INVITED REVIEW ARTICLE

https://doi.org/10.5005/jp-journals-10001-1524
International Journal of Head and Neck Surgery
Volume 13 | Issue 1 | Year 2022

Posterior Glottic Stenosis: A Review of Surgical Management Outcomes

Taylor G Lackey¹, Carolyn A Chabuz², Daniel S Fink³

^1-3Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA

Corresponding Author: Taylor G Lackey, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA, Phone: +1 303-724-1961, e-mail: Taylor.Lackey@cuanschutz.edu

ABSTRACT

The objective of this review is to describe management options and their success in adults with acquired posterior glottic stenosis (PGS). Literature from PubMed search engine was reviewed, including recent and historical reports covering etiology, surgical techniques, and voice and swallowing outcomes in PGS. Damage to the posterior commissure after intubation is still the most common etiology for acquired PGS, with patients presenting with dyspnea weeks to months after injury. There is a multitude of surgical techniques described, regardless of the technique chosen, PGS is a challenging disease that often requires more than one procedure. Tracheostomy should be considered to secure the airway in the perioperative period, and decannulation is typically successful. Swallowing dysfunction is often temporary, and voice is often stable or improved after surgical intervention. As the laryngologist will continue to face this disease, especially with the recent pandemic, being familiar with various techniques options will be important in providing a safe and functional larynx.

How to cite this article: Lackey TG, Chabuz CA, Fink DS. Posterior Glottic Stenosis: A Review of Surgical Management Outcomes. Int J Head Neck Surg 2022;13(1):47-54.

Source of support: Nil

Conflict of interest: None

Keywords: Adult, Posterior glottic stenosis, Swallowing, Surgical outcomes, Voice

INTRODUCTION

Posterior glottic stenosis (PGS) is a potentially life-threatening condition characterized by narrowing of the glottic airway due to fibrosis and fixation of the cricoarytenoid joints (CAJ) leading to restriction of the vocal cord motion and ultimately ventilatory compromise. The most common etiology is prolonged intubation.

In 1878, the first orotracheal intubation was performed by William McEwen, a British surgeon; since our understanding of the consequences of intubation has evolved over the last century.¹ Prolonged intubation was encouraged in premature infants as a substitute to tracheostomy for the management of respiratory distress syndrome in 1965.² In 1993, Benjamin examined over 700 patients describing “tongue of granulation tissue” and “healed fibrous nodules” caused by long-term intubation.³ These findings brought to light the deleterious effects of prolonged intubation, drastically decreasing the use of long-term intubation, altering the incidence of subglottic stenosis from ~8.3% to less than 2%.⁴

Amid the coronavirus disease 2019 (COVID-19) pandemic there has been a dramatic increase in severe acute respiratory syndrome requiring intubation and ventilatory support. Per the CDC there have been 30,737,477 total cases reported with 1,985,128 million hospital admissions with a large majority requiring intubation and mechanical ventilation.⁵ Furthermore, COVID-19 prompts a cytokine storm causing an inflammatory cascade that could potentially encourage fibrosis and the formation of scars. Fried et al. determined an intubation rate of 16.8% in COVID-19 hospitalized patients between February and April of 2020.⁶

With improvements in technology, surgical techniques, and treatments, many critically ill patients who require prolonged ventilatory support are surviving longer than previously. The COVID-19 pandemic has created a necessity for prolonged intubation in patients with a disease process with pro-inflammatory features and often delayed tracheostomy due to the aerosolizing nature of the procedure. This provides the perfect storm for an increasing incidence of PGS. This illustrates the importance of understanding PGS and its presentation, diagnosis, and treatment strategies.

METHODS

Utilizing the PubMed search engine, the first and second author searched for articles in this review. The search included historical and recent studies covering different aspects of pathogenesis, surgical techniques, and outcomes. The search used laryngotracheal stenosis and PGS as the most common keywords. Articles were included if it studied predominately adults and stenosis only of the posterior glottis. Studies that evaluated pediatric or congenital stenosis, anterior glottis, or stenosis extending beyond the glottis were generally excluded.

