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Tongue Edema Secondary to Suspension Laryngoscopy
ARTICLE IN PRESS
Tongue Edema Secondary to Suspension Laryngoscopy *David Lafferty, †Abigail Tami, ‡William L. Valentino, and §Robert T. Sataloff, *yzxPhiladelphia, Pennsylvania Summary: Objectives. Suspension microlaryngoscopy (SML) is generally a safe, same-day procedure. Complications have been linked to prolonged operative time and substantial force applied to the tongue. This report of two cases describes marked tongue edema following SML, a complication not yet reported in the literature. Methods. This is a retrospective review of two cases of severe tongue edema following SML. We reviewed the literature for similar reports and proposed treatment plans. Results. Two patients, age 67 and 75, underwent SML for an interval of 247 minutes and 224 minutes for patient 1 and patient 2 respectively. Both developed severe tongue edema requiring inpatient monitoring and steroids. In both patients, the edema improved over several days and returned to baseline. There are no reported cases of this complication in the literature. Conclusion. Prolonged SML can lead to tongue edema requiring close airway monitoring. The edema was selflimited and resolved with steroids and close monitoring. Key Words: Suspension microlaryngoscopy−Laryngology−Tongue edema.
INTRODUCTION Gustav Killian, who performed vocal fold surgery using what he described as an “endoscopic spatula,” reported the use of microlaryngoscopic surgery over 100 years ago.1 Suspension microlaryngoscopy (SML) is now the most common surgical approach for the removal of benign and malignant lesions of the larynx.2 SML is advantageous because it provides a stable view of the larynx with excellent illumination and binocular vision, while also freeing both hands for operative procedures.3 Usually, it is safe to perform SML as an outpatient procedure, with serious airway complications occurring in fewer than 3 per 1000 cases.4 Minor complications including mucosal injury, sore throat, taste disturbances, and dysphagia are relatively common, with rates in the literature between 37.5% and 75%.5−7 Dos Anjor Corvo et al noted an association between surgical time and the rate of complications. Procedures lasting less than 30 minutes had no recorded complications, and all procedures over 60 minutes were associated with at least one extralaryngeal injury.8 Due to the fulcrum mechanism used in suspension laryngoscopy, substantial force is applied to the tongue. Feng et al developed a laryngeal forced sensor and determined that the mean force across all patients undergoing SML at their institution was 164.7 N. A significant relationship between maximum force applied during the surgery and the development of tongue-related symptoms such as dysgeusia, paresthesia, pain, and paresis was noted.2 In this paper, we present two patients who underwent prolonged SML and developed severe edema of the tongue Accepted for publication September 23, 2019. From the *Department of Otolaryngology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania; yDrexel University College of Medicine, Philadelphia, Pennsylvania; zDepartment of Surgery, Temple University Hospital, Philadelphia, Pennsylvania; and the xDepartment of Otolaryngology − Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania. Address correspondence and reprint requests to Robert T. Sataloff, Drexel University College of Medicine, 219 N. Broad Street, 10th Floor, Philadelphia, PA 19107. Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.09.014
requiring close airway observation and intensive care unit admission. To our knowledge, this complication has not been reported to date. Cases Patient 1 A 75 year-old male with a history of recurrent right vocal fold dysplasia and carcinoma-in-situ status-post 11 excisions over the past 10 years (established in our practice 5 years ago) presented with recurrent hoarseness. He denied any difficulty or pain with swallowing. He was a former smoker (40 pack-years, quit in 1983) and drank two alcoholic beverages daily while under our care. His most recent excision had been one year prior, and it had included vocal fold reconstruction with a buccal graft. Strobovideolaryngoscopic examination revealed glottic insufficiency secondary to left vocal fold bowing and right vocal foldscarring and stiffness. The patient was scheduled for microdirect laryngoscopy (MDL) with vocal fold scar excision and reconstruction with buccal graft. Complete left vocal fold reconstruction was performed from the level of the vocal process to the anterior commissure. Exposure and other technical difficulties were encountered. A Lindholm laryngoscope was used. The duration of the procedure was 247 minutes, as compared with our usual MDL cases which are usually 30-60 minutes, and no immediate complications occurred. The patient was taken out of suspension periodically throughout the procedure. He was transferred to the post-anesthesia care unit (PACU) in stable condition. In the PACU, he was noted to have substantial swelling of the tongue [Figure 1]. He denied respiratory distress but was unable to tolerate his own salivary secretions. He was transferred to the step down unit for airway monitoring and continuous pulse oximetry. Intravenous dexamethasone and fluids were prescribed. On postoperative day (POD) 1, his tongue swelling had not improved, and he had nontender submental edema. His vital signs remained stable, but he was still not tolerating his oral secretions or a liquid diet. He was first able to manage his own
