Annals of Otology, Rhinology & Laryngology 122(11):672-678. © 2013 Annals Publishing Company. All rights reserved.
Endoscopic Keel Placement to Treat and Prevent Anterior Glottic Webs Randal C. Paniello, MD; Shaun C. Desai, MD; Clint T. Allen, MD; Siddarth M. Khosla, MD We performed a retrospective chart review to examine and describe our clinical experience of use of the Lichtenberger technique to place silicone elastomer keels after lysis of existing webs or for prevention of webs following anterior commissure surgery in adults. Twenty-two patients were identified for inclusion, ranging in age from 24 to 80 years. For 18 patients with existing glottic webs, the surgical procedure involved laryngoscopy with complete lysis of the anterior glottic web by laser or sharp technique, followed by placement of a square of silicone elastomer that is sutured in place with the Lichtenberger needle holder and left in place for 3 to 5 weeks. The procedure was well tolerated, and successfully corrected the web in all but 2 cases. For 4 patients, the procedure was performed prophylactically at the time of anterior commissure surgery considered high-risk for web formation. The procedure does not require a tracheotomy, and patients can maintain a normal diet and have functional phonation while the keel is in place. This approach to treating anterior glottic webs offers several advantages over traditional open thyrotomy with keel placement and should be considered to treat or prevent anterior glottic webs. Key Words: endoscopy, keel, larynx, surgery, web.
web via a cold approach (eg, sickle knife or micro scissors) or a carbon dioxide (CO2) laser approach, followed by open thyrotomy with placement of a keel to prevent approximation of the raw surfaces and re-formation of the web.6
Introduction
Anterior glottic webs can be classified as congenital or acquired. In adults, acquired webs are most commonly due to trauma, infection, laryngopharyngeal reflux, or a prior surgical procedure (eg, resection of laryngeal cancer).1 Laryngeal webs may range in size from a small anterior lesion comprising less than one third of the membranous fold to a complete glottic web with possible extension superiorly or inferiorly to the supraglottis or subglottis. Benjamin2 and Cohen3 established classification systems for glottic webs that were intended primarily for use in describing congenital lesions. Koltai and Mouzakes4 described a staging system for acquired lesions in adults based on the percentage of vocal fold length involved in the web.
Several authors have reported making improvements on the original McNaught keel approach by using totally endoscopic approaches. Dedo7 reported endoscopic placement of a Teflon keel. Others have used a silicone elastomer sheet, folded and fixed at the anterior commissure and usually without a tracheotomy.8-14 The stent in these cases no longer resembles the keel of a boat, but the term “keel” has stuck. The use of soft tissue such as perichondrium to form a keel has also been reported.15 The goal of these procedures is the same: to place a foreign body between the raw surfaces of the freshly divided web edges and leave it in place long enough that the edges do not scar back together and re-form the web. Alternative approaches have been proposed to reduce the risk of web recurrence, such as the use of mitomycin-C,16 or leaving a 3- to 5- mm “alley” between the anterior vocal folds, as reported by Su et al.17
Symptoms of acquired laryngeal webs range from minor voice changes to acute respiratory distress, depending on the degree of obstruction.5 Diagnosis of acquired webs involves direct or fiberoptic laryngoscopy to fully evaluate the extent of web involvement. The goal of therapy is airway management, followed secondarily by voice rehabilitation.5 Traditionally, the surgical approach involves lysis of the
From the Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri (Paniello, Desai, Allen), and the Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio (Khosla). Presented at the meeting of the American Laryngological Association, Chicago, Illinois, April 27-28, 2011. Correspondence: Randal C. Paniello, MD, Dept of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, 660 S Euclid Ave, CB 8115, St Louis, MO 63110.
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B
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D
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Fig 1. (Patient 11) Intraoperative views through laryngoscope. A) Fifty-percent web and granulation along right vocal fold caused dysphonia and moderate airway obstruction. B) Division of web with microlaryngeal scissors. C) Immediately after lysis of web. D) Keel in place. E) Immediately after removal of keel at 5 weeks. Voice and airway were both markedly improved.
E Anterior commissure lesions that require surgery are often treated in two stages, in which the first side is allowed to heal and mucosalize before the second side is treated, in order to prevent web formation. Such “high-risk” lesions could be treated simultaneously with placement of a prophylactic keel, but this approach has not been reported. The present study introduces this concept with the inclusion of 4 such cases.
In 1991, Lichtenberger and Toohill18 introduced a new instrument designed for passing sutures from the endolarynx to the anterior neck, called the “endo-extralaryngeal needle carrier.” They subsequently reported a small series of anterior glottic webs
that were divided endoscopically, then stented with a silicone elastomer sheet placed with the aid of this instrument.19 We have found this procedure to be the simplest and most effective method for placing anterior glottic keels. We report herein our clinical experience and results with this technique. Materials and Methods
Institutional Review Board approval for chart review was obtained, and patients who had undergone this procedure were identified. Patient demographics, the cause of the web, and the result of the procedure, including any complications, were tabulated. We considered a web to involve 100% of the vo-
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B
C
D
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Fig 2. (Patient 9) Intraoperative views of keel procedure. A) Twocentimeter square of thin silicone elastomer sheet is weaved in midline with 2-0 Prolene suture. B) Suture is loaded onto endoextralaryngeal needle carrier. C) First suture is positioned at cricothyroid membrane and passed through skin. D) Both sutures in position. Tension allows keel to be positioned at anterior commissure. E) Sutures are tied down over sterile button.