Etiology

PGS is predominately associated with intubation as over time an endotracheal tube (ETT) causes pressure necrosis and fibrosis of the interarytenoid mucosa and underlying cartilage. This affects the CAJ, limiting vocal cord abduction producing a severely narrowed glottic airway. PGS occurs in up to 12% of adult patients intubated for more than 10 days.⁷ The prevalence is also thought to be underestimated as it is often incorrectly diagnosed as bilateral vocal fold paralysis (BVFP).

Congenital causes of PGS are very rare and thought to be due to abnormalities of the 6th branchial arch and include a posterior glottic web, congenital CAJ fixation, and posterior subglottic hemangioma.⁸

Recurrent respiratory papillomatosis (RRP) is a disease of small benign wart-like lesions that develop along the respiratory tract due to infection with the human papillomavirus (HPV) which can occur in children or adults. The most concerning development is airway obstruction leading to life-threatening respiratory distress. Management of this disorder typically involves surgical removal of lesions using various techniques. Latrogenic airway stenosis, commonly PGS, occurs with CO₂ excision of papillomas in up to 36% of patients due to web formation impairing arytenoid mobility which often spares the CAJ.⁹

Multiple autoimmune diseases including granulomatosis with polyangiitis (GPA), relapsing polychondritis (RP), rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, and amyloidosis may present with PGS. In RP, the immune cells attack proteoglycan, the main component of cartilage, leading to inflammatory cell infiltration, chondrocyte cell death and ultimately calcification and fibrosis.¹⁰ ANCA-mediated leukocyte activation causing a cascade of necrotizing inflammation, granuloma formation, and finally fibrosis occurs in GPA associated PGS.¹¹^,¹²

Other associated etiologies of PGS include infection, laryngopharyngeal reflux (LPR), radiation, trauma, inhalation injury, and caustic ingestion.¹³

Pathogenesis

The posterior glottis is comprised of the posterior commissure and posterior one-third of the true vocal cords. The posterior commissure is comprised of the interarytenoid muscle, cricoid lamina, CAJ, arytenoid cartilage, and a thin layer of mucosa that covers the cartilage. With endotracheal intubation, the tongue base and curvature of the cervical spine contort the ETT into an S shape which directs pressure onto the posterior glottis. The anatomy of the posterior subglottis is distinctly different than that of the anterior subglottis as it is derived from the 6th branchial arch and the overlying epithelium is respiratory as opposed to the anterior subglottis which is composed of squamous epithelium. This difference is important because the delicate respiratory epithelium of the posterior glottis is more susceptible to injury than that of the more resistant squamous mucosa of the anterior glottis.⁸

When the pressure of the ETT on the epithelium exceeds capillary pressure within the epithelium there is a disruption of the circulation to the mucosa and muoperichondrium. Initially this pressure causes an ulceration which can progress to expose the underlying cartilage and lead to perichondritis or even frank cartilage necrosis. As inflammatory cells concentrate at the margins, fibroblasts are activated forming granulation tissue. Healing cannot begin until the ETT is removed. While the superficial layer will regenerate epithelium, the deeper layers must heal via secondary intention. Remodeling occurs with collagen deposition from fibrocytes, replacing granulation tissue for fibrosis and wound contracture of the CAJ (Fig. 1).¹^,¹⁴

Figs 1A to C: Cascade of inflammation leading to PGS. (A) Initial ulceration (B) progresses to granulation tissue that (C) contractor the arytenoids18

While pressure via an ETT is the most common cause of PGS, the cascade of events is similar in other causes: ulceration of tissue, inflammation, granulation tissue formation, and finally fibrosis leading to contracture. Histopathology from tissue biopsy can be used to differentiate the presence of vasculitis, caseous necrosis, or infectious pathogens.¹⁵

