Preoperative clinical predictors of difficult laryngeal exposure for microlaryngoscopy: The laryngoscore

Abstract

Objectives/Hypothesis: To identify a clinical predictor score for difficult laryngeal exposure (DLE) during operative microlaryngoscopy.Study Design: Prospective cohort study in two academic institutions. Methods: We evaluated 319 patients before microlaryngoscopy for benign and malignant glottic diseases by a standardized preoperative assessment protocol (Laryngoscore) that included 11 parameters: interincisors gap (IIG), thyro-mental distance, upper jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexionextension, history of previous open-neck and/or radiotherapy, Mallampati's modified score, and body mass index (BMI). Each parameter was assessed to obtain a total score. Patients were divided into five classes according to the anterior commissure (AC) visualization: class 0, complete AC visualization with large-bore laryngoscopes in the Boyce-Jackson position; class I, as class 0 with external laryngeal counterpressure; class II, as class I in the flexion-flexion position; class III, as class II using small-bore laryngoscopes; and class IV, impossible AC visualization.Results: Class 0-I-II (good/acceptable laryngeal exposure) presented a median score < 6. This value was chosen as cutoff for distinguishing favorable versus difficult/impossible laryngeal exposures. When the Laryngoscore was < 6, good laryngeal exposure was observed in 94% of patients, whereas when 6, DLE was encountered in 40%. When considering a Laryngoscore of 9, 67% of patients had a DLE. At univariate analysis, IIG, upper jaw dental status, macroglossia, micrognathia, degree of neck flexion-extension, and BMI statistically impacted on DLE (P < 0.05).Conclusions: The Laryngoscore is a good predictor of DLE and assists in selecting the ideal candidates for operative microlaryngoscopy.

Laryngeal exposure and margin status in glottic cancer treated by transoral laser microsurgery

“…In particular, if less than 1 mm, superficial surgical margin may well be accepted for carcinoma in situ and microinvasive cancers; this may not represent an adequate treatment policy for lesions involving the AC or larger T2 lesions. However, regardless of the many advancements in the field of biologic endoscopy in defining the ideal resection margins, visualization of the surgical field still deeply relies on laryngeal exposure …”

Transoral laser microsurgery as primary treatment for selected T3 glottic and supraglottic cancers

“…Inclusion criteria were glottic and supraglottic cT3 lesions with radiologic evidence of limited paraglottic and/or preepiglottic spaces involvement with preservation of a rim of fatty tissue between the tumor and the thyrohyoid membrane. Furthermore, adequate laryngeal exposure was considered mandatory as preoperatively assessed by the Laryngoscore, which is our rating system for transoral laryngeal exposure . By contrast, no exclusion criteria was followed for the N classification, because neck management is not significantly influenced by the approach chosen for the T management.…”

Salvage Transoral Laser Microsurgery for Radiorecurrent Laryngeal Cancer: Indications, Limits, and Outcomes

“…Next, adequate laryngeal exposure is considered as an absolute necessity for an oncologically sound transoral resection. In order to estimate the laryngeal exposure preoperatively, Piazza et al developed a scoring system, the “Laryngoscore,” which proves to be a good predictor of difficult laryngeal exposure and assists in selecting the ideal candidates for TLM, but which awaits external validation [30•]. However, developing their scoring system, the authors identified previous RT, as well as open-neck surgical approaches, as negative prognosticators for favorable laryngeal exposure [30•].…”

“…In order to estimate the laryngeal exposure preoperatively, Piazza et al developed a scoring system, the “Laryngoscore,” which proves to be a good predictor of difficult laryngeal exposure and assists in selecting the ideal candidates for TLM, but which awaits external validation [30•]. However, developing their scoring system, the authors identified previous RT, as well as open-neck surgical approaches, as negative prognosticators for favorable laryngeal exposure [30•]. Infiltration of the thyroid and cricoid cartilages as detectable by CT or MR and extensive infiltration of the soft tissue of the neck are generally accepted strict contraindications.…”