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Carbon dioxide laser microtrapdoor flap for anterior glottic webs
CARBON DIOXIDE LASER MICROTRAPDOOR FLAP FOR ANTERIOR GLOTTIC WEBS JAY A. WERKHAVEN, MD, ROBERT H. OSSOFF, DMD, MD , PAUL GROSS
Congenital laryngeal webs are manifestations of developmental arrest in the embryologic larynx.' Acquired laryngeal webs are the result of trauma to the anterior or posterior commissure and are slightly more common than the congenital webs. The characteristic appearance of a web is that of a band of tissue stretching from one side of the glottis to the other side. Webs may be supraglottic, glottic, or infraglottic. They may be thin or thick, and may be insignificant in size or completely obstruct the lumen of the airway. Patients with laryngeal webs that do not obstruct the airway present with variable degrees of hoarseness or vocal dysfunction, Most often, the diagnosis is made on indirect laryngoscopy. The hoarseness is a function of the limitations of vibration of the vocal fold. Congenital webs with airway compromise present at birth with stridor or serious airway distress and immediate attention to establishment of an airway is necessary. While indirect examination may show the presence of a web, direct laryngoscopy is required for complete examination and characterization of the location and quality of the web . Most webs are glottic in location as opposed to supraglottic or subglottic. Posterior glottic webs are infrequent." Treatment is dependent primarily on the quality of the web (ie, thin vs thick). Historically, thin glottic webs have been treated by direct scissors lysis, bougienage, or more recently CO 2 laser incision.P'' For the thin laryngeal web, all these methods have had moderate to good success. Thick glottic webs require more aggressive intervention. Lysis with scissors or CO 2 laser frequently fails with reformation of the web. Open or endoscopic incision and placement of a laryngeal keel has been the traditional method of treatment for thick laryngeal webs? In 1984, McGuirt et al 2 reported the use of the CO 2 laser to develop a mucosal flap for treatment of the glottic web. In their technique, mucosa was elevated from the opposite vocal fold to ensure enough tissue for flap transfer. They reported 10 cases, with good voice postoperatively in 6. With the development of the newer generations of microspot micromanipulators for the CO 2 laser, this technique has been modified with the use of a microtrapdoor flap for mucosal tissue transfer in the treatment of these webs. The older laser micromanipulator used in 1984
From the Nemours Children's Clinic, Jacksonville, FL, Department of Otolaryngology, Vanderbilt University Medical Center, and Biomedical Communications, Nashville, TN. Address reprint requests to Robert H. Ossoff, DMD, MD, Depart· ment of Otolaryngology, Vanderbilt University Medical Center, 5·2100 Medical Center North, Nashville , TN 37232-2559. Copyright © 1992 by W.B. Saunders Company 1043·1810/92/0302-0002$05.00/0
120
had a CO 2 beam spot size on the order of 800 urn in diameter. The newer generation micromanipulator now available produces spot diameters as small as 250 urn, with corresponding improvement in precision and limitation of tissue thermal coagulation.
ANESTHESIA Micro direct laryngoscopy with suspension is necessary to obtain the optimum lighting and magnification for the procedure. Venturi jet ventilation with apneic pauses gives the best exposure for the procedure, and is appropriate for small- to medium-s ized webs. Endotracheal intubation with an acceptable CO 2 laser-safe endotracheal tube may also be used. The smallest endotracheal tube size that will adequately maintain patient ventilation should be selected to minimize distortion of the glottis by a large tube. Endotracheal intubation and apneic pauses with removal of the endotracheal intubation and apneic pauses with removal of the endotracheal tube may also be used. Care in the use of this technique must be emphasized, or trauma to the microflap may occur with the repetitive replacement of the endotracheal tube necessary with this technique.