This cascade may be exacerbated by LPR, abnormal laryngeal anatomy caused by external trauma, traumatic intubation, numerous reintubations, excessive movement during the intubation period, history of keloids, hypoperfused state, infection, and diabetes mellitus (DM).¹⁶^,¹⁷ Volpi studied patient-dependent processes that could increase the risk of PGS. DM, congestive heart failure, and history of stroke increased a patient’s risk of laryngeal injury through either impaired wound healing and/or its disruption via increased agitation.¹⁶ Hillel noted predictors of PGS in male intubated patients included the use of large ETTs (greater than 7.5), a longer duration of intubation, ischemia, and diabetes.¹⁷ Prolonged intubation, defined as greater than 10 days, was associated with an increased risk of PGS in a prospective study by Whited et al.¹⁴ Katsantonis illustrated an association between shorter height and developing PGS noting that for every centimeter increase in height, the odds of developing PGS decrease by 9%. This was felt to be secondary to shorter patients with smaller airways having the same sized ETT which would, in turn, apply more pressure to the airway.¹⁸

Presentation

PGS has variable presentations secondary to varying etiologies and degree of partial or total fixation of the vocal cords. Symptoms can mimic those of vocal cord paralysis and vary from mild dyspnea and inspiratory stridor with exertion to severe biphasic stridor and respiratory distress at rest. Given the etiology and pathogenesis of this disorder, symptom onset is usually slow and gradual. Patients and observers may not notice voice symptoms as PGS causes adduction of the vocal cords. However, voice changes are not uncommon, and patients will often experience hoarseness, and a more detailed history can elicit patient complaints of decreased range in frequency and loudness, as well as vocal fatigue.

Symptom onset occurs weeks to months after extubation as the fibrosis, scar formation, and wound contracture takes time. In radiated patients, an expected inflammatory response leading to fibrosis often occurs over months to years after treatment.

Evaluation

Evaluation begins with a history followed by the physical exam, listening for stridor, subtle changes in voice, accessory muscle use and signs of respiratory distress. Flexible laryngoscopy findings can demonstrate inflammatory changes such as mucosal erythema, diminished vocal fold mobility, and a posterior glottic scar band (Fig. 2). In more severe cases of PGS, the vocal cords will appear immobile in the paramedian position and can often be misinterpreted as bilateral vocal cord paralysis. Vahidi described findings in type I PGS which included hypomobile vocal cords with a posterior glottic scar band and restricted CAJ movement without a jostle sign.¹⁹ A jostle sign is the passive medial movement of a paralyzed vocal cord due contact from the contralateral, mobile arytenoid. With the CAJ being fixed, contact will not mobilize the immobile joint.¹⁹ Transnasal tracheoscopy (TNT) may be utilized to improve visualization of the posterior glottis in challenging cases.²⁰ Additionally, patients who have a tracheostomy can be examined through their stoma by retroflexing the laryngoscope through the stoma to visualize the infraglottis.

Fig. 2: Flexible laryngoscopy view of PGS in the office

Other ancillary diagnostic tools include pulmonary function tests (PFTs) and imaging. PFTs will demonstrate an abnormal fixed-lesion flow-volume loop with flattening of the inspiratory and expiratory portions, as well as a reduced peak-inspiratory flow (PIF). PIF is useful in quantifying the severity of obstruction, and degree of objective improvement postoperatively. Imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) of the neck can provide a detailed evaluation of the cartilaginous framework distinguishing other potential causes of dysphonia and dyspnea. CT will often reveal airway narrowing of the glottic airway with redundant interarytenoid soft tissue, a medialized vocal cord, or arytenoid cartilage. Imaging may assist in ruling out tumors and secondary stenoses in the subglottis or upper trachea.

Weddel first described laryngeal EMG in 1944 and can be performed in-office as an adjunct in the diagnosis, prognosis, and management. The thyroarytenoid innervated by the recurrent laryngeal nerve (RLN) and the cricothyroid muscle innervated by the superior laryngeal nerve is typically investigated. EMG can distinguish between abnormal findings in BVFP compared with normal findings in PGS without the need for general anesthesia.²¹

The definitive diagnostic test is an operative evaluation via direct laryngoscopy and bronchoscopy to palpate the vocal folds and arytenoid cartilages. This tool is used to assess the mobility of the CAJ which can detail the extent of disease as well as to rule out other lesions in the subglottis or trachea.