E cal fold length if it extended posteriorly to the vocal process or beyond. Our surgical procedure is similar to that reported by Lichtenberger and Toohill.18 The patient is placed in the supine position on the operating room table, and general anesthesia is administered via a small-caliber endotracheal tube. Microlaryngoscopy is performed, and the laryngeal web is divided in the midline to the inner perichondrium of the anterior commissure (Fig 1A-C) by a cold technique (microlaryngeal scissors or sickle knife) or with a microspot CO2 laser. A vocal fold spreader is used to help divide the web to the anterior commissure perichondrium.
The keel is fashioned from a 2 × 2-cm square of a 0.020-inch (0.5-mm) silicone elastomer sheet; these dimensions are adjusted for an unusually small or large larynx. A 2-0 Prolene suture is weaved through the midline of the square in a series of small perforations that enables the sheet to fold along this line (Fig 2A). The suture is loaded into the special needle used for the Lichtenberger endo-extralaryngeal needle carrier (Fig 2B). This instrument is positioned through the laryngoscope (Fig 2C) so that the needle tip is below the true vocal folds, in the midline, just above the cricoid cartilage. The needle driver is used to advance the needle through the cricothyroid membrane and prepared skin to a sterile assistant, who retrieves it. The opposite end of the suture is
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Table 1. demographics and operative details of patients with Keel placed with lysis of web
Pt Age No. Gender (y) Cause of Web
Glottis Involved
Tracheotomy
Recurrence
1 M 30 Multiple papilloma surgeries 33% No No 2 F 62 Laryngeal cancer and open 33% No No hemilaryngectomy 3 M 45 Laryngeal cancer and open 50% No No hemilaryngectomy 4 M 48 Multiple papilloma surgeries 33% No No 5 F 24 Trauma, history of tracheotomy 100% No No 6 M 74 Laryngeal cancer and CO2 laser 33% No Yes resection 7 M 39 Trauma, history of tracheotomy and 100% * No subglottic stenosis 8 F 41 Laryngopharyngeal reflux 50% No No 9 M 71 Bilateral saccular cysts 33%† No No 10 F 65 Previous thyroplasty, reaction to implant 33% No No 11 F 25 Intubation trauma 50% No No 12 M 27 Anterior true vocal fold polyp surgery 33% No No M 60 Laryngeal cancer and open bilateral 33%† No No 13 cordectomy 14 F 45 Laryngeal cancer and CO2 laser 50% No No resection 15 F 33 Granulomatosis with polyangiitis 100% No No 16 F 33 Granulomatosis with polyangiitis 100% * Yes 17 M 80 Multiple papilloma surgeries 30% No No M 68 Multiple papilloma surgeries 100% * No 18
Complications
Anterior commissure granuloma (3 mo later) Early extrusion Early extrusion
Needle tract infection
*Tracheotomy was already present at time of procedure. †Web involved false vocal folds.
loaded onto another needle in a similar fashion and loaded into the endo-extralaryngeal needle carrier, and the laryngoscope is backed up a few millimeters to allow access to the epiglottic petiole. The instrument tip is placed in the midline, against the petiole, about 8 to 10 mm superior to the anterior commissure, and the needle is advanced through the thyroid notch and the prelaryngeal neck skin (Fig 2D), at which point it is retrieved in a similar way by the assistant. Tension placed on the sutures by the assistant allows for proper placement of the keel, which is guided into position endoscopically (Fig 1D). Once the keel is tugged up into the anterior commissure to separate the raw laryngeal surfaces, the suture is tied over a sterile button, which is either buried subcutaneously or left external (over a small piece of Telfa; Fig 2E), according to the patient’s preference. Patients are prescribed a proton pump inhibitor for reflux prophylaxis, and an antibiotic if the button is buried. Tracheotomy is not required. The keel is removed 3 to 5 weeks later (Fig 1E). If the button is buried in a subcutaneous pocket, the patient is returned to the operating room and the keel is removed by direct laryngoscopy with opening and re-closure of the subcutaneous pocket. If the button
is left external, the keel may be removed in the operating room — or, optionally, in the office, under topical anesthesia — by grasping it with transoral forceps or with biopsy forceps through the working channel of an endoscope. Results
Twenty-two patients who had undergone endoscopic keel placement since 1997 were identified for the study. The patients’ ages at the time of the procedure ranged from 24 to 80 years (Table 1). There were 12 men and 10 women. The most common causes of the anterior webs were surgeries for laryngeal cancer (6 patients), surgeries for laryngeal papillomatosis (5), surgeries for large laryngeal polyps (3), trauma (2), and granulomatosis with polyangi itis20 (2); other causes are listed in Table 1. Eighteen procedures were performed as treatment for an existing web, and 4 procedures were performed as prophylaxis at the time of anterior commissure surgery that was considered high-risk for web formation. Results are reported with a minimum of 3 months of follow-up. Existing Web Group. In this group, 2 of the 18 patients had web recurrences. In the first case, the
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Paniello et al, Endoscopic Keel Placement Table 2. demographics and operative details of patients with Keel placed prophylactically at time of anterior commissure surgery
Pt No. Gender Age (y) Indication Tracheotomy
19 20 21 22
M F F M
56 56 45 49
Bilateral large anterior true vocal fold polyps Bilateral large anterior true vocal fold polyps Laryngeal cancer and CO2 laser resection Recurrent papilloma excision
suture ruptured 2 days after the procedure, and the raw vocal fold surfaces had not yet healed. The patient declined replacement of the keel, and the web re-formed, although it was smaller than it was originally. Ultimately, the patient was satisfied with his voice and declined further intervention. The second case was that of a patient with severe granulomatosis with polyangiitis who had previously demonstrated a severe fibrotic reaction to any endolaryngeal procedure, despite high-dose perioperative steroid management. All remaining patients had complete resolution of their anterior glottic web (16 of 18, or 89%).
