Glottic Plane Research Articles

Using Office-Based Zero-Degree Rigid Laryngoscopy to Predict Glottic Exposure in Microlaryngoscopy

OBJECTIVESPoor glottic exposure in microlaryngeal surgery can result in difficult instrumentation or incomplete surgery affecting surgical outcomes. Anticipating poor glottic exposure preoperatively allows surgeons to prepare adequately, ensuring successful surgery. This study aims to determine diagnostic utility of 4mm zero-degree rigid endoscopic laryngeal examination as a tool to predict glottic exposure in microlaryngoscopy. STUDY DESIGNCross-sectional observational study. METHODSThis is a cross-sectional study, conducted from 1st March 2022 to 30th November 2023 at the ENT department of a tertiary care hospital in North India. Total of 35 adult participants who underwent MLS were consecutively enrolled. Participants in whom the lesion was obscuring the anterior commissure and in whom gag reflex prevented complete 0-degree laryngeal examination were excluded from the study. All enrolled participants were evaluated preoperatively with a 4 mm rigid zero-degree laryngoscopic examination and the laryngoscore. The total score on the laryngoscore proforma was calculated and recorded. The visualized glottis on zero-degree laryngoscopy was graded as follows: Grade 1, anterior commissure and the entire glottic plane can be seen; Grade 2, glottis can be seen but not the anterior commissure; Grade 3, only the posterior half of the glottis can be seen; Grade 4, only the arytenoids can be seen. The glottic exposure on microlaryngoscopy was also assessed using the same grading system. Depending on the exposure of the anterior commissure, the cohort was divided into two groups: good laryngeal exposure and difficult laryngeal exposure. Receiver operating characteristic curve analysis was done to evaluate the predictive accuracy of 0-degree laryngoscopy and to compare it with laryngoscore. RESULTSA total of 35 adults participated in the study, of which 28 were men (80%) with median (range) age of 45(24-76) years. The area under the curve for 0-degree laryngoscopy and laryngoscore were 0.97 and 0.83 respectively. Optimal cutoff value (sensitivity, specificity) to identify difficult laryngeal exposure for 0-degree laryngoscopy and laryngoscore were 1.5 (93.3%,100%) and 4.5 (80%,85%) respectively. CONCLUSIONZero-degree laryngoscopy is an excellent predictor of glottic exposure on microlaryngoscopy. Its accuracy surpasses that of the laryngoscore in identifying an ideal candidate for microlaryngoscopy.

Foreign Body (FB) in High Respiratory Tract: Case Report

Objectives: The objective of our case report is to describe the clinical, radiological and therapeutic aspects of foreign body aspiration at the ENT department in the Military Teaching Hospital Mohammed V, RABAT, Morocco. Case report: a 48-YEAR-OLD patient with no particular history, who presented to the hospital emergency room 4 days after an aspiration syndrome during a dinner. a pharyngo-laryngeal scan was requested urgently and which showed the presence of an embedded chicken bone in the patient's glottic plane, the treatment was rapid and the patient benefited from sedation in the operating room with extraction of the foreign body. Discussion: Foreign bodies (FB) represent a pathology frequently encountered in emergency ENT practice. They can constitute a life-threatening emergency due to their appearance or location. FBs in the ENT sphere remain frequent in daily practice, especially in children. Their treatment requires rapid intervention with suitable equipment and trained doctors. Prevention remains the best solution. Conclusion: Inhalation of a foreign body is a public health problem. The increase in the incidence of this accident and the epidemiological transition require better prevention.

Vocal Cord Monitoring by Flexible Fiberoptic Laryngoscopy During Thyroid Radiofrequency Ablation.

