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Clark A. Rosen, C.

Blake Simpson
Operative Techniques in Laryngology

Clark A. Rosen
C. Blake Simpson

Operative Techniques
in Laryngology
Forewords by Hans von Leden
and Robert H. Ossoff

With 390 Figures and 11 Tables

123

Clark A. Rosen, M.D.

C. Blake Simpson, M.D.

University of Pittsburgh Voice Center
UPMC Mercy Hospital
1400 Locust Street, 2100 Bldg D
Pittsburgh, PA 15219, USA
E-mail: rosenca@upmc.edu

The University of Texas Health Science Center
Department of Otolaryngology
7703 Floyd Curl Drive MC-7777
San Antonio, TX 78229-390, USA
E-mail: simpsonc@uthscsa.edu

ISBN  978-3-540-25806-3     e-ISBN  978-3-540-68107-6
Library of Congress Control Number: 2008926220
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Dedication

I have had the incredible good fortune to be blessed with supportive family, teachers, and friends. It is imperative that I
recognize the huge impact of some of these individuals on my
personal and professional development and growth. I would
like to dedicate this book to my parents, Paul Jack Rosen, M.D.,
and Shirley Maureen Orr Rosen, who worked tirelessly to provide the optimal growth environment for me and instill in me
the best possible work ethic.
Over my many years of education, I have had many wonderful teachers. However, one has had the greatest impact,
not only on my knowledge base, but also on my approach to
learning, teaching, and academic life. I would like to thank Jamie Cohen, M.D., Ph.D., for being an outstanding role model,
mentor, and friend. Eugene N. Myers, M.D. has been vital to
me from a professional and career development perspective,
for providing me the opportunity to achieve my dreams and
goals. Without his support, this book would not have been
possible. I would like to acknowledge the primal role of Blake
Simpson, M.D., in the development of this book from con-

cept to completion. I have grown as a laryngologist due to our
“mind meld” of laryngologic experience and philosophy while
writing this book together.
I am indebted to the wonderful group of teachers and colleagues with whom I have had the pleasure and privilege to
work: Gayle Woodson, M.D.; Thomas Murry, Ph.D.; Robert
Buckmire, M.D.; Lori Lombard, Ph.D.; and Jackie GartnerSchmidt, Ph.D. I would like to acknowledge the importance of
my Fellows and OR staff, without whom many of the concepts
in this book would not exist: AT, TK, PK, MJB, AF, TC, SR, SO,
NS, CP, MB, Icarus, and MLL.
Lastly and most importantly, I dedicate this book to Monica
Anne Linde, without whose support, energy and love, none of
my professional success would have been possible.
Sincerely and with deepest gratitude,
Clark A. Rosen M.D.
Pittsburgh, Pennsylvania
March 2008

Dedication

This work is dedicated to my wife, Cristina, and my twin
daughters, Juliana and Audrey. I am eternally grateful for all
the love and support you have given me.
C. Blake Simpson, M.D.
San Antonio, Texas
March 2008

Foreword

In this age of communication, the care of the human voice and
the vocal organ has assumed greater and greater importance.
The maintenance of good vocal health and the treatment of the
diseased larynx are essential for all members of society—from
heads of state to the receptionist with the golden voice on
the telephone. The necessity for the restoration of pathologic
changes in the larynx has resulted in the application of numerous operative techniques, which may bewilder the clinician.
There is a real need for a comprehensive educational resource
like Operative Techniques in Laryngology.
The two authors of this textbook, Clark A. Rosen and C.
Blake Simpson, both leading scholars and experienced surgeons at major medical centers, have created a superb treatise,
which expertly details the surgical care of different laryngeal
pathologies. The introductory chapters call attention to the
current methods of clinical evaluation for laryngeal disorders,
including videostroboscopy and flexible laryngoscopy, as well
as the medical treatment of patients with vocal problems. The
indicated preoperative measures are discussed in detail, and
the importance of anesthesia and airway management during
surgical procedures within the larynx are stressed.
Subsequent chapters advance the reader from the fundamental principals of laryngeal surgery to such major surgical
techniques as phonomicrosurgery, laser surgery, vocal fold
augmentation, and surgery of the laryngeal framework. In
successive chapters, each pathologic entity is presented in
detail, including the etiology, history, vocal quality, physical
examination, surgical intervention, postoperative care, and
potential complications. Specific microsurgical procedures are