Four patients experienced complications. Two patients had early spontaneous extrusion of the keel; in both cases, it was found that the supporting suture had ruptured. One of these patients had a recurrence of the web (as detailed above). In these early cases, a smaller-caliber suture was used (3-0), and it was tied down fairly tightly. After these two ruptures, we switched to 2-0 sutures and left the suture tied with just a little “play” in it to reduce the tension from laryngeal motion during swallowing. Since we made these changes, there have been no further suture ruptures. Another patient with known laryngopharyngeal reflux disease developed a postoperative granuloma 3 months after the keel was removed; the granuloma was eventually removed with a CO2 laser. One patient had a needle tract infection, as evidenced by a small amount of purulent drainage along the suture beneath his external button. This responded quickly to a course of broad-spectrum antibiotics, without sequelae. None of the patients required a tracheotomy. Three of the patients already had a tracheotomy in place for airway management because of additional subglottic disease and/or other previous laryngeal surgery; these were left in place. None of the patients experienced intraoperative or postoperative airway obstruction. Web Prophylaxis Group. The 4 patients in this group had lesions that were expected to place them at high risk for the development of an anterior web following surgery (Table 2). Two had very large anterior polyps, 1 had multiply recurrent laryngeal
Web Prevented
No Yes No Yes No No No Yes
Complications
Thin keel migrated inferiorly
papilloma at the anterior commissure, and 1 had a T1b glottic carcinoma involving the entire length of both membranous vocal folds. The keel placement was performed in the same manner as for the existing webs, after the removal of their bilateral anterior lesions except in the case of patient 22 (see below). Patient 21 in this series, a smoker with a chronic cough, had a small larynx with a narrower-thanaverage lumen, and we attempted to use a thinner silicone elastomer sheet (0.005 inch, or 0.127 mm) in order to increase her airway. At the time of keel removal, it was found that the thin silicone elastomer sheet had migrated inferiorly and was no longer positioned between the vocal folds; instead, an anterior web had formed. It was hypothesized that the combination of thin material and frequent forceful coughing led to this migration. The web was lysed and a new 0.020-inch (0.5-mm) keel was placed with successful resolution. This patient was thus also included in the existing web group (as patient 14). Patient 22 presented with a limited time frame for treatment, as he was scheduled for active military deployment only 1 month after his visit. He had significant papilloma present at the anterior commissure and needed to produce a loud voice when he arrived at his duty station. In this case, we elected to treat both sides simultaneously and place a keel, but the sutures were placed “outside-in” by means of angiocatheters placed percutaneously (similar to the approach of Koltai and Mouzakes4). This choice avoided potentially seeding papilloma in the soft tissue of the neck along an “inside-out” needle tract. Discussion
The original McNaught keel procedure was, at the time (1950), a major advance in the treatment of anterior glottic webs and quickly became the standard of care. However, it required an open thyrotomy for placement of the keel, as well as a tracheotomy; and removal of the keel often required a second open procedure.6 Since 1950, improvements in instrumentation and technology have led to the development of a fully endoscopic approach. Dedo7 was the first to describe an endoscopic approach in which a triangular Teflon keel was fixed with 26-gauge
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stainless steel wire. This wire was placed by the use of straight needles passed through the skin and the cricothyroid and thyrohyoid membranes and then retrieved endoscopically. In our experience, it is less cumbersome to use an internal-to-external approach, rather than the reverse, and our approach allows for more precise placement of the keel. Lichtenberger and Toohill18 noted that the outside-in approach is associated with a higher incidence of needle tract infection. Only 1 of our patients exhibited evidence of an infection following the endoscopic keel procedure. Several other authors have used a silicone elastomer sheet placed endoscopically to prevent recurrence of the web, and their success rates are comparable to ours.8-14 Our report adds to the experience published by Lichtenberger and Toohill18,19 in using the special endo-extralaryngeal needle carrier, which is ideally suited for this procedure. We note that 8 of their 13 patients (62%) had postoperative webs of 10% to 20%,19 whereas 16 of 18 patients (89%) in our series had no residual web after keel removal. Our method may result in a more complete division of the web, as the cut is carried anteriorly to the inner perichondrium of the anterior commissure; this cut is aided significantly by use of the