Introduction: Thermal injury to recurrent laryngeal nerve (RLN) during radiofrequency ablation (RFA) can produce temporary or permanent vocal cord paralysis.1 Hydrodissection with cold 5% glucose of "danger triangle" protects RLN during RFA.2 When RFA is performed under local anesthesia, RLN function is monitored by patients producing vocal sounds.3 Large lesions requiring longer RFAs warrant general sedation where voice cannot be assessed, therefore, an additional technique for RLN protection is advisable. Observation of passive symmetrical vocal cord movements during breathing by laryngeal ultrasonography is useful in assessing vocal cord function4; however, flexible-fiberoptic fibrolaringoscopy (FFL) is gold standard for assessing vocal cord movements,5 anticipating potential RLN damage. We report FFL monitoring during RFA under general sedation on a large thyroid nodule. FFL during RFA may detect RLN irritation and dysfunction if asymmetry in passive vocal cord movements is noted. Should asymmetry appear, RFA operator stops delivering energy and repositions electrode needle. Materials and Methods: Thyroid function tests, blood glucose, creatinine, transaminase, International-Normalized-Ratio, and electrocardiogram were performed. Operating room (OR) layout created sufficient space for ear-nose-throat (ENT) and RFA operators. An examination with a fiberscope camera demonstrated normal vocal cord adduction during phonation and abduction during breathing. The procedure was assisted by an anesthetist administering fentanyl 50 mcg, midazolam 1.5 to 5.0 mg, and propofol infusion 2 mg/(kg·h). General sedation was conducted so that reflexes were attenuated but still observable. Incorporating in OR by an anesthetist who performs general sedation reduces side effects and complications.6 Ultrasonography showed a 34-mL right lobe nodule abutting on the RLN area. After sedation with propofol, the ENT specialist inserted an endoscope until the glottic plane. During calm breathing, vocal cords moved symmetrically. After obtaining anterior nodule hydrodissection from strap and sternocleidomastoid muscles with 10 mL of 2% lidocaine, posterior hydrodissection was achieved by ultrasound-guided administration of 30 mL of 5% cold glucose. Anterior and posterior hydrodissections merged, separating nodule from neck structures. The radiofrequency electrode needle was then inserted into the nodule, initially positioned in inferior nodule portion adjacent to danger triangle previously isolated by hydrodissection. Initial power was 30 watts. Moving-shot technique was used. Results: FFL was performed throughout thyroid RFA. Symmetric vocal cord movements during breathing demonstrated no RLN irritation. FFL monitoring allowed observation of natural reflexive phenomena, including swallowing. Complete nodule ablation was achieved. FFL performed post-RFA confirmed normal vocal cord motility. Conclusions: We report the first-time use of FFL for vocal cord monitoring during RFA. FFL was easily performed by the ENT specialist and well tolerated by the patient. Avoiding danger triangle and precise RFA needle positioning is key in preventing RLN injury. Benign nodules regrow if total ablation is not achieved7 and some authors propose additional procedures to complete ablation8 that obviously incurs costs. Total RFA nodule ablation-assisted FFL monitoring eliminates the need for repetitive RFAs, thus reducing overall treatment costs. Finally, FFL monitoring does not prolong procedure, as it is performed simultaneously with RFA. FFL is a valid technique when used in conjunction with hydrodissection to further prevent RLN thermal injury during RFA, especially indicated for large thyroid nodule ablation and professional voice users. Patient Consent and Permission: The patient provided written consent for FFL monitoring and permission to use his portrayals and ultrasonographic images during RFA. The study was completed in accordance with the Declaration of Helsinki as revised in 2013. Adherence to institutional review board protocols was granted. Disclaimer: Representation of any instrumentation within the video does not indicate any endorsement of the product and/or company by the publisher, the American Thyroid Association, or the authors. No competing financial interests exist. Runtime of video: 9 mins 39 secs.

Erratum: Endotracheal Intubation Using a Flexible Intubation Endoscope As a Standardized Model for Safe Airway Management in Swine.

Erratum: Endotracheal Intubation Using a Flexible Intubation Endoscope As a Standardized Model for Safe Airway Management in Swine.

Comparative Preference of Airtraq Laryngoscope Over Macintosh Laryngoscope- A Review

Tracheal intubation using a Macintosh laryngoscope can save lives. However, because intubation is a difficult procedure to master, failures can have disastrous results. A more recent intubation tool than the Macintosh is the Airtraq optical laryngoscope, which offers glottic plane visualization without requiring correct tracheal, pharyngeal and oral axes alignment. Airtraq can improve the incidence of failed first intubations and the time required to manage an airway, especially in patients who have had cervical spine trauma which requires manual stabilization of the cervical spine. With no differences in hemodynamics or intubation duration, the Airtraq laryngoscope offered patients a better laryngeal vision than the Macintosh laryngoscope by providing shorter laryngoscopy and intubation time, and easier intubation. The aim of this literature review was to compare these two laryngoscopes with respect to endotracheal intubation. This review article was put together after a comprehensive study of the literature using the electronic databases PubMed, Medline, Embase and Google. Airtraq laryngoscope was found to be superior to Macintosh laryngoscope as it provides a better view of the glottic region with more ease and less intubation time than the conventional Macintosh laryngoscope.

