Cartilage Window Research Articles

Modified Montgomery thyroplasty: Customisation of the cartilage window according to laryngeal anatomy

We described a Montgomery's thyroplasty using a set of measurement devices designed to achieve accurate individualised prosthesis placement. The objective of the present study was to describe the surgical techniques employed via a step-by-step video and show our results.In total, 42 modified thyroplasties were performed during the 10-year study period.The verification of both points: adequate location and size of the prosthesis are the keys to the success of this intervention. The individualisation of the cartilage window location produces optimal functional results in patients post-intervention in terms of the MPT, GRB score, and VHI-30.

Dimensions of Thyroid Cartilage Window for Medialisation Thyroplasty in Indian Population.

To derive optimal thyroid cartilage window for medialisation thyroplasty in Indian population and comparision of the same with standard parameters including Isshiki's thyroplasty type I. Along with comparision it is also attempted to bring out difference if any, to provide a better guidelines of medialisation thyroplasty in Indian population. A total No of 52 (35 male and 17 female) cadaveric laryngeal samples (formalin fixed) taken into study. Cartilage window over thyroid lamina is created and increased gradually. Endoscopic examination of medialisation by appropriate silastic block of true vocal cord noted at each level. Relevant thyroid anatomy at window corners also taken into consideration. In Indian set up, dimensions of window required for medialisation thyroplasty are slightly lesser than the average size quoted by premier study of Isshiki when compared in male population. The window size of males which produced ideal medialisation was 12-14mm in length and 5mm in height. In females it was 10-11mm in length and 4mm in height.

Our Experience at Tertiary Medical College: Comparative Study Between Surgical Deroofing with Buttoning Technique and Posterior Cartilage Window with Pressure Gauze Dressing Technique in Patients with Pseudocyst of Pinna.

Our Experience at Tertiary Medical College: Comparative Study Between Surgical Deroofing with Buttoning Technique and Posterior Cartilage Window with Pressure Gauze Dressing Technique in Patients with Pseudocyst of Pinna.

Feasibility and efficacy of a thyroid cartilage window technique for transoral CO₂ laser resection of early glottic cancer involving the anterior commissure

Objective:To evaluate the feasibility and efficacy of a thyroid cartilage window resection（TCWR） technique for transoral CO₂ laser resection of early glottic cancer with involvement of the anterior commissure. Methods:Twenty-one patient who underwent a TCWR technique for transoral CO₂ laser resection early glottic carcinoma involving the anterior commissure, were retrospectively analyzed. Indices including margin status, perioperative comorbidities, voice outcomes, local control rate and recurrence free survival, were assessed. Results:All 21 patients underwent a TCWR technique for resection, the organ preservation rate and negative margin achieved 100%. The local control rate achieved 100%. For two patients with subglottic involvement（9.5%）, regional recurrence with confirmation of a positive pre-laryngeal lymph node was subsequently observed; and the 5 years recurrence free survival was 90.5%. Postoperative granulomas were detected in all 21 patients in 4 weeks postoperatively, 13 of which（61.9%） spontaneously disappeared; whereas the remaining 8 patients（38.1%） demonstrated consistent presence of granuloma more than 12 weeks and underwent an additional surgical extirpation under topical anesthesia. Despite the laryngeal web developed in all 21 patients, no dyspnea and laryngeal stenosis occurred at the time of analysis. By comparison with preoperative baseline, postoperative self-assessment voice demonstrated a significant improvement（P=0.01）, while objective voice indices were not significantly altered（P>0.05）. Conclusion:TCWR technique is a valuable means for transoral CO₂ laser resection of early glottic laryngeal cancer involving the anterior commissure, with favorable voice quality and seemingly low comorbidities, which can effectively improve the safety of the anterior resection margin.