recommended for all common benign lesions and for localized neoplasms of the vocal folds. The use of lasers is described
for stenosis of the vocal folds and circumscribed malignant
lesions.
The chapters on vocal fold augmentation include precise
information on injection techniques via microlaryngoscopy,
as well as peroral and percutaneous approaches. Specific chapters are devoted to the principles of operative care for laryngeal framework surgery. These procedures range medialization laryngoplasty or arytenoid adduction to problems more
complex such as cricothyroid subluxation, laryngeal fractures,
sulcus vocalis, and stenosis of the larynx and trachea.
The reader will be impressed with the clarity of the presentations, which is enhanced by the use of systematic headings,
and by the precision and the rich color of the illustrations within each chapter. An abundance of carefully selected references
enables the prospective surgeon to pursue further detailed information from various experts as desired. It is apparent that
the authors and the publisher have combined their expertise to
present an outstanding educational and inspirational textbook
for both the clinical otorhinolaryngologist as well as the experienced laryngeal surgeon. I shall cherish my own copy of this
exciting edition.
Hans von Leden, M.D., Sc.D.
Professor Emeritus
University of Southern California
Los Angeles, California
February 2008

patient care. Now. Drs. Gayle Woodson. Furthermore. with several of the earlier fellowship-trained laryngologists directing laryngology fellowship training programs of their own. I am further honored to be asked by Blake and Clark to write this foreword to their excellent and very important book. Operative Techniques in Laryngology fills a real void in the field of laryngology and voice care. the cycle has come full circle. Blake Simpson and Clark Rosen are excellent examples of this training model. Drs.D. This atlas represents a major contribution to our laryngology literature..M. and the reader will feel very confident using this atlas as a primary reference for managing appropriate cases in the operating theatre.D. M. Now. but also addressing the important medical information associated with the various conditions requiring the surgical procedures highlighted in this book. They have selected an outstanding group of experts in the field to whose contributions include not only the step-by-step surgical approach to the many problems covered in the atlas. D. The quality of the illustrations are excellent. resident education program libraries. Simpson and Rosen present us with a surgical atlas dedicated to and highlighting modern techniques for microlaryngeal surgery and laryngeal framework surgery. I am very proud of Blake and Clark for realizing the vision of the growing need for an atlas of surgical techniques in laryngology. laryngology fellows. Tennessee March 2008 . Guy M. it is now very common to find at least one fellowship-trained laryngologist on the full-time faculty of many of our resident education programs in otolaryngology–head and neck surgery in the United States and Canada. Woodson. Maness Professor and Chairman Department of Otolaryngology Vanderbilt University Medical Center Nashville. I am honored to have had the opportunity to serve as Blake’s fellowship mentor and to have had Clark spend a visiting fellow week at Vanderbilt during his fellowship year with Dr. Blake spent a year at Vanderbilt in fellowship with me and my colleagues. and many community-based otolaryngologist–head and neck surgeons who perform a moderated volume of laryngeal surgery in their practices.  Foreword The subspecialty of laryngology has gone through a tremendous period of growth and maturation during the past 20 years. Ossoff. and it should find its way to the office of all laryngologists. and voice care are now available at several academic health centers and private practices. Robert H. Fellowships dedicated to advanced training in laryngology. and Clark spent a year of fellowship training at the University of Tennessee with Dr. and laryngology-related research has improved because of the advances in this subspecialty promoted by this growing critical mass of individuals who have completed fellowships in laryngology and voice care after their formal residency training in otolaryngology. both Blake and Clark direct fellowship training programs at their respective institutions. neurolaryngology. The quality of resident education.

contraindications. as well as the nonsurgical treatment modalities. This surgical atlas is richly illustrated with detailed. however. and management of complications. including Marion M. step-by-step aspects of the procedure. planning. perioperative care. The book was written to provide the laryngeal surgeon with: (1) essential background information in voice disorders. This book would not have been possible without the hard work and phenomenal talent of the medical illustration team at the University of Texas Health Science Center. The laryngeal framework surgery sections include essential chapters on “open” treatment for unilateral vocal fold paralysis. (2) step-by-step surgical information for laryngeal surgery. have only been taught verbally by mentor to student. we have been honored to have leaders in our field with whom we collaborated. Within phonomicrosurgery. Rosen.D. and must always approach each patient in a holistic manner. and general otolaryngologists performing laryngeal surgery. The book encompasses a wide range of laryngeal procedures. M. for selected chapters. and thus understand the essential anatomy and pathology of voice disorders. Philipp and Irmela Bohn. David Aten. as well as Springer for valuable support from their staff. San Antonio. we feel that this book brings together a wide variety of new and exciting surgical procedures involving the larynx and upper airway. one will find important insights or pearls that. Clark A. We feel strongly that a true surgeon is a physician first. In almost every chapter. and vocal fold scar/sulcus vocalis. bilateral vocal fold paralysis. laryngeal trauma. airway stenosis (glottic. Blake Simpson. We feel that this book will become essential reading for all students of laryngology. anesthesia. not just vocal surgery. and airway considerations. We would like to personally thank these gifted and insightful individuals: David Baker.  Preface The field of laryngeal surgery for voice and airway pathologic conditions has dramatically changed over the last 20 years. Once surgery has been chosen as a treatment modality. equipment required. the surgeon must carefully consider timing. We would like to thank all of these truly gifted surgeons for sharing their knowledge and expertise. All the chapters have been designed to allow the reader to understand indications.D. subglottic and tracheal). and laser laryngeal surgery. The book provides essential “background” information of which any laryngeal surgeon must have mastery. and (3) key pearls and pitfalls about indications. surgical steps. We would like to thank our supporting staff of Diane Keane and Veronica Aleman. and bring together in one place essential information on the rapidly growing and changing field of laryngeal surgery. colorful artwork as well as essential photographic documentation. . In closing. and Chris McKee. 8 and 9. and postoperative management of laryngeal surgeries. detailed information is provided regarding surgery for benign and malignant vocal fold lesions. We have written each chapter of this book. C. and it has been organized around the broad categories of phonomicrosurgery and laryngeal framework surgery. vocal fold augmentation. These important issues are reviewed in Chaps. until now. M. This supports the concept of vocal medicine. and the impetus for this book was to reflect these major paradigm shifts.

