Complications of prosthetic laryngoplasty

Despite good surgical techniques, surgical complications after a laryngoplasty have always been the most difficult part of managing a case.

Intra-operative Complications

- Hemorrhage: Initial problem reducing visualization, increasing difficulty of surgery, and predisposing for other incisional complications. During the approach, the linguofacial vein or one of its branches can be the first source of hemorrhage. Then, when increasing the size of the surgical incision caudally from the cricoid, the cranial thyroid artery and venous plexus can be lacerated. Identification of the bleeding vessel and direct ligation usually stops the bleeding. When inserting the needle through the cricoid cartilage and cricoarytenoideus dorsalis muscle the plexus of laryngeal vessels can be punctured. Temporary packing with sponges often slows bleeding and allows the placement of the prosthetic sutures. Once sutures are placed, tightened, and tied, hemorrhage usually stops or reduces significantly.

- Laryngeal and nasopharyngeal penetration: Perforation of the laryngeal mucosa can occur when placing the needle under the caudal border of the cricoid cartilage. This can cause chronic incisional infection and coughing. Intra-operative endoscopy should be used to prevent and correct this problem. During surgery, manipulating the cricoid cartilage and soft tissue caudal to the cartilage can also help avoid this problem. If mucosal penetration is detected, sutures should be transected at the caudal aspect of the cricoid cartilage. The area should be lavage and sutures replaced.

- Suture pullout: This is a serious problem, especially when it affects the muscular process. The suture must be replaced, avoiding the damaged portion of the muscular process and placing the new suture down the spine of the muscular process avoiding the penetration of the adventitia of the vestibulum of the esophagus.

Immediate Post-operative Complications

- Seroma formation: Common problem that usually resolves itself, unless it becomes extensive or infected. If severe, it can cause a collapse of the pharynx and compression of the esophagus causing dysphagia. Aseptic aspiration of the seroma with fluid analysis (cytology) can be performed. Usually this is not necessary unless the swelling is extensive. Post-operative anti-inflammatory and anti-microbial medication should suffice.

- Surgical site infection and dehiscence: Deep wound infection with dehiscence is not a common problem. This can occur when there is penetration through the laryngeal mucosa. Treatment: opening the wound, wound lavage and broad-spectrum anti-microbials. Laryngoplasty sutures do not need to be removed; however, in chronic cases this is the only thing that stops the infection.

- Loss of abduction: Partial or complete loss of arytenoid abduction occurs in 3–11% cases, usually in the first week following surgery. Suture pull-through or fractures in the muscular process can be a cause of this complication. Suture breakage is a less common cause of loss of abduction.

- Dysphagia: This is one of the most feared complications. It has been proposed that this happens due to: 1) excessive retraction of the cricopharyngeus and thyropharyngeus muscles during surgery affecting the esophageal sphincter function, 2) excessive surgical abduction of the arytenoid, or 3) penetration in the adventitia or lumen of the vestibulum esophagus when placing sutures in the muscular process. Good surgical technique and intra-operative endoscopic assessment should prevent excessive abduction and help ameliorate this complication.

- Coughing: Incidence of coughing in the immediate post-operative period has been reported to be as high as 43%. This commonly occurs in the immediate post-operative period and is usually associated with high levels of arytenoid abduction with concurrent aspiration of food and/or saliva. The presence and frequency subsides 7–10 days post operatively, but long-term coughing during eating persists in a small proportion of cases.

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