Post-intubation Tracheoesophageal Fistula In Severe Sars-cov-2 Covid-19 Patient: An Unexpected Finding During Swallowing Test

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) has cause the COVID-19 pandemic that had led to an increase in intensive care unit admission for massive interstitial pneumonia. Many patients underwent mechanical ventilation and endotracheal intubation for a prolonged period of time followed by a subsequent tracheostomy. The most common complications related to these maneuvers are stenosis, malacia, laryngotracheal granulomas, webs. The least common complications are tracheal necrosis due to tracheo-arterial or trachea-esophageal fistulas, caused by compression between the nasogastric tube and the orotracheal tube cuff. A case of 58-year-old female COVID-19 patient with severe pneumonia who underwent prolonged mechanical ventilation and intubation and for two months with unexplained episodes of food inhalation. During the swallowing test, it was observed inhalation, without natural passage of food from the glottic plane. Therefore, ENT specialist in swallowing, suspecting the feared tracheo-esophageal fistula, requested a double contrast esophageal x-ray that confirmed the diagnostic hypothesis. Thoracic surgery team performed surgical correction by resection and tracheal anastomosis with esophagoraffia. TEF is a very rare, but potentially fatal, complication of invasive VM. Predisposing factors are prolonged periods of invasive VM, elevated cuff pressures, oversized endotracheal tubes, patient comorbidities, local and general infections, use of a nasogastric tube. The endoscopic swallow test is a relatively simple test, performed at the patient's bed, that can identify oropharyngeal swallowing disorders and esophageal changes, such as tracheoesophageal fistula.

Post-intubation tracheoesophageal fistula in severe SARS-CoV-2 - COVID-19 patient: Unexpected finding during swallowing test

Introduction: COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2, led to an increase in intensive care admission for massive interstitial pneumonia. Many patients underwent long periods of endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common complications related to these maneuvers are known: laryngotracheal granulomas, webs, stenosis and malacia. Less common complications are tracheal necrosis with trachea-esophageal or tracheo-arterial fistulas, caused by compression between the orotracheal tube cuff and the nasogastric tube. Case report: We present the case of a patient with severe COVID-19 associated pneumonia who underwent orotracheal intubation and prolonged mechanical ventilation for two months with unexplained episodes of food inhalation. During the swallowing test, it was observed inhalation, without natural passage of food from the glottic plane. Therefore, ENT specialist in swallowing, suspecting the feared tracheo-esophageal fistula, requested a double contrast esophageal xray that confirmed the diagnostic hypothesis. Thoracic surgery team performed surgical correction by resection and tracheal anastomosis with esophagoraffia. Discussion: TEF is a very rare, but potentially fatal, complication of invasive VM. Predisposing factors are prolonged periods of invasive VM, elevated cuff pressures, oversized endotracheal tubes, patient comorbidities, local and general infections, use of a nasogastric tube. The endoscopic swallow test is a relatively simple test, performed at the patient’s bed, that can identify oropharyngeal swallowing disorders and esophageal changes, such as tracheoesophageal fistula.

A New Solution for Routine Endoscopic Aerosol-Generating Procedures (AGPs) in the COVID-19 Pandemic.

There is urgent need to find a swift and cheap way to safely perform routine endoscopic procedures during the otolaryngological and anesthesiological practice. We want to share our experience of a novel device, inspired by the pediatric head box experience. Five otolaryngologists and four anesthesiologists were asked to visualize the glottic plane by using the device. A total of 15 attempts was allowed to reach the vocal folds within 60 seconds after entering the box. Student's t-test for unpaired samples was used to compare groups. Transnasal laryngoscopy through our endobox could be successfully performed by all the physicians involved and the mean number of attempts before visualizing and passing the glottis for the first time was 2.8 (range 1-5) in the otolaryngologists' group versus 3.2 (range 1-6) in the anesthesiologists' group (P=0.583). Out of the 15 attempts, the group of otolaryngologists reached the glottis 10.2 times, on average, against 9.7 in the other group (P=0.692). Our endobox seems a practical and feasible strategy to control droplets diffusion during standard ear, nose, and throat and anesthesiological practice.