M. Chap. Jr.  Acknowledgements The authors wish to thank the following individuals for their important contributions to the book: Kristin J. Michael King. Carter Wright.D. 39 Each one of these individuals contributed a portion of the chapter’s contents or supplied the initial draft prior to editing.D. Without their support. M. and reviewing surgical photos from multiple perspectives. 23 Robert Eller. 1 Phillip Song. The illustrators went the extra mile.D. Green. 2 Scott M. the highest quality laryngeal surgical illustrations to date.D. M. this book would not have been possible. .. M. M.D. M. attending surgical procedures. Their efforts ultimately resulted in. The authors would like to thank the superb team of medical illustrators at the University of Texas Health Science Center. Chap. 34 S. Chap. Their mastery of laryngeal anatomy and the surgical perspectives of laryngeal surgery are without peer.D.. studying cadaveric specimens. Chap. San Antonio: David Baker David Aten Chris McKee These individuals worked closely with the authors over a fouryear period during the writing of this book. 25 J.. Otto. Chap.. Chap.. The authors wish to express thanks to the following companies for their financial support in the making of this book: Olympus Surgical Medtronic ENT Kay Pentax Karl Storz Endoscopy America Salary support for the medical illustrators was significantly funded though generous donations from these corporations... Chap. we believe. 13 Paolo Pontez.

