Treatment of Anterior Glottic Web
Endoscopic buccal graft after web lysis is a two-stage procedure that may be considered to bring the patient′s own tissue into the membranous vocal fold for improvement of voice production. The first stage is harvest and endoscopic placement of a buccal graft after division of the web. The second stage is removal of the Silastic sheeting that holds the graft in place for two weeks. The primary advantage of endoscopic buccal graft, versus an open procedure, is that this procedure does not require an external incision, can be done without a tracheotomy and may be performed as an outpatient procedure.
Indications/Contraindications
Endoscopic buccal mucosal grafting is an excellent approach in patients with severe scarring involving both vocal folds where there is no pliable mucosa for oscillation.
Anterior glottic webs often result from endoscopic laser resection of glottic cancer, open hemilaryngectomy, or external laryngeal trauma.
Contraindications include patients with a history of radiation or those with poor wound healing as in diabetes. Other barriers include risks of poor laryngeal exposure and risks of general anesthesia, such as multiple medical comorbidities.
In the Clinical Setting
Key Points
With the placement of pliable mucosa into a surgical defect, the patient will have a much higher likelihood of having tissue with rheological properties favorable for oscillation than of having scarred epithelium from secondary healing.
Furthermore, a web prevents significant portions of the anterior segment of the musculomembranous vocal fold from oscillation, thereby shortening the functioning vocal fold.
A successful graft placement will lengthen the vocal fold, creating more vocal fold available to oscillate, thereby better mimicking healthy anatomy.
Pitfalls
Careful intraoperative assessment prior to beginning the procedure is essential to evaluate the web and establish a lack of other pathology (cancer, subglottic stenosis, etc.).
This assessment also ensures that adequate laryngeal exposure can be achieved.
Proper equipment availability is essential, as is allowing enough time for some technically challenging segments of the procedure.
From a Technical Perspective
Key Points
A strong conceptual understanding of the procedure will greatly assist in completing it properly.
Over- or under-measurement of the graft is easy to do. It is better to harvest too large a graft and then trim in, than harvest a graft that is too small and therefore of limited use.
Angled telescopes can greatly assist the surgical view when sutures are passed through needle cannulas from the interior to the exterior of the larynx.
Pitfalls
The non-absorbable sutures used are monofilament and can be roughened or cut by the tips of the needles through which they are passed. Patience and good visualization will help to avoid damaging the suture.
Making sure that the graft is placed at the level of the glottis and is well centered is critical.
Stepwise Procedure
Mount a larynx for endoscopic surgery.
OR Pearl: In the live patient, the patient is placed in suspension laryngoscopy and the first portion of the procedure is removal of the scar using sharp instruments or a carbon dioxide laser. This will leave two raw surfaces, only one of which is grafted.
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