Get access to all handy features included in the IVIS website
- Get unlimited access to books, proceedings and journals.
- Get access to a global catalogue of meetings, on-site and online courses, webinars and educational videos.
- Bookmark your favorite articles in My Library for future reading.
- Save future meetings and courses in My Calendar and My e-Learning.
- Ask authors questions and read what others have to say.
Problems of the epiglottis
Get access to all handy features included in the IVIS website
- Get unlimited access to books, proceedings and journals.
- Get access to a global catalogue of meetings, on-site and online courses, webinars and educational videos.
- Bookmark your favorite articles in My Library for future reading.
- Save future meetings and courses in My Calendar and My e-Learning.
- Ask authors questions and read what others have to say.
Read
Introduction: Complications or problems of the epiglottis can be associated with significance primary disease (i.e., epiglottic entrapment, epiglottic condritis, etc.) or from complications associated with their surgical treatments. Although the results of surgery in the literature can be excellent, very difficult problems occur in a small percentage of cases. Yet those problems/ complications can be career ending.(1–6)
Objectives: Review our experiences with the complication epiglottic entrapment performed at either Cornell clinic.
Methods: Cases were reviewed from the respective surgical logs from each electronic medical record (EMR) from 2014- 2017 and the complications reviewed. Summary of the handling of the complications were recorded and will be presented.
Results: Diagnosis of persistent epiglottic entrapment (EE) is readily confirmed by endoscopic examination either at rest or during dynamic endoscopy in some cases of intermittent entrapment. Most entrapments are reported to be uncomplicated. However, in our referral situation the majority of horses presented with significant swelling and ulceration. This is likely a referral bias where simple cases are treated locally and only cases thought to be more complicated or have a less favorable prognosis are referred (Figure 1). Uncomplicated cases of EE cause significantly mild airway obstruction. However EE especially ulcerated and thickened membranes may cause DDSP and thus greater airway obstruction. Excessively thickened and inflamed EE induces can be associated with permanent DDSP. All cases were successfully released and no adhesions to the epiglottic cartilage were seen. Problems seen after surgery were persistent DDSP, epiglottic chondritis, excessive swelling and sub-epiglottic ulceration.
These chronic cases can become excessively thickened, ulcerated, with an apparently fibrotic entrapping membrane (Figure 1). The decision tree in the management involves: a) the timing of surgery (very inflamed cases should be treated with local and perhaps systemic anti-inflammatory agents first), b) a release technique which does not risk further trauma to the epiglottic cartilage, 3) weigh the benefit of resection of swollen tissue vs the formation of a sub-epiglottic wound resection.
Prevention of iatrogenic damage/ burn at the tip of the epiglottis when using the hook or laser is important. The use of the hook (guarded or not) should be avoided if the outline of the tip of the epiglottis cannot be identified through the entrapping membrane. If a laser is used the minimal energy level should be used with a target of maximal joules of 500J. Use a blunt silicon-covered hook to protect the epiglottis or lift it with forceps. Be very careful to place your cut so that the edge of the epiglottic cartilage is covered dorsally, laterally and ventrally with mucosa. When performing further sections close to the tip of the epiglottis, the preference is to use endoscopic scissors instead of laser, and forceps to apply rostral traction while cutting.
If persistent DDSP occurs after surgery, it can be due to re-entrapment, epiglottitis, excessive sub-epiglottic swelling, epiglottic abscess/ chondritis, or excessive sub-epiglottic scarring (i.e., epiglottic tie-down). This is managed by proper identification of the cause and targeted treatment. If persistent DDSP is not resolved, then laryngeal tie-forward followed by staphylectomy is used.(7)
Re-entrapment is seen in 5 to 15% using the hook or laser but is more frequent with electrosurgery. Recurrence seems to be increased in cases of complicated entrapment with chronic inflammation and ulceration and if some subepiglottic tissue remains after the initial sagittal division. This is managed by Revision surgery, with some excision of the remaining tissue (lateral triangles resection), and prolonged postoperative anti-inflammatory treatment. It is best prevented by using a minimally invasive technique as described earlier. Remove extra tissue according to appearance after swallowing.
Conclusions: Epiglottic problems can be one of the most challenging conditions in upper airway surgery. Minimal trauma/energy and time are two of the most efficient methods to manage these occurrences.
Get access to all handy features included in the IVIS website
- Get unlimited access to books, proceedings and journals.
- Get access to a global catalogue of meetings, on-site and online courses, webinars and educational videos.
- Bookmark your favorite articles in My Library for future reading.
- Save future meetings and courses in My Calendar and My e-Learning.
- Ask authors questions and read what others have to say.
Comments (0)
Ask the author
0 comments