. . . . . . . . . . . . . . . . . . . . . . . .   9 Introduction  .   12 Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Microanatomy of the Vocal Fold  . . . . . .   27 Selected Bibliography  . . . . .1 4. . . . . . . . . . . .   14 Selected Bibliography  . . . . . . . . . . . . . . . .   20 Pathological Conditions of the Vocal Fold  . . . .5 1. . . . . . . . . . . .3 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phonation  . . . . . . . . . . .4. . . . . . . . . . . Physiology  .2 4. . . .   9 Fundamental and Related Chapters  . . .   17 Introduction  .3 3. . . . . . .5 2. . . . . . . . . . and Phonation  . . . . . . . . . . . . . . . . . . . . .3 3. . . . . . . . . . . . .11 2. . .5. . . . . . . . . . . Laryngeal Cartilages  .   9 Gathering a Patient History  . . . . Intrinsic Laryngeal Muscles  . . . .3. . . . .   11 Occupational History  . . . . . . . . . . . .1. . . . .3. .   19 Recording of Laryngeal Examination  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. . . . . . . . . . . . .9 4. . . . . . . . .1. . .   11 Listening to the Voice  . . . .   9 Past Medical History  .1. . . . .3. Major Laryngeal Functions: Lower Airway Protection. . . . . . . . . . .4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 4. . . . . . .2.   17 Fundamental and Related Chapters  . . . . . .1.   25 Polypoid Corditis (Reinke’s Edema)  . . . . . . . . . . .2 1.1. . . . . . . . . . . . . . . .  Contents Part A Clinical Evaluation of Laryngeal Disorders 1 1. . . . . .5 4. . . . Cricoid  . . Laryngeal Joints  . . . . .4 3. . . . . . . . . . . . . . . . . . . . Accessory Cartilages: Cuneiform and Corniculate  . . . . . . . .1 3. .1.   9 History of Present Illness  . . . . . . . .1 4.1. . . . . .1 3. . . . . . . . . . . . . .1. . .1. . . . . . . . . . . . . . . . . . .3 4. . . . . . . . . . . . . . . . . . .   27 . . .   11 Social History  . . . . . .   14 3. . . .7 2. . Cricothyroid Joint  . . . . . . .4. . . . . . . .1 1. . . . . . .1. . . . . . . . Key Points  . . . .   21 Dysplasia–Carcinoma in Situ of the Vocal Folds  .   17 Dynamic Voice Assessment with Flexible Laryngoscopy  . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . .3. . . . .   24 Vocal Fold Polyp  . . . . . . .   19 Larynx (Global)  .1 1. . . . . . . . . . . . .   12 Professional Speaking/Singing Voice  . . . . . . . . . . . . . . . . . . . . . . . . . . . .   21 Epithelial Pathology of the Vocal Folds  . . . . . . . Quadrangular Membrane  . . . . . . . . .5. . . . . . . . . .1. . . . . . . . . . . .8 2.   26 Vocal Fold Scar and Sulcus Vocalis  . . . .   23 Vocal Fold Nodules  .12 Anatomy and Physiology of the Larynx  . . . . . . . . . . . .1. . . . . . . . . . . . . . . .   26 Vascular Lesions of the Vocal Folds  . . . . .   24 Reactive Lesion  .   18 Nasopharynx  . . . . Extrinsic Laryngeal Muscles  . . Innervation  . . . . . . . . . . .   21 Introduction  . . . . . . . . . . . . . .4. . . . . . . . . . . . . . . . . . . . . .2. . . . . .   19 Vocal Fold (Focal)  . . . . . . . . . . . . . . . . . . . .1. . . . . . . . .   22 Benign Diseases of the Vocal Fold Lamina Propria  . . . . .2 2.1. . . . . . . . . . . . . . . . .   19 Key Points  . . . . . . . . . . . . . . . . 3  3  3  3  3  3  3  3  4  4  4  4  4  4  5  5  5  5  6  6  6  7  7  7  8  8 Principles of Clinical Evaluation for Voice Disorders  . . . . . . Vasculature  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cricoarytenoid Joint  . Laryngeal Musculature  . . .   24 Fibrous Mass (Subepithelial)  . . . . .   23 Vocal Fold Cyst (Ligament)  . . . . . . . . . . . Respiration. . . . . . . . . . . . . . . .2 1. . . . . . . . . . .1 2 2. .   27 Key Points  . . . .6 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 2.5 Videostroboscopy and Dynamic Voice Evaluation with Flexible Laryngoscopy  . . . . . . . . . . . . . .   21 Fundamental and Related Chapters  . . . .   25 Rheumatologic Lesions of the Vocal Folds  . . . . . . . . . . .2 4. . . . . . .   20 Selected Bibliography  . .   19 Base of Tongue  .   23 Overview of Midmembranous Vocal Fold Lesions  . . . . . . . . . . . . . . . . . . . . . . . . .1 1.3 1. . . . . . . . . . .8 4. . . . . .2 4. . . . . . . . . . . .1 1.4. . . . . . . . . . . . . . . . . . .1. . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. . . . . . . . . . . .1. . . . . . . . . . . . . .3 4. . .4. . . . . . . . . . . . . . . . . . . . .   21 Recurrent Respiratory Papillomatosis of the Larynx   . . . . . Arytenoid   .   22 Carcinoma of the Vocal Fold  . . . . .4. . . . .4. . . . . . . .5. . .1. .1. . . . . . . . . . . . . .5 1.4. .   23 Vocal Fold Cyst (Subepithelial)  . . . . . . . . . . . . . .6 4. . .6 2. . . .   11 Perceptual Analysis  . . . . . . .4 2. . . . . . .9 2. . . . . . . . . . . . . . . . . . . . . . .2 1. . . . .3 4. . . . .4 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1. . . . . . . . . . . . . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 1. . . . . . . . . . . . . . . . . . . . . . . . . . . .   25 Vocal Fold Granuloma  . . . . . . . . . .   10 Past Surgical History  . .1 1. . . . . .4. . . .2 3. . . . . . .4 3.7 1. . . . . . . . . . . . . . . . . . . . .2 1. . . . .4 4. . . . .3 4. .4.1 1. . . . . . . . . . . . . . . . . . . . . .2 4. . . . . . . . .4 1. Selected Bibliography  . .2. . . . . . . . .3. . . . .4. . Conus Elasticus  . .   24 Fibrous Mass (Ligament)  . . . . . . . .1. . . . .2. . . . .7 4. . . . . . . . . . . . . . . .5 4 4. . . . . . . . . . . . . . . . . . . . . . . . . . . .1 4. . . .1. . . . . Thyroid  . . . . . . . .4.5. . . .2 1. . . . . .1 1. .5. . . . . . . . . Fibroelastic Tissue of the Larynx  . . . . .   23 Approach to Midmembranous Vocal Fold Lesions  . . .2 3.3 1. . . . . . . . . .   17 Surgical Indications and Contraindications  . . . . . . . .4 4. . . . . . . . . . . .5 4. . .   12 Quality-of-Life Questionnaires  . .1. . . . . . . . . . . . . Epiglottis  . .1 2. . . . . . . . . . . . . . . . . . Anatomy  . . . . . . .4 4. . . . . .   25 Miscellaneous Disorders of the Vocal Fold  . . . . .   21 Leukoplakia of the Vocal Fold  . . . . .

