Suspension Microlaryngoscopy Research Articles

Powered Instrumentation in the Treatment of Recurrent Respiratory Papillomatosis

To assess the advantages of powered instrumentation vs the carbon dioxide laser in treating patients with juvenile-onset recurrent respiratory papillomatosis. A retrospective study. Tertiary care children's hospital. Patients operated on for juvenile-onset recurrent respiratory papillomatosis between January 1, 1999, and December 31, 2000. Papillomas were excised using the microdebrider in one group and the carbon dioxide laser in the second group. Direct laryngoscopy and bronchoscopy, suspension microlaryngoscopy, and excision of papillomas by the carbon dioxide laser or the microdebrider. Operative time and postoperative complications. Seventy-three operations were performed (23 with the laser and 50 with the microdebrider). Sixteen patients were included, 10 with active disease and 5 with disease in remission; 1 was lost to follow-up. They had a mean age of 3.75 years, and the male-female ratio was 7:9. The patients presented mostly with hoarseness (13 [81%]). Four (25%) had soft tissue complications with the laser. The microdebrider was less time-consuming than the laser, although those treated with the microdebrider had more active disease. No factor could be used to measure treatment outcome due to disease variability. Those who were older, female, and African American tended to have less severe manifestations of disease. The microdebrider proved to be less time-consuming than the carbon dioxide laser when used in patients with juvenile-onset recurrent respiratory papillomatosis. Soft tissue complications were nonexistent. In addition to safety, the microdebrider is more appealing to the surgeon, anesthesiologist, and parents, especially because these children often need subsequent surgical procedures.

Spindle Cell Lipoma of the Hypopharynx

Larynx and hypopharynx lipomas are reported to account for approximately 0.6% of benign laryngeal neoplasms. Spindle cell lipoma is a histologically distinct variant characterized by mature adipocytes mixed with collagen-forming spindle cells; only one case of spindle cell lipoma of the larynx has been previously reported. We here describe a new case of spindle cell lipoma of the pyriform sinus successfully treated by means of endoscopic surgical excision. A 77-year-old woman with a 40-year history of dysphagia reported that the condition had markedly worsened over the three years before she came to us. She had difficulty swallowing even semisolid food and she experienced occasional nasal regurgitation of liquid or solid food. Flexible videolaryngoscopy showed a very large mass, covered by normal mucosa that almost totally occupied the right pyriform sinus and was apparently attached to the right arytenoid. Functional endoscopic study and videofluoroscopy of swallowing showed that the bolus progressed exclusively in the left pyriform sinus, with postdeglutitory pooling in the right pyriform sinus and a reflux toward the valleculae during consecutive deglutitions. Computed tomography demonstrated that the hypopharyngeal mass had low attenuation values and negative densitometry. The entire mass was surgically removed during suspension microlaryngoscopy. The histological sections showed mature adipocytes mixed with small and slender spindle cells. Postoperative endoscopic and videofluorosocpic deglutition studies revealed the recovery of normal swallowing. This case indicates that hypopharyngeal lipomas should be included in the differential diagnosis of slowly occurring swallowing impairments.

Effect of mitomycin-C on vocal fold healing in a canine model.

For evaluation of the effect of topical mitomycin-C on vocal fold healing and return of function after surgical excision of mucosa, 6 dogs underwent suspension microlaryngoscopy with bilateral microflap excision of vocal fold mucosa. Topical mitomycin-C, a chemotherapeutic agent and a fibroblast inhibitor, was applied randomly to one side, with the contralateral side serving as the control. Laryngeal videostroboscopy (LVS) was performed on each animal before the operation, at 2 weeks, and before sacrifice at 4 weeks. Both functional analysis with LVS and histologic analysis were performed in a blinded fashion to determine the effect of mitomycin-C on healing. Histologic analysis was augmented with computer morphometrics. The LVS revealed diminished mucosal wave vibration in the vocal folds treated with mitomycin-C, as well as a more atrophic appearance to the vibratory surface. The vocal folds treated with mitomycin-C showed fewer fibroblasts and less collagen within the superficial layer of the lamina propria than the control vocal folds (p < .05, Student's t-test, paired analysis). Inflammatory infiltrate was not significantly different between the two sides. Consistent with the known suppression of fibroblast proliferation by mitomycin-C, the treated vocal folds showed less connective tissue response to the surgical injury. In contrast to the reported positive effects of mitomycin-C on tracheal and glottic stenosis, the observed decrease in the healing response in the present study had negative consequences on the vocal fold vibratory pattern.