vocal fold spreader instrument. To our knowledge, the placement of a keel prophylactically for web prevention has not been previously reported. When the keel is removed in the office, there may be concern that it could slip below the vocal folds, out of reach of the forceps, and possibly cause an airway obstruction. This has not occurred in any of our patients. The silicone elastomer sheet normally collects a layer of mucus that causes it to stick to the epiglottis and anterior false and true vocal folds, so that even with the anchoring suture divided it does not slip inferiorly. There were 2 cases in this series in which the keel, with its suture released, slipped from the grasp of the forceps and was potentially free to fall into the trachea. Each time, the patient simply worked the keel forward into the mouth and spit it out. Even if the keel were to fall into the trachea, we believe it would not cause an airway obstruction and would be easy to retrieve by bronchoscopy. The presence of the keel is well tolerated by patients. Initially, the patient may have a sense of a foreign body in the larynx or globus sensation, but this
quickly dissipates. The patients are able to swallow a normal diet without aspiration (provided that the vocal folds are mobile), and many have a surprisingly good voice — not normal, but very functional — during the few weeks that the keel is in place.
Our experience with this procedure has led us to be more aggressive with benign lesions of the anterior commissure. When assessing the risk of web formation against that of leaving residual disease behind, we now consider the risk of web formation to be less of a problem, because it is fairly easy to correct, as evidenced by this series of patients. The procedure can also be used prophylactically, as demonstrated in patients 19 through 22 (Table 2), and thus may reduce the need for multiple operations in cases of bilateral disease. We do not use this approach for patients with active laryngeal papillomatosis, however, given the concern about seeding live papillomavirus into the soft tissues of the neck in the prelaryngeal region by passing the needle from the inside out. The patients in this series who had existing webs from prior papilloma surgery had all been free of disease for at least 2 years before this approach was offered to them (except for patient 22). This series also demonstrates the versatility of this approach. Two of the patients had lesions at the level of the false vocal folds; the procedure required no special adjustment to handle this situation. Two of the patients had had a prior hemilaryngectomy for carcinoma; the keel was used to prevent recurrent webbing when the reconstructed hemilarynx was released from the remaining good vocal fold. There may be many other potential applications not listed here, limited only by the surgeon’s imagination. Conclusions
The described method of endoscopic lysis of anterior glottic webs and keel placement is simple to perform, is well tolerated by patients, and offers a low rate of web recurrence. The endo-extralaryngeal needle carrier used by Lichtenberger and Toohill18,19 is ideally suited to streamlining this procedure. A tracheotomy is not required, and often the keel may be removed in the office. A new option for prophylactic keel placement in high-risk cases is described. These procedures should be considered in all patients with symptomatic anterior glottic webs or with surgical conditions involving the anterior commissure.
References 1. Holland BW, Koufman JA, Postma GN, McGuirt WF Jr. Laryngopharyngeal reflux and laryngeal web formation in patients with pediatric recurrent respiratory papillomas. Laryngoscope 2002;112:1926-9.
2. Benjamin B. Chevalier Jackson Lecture. Congenital laryngeal webs. Ann Otol Rhinol Laryngol 1983;92:317-26. 3. Cohen SR. Congenital glottic webs in children. A retro-
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spective review of 51 patients. Ann Otol Rhinol Laryngol Suppl 1985;94(suppl 121):2-16.
4. Koltai PJ, Mouzakes J. The surgical management of anterior glottic webs. Oper Tech Otolaryngol Head Neck Surg 1999;10:325-30. 5. Nicollas R, Triglia JM. The anterior laryngeal webs. Otolaryngol Clin North Am 2008;41:877-88, viii. 6. McNaught RC. Surgical correction of anterior web of the larynx. Trans Am Laryngol Rhinol Otol Soc 1950;54th Meeting:232-42. 7. Dedo HH. Endoscopic Teflon keel for anterior glottic web. Ann Otol Rhinol Laryngol 1979;88:467-73. 8. Giancarlo H, Mattucci KF. Silastic sheet keel in laryngeal reconstruction. Laryngoscope 1985;95:1123. 9. Parker DA, Das Gupta AR. An endoscopic Silastic keel for anterior glottic webs. J Laryngol Otol 1987;101:1055-61. 10. Casiano RR, Lundy DS. Outpatient transoral laser vaporization of anterior glottic webs and keel placement: risks of airway compromise. J Voice 1998;12:536-9. 11. Hsueh JY, Tsai CS, Hsu HT. Intralaryngeal approach to laryngeal web using lateralization with Silastic. Laryngoscope 2000;110:1780-2. 12. Liyanage SH, Khemani S, Lloyd S, Farrell R. Simple keel fixation technique for endoscopic repair of anterior glottic stenosis. J Laryngol Otol 2006;120:322-4.