  58 .1 5. . . . . . . . . . . . . . . . . . .2 Air-Flow Measures  . . . . . .   43 Vocal Fold Granuloma  . . . . .2 6. . . . . . .   38 6. . . . . . . . . . .2 5. .7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   33 Physical Examination  . . . . . . . . . . . . . . . . . . . .5. . . . . . .2 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   50 Informed Consent Regarding Phonosurgery   . . . . . . . . . . . . .   35 Glottic and Subglottic Stenosis: Evaluation and Surgical Planning  . . . . .   33 History  . . . . . . . . . . . . . . . . .5. . . . . . . . . .   49 Key Components to Successful Care of Patients with Voice Disorders  . . . . . . .   55 Anesthesia for Laryngeal Framework Surgery  . . .   39 6. . . . . . . .   32 Serology  . . . . . . . . . . . . . . . . . . . . .5 Glottic and Subglottic Stenosis: Physical Examination  . . .   42 7 7. .6. . . . .6. . . . . . .7. . . . . . . . .   47 Key Points  . . . .   40 6. . . . . . . . . .7. . . . . . . . . . . . . . .3 8. . . . . . . . . . . . . . . . .   48 Selected Bibliography  .   40 6. .   38 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . .   29 Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . .1 Local Anesthesia Techniques for Examination  . . . . .   42 Criteria for External Treatment of Glottic/ Subglottic Stenosis  . . . . . . . . . . . . . . . . . . . .8 5. . . . .1 Fundamental and Related Chapters  . . . . . . . . . . . . . .   41 Criteria for T-Tube Stenting for Subglottic Stenosis  .1 Symptoms/Time Course  . . . . .6. . . . . . . . . . . . . . . . . . . . . . .2 5. . .3 Radiographic Studies  . . . . . . . . . .1 5. . . . . . . . .2 5. .   51 Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . .   37 6. . . . . . . . . . . . . . . . . . .   38 6. .   41   6. .   38 6. . . . . . .   45 Muscle Tension Dysphonia  . . . . . . . . . . . . . . . . . . . . . . . . . . .   46 Allergy and Voice Disorders  . . . . . . . . . . . . . .   49 Decision Making in Phonosurgery  .5. . . . . . . .4. .4 5. . . . . .7 Glottic and Subglottic Stenosis: Surgical Planning  . . . . . . . . . . . . . . . . . . .3 7. . . . . . . . . . . . . . . . . . . .   37 6. . . .6. . . . . . . . . . . . . . . . . . . . .   45 Essential Tremor  . . .   42 Key Points  . . . . . . . .   43 Surgical Indications and Contraindications  . . . . . . . .8 7. .6 Anesthesia and Airway Management for Laryngeal Surgery  . . . . . . . . . . . . .1 Corrective Surgical Procedures for Glottic/ Subglottic Stenosis   . . . . . . . . . . . . . . . . . .6 7. . . . . . . . . .1 7. . . . . . . . . . . . . . .4 Laboratory Testing  . . . . . .1 9. . . . . . .5 7. . . . . . . . Paresis. . . .   54 Special Circumstances: Difficult Exposure of the Larynx  . . . . . . .   45 Spasmodic Dysphonia  . . .1 8. . . .7. . . . . . . . . . . . . .5. . . . . . . . . .2 7. . . . . . . Planning. . . .8. . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . .6. . . . .6. . . . . . .4. . . . . .3. . . . . . . . . . .5 9. . . . . . . . .4 7.   45 Parkinson’s Disease  . . . . . . . . . . . . . . . . . . . . . . . . . . . . History. . . . . . Audio Recording)   . . . . . . . . . . . . and Decision Making in Phonosurgery  . . . . . . .   53 Fundamental and Related Chapters  . .2 7. .   44 Neurologic Disorders  . . . . . . . . .4 Criteria for Endoscopic Treatment for Subglottic Stenosis  . . . . . . . . . . . . . . . . . . . . . . .10 Nonsurgical Treatment of Voice Disorders  . . . . . . . .   37 6.4 7. . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . .7. . . . . .   34 Workup  . . . . . . . . . . . . . . . . . . . . . . . . . . .   40 6. . . .   53 Surgical Indications and Contraindications  . . . . . . . . . . . .3 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   45 Paradoxical Vocal Fold Motion Disorder   .   58 Key Points  .5 7. .7 7. . . . . . . . . .   49 Preoperative Considerations for Phonomicrosurgery  . . . . . . . . . . . . . . . . . . . . .   33 Etiology  .   38 6. . . . . . . . . . . . . . . . .2 5. . . . . . . .3 Etiology of Glottic and Subglottic (Laryngotracheal) Narrowing  .2 8. . .   38 6. . . . . .   49 Timing of Phonomicrosurgery  . . . . . .1 Voice Evaluation (VHI-10. . . . . . . . . . . . . . . . . . . .   37 6. . . . .   32 Unilateral Vocal Fold Paralysis: Treatment  . . . . .7. . . .4 Glottic and Subglottic Stenosis: History  . . . . . . . .1 5.   53 Equipment  . . . .4. . . . . . .   