PROCEDURE The CO 2 laser is used with the microspot micromanipulator focused to the most precise spot size. The laser is used at 2 to 5 Wand 0.01- to O.OS-second pulse duration. If superpulse or ultra pulse is available, these settings may be useful to minimize char. Th e web is incised along the lateral edge where the web joins to the opposite vocal fold. This incision is made vertically to minimize the tissue removed from this vocal fold. The incision is carried to the anterior commissure (Fig 1). The web is gently grasped with a micro alligator grasping forceps and retracted laterally (Fig 2). This gives exposure to the incised and inferior surface of the web (Fig 3). The mucosal flap is then redraped over the vocal fold to give tissue coverage. The mucosal flap often is mildly edematous and has retracted slightly, but usually is of sufficient size to cover the raw tissue surface that resulted from ablation of the inferior surface of the web (Fig 4), This mucosa is allowed to adhere to the raw surface or may be welded into position with a milliwatt CO 2 laser (Fig 5). Occasionally, a repeat microflap is needed at the anterior commissure, but to date results have been good for most webs. Thin webs result in immediate tissue cover-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY. VOL 3, NO 2 (JUNl , 1992: PP 120-122
FIGURE 1. Line of incision along edge of anterior glottic web.
FIGURE 2. The web is retracted laterally to expose the scar and inferior mucosal surface.
FIGURE 3. The scar and inferior mucosal surface is ablated with the CO 2 laser and microspot.
FIGURE 4. The mucos a is replaced over the raw tissue surface.
FIGURE 5. .Appearance at conclusion of procedure. WERKHAVEN, OSSOFF, AND GROSS
121
age with ablation of the inferior mucosa of the web. Uniformly thick webs also have given good results with this technique. Webs that are thin at the free edge, but thick at the anterior commissure have not been as successfully treated, with reformation of the scar at the commissure and only fair improvement in voice.
CONCLUSIONS
Laryngeal webs may be successfully treated with an endoscopic microtrapdoor flap. The 250-Jl.m spot size avail-
122
able with the new generation micros pot micromanipulator for the CO 2 laser is vital to this procedure's success.
REFERENCES 1. McHugh HE, Lock WE: Congenital webs of the laryn x. laryngo-
scope 52:43-65, 1942 2. McGuirt WF, Salmon J, Blalock D: Normal speech for patients with laryn geal webs: An achi evable goal. Laryngoscope 94:1176-1180, 1984 3. Holinger LD: Congenital anomalies of the larynx , in English GM (ed): Otolaryngology, Vol 3. Philad elphia, PA, Lippincott, 1991, pp 10-11 4. Werkhaven JA, Ossoff RH: Surgery of benign lesions of the glottis . Otolaryngol CIin North Am 24:1179-1199,1991
CO2 LASER FOR ANTERIOR GLOTIIC WEBS
Congenital laryngeal webs are manifestations of developmental arrest in the embryologic larynx.' Acquired laryngeal webs are the result of trauma to the anterior or posterior commissure and are slightly more common than the congenital webs. The characteristic appearance of a web is that of a band of tissue stretching from one side of the glottis to the other side. Webs may be supraglottic, glottic, or infraglottic. They may be thin or thick, and may be insignificant in size or completely obstruct the lumen of the airway. Patients with laryngeal webs that do not obstruct the airway present with variable degrees of hoarseness or vocal dysfunction, Most often, the diagnosis is made on indirect laryngoscopy. The hoarseness is a function of the limitations of vibration of the vocal fold. Congenital webs with airway compromise present at birth with stridor or serious airway distress and immediate attention to establishment of an airway is necessary. While indirect examination may show the presence of a web, direct laryngoscopy is required for complete examination and characterization of the location and quality of the web . Most webs are glottic in location as opposed to supraglottic or subglottic. Posterior glottic webs are infrequent." Treatment is dependent primarily on the quality of the web (ie, thin vs thick). Historically, thin glottic webs have been treated by direct scissors lysis, bougienage, or more recently CO 2 laser incision.P'' For the thin laryngeal web, all these methods have had moderate to good success. Thick glottic webs require more aggressive intervention. Lysis with scissors or CO 2 laser frequently fails with reformation of the web. Open or endoscopic incision and placement of a laryngeal keel has been the traditional method of treatment for thick laryngeal webs? In 1984, McGuirt et al 2 reported the use of the CO 2 laser to develop a mucosal flap for treatment of the glottic web. In their technique, mucosa was elevated from the opposite vocal fold to ensure enough tissue for flap transfer. They reported 10 cases, with good voice postoperatively in 6. With the development of the newer generations of microspot micromanipulators for the CO 2 laser, this technique has been modified with the use of a microtrapdoor flap for mucosal tissue transfer in the treatment of these webs. The older laser micromanipulator used in 1984
From the Nemours Children's Clinic, Jacksonville, FL, Department of Otolaryngology, Vanderbilt University Medical Center, and Biomedical Communications, Nashville, TN. Address reprint requests to Robert H. Ossoff, DMD, MD, Depart· ment of Otolaryngology, Vanderbilt University Medical Center, 5·2100 Medical Center North, Nashville , TN 37232-2559. Copyright © 1992 by W.B. Saunders Company 1043·1810/92/0302-0002$05.00/0
120
had a CO 2 beam spot size on the order of 800 urn in diameter. The newer generation micromanipulator now available produces spot diameters as small as 250 urn, with corresponding improvement in precision and limitation of tissue thermal coagulation.