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13. Edwards J, Tanna N, Bielamowicz SA. Endoscopic lysis of anterior glottic webs and silicone keel placement. Ann Otol Rhinol Laryngol 2007;116:211-6.
14. Benmansour N, Remacle M, Matar N, Lawson G, Bachy V, Van Der Vorst S. Endoscopic treatment of anterior glottic webs according to Lichtenberger technique and results on 18 patients. Eur Arch Otorhinolaryngol 2012;269:2075-80. 15. Cheng AT, Beckenham EJ. Congenital anterior glottic webs with subglottic stenosis: surgery using perichondrial keels. Int J Pediatr Otorhinolaryngol 2009;73:945-9.
16. Unal M. The successful management of congenital laryngeal web with endoscopic lysis and topical mitomycin-C. Int J Pediatr Otorhinolaryngol 2004;68:231-5.
17. Su CY, Alswiahb JN, Hwang CF, Hsu CM, Wu PY, Huang HH. Endoscopic laser anterior commissurotomy for anterior glottic web: one-stage procedure. Ann Otol Rhinol Laryngol 2010;119:297-303. 18. Lichtenberger G, Toohill RJ. The endo-extralaryngeal needle carrier. Otolaryngol Head Neck Surg 1991;105:755-6. 19. Lichtenberger G, Toohill RJ. New keel fixing technique for endoscopic repair of anterior commissure webs. Laryngoscope 1994;104:771-4.
20. Falk RJ, Gross WL, Guillevin L, et al. Granulomatosis with polyangiitis (Wegener’s): an alternative name for Wege ner’s granulomatosis. Ann Rheum Dis 2011;70:704.
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Endoscopic Keel Placement to Treat and Prevent Anterior Glottic Webs Randal C. Paniello, MD; Shaun C. Desai, MD; Clint T. Allen, MD; Siddarth M. Khosla, MD We performed a retrospective chart review to examine and describe our clinical experience of use of the Lichtenberger technique to place silicone elastomer keels after lysis of existing webs or for prevention of webs following anterior commissure surgery in adults. Twenty-two patients were identified for inclusion, ranging in age from 24 to 80 years. For 18 patients with existing glottic webs, the surgical procedure involved laryngoscopy with complete lysis of the anterior glottic web by laser or sharp technique, followed by placement of a square of silicone elastomer that is sutured in place with the Lichtenberger needle holder and left in place for 3 to 5 weeks. The procedure was well tolerated, and successfully corrected the web in all but 2 cases. For 4 patients, the procedure was performed prophylactically at the time of anterior commissure surgery considered high-risk for web formation. The procedure does not require a tracheotomy, and patients can maintain a normal diet and have functional phonation while the keel is in place. This approach to treating anterior glottic webs offers several advantages over traditional open thyrotomy with keel placement and should be considered to treat or prevent anterior glottic webs. Key Words: endoscopy, keel, larynx, surgery, web.
web via a cold approach (eg, sickle knife or micro scissors) or a carbon dioxide (CO2) laser approach, followed by open thyrotomy with placement of a keel to prevent approximation of the raw surfaces and re-formation of the web.6
Introduction
Anterior glottic webs can be classified as congenital or acquired. In adults, acquired webs are most commonly due to trauma, infection, laryngopharyngeal reflux, or a prior surgical procedure (eg, resection of laryngeal cancer).1 Laryngeal webs may range in size from a small anterior lesion comprising less than one third of the membranous fold to a complete glottic web with possible extension superiorly or inferiorly to the supraglottis or subglottis. Benjamin2 and Cohen3 established classification systems for glottic webs that were intended primarily for use in describing congenital lesions. Koltai and Mouzakes4 described a staging system for acquired lesions in adults based on the percentage of vocal fold length involved in the web.
Several authors have reported making improvements on the original McNaught keel approach by using totally endoscopic approaches. Dedo7 reported endoscopic placement of a Teflon keel. Others have used a silicone elastomer sheet, folded and fixed at the anterior commissure and usually without a tracheotomy.8-14 The stent in these cases no longer resembles the keel of a boat, but the term “keel” has stuck. The use of soft tissue such as perichondrium to form a keel has also been reported.15 The goal of these procedures is the same: to place a foreign body between the raw surfaces of the freshly divided web edges and leave it in place long enough that the edges do not scar back together and re-form the web. Alternative approaches have been proposed to reduce the risk of web recurrence, such as the use of mitomycin-C,16 or leaving a 3- to 5- mm “alley” between the anterior vocal folds, as reported by Su et al.17
Symptoms of acquired laryngeal webs range from minor voice changes to acute respiratory distress, depending on the degree of obstruction.5 Diagnosis of acquired webs involves direct or fiberoptic laryngoscopy to fully evaluate the extent of web involvement. The goal of therapy is airway management, followed secondarily by voice rehabilitation.5 Traditionally, the surgical approach involves lysis of the
From the Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri (Paniello, Desai, Allen), and the Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio (Khosla). Presented at the meeting of the American Laryngological Association, Chicago, Illinois, April 27-28, 2011. Correspondence: Randal C. Paniello, MD, Dept of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, 660 S Euclid Ave, CB 8115, St Louis, MO 63110.