Classification System

The most widely accepted classification system for PGS is that of Bogdasarian and Olsen which divides PGS into four groups depending on the severity of vocal cord immobility and location of scarring (Fig. 3). Class I is described as having an interarytenoid scar and a sinus tract posteriorly. In this class, a small band of tissue is seen between the vocal processes with diminished abduction of the vocal cords on laryngoscopy. Class II will have limited mobility of the arytenoids due to the posterior commissure scar. The arytenoids can be moved in the anteroposterior direction but not independently in the medial-to-lateral direction in this class. Class III has fixation of a single CAJ in addition to the posterior commissure scar. On exam these patients will have a narrowed airway due to adduction of the vocal cords with an immobile cord, and hypomobile cord in the nonfixated joint. Finally, Class IV is the most severe form and is complete fixation of bilateral CAJs.²² In the authors’ experience, discriminating between Class II, III, and IV during office endoscopy is challenging.

Figs 3A to D: Bogdasarian and Olsen classification system. (A) Class I with an interarytenoid adhesion. (B) Class II with Interarytenoid and posterior commissure scar. (C) Class III PGS with scar extending into the right CAJ. (D) Class IV PGS with scar extending into bilateral CAJ30

Management Techniques

Surgical intervention is necessary when patients present with respiratory distress, at times requiring tracheostomy for the establishment of a safe airway prior to addressing the stenosis. It may also be considered for patients with dyspnea on exertion and dysphonia. The surgical approach should be tailored to the severity of stenosis while also considering individual patient considerations. It is not unusual for these patients to require multiple interventions until symptom resolution or significant improvement.²³^-²⁶ We present surgical interventions with increasing aggressiveness, which often correlates with the severity of stenosis being addressed.

Endoscopic lysis or excision of the interarytenoid scar band, often with CO₂ or Nd-YAG laser, is described for low grade PGS.²⁶^,³⁰^-³⁴ Meyer et al. reported an 83% success rate in a series of 13 patients with PGS who underwent laser resection of interarytenoid scar band, with success defined as tracheostomy decannulation (Fig. 4).²⁷

Figs 4A to C: Lysis of type I PGS. (A) Initial appearance of the scar band intraoperatively. (B) After excision of scar band. (C) Following after dilation and injection of triamcinolone acetonide36

Dilation of the stenosis with pneumatic balloon dilation and/or rigid Jackson laryngeal dilator is often used following lysis of scar. However, it may be used alone in PGS that presents within 3 months of injury. Rosen et al. evaluated teardrop-shaped glottic dilation in five patients with early PGS, three requiring repeat dilation, but all had improved subjective dyspnea and vocal cord mobility.³³ Advocates report a better posterior-lateral force translation using the combination of a Jackson laryngeal dilator in the anterior glottis and a pneumatic balloon dilator in the posterior glottis.

After lysis of the scar, laterofixation of the vocal cord can be completed unilaterally or bilaterally to assist with prevention of scar-forming between the opposing scar edges.²⁹^,³⁴^-³⁶ This is generally completed with a reinforced Lichtenberger’s needle carrier to create a thread loop around the vocal process fixating the arytenoid more superior, posterior, and laterally. The fixation suture is secured above the prelaryngeal muscles in a skin incision. This fixation suture can be removed once re-epithelization is complete, 4-8 weeks postoperatively. Rovo et al. evaluated this technique in 32 subjects with PGS with 87.5% having a resolution of dyspnea and five of the six tracheostomy subjects decannulated in a minimum follow-up period of 2 years. High-grade stenosis (Grade IV, N = 17) had decreased postoperative airway function as measured by PIF on longer-term follow-up compared to the low-grade stenosis group (Grade I-III), but still was better than the preoperative values.²⁹

Dedo et al. were the first to describe an endoscopic approach for a mucosal flap technique, the microtrapdoor flap, to cover the denuded surface of the excised scar to prevent granulation and scar tissue formation.³⁷ A superiorly-based incision is made with submucosal dissection through the scar, creating lateral pockets that are incised to have an inferior flap that is secured over the raw surface. The trapdoor flap in general can be based in any direction to optimize wound coverage.³⁸ Success, defined as tracheostomy decannulation, has been reported at 75-100%.³⁷^-⁴⁰ Yilmaz et al. had 33 of 34 patients who remained dyspnea-free at the follow-up period minimum of 2 years. Of note severity of PGS was not well characterized in studies of the microtrapdoor flap technique, and patients often required multiple procedures.³⁷^,³⁹ Advocates for this technique, suggest its use in thin stenosis.³⁹^,⁴⁰

