Supraglottoplasty in a 39-year-old woman.
On physical examination, the patient was found to have oral thrush. Her voice was severely hoarse and rough. She was tachypneic, but she had no stridor and was not in acute distress. Stroboscopy revealed pachydermia laryngitis with severe tissue redundancy that prevented vocal fold visualization (figure 1). The redundancy was much worse on the left, and the tissue in the arytenoids region prolapsed into the glottis. The larynx was diffusely erythematous and edematous, with thick secretions and severe posterior "cobble-stoning." There was blunting of the anterior commissure, diffuse laryngeal thrush, and severe Reinke edema. Supraglottic hyperfunction, characterized by decreased anterior-posterior distance, was also present.
The patient was started on a proton-pump inhibitor twice daily, nightly ranitidine, a 3-week course of oral antifungal medication, and prednisone 60 mg daily for 1 week followed by a taper. At the 2-week follow-up, the patient reported improved symptoms; however, repeat stroboscopy exhibited persistent, severe redundancy of the posterior arytenoid tissue.
Supraglottoplasty was performed with a CO, laser to excise the excess mucosa. Redundant mucosa was removed from the post-cricoid area and the arytenoids bilaterally. Gross pathologic evaluation revealed 1.3 x 1.2 x 0.6 cm of soft, pink, mucosal tissue with an underlying firm, tan, white nodule on the right and a 1.6 x 1.1 x 0.4-cm soft, pink, mucosal tissue specimen on the left. Microscopic examination revealed focal chondroid metaplasia on the right and squamous mucosa with congestion, mild edema, and focal keratosis bilaterally.
Improvement in the patient's voice was noted in the months after the procedure. The posterior glottic tissue no longer prolapsed into the glottis, but there was continued mucosal thickening and inflammation. The patient was instructed to continue her antireflux medications and to undergo a sleep study. Unfortunately, she was lost to follow-up.
Three years later, the patient presented with a complaint of continued hoarseness. She had a severely hoarse voice with an abnormally low pitch.
On stroboscopy, the posterior glottic tissue no longer prolapsed into the airway, but there was persistent pachydermia laryngitis, Reinke edema, and mucosal redundancy (figure 2). It was reiterated to the patient that she should undergo a sleep study, a 24-hour pH impedance study, and esophageal manometry. She was instructed to continue her antireflux medications, have a refresher course of voice therapy, and follow up as directed. Smoking cessation was also strongly recommended.
Historically, the supraglottoplasty has been used primarily for the treatment of laryngomalacia in the pediatric population and has been indicated less often in the adult population. In 1985, use of the C[O.sub.2] laser in supraglottoplasty was first described by Seid et al. (1) In our experience, it has worked well for adult supraglottoplasty.
In the literature, the utilization of supraglottoplasty in adults is nearly nonexistent, with one case report profiling the use of supraglottoplasty to treat laryngomalacia in adulthood. (2) and another using the C[O.sub.2] laser for supraglottoplasty in a case similar to the one reported here. (3) The findings in our patient were amenable to supraglottoplasty with a C[O.sub.2] laser, which relieved her symptoms. This procedure should be considered in any patient with persistent, obstructing tissue redundancy.
Hilary M. Caruso Sales, DO; Amanda Hu, MD, FRCSC; Robert T. Sataloff, MD, DMA, FACS
From the Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine (Dr. Sales); and the Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine (Dr. Hu and Dr. Sataloff), Philadelphia.
(1.) Seid AB, Park SM, Kearns MJ, Gugenheim S. Laser division of the aryepiglottic folds for severe laryngomalacia. Int J Pediatr Otorhinolaryngol 1985;10(2):153-8.
(2.) Gessler EM, Simko EJ, Greinwald JH Jr. Adult laryngomalacia: An uncommon clinical entity. Am J Otolaryngol 2002;23(6):386-9.
(3.) Jamal N, Chowdhury F, Gupta R, Sataloff RT. Supraglottoplasty for airway obstruction. Ear Nose Throat J 2013;92(6):244, 246.
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|Title Annotation:||LARYNGOSCOPIC CLINIC|
|Author:||Sales, Hilary M. Caruso; Hu, Amanda; Sataloff, Robert T.|
|Publication:||Ear, Nose and Throat Journal|
|Article Type:||Clinical report|
|Date:||Aug 1, 2015|
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