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A
B
C
D
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Fig 1. (Patient 11) Intraoperative views through laryngoscope. A) Fifty-percent web and granulation along right vocal fold caused dysphonia and moderate airway obstruction. B) Division of web with microlaryngeal scissors. C) Immediately after lysis of web. D) Keel in place. E) Immediately after removal of keel at 5 weeks. Voice and airway were both markedly improved.
E Anterior commissure lesions that require surgery are often treated in two stages, in which the first side is allowed to heal and mucosalize before the second side is treated, in order to prevent web formation. Such “high-risk” lesions could be treated simultaneously with placement of a prophylactic keel, but this approach has not been reported. The present study introduces this concept with the inclusion of 4 such cases.
In 1991, Lichtenberger and Toohill18 introduced a new instrument designed for passing sutures from the endolarynx to the anterior neck, called the “endo-extralaryngeal needle carrier.” They subsequently reported a small series of anterior glottic webs
that were divided endoscopically, then stented with a silicone elastomer sheet placed with the aid of this instrument.19 We have found this procedure to be the simplest and most effective method for placing anterior glottic keels. We report herein our clinical experience and results with this technique. Materials and Methods
Institutional Review Board approval for chart review was obtained, and patients who had undergone this procedure were identified. Patient demographics, the cause of the web, and the result of the procedure, including any complications, were tabulated. We considered a web to involve 100% of the vo-
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A
B
C
D
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Fig 2. (Patient 9) Intraoperative views of keel procedure. A) Twocentimeter square of thin silicone elastomer sheet is weaved in midline with 2-0 Prolene suture. B) Suture is loaded onto endoextralaryngeal needle carrier. C) First suture is positioned at cricothyroid membrane and passed through skin. D) Both sutures in position. Tension allows keel to be positioned at anterior commissure. E) Sutures are tied down over sterile button.
E cal fold length if it extended posteriorly to the vocal process or beyond. Our surgical procedure is similar to that reported by Lichtenberger and Toohill.18 The patient is placed in the supine position on the operating room table, and general anesthesia is administered via a small-caliber endotracheal tube. Microlaryngoscopy is performed, and the laryngeal web is divided in the midline to the inner perichondrium of the anterior commissure (Fig 1A-C) by a cold technique (microlaryngeal scissors or sickle knife) or with a microspot CO2 laser. A vocal fold spreader is used to help divide the web to the anterior commissure perichondrium.
The keel is fashioned from a 2 × 2-cm square of a 0.020-inch (0.5-mm) silicone elastomer sheet; these dimensions are adjusted for an unusually small or large larynx. A 2-0 Prolene suture is weaved through the midline of the square in a series of small perforations that enables the sheet to fold along this line (Fig 2A). The suture is loaded into the special needle used for the Lichtenberger endo-extralaryngeal needle carrier (Fig 2B). This instrument is positioned through the laryngoscope (Fig 2C) so that the needle tip is below the true vocal folds, in the midline, just above the cricoid cartilage. The needle driver is used to advance the needle through the cricothyroid membrane and prepared skin to a sterile assistant, who retrieves it. The opposite end of the suture is
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Table 1. demographics and operative details of patients with Keel placed with lysis of web
Pt Age No. Gender (y) Cause of Web
Glottis Involved
Tracheotomy
Recurrence
1 M 30 Multiple papilloma surgeries 33% No No 2 F 62 Laryngeal cancer and open 33% No No hemilaryngectomy 3 M 45 Laryngeal cancer and open 50% No No hemilaryngectomy 4 M 48 Multiple papilloma surgeries 33% No No 5 F 24 Trauma, history of tracheotomy 100% No No 6 M 74 Laryngeal cancer and CO2 laser 33% No Yes resection 7 M 39 Trauma, history of tracheotomy and 100% * No subglottic stenosis 8 F 41 Laryngopharyngeal reflux 50% No No 9 M 71 Bilateral saccular cysts 33%† No No 10 F 65 Previous thyroplasty, reaction to implant 33% No No 11 F 25 Intubation trauma 50% No No 12 M 27 Anterior true vocal fold polyp surgery 33% No No M 60 Laryngeal cancer and open bilateral 33%† No No 13 cordectomy 14 F 45 Laryngeal cancer and CO2 laser 50% No No resection 15 F 33 Granulomatosis with polyangiitis 100% No No 16 F 33 Granulomatosis with polyangiitis 100% * Yes 17 M 80 Multiple papilloma surgeries 30% No No M 68 Multiple papilloma surgeries 100% * No 18
Complications
Anterior commissure granuloma (3 mo later) Early extrusion Early extrusion
Needle tract infection
*Tracheotomy was already present at time of procedure. †Web involved false vocal folds.
