Microcirurgia de laringe no tratamento de crianças disfônicas: Quando e por que indicar
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2018-02-27
Autores
Siqueira, Dândara Bernardo
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Universidade Estadual Paulista (Unesp)
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Introdução: A disfonia afeta 10% da população infantil, com pico de incidência entre cinco e dez anos, especialmente os meninos. Após essa faixa etária, observa-se uma mudança no comportamento com predomínio no sexo feminino. Os nódulos vocais são as lesões mais frequentes, seguidas pelos cistos. Além dessas, as alterações estruturais mínimas são alterações congênitas da laringe que também provocam disfonia, como por exemplo: sulco vocal, microweb, ponte de mucosa e cisto epidérmico. Não há consenso na literatura entre os autores quanto às indicações de microcirurgia de laringe em crianças, exceto nos casos de dispnéia e/ou estridor. Objetivos: Descrever nossa experiência com microcirurgia de laringe na infância e propor um protocolo de conduta terapêutica para as lesões mais prevalentes. Material e métodos: Estudo do tipo transversal que incluiu crianças de quatro a 18 anos atendidas em um hospital universitário nos últimos cinco anos com indicação de microcirurgia de laringe após um período de tratamento fonoterápico regular. Os critérios de exclusão foram: crianças que não permitiram videolaringoscopia, que perderam seguimento ou que realizaram fonoterapia irregular ou inconstante. Os resultados do tratamento foram avaliados após seis meses da cirurgia e classificados didaticamente em três tipos: melhora total (sem sintomas vocais e videolaringoscopia normal), melhora parcial (com algum grau de sintomas vocais e/ou lesões remanescentes ao exame videolaringoscópico) ou sem melhora (persistência de sintomas vocais na mesma intensidade e/ou lesão ao exame videolaringoscópico). Resultados: Foram selecionadas 119 crianças no estudo, com predomínio no sexo masculino até os 12 anos e do sexo feminino após essa idade. Destes, 29 pacientes foram submetidos à microcirurgia (M-14; F-15) com as seguintes indicações: cistos epidérmicos (n-12), nódulos vocais (n-12), sulco vocal (n-3), ponte de mucosa bilateral (n-1) e microweb (n-1). Todas as crianças foram previamente submetidas à fonoterapia de forma regular e a indicação cirúrgica se deu após o insucesso da mesma. Das crianças com nódulos vocais, houve indicação de microcirurgia em 15,38% dos casos com desfecho favorável em 75,00% deles. Dentre as crianças com cisto vocal, todas apresentavam o tipo epidérmico e nos casos cirúrgicos foi utilizada a técnica de microflap lateral. O sucesso da cirurgia nesses pacientes foi de 83,34%. Os casos de sulco vocal e ponte de mucosa realizaram microcirurgia somente após a puberdade e em nenhum caso foi observado resultado completamente satisfatório. Um único caso de microweb teve indicação cirúrgica com melhora apenas parcial. Conclusão: Apresentamos as principais indicações e os resultados da microcirurgia de laringe adotadas em nosso serviço em crianças disfônicas. Os resultados mais favoráveis foram observados nos casos de cistos e nódulos vocais e a partir deles elaboramos um fluxograma de condutas terapêuticas, que resultou em um protocolo que poderá ser compartilhado por outros autores, a fim de se determinar o melhor tratamento para as disfonias da infância.