Application of a thyroid cartilage window technique for transoral resection of early glottic cancer involving the anterior commissure

Background Management of early stage glottic carcinoma involving the anterior commissure is challenging. Aims/objectives This study aimed to evaluate the efficacy of a thyroid cartilage window (TCW) technique for transoral laser resection of early glottic cancer with involvement of the anterior commissure. Material and methods Twenty-one patient who underwent a TCW technique for transoral resection early glottic carcinoma involving the anterior commissure, were retrospectively analyzed. The technical nuances, organ preservation rate and voice outcomes, local and regional recurrence, and perioperative comorbidities, were assessed. Results All 21 patients underwent a TCW technique for resection, both the organ preservation rate and negative margin achieved 100%. The local control rate achieved 100%, and the 5 years recurrence free survival was 90.5%. For two patients with subglottic involvement (9.5%), regional recurrence with confirmation of a positive pre-laryngeal lymph node was observed. Postoperative granuloma was detected in all 21 patients, 13 of whom spontaneously disappeared (61.9%); whereas the remaining 8 patients (38.1%) demonstrated a consistent presence of granuloma more than 12 weeks, and they accepted surgical extirpation of granuloma under surface anesthesia. The laryngeal web developed in all 21 patients, while no dyspnea and local recurrence were present. By comparison with preoperative baseline, postoperative self-assessment voice demonstrated a significant improvement (p = .01), while objective voice indices were not significantly altered (p > .05). Conclusions and significance TCW technique is a valuable means for transoral resection of early glottic laryngeal cancer involving the anterior commissure, with acceptable voice quality and seemingly low comorbidities.

Anatomical Course of the Thyroarytenoid Branch of the Recurrent Laryngeal Nerve.

To determine the position and anatomic variability of the thyroarytenoid (TA) branch of the recurrent laryngeal nerve (RLN) in an Indian population. This study is specifically targeted to aid in identifying the nerve for reinnervation procedures for unilateral and bilateral vocal fold paralysis, as well as denervation surgeries such as TA myoneurectomy and Selective Laryngeal Adductor Denervation and Reinnervation (SLAD-R) for adductor spasmodic dysphonia. We dissected 46 fresh-frozen adult larynges (92 sides) without pathology. A window was created in the thyroid cartilage lamina. The intralaryngeal part of the dissection was done using magnification with an ocular loupe. The position and direction of the nerve and branching within the cartilage window were noted. The TA nerve was found to emerge from the posteroinferior quadrant of the cartilage window, irrespective of the dissected side (right/left) and gender in all of the 46 larynges. The nerve traveled in an oblique direction in 29 specimens (63.04%) and in a vertical direction in 17 specimens (36.96%). The orientation of the nerve was the same on the two sides of the larynx in all of the specimens. Branching was seen within the cartilage window in eight larynges (17.39%). Knowledge of the possible variabilities in the course of the TA nerve aids in its localization while avoiding trauma to the posterior branch of the RLN that innervates the posterior cricoarytenoid and is responsible for vocal fold abduction. NA Laryngoscope, 129:704-708, 2019.

Excised larynx evaluation of subthyroid cartilage approach to medialization thyroplasty.

To describe an alternative approach to medialization thyroplasty involving dissection underneath the thyroid cartilage with placement of a Gore-Tex implant, and to evaluate its effect on a range of phonatory measures using an excised canine larynx model. Animal model. On each of eight excised canine larynges, the conditions of normal, paralysis, medialization thyroplasty by standard transthyroid cartilage approach, and medialization thyroplasty by experimental subthyroid cartilage approach were performed. Aerodynamic, acoustic, and mucosal wave parameters were measured for each condition. Compared to the vocal fold paralysis state, both the transthyroid and subthyroid approaches for Gore-Tex insertion resulted in significant decreases in phonation threshold pressure and phonation threshold flow. Both approaches also significantly decreased percent jitter, decreased percent shimmer, and improved signal-to-noise ratio. The mucosal wave was preserved after insertion of the Gore-Tex implant for both approaches. For all the phonatory measures except phonation threshold flow, there were no significant differences between the transthyroid and subthyroid approaches. Gore-Tex implantation via a subthyroid approach in an excised canine larynx model can produce effective medialization, preserve the mucosal wave, and significantly improve aerodynamic and acoustic parameters without meaningful difference compared to a traditional transthyroid approach. The subthyroid approach does not require creation of a thyroid cartilage window and could be a potentially valuable alternative method of performing medialization thyroplasty. NA. Laryngoscope, 128:675-681, 2018.

A Simple Modified Flip-Flop Flap for the Reconstruction of Antihelix and Triangular Fossa Defects.

A Simple Modified Flip-Flop Flap for the Reconstruction of Antihelix and Triangular Fossa Defects.