loaded onto another needle in a similar fashion and loaded into the endo-extralaryngeal needle carrier, and the laryngoscope is backed up a few millimeters to allow access to the epiglottic petiole. The instrument tip is placed in the midline, against the petiole, about 8 to 10 mm superior to the anterior commissure, and the needle is advanced through the thyroid notch and the prelaryngeal neck skin (Fig 2D), at which point it is retrieved in a similar way by the assistant. Tension placed on the sutures by the assistant allows for proper placement of the keel, which is guided into position endoscopically (Fig 1D). Once the keel is tugged up into the anterior commissure to separate the raw laryngeal surfaces, the suture is tied over a sterile button, which is either buried subcutaneously or left external (over a small piece of Telfa; Fig 2E), according to the patient’s preference. Patients are prescribed a proton pump inhibitor for reflux prophylaxis, and an antibiotic if the button is buried. Tracheotomy is not required. The keel is removed 3 to 5 weeks later (Fig 1E). If the button is buried in a subcutaneous pocket, the patient is returned to the operating room and the keel is removed by direct laryngoscopy with opening and re-closure of the subcutaneous pocket. If the button
is left external, the keel may be removed in the operating room — or, optionally, in the office, under topical anesthesia — by grasping it with transoral forceps or with biopsy forceps through the working channel of an endoscope. Results
Twenty-two patients who had undergone endoscopic keel placement since 1997 were identified for the study. The patients’ ages at the time of the procedure ranged from 24 to 80 years (Table 1). There were 12 men and 10 women. The most common causes of the anterior webs were surgeries for laryngeal cancer (6 patients), surgeries for laryngeal papillomatosis (5), surgeries for large laryngeal polyps (3), trauma (2), and granulomatosis with polyangi itis20 (2); other causes are listed in Table 1. Eighteen procedures were performed as treatment for an existing web, and 4 procedures were performed as prophylaxis at the time of anterior commissure surgery that was considered high-risk for web formation. Results are reported with a minimum of 3 months of follow-up. Existing Web Group. In this group, 2 of the 18 patients had web recurrences. In the first case, the
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Paniello et al, Endoscopic Keel Placement Table 2. demographics and operative details of patients with Keel placed prophylactically at time of anterior commissure surgery
Pt No. Gender Age (y) Indication Tracheotomy
19 20 21 22
M F F M
56 56 45 49
Bilateral large anterior true vocal fold polyps Bilateral large anterior true vocal fold polyps Laryngeal cancer and CO2 laser resection Recurrent papilloma excision
suture ruptured 2 days after the procedure, and the raw vocal fold surfaces had not yet healed. The patient declined replacement of the keel, and the web re-formed, although it was smaller than it was originally. Ultimately, the patient was satisfied with his voice and declined further intervention. The second case was that of a patient with severe granulomatosis with polyangiitis who had previously demonstrated a severe fibrotic reaction to any endolaryngeal procedure, despite high-dose perioperative steroid management. All remaining patients had complete resolution of their anterior glottic web (16 of 18, or 89%).
Four patients experienced complications. Two patients had early spontaneous extrusion of the keel; in both cases, it was found that the supporting suture had ruptured. One of these patients had a recurrence of the web (as detailed above). In these early cases, a smaller-caliber suture was used (3-0), and it was tied down fairly tightly. After these two ruptures, we switched to 2-0 sutures and left the suture tied with just a little “play” in it to reduce the tension from laryngeal motion during swallowing. Since we made these changes, there have been no further suture ruptures. Another patient with known laryngopharyngeal reflux disease developed a postoperative granuloma 3 months after the keel was removed; the granuloma was eventually removed with a CO2 laser. One patient had a needle tract infection, as evidenced by a small amount of purulent drainage along the suture beneath his external button. This responded quickly to a course of broad-spectrum antibiotics, without sequelae. None of the patients required a tracheotomy. Three of the patients already had a tracheotomy in place for airway management because of additional subglottic disease and/or other previous laryngeal surgery; these were left in place. None of the patients experienced intraoperative or postoperative airway obstruction. Web Prophylaxis Group. The 4 patients in this group had lesions that were expected to place them at high risk for the development of an anterior web following surgery (Table 2). Two had very large anterior polyps, 1 had multiply recurrent laryngeal
Web Prevented
No Yes No Yes No No No Yes
Complications
Thin keel migrated inferiorly
papilloma at the anterior commissure, and 1 had a T1b glottic carcinoma involving the entire length of both membranous vocal folds. The keel placement was performed in the same manner as for the existing webs, after the removal of their bilateral anterior lesions except in the case of patient 22 (see below). Patient 21 in this series, a smoker with a chronic cough, had a small larynx with a narrower-thanaverage lumen, and we attempted to use a thinner silicone elastomer sheet (0.005 inch, or 0.127 mm) in order to increase her airway. At the time of keel removal, it was found that the thin silicone elastomer sheet had migrated inferiorly and was no longer positioned between the vocal folds; instead, an anterior web had formed. It was hypothesized that the combination of thin material and frequent forceful coughing led to this migration. The web was lysed and a new 0.020-inch (0.5-mm) keel was placed with successful resolution. This patient was thus also included in the existing web group (as patient 14). Patient 22 presented with a limited time frame for treatment, as he was scheduled for active military deployment only 1 month after his visit. He had significant papilloma present at the anterior commissure and needed to produce a loud voice when he arrived at his duty station. In this case, we elected to treat both sides simultaneously and place a keel, but the sutures were placed “outside-in” by means of angiocatheters placed percutaneously (similar to the approach of Koltai and Mouzakes4). This choice avoided potentially seeding papilloma in the soft tissue of the neck along an “inside-out” needle tract. Discussion