ARTICLE IN PRESS 2
Journal of Voice, Vol. &&, No. &&, 2019
FIGURE 1. Edema of the right side of the tongue corresponding with the location of the laryngoscope. salivary secretions and drink small amounts of liquid on POD4. He was discharged on POD5. He was seen in the office on POD8 when his tongue and submental edema had resolved nearly completely. Patient 2 A 67 year-old male, with a history of laryngeal stenosis secondary to prolonged intubation status post resection with CO2 laser and 5-fluorouracil (5-FU) injection one year prior to the current MDL, presented with exertional shortness of breath with biphasic stridor. He denied any dysphagia, throat pain, and dysphonia. Stroboscopy at presentation revealed limited abduction with a large posterior glottic band. He was scheduled for MDL with resection of posterior glottic stenosis, and stent placement and 5-FU injection. A Lindholm laryngoscope was used to obtain visualization. The posterior laryngeal web was injected with lidocaine with epinephrine, and then with a mixture of 5-FU and triamcinolone. In an effort to create a posterior laryngeal bridge rather than a web, silastic was sutured posteriorly as a stent. Due to an unusually long operating time (224 minutes) due to tissue friability and difficulty establishing secure suture placement, the laryngoscope was relaxed occasionally to relieve tongue pressure. At the conclusion of the procedure, the patient was transferred to the recovery room in stable condition. While in the PACU, the patient experienced tongue edema and was admitted for overnight observation in the step down unit. He exhibited stridor and reported shortness of breath but retained adequate oxygen saturation. Racemic epinephrine and dexamethasone were given. Later that evening, he developed increased airway edema and was transferred to the intensive care unit for airway monitoring. On POD1, the patient was able to swallow his secretions, and his breathing had improved; however, there was still marked tongue swelling. By POD2, the
patient was able to tolerate a full liquid diet and was discharged. At his office visit on POD22, the tongue edema had resolved completely. DISCUSSION The two patients presented underwent unusually long SML with durations of 224 and 247 minutes. Both patients developed severe edema of the tongue leading to concern for airway obstruction and requiring admission to the hospital for close monitoring. The edema developed despite repeated breaks from suspension during the procedures. Both patients were treated with steroids and ultimately were discharged on POD5 and POD3, respectively. At follow-up on, POD8 and POD22, the postoperative edema had resolved completely, and the patients were back at their baseline. The mechanism of development of the edema is unclear. The literature has shown that increased operative time and increased force applied to the tongue during SML are correlated significantly with postoperative complications.2,8 Based on our experience, we would recommend that patients who have undergone prolonged SML be monitored closely following the procedure for development of edema of the tongue. If a patient develops marked edema leading to concern for airway obstruction, close airway monitoring is appropriate. We prescribed treatment with steroids, but there are no data to determine efficacy of this practice. CONCLUSION Prolonged operative time and the amount of force applied to the tongue have both been correlated with the development of complications following SML. Our two patients developed edema of the tongue following prolonged SML and required monitoring in the hospital. They did well and returned to baseline condition, but both were at risk of airway obstruction. To our knowledge, this complication as not been
ARTICLE IN PRESS David Lafferty, et al
Tongue Edema Secondary to Suspension Laryngoscopy
discussed in the literature. Laryngologists should be aware of this potential consequence of SML and should observe such patients in the PACU long enough to be certain that it has not occurred before discharging them to home. REFERENCES 1. Killian G. Demonstration of an endoscopic spatula. J Laryngol Rhinol. 1910;25:549–550. 2. Feng AL, Song PC. Laryngeal force sensor: quantifying extralaryngeal complications after suspension microlaryngoscopy. Otolaryngol. 2018;159:328–334. https://doi.org/10.1177/0194599818768482. 3. Benjamin B, Lindholm CE. Systematic direct laryngoscopy: the Lindholm laryngoscopes. Ann Otol Rhinol Laryngol. 2003. https://doi.org/ 10.1177/000348940311200908.
