Subtotal Submucosal Arytenoidectomy with Lateralization Sutures (SMALS) Covered by a Mucosal Flap

Hagit Shoffel-Havakuk*, Yonatan Lahav, Yonatan Reuven, Yoni Shopen, Yeal Shapira-Galitz, Yaniv Hamzany

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Objective: Glottic airway stenosis (GAWS) may result from bilateral paralysis (BVFP) or posterior glottic stenosis (PGS). Since the glottis is the principal airway sphincter, surgeons shift on the balance between airway, aspirations, and voice. We aim to describe our surgical technique and outcome of the SMALS procedure for GAWS correction. Methods: A retrospective cohort of patients who underwent SMALS for PGS between 2018 and 2021. SMALS involves: endoscopic submucosal subtotal arytenoidectmy (preserving medial mucosal flap) and lateralization sutures. The sutures lateralize the mucosal flap to cover the arytenoidectomy bed without lateralization of the membranous vocal fold; expanding the posterior glottis, while preserving a relatively good voice. Covering the arytenoidectomy bed enhances healing. Medical and surgical data, airway, voice, and swallowing symptoms were collected. Relative glottic opening area (RGOA) and relative glottic insufficiency area (RGIA) were calculated. Results: Eleven PGS patients who underwent 15 SMALS were included (4 bilateral), all patients had post-intubation PGS, 1 patient also had prior radiation to the larynx. All patients were tracheostomy-dependent. There were no major complications. No granulation or retracting scar was observed at follow-up. None had a persistent voice or swallowing disability. Successful outcome (decannulation) was achieved in 8 (73%); RGOA increased in all (Δ = 0.37; p = 0.003), while RGIA remained relatively stable (Δ = 0.02; p = 0.055). Conclusions: SMALS is a safe and effective, novel modification of the classic arytenoidectomy, for GAWS correction that can be easily applied and may expand the airway without significant glottic insufficiency symptoms. Level of Evidence: 4 Laryngoscope, 134:353–360, 2024.

Original languageEnglish
Pages (from-to)353-360
Number of pages8
Issue number1
StatePublished - Jan 2024


  • airway
  • arytenoid cartilage; arytenoidectomy
  • bilateral vocal folds paralysis
  • glottic stenosis
  • lateralization
  • mucosal flap
  • submucosal arytenoidectomy


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