Pre-Clinical Experience With the VITOM 3D and the ARTip Cruise System for Micro-Laryngeal Surgery.

Pre-Clinical Experience With the VITOM 3D and the ARTip Cruise System for Micro-Laryngeal Surgery.

Histoanatomical structures of laryngeal atresia: Functional considerations.

To study the histoanatomical structure of laryngeal atresia with a focus on the laryngeal functional components in order to evaluate the functional prognosis of laryngeal atresia repair. Twenty-one consecutives cases of laryngeal atresia were diagnosed at our institution between 2009 and 2016. Morphological analysis by macroscopic exam during autopsy was performed in 19 cases. Histological study of the larynx included hematoxylin and eosin staining and protein S100 immunostaining. Our analysis focused on the vocal folds, structures of the lamina propria, cricoarytenoid joints, muscles, and innervation. For each case, associated malformations were classified into two groups: severe and moderate. Antenatal diagnosis was suspected because of congenital high airway obstruction syndrome in nine cases (37%). Associated malformations were present in 19 cases (90%), including severe malformations in 12 cases (57%). Atresia involved the cricoid in all cases, with a residual lumen in only one case and the glottis in 18 cases. Separation between the cricoid and arytenoid cartilages was observed in all cases. Fusion of the vocal process of the arytenoids in the midline was present in 13 cases. According to the gestational age, posterior maculae flavae (MF) were present in 17 of 19 cases, with abnormal structure and median fusion in 13 cases. Anterior MF were present in nine of 18 cases, with fusion on the midline in five cases. Intrinsic abductors and adductors muscles were identifiable in all cases, with fusion of thyroarytenoids muscles in the midline in 18 cases. Both recurrent laryngeal nerves were observed in all cases. Laryngeal atresia is generally associated with other malformations, with a high risk of fatal outcomes. We observed that the functional structures of the glottic plane were present in most cases, with the exception of MF, which were frequently abnormal. 4 Laryngoscope, 130:252-256, 2020.

Anatomical Cadaver Study of Endolaryngeal Vascularization: Focus on the Glottis, Supraglottis, and Subglottis From the Transoral Microsurgical Point of View.

Carbon dioxide laser coagulation during transoral laser microsurgery (TLM) for laryngeal cancer allows control of bleeding from vessels smaller than 0.5 mm. Therefore, larger arteries and veins must be carefully managed by clipping and/or monopolar cautery. The aim of this paper is to detail endolaryngeal vascular anatomy and identify areas of possible bleeding during TLM. We performed an anatomical study on a series of 11 fresh-frozen human cadavers. After injection of a bicomponent red silicone into the innominate, left common carotid, and left subclavian arteries, 22 hemilarynges were dissected, the course of the supraglottic, glottic, and subglottic vessels were traced after microdissection of the intervening structures, and their size measured at specific landmark points where such vessels are more frequently encountered during TLM. Three vessels arising from the superior laryngeal artery were identified after its entry point at the level of the thyro-hyoid membrane: (1) the epiglottic artery (EA), documented in 100% of cases, a common trunk dividing into two main vessels (2) the postero-inferior artery (PIA), present in 100% of the specimens, running downward and dividing in a posterior (pPIA), and anterior (aPIA) branches (3) the antero-inferior artery (AIA), present in 95% of our specimens, running downward to the anterior commissure (AC). Two transverse anastomotic networks (TANs) connected the AIA and PIA, both parallel to the vocal muscle, one lateral (present in 100% of cases), and another medial (91% of specimens). Finally, a fourth vessel supplying the glottic plane was found to be the endolaryngeal paracommissural branch of the crico-thyroid artery (PCA), arising from the inferior laryngeal artery and emerging just below the AC, through the crico-thyroid membrane (reported in 100% of the specimens). This vessel anastomosed in 91% of cases with the AIA, through one or both of the TANs. The course of the endolaryngeal arteries, their relationships with adjacent structures, and size at specific landmark points have been herein described in order to provide surgeons with a map to guide them during the steep learning curve of transoral surgery of the larynx, with special emphasis given to TLM.

Consideration of vocal fold position in unilateral vocal fold paralyses.