3
4. Orosco RK, Lin HW, Bhattacharyya N. Safety of adult ambulatory direct laryngoscopy. JAMA Otolaryngol Neck Surg. 2015;141:685. https://doi.org/10.1001/jamaoto.2015.1172. 5. Klussmann JP, Knoedgen R, Wittekindt C, et al. Complications of suspension laryngoscopy. Ann Otol Rhinol Laryngol. 2002. https://doi.org/ 10.1177/000348940211101104. 6. Okui A, Konomi U, Watanabe Y. Complaints and complications of microlaryngoscopic surgery. J Voice. 2019. https://doi.org/10.1016/j. jvoice.2019.05.006. 7. Rosen CA, Andrade Filho PA, Scheffel L, et al. Oropharyngeal complications of suspension laryngoscopy: a prospective study. Laryngoscope. 2005. https://doi.org/10.1097/01.MLG.0000175538.89627.0D. 8. dos Anjos Corvo MA, Inacio A, de Campos Mello MB, et al. Extralaryngeal complications of suspension laryngoscopy. Braz J Otorhinolaryngol. 2015;73:727–732. https://doi.org/10.1016/s1808-8694(15) 31167-8.
Tongue Edema Secondary to Suspension Laryngoscopy *David Lafferty, †Abigail Tami, ‡William L. Valentino, and §Robert T. Sataloff, *yzxPhiladelphia, Pennsylvania Summary: Objectives. Suspension microlaryngoscopy (SML) is generally a safe, same-day procedure. Complications have been linked to prolonged operative time and substantial force applied to the tongue. This report of two cases describes marked tongue edema following SML, a complication not yet reported in the literature. Methods. This is a retrospective review of two cases of severe tongue edema following SML. We reviewed the literature for similar reports and proposed treatment plans. Results. Two patients, age 67 and 75, underwent SML for an interval of 247 minutes and 224 minutes for patient 1 and patient 2 respectively. Both developed severe tongue edema requiring inpatient monitoring and steroids. In both patients, the edema improved over several days and returned to baseline. There are no reported cases of this complication in the literature. Conclusion. Prolonged SML can lead to tongue edema requiring close airway monitoring. The edema was selflimited and resolved with steroids and close monitoring. Key Words: Suspension microlaryngoscopy−Laryngology−Tongue edema.