Reconstruction of a Large Anterior Ear Defect after Mohs Micrographic Surgery with a Cartilage Graft and Postauricular Revolving Door Flap.

A novel postauricular revolving door island flap and cartilage graft combination was employed to correct a large defect on the anterior ear of an 84-year-old man who underwent Mohs micrographic surgery for an antihelical squamous cell carcinoma. The defect measured 4.6 × 2.4 cm and spanned the antihelix, scapha, a small portion of the helix, and a large segment of underlying cartilage, with loss of structural integrity and anterior folding of the ear. The repair involved harvesting 1.5 cm2 of exposed cartilage from the scaphoid fossa and then sculpting and suturing it to the remnant of the antihelical cartilage in order to recreate the antihelical crura. The skin of the posterior auricle was then incised just below the helical rim and folded anteriorly to cover the cartilage graft. The flap remained attached by a central subcutaneous pedicle, and an island designed using the full-thickness defect as a stencil template was pulled through the cartilage window anteriorly to resurface the anterior ear. This case demonstrates the use of the revolving door flap for coverage of large central ear defects with loss of cartilaginous support and illustrates how cartilage grafts may be used in combination with the flap to improve ear contour after resection.

Ultrasonic surgical aspirator‐assisted phonosurgery: A novel technique for laryngeal cartilage dissection

INTRODUCTION Type I laryngoplasty has become the most dependable procedure for the management of anterior and midglottic incompetence since its classification by Isshiki in 1974. Many procedure variations have emerged, including the development of numerous techniques, implants, and prefabricated systems increasing the utilization of medialization laryngoplasty. Sharp dissection of the cartilage window becomes difficult with calcified thyroid cartilages, often encountered in older men. The surgical drill with a small cutting or diamond burr is used adjunctively to overcome this frequent anatomic variant. Halum et al. first described ultrasonic surgical system thyroplasty window creation in cadavers. The Sonopet ultrasonic surgical aspirator—developed by Synergetics USA, Inc. (O’Fallon, MO) and distributed by Stryker, Inc. (Kalamazoo, MI)—consists of a main control unit (Fig. 1), handpiece, ultrasonic tip, and foot control. This device produces ultrasonic vibrations that selectively grade rigid structures such as cartilage and bone while sparing adjacent soft tissue. The handpiece provides concurrent irrigation and suction (Fig. 2) while a piezoelectric element vibrates the tip at 25 kHz. The ultrasonic vibration moves in two planes, creating longitudinal and torsional forces without grabbing or kicking typical of rotary drill motion. This motion emulsifies tissue without excess heat production and requires minimal downward pressure. This ultrasonic surgical aspirator, initially created for neurosurgical applications, is now being used by a broader group of surgical subspecialties such as plastic surgery, ophthalmology, and oralmaxillofacial surgery. We now describe the first invivo series of the ultrasonic surgical aspirator for laryngeal framework surgery.

Comparison Between Posterior Cartilage Window and Aspiration and Quilting Technique in Treatment of Pseudocyst of Pinna

Nepalese Journal of ENT Head and Neck Surgery Vol.2 No.2 Issue 2 (July-Dec 2011) 10-12 DOI: http://dx.doi.org/10.3126/njenthns.v2i2.6795

Glottal Reconstruction with a Tissue Engineering Technique Using Polypropylene Mesh: A Canine Experiment

The larynx must be resected in some cases of cancer or stenosis, and various techniques are generally employed to fill the resulting defect. No ideal way, however, has been established to restore vocal function after this form of insult. The aim of this preliminary feasibility study in a canine model was to investigate the effectiveness of a polypropylene-based tissue engineering approach to repair a partial glottal defect. Eight dogs were used in this study. A laryngeal defect involving resection of the left vocal fold was created through a thyroid cartilage window. A scaffold made of polypropylene and collagen was preclotted and wrapped with autologous fascia lata, inserted through the window, and sutured to the laryngeal defect in 5 dogs. The defect was reconstructed with an adjacent sternohyoid muscle flap in 3 control dogs. The surgical site was evaluated 3 months after operation by fiberscopic examination, computed tomographic imaging, histologic evaluation, and study of excised larynges. On fiberscopic examination, the experimental group implants were completely covered with regenerated mucosa in all cases, and a favorable vocal fold contour was found in 4 of the 5 cases. One case was characterized by a concave vocal fold shape and red granulation. In the control group, the muscle flap was replaced by scarred mucosa with a concave vocal fold contour in 2 cases, and there was soft white granulation at the anterior resected edge in the third case. The histologic data revealed the regeneration of lined epithelium, subepithelial tissue, and muscle structure in both groups. The excised larynx phonatory data revealed reduced vibratory amplitude in the experimental group compared with the control group; however, excised phonation was not achieved in 2 of the 3 cases in the control group. This polypropylene-based tissue engineering technique appears to be a viable tool for glottal reconstruction; however, additional refinement is required to maximize long-term phonatory function.

