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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4634_Библиотеки_им_академика_М_И_Перельмана
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9 Blue Laser Therapy ofLaryngeal Stenosis
fold and subglottic area (Fig.9.1). The web was
inltrated with xylocaine and epinephrine on the
left side. Incision was made with Sataloff microknife, and a portion of web epithelium was preserved. Blue laser was used to resect the web
submucosally (Fig. 9.2). An epithelial ap was
preserved on the right and the left. Both arytenoids' cartilages were palpated. The left arytenoid
was mobilized using 28 Jackson dilators and the
left cricoarytenoid joint was injected with dexa-
methasone. The right thyroarytenoid muscle was
injected with Botulinum Toxin A. 4-0 chromic
suture was placed medial to lateral through the
body of the arytenoid cartilage and it was then
passed from lateral to medial through avulsed
vocal process and adjacent muscles to repair the
vocal process avulsion (Fig. 9.3, Video 9.1). A
total 1032 J were used. 6 months after surgery,
there was with no web recurrence and right vocal
fold tension remained good (Fig.9.4).
Fig. 9.1 Intraoperative microscopic view showing anterior web with subglottic component
Fig. 9.2 Intraoperative microscopic view showing blue
laser using to resect anterior vocal fold web. (Video 9.1
Video showing web resection using blue laser)
(▶ https://doi.org/10.1007/000- any)
Fig. 9.3 Intraoperative microscopic view showing complete vocal fold web resection
Fig. 9.4 Laryngeal examination showing no web recurrence 6 months after the surgery
9.2 Case Presentations
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9.2.2 Case 2: Posterior Supraglottic
Stenosis
A 56-year-old female had laryngeal posterior
supraglottic and subglottic stenosis due to prolonged intubation. She still had laryngeal stenosis despite having had multiple surgical
procedures and still was dependent on tracheotomy. Laryngeal examination demonstrated
posterior and subglottic stenosis narrowing to
about 50% of airway. In the operating room, a
Sataloff medium female laryngoscope
achieved good visualization. The airway was
narrow, and intubation was performed through
the tracheotomy tube. There was a firm fibrotic
of posterior laryngeal stenosis (Fig.9.5). Blue
laser was used to create a releasing incision
posteriorly (Fig.9.6). Laryngotracheal stenosis was then managed using Jackson dilators
and 26 to 42 5-FU with Triamcinolone was
injected into the area of stenosis (Fig. 9.7,
Video 9.2). A total 163J were used. Her laryngeal examination 6 months after the surgery
demonstrated substantial anatomical improvement (Fig.9.8).
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Fig. 9.6 Intraoperative microscopic view showing blue
laser using to create a posterior releasing incision
Fig. 9.5 Intraoperative microscopic view showing supraglottic posterior laryngeal stenosis. (Video 9.2 Video
showing a posterior releasing incision done by blue laser.
Jackson dilators were used to dilate the laryngeal stenosis)
(▶ https://doi.org/10.1007/000- anw)
Fig. 9.7 Intraoperative microscopic view showing posterior laryngeal stenosis
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9 Blue Laser Therapy ofLaryngeal Stenosis
Fig. 9.8 Endoscopic view showing substantial anatomical improvement 6 months after the surgery
9.2.3 Case 3: Posterior Glottic Scar
A 56-year-old female with chronic obstructive
pulmonary disease, anemia, and DM presented
with stridor and shortness of breath (SOB) following prolonged intubation due to COVID-19
complications months before we saw her. She
had a tracheotomy but had self-decannulated two
months after placement. She still had mild SOB
after decannulation. CT of the neck without contrast demonstrated soft tissue between the arytenoid cartilage represented scar and caused mild
narrowing. Laryngoscopy revealed vocal fold
hypomobility in abduction, muscle tension dysphonia, LPR, bilateral uctuating paresis,
Reinke's edema, and limited vocal fold abduction
bilaterally due to posterior glottic scar. General
anesthesia was administered via jet ventilation.
High oxygen level should be avoided as much as
possible if a laser is used and FiO2 must be 30%
or less during laser use. The jet ventilation catheter usually is removed during laser use and
replaced to optimize ventilation and surgical
exposure. If it is left in place, ventilation is
Fig. 9.9 Intraoperative microscopic view showing posterior laryngeal stenosis
stopped while the laser is in use, and restarted if
oxygen saturation drops. Suspension microlaryngoscopy using a Sataloff Vallecula laryngoscope
showed redundant soft tissue in the posterior
glottis compromising airway patency (Fig.9.9).
Jackson dilator was used to enlarge the airway
from a 28 to a 42 dilator. There was still a palpable dense scar to the right to midline. It was
vaporized using the blue laser in cutting mode at
10W 60 ms pulse duration time, 150 ms pulse
pause. The scar band was released well
(Fig. 9.10). The intraarytenoid area where the
posterior glottic stenosis had been released was
then injected with mixture made of 4.5ml of 5
FU (50 mg/ml) and 0.5ml of triamcinolone (40
mg/ml) (Fig. 9.11). Usually, deep extubation is
followed by emersion using a mask or laryngeal
mask ventilation. However, the patient can be
intubated after jet ventilation has been completed, if necessary. Patient did not show up for
6-month follow-up. However, her laryngeal
examination 2 months after the surgery demonstrated substantial anatomical improvement
(Fig.9.12).
