Interarytenoid Space Research Articles

Laryngeal cleft repair – formal suture technique

Laryngeal clefts are congenital anomalies characterized by an abnormal connection between the upper airway and esophagus due to incomplete fusion of the tracheaesophageal septum. These clefts can be mild, with just a deficiency of soft tissue in the interarytenoid space (Type 1) or can extend down into the cartilage of the cricoid (Type 2) as well as into the trachea (Type 3, 4). Presentation of laryngeal clefts is most often characterized by aspiration of thin liquids, recurrent respiratory infections, cough, respiratory distress, and cyanotic episodes. The treatment of Type I laryngeal clefts can be conservative, such as with thickening of feeds and medical management or procedural, such as with injection laryngoplasty or endoscopic surgical repair. Endoscopic surgical repair has been utilized to repair these clefts for several decades, and more recently is being utilized to repair deeper clefts that were previously repaired via an open approach. In this article we will describe the background and indications for repair of laryngeal clefts, and the details of the endoscopic suturing technique. Laryngeal clefts are congenital anomalies characterized by an abnormal connection between the upper airway and esophagus due to incomplete fusion of the tracheaesophageal septum. These clefts can be mild, with just a deficiency of soft tissue in the interarytenoid space (Type 1) or can extend down into the cartilage of the cricoid (Type 2) as well as into the trachea (Type 3, 4). Presentation of laryngeal clefts is most often characterized by aspiration of thin liquids, recurrent respiratory infections, cough, respiratory distress, and cyanotic episodes. The treatment of Type I laryngeal clefts can be conservative, such as with thickening of feeds and medical management or procedural, such as with injection laryngoplasty or endoscopic surgical repair. Endoscopic surgical repair has been utilized to repair these clefts for several decades, and more recently is being utilized to repair deeper clefts that were previously repaired via an open approach. In this article we will describe the background and indications for repair of laryngeal clefts, and the details of the endoscopic suturing technique.

Rapid Progression of Neonatal Respiratory Distress from Laryngeal Cleft Type I: A Case Report

A one-month-old boy showed cyanosis and severe retraction on crying. He underwent diagnostic rigid bronchoscopy under general anesthesia, maintaining spontaneous ventilation. Rigid bronchoscopy revealed laryngeal cleft type I and excessive mucosa in the interarytenoid space that protruded into the subglottic area, very unusual findings in laryngeal cleft. His clinical condition quickly deteriorated and tracheotomy was performed to prevent complete airway obstruction in the few days until surgical repair of the cleft.

Assessing the learning curve associated with a novel flexible robot in the pre-clinical and clinical setting

BackgroundTransoral robotic surgery has been successfully used by head and neck surgeons for a variety of procedures but is limited by rigid instrumentation and line-of-sight visualization. Non-linear systems specifically designed for the aerodigestive tract are needed. Ease of use of these new systems in both training and clinical environments is critical in its widespread adoption.MethodsResidents, fellows, and junior faculty performed four tasks on an anatomical airway mannequin using the Medrobotics FLEX™ Robotic System: expose and incise the tonsil, grasp the epiglottis, palpate the vocal processes, and grasp the interarytenoid space. These tasks were performed once a day for four days; after a 4-month time gap, subjects were asked to perform these same tasks for three more days. Time to task completion and total distance driven were tracked. In addition, a retrospective analysis was performed analyzing one attending physician’s experience with clinical usage of the robot.Results13 subjects completed the initial round of the mannequin simulation and 8 subjects completed the additional testing 4 months later. Subjects rapidly improved their speed and efficiency at task completion. Junior residents were slower in most tasks initially compared to senior trainees but quickly reached similar levels of efficiency. Following the break there was minimal degradation in skills and continued improvement in efficiency was observed with additional trials. There was significant heterogeneity in the analyzed clinical cases, but when analyzing cases of similar complexity and pathology, clear decreases in overall operative times were demonstrable.ConclusionNovice users quickly gained proficiency with the FLEX™ Robotic System in a training environment, and these skills are retained after several months. This learning could translate to the clinical setting if a proper training regimen is developed. The Medrobotics FLEX™ Robotic System shows promise as a surgical tool in head and neck surgery in this study.

A Dissectional Study of the Level of Anterior Commissure of the Larynx.