INTRODUCTION Gustav Killian, who performed vocal fold surgery using what he described as an “endoscopic spatula,” reported the use of microlaryngoscopic surgery over 100 years ago.1 Suspension microlaryngoscopy (SML) is now the most common surgical approach for the removal of benign and malignant lesions of the larynx.2 SML is advantageous because it provides a stable view of the larynx with excellent illumination and binocular vision, while also freeing both hands for operative procedures.3 Usually, it is safe to perform SML as an outpatient procedure, with serious airway complications occurring in fewer than 3 per 1000 cases.4 Minor complications including mucosal injury, sore throat, taste disturbances, and dysphagia are relatively common, with rates in the literature between 37.5% and 75%.5−7 Dos Anjor Corvo et al noted an association between surgical time and the rate of complications. Procedures lasting less than 30 minutes had no recorded complications, and all procedures over 60 minutes were associated with at least one extralaryngeal injury.8 Due to the fulcrum mechanism used in suspension laryngoscopy, substantial force is applied to the tongue. Feng et al developed a laryngeal forced sensor and determined that the mean force across all patients undergoing SML at their institution was 164.7 N. A significant relationship between maximum force applied during the surgery and the development of tongue-related symptoms such as dysgeusia, paresthesia, pain, and paresis was noted.2 In this paper, we present two patients who underwent prolonged SML and developed severe edema of the tongue Accepted for publication September 23, 2019. From the *Department of Otolaryngology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania; yDrexel University College of Medicine, Philadelphia, Pennsylvania; zDepartment of Surgery, Temple University Hospital, Philadelphia, Pennsylvania; and the xDepartment of Otolaryngology − Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania. Address correspondence and reprint requests to Robert T. Sataloff, Drexel University College of Medicine, 219 N. Broad Street, 10th Floor, Philadelphia, PA 19107. Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.09.014
requiring close airway observation and intensive care unit admission. To our knowledge, this complication has not been reported to date. Cases Patient 1 A 75 year-old male with a history of recurrent right vocal fold dysplasia and carcinoma-in-situ status-post 11 excisions over the past 10 years (established in our practice 5 years ago) presented with recurrent hoarseness. He denied any difficulty or pain with swallowing. He was a former smoker (40 pack-years, quit in 1983) and drank two alcoholic beverages daily while under our care. His most recent excision had been one year prior, and it had included vocal fold reconstruction with a buccal graft. Strobovideolaryngoscopic examination revealed glottic insufficiency secondary to left vocal fold bowing and right vocal foldscarring and stiffness. The patient was scheduled for microdirect laryngoscopy (MDL) with vocal fold scar excision and reconstruction with buccal graft. Complete left vocal fold reconstruction was performed from the level of the vocal process to the anterior commissure. Exposure and other technical difficulties were encountered. A Lindholm laryngoscope was used. The duration of the procedure was 247 minutes, as compared with our usual MDL cases which are usually 30-60 minutes, and no immediate complications occurred. The patient was taken out of suspension periodically throughout the procedure. He was transferred to the post-anesthesia care unit (PACU) in stable condition. In the PACU, he was noted to have substantial swelling of the tongue [Figure 1]. He denied respiratory distress but was unable to tolerate his own salivary secretions. He was transferred to the step down unit for airway monitoring and continuous pulse oximetry. Intravenous dexamethasone and fluids were prescribed. On postoperative day (POD) 1, his tongue swelling had not improved, and he had nontender submental edema. His vital signs remained stable, but he was still not tolerating his oral secretions or a liquid diet. He was first able to manage his own
ARTICLE IN PRESS 2
Journal of Voice, Vol. &&, No. &&, 2019
