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.
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May 2007In 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.
In the procedure, the anterior commissure laryngoplasty consisted of a cold instrument lysis of the web. Subsequently an inferiorly based microflap composed of papillomatous epithelium was dissected.
Dr. Akst said that his surgical advancement involved the rotation of the microflap by suture stabilizing it to the anterior commissure tendon.
The papillomatous disease not associated with the microflap was treated with an angiolytic laser after the glottal aperture was lengthened, he said. A second-stage laser procedure was done to treat the residual disease in the microflap. Microlaryngoscopy and telescopic videostroboscopy were used to assess outcomes.
As the laser lyses the webbing, doctors can view those structures beneath the web itself, Dr. Akst said. The microflap prevents synechia reformation during re-epithelialization. The length of glottal aperture is restored. The remaining disease on microflap itself can be treated with staged angiolysis 6 to 10 weeks later.
Case Studies
In the prospective, nonrandomized case series reported at the meeting, Dr. Akst said that in all five patients the glottal length was improved in all patients by an average of 5 mm. The improved exposure allowed all patients to progress to office-based management, he said.
Patients were selected who presented with substantial anterior commissure web formation with recurrent respiratory papillomatosis on its undersurface, he said.
Overall, we found this to be a very effective technique. It capitalizes on the presence of the redundant papillomatous tissue, he explained. The microflap can actually be raised and put into position to prevent restenosis. Therefore, it is not limited by scar tissue like other mucosal advancement flaps. You are not using the scar; you are using the disease itself and then involuting that disease in the second stage. Sometimes that takes place in the operating room, but as you have seen here, sometimes it can be accomplished in the office.
He added, Given that many of these patients have failed office-based therapy or are not candidates for office-based therapy because we can’t see the disease in the subcordal and subglottic regions, we don’t feel that this is in any way a negative to have two separate operative microendoscopies in something like this.
Another advantage of this technique is that it can be adapted to any particular surgical preference that anyone might have for treatment of papilloma, Dr. Akst said. He said that the procedure does not increase the number of operating room treatments. He added that the general paradigm for the correction of the webbing requires two operative microlaryngoscopies followed by transition to office-based care.
Criticism of the Procedure
The surgical procedure performed by Dr. Akst received some criticism, however. In regard to the paper presented at the Marco Island meeting, I do believe that this concept is somewhat controversial, said Stanley Shapshay, MD, Professor of Otolaryngology at Albany Medical College in New York and a partner in University Ear, Nose & Throat of Northeastern NY, an affiliate of Albany Medical Center.
The use of local tissue flaps to repair anterior commissure webbing is not a new technique, Dr. Shapshay said in commenting on the procedure. However, the use of diseased tissue to accomplish this is a new concept which is subject to some criticism. The standard treatment for anterior commissure stenosis associated with treatment for papillomatosis is not to reconstruct the anterior commissure web until the disease process-papillomatosis-is in remission.
Dr. Shapshay noted that regrowth of papillomas in the anterior commissure has the same deleterious effect on the voice as does webbing.
Dr. Akst reported that his work was supported in part by the Eugene B. Casey Foundation and the Institute of Laryngology and Voice Restoration. The 532-nm Pulsed KTP Laser, used in the surgeries, was on-loan from Laserscope Inc. No consulting or research funding support was received from this company, he said.
©2007 The Triological Society
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