Precise knowledge of the level of the vocal fold as projected on the external thyroid cartilage is of critical importance for the performance of many surgical approaches. This study aims to identify the level of the anterior commissure, as well as the lengths of the vocal muscle and arytenoid cartilage in Turkish population. Specimens were collected after autopsy from the Council of Forensic Medicine. One hundred human larynges (52 men, 48 women; age range: 25-80 years) were dissected under a stereomicroscope. Projection of the vocal fold was analyzed in relation to the superior thyroid (A) and the inferior border of the thyroid cartilage (B). Then, the larynx was dissected parallel to the level of the vocal fold to measure the length of the vocal muscle (C) and the length of the interarytenoid space (D). The mean value of the "a" was 9.15 ± 1.99 mm in male and 9.38 ± 3.43 mm in female. Mean value of the "b" was 10.54 ± 1.73 mm and 8.88 ± 1.81 mm in male and female, respectively. The mean value of the parameter corresponding the length of vocal muscle which was "c" was found 15.00 ± 3.18 mm in male and 12.88 ± 4.12 mm in female. The mean value of the interarytenoid space "d" was 8.31 ± 1.76 mm in male and 8.13 ± 1.90 mm in female. Comparing between genders, no statistical differences were observed in parameters of a, c, d, a + b, a + b/2 (P > .05). However, the difference with female and male for the parameters of b and c + d was statistically significant (P < .05). Our results indicate that the anterior commissure projects slightly above the midline height for male and at the level to slightly below in female subjects in Turkish population.

Side effects and complications of injection laryngoplasty for treatment of congenital type 1 laryngeal clefts

IntroductionInjection laryngoplasty (IL) is a brief, minimally invasive procedure involving injection of agents to augment the interarytenoid space. It was initially described as a diagnostic and temporizing measure for management of type one laryngeal clefts (LC1) and associated swallowing dysfunction (SwD), but more gradually it is being proposed as a definitive treatment modality. However, the morbidity of this treatment for LC1 remains under-investigated. This study sought to determine the morbidities associated with IL as a treatment modality for LC1 and associated SwD. MethodSingle centre retrospective review of a prospective surgical database of one Pediatric Otolaryngologist at a tertiary care center. Participants included pediatric patients with an endoscopic diagnosis of LC1, treated with IL between 2000 and 2018—excluding those with concurrent upper airway anomalies. Patient charts were reviewed for demographic information, immediate post-op complications (within the first 14 days following IL), and subsequent management. ResultsOut of 85 consecutive, eligible patients, 12 were excluded (5 subglottic stenosis, 6 laryngomalacia, and one tracheomalacia). Of the 73 included patients, 42 were male and 31 females. The median age at IL was 29 months (range 1–132, interquartile range of 38 months). All IL procedures in this study utilized hyaluronic acid derivatives. From this series, 13 patients experienced post-operative complications. The complications encountered were respiratory distress (N = 5), croup-like cough (N = 6), and stridor (N = 6). These complications were either self-limiting (N=9), managed by systemic or inhaled steroids (N = 4), or admitted to hospital for monitoring (N=3). One case (augmented with dextranomer and hyaluronic acid) required intubation, repeat endoscopy, and drainage of seroma. ConclusionIL was followed by respiratory morbidity in nearly two in ten of this series of consecutive patients. All the morbidities occurred in association with one injection product. Parents should be counselled appropriately about potential morbidities associated with this procedure.

Mucosal impedance of the larynx: A technical report

IntroductionMucosal impedance testing measures changes in resistance to alternating electrical current. The purpose of this study is to establish the feasibility of mucosal impedance (MI) measurement in the pediatric larynx. MethodsA flexible plastic catheter, whose tip contains paired 2 mm mucosal impedance, is directly applied to the larynx under suspension microlaryngoscopy. Milliohms of resistance is relayed real-time from the catheter and output onto a PC. Results were obtained safely over the course of 5 min of intraoperative time for all 49 patients undergoing routine microlaryngoscopy at a tertiary care pediatric hospital. ResultsThe technique was successful in identifying MI values with reliable and reproducible results. The risk was minimal with no adverse events occurring. Impedance noise reduction was improved by the use of an aqueous gel coating on the probe and an emphasis on measurements of the interarytenoid space, which enabled the sensor rings to contact 360° of the mucosa. ConclusionLaryngeal MI can be safely and reliably performed with reproducible measurements and minimal added procedure time.