The original McNaught keel procedure was, at the time (1950), a major advance in the treatment of anterior glottic webs and quickly became the standard of care. However, it required an open thyrotomy for placement of the keel, as well as a tracheotomy; and removal of the keel often required a second open procedure.6 Since 1950, improvements in instrumentation and technology have led to the development of a fully endoscopic approach. Dedo7 was the first to describe an endoscopic approach in which a triangular Teflon keel was fixed with 26-gauge
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stainless steel wire. This wire was placed by the use of straight needles passed through the skin and the cricothyroid and thyrohyoid membranes and then retrieved endoscopically. In our experience, it is less cumbersome to use an internal-to-external approach, rather than the reverse, and our approach allows for more precise placement of the keel. Lichtenberger and Toohill18 noted that the outside-in approach is associated with a higher incidence of needle tract infection. Only 1 of our patients exhibited evidence of an infection following the endoscopic keel procedure. Several other authors have used a silicone elastomer sheet placed endoscopically to prevent recurrence of the web, and their success rates are comparable to ours.8-14 Our report adds to the experience published by Lichtenberger and Toohill18,19 in using the special endo-extralaryngeal needle carrier, which is ideally suited for this procedure. We note that 8 of their 13 patients (62%) had postoperative webs of 10% to 20%,19 whereas 16 of 18 patients (89%) in our series had no residual web after keel removal. Our method may result in a more complete division of the web, as the cut is carried anteriorly to the inner perichondrium of the anterior commissure; this cut is aided significantly by use of the vocal fold spreader instrument. To our knowledge, the placement of a keel prophylactically for web prevention has not been previously reported. When the keel is removed in the office, there may be concern that it could slip below the vocal folds, out of reach of the forceps, and possibly cause an airway obstruction. This has not occurred in any of our patients. The silicone elastomer sheet normally collects a layer of mucus that causes it to stick to the epiglottis and anterior false and true vocal folds, so that even with the anchoring suture divided it does not slip inferiorly. There were 2 cases in this series in which the keel, with its suture released, slipped from the grasp of the forceps and was potentially free to fall into the trachea. Each time, the patient simply worked the keel forward into the mouth and spit it out. Even if the keel were to fall into the trachea, we believe it would not cause an airway obstruction and would be easy to retrieve by bronchoscopy. The presence of the keel is well tolerated by patients. Initially, the patient may have a sense of a foreign body in the larynx or globus sensation, but this
quickly dissipates. The patients are able to swallow a normal diet without aspiration (provided that the vocal folds are mobile), and many have a surprisingly good voice — not normal, but very functional — during the few weeks that the keel is in place.
Our experience with this procedure has led us to be more aggressive with benign lesions of the anterior commissure. When assessing the risk of web formation against that of leaving residual disease behind, we now consider the risk of web formation to be less of a problem, because it is fairly easy to correct, as evidenced by this series of patients. The procedure can also be used prophylactically, as demonstrated in patients 19 through 22 (Table 2), and thus may reduce the need for multiple operations in cases of bilateral disease. We do not use this approach for patients with active laryngeal papillomatosis, however, given the concern about seeding live papillomavirus into the soft tissues of the neck in the prelaryngeal region by passing the needle from the inside out. The patients in this series who had existing webs from prior papilloma surgery had all been free of disease for at least 2 years before this approach was offered to them (except for patient 22). This series also demonstrates the versatility of this approach. Two of the patients had lesions at the level of the false vocal folds; the procedure required no special adjustment to handle this situation. Two of the patients had had a prior hemilaryngectomy for carcinoma; the keel was used to prevent recurrent webbing when the reconstructed hemilarynx was released from the remaining good vocal fold. There may be many other potential applications not listed here, limited only by the surgeon’s imagination. Conclusions
The described method of endoscopic lysis of anterior glottic webs and keel placement is simple to perform, is well tolerated by patients, and offers a low rate of web recurrence. The endo-extralaryngeal needle carrier used by Lichtenberger and Toohill18,19 is ideally suited to streamlining this procedure. A tracheotomy is not required, and often the keel may be removed in the office. A new option for prophylactic keel placement in high-risk cases is described. These procedures should be considered in all patients with symptomatic anterior glottic webs or with surgical conditions involving the anterior commissure.
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