Endoscopic posterior cricoid reduction: A surgical method to improve posterior glottic diastasis

Abstract

Objectives/Hypothesis Describe the preoperative evaluation of patients with glottic diastasis who are candidates for endoscopic posterior cricoid reduction (EPCR) and their perioperative and postoperative surgical and voice outcomes, and validate the aerodynamic benefit of EPCR using computation fluid dynamics (CFD)‐based modeling from computed tomography (CT) scans. Study Design Retrospective case series. Methods Thirteen patients who underwent EPCR were followed from 2013 to 2017. They received a preoperative voice evaluation, microlaryngoscopy and bronchoscopy, dynamic voice CT (performed on patients seen from 2014 to study completion), and postoperative voice evaluation (n = 12). Postoperative inpatient days, complications, and postoperative endoscopic intervention were collected. To validate the aerodynamic benefit of EPCR, CFD modeling was carried out on one patient. Results Thirteen patients (nine females, nine with intubation injury, and four with post–airway reconstruction dysphonia) underwent EPCR at a mean age of 11.0 years. The mean preoperative and postoperative Pediatric Voice handicap Index scores were 53.8 and 33.8, respectively (P = .006). Mean maximum phonation time preoperatively and postoperatively was 5.3 and 6.7, respectively (P = .04). Of eight patients who underwent preoperative CT imaging, all demonstrated a posterior gap. Modeling demonstrated a change in flow and pressure. The mean hospital stay was 2.4 days. Nine patients underwent postoperative endoscopic intervention, and one experienced a complication that resolved with intervention. Conclusions Patients who underwent EPCR for dysphonia following intubation or airway reconstruction showed improvements in vocal efficiency, loudness, and perceived voice handicapping. Their hospital stay was brief, with few complications. CFD modeling corroborated these clinical findings. EPCR thus warrants consideration in the management of patients with posterior glottic diastasis. Level of Evidence 4 Laryngoscope, 129:S1–S9, 2019

Intubation‐Related Laryngeal Deficiency and Vocal Fold Immobility in Pediatric Premature Patients

“…Might this be an unintended strategy to manage a severe BD? Among older patients, posterior cricoid reduction laryngoplasty has shown to improve voice outcomes for posterior defects years following LTRs 37,38 . Our subjects with BDSS rating of 2 were found to have similar reduction in pVHI when compared with de Alarcón et al 38 Our study did not include subjects with cricoid reduction or adduction arytenoidoplexy intervention, but utilized either recurrent laryngeal nerve reinnervation or injection laryngoplasty to improve glottic closure for the patients with unilateral vocal fold immobility.…”

“…Among older patients, posterior cricoid reduction laryngoplasty has shown to improve voice outcomes for posterior defects years following LTRs 37,38 . Our subjects with BDSS rating of 2 were found to have similar reduction in pVHI when compared with de Alarcón et al 38 Our study did not include subjects with cricoid reduction or adduction arytenoidoplexy intervention, but utilized either recurrent laryngeal nerve reinnervation or injection laryngoplasty to improve glottic closure for the patients with unilateral vocal fold immobility. Although the underlying etiology of the breathiness is different (insertion of a graft during airway reconstruction vs deficiency from intubation), the concept of reducing glottal air escape posteriorly may be a potential surgical approach to manage this patient population as they get older.…”

Upper Airway Anomalies

“…A cohort of 13 patients undergoing this procedure had objective and subjective improvement in voice with an average hospital stay of 2.4 days. There was only one major complication (pneumothorax) [57].…”

Simulation of Pediatric Endoscopic Cricoid Reduction and Expansion

“…Simulation training has also been linked to improved patient outcomes. Correspondingly, the American Residency Review Committee for Surgery and the American Surgical Association recommend simulation training 13,14 …”

“…Correspondingly, the American Residency Review Committee for Surgery and the American Surgical Association recommend simulation training. 13,14 We describe a modification to an aforementioned dissection station 15 that can be used to simulate endoscopic cricoid reduction and expansion. No other endoscopic simulations are available for pediatric cricoid grafting.…”