9.2 Case Presentations
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Fig. 9.12 Laryngeal examination showing substantial
anatomical improvement 2 months after the surgery
9.2.4 Case 4: Anterior Laryngeal
Vocal Fold Web
Fig. 9.10 Intraoperative view showing blue laser using to
vaporize the posterior laryngeal scar
Fig. 9.11 Intraoperative microscopic view showing complete posterior laryngeal scar vaporizing
A 49-year-old male with LPR presented to clinic
with dysphonia. The laryngeal examination
demonstrated anterior laryngeal vocal fold scar
web bilaterally and bilateral brotic mass. The
web was thick and acted as vocal fold separator
causing a gap, as well voice strain from
increased compensatory muscle effort. In the
operating room, a Sataloff medium female
medium laryngoscope provided good visualization. Ectasis and varicosities on the superior
faces of both true vocal folds were vaporized
with blue laser. There was a thick, anterior web
that extended inferiorly extensively and
restricted the movement of the vocal folds
(Fig. 9.13). The web was vaporized with blue
laser (Fig.9.14). There was also a small brotic
mass in the anterior portion of the right vocal
fold that was vaporized with blue laser. A total
292J were used.
5 FU with triamcinolone was injected in the
area of scar. The conclusion of the surgery shows
smooth edges, no web, and good vocal fold separation (Fig.9.15, Video 9.3).
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Fig. 9.13 Intraoperative view showing subglottic web
9 Blue Laser Therapy ofLaryngeal Stenosis
Fig. 9.15 Intraoperative view showing complete web
vaporizing
Fig. 9.14 Intraoperative view showing web vaporization
using blue laser. (Video 9.3 Video showing web vaporization using blue laser) (▶ https://doi.org/10.1007/000- anx)
The patient was re-evaluated 6-monthslater
and there was no web recurrence (Fig.9.16).
9.2.5 Case 5: Subglottic Stenosis
A 39-year-old female presented with chronic
cough and shortness of breath that had persisted
for 8 years despite using LPR treatment and bronchial inhalers. Pulmonary function testing demonstrated a at inspiratory loop. CT of the neck
showed moderate narrowing 2cm below the level
of the vocal folds. The airway was narrowed 50%,
Fig. 9.16 Intraoperative view showing no web recurrence 6 months after the surgery
and the stenosis extended over a length of 3mm.
Laryngoscopy conrmed grade 2 subglottic stenosis (Fig. 9.17). In the operation room, a Sataloff
vallecula laryngoscope was positioned, and visualization was good with anterior retraction
(Fig.9.18).
The airway was narrow, and the procedure
was performed using jet ventilation. The catheter
was removed while surgery was being performed
and replaced intermittently when oxygen saturation decreased.
9.2 Case Presentations
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Fig. 9.17 Endoscopic view showing grade 2 subglottic
stenosis
Fig. 9.18 Intraoperative view of the subglottic stenosis
Fig. 9.19 Intraoperative view showing subglottic steno-
sis vaporizing using blue laser
Fig. 9.20 Intraoperative surgical view showing complete
subglottic stenosis vaporization
The anterior portion of stenosis was rm but
eshy. It was grasped with forceps and resected
near its base using blue laser (Fig.9.19). Using
blue laser, vaporization continued until patency
of the airway was achieved. A total 624 J were
used. Dexamethasone was injected into the areas
of stenosis. Jackson dilators were placed carefully between the vocal folds, and the area of subglottic stenosis was dilated to a size 40 (Fig.9.20).
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Fig. 9.21 Laryngeal examination showing substantial
anatomic improvement 6 months after the surgery
The patient was re-evaluated 6 months after
the surgery. She had maintained substantial anatomic improvement and remained asymptomatic
(Fig.9.21).
9 Blue Laser Therapy ofLaryngeal Stenosis
Fig. 9.22 Intraoperative view using zero-degree laryngeal telescope showing internal stenosis anteriorly at the
level of tracheotomy stoma. (Video 9.4 Video demonstrating resection brosis around the tracheotomy stoma)
(▶ https://doi.org/10.1007/000- anv)
9.2.6 Case 6: Tracheotomy Stoma
Stenosis
A 39-year-old male with diabetes and laryngeal
stenosis due to prolonged intubation had required
tracheotomy. He had multiple surgical procedures. However, he was still dependent on the
tracheotomy.
In the operating room, there was stenosis anteriorly at the level of the tracheotomy stoma seen
through a bronchoscope that had been passed
through the suspended laryngoscope (Fig.9.22).
Blue laser at 10 W, 60 ms pulse duration, 150
ms pulse pause was used through a bronchoscope
working channel to resect and vaporize the brosis around the stoma (Fig. 9.23). A total 440 J
were used.