32 Unilateral/Bilateral Vocal Fold Paresis  . . . . .2 5. . . . . . . . .1 5. . . . . . .   34 General Considerations  . . . . . . .8. . . . . . .   46 Medications and Their Effects on Voice  . . . . . .2 Documentation of Examination  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   34 Key Points  . . . . . . . . . . .   41 6. .   30 Unilateral Vocal Fold Paralysis: Physical Examination  . . . . .6. . . . . . . . . .1 5. . . .4 9. . . . . . . . . . . and Physical Findings  .3. . . . . . . . . . . . . . . . . . . . .4 5. . . . . . . . . . .3 5.   46 Vocal Hygiene   . . . . . . . . . . . . . . . . . . .   29 Etiology  . . .   34 Selected Bibliography  . .   32 Imaging Studies  . . . . . . . . . . . . . . . . . . . . .1 5. .5 5. .5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   46 Postviral Vagal Neuropathy  . . . . . . . . . . .   51 Selected Bibliography   . . . . . . . . .   31 General  . . . . . .3 5. . . . . . . . . . . . . . . . . . . . . .   29 Surgical Indications and Contraindications  .1 5. . . . . . . . . . .4. . . . . . . .2 Introduction  . . . .3 Glottic Insufficiency: Vocal Fold Paralysis. .5 9 9. .   53 Principles of Airway Management: Subglottic and Tracheal Stenosis  . . . . . . . . . . . .   40 6. . . . . . . . . . . . . .   33 Diagnostic Workup   . . . . . . . . . . . . . . . . .6 Additional Studies for the Evaluation of Glottic/Subglottic Stenosis  . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Flexible Laryngoscopy/Tracheoscopy Protocol  . . . . . . . . . . .3 6. . . . . . . . .6 5. . . . . .   48 8 Timing. . . . . .7. . . .   43 Infectious and Inflammatory Disorders  . . . . . . . . . . . .7 5. . . . . . . . . . . . .7.   40 6.   34 Etiology.   49 Surgical Indications and Contraindications  . . . . . . . . . . . .1 8. . . . .6. . . . . . .   30 Vocal Quality and Swallowing  . . . . .   33 Treatment  . . . . . . . . . . . . . . . .8. . . . . . . . . .2 8. . . .6. . . . . . . . .4 8. . . . . . . . . .5 5. . . .   33 Presbylaryngis/Age-Related Changes in the Larynx  . . . . . .1 7. . .2. . . . . . . . . . . . . . .9 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   37 6. . . . .1 Common Clinical Conditions and Associated Risk Factors  . . . . . . . . . .   47 Role of the Speech–Language Pathologist in Voice Therapy  . . . . . . . . . . . . . . .2 Medical Comorbidities  . . . . . . . . . . . . . . . . . . . . . . . . .   51 6 8. . . . . . .   43 Introduction  . .   31 Unilateral Vocal Fold Paralysis: Workup  . .   49 Fundamental and Related Chapters  . . . . . . . . . . . . . .6 7. . . . . . .XVIII Contents 5 5. . .7. . . . . . . . . . . and Atrophy  . . . . . . . . .   29 Unilateral Vocal Fold Paralysis  . .   42 Selected Bibliography  .   58 Selected Bibliography  . . . .6. . . . . .3 9. . . . . . . . . . . . . . . . .   31 Laryngeal  . . . .   43 Fundamental and Related Chapters  . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .  Contents Part B Phonomicrosurgery for Benign Laryngeal Pathology I Fundamentals of Phonomicrosurgery 10 10. . . . . . . . . . . . . . .1 Overview  . . . . . . . . . . . . . . . . . .5 10. . . . . .4 10. . . . . . . .2 Categories of Vocal Fold Augmentation Materials  . . . . . . . . . . . . . . . . . . . . .4 10. . . . . . Key Points  . . .1 10. . . . . . . .1 11. . . . . . .6. . . . .1 13. . . . . . . . . . . . . . . . . . . . .4. . . . . . . 14. . . . . . . . . . . Vocal Fold Augmentation: Advantages. . . . . . . . . .5. . . . .   99 Surgical Equipment  . .6. . . . . . . . . . .   103 Vocal Fold Nodules  . . . .2 13. . .5.   82 Key Points  . . . . . . . . . . . . . . . .   68 Suspension Device   . .   99 Surgical Indications and Contraindications  . . . . . . . . . . . . . .3 10. . . . . . . . . . . . . .   67 Anesthesia   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Laser Fire  . . . . . . . . . . . . . . . . . . . . .   68 Laryngoscope Placement  . . . 14. . . . . . . . . . . . . General Guidelines (Fig. . . . . . .   79 Management and Prevention of Complications Related to Phonomicrosurgery  . . . .   63 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . . . . . . Equipment: Laser Microlaryngoscopy Setup  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 10.3 11. . 13. . . . . . . . . . . . . . . . .   83 Principles of Laser Microlaryngoscopy  . .7. . . . . . . . . . . . . .   