The objective of this study was to improve the evaluation of unilateral vocal fold paralyses (uVFP) by means of an area measurement of the glottic plane, which describes the position of the paralysed vocal fold. The area measurements were related to electromyographic findings and clinical outcome (recovery, voice quality). In 56 patients (33 women and 23 men), uVFP were confirmed by endolaryngeal electromyography (EMG) of the paralysed vocal fold and cricothyroid muscles (CT). The EMG response was classified on a 4-point scale (from 0 to 3). Vocal fold position was divided into 'paramedian' and 'intermediate' and additionally quantified by measurement of the glottic area. An 'area quotient' (AQ) was calculated and related to the EMG findings and clinical outcome. Voice qualities were objectified regarding their additive noise (breathiness) and irregularity (roughness) using the 'Göttingen Hoarseness Diagram'. The majority of uVFP was due to iatrogenic lesions. The AQ of classically graduated 'paramedian' and 'intermediate' vocal fold positions was significantly different but did not correlate with objective voice quality values. There were no significant correlations regarding EMG findings, duration or recovery from paralyses. Laryngeal EMG remains the gold standard for verifying uVFP. But EMG did not correlate significantly with AQ or functional outcome of uVFP. The measurement of an AQ is suitable for obtaining continuous data describing the position of paralysed vocal folds beyond the terms 'paramedian' or 'intermediate' and provides the basis for clinical evaluations of diagnostic tools and therapeutic interventions.

Teaching tracheal intubation: Airtraq is superior to Macintosh laryngoscope.

BackgroundTracheal intubation with Macintosh laryngoscope is taught to medical students as it is a lifesaving procedure. However, it is a difficult technique to learn and the consequences of intubation failure are potentially serious. The Airtraq optical laryngoscope is a relatively novel intubation device, which allows visualization of the glottic plane without alignment of the oral, pharyngeal, and tracheal axes, possessing advantages over Macintosh for novice personnel. We introduced a teaching mode featured with a progressive evaluation scheme for preparation and performance of tracheal intubation with medical students in this prospective randomized crossover trial who had no prior airway management experience to find the superior one.MethodsTwenty-six medical students of the 8-year programme in the 6th year participated in this trial, when they did their one-week rotation in the department of anaesthesiology. Each of the students intubated 6 patients, who were scheduled for surgeries under general anaesthesia, each laryngoscope for 3 patients respectively. One hundred and forty-nine consecutive patients scheduled for surgical procedures requiring tracheal intubation were enrolled. Patients were randomly allocated to undergo tracheal intubation using Macintosh (n = 75) or Airtraq (n =74) laryngoscope. The progressive evaluation scheme was applied to each intubation attempt.ResultsIntubation success rate was significantly higher in Airtraq group than Macintosh group (87.8% vs. 66.7%, P < 0.05). Duration of glottis exposure was significantly shorter in Airtraq group compared to Macintosh group (50 ± 19 s vs. 81 ± 27 s, P < 0.001). A grade I Cormack and Lehane glottic view was obtained in 94.6% of patients in the Airtraq group versus 32% of patients in the Macintosh group (P <0.001). Duration of intubation in Airtraq group was significantly shorter (68 ± 21 s vs. 96 ± 22 s, P < 0.05) compared to Macintosh group.ConclusionsAirtraq laryngoscope is easier to master for novice personnel with a higher intubation success rate and shorter intubation duration compared with the Macintosh laryngoscope.Trial registrationTrial registration number is ChiCTR-TRC-13003987, approval date Dec 12, 2013.

Injury risk related to the helmet strap: Mandible and hyoid bone fractures with a hyoepiglottic ligament lesion