Final surgical view demonstrated complete
resection of stoma brotic segment that had
caused stenosis (Fig.9.24, Video 9.4).
Due to his aggressive pattern of recurrent
laryngeal stenosis, the patient required several
Fig. 9.23 Intraoperative view using zero-degree laryngeal telescope showing brosis was vaporized with blue
laser
more laryngeal procedures. However, tracheotomy tube was removed and he remained decannulated and breathing well months after his last
procedure (Fig.9.25).
9.2 Case Presentations
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Fig. 9.24 Intraoperative view using zero-degree laryngeal telescope showing complete brosis vaporization
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Fig. 9.26 Intraoperative view showing posterior supraglottic and subglottic stenosis
Fig 9.25 Laryngeal examination showing substantial
anatomic improvement
9.2.7 Case 7: Subglottic
andPosterior Glottic Stenosis
A 70-year-old female with subglottic and posterior glottic stenosis due to prolonged intubation.
She was still dependent on tracheostomy despite
having multiple laryngeal procedures.
Fig. 9.27 Intraoperative view showing the use of blue
laser to vaporize the laryngeal stenosis
In the operating room, the laryngeal exam
demonstrated dense brotic tissue in the posterior laryngeal area (Fig.9.26).
Trying to dilate the stenotic area with Jackson
dilator revealed substantial resistance even to a
size 24.
Blue laser was used to remove the dense
brotic tissue in the left posterior laryngeal area
(Figs.9.27, 9.28, and 9.29). A total 947J were
used.
The scar area was injected with mixture of 5
uorouracil with triamcinolone.
The airway improved after the surgery.
However, she was still dependent on a tracheotomy (Fig.9.30).
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Fig. 9.28 Intraoperative view showing the use of blue
laser to vaporize the laryngeal stenosis
9 Blue Laser Therapy ofLaryngeal Stenosis
Fig. 9.30 Endoscopic view showing substantial anatomic improvement 6 months after the surgery
Fig. 9.29 Intraoperative view showing the use of blue
laser to vaporize the laryngeal stenosis
9.2.8 Case 8: Subglottic Stenosis
A 57-year-old man had subglottic stenosis characterized by anterior subglottic polypoid inammatory changes secondary to a prolonged
intubation. The patient underwent in-ofce blue
laser treatment of subglottic stenosis (Figs.9.31
and 9.32, Video 9.5). He was lost to follow-up
after treatment.
Fig. 9.31 Still image taken during beginning of in-ofce
blue laser vaporization of subglottic polypoid inammation related to prolonged intubation. (Video 9.5 Surgical
video showing in-ofce blue laser treatment of subglottic
stenosis caused by anterior subglottic fullness with polypoid changes. Local anesthesia was applied with topical
4% lidocaine. A blue laser ber was used through the
working channel of a exible laryngoscope at a setting of
6W with 60 ms pulse duration and 150 ms pulse pause)
(▶ https://doi.org/10.1007/000- anz)
9.2.9 Case 9: Anterior Glottic Web
A 51-year-old retired army colonel presented
with a chief complaint of dysphonia related to his
known history of laryngeal papillomatosis. He
9.2 Case Presentations
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Fig. 9.32 Still image taken immediately after in-ofce
blue laser vaporization of subglottic stenosis. Treatment
focused on the most proximal aspect of the subglottis and
approached the inferior surface of the anterior true vocal
folds. Settings were 6 W, 60 ms pulse duration, and 150
ms pulse pause
Fig. 9.33 Intraoperative, pre-treatment still image of
anterior glottic web occupying one-third of the length of
the musculomembranous vocal fold
Fig. 9.34 Intraoperative, still image after right half of
anterior glottic web resected with blue laser in contact and
non-contact modes of 10 W, 60 ms pulse duration, 150 ms
pulse pause
Fig. 9.35 Intraoperative, still image after complete
resection of anterior glottic web using blue laser. Note that
there is relatively little char or evidence of thermal injury.
This differs from the appearance when CO2 laser had been
used in a similar fashion, although the surgery takes
slightly longer with the blue laser than with CO
2
had undergone several debulking procedures
with intralesional cidofovir at an outside institution. On laryngeal examination he was found to
have true vocal fold papillomatosis as well as an
anterior glottic web spanning approximately onethird of the anterior–posterior distance of the
glottis. He was taken to the operating room for
microdirect laryngoscopy, excision of papillomas
with intralesional cidofovir and resection of anterior glottic web with blue laser. Blue laser resection of anterior glottic web shown below
(Figs. 9.33, 9.34, and 9.35, Video 9.6). Patient
showed complete regression of anterior glottic
web 3 months after surgery (Fig.9.36).
Fig. 9.36 Videostroboscopic still image 3 months after
surgery showing complete regression of anterior glottic
web. (Video 9.6 Surgical video showing blue laser resection of an anterior glottic web spanning approximately
one-third of the musculomembranous vocal fold.
Additional laryngeal papilloma was uncovered as the web
was resected, but the video is focused on treatment of the
web. The blue laser was used in both contact and noncontact modes) (▶ https://doi.org/10.1007/000- ap0)
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