ANESTHESIA Micro direct laryngoscopy with suspension is necessary to obtain the optimum lighting and magnification for the procedure. Venturi jet ventilation with apneic pauses gives the best exposure for the procedure, and is appropriate for small- to medium-s ized webs. Endotracheal intubation with an acceptable CO 2 laser-safe endotracheal tube may also be used. The smallest endotracheal tube size that will adequately maintain patient ventilation should be selected to minimize distortion of the glottis by a large tube. Endotracheal intubation and apneic pauses with removal of the endotracheal intubation and apneic pauses with removal of the endotracheal tube may also be used. Care in the use of this technique must be emphasized, or trauma to the microflap may occur with the repetitive replacement of the endotracheal tube necessary with this technique.
PROCEDURE The CO 2 laser is used with the microspot micromanipulator focused to the most precise spot size. The laser is used at 2 to 5 Wand 0.01- to O.OS-second pulse duration. If superpulse or ultra pulse is available, these settings may be useful to minimize char. Th e web is incised along the lateral edge where the web joins to the opposite vocal fold. This incision is made vertically to minimize the tissue removed from this vocal fold. The incision is carried to the anterior commissure (Fig 1). The web is gently grasped with a micro alligator grasping forceps and retracted laterally (Fig 2). This gives exposure to the incised and inferior surface of the web (Fig 3). The mucosal flap is then redraped over the vocal fold to give tissue coverage. The mucosal flap often is mildly edematous and has retracted slightly, but usually is of sufficient size to cover the raw tissue surface that resulted from ablation of the inferior surface of the web (Fig 4), This mucosa is allowed to adhere to the raw surface or may be welded into position with a milliwatt CO 2 laser (Fig 5). Occasionally, a repeat microflap is needed at the anterior commissure, but to date results have been good for most webs. Thin webs result in immediate tissue cover-
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY. VOL 3, NO 2 (JUNl , 1992: PP 120-122
FIGURE 1. Line of incision along edge of anterior glottic web.
FIGURE 2. The web is retracted laterally to expose the scar and inferior mucosal surface.
FIGURE 3. The scar and inferior mucosal surface is ablated with the CO 2 laser and microspot.
FIGURE 4. The mucos a is replaced over the raw tissue surface.
FIGURE 5. .Appearance at conclusion of procedure. WERKHAVEN, OSSOFF, AND GROSS
121
age with ablation of the inferior mucosa of the web. Uniformly thick webs also have given good results with this technique. Webs that are thin at the free edge, but thick at the anterior commissure have not been as successfully treated, with reformation of the scar at the commissure and only fair improvement in voice.
CONCLUSIONS
Laryngeal webs may be successfully treated with an endoscopic microtrapdoor flap. The 250-Jl.m spot size avail-
122
able with the new generation micros pot micromanipulator for the CO 2 laser is vital to this procedure's success.
REFERENCES 1. McHugh HE, Lock WE: Congenital webs of the laryn x. laryngo-
scope 52:43-65, 1942 2. McGuirt WF, Salmon J, Blalock D: Normal speech for patients with laryn geal webs: An achi evable goal. Laryngoscope 94:1176-1180, 1984 3. Holinger LD: Congenital anomalies of the larynx , in English GM (ed): Otolaryngology, Vol 3. Philad elphia, PA, Lippincott, 1991, pp 10-11 4. Werkhaven JA, Ossoff RH: Surgery of benign lesions of the glottis . Otolaryngol CIin North Am 24:1179-1199,1991
CO2 LASER FOR ANTERIOR GLOTIIC WEBS