ゴアテックスを用いた甲状軟骨形成術後の喉頭病理組織像

We studied the long-term histological response of the human larynx to Gore-Tex implant and evaluated whether its biocompatibility. Retrospective histological study. We conducted medialization laryngoplasty with expanded polytetrafluoroethylene (ePTEE or Gore-Tex) in a patient with vocal-fold paralysis. A strip of Gore-Tex was folded several times and inserted into the pocket preserving the inner perichondrium through a thyroid cartilage window. The patient died 12 months later and we histologically analyzed the larynx. No evidence was seen of foreign body granuloma, migration, extrusion, or infection. A modest inflammatory response with a fibrous capsule was present around implants. We confirmed the infiltration of abundant collagen and numerous fibroblasts into the microporous implant structure. Histological examination results suggest that Gore-Tex implants are safe and biocompatible with the human larynx. A slight inflammatory response and infiltration of fibrous tissue into the implant itself demonstrated that Gore-Tex implants are immunologically well tolerated.

S198 – Muscle Pedicle Thyroplasty for Difficult or Revision Cases

Objectives 1) Describe a modification of the type I thyroplasty procedure of Isshiki, incorporating a pedicled muscle flap which is rotated through the thyroid cartilage window into a pocket lateral to the thyroarytenoid muscle. The muscle flap is used to replace or augment an alloplastic implant. 2) Be able to understand the applications and indications for this procedure. Methods Our series describes 6 patients undergoing primary or revision thyroplasty since January 2006. In primary cases, the muscle pedicle was utilized after initial dissection resulted in an injury to the endolaryngeal mucosa, or to augment an implant that did not produce adequate medialization. In the revision cases, the muscle pedicle was utilized to replace a Silastic implant at the time of removal. Pre-operative and postoperative videostroboscopy was performed on all patients. Results Postoperative videostroboscopy revealed satisfactory glottic closure in all 6 patients between 1 and 3 months after their operations. Conclusions The procedure of muscle pedicle thyroplasty provides adequate glottic closure in cases of revision thyroplasty and in cases where it was used to augment another implant. It represents an alternative medialization technique in difficult and unusual cases, or when an alloplastic implant is contraindicated. Long-term durability of the medialization is not assessed in this series.

Transventricular Chondroplastic Laryngotomy—A New Surgical Technique for the Endolarynx

Current surgical techniques for laryngeal exposure pose distinct limitations. To address these issues, this article describes a novel surgical technique. Our technique, termed Transventricular Chondroplastic Laryngotomy, allows for extensive and direct external access to the endolarynx. This procedure is described in both a cadaver and animal models. Three pigs were submitted to thyroid cartilage window opening without touching the laryngeal ventricle, and seven animals were submitted to the full procedure, opening a thyroid cartilage window with wide ventricular opening. The animals were sacrificed 20 days following the procedure. Prior to sacrifice, all animals underwent laryngoscopic examination and following euthanasia, the larynx and cervical regions were examined grossly, in addition to histologically. This surgery allowed for extensive exposure of the ipsilateral vocal fold and the contralateral hemilarynx, through the laryngeal ventricle, and thus enabled bi-instrumental handling of the vestibular fold, laryngeal ventricle, and from the anterior commissure to the arytenoids, bilaterally. No postoperative complications were observed. Access to the ventricle was easily and directly achieved through the thyroarytenoid muscle. We hypothesize that transventricular chondroplastic laryngotomy will emerge as the surgical technique of choice in patients presenting with difficult exposure and/or traditional surgical instruments are not feasible. Future transventricular chondroplastic laryngotomy clinical applications of the procedure are discussed including the resection of lesions and more complex reconstruction of vocal folds.

Thyroplasty with simultaneously use of silastic and Gore-Tex implants

Introduction: Type I thyroplasty for unilateral vocal fold paralysis restores voice. In medialization thyroplasty carved sailastic, prefabricated, dense hydroxyapatite and Gore-Tex implants are routinely used. Materials and Methods: In this prospectively study thyroplasty performed with simultaneously use of carved sailastic and Gore-Tex implants. Nine patients with true vocal fold paralysis due to complication of cardiac surgery, thyroidectomy and idiopatic, underwent medialization thyroplasty by this method. In six patients, just sailastic implant was used and results compared together. Results: Mean duration of follow was 9 months. 5 patients had excellent voice improvement. The voice improvement in four patients was good. In patients with only sailastic implant, just one patient had excellent voice improvement and 5 patients had dysphonia. Conclusion: In this method carved silastic is placed in thyroid cartilage window just one time and additional medialization is performed by insertion of Gore –Tex strips between cartilage and silastic implant. Resulting decreased manipulation of surgical field and surgical time, paralyzed true vocal fold edema is reduced and judgment of voice improvement was exact.

甲状軟骨形成術Ｉ型と披裂軟骨内転術の同時手術における筋突起の牽引方法について

Isshiki's arytenoid adduction combined with thyroplasty type I is a useful procedure for correcting the membranous vocal fold atrophy and the height difference between the two vocal folds, particularly in patients with a large posterior glottal chink and atrophy. Conventional arytenoid adduction (Isshiki's arytenoid adduction) is designed to place a suture through the muscular process of the arytenoid attached anteriorly to the thyroid ala, stimulating the function of the thyroarytenoid muscle and lateral cricoarytenoid muscle. Combining with thyroplasty type I, the suture direction of conventional arytenoid adduction prevented inserting implant material into the pocket of the thyroid cartilage window. In contrast to conventional arytenoid adduction, the suture direction in our approach is anchored anteroinferiorly, mimicking only the action of the lateral cricoarytenoid muscle (the major adductor of the larynx). It is used the thyroid cartilage window in thyroplasty type I to determine the direction of the lateral cricoarytenoid muscle. After approaching the muscular process based on Isshiki's arytenoid adduction, two nylon sutures are tied across the muscular process or the lateral cricoarytenoid muscle nearby the muscular process. The cricoarytenoid joint is not dislocated. One of the sutures was anchored to the inferior rear corner of the thyroid cartilage window to be used with thyroplasty type I and the other was anchored to the rear lower margin of the thyroid lamina. Gore-tex medialization thyroplasty is done after tying the sutures on the thyroid ala. Subjects were 30 unilateral paralytic dysphonia. Maximum phonation of all patients improved significantly after surgery. The preoperative and postoperative mean maximum phonation times were 6.0 and 17.9 seconds. No major complications occurred in this study. Our approach effectively combined arytenoid adduction and thyroplasty type I for patients with severe insufficient glottic closure.

Thyroplasty Type I With Montgomery Implant among Native French Language Speakers with Unilateral Laryngeal Nerve Paralysis

