Authors: Yonatan Lahav, MD, Doron Halperin, MD, Hagit Shoffel-Havakuk, MD.
Subepithelial vocal fold cordectomy (Type I cordectomy according to the ELS classification) for Carcinoma In Situ, performed under general anesthesia with direct microlaryngoscopy and suspension using a free beam CO2 Laser. The resection respects the layered structure of the vocal folds and preserves the superficial lamina propria and its vasculature. The video follows the procedure step by step and includes detailed instructions.
Endoscopic posterior cricoid split with rib grafting can be used in children with bilateral vocal fold immobility due to bilateral vocal fold paralysis or cricoarytenoid joint fixation with posterior glottic stenosis. It is preferred to vocal cordotomy/arytenoidectomy because it is a non-destructive procedure with no impact on voice and swallowing. It is also preferred to open laryngotracheal reconstruction because it does not disrupt the anterior cricoid ring thereby preserving the “spring” of the cricoid.
Contributors: Michael Lerner and Lucian Sulica
Gray Minithyrotomy with fat implantation
Contributors: Clark A. Rosen
Peroral vocal fold augmentation provides the patient an opportunity for permanent or temporary vocal fold augmentation under local anesthesia, obviating a trip to the operating room and general anesthesia.
Contributors: Christian Lava, Hagit Shoffel-havakuk, and Michael M Johns Iii
Adductor spasmodic dysphonia is the most common form of laryngeal dystonia, causing inappropriate glottic closure and strangled choppy voice. This video demonstrates step by step, the standard treatment for adductor spasmodic dysphonia: bilateral, EMG-guided, percutaneous botulinum toxin injections to the TA-LCA (thyroarytenoid and lateral cricoarytenoid) muscles.
Contributors: Jan Kasperbauer
Subglottic stenosis can occur from a variety of causes and is often treated with balloon dilation +/- CO2 laser radial incisions. This video shows an approach used for many years at our institution (wedge excisions without dilation) with good success.
The video goes over the steps of an extended partial Cricotracheal resection in a 8 year old child with Grade 4 subglottic stenosis with posterior glottis involvement.
History of airway stenosis, s/p laryngotracheal reconstruction. Developed restenosis, and balloon dilated three times.
In this video we describe our technique for airway stent insertion and its securing to the neck skin.
Balloon dilation of the airway expanded the airway to its appropriate size. After sizing, an 8mm modified Mehta laryngeal stent with rings (Hood Laboratories, Pembroke, Mass., USA)is inserted in the airway with laryngeal forceps. The scope is inserted into the stent to verify its position. Then a 2.0 prolene stitch is taken through the neck, trachea, stent, and taken out through the contralateral skin. This is performed under visualization with a 2.3mm endoscope through the stent. The needle is then re-inserted through the exit puncture and again taken out next to the entry puncture after passing through a subcutaneous tunnel, without re-entering the stent. A small skin incision is performed between the two prolene threads. Multiple knots are taken over an angiocath, which is then buried under the skin.
The stent is taken out 2-6 weeks after the procedure. A neck incision is performed, the angiocath is identified, the knot is cut and the stent is removed under the vision of the endoscope.
Anna Celeste Gibson, B.S., Mariah Small, M.D., Gresham Richter, M.D.
University of Arkansas for Medical Sciences, Arkansas Children’s Hospital
A papilloma is a benign tumor that is caused by human papillomavirus (HPV) commonly due to the strains 6 and 11. Children acquire these tumors intrapartum from an infected mother. HPV infects natural and metaplastic squamous mucosa which is the type of epithelium that lines the vocal folds. Tumors present as numerous, verrucous outgrowths from the mucosa and can become symptomatic due to mass effect. Common symptoms include hoarseness, dysphonia, aphonia and most concerning, respiratory distress.
A 7-year-old patient with dysphonia secondary to laryngeal papillomatosis also known as recurrent respiratory papillomatosis undergoes microlaryngoscopy and bronchoscopy with microdebridement, CO2 laser ablation, and cidofovir injections.
The patient underwent spontaneous ventilation anesthesia and a dental guard was placed. The patient was positioned for microlaryngoscopy and the larynx was visualized and anesthetized with topical lidocaine. A zero-degree Hopkins rods was passed through the supraglottis, glottis and subglottis to document findings. There was supraglottic papillomatosis notably of the laryngeal surface of the left epiglottis, papillomatosis of the bilateral false vocal folds and papillomatosis of the bilateral true vocal folds with right more affected than left and anterior commissure involvement. The scope was then withdrawn and reintroduced to perform bronchoscopy. The scope was advanced through the trachea, carina and primary and secondary bronchi bilaterally. All were within normal limits. The Benjamin-Lindholm laryngoscope was passed into the vallecula and larynx and suspended in a normal fashion. The zero-degree Hopkins rod was used to visualize the larynx. 2 cc of 1% lidocaine with 1:100,000 epinephrine was injected into the bulk of the papillomas and then several biopsies were taken from this area. The microdebrider was used to debulk these areas. Protective eyewear was used by everyone in the operating room. The patient’s face was protected with water soaked towels and all oxygen sources were removed from the patient. The CO2 laser was set to 2 watts continuous and used to debulk the papillomas with eschar noted after each application. Care was taken to avoid injury to the deep elements of the true vocal folds. Any residual papillomas at the anterior vocal folds were then injected with 1 cc of cidofovir. All instrumentation was removed, the patient was extubated, awakened, and transferred to the recovery room.
The patient was discharged the same day without complications. He will follow up for revision microdebridement, CO2 laser ablation and cidofovir injections.
Microlaryngoscopy and bronchoscopy with microdebridement, CO2 laser ablation, and cidofovir injections is a successful solution for laryngeal papillomatosis and has been proven to eradicate the disease in many cases.
This video demonstrates a rigid transoral esophagoscopy with endoscopic stapler cricopharyngeus myotomy and diverticulotomy in a patient with Zenker’s Diverticulum.