63 Fundamental and Related Chapters  . . .3 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 13. . . . . . . . 13. . . . . . . . .2 15. . . . .   78 Intralaryngeal Steroid Injection to Soften Postoperative Scar in the Vocal Fold  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   103 Key Points  . . . . . . . . . .1 Principles of Phonomicrosurgery  . . . 14. . . . . . . . . .5 13. . . . .   71 Telescopic Evaluation of Vocal Fold Pathology  . . .5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   85 Laser Physics  .   105 Surgical Procedure  . .2. . . . . .   67 Patient Position  . . . . . . . . .4 13. . . . .1)  . . Disadvantages. . . . . . .1 16. . . . . . . . . . . . . . . .2 13. . . . . . .7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   78 Postoperative Voice Rest  . . . . . . . . . . . . . . . . .3 16. . .4. . .5 10. . .3 12. . . . . . . . . . . . . . . .1 14. . . . . . . . . . . . . . . . . . .3 Description of Vocal Fold Augmentation Materials Characteristics  . .   78 Postoperative Voice Care  . . . . . . . . . . . . . and Methods  . . . . . . . .   72 Microflap Approach to Submucosal Pathology  . . . . . . . . Key Points  . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . .   106 . . . . . . . . . .1 15. . .7 10. . . . . .2 16. . . .5 11. . .   99 Disease Characteristics and Differential Diagnosis  . . . . . . . . . . .   77 Timing of Phonomicrosurgery   . . . . . . . . . .   79 Selected Bibliography  .   99 Surgical Procedures  . . . . .2. . . . . . . CO2 Laser Settings  . . . . . .   99 Fundamental and Related Chapters  . . . . . . Types of Laser   . . .5. . . . . . . . . . . . . . . . .   63 Introduction  . . .5 15. . . . .6 16 16. . . . . . . . . . . . . . . . . . Techniques. . . . . . . . . . . . . . . . . . . . . . . . . .2 15 15. . . .   75 Perioperative Care for Phonomicrosurgery  . . . . and Clinical Utility   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   73 Postoperative Care and Complications  . . . . . . . . . . . . . . . . 14. . . . . . . . . . . . . .   105 Disease Characteristics and Differential Diagnosis  . . . . . . . . . . . . . . . . . .3 13. . .4. . . . . . .1 12. Fundamental and Related Chapters  . . . . . . . . . . . . . .4 Characteristics of Vocal Fold Augmentation Materials  . . . . . . . . . . . .4 12.   81 Overview of Management and Prevention of Complications Related to Phonomicrosurgery     81 Surgical Indications and Contraindications   . . . . . . . . . . . . . .   77 Considerations for the Day of Phonomicrosurgery   . . . . . . . . . . .   85 Wavelength  . .   91   91 14 14. . . . . . . . .   105 Surgical Equipment  . . . . . . . . . . . .3 15. . . . . . . . .   78 Key Points  . . . . . . . . . .1 13. . . . . 13. . Delivery Systems  . . . . . . . . . . . . . . . . . . . . . .   70 External Counter-Pressure  . . . . . . . . . . . . . . . .   85 XIX 13. . . . . . . .3 Surgical Indications and Contraindications  . . Protecting Surrounding Tissue from Laser Damage  . . . .8 10. . . . . . . . . . . . . . . . . . . . . . . CO2 Laser Safety Guidelines  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   105 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . .   65 Phonomicrosurgery Procedures.   77 Fundamental and Related Chapters  . . . . . . .4 11. . . . .6 11. . . . . . . .2 10. . . . 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Tracheal Perforation  . . . . . . .2 12. . 13. . . . . . . . . . . . . . Selected Bibliography  . . . . . . . . . . . .5   88   88   89   89   89   89   89   91   91   92   92   92   92   94   95   96 II Phonomicrosurgical Voice Procedures Vocal Fold Polyp  . . . Surgical Principles   . . . . . .   75 Key Points  . . . . . . .2 10. . . . . .6 11 11. . . . . . . . . .5 13 13. . . . . . . . . .   85 Fundamental and Related Chapters  . . . . . . . .2 Tissue Interaction  . .4 15. . . . . . . . . . . . .2 13. . . . . . . . . .   103 Selected Bibliography  .   75 Selected Bibliography  . . .7 Complications and Their Treatments  . . . . . . .   81 Fundamental and Related Chapters  . . . . . . .   63 Equipment for Phonomicrosurgery  . . . . . . .   100 Postoperative Care/Complications  . . . . . . . .   105 Fundamental and Related Chapters  . . . . . . . . . . . . . . . . Surgical Indications and Contraindications  . . . . . . . . . . . . . . .5 General Principles of Vocal Fold Augmentation  . . . . . . . . . . . . . . . . . . . . . . . . . . Selected Bibliography  . . . . .5. . . . . . . .   