|Year : 2018 | Volume
| Issue : 1 | Page : 24-28
Endoscopic phonomicrosurgery of an anterior commissure polyp using McCoy laryngoscope in a patient with difficult laryngeal exposure
Sandeep Singh Sindhu, Suresh Singh Naruka, Ayush Chawla
Department of ENT, Indraprastha Apollo Hospital, New Delhi, India
|Date of Web Publication||8-May-2019|
Dr. Ayush Chawla
8/20, First Floor, West Patel Nagar, New Delhi - 110 008
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Phonomicrosurgery for benign vocal cord lesions is a common surgical procedure with an excellent phonetic outcome. Adequate laryngeal exposure is essential for complete and precise excision of vocal cord lesions. Anterior commissure is a site which can sometimes pose a challenge of exposure and difficulty in access. Various anatomical and physiological factors can lead to difficulty in the exposure of larynx. There are different scoring systems and parameters to preoperatively predict a case of difficult laryngeal exposure (DLE). However, management options for such cases remain limited. Here, we present such a case which was managed using McCoy intubating laryngoscope and modified microlaryngeal instruments.
Keywords: Difficult laryngeal exposure, McCoy laryngoscope, phonomicrosurgery
|How to cite this article:|
Sindhu SS, Naruka SS, Chawla A. Endoscopic phonomicrosurgery of an anterior commissure polyp using McCoy laryngoscope in a patient with difficult laryngeal exposure. J Laryngol Voice 2018;8:24-8
|How to cite this URL:|
Sindhu SS, Naruka SS, Chawla A. Endoscopic phonomicrosurgery of an anterior commissure polyp using McCoy laryngoscope in a patient with difficult laryngeal exposure. J Laryngol Voice [serial online] 2018 [cited 2019 Jul 19];8:24-8. Available from: http://www.laryngologyandvoice.org/text.asp?2018/8/1/24/257805
| Introduction|| |
Microlaryngeal surgery is a routine surgery performed by otolaryngologists for benign vocal cords lesions. It is considered to be a highly rewarding surgery with short operating time and minimal complications. Vocal polyps are a common finding in patients presenting with hoarseness of voice. Polyps arising at the anterior commissure, though uncommon, can sometimes pose difficulty in visualization and instrumentation in an otherwise, routine microlaryngeal surgery. Optimal exposure of larynx is essential for successful phonomicrosurgery, and some anatomical and physiological factors can lead to difficult laryngeal exposure (DLE), which may result in unnecessary trauma, incomplete surgery, and even abortion of the operation.
| Case Report|| |
A 42-year-old gentleman presented to us with complaints of hoarseness of voice for 6 months with a positive history of voice abuse. He was a smoker for 5 years and had stopped smoking since the onset of hoarseness of voice. He had been evaluated previously at another center, where he underwent tracheostomy and direct laryngoscopy and biopsy, which was reported as inconclusive. However, the records mentioning the exact nature of the symptoms leading to the decision of performing a tracheostomy were unavailable. Later, tracheostoma was closed, and he had underwent a repeat direct laryngoscopy 3 months later at the same center, during which the procedure was abandoned, the reason being stated as nonvisualization of the mass/polyp due to short neck and anteriorly placed larynx.
Based on the above history, a critical examination of the various anatomical factors contributing to a DLE was performed. On examination, the patient had restricted mouth opening; the oropharynx was narrow, with crowding of structures; Mallampati Stage III; and also had macroglossia, retrognathia, a short and muscular neck, and slightly restricted neck extension. The interincisor distance was 3.7 cm, and the thyromental distance was 5.4 cm. On indirect laryngeal mirror examination, visualization of the larynx beyond the epiglottis could not be performed. Direct laryngoscopy using 70° telescope was performed, by which the posterior glottis could be seen, and a mass could be partially seen anteriorly, but complete visualization was not possible. Following this, a flexible fiber-optic laryngoscopy was performed, a large polypoidal mass could be seen arising from the anterior commissure, with normal vocal cord mobility. Based on the above history and findings, a videolaryngoscopy/microlaryngoscopy and excision biopsy of the polypoidal mass was planned.
Anticipating a difficult airway, a Bougie-assisted intubation was performed using a McCoy laryngoscope, and a size 6 microlaryngeal tube was placed. However, the anesthetist could only visualize the posterior glottis, and the mass/polyp remained unvisualized during intubation. Direct laryngoscopy was performed using Kleinsasser laryngoscope, but visualization beyond the arytenoids could not be achieved. Then, direct laryngoscopy was attempted using an anterior commissure scope with triangular distal opening and a distending laryngoscope, but, despite various technical adjustments and maneuvers such as neck extension flexion and external compression over the larynx, visualization of the glottis could not be achieved.