Lingual Nerve Injury During Suspension Microlaryngoscopy

Lingual nerve injury is an uncommon complication of laryngoscopy. We report a case of isolated unilateral lingual nerve injury that occurred during suspension microlaryngoscopy. The injury was transient, with complete return of sensation within 3 months after surgery. Several mechanisms have been proposed to explain the occurrence of lingual nerve injury during laryngoscopy, including direct compression of the nerve caused by the laryngoscope, stretching of the nerve caused by cricoid pressure or instrumentation, and compression of the nerve between the medial and lateral pterygoid caused by manipulation of the mandible. The precise mechanism of injury in this case was not obvious, but stretching of the lingual nerve caused by pressure of the suspended laryngoscope on the tongue or retrolingual region was likely. The transient nature of the injury and the rapid return of the nerve to baseline function in this case are consistent with a neurapraxic injury.

Indications and results of fronto-lateral laryngectomy using a combined endolaryngeal and external approach

Patients with laryngeal anterior commissure, cord-commissure, bilateral anterior cord-commissure carcinomas (T1 and T2 N0 M0) were subjected to a new method of frontolateral laryngectomy using a combined endolaryngeal and external approach. The proposed surgical procedure allowed the removal of the anterior commissure and part of one or both vocal cords in a single unit, together with the cartilaginous framework, respecting the integrity of the superior portion of the thyroid cartilage. The internal procedure permitted an accurate delimitation of the posterior part of the laryngeal neoplasm. In particular, this was performed during suspension microlaryngoscopy using the CO(2) laser or traditional cutting tools for section of the laryngeal visceral structures to the internal surface of the thyroid cartilage. Following this, the external approach included incision of the external perichondrium along the superior edge of the thyroid cartilage and along the median line, from the incisura to the inferior edge of the thyroid cartilage. The superior opening of the larynx is made side-to-side and the epiglottis separated at the level of the superior edge of the thyroid cartilage. The ends of the section are joined together with the superior parts of the section created during the laryngeal approach. Then progressive craniocaudal detachment of the internal perichondrium is performed backwards until the endolaryngeal sections are reached and downwards to the insertion of the cord ligaments. The inferior opening of the larynx is made by a horizontal section of the cricothyroid membrane at the level of the superior edge of the cricoid cartilage. Section of the thyroid cartilage is therefore performed in a trapezoidal shape. This section involves the inferior part of the protruding corner of the thyroid cartilage. After joining the ends of the cricothyroid section with the inferior extremities of the endolaryngeal sections, the surgical specimen is removed as a single unit. The method must be used only after accurate clinical evaluation. It is mostly recommended in subjects with cord-commissure carcinomas previously treated with radiotherapy. The results obtained were extremely satisfactory both as regards survival and functional results. In all, 27/28 patients (96.4%) were free from disease. The quality of voice was satisfactory but hoarse in 30% and breathy in 70% of the patients.

The laryngeal mask airway: A new technique for fiberoptic guided vocal cord biopsy