Injection laryngoplasty in children with cystic fibrosis and abnormal swallow

ObjectiveChildren with cystic fibrosis (CF) are uniquely vulnerable to the pulmonary complications of chronic aspiration. We present a case series of children with CF and evidence of chronic aspiration who underwent injection laryngoplasty to improve the safety and efficacy of their swallow. Study designRetrospective chart review. SettingTertiary care children's hospital. Methods/SubjectsA chart review was performed on three consecutive cases of children with CF and evidence of aspiration on modified barium swallow (MBS) evaluated at a tertiary care, academic children's medical center. ResultsThree patients with CF underwent injection laryngoplasty for evidence of aspiration or laryngeal penetration on MBS evaluation. Normal laryngeal anatomy was identified intraoperatively in each case. At the time of the procedure, patients were 22 months, 70 months, and 24 months old, and follow-up information was available for 7 months, 11 months, and 12 months post-procedure, respectively. Presenting symptoms included chronic cough, cough with oral liquids, and recurrent pneumonia. Each patient underwent successful injection into the interarytenoid space. Post-operatively, modified barium swallow demonstrated resolution of aspiration or penetration in all patients. No procedure-related complications were encountered. ConclusionPatients with CF are highly susceptible to pulmonary infections, and aggressive treatment of chronic aspiration is often necessary. Injection laryngoplasty may be effective in normalizing swallowing in these children. Future study will elucidate the duration of effect and if this technique improves long-term pulmonary outcomes in CF patients.

Detection of Chronic Laryngitis due to Laryngopharyngeal Reflux Using Color and Texture Analysis of Laryngoscopic Images

To determine if pattern recognition of hue and textural parameters can be used to identify laryngopharyngeal reflux (LPR). Laryngoscopic images from 20 subjects with LPR and 42 control subjects without LPR were obtained. LPR status was determined using the reflux finding score. Color and texture features were quantified using hue calculation and two-dimensional Gabor filtering. Five regions were analyzed: true vocal folds, false vocal folds, epiglottis, interarytenoid space, and arytenoid mucosae. A multilayer perceptron artificial neural network with varying numbers of hidden nodes was used to classify images according to pattern recognition. Receiver operating characteristic (ROC) analysis was used to evaluate diagnostic utility, and intraclass correlation coefficient analysis was performed to determine interrater reliability. Classification accuracy when including all parameters was 80.5%±1.2% with an area under the ROC curve of 0.887. Classification accuracy decreased when including only hue (73.1%±3.5%; area under the curve=0.834) or texture (74.9%±3.6%; area under the curve=0.852) parameters. Interrater reliability was 0.97±0.03 for hue parameters and 0.85±0.11 for texture parameters. This preliminary study suggests that a combination of hue and texture features can be used to detect chronic laryngitis due to LPR. A simple, minimally invasive assessment would be a valuable addition to the currently invasive and somewhat unreliable methods currently used for diagnosis. Including more data will likely improve classification accuracy. Additional investigations will be performed to determine if results are in accordance with those provided by pH probe monitoring.

Supraglottic Laryngeal Abscess of Idiopathic Etiology Secondary to Community‐Acquired, Methicillin‐Resistant Staphylococcus aureus

Objectives:Prior to the widespread use of antibiotics, laryngeal abscesses typically presented secondary to systemic illnesses. Today, laryngeal abscesses are rarely observed, and most result from disease processes intrinsic to the larynx, such as airway instrumentation or malignancy. This report describes the unique case of an arytenoid abscess of insidious etiology. A supraglottic laryngeal abscess of this anatomic location has not previously been described in the literature and is of particular interest given the increasing prevalence of community acquired, methicillin‐resistant Staphylococcus aureus (MRSA). We seek to characterize the presentation, work‐up, and treatment of this condition.Methods:A single case of an arytenoid abscess is described. The electronic medical record was used to collect demographic and clinical information.Results:The patient had no prior history of laryngeal disease or airway instrumentation; however, her past medical history was significant for poorly controlled type 1 diabetes mellitus, as well as alcohol and methamphetamine abuse. Severe dysphagia and hoarseness prompted computerized tomographic imaging of the neck, which revealed a laryngeal abscess. Incision and drainage under direct laryngoscopy identified an abscess involving the right arytenoid with extension into the interarytenoid space. Cultures at the time of surgery grew MRSA, and biopsy of the abscess cavity was negative for malignancy. Following surgical drainage and appropriate antibiotic therapy, the patient recovered without long‐term sequelae.Conclusions:Laryngeal abscesses are rarely encountered in modern practice. This case offers a previously undescribed example of an idiopathic arytenoid abscess in the setting of an increasingly common infection, community acquired, MRSA.