Goldberg et al. was the first to describe the endoscopic postcricoid advancement flap (EPAF), which is an inferiorly based mucosal flap from the posterior cricoid mucosa indicated for type II or III PGS to improve vocal fold mobility. Damrose et al. modified this technique combining the submucosal trapdoor flap with the EPAF technique.⁴¹ In this study they evaluated 10 patients with 100% success in tracheostomy decannulation.⁴¹ Atallah et al. performed a trapezoid-shaped EPAF in 52 patients in which all 22 patients with tracheostomy were decannulated and dyspnea index improved significantly postoperatively.³⁶ The study did not distinguish which patients among those who were decannulated that required adjunctive procedures (N = 22) including dilation or arytenoidectomy.³⁶ In this study, type II PGS had the least number of additional procedures with an average of 1.14 procedures. Semmler et al. introduced a modified endolaryngeal posterior mucosal flap, a medial mucosal flap created at the level of the false cords which is rotated downwards into the posterior glottic commissure. This technique was introduced to avoid the risk of aspiration and stenosis above the posterior commissure, which is not well reported.⁴² Three of four subjects with type I or II severity had improvement in their airway. Novel to their study was the use of fibrin glue to secure the flap, instead of sutures as commonly described.⁴²

In attempting to further improve vocal cord mobility, some advocate for mobilization of the CAJ in severe PGS.⁴³^,⁴⁴ Weidenbecher et al. proposed mobilization by incising circumferentially around the CAJ followed by a rotational advancement mucosal flap from the medial piriform sinus. All five subjects were decannulated postoperatively with a follow-up period of 6-18 months. Vocal cord mobility decreased with time postoperatively but retained at least unilateral hypomobility in all patients.⁴³ Atallah et al. performed mobilization with graduated arytenoidectomy and EPAF in 23 subjects with severe PGS. All subjects were decannulated or had significant improvement in their dyspnea index, which was measured at 12 weeks postoperatively.⁴⁴ Deducing the isolated success of mobilization is difficult in the setting of EPAF and arytenoidectomy that was performed concurrently. Furthermore, they did not report mobility of the cords, the study follow-up period, or the average number of procedures required.

Transverse posterior cordotomy is a technique first described for BVFP by Dennis and Kashima which allows retraction of the vocal ligament and muscle from the vocal process, enlarging the airway.⁴⁵ Qazi et al. report on seven patients with PGS of which 86% were unsuccessful initially due to obstructive granuloma formation which required surgical intervention. Overall, they report 80% success with improvement in dyspnea and tracheostomy decannulation in a cohort of 20 patients with BVFP and PGS.²⁴

Arytenoidectomy is commonly performed endoscopically with the removal of the medial body of the arytenoid cartilage, widening the posterior glottic airway. A total or complete arytenoidectomy is the removal of the entire body of the arytenoid until flush with the wall of the cricoid ring. Complete arytenoidectomy is often not recommended due to significant aspiration and dysphonia. Lim et al. report 100% decannulation rate in ten patients with PGS treated with unilateral arytenoidectomy, with residual dyspnea on exertion in two patients.⁴⁶ A medial or partial arytenoidectomy can be done in conjunction with a cordotomy to maximize the posterior glottis (Fig. 5). Ghodke et al. performed cordotomy and anteromedial arytenoidectomy in 26 patients, of which 16 had PGS. PGS diagnosis more frequently had two-sided interventions (45.5%) compared to the BVFP cohort.²⁵ All patients with tracheostomies were decannulated.²⁵

Figs 5A and B: Transverse cordotomy with anteromedial arytenoidectomy. (A) Surgical diagram depicting the anticipated area of resection.34 (B) Postoperative view

