenosis, TEF TEF, 2nd posterior cordotomy 8 Anterior and posterior No EMG, G4
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