The role of direct laryngoscopy in the diagnosis of laryngeal cleft

Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, presenting features, and results of bedside swallow evaluation. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Eleven patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy. Nine of eleven had signs of aspiration on modified barium swallow study (MBSS). Of the eight subjects who underwent flexible laryngoscopy by a pulmonologist, a deep interarytenoid groove was only reported in four cases. In all eleven cases, the arytenoids could be physically separated during direct laryngoscopy, allowing for definitive diagnosis of the cleft and identification of its type and severity. Conclusion: Video swallow studies and flexible laryngoscopy may raise suspicion or even diagnose a laryngeal cleft, however, a laryngeal cleft must be confirmed by direct laryngscopy in which the interarytenoid space is palpated. Furthermore, a patient in whom symptoms persist but no laryngeal cleft is identified on flexible examination should have a direct laryngoscopy to rule out a cleft.

Partial cricotracheal resection with tracheal intussusception and cricoarytenoid joint mobilization: Early experience in a new technical variant

Partial cricotracheal resection with tracheal intussusception and cricoarytenoid joint mobilization: Early experience in a new technical variant

Rigid Laryngoscopy Is Necessary to Diagnose Laryngeal Cleft

Objective: 1) Identify the signs and symptoms of a laryngeal cleft in children. 2) Compare diagnostic methods available for identifying laryngeal cleft and determine their utility. Method: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, symptoms, bedside swallow evaluation, and results of imaging studies. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Six patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy, performed for cough and signs of aspiration. In 3 cases the pattern on a barium video swallow examination heightened suspicion of laryngeal cleft. Flexible laryngoscopy was performed on all patients by a pulmonologist. Laryngeal cleft was suspected in four cases but could not be confirmed. Direct laryngoscopy was performed by an otolaryngologist. Direct laryngoscopy, in which the arytenoids could be physically separated, allowed for definitive diagnosis of the cleft and identification of its type and severity in all 6 cases. Conclusion: Video swallow and flexible laryngoscopy can raise suspicion of a rare laryngeal cleft in patients with otherwise common symptoms. A laryngeal cleft and its type can be definitively diagnosed by a direct laryngoscopy in which the inter-arytenoid space is palpated.

Laryngeal Chemoreflexes and Development

In the mid-1970’s, Johnson et al. and Harding and colleges discovered that when water is introduced into the larynx of the newborn lamb, the responses include startle, arousal from sleep, rapid swallowing, prolonged apnoea, bradycardia, hypertension, and constriction of the peripheral vascular bed resulting in redistribution of perfusion. On the other hand, when saline replaced water in this study, there was little or no effect. These studies comprised the first detailed description of the LCR. Later, these findings were confirmed in puppies as well as piglets, kittens and newborn monkeys. It was shown that LCR reflexes arise from stimulation of sensory afferent nerve fibers in the superior laryngeal nerves (SLN). Anatomical and physiological studies indicate that unencapsulated, unmyelinated nerve endings terminating in the mucosal epithelium of the epiglottis, aryepiglottic folds and interarytenoid space are the sole receptors mediating these reflexes (Fig. 1). The intraepithelial location of these receptors would appear to be ideal

Maturation of cough and other reflexes that protect the fetal and neonatal airway

Although aspiration of contaminated amniotic fluid and gastric contents is common at birth, anecdotal evidence indicates that coughing occurs rarely if at all. Studies in which cough and other airway protective responses have been stimulated by introducing a small bolus of water or saline into the pharynx of sleeping infants have found that the predominant responses are swallowing, apnea and laryngeal closure. Coughing is rare. Collectively, these responses are known as the laryngeal chemoreflexes (LCR). These are mediated by receptors in the inter-arytenoid space. The LCR has been studied extensively in animal models. Upper airway infection increases the responses and in this case coughing becomes a common component. Studies in animal models indicate that with maturation, apnea and swallowing components of the LCR decrease while cough becomes increasingly prominent.

Trends in mortality from upper gastrointestinal bleeding

cobblestoning and erosive esophagitis. Histologic inflammation tended to be seen more frequently in patients with OP erythema than in those without erythema (RR 2.3; 95% CI: 1.1–4.9; p 0.1) and in those with cobblestoning vs. no cobblestoning (RR 2.3; 95%CI:1.1–4.9; p 0.08) Conclusions: Routine examination of the oro-pharynx (inter-arytenoid space) during endoscopy of GERD patients may be warranted and deserves further study. Oro-pharyngeal biopsy can safely be performed by gastroenterologists. Validation of an endoscopic grading system might help to standardize management of atypical GERD patients.

Reflux Associated Apnea in Infants: Evidence for a Laryngeal Chemoreflex

The mucosa covering the interarytenoid space at the entrance to the larynx contains specialized nerve endings (receptors) that are stimulated when a fluid comes into contact with the mucosal surface. These receptors mediate several aspiration preventive reflex responses, which include swallowing, cessation of breathing, airway constriction or closure, and coughing. The laryngeal receptors are more sensitive to water than to saline, and therefore the combined reflex response to receptor stimulation is termed the “laryngeal chemoreflex.” This reflex can be activated during regurgitation of gastric contents into the pharynx, in which case the several components of the reflex serve to prevent intrapulmonary aspiration of gastric fluid. In certain infants a hyperactive laryngeal chemoreflex may cause episodic prolonged apnea. Such reflex-mediated apnea has been implicated in several kinds of prolonged infantile apnea, including apea of prematurity, gastric regurgitation-related apnea, and apnea associated with upper respiratory infection.

Endoscopic Carbon Dioxide Laser Arytenoidectomy for Postintubation Glottic Obstruction

At the annual meeting of the American Academy of Otolaryngology—Head and Neck Surgery, San Diego, Calif, September 1990, Romeo Y. Lim, MD, Charleston, WVa, recently reported his experience utilizing endoscopic carbon dioxide laser arytenoidectomy for postintubation glottic obstruction. He described how 10 patients were treated who had developed fixation of an arytenoid after prolonged intubation for respiratory insufficiency. All of the patients had been unable to be decannulated after tracheostomy. His technique involved using the carbon dioxide laser set at 15 W and pulses of 0.2 to 0.5 seconds to first incise the mucosa over the arytenoid. The arytenoid, vocal process, and posterior vocal cord were then resected, being careful not to injure the interarytenoid space. Following surgery, all patients were successfully decannulated within 3 to 14 days and their voices returned. After adequate time for healing, laryngeal examination revealed posterior glottic chink sizes of 4 to 5 mm and

HYPERTROPHIC CHANGES IN THE INTERARYTENOID SPACE.

AN EXTENSIVE study of the literature yields convincing evidence of a need for revision in the description and nomenclature of certain lesions of the larynx, from the viewpoint of both anatomic location and histologic change. It is the purpose of this paper to review 32 cases of laryngeal pathology evidencing tissue changes in the interarytenoid space in an effort to approach the problems of this area. The laryngologist speaks commonly of the anterior and commissures.Webster's New World Dictionarystates under the definition of commissure: In anatomy, a band of fibers joining symmetrical parts, as of the right and left sides of the brain and spinal cord. One might justify this reference to the wide interarytenoid space as the All too frequently, however, the vocal processes of the arytenoids or extremities of the true cords are mistakenly considered a part of the posterior commissure. Originally

Choice of operation in carcinoma of the larynx.

IN ORDER to discuss the choice of operation in the treatment of carcinoma of the larynx, the nomenclature must be defined. There have been many interpretations of the terms "intrinsic" and "extrinsic" lesions of the larynx, but in this article the classifications suggested by T. E. Walsh, of St. Louis, will be used: Intrinsic: Confined to the true vocal cord only Endolaryngeal: Involving structures within the laryngeal box, i. e., the ventricles, ventricular bands, arytenoids, and interarytenoid space and those cancers of the vocal cord which have spread across the anterior commissure Without fixation of the vocal cord or arytenoid With fixation of the vocal cord or arytenoid Histologic grade Subglottic Extrinsic or Extralaryngeal It must be remembered that a cancer starting in one area may enlarge and invade another. It is said that the tumors should be classified according to the place

HYPERPLASTIC LARYNGITIS OF SINGERS

When a particular organ is constantly strained during the course of professional work, certain pathologic conditions characteristic of this particular profession develop. In singers incorrect methods of voice training and of singing, the necessity of using the voice during or after colds, neglectful or improper dealing with repeated attacks of sore throat, and inflammation of the larynx usually result in chronic catarrh of the larynx, which sooner or later impairs the functional capacity of the organ. Fortunately, nature created the vocal organ in such a way that the most vital parts of the larynx are resistant and become affected late. Experiments carried out on cadavers demonstrate that if liquid is injected into the mucosa of the larynx it spreads according to certain laws. The liquid accumulates in the interarytenoid space, forming a swelling, and it does not penetrate the true vocal cords. This fact corresponds with the