The case we present isunusual.2. Case reportA 65-year-old male motorcycle accident victim wasbrought to the emergency department of our hospital.On arrival, he was awake and oriented. He had significantbleeding from the mouth and was in respiratory distress; healso had neck swelling and subcutaneous crepitus withoutsignificant pain (spontaneous or provoked by pressure). Physicalexamination of the neck was difficult because of the presenceof an orthopedic collar; he reported painful swallowing. Theskin on the chin was lacerated. No nosebleed or other skin injurywas present. He had dysphonia, with a guttural, helium-likevoice.The patient wore superior and inferior removable dentalprostheses: the inferior one had been broken and lost duringthe crash, while the superior one had been damaged, but notdislodged. After removing it, no mucosal wounds were seen in theoral cavity and no blood was seen draining from the pharynxposteriorly.Because bleeding from the nose and mouth were excluded, anENT surgeon and anesthesiologist were consulted with regard tothe respiratory distress, and the patient was intubated. Subse-quently, fibre optic endoscopy was used to evaluate the upperaero-digestive tract (UADT): a large laceration was found in theglossoepiglottic region, with a hyoepiglottic ligament lesion andsubsequent posterior epiglottis collapse on the glottic plane(Fig. 1). As the patient was stable and could be monitored,computed tomography (CT) was performed and showed fracturesof the mandibular symphysis and left condyle, thyroid cartilage,andhyoidbonebilaterally,withdisarticulationofthehyoidcorpusfrom the greater horns (Fig. 2). Significant subcutaneous emphy-sema of the neck was also seen. A maxillofacial surgeon was askedto evaluate the mandibular fractures. The physical examinationalso revealed left wrist trauma; standard X-rays showed disloca-tion of the lunate bone and a temporary brace was applied toimmobilise the wrist.The patient was transferred to the intensive care unit (ICU).Three days later, CT was repeated to re-evaluate the cervical softtissue emphysema, which appeared to have decreased slightly,with expected partial healing of the UADT fistula.Subsequently,thepatientwasbroughttotheoperatingroomtoundergo laryngoscopy, a tracheostomy to protect the lowerairways, a CO

Modified supracricoid laryngectomy

The objective of thisstudy was to maintain the surgical strategy of supracricoidlaryngectomy while focusing on reconstruction of the glot-tic plane. An essential part of the study was to recreate theanatomical conditions that allow phonation using the ster-nohyoid muscles for neoglottis reconstruction.

Determination of Endotracheal Tube Size in a Perinatal Population

This study aimed at correlating anatomical dimensions of the larynx and trachea to age and weight in a prenatal population. Endotracheal tube size determination was then proposed according to these considerations. Anatomical measurements were obtained during 150 fetal and infant postmortem examinations. The optimal endotracheal tube size was determined by three methods: clinically, by a pressure method using calibrated inextensible balloons, and anatomically by comparing the laryngotracheal perimeter to the tube perimeters. Based on these results, recommended tube sizes were calculated. In premature babies before 37 weeks gestation, the optimal tube size according to pressure estimation was significantly greater than that determined by anatomical measurement alone. This difference was no longer valid after 40 weeks gestation. This study identified the elasticity of laryngeal structures in premature babies, allowing intubation with tube sizes greater than predicted by anatomical measurements with an increasing injury risk located in the posterior part of the glottic plane. This elasticity disappears near 40 weeks gestation, and the injury risk then predominates in the subglottic region. These results lead the authors to recommend that the size of the endotracheal tube used in the perinatal population should be based on anatomical and experimental data to limit the injury risks.

Inhaled Corticosteroids: Hazardous Effects on Voice—An Update

Inhaled corticosteroids (ICS) have become the prevalent treatment in asthmatics. Hazards to voice are under-recognized. A total of 38 patients with voice complaints associated with the use of ICS were assessed by 79 strobovideolaryngoscopy (SVL) examinations, 24 single and 14 multiple SVL. Hoarseness and dysphonia were the primary reasons for referral. The ICS initially used most frequently was Advair Diskus (fluticasone propionate and salmeterol-inhalation powder-[IP]) in 22 patients, followed by Flovent (fluticasone propionate inhalation aerosol-pressurized metered-dose inhaler-[PMDI]) in 11. Duration of ICS usage varied from 2 weeks to 4-5 years. Higher dosage and frequency of use exacerbated problems. Hazards to voice previously unrecognized by real-time indirect mirror or fiberoptic laryngoscopy were identified by meticulous attention to SVL abnormalities. There was essentially no difference in occurrence of abnormalities whether analyzed from the perspective of the initial 38 or all 79 examinations. These included abnormal mucosal wave symmetry/periodicity (76-63%), phase closure (74-63%), glottic closure (63-59%), mucosal wave amplitude/magnitude (50-35%), supraglottic hyperactivity (39-25%), mucosal quality (34-34%), and glottic plane (10-5%). Candidiasis of the larynx was infrequently observed. Fluticasone ICS were a cause of steroid inhaler laryngitis, and the best treatment was their avoidance or cessation. Further prospective studies ideally might include SVL documented as a pretherapy baseline and then repeated in each ICS patient who developed hoarseness/dysphonia.

Radiosurgery in the treatment of the glottic plane carcinoma

During the last 20 years, various conservative surgical techniques have been proposed to treat larynx cancer. On the basis of our various experiences and of the ultrastructural data on the tissues treated with radiowaves, we decided to also use radiosurgery in operations under direct microlaryngoscopy. We select 18 patients suffering from epidermoid carcinoma. These patients had been referred to our ENT clinic at the Polichnico of Palermo between 1999 and 2001. The authors describe the surgical procedures used and emphasize the advantages of radiosurgery in the treatment of larynx cancer.

Morphometrische Untersuchungen der Glottisebene als Grundlage kehlkopferweiternder mikrolaryngoskopischer Operationsverfahren bei beidseitiger Rekurrenslähmung*

Dimensions of laryngeal and tracheal cross-sectional areas are not well explored and yet are of definite interest in endoscopic airway restorative surgery for the treatment of bilateral vocal cord paralysis. Twenty fresh, intact human larynges were shock-frozen in liquid nitrogen. Four-millimetre horizontal sections were then produced with a slicing machine. Cross-sectional areas of the vocal cords and arytenoids were measured using a computer-aided morphometry device. In addition, casts of 14 larynges were available for morphometric investigation as well as video-laryngoscopic images of 50 volunteers. The results demonstrate that the glottis is the narrowest part of the larynx even in healthy subjects. Its diameter is reduced approximately by the factor 4 in the bilaterally paralysed larynx. Cordectomy potentially offers more enlargement of the glottic airway (169 +/- 20 mm2 in males and 138 +/- 22 mm2 in females) than arytenoidectomy (42 +/- 12 mm2 in males and 34 +/- 6 mm2 in females). The knowledge of morphometric details of the glottic plane should contribute to an individualized planning of airway restoring surgery in bilateral vocal cord paralysis.

Laryngeal reconstruction following vertical partial laryngectomy.

Laryngeal reconstruction following vertical partial laryngectomy (VPL) with arytenoidectomy was studied in 30 dogs. Variations of a superiorly based thyroid cartilage flap (TCF) were used for reconstruction. In addition, sternohyoid muscle reconstruction and endolaryngeal muscle coverage were studied. Larynges were recovered after a 6-month period in 28 surviving dogs and were analyzed by endoscopic photographs and axial whole-organ sections. Endoscopic assessment (n = 18) demonstrated good results for arytenoid replacement (100%), pseudocord position (94%), pseudocord development (94%), and airway patency (100%). Arytenoid replacement was judged as completely (78%) or partially (22%) replaced. This was accomplished by a pseudocord extending to the cricoid in the horizontal plane. Pseudocord position was judged as normal (83%) or paramedian (11%), with the remainder lateralized (6%). Pseudocord development was judged as complete (72%) or partial (22%), with the remainder poor (6%). Reviewing both endoscopic photographs and gross sections (n = 28), airways were all normal without laryngeal or tracheal stenosis. Histologic assessment (n = 24) also demonstrated good results for arytenoid replacement (79%), pseudocord position (87%), and TCF survival in the glottic plane (79%). Arytenoid replacement was judged as complete (62%) or partial (17%), with the remainder poor (21%). Pseudocord position was judged as normal (50%) or paramedian (37%), with the remainder lateralized (13%). TCF survival was judged as total (63%) or partial (16%). Although not present in the glottic plane in the remaining cases (21%), a portion of the TCF was always present in the supraglottic region. The TCF was largely replaced by bone in the region of the pseudocord, and was covered by nonkeratinizing stratified squamous epithelium and a thick fibrous layer. Breakdown over the TCF was infrequent, with a small focus of granulation tissue over cartilage present in 1 (4%) of 24 cases. Clinically insignificant granulation tissue was present in a total of 6 (25%) cases. In the other 5 cases, this was over muscle or over permanent sutures. Focal cartilage necrosis was present in 2 (8%) of 24 cases, and was localized, self limiting, and deep to the endolaryngeal surface. When the TCF failed to survive histologically, poorer results for arytenoid replacement and pseudocord position generally resulted. However, this apparent difference was not statistically significant due to small sample sizes and variability in results. Other factors that may have kept this difference from becoming larger were thought to be contraction of th e normal cord towards the operated side with fore-shortening of the glottis, and medial rotation and ossification of the posterior thyroid ala remnant.(ABSTRACT TRUNCATED AT 400 WORDS)