To document the long-term results achieved with the Montgomery implant in 96 French speakers with a unilateral laryngeal nerve paralysis (ULNP). Retrospective series, inception cohort of 96 patients. Data regarding morbidity and functional results were obtained at regular visits to our clinic. All patients were followed for a minimum of 6 months or until death. Forty-two patients had a minimum of 12 months of follow-up. Early in the study, 36 patients were prospectively recorded under similar conditions before placement of the Montgomery implant and at 1, 3, 6, and 12 months postoperatively. None of the 96 patients died in the immediate postoperative period. The perioperative course was unremarkable in 94.8% of cases. Perioperative problems included failure to obtain a satisfactory phonatory result in three patients, difficulty to stabilize the implant posteriorly in one patient, and fracture of the inferior rim of the thyroid cartilage window in another patient. The primary immediate postoperative problem (within the first postoperative month) was laryngeal dyspnea, noted in four patients. According to the patient's subjective assessment, speech and voice was always improved in the immediate postoperative period. However, three patients had secondary degradation of speech and voice. Revision surgery under local anesthesia resulted in a 97.9% ultimate speech and voice success rate. According to the patient's subjective assessment, adequate swallowing in the immediate postoperative period was achieved in 94.2% of cases that had swallowing problems preoperatively. A significant statistical increase in the duration parameters (phonation time, phrase grouping, speech rate) together with a statistical significant decrease in both the jitter and shimmer values was noted when comparing the preoperative and the postoperative values at 1 month. Analysis of the evolution of the speech and voice parameters at 1, 3, 6, and 12 months postoperatively showed a significant decrease in the fundamental frequency and noise-to-harmonic ratio values but did not demonstrate any significant differences for the other speech and voice parameters. From the reported data, we conclude that the type I thyroplasty with Montgomery implant insertion is a safe and reproducible method to treat ULNP. Furthermore, this system achieves very good and stable phonatory results. Finally, the use of this technique and implant system appears safe in patients from various cultures with ULNP from a variety of causes and severe comorbidity. Over the past decade at our department, this procedure progressively replaced the use of the intracordal injection of autologous fat injection that was initially advocated in patients with ULNP.

Medialization Thyroplasty Window Creation Using an Ultrasonic Surgical Aspirator

The aim of the study was to investigate the use of an ultrasonic surgical aspirator for creation of the laryngeal cartilage window during medialization thyroplasty. Basic science. Forty thyroplasty windows were constructed in fresh, unpreserved cadaver larynges. A 6 x 13-mm rectangular window and a 4 x 4-mm round window were created on each side of the larynges in a symmetrical fashion. A standard surgical drill with a 3-mm cutting burr was used on one side; the ultrasonic surgical aspirator was used on the contralateral side. The time required for window construction was recorded, as was the status of the inner perichondrium at window completion. For creation of the 6 x 13-mm window, a mean time of 128 seconds was required using a standard surgical drill. The mean time using the ultrasonic aspirator device was 91 seconds for the window of the same size (P < .008). For the 4-mm round window, drilling completed the task in a mean time of 63 seconds, compared with 40 seconds (P < .016) for the ultrasonic aspirator. On creation of the 6 x 13-mm window, there were 4 of 10 perichondrial violations in the drilled specimens, and there were no violations in creation of the window of the same size with the ultrasonic aspirator (P = .12). The 4-mm round window had no perichondrium violations in the standard drill group and only 1 of 10 violations in the ultrasonic aspirator group (P = .99). The study suggested that the ultrasonic surgical aspirator device may be an effective, efficient alternative to the standard drill for medialization thyroplasty window creation. Prospective clinical trials are warranted to better characterize its applicability.

Indications, complications, and surgical techniques for pediatric tracheostomies—An update

Background: With the decrease of life-threatening obstructive upper airway infections and the ongoing improvement of intensive care medicine, the role of tracheostomy in children has been changing considerably, until now. The aim of this study was to establish data regarding indications, complications, and techniques of pediatric tracheostomy, which would reflect the current state of science. Methods: The authors analyzed the international literature as well as their own experience with 25 children less than 6 years of age who were operated on between 1980 and 1996. Results: Literature proved to be very heterogeneous in terms of terminology, patient groups, operation techniques, indications, and complications. Within the past decades, long-term intubation and congenital anomalies of the upper respiratory tract have become increasingly prevalent, whereas inflammatory diseases were less and less an indication for tracheostomy. Endotracheal intubation as an alternative has resulted in less frequent tracheostomies in general. Today, children can be ventilated for months without considerable complications. However, individual, clinical, and fiberoptical controls are necessary. Tracheostomy-related complications have not changed significantly. Fatalities are mostly caused by the underlying disease. The most frequent causes of tracheostomy-related death are cannula obstruction and accidental decannulation. The most frequent early complications are pneumomediastinum, pneumothorax, wound complications, and bleedings. Subsequent complications most often are granulations and tracheal stenosis. Conclusions: The authors' research agreed widely with that in the literature. However, no tracheostomy-related death occurred. Possibly, this was because of their operative technique. In the opinion of the authors, establishing a cartilage window facilitates cannula exchange and reduces the risk of a fatal accidental decannulation. J Pediatr Surg 37:1556-1562. Copyright 2002, Elsevier Science (USA). All rights reserved.