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Mitomycin C

Outside the field of laryngology, Mitomycin C is used more commonly as a cancer chemotherapy agent, but within laryngology, Mitomycin C is often applied by a clinician to prevent scarring after procedures like laryngeal or tracheal dilation or division of a glottic web. Topical application of Mitomycin C is used to prevent post-procedural scarring in the larynx or trachea.

A common way to apply Mitomycin C would be to take the drug in dilute form (e.g., 0.3mg per ml), saturate a cottonoid sponge with it, and then “paint” it on the area where one wants to inhibit a scarring response, holding the sponge in position for about three minutes. Mitomycin C’s mechanism of action is reported to be absorption of the drug by fibroblasts, which are then “decommissioned” from producing collagen, the major component of scar tissue.

Subglottic Stenosis, Due to Wegener’s Granulomatosis

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Subglottic stenosis, due to Wegener's

Subglottic stenosis, due to Wegener's (1 of 2)

This person has Wegener’s granulomatosis, confirmed by anti-neutrophil cytoplasmic antibodies (ANCA) testing. Here, looking from above the vocal cords, one can see an estimated 50% narrowing of the subglottic and high tracheal passageway.
Subglottic stenosis, due to Wegener's

Subglottic stenosis, due to Wegener's (2 of 2)

Viewed from within the subglottis, one can see more clearly the inflammatory nature of this stenosis. A dotted oval estimates what the normal caliber or width of this airway would be. This patient has been managed with systemic medication, but also occasional dilation, steroid injection, and Mitomycin C application.

Glottic Web Management Without A Keel

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web joining the anterior half of the vocal cords

Glottic Web (1 of 7)

More than a year after laser excision elsewhere of a small vocal cord cancer, this man has a web joining the anterior half of the vocal cords. Voice is a whisper. A simple division with a microscissor is worthwhile before contemplating something more invasive, such as insertion of a keel.
Glottic Web

Glottic Web (2 of 7)

A closer view. The dotted line indicates the proposed division. The tag of extra tissue at * in all photos is not to be disturbed, preferring to preserve all tissue until the mucosa’s vibratory ability could be assessed.
anterior vocal cords have not yet re-mucosalized

Glottic Web (3 of 7)

A week after that simple endoscopic division of the web, steroid injection, and topical mitomycin C application. The anterior vocal cords have not yet re-mucosalized. Voice is remarkably functional.
3 weeks after division

Glottic Web (4 of 7)

Approximately 3 weeks after division, voice remains very good. Compare with photo 1.
small part of the cut surface is not yet covered with new mucosa

Re-grown mucosa (5 of 7)

Only a small part of the cut surface is not yet covered with new mucosa. This photo is illuminated with narrow band (blue-green) light to accentuate capillaries on re-grown mucosa.
closed phase of vibration

Closed phase of vibration (6 of 7)

Under strobe light, the closed phase of vibration.
restoration of oscillatory ability on both cords

Restoration of oscillatory ability (7 of 7)

Open phase of vibration, showing restoration of oscillatory ability on both cords. Voice remains rough but highly functional without syllable dropouts or “effort” in the quality.

Glottic Web After Surgery

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Cyst and web

Cyst and web (1 of 4)

After surgery elsewhere, a glottic web and mucus cyst. The original laryngeal condition that led to surgery is not known.
Surgical division of web

Surgical division of web (2 of 4)

A few weeks after surgical division of the web, topical mitomycin C, early postop voice use to prevent reattachment. Voice is already noticeably improved. As expected, there is a small web re-forming, but well below the margins of the cords (at 'X').
Coagulating cyst

Coagulating cyst (3 of 4)

Given her prior bad experience with surgery, the patient was unwilling to go to the operating room to address the web, but was willing to address the cyst in the voice lab, using the Thulium laser. The cyst originates from well below the vocal cord, and can therefore be coagulated without risk to voice.
Complete healing

Complete healing (4 of 4)

Four months later, with complete healing and a residual subglottic web that does not interfere with vibration. The patient says voice improvement is “moderate” for both quality and effort required. She also noted that “people no longer ask me if I’m sick.” She does not feel the need to attempt any further improvement via trimming for better match.
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