FIGURE 1. Edema of the right side of the tongue corresponding with the location of the laryngoscope. salivary secretions and drink small amounts of liquid on POD4. He was discharged on POD5. He was seen in the office on POD8 when his tongue and submental edema had resolved nearly completely. Patient 2 A 67 year-old male, with a history of laryngeal stenosis secondary to prolonged intubation status post resection with CO2 laser and 5-fluorouracil (5-FU) injection one year prior to the current MDL, presented with exertional shortness of breath with biphasic stridor. He denied any dysphagia, throat pain, and dysphonia. Stroboscopy at presentation revealed limited abduction with a large posterior glottic band. He was scheduled for MDL with resection of posterior glottic stenosis, and stent placement and 5-FU injection. A Lindholm laryngoscope was used to obtain visualization. The posterior laryngeal web was injected with lidocaine with epinephrine, and then with a mixture of 5-FU and triamcinolone. In an effort to create a posterior laryngeal bridge rather than a web, silastic was sutured posteriorly as a stent. Due to an unusually long operating time (224 minutes) due to tissue friability and difficulty establishing secure suture placement, the laryngoscope was relaxed occasionally to relieve tongue pressure. At the conclusion of the procedure, the patient was transferred to the recovery room in stable condition. While in the PACU, the patient experienced tongue edema and was admitted for overnight observation in the step down unit. He exhibited stridor and reported shortness of breath but retained adequate oxygen saturation. Racemic epinephrine and dexamethasone were given. Later that evening, he developed increased airway edema and was transferred to the intensive care unit for airway monitoring. On POD1, the patient was able to swallow his secretions, and his breathing had improved; however, there was still marked tongue swelling. By POD2, the
patient was able to tolerate a full liquid diet and was discharged. At his office visit on POD22, the tongue edema had resolved completely. DISCUSSION The two patients presented underwent unusually long SML with durations of 224 and 247 minutes. Both patients developed severe edema of the tongue leading to concern for airway obstruction and requiring admission to the hospital for close monitoring. The edema developed despite repeated breaks from suspension during the procedures. Both patients were treated with steroids and ultimately were discharged on POD5 and POD3, respectively. At follow-up on, POD8 and POD22, the postoperative edema had resolved completely, and the patients were back at their baseline. The mechanism of development of the edema is unclear. The literature has shown that increased operative time and increased force applied to the tongue during SML are correlated significantly with postoperative complications.2,8 Based on our experience, we would recommend that patients who have undergone prolonged SML be monitored closely following the procedure for development of edema of the tongue. If a patient develops marked edema leading to concern for airway obstruction, close airway monitoring is appropriate. We prescribed treatment with steroids, but there are no data to determine efficacy of this practice. CONCLUSION Prolonged operative time and the amount of force applied to the tongue have both been correlated with the development of complications following SML. Our two patients developed edema of the tongue following prolonged SML and required monitoring in the hospital. They did well and returned to baseline condition, but both were at risk of airway obstruction. To our knowledge, this complication as not been
ARTICLE IN PRESS David Lafferty, et al
Tongue Edema Secondary to Suspension Laryngoscopy
discussed in the literature. Laryngologists should be aware of this potential consequence of SML and should observe such patients in the PACU long enough to be certain that it has not occurred before discharging them to home. REFERENCES 1. Killian G. Demonstration of an endoscopic spatula. J Laryngol Rhinol. 1910;25:549–550. 2. Feng AL, Song PC. Laryngeal force sensor: quantifying extralaryngeal complications after suspension microlaryngoscopy. Otolaryngol. 2018;159:328–334. https://doi.org/10.1177/0194599818768482. 3. Benjamin B, Lindholm CE. Systematic direct laryngoscopy: the Lindholm laryngoscopes. Ann Otol Rhinol Laryngol. 2003. https://doi.org/ 10.1177/000348940311200908.
3
4. Orosco RK, Lin HW, Bhattacharyya N. Safety of adult ambulatory direct laryngoscopy. JAMA Otolaryngol Neck Surg. 2015;141:685. https://doi.org/10.1001/jamaoto.2015.1172. 5. Klussmann JP, Knoedgen R, Wittekindt C, et al. Complications of suspension laryngoscopy. Ann Otol Rhinol Laryngol. 2002. https://doi.org/ 10.1177/000348940211101104. 6. Okui A, Konomi U, Watanabe Y. Complaints and complications of microlaryngoscopic surgery. J Voice. 2019. https://doi.org/10.1016/j. jvoice.2019.05.006. 7. Rosen CA, Andrade Filho PA, Scheffel L, et al. Oropharyngeal complications of suspension laryngoscopy: a prospective study. Laryngoscope. 2005. https://doi.org/10.1097/01.MLG.0000175538.89627.0D. 8. dos Anjos Corvo MA, Inacio A, de Campos Mello MB, et al. Extralaryngeal complications of suspension laryngoscopy. Braz J Otorhinolaryngol. 2015;73:727–732. https://doi.org/10.1016/s1808-8694(15) 31167-8.