Following this, we pulled the tongue out of the oral cavity (a procedure commonly used for transoral robotic surgeries) and used the McCoy's intubating laryngoscope in an attempt to visualize the mass. By this technique, we could visualize the mass clearly using a 45° telescope [Figure 1], but the challenge of instrumentation and access remained as the polyp could not be reached and grasped using conventional microlaryngeal surgery instruments.
|Figure 1: 45° telescopic view of the anterior commissure polyp, the larynx being exposed using the McCoy laryngoscope|
Click here to view
To address this issue, we modified our instruments (microlaryngeal cup forceps and microlaryngeal suction) by bending the shaft of the instrument distally to suit the anterior curvature of the larynx.
The McCoy laryngoscope was held in position by the assistant after tongue retraction, leaving both hands of the surgeon free. With 45° telescope held in the left hand, using modified curved microlaryngeal cup forceps, the polyp was excised piecemeal under vision [Figure 2] and [Figure 3]. The patient was extubated on table and had no respiratory distress and was discharged on the 1st postoperative day on oral medications. The histopathology was reported as a benign inflammatory polyp. The patient was relieved of hoarseness of voice and had no recurrence on laryngoscopy done at 1-month follow-up [Figure 4].
|Figure 2: The polyp being grasped using upturned microcup forceps bent distally at its shaft to achieve access to the anterior commissure|
Click here to view
|Figure 4: One-month follow-up laryngoscopic examination showing no recurrence|
Click here to view
| Discussion|| |
Microlaryngeal surgery for benign vocal cord lesions can sometimes be challenging when the site involves anterior commissure, especially in obese patients with short neck, narrow airway, and anteriorly placed larynx. DLE is defined as a clinical situation in which a trained otolaryngologist experiences difficulties in exposing the larynx in phonomicrosurgery using a suspension laryngoscope. There are various preoperative predictors and scoring systems to anticipate difficult visualization of the glottis. The Laryngoscore is one such scoring system that includes 11 parameters, namely interincisor gap, thyromental distance, upper-jaw dental status, trismus, mandibular prognathism, macroglossia, micrognathia, degree of neck flexion-extension, history of previous open-neck and/or radiotherapy, Mallampati's modified score, and body mass index [Figure 5]. The modified Cormack–Lehane system has been used to grade the DLE cases on direct laryngoscopy as shown in [Figure 6].
Despite preoperative suspicion and anticipation of a difficult laryngoscopy and visualization, the options to overcome the same remain limited. Adequate laryngeal exposure depends on three basic factors, namely, patient posture, external laryngeal counterpressure, and internal laryngeal distension.,,, Modifications in these factors can provide near-adequate exposure and visualization in most of the cases. Modifications in patient posture include head elevation to straighten the cervical spine, which makes the glottis easier to visualize. Three positions relating the atlanto-occipital and cervicothoracic vertebrae have been studied, namely, extension-extension position, sniffing: extension-flexion position, and flexion-flexion position. The best position for laryngeal exposure is believed to be the sniffing (Boyce–Jackson) position.
The use of both external counterpressure and internal distention is most helpful for exposure of lesions located near the anterior commissure. External laryngeal counterpressure directed posteriorly on the cricoid and lower thyroid cartilage can displace the anterior commissure posteriorly up to 6 mm, despite movement restriction caused by the endotracheal tube. This can be achieved by a third hand or by elastoplast bandage applied across the larynx and fixed bilaterally to the operating table. Internal laryngeal distention displaces the supraglottic structures peripherally in order to obtain the widest possible view of the vocal folds. It is performed by using the largest possible laryngoscope or by the use of distending laryngoscopes such as Weerda, Lindholm, and Steiner laryngoscopes.
Various laryngoscopes including Vaughn, Zeitels', Kleinsasser, Bercy–Ward, Bouchayer, and Lindholm have been used which have different angulations of distal opening to improve the visualization of the anterior commissure. A triangular-shaped laryngoscope corresponds to the contour of the anterior commissure of the vocal folds and provides sufficient laryngeal exposure. A round-shaped laryngoscope (Kleinsasser) is inferior to a triangular laryngoscope in terms of exposure of the anterior commissure, but in DLE cases, it allows for easier insertion into the glottis. The Boston suspension gallow system has been used which has been found superior to the conventional support platform used commonly.
