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Minicricothyrotomy Approach With Fiberoptic Guidance for Management of Posterior Glottic Stenosis

INTRODUCTION Posterior glottic stenosis (PGS) is a well-described complication of prolonged endotracheal intubation.1,2 Direct pressure of the endotracheal tube on the mucosa of the posterior glottis can cause ulceration, perichondritis, and/or chondritis. Excessive granulation tissue formation can lead to interarytenoid scarring with or without involvement of the posterior commissure and the cricoarytenoid joints.3 Depending on the nature of the stenosis, patients suffer from various degrees of airway obstruction and dysphonia. A host of endoscopic and open surgical techniques exist to address PGS.4 –7 The technique chosen for a given patient must be tailored to the particular type of stenosis. In general, PGS consisting of an isolated interarytenoid scar without involvement of the posterior commissure should be amenable to endoscopic excision to avoid the morbidity of laryngofissure with regard to postoperative voice. We present a minimally invasive external approach for excision of interarytenoid scar for patients who cannot tolerate direct laryngoscopy. The excision is carried out with the guidance of a transnasal or transoral flexible fiberoptic laryngoscope. This technique has been successfully employed to excise a calcified interarytenoid scar in a patient with restoration of normal voice and swallowing. Technique/Case Report A 69-year-old man presented with longstanding breathy dysphonia and aspiration. Ten years prior, he sustained cervical and mandibular fractures in a motor vehicle accident and required urgent endotracheal intubation. This was converted to a tracheotomy at an unknown interval, and he was decannulated at the end of a 3-month hospital course. He had had a breathy voice ever since. He did not have symptoms of airway obstruction and denied shortness of breath on exertion. He did have mild aspiration with liquids without noticeable sequelae. Several years before the current presentation, he had an attempted endoscopic procedure, which was aborted because his airway could not be secured. On physical examination, he had a breathy voice. Attempt at indirect laryngoscopy revealed limited neck extension and jaw opening, presumably secondary to the prior injuries. Flexible fiberoptic laryngoscopy showed bilateral true vocal folds to be immobile with an approximately 5-mm posterior gap. There was supraglottic constriction with attempted phonation, but the vocal folds remained apart. During videolaryngoscopy, a scar band across the posterior glottis posterior to the vocal processes was noted (Fig. 1A). A high-resolution computed tomography scan showed the scar band to be calcified (Fig. 1B). The cricoarytenoid joints had a normal appearance on the computed tomography scan. The calcified scar appeared to severely restrict movement of the arytenoids. Treatment options were discussed with the patient. On the basis of the history of the unsuccessful direct laryngoscopy and the limited neck extension and jaw opening on examination, operative direct laryngoscopy was unlikely to be successful. Since the patient’s primary symptom was dysphonia rather than airway obstruction, an open procedure that disrupted the anterior commissure was undesirable. We elected to proceed with a minicricothyrotomy approach. From the Department of Otolaryngology-Head and Neck Surgery (T.M., S.D.P., M.S.C.), University of California, San Francisco, California, U.S.A., and the Veterans Administration Medical Center (P.W.C., S.J.W.), San Francisco, California, U.S.A. Editor’s Note: This Manuscript was accepted for publication March 26, 2007. Presented at the Western/Middle Section Meeting of the Triological Society, San Diego, California, U.S.A., February 2–5, 2006. Send correspondence to Steven J. Wang, MD, 4150 Clement St., Box 112B, San Francisco, CA 94121, U.S.A. E-mail: swang@ohns.ucsf.edu