Introduction: Dysphonia affects 10% of children, with a peak incidence of five to ten years, especially in boys. After this age group, there is a change in behaviour with predominance in females. Vocal nodules are the most frequent lesions, followed by cysts. In addition, minimal structural alterations are congenital alterations of the larynx that also causes dysphonia, such as: vocal sulcus, microweb, mucosal bridge and epidermal cyst. There is no consensus in the literature among the authors regarding indications for laryngeal microsurgery in children. Propose: To describe our experience with childhood laryngeal microsurgery and propound a protocol of therapeutic management for the most prevalent lesions. Material and methods: A cross-sectional study including children aged four to 18 years who were attended at a hospital university in the last five years with indication of laryngeal microsurgery after a period of regular voice therapy. The exclusion criteria were: children who did not allow videolaringoscopy, who lost follow-up or who performed irregular or inconstant voice therapy. The results for the treatment were evaluated after six months of surgery and didactically classified into three types: total improvement (without vocal symptoms and normal videolaryngoscopy), partial improvement (with some degree of vocal symptoms and/or remaining lesions at the videolaryngoscopyexam) or no improvement (persistence of vocal symptoms in the same intensity and/or lesion to the videolaringocopy exam). Results: 119 children were selected inthe study, with predominance in males up to 12 years and females after that age. Of these, 29 patients underwent microsurgery (M-14; F15) due to: epidermal cysts (n-12), vocal nodules (n-12), vocal sulcus (n-3), bilateral mucosal bridge (n-1) and microweb (n-1). All children were previously submitted to regular voice therapy and the surgical indication was given after their failure. Of the children with vocal nodules, microsurgery was indicated in 15.38% of the cases with a favorable outcome in 75.00% of them. Of the children with vocal cyst, all of them presented with an epidermal cyst and in the surgical cases the lateral microflap technique was used. The success of the surgery in these patients was 83.34%. The cases of vocal sulcus and mucosal bridge performed microsurgery only after puberty and in no case was observed completely satisfactory result. A single case of microweb had surgical indication with only partial improvement. Conclusion: We presented the main indications and results of laryngeal microsurgery adopted in our service in dysphonic children. The most favorable results were observed in cases of cysts and vocal nodules, and from them we developed a flowchart of therapeutic conducts, wich resulted in a protocol that could be shared by other authors in order to determine the best treatment for childhood dysphonia.
Introduction: Dysphonia affects 10% of children, with a peak incidence of five to ten years, especially in boys. After this age group, there is a change in behaviour with predominance in females. Vocal nodules are the most frequent lesions, followed by cysts. In addition, minimal structural alterations are congenital alterations of the larynx that also causes dysphonia, such as: vocal sulcus, microweb, mucosal bridge and epidermal cyst. There is no consensus in the literature among the authors regarding indications for laryngeal microsurgery in children. Propose: To describe our experience with childhood laryngeal microsurgery and propound a protocol of therapeutic management for the most prevalent lesions. Material and methods: A cross-sectional study including children aged four to 18 years who were attended at a hospital university in the last five years with indication of laryngeal microsurgery after a period of regular voice therapy. The exclusion criteria were: children who did not allow videolaringoscopy, who lost follow-up or who performed irregular or inconstant voice therapy. The results for the treatment were evaluated after six months of surgery and didactically classified into three types: total improvement (without vocal symptoms and normal videolaryngoscopy), partial improvement (with some degree of vocal symptoms and/or remaining lesions at the videolaryngoscopyexam) or no improvement (persistence of vocal symptoms in the same intensity and/or lesion to the videolaringocopy exam). Results: 119 children were selected inthe study, with predominance in males up to 12 years and females after that age. Of these, 29 patients underwent microsurgery (M-14; F15) due to: epidermal cysts (n-12), vocal nodules (n-12), vocal sulcus (n-3), bilateral mucosal bridge (n-1) and microweb (n-1). All children were previously submitted to regular voice therapy and the surgical indication was given after their failure. Of the children with vocal nodules, microsurgery was indicated in 15.38% of the cases with a favorable outcome in 75.00% of them. Of the children with vocal cyst, all of them presented with an epidermal cyst and in the surgical cases the lateral microflap technique was used. The success of the surgery in these patients was 83.34%. The cases of vocal sulcus and mucosal bridge performed microsurgery only after puberty and in no case was observed completely satisfactory result. A single case of microweb had surgical indication with only partial improvement. Conclusion: We presented the main indications and results of laryngeal microsurgery adopted in our service in dysphonic children. The most favorable results were observed in cases of cysts and vocal nodules, and from them we developed a flowchart of therapeutic conducts, wich resulted in a protocol that could be shared by other authors in order to determine the best treatment for childhood dysphonia.
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microcirurgia de laringe, disfonia, infantil, crianças, laryngeal microsurgery, dysphonia, infantile, children