The use of video-assisted angled rigid telescopes, has a distinct and undeniable advantage over the microscope in the visualization of anteriorly placed glottis lesions, but access to the lesion with conventional microlaryngoscopy instruments still remains a challenge. Malleable microlaryngeal instruments are available to access such lesions. Finally, in cases of severe DLE, flexible fiber-optic laryngoscopy with a channel for instrumentation has been used to excise vocal cord polyps, under topical anesthesia.
Li et al. have used the Airtraq™VR optical laryngoscope which is an anatomically curved laryngoscope designed for tracheal intubation for phonomicrosurgery in 158 cases which included nine DLE cases, by combining the AirtraqVR laryngoscope with an endoscopic video system. The principal surgeon held AirtraqVR in the left hand and performed the surgery holding specially designed curved microlaryngeal instruments in the right hand. If necessary, an assistant held the laryngoscope and thus, the principal surgeon could perform the surgery bimanually.
In our case, the already difficult-to-access location of the polyp was compounded by various anatomical factors, such as short neck, retrognathia, and restricted mouth opening. We could not visualize the anterior glottis by conventional means, and the option of excision under topical anesthesia using flexible fiber-optic laryngoscope was not feasible owing to the large size and anterior attachment of the polyp. We resorted to a similar technique as used by Li et al. and used a McCoy intubating laryngoscope (which has a hinged tip that aids in improving the laryngoscopic view) and modified curved microlaryngeal instruments.
Thus, after initially failing to visualize and access the polyp using various known techniques and maneuvers, we could eventually excise the polyp successfully by innovatively using the available instruments and equipment.
| Conclusion|| |
Microlaryngeal surgery, although a commonly practiced, highly rewarding, and uncomplicated surgery, can sometimes, although rarely, prove challenging, by posing limitations in visualization and access. Such DLE cases are increasing in incidence, due to increase in the incidence of obesity and neck stiffness in elderly age group. Such cases have been managed individualistically by innovative means, but often tend to get abandoned, demanding the need for designing specialized/flexible microlaryngeal instruments.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fang R, Chen H, Sun J. Analysis of pressure applied during microlaryngoscopy. Eur Arch Otorhinolaryngol 2012;269:1471-6.
Li L, Xu T, Song Y, Yan Y, Ma F, Wang L, et al.
Airtraq™ laryngoscope: A solution for difficult laryngeal exposure in phonomicrosurgery. Acta Otolaryngol 2017;137:635-9.
Piazza C, Mangili S, Bon FD, Paderno A, Grazioli P, Barbieri D, et al.
Preoperative clinical predictors of difficult laryngeal exposure for microlaryngoscopy: The Laryngoscore. Laryngoscope 2014;124:2561-7.
Yentis SM, Lee DJ. Evaluation of an improved scoring system for the grading of direct laryngoscopy. Anaesthesia 1998;53:1041-4.
Zeitels SM, Vaughan CW. “External counterpressure” and “internal distention” for optimal laryngoscopic exposure of the anterior glottal commissure. Ann Otol Rhinol Laryngol 1994;103:669-75.
Zeitels SM. Universal modular glottiscope system: The evolution of a century of design and technique for direct laryngoscopy. Ann Otol Rhinol Laryngol Suppl 1999;179:2-4.
Zeitels SM, Burns JA, Dailey SH. Suspension laryngoscopy revisited. Ann Otol Rhinol Laryngol 2004;113:16-22.
Jackson C. Position of the patient for peroral endoscopy. In: Peroral Endoscopy and Laryngeal Surgery. St. Louis, Mo: The Laryngoscope Co.; 1915. p. 77-88.
Vaughan CW. Vocal fold exposure in phonosurgery. J Voice 1993;7:189-94.
Hochman II, Zeitels SM, Heaton JT. Analysis of the forces and position required for direct laryngoscopic exposure of the anterior vocal folds. Ann Otol Rhinol Laryngol 1999;108:715-24.
Kawaida M, Fukuda H, Kohno N. Video-assisted rigid endoscopic laryngosurgery: Application to cases with difficult laryngeal exposure. J Voice 2001;15:305-12.
Kantor E, Berci G, Hagiike M. Operating videoscope for microlaryngeal surgery. Surg Endosc 2006;20 Suppl 2:S484-7.
Anand V, Reji R, Santosh S, Preeti IA. Laryngeal fiberscopic surgery – An alternate approach to microlaryngeal surgery. Indian J Otolaryngol Head Neck Surg 2009;61:2-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]