Study Objective: To describe a new technique for vocal cord biopsy involving placement of a laryngeal mask airway (LMA) during general anesthesia and fiberoptic guided biopsy. To report our early experience with this technique. Design: Descriptive study. Setting: Teaching hospital. Patients: 10 patients undergoing vocal cord biopsy for minor laryngeal pathology and with no evidence of infraglottic airway obstruction. Interventions: Patients were premedicated 1 hour preoperatively with pethidine 1 mg/kg and atropine 0.01 mg/kg. Following preoxygenation, anesthesia was induced with propofol 2.5 mg/kg and fentanyl 1 mg/kg. Once airway control was established with a facemask, vecuronium 0.1 mg was given and anesthesia established with oxygen (O 2) and nitrous oxide mixture and isoflurane 1% to 2%. Gentle direct laryngoscopy was then performed to inspect the pharyngeal structures and the LMA was then inserted in the standard manner by highly experienced LMA users. A fiberoptic scope was passed via a self-sealing mount down the shaft of the LMA to the level of the vocal cords. The vocal cords were then sprayed with local anesthetic and the biopsy taken. Measurements and Main Results: The age and weight range were 29 to 57 years and 65 to 85 kg, respectively. All patients were smokers or recent ex-smokers. LMA insertion was readily achieved in all patients, and an excellent view of the vocal cords was obtained. There were no problems with ventilation or obtaining tissue samples, and O 2 saturation remained greater than 95% throughout the perioperative period. Tissue samples were adequate in all patients. Hypertension and other adverse cardiac events did not occur during the procedure, which lasted 10 to 20 minutes. There were no problems during emergence from anesthesia, and all patients were discharged home on the same day. Conclusions: The technique has potential advantages over suspension microlaryngoscopy in that it is relatively noninvasive, it allows good airway control with adequate views of the vocal cords, and it facilitates a smooth recovery.

Anesthesia for Microlaryngeal Surgery: The Case for Subglottic Jet Ventilation

Although the techniques for surgery on the endolarynx using suspension and the operating microscope have been fully developed, the safest, and least obtrusive anesthetic technique has yet to be manifested, as evidenced by more than 200 references to anesthesia for microlaryngoscopy in the world literature. This study reviews the physiology, physics, and problems of each anesthetic technique. In light of this review, animal and human studies are reported demonstrating the utility and safety of subglottic ventilation when provided with proper monitoring using an automatic ventilator. A modified Ben-Jet tube is reported, which has a 1-mm ID channel to monitor PCO2 and tracheal pressure. This self-centering 3.0-mm tube, which extends 6 to 8 cm below the glottis, is unobtrusive for the surgeon. The subglottic tube, which is much less likely to be malaligned, is much more acceptable to the anesthesiologist. Anesthesia, by intravenous sedation, utilizes neuromuscular blockade while ventilating through the jet tube powered by an automatic ventilator with an automatic shutdown feature attached to the monitor tube to prevent inadvertent barotrauma. The third phase of this study compared fluoroplastic, used in a prototype jet ventilation tube, with 6-mm Silastic, Red Rubber, and polyvinyl chloride (PVC) tubes when struck by maximum power of CO2, Nd-YAG, and K-532 lasers. The test was performed in a closed chamber in which concentrations of oxygen and nitrogen were controlled. Although damaged by the CO2 laser beam, the fluoroplastic tubes did not continue burning when the laser was turned off in 100% oxygen, even when coated by blood. The other three tubes continued to burn in 23% oxygen. Neither the KTP nor Nd-YAG laser damaged the Teflon tube, while they ignited a sustained flame in 30% oxygen. This study supports the use of fluoroplastic for a laser safe jet ventilation tube. It also demonstrates the danger of tube fires, even in low oxygen concentrations, when using Silastic, rubber, and PVC tubes in laser laryngeal surgery. There was no difference in the flammability of Silastic, rubber or PVC when struck by these lasers in this study. For these reasons, subglottic ventilation using a fluoroplastic, monitored, self-centering, subglottic, jet ventilation tube driven by an automatic ventilator with a shutdown feature, in the event of excessive pressure buildup, is proposed for anesthetizing healthy patients undergoing suspension microlaryngoscopy, and who have no airway obstructing lesion. A large tube with inflatable cuff is indicated when a supraglottic lesion may obstruct the airway.

Anesthesia management of microlaryngeal laser surgery in children: apneic technique anesthesia.

The purpose of this paper is to describe apneic technique general anesthesia which has been used in children for suspension microlaryngoscopy in the nontracheotomized patient. Apneic anesthesia uses a paralyzing drug in combination with controlled ventilation using halothane or isoflurane, nitrous oxide and oxygen, delivered through an endotracheal tube. Patients are monitored throughout the procedure with end-tidal CO2 levels and a cutaneous oximeter. Surgery is performed without the impediment of an endotracheal tube. This method, used in 240 patients ranging in age from 3 months to 18 years, eliminates the danger of a laser fire, gives an unobstructed view of the larynx, is safe, and is free of complications. All outpatients were discharged from the hospital within a few hours after the surgical procedure.