Endoscopic posterior cricoid split with cartilage graft placement is commonly performed in children (Fig. 6). Yawn et al. reports 83% decannulation success in six adult patients who underwent endoscopic posterior cricoid split with cartilage graft laryngoplasty.⁴⁷

Fig. 6: Endoscopic view showing healing posterior cricoid graft58

For patients in which the posterior glottis cannot be visualized, often due to cervical fusion, a minicricothyrotomy is done to access the scar.⁴⁸^,⁴⁹ Lysis of the scar is visualized using a rigid endoscope or fiberoptic laryngoscope through a laryngeal mask airway (LMA). This has been described as successful in two case reports.⁴⁸^,⁴⁹

Open resection of scar via a laryngofissure approach is indicated in patients with the recalcitrant disease and/or unfavorable anatomy including poor transoral access. The resected scar tissue is grafted with a mucosal advancement flap or a skin, perichondrocutaneous, or buccal mucosa graft.³⁰^,⁵⁰^-⁵⁴ The posterior cricoid may be split with or without a costal cartilage graft placement.³⁰^,⁵¹^,⁵⁴ A stent is often used for 2-8 weeks postoperatively.⁵⁰^-⁵³ Decannulation success following an open approach is typically high, though 30-40% of subjects required additional procedures including granuloma removal and necrosis of the graft.³⁰^,⁵⁰^,⁵¹^,⁵³ Hoasjoe et al. report 90% success on 10 patients, the largest cohort of PGS without other stenosis.

Successful decannulation rate in isolated PGS reached 61% in a retrospective review of laryngotracheal stenosis, though 50% of the PGS patients decannulated did not require surgery as they had mild disease.⁵⁵ Maeso-Plaza et al. reports on 34 PGS patients with or without other sites of stenosis and noted PGS severity did not influence their decannulation rate of 85%.²⁶ A recent meta-analysis investigated the association of prior surgeries and stent usage with outcomes in 140 patients. Prior surgeries were associated with additional surgeries, and the use of a stent was associated with a lower likelihood of decannulation.⁵⁶

Adjuncts to Surgical Technique

Mitomycin C and steroids are medications commonly used intraoperatively, topically applied or injected into the scar tissue to modulate the wound healing process to minimize restenosis. Mitomycin C inhibits collagen deposition and enhanced proliferation of epithelial cells, and in clinical use is suggested to delay but prevent recurrence of airway stenosis.⁵⁷ One randomized study of 25 patients with bilateral vocal cord paralysis who underwent unilateral cordotomy had less granulation tissue postoperatively with intraoperative Mitomycin C use.⁵⁸ Similarly, intralesional steroid use in SGS patients, lengthens the time to surgical dilation.⁵⁹

The use of stents after lysis and dilation is described of uncertain utility. Langman describes success in six of nine patients with the placement of Teflon keel in the posterior commissure following scar lysis.⁶⁰ Similarly, Zeitels placed a self-retaining interarytenoid spring of similar teardrop shape in five patients for three months with all patients decannulated. Voice and breathing were functional for all patients though mobility of the cords did not return to normal.⁶¹ This is generally avoided in favor of one of the above techniques when tissue interposition is necessary.

Postoperative Care

Variations are reported in postoperative care with a combination of using antibiotics,²⁴^,²⁵^,²⁸^-³⁰^,³⁶^,⁴²^,⁵⁰^,⁶² proton pump inhibitors (PPI),²⁴^,²⁵^,²⁷^,³⁰^,⁴²^,⁴⁹^,⁵⁰^,⁶² and steroids.²⁴^,²⁷^,²⁹ A lack of randomized trials limits the ability to discern the most effective postoperative medication regimen. The need for tracheostomy for the procedure is patient, surgeon, and surgery dependent, as well as time, to stent removal and decannulation. Ghodke et al. reported patients who required bilateral surgery had an average of 134.3 days prior to decannulation compared to 46 days for patients who only required unilateral surgery.²⁵

