The sniffing position is traditionally considered optimal for direct laryngoscopic examination of the vocal folds. This study examined head and neck positions associated with ideal exposure of the anterior glottal commissure with a variety of laryngoscopes. A prospective investigation was done in 20 patients by comparing the force required to expose the anterior vocal folds by utilizing 3 head and neck positions with 3 different-sized tubular laryngoscopes. The completeness of anterior glottal exposure was rated and the force required to achieve this exposure was measured with a strain gauge. Three positions relating the atlanto-occipital and cervicothoracic vertebrae were analyzed: 1) extension-extension. 2) sniffing: extension-flexion, and 3) flexion-flexion. Head and neck position and laryngoscope size were both statistically significant factors for achieving complete anterior vocal fold exposure. Regardless of the laryngoscope, the number of patients in whom complete exposure could be achieved increased gradually when the position was changed from extension-extension to extension-flexion to flexion-flexion. Complete exposure was inversely related to larger laryngoscope size. According to the data herein, the flexion-flexion position provides the best glottal exposure for endotracheal intubation in those patients who are anatomically predisposed to difficulty in direct examination of the glottis. Because this places the laryngoscope lumen in a vertical position, this position is inappropriate for microlaryngoscopy. The study reinforced the concept that the sniffing position is the optimal position for microlaryngoscopy because it enables the use of the largest-lumened laryngoscope. This facilitates ideal exposure of the anterior vocal folds, which is necessary for phonomicrosurgery.
Vascular malformations such as ectasias and varices (Es and Vs) are frequently encountered in patients who present with recurrent vocal fold hemorrhage and/or other traumatic vocal fold lesions. This study examined Es and Vs with regard to their anatomic presentation, phonomicrosurgical management, and treatment outcome. Forty-two patients (39 of them singers) were treated for a total of 87 Es and Vs: 67 of 87 (77%) were on the superior surface of the vocal fold and 20 of 87 (23%) were on the medial surface of the vocal fold. Eighty-three percent were located in the middle musculomembranous region (the striking zone), where the greatest aerodynamically induced shearing stresses occur during phonation. Treatment was performed with carbon dioxide laser cauterization (13 patients), or a new technique utilizing cold instrument excision by means of epithelial cordotomies (23 patients), while a combined approach was employed in 6 patients. Comparisons of preoperative and postoperative stroboscopy revealed improvement or no significant change in all patients in whom the cold instrument technique was used, and increased epithelial stiffness was noted in 4 of 19 patients in whom the carbon dioxide laser was used. Clearing the striking zone appears to have halted further hemorrhages by removing the the fragile Es and Vs from this injury-prone region of the vocal fold. Interpretations of stroboscopic examinations were directed at providing new insights into the biomechanical forces of vocal fold vibration that probably contribute to the genesis of Es and Vs in the vocal folds.
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