Treatment of severe subglottic stenosis without tracheotomy: a preliminary report.

Subglottic stenosis in neonates, infants and children is one of the most challenging problems confronting the pediatric otolaryngologist today. Small patients with congenital or acquired stenosis were enough to require tracheotomy must undergo repeated endoscopic procedures or laryngotracheal reconstruction; weeks, months, or years may be required to attain a lumen large enough to permit decannulation. During 1981, six infants and children with severe subglottic stenosis were managed without tracheotomy. The surgical technique employed involves endoscopic excision of the offending subglottic tissue using the CO2 laser and suspension microlaryngoscopy. Intraoperative intubation is avoided by using an insufflation technique for general anesthesia which permits unobstructed visualization of the larynx, thereby avoiding laryngeal trauma and edema.

Suspension microlaryngoscopy in the Boyce position with a new suspension gallows.

The patient in whom laryngoscopy is difficult, calls for the placement of the patient's head in the optimum (Boyce) position prior to insertion of the laryngoscope. A new suspension gallows has been developed which provides for suspension of the laryngoscope with the patient in the Boyce position; this ensemble maintains stability of the laryngoscope, minimizes pressure on the maxilla and gives the best possible view of the anterior commissure.

Forum. General anaesthesia with propanidid infusion for suspension microlaryngoscopy without intubation.

AnaesthesiaVolume 31, Issue 2 p. 276-280 Free Access General anaesthesia with propanidid infusion for suspension microlaryngoscopy without intubation G. Mocavero MD, G. Mocavero MD Director, Istituto di Anestesiologia e RianimazioneSearch for more papers by this authorS. Gregoretti MD, S. Gregoretti MD Assistant, Istituto di Anestesiologia e RianimazioneSearch for more papers by this authorA. Bosatra MD, A. Bosatra MD Director, Clinica Otorinolaringoiatrica dell'Universitá degli Studi di Trieste, Ospedale Maggiore, TriesteSearch for more papers by this author G. Mocavero MD, G. Mocavero MD Director, Istituto di Anestesiologia e RianimazioneSearch for more papers by this authorS. Gregoretti MD, S. Gregoretti MD Assistant, Istituto di Anestesiologia e RianimazioneSearch for more papers by this authorA. Bosatra MD, A. Bosatra MD Director, Clinica Otorinolaringoiatrica dell'Universitá degli Studi di Trieste, Ospedale Maggiore, TriesteSearch for more papers by this author First published: March 1976 https://doi.org/10.1111/j.1365-2044.1976.tb11805.xCitations: 4AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume31, Issue2March 1976Pages 276-280 ReferencesRelatedInformation

Local anesthesia for suspension microlaryngoscopy.

Despite the strong trend toward use of general anesthesia for laryngoscopy, local anesthesia retains inherent advantages from the standpoint of patient safety and maintenance of physiologic function of the larynx during endoscopy. Topical anesthesia produces incomplete sensory blockade and is unsatisfactory for suspension laryngoscopy. A method of infiltration anesthesia is described whereby profound anesthesia of the base of the tongue, valleculae, and larynx can be achieved to allow suspension laryngoscopy.

Laryngoscopy

High-frequency subglottic jet ventilation was used in 142 consecutive adults with grade I airways treated with suspension microlaryngoscopy. All cases were managed by the senior anesthesiologist (AP) and the large majority by the senior surgeon (JR), between 2000 and 2002. The laser was used in 30% of cases.There were few complications, none serious, associated with this technique in this series. The subglottic catheter never proved impossible to insert and only needed to be replaced by the supraglottic catheter in two patients because of limitation of visualization of the posterior glottis.The technique was used in a wide variety of surgical pathology from benign hyperfunction-related laryngeal pathology through paralytic vocal fold conditions through papilloma.Advantages and disadvantages over traditional intubation techniques and supraglottic jet ventilation are reviewed, including such issues as ease of intubation/ventilation, surgical exposure/control, maintenance of O2 and CO2 levels, and use in the limited/borderline airway.