Microflap laryngosplasty for treating an anterior-commissure web with papillomatosis.

INTRODUCTION Based on postmortem examinations of the larynx and trachea, recurrent respiratory papillomatosis (RRP) was well described as a cause of death from airway obstruction in the early 19th century.1 Laryngeal RRP has been an omnipresent surgical problem in Laryngology2since the origin of the specialty 150 years ago. Laryngeal papillomatosis has had a predilection for glottal membranes and it has always been commonplace to identify disease in the anterior commissure. Resection of laryngeal papillomatosis was an office-based mirror-guided procedure in the 19th century and became a direct laryngoscopic method3 that migrated to the operating room4 with systemic anesthesia in the 20th century.5 Although magnification provided by the microscope6,7 and hemostatic cutting/ablation characteristics of the CO2 laser enhance precision,8–10 anterior-commissure scarring and synechia (web) commonly occur in association with any form of surgical treatment. When papillomatous epithelium recurs in a surgically induced anterior-commissure web, further treatment becomes increasingly more difficult and more morbid. There are two key indications to treat an anteriorcommissure web associated with papillomatosis. First, it is essential to expand the glottal aperture in those patients with restricted airways. Second, it is important to expose papillomatosis on the undersurface of the web and in the subglottis. (Fig. 1A, B) In our practice, exposure of the anterior subcordal and subglottal regions is now of greater consequence. This is because we now manage the majority of our papillomatosis patients as an office-based procedure through a flexible laryngoscope5,11 and substantive intraprocedural retraction is not currently practical with this treatment paradigm. Although reducing papillomatous epithelium overlying a web will typically enhance vocal function, we do not generally treat limited webs for pure phonatory indications. This is because vocal function is unlikely to improve if there is not pliable superficial lamina propria (SLP) underlying the epithelium. Therefore, we treat an anterior glottal web surgically when it significantly impacts our ability to treat the patient’s papilloma, or if the web itself is large enough to substantively restrict the airway. Treating anterior-commissure glottal webs can be done through open neck surgery or microlaryngoscopic mucosal flaps. Transcervical laryngofissure techniques often used for treating nonpapillomatosis webs are generally discouraged with RRP. Microlaryngoscopic mucosal advancement-rotation flaps were described many years ago and are most successful in congenital webs. Typically, there is subepithelial pliable SLP, which allows for stretching and advancing the epithelial flap anteriorly. Mucosal advancement flaps are far less successful when there is normal epithelium adherent to fibrotic scar. Despite dividing the web and borrowing epithelium from one side, the mucosal advancement-rotation flap cannot usually be affixed to its optimal position anteriorly. Moreover, suturing the flap anteriorly is technically very difficult if one is working at the perimeter of the laryngoscope speculum.12,13 We therefore instituted a novel technique for endoscopic laryngoplasty in patients with RRP overlying an anterior-commissure web.