Papillomatosis Tissue Utilized to Correct Anterior Commissure Webbing

MARCO ISLAND, FL-Doctors said they have successfully corrected anterior commissure web formation in papilloma patients with a unique endoscopic microflap laryngoplasty that actually makes use of excess tissue produced in patients with recurrent respiratory papillomatosis.

In an oral presentation at the combined section meeting of the Triological Society here, Lee Akst, MD, Assistant Professor of Otolaryngology at Loyola University Stritch School of Medicine in Maywood, IL, demonstrated and described treatment of five patients who developed the webbing.

Endoscopic microflap layngoplasty utilizing redundant papillomatous epithelium is an effective strategy for lengthening the glottal aperture and enhancing anterior glottic-subglottal exposure for future recurrent respiratory papillomatosis treatment, Dr. Akst said. This approach combines precise cold instrument phonomicrosurgical techniques to manage the web while using an angiolytic laser to precisely involute the diseased epithelium.

Anterior commissure webbing occurs in approximately 13.6 percent to 42 percent of patients with recurrent respiratory papillomatosis as documented in several studies, Dr. Akst said. The incidence of webbing occurs despite the recommendations of many surgeons to treat anterior commissure disease very carefully.

Patients with recurrent respiratory papillomatosis of the glottis may develop an anterior commissure web after repeated treatment with injudicious use of any modality. These synechia can obscure disease on the undersurface of the web and more caudally in the subglottis, he explained.

Dr. Akst said that some of the webs that form can be large enough to affect the airway. At any time they can hide disease in the anterior subcordal and subglottic areas and that can limit your ability to manage these patients in the office, he said.

Dr. Akst suggested that previous surgical solutions to the problem, such as endoscopic keel placement or transcervical laryngofissure techniques, do not seem to work well in the presence of papillomatosis.

Mucosal advancement flaps works well for congenital webs, but it is more difficult when the epithelium is adherent to scar tissue, he said. It is difficult to suture, particularly when anterior commissure exposure is limited and the treatment has not been described in conjunction with management of papilloma.

Purpose of the Procedure

The goal of the procedure, he said, is to restore vocal fold length by anterior commissure laryngoplasy in patients with recurrent respiratory papillomatosis.

Dr. Akst said that his study presents a novel endoscopic laryngoplasty technique designed to lengthen the glottal aperture and enhance exposure of the subcordal and subglottic airway. He said the procedure requires a universal modular glottiscope; a posterior cord spreader was used to provide better anterior commissure exposure during the operative microendoscopy.