Complications

A commonly reported complication is granulation formation in the various surgical techniques including microtrapdoor flap, lateropexy, cordectomy and/or arytenoidectomy, and larynogfissure with graft placement.²⁴^-²⁶^,³⁰^,³⁶^,³⁹^,⁵⁰^,⁵³ Granulation tissue was reported in up to 35% of patients, which often required surgical removal prior to decannulation.²⁴^,²⁵ In addition to restenosis and/or need for additional procedures, flap necrosis or displacement is uncommon but may occur.⁵³^,⁵⁴ Infection can also occur but does not appear to impact outcomes.⁵³ Subcutaneous emphysema is a risk in open procedures and was seen in the minicricothyrotomy approach by Mau et al.; placement of a drain can assist in avoiding this complication.⁴⁹ Gastroesophageal reflux (GERD) has not been associated with complications,²⁴^,²⁵^,⁵¹ and tobacco use is associated with more complications.²⁴

Voice and Swallowing Outcomes

Regardless of technique, voice and swallowing are relatively maintained following surgery. Vocal fold mobility is not always reported but returns in up to 92% of patients with type I PGS following endoscopic scar lysis²⁷ and 100% of patients with type II PGS following EPAF.⁴¹ Voice improved in most patients following scar lysis,²⁷ vocal fold lateralization,²⁹^,³⁶ and posterior mucosal flap.⁴² Arytenoidectomy and posterior cordectomy increase the risk of impaired voice quality, though in Ghodke et al., found no difference in voice outcomes except for a decrease in maximum phonation time.²⁵ Voice in laryngofissure surgeries is often described as functional or breathy,³⁰^,⁵⁰^,⁵¹ undermining the disruption of vocal cord opposition. Hatcher et al. found vocal outcomes in patients with PGS, SGS, and tracheal stenosis were better for those with stenosis at least 2 cm distal to the vocal folds. In this study PGS was treated with stenosis lysis, arytenoidectomy, or cordectomy.⁶³

Swallowing dysfunction is seen postoperatively with suture lateralization,²⁹ joint mobilization,⁴³ cordectomy, and arytenoidectomy.²⁵ Patients otherwise return to their baseline swallowing status,²⁵^,⁴³ except in patients with interarytenoid atrophy following laryngofissure with scar lysis, cricoid split, and buccal mucosal graft placement.⁵¹ Other studies only reported no aspiration or aspiration pneumonia.⁴¹^,⁵³^,⁶² Conklin et al. found no difference in dysphagia symptoms using the Eating Assessment Tool (EAT-10) following cordotomy.⁶⁴

DISCUSSION

PGS is a heterogeneous group of medical conditions, commonly due to prolonged intubation. Potential methods to reduce PGS include using appropriately sized or smaller ETTs for patients, and reducing the duration of intubation, if possible. Patients often present with severe dyspnea weeks to months following extubation, which may require tracheostomy to provide a safe airway until a wider glottis can be consistently maintained. Multiple interventions are often required to provide a patent posterior glottis with or without return of vocal cord mobility. Patients with more severe PGS are less likely to have vocal cord motion return to normal bilaterally.

Surgical management is initially a conservative endoscopic approach, avoiding destructive maneuvers that will permanently alter voice and swallowing function. Transverse cordectomy and/or arytenoidectomy appear to be effective for recalcitrant disease. Patients who cannot be accessed via a transoral approach or have the recalcitrant severe disease may undergo an open laryngofissure approach with or without graft placement. Destructive procedures are at higher risk for altering voice permanently and temporary swallowing dysfunction.

Studies of sufficient power are necessary to determine prognosis by PGS severity and effectiveness of the various surgical techniques proposed in the last four decades. Currently, the literature can be difficult to interpret as concurrent stenosis also impact decannulation success. It is unclear the impact of reflux management and steroid or mitomycin C use on surgical success but is routinely used in the perioperative period.

CONCLUSION

PGS is a challenging disease with multiple surgical techniques that can be utilized for treatment. Diligence is necessary to provide a safe airway and effective larynx throughout the clinical disease course. Sufficiently powered studies are necessary to further provide accurate guidelines for PGS management.

All authors have seen and approved the manuscript. The authors have no financial relationships or support relevant to this manuscript. The authors have no conflicts of interest to report.

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