Abstract
Purpose
To explore the effectiveness of fibrin coating in reducing web formation after endoscopic management of the anterior commissure of the larynx.
Materials and methods
Using a spray device that is generally used for laparoscopic operations, we covered the wound with fibrin glue (Bolheal®) to avoid web formation. This technique was employed in cases wherein the anterior commissure was mainly managed by laser operation; the glue was sprayed after vaporization. Fibrinogen was first sprayed and the wound was properly soaked with a swab, which was followed by application of thrombin. We used this method in 17 cases and evaluated voice function by acoustic analysis – pitch perturbation quotient (PPQ) and amplitude perturbation quotient (APQ) – and maximum phonation time (MPT) before and after the operation.
Results
No severe web formation was observed at three months after the operation. PPQ values improved from 3.048 ± 2.801% to 0.653 ± 0.463% ( p < 0.05, paired t -test). APQ values improved from 7.996 ± 5.003% to 3.042 ± 1.872% ( p < 0.05, paired t -test). Voice quality did not worsen in any of the cases. MPT values improved from 17.2 ± 10.8 s to 26.7 ± 14.2 s ( p < 0.05, paired t -test) Voice function improved 3 months after the operation in all cases.
Conclusion
The fibrin coating method is an easy and effective approach to avoid web formation without creating cervical wounds in cases that require handling of the anterior commissure under laryngomicrosurgery.
1
Introduction
During laryngomicrosurgeries for tumorous lesions, instruments such as carbon dioxide (C o 2 ) lasers are often used. In these procedures , glottic web formation may occur after handling of the anterior commissure of the vocal fold for various reasons such as transpiration from C o 2 laser application to laryngeal carcinomas or invasion of laryngeal papillomatosis into the anterior commissure. Web formation can limit the membrane of the vibrating portion and decrease the vibrations themselves, thereby affecting the patient’s voice function .
Adhesions of the anterior commissure are usually treated using stent or keel insertions. However, this procedure may cause dyspnea if the web formation is extensive . Therefore, we have performed staged operations with the goal of preventing glottic web formation after laryngomicrosurgery for lesions involving the anterior commissure in some cases. The surgery was designed such that one vocal cord could be treated first, and the vocal cord on the other side would be treated after epithelialization of the first one was complete. However, this procedure is complicated and the repeated surgeries are troublesome. Therefore, we attempted to avoid adhesion of the anterior commissure by coating the wound with fibrin glue to cover the edge of the commissure, which could prevent glottic web formation. Here, we describe the course of treatment and the outcomes in patients who underwent this procedure, which we referred to as the fibrin coating method (FCM).
2
Materials and methods
The fibrin glue employed in FCM contained coagulation factor XIII derived from human plasma (Bolheal®). A spray device that is generally used for laparoscopic operations was used to apply the glue ( Fig. 1 ). From January 2010 to December 2013, we used this approach in cases that required handling of the anterior commissure. The procedure was performed only in adults. A total of 17 cases were included in this study ( Table 1 ). The lesions identified in these cases included vocal fold laryngeal polypoid lesions (n = 4), laryngeal webs (n = 4), and laryngeal papilloma (n = 9). The procedure was performed after laser operation and irradiation for glottic cancer in 2 cases and after operations for laryngeal papillomatosis and laryngeal polypoid lesions in 1 case each. In all other cases the patients had not undergone any previous operations. The laryngeal web cases showed about 1-cm long adhesion of the anterior commissure of the vocal fold after another laryngomicrosurgery. All cases involving laryngeal papillomas showed anterior commissure involvement, an irregular surface, and rough surfaces at both anterior mucosal margins. Cauterization was performed using a C o 2 laser in the laryngeal papilloma and web cases. In the cases involving papilloma lesions, cauterization was performed to the visible regions at the level of the basal lamina. In contrast, in cases involving webs, cauterization was performed in the scar regions to obtain a linear vocal margin. The C o 2 laser was not used in the polypoid cases, which were treated using the squeezing and sucking method instead. In all cases, we handled only the mucosal layer in this operation.
| Age | |
| Mean ± SD | 51 ± 17 |
| Range | 8–76 |
| Sex | |
| Male | 13 |
| Female | 4 |
| Diagnosis | |
| Laryngeal papilloma | 9 |
| Laryngeal polypoid | 4 |
| Laryngeal web | 4 |
We agreed with all cases using fibrin glue before operation. The method used in the current study was as follows. The wound was wiped well to drying the surface and sprayed with about 0.3 cm 3 of fibrinogen, which was allowed to infiltrate deeply into the wound by widening it with a swab. Next, 0.3 cm 3 of thrombin was sprayed onto the wound, which created a solid fibrin glue at the surface ( Fig. 2 ). The fibrin glue soaked into the irregular surface and adhered well ( Fig. 3 ). An injector used for laparoscopic surgery was bent and inserted into the laryngoscope. The anterior commissure of each patient was assessed 6 months after surgery. The degree of adhesion was classified into four groups ( Table 2 ; Fig. 4 ), and the maximum phonation time (MPT) was measured before and six months after the operation. Acoustic analysis involving evaluation of the pitch perturbation quotient (PPQ) and the amplitude perturbation quotient (APQ) was performed using a Kay Elemetrics Computerized Speech Lab (model CSL 4100) before and six months after the operation.
| Grade | Degree of adhesion |
|---|---|
| 0 | Almost no adhesion |
| 1 | Adhesion less than 10% of the length of the vocal fold |
| 2 | Adhesion less than 30% of the length of the vocal fold |
| 3 | Adhesion more than 30% of the length of the vocal fold |
We obtained informed consent from all patients before the operation. This study was performed as per the Declaration of Helsinki and approved by the ethical standards of Kyushu University’s guidelines on human experimentation.
2
Materials and methods
The fibrin glue employed in FCM contained coagulation factor XIII derived from human plasma (Bolheal®). A spray device that is generally used for laparoscopic operations was used to apply the glue ( Fig. 1 ). From January 2010 to December 2013, we used this approach in cases that required handling of the anterior commissure. The procedure was performed only in adults. A total of 17 cases were included in this study ( Table 1 ). The lesions identified in these cases included vocal fold laryngeal polypoid lesions (n = 4), laryngeal webs (n = 4), and laryngeal papilloma (n = 9). The procedure was performed after laser operation and irradiation for glottic cancer in 2 cases and after operations for laryngeal papillomatosis and laryngeal polypoid lesions in 1 case each. In all other cases the patients had not undergone any previous operations. The laryngeal web cases showed about 1-cm long adhesion of the anterior commissure of the vocal fold after another laryngomicrosurgery. All cases involving laryngeal papillomas showed anterior commissure involvement, an irregular surface, and rough surfaces at both anterior mucosal margins. Cauterization was performed using a C o 2 laser in the laryngeal papilloma and web cases. In the cases involving papilloma lesions, cauterization was performed to the visible regions at the level of the basal lamina. In contrast, in cases involving webs, cauterization was performed in the scar regions to obtain a linear vocal margin. The C o 2 laser was not used in the polypoid cases, which were treated using the squeezing and sucking method instead. In all cases, we handled only the mucosal layer in this operation.