81 Postoperative Dysphonia   . .2 11. . . . . . . . . . . . . . . . . . . . . . . Safety Protocol  . . . . . .2.5. . .5. . . . . . . . . . . . . . . .5. . . . . . . .4 13. . . . . . . . .6 10. 13. . . . . .5. . . . . . . . .1 13. . . . . . . . . . . . . . . . . . . .   77 Surgical Indications and Contraindications  . . . . .5. . . 14. . . . .   81 Medical Complications Associated with Phonomicrosurgery   .   85   85   86   86   87   87   87   88   88   88   88 Principles of Vocal Fold Augmentation  .4 16. . . . . . .   82 Selected Bibliography  . . . . . . .   71 Operating Microscope and Surgeon Ergonomics  . . . .7 12 12. . . .3 10. . . . . . . . . . . .6. . . . . . . . . . .5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Smoke Evacuation  . . . . . . . . . . . . . . .3 Maintenance of a Clean Surgical Field  .6 13. . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 23. . . . . . . . . .   119 Surgical Equipment  . . . . . . .1 18. . . . . . . . . . . . . . . . . . . . . . . . . .   141 Fundamental and Related Chapters  . . . . . . . .2 25. . . . . . .   159 Fundamental and Related Chapters  . . . . . . . . . . . . . . . . . . . . . . . .   119 Surgical Procedure  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   126 Selected Bibliography  .   153 Selected Bibliography  . . . . . . . . . . . . . . . . . . . . . . . . . . .3 17. . . . . . . . . . . . . . . . . .   129 Surgical Indications and Contraindications  .   109 Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . .1 24. . . . . . . . . .   150 Endoscopic Management of Teflon Granuloma  . . . . . . . . . . . . . .   120 Postoperative Care and Complications  . . . . . . .   121 Selected Bibliography   . . . . . . . . . . . . . . . . . . . . . . . . . .   109 Surgical Indications and Contraindications  . . . . . .1 25. . . . . . . . .3 23. . .   119 Fundamental and Related Chapters  . .4 17. . . . . . . . . . .2 22. . . . . . . .1 23. . . . . . . . . . . . . . . . . . . . . . . .1 17. . . . . . .1 19. . . . . . . . . .2 21. . .   151 Surgical Procedure  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 18. . . . . . . . . . . . . . . . . . . . .3 25. . . . . .4 24. . . . . . . .   109 Postoperative Care and Complications   . . .   113 Fundamental and Related Chapters  . . . . .   134 Selected Bibliography  . . .   141 Disease Characteristics and Differential Diagnosis   . . . . .   151 Postoperative Care and Complications  . . .6 23 23.5 17. . . . . . . . .   154 Endoscopic Excision of Saccular Cyst  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   113 Disease Characteristics  . . . . . . . . . . . . .   129 Fundamental and Related Chapters   . . . . . .XX Contents 16. . . . . . . . . . .   143 Postoperative Care and Complications  . . . . . . . .   123 Surgical Equipment  . . .   116 Key Points  . .   150 Selected Bibliography  . . . . . . . . . . . . . . . . . . . . . . .3 19. . . . . . . . . . . . . . .5 21. . . . . . . . . . . . . . . . . . . . . . . . . .   107 Selected Bibliography  . . .   119 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . . . . . . . . .2 17. . . . . . .6 Polypoid Corditis  . . . . . . . . . . . . . . . . . . . . . . .6 Postoperative Care and Complications  . . . . . . . . .   133 Key Points  . . . . . .6 20 20. . . . . . . . . . . .   139 Selected Bibliography  . . . . . . . . . . . .   119 Disease Characteristics and Differential Diagnosis  . .2 23.   107 Key Points  . . . .   116 Selected Bibliography  . . . . . . . . . . . . . . . . . . . . .3 Vocal Fold Leukoplakia and Hyperkeratosis    123 Fundamental and Related Chapters  . . . . . .   151 Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 20. . . . .6 24 24. . . .   123 Surgical Indications and Contraindications  . . . . . .   109 Fundamental and Related Chapters  . . . . . . . . . . .   113 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . . . . . .   141 Surgical Indications and Contraindications  .5 22. .2 24. . . . . . . . . . . . . . . . . . . .4 22. . . . . . . . . . . . . . . . . . . . . . .   151 Disease Characteristics and Differential Diagnosis  . . . . .   136 Surgical Procedure   . . . . . . . . . . . . . . . . . . . . .6 Surgical Equipment  . .   127 Surgical Treatment of Recurrent Respiratory Papillomatosis of the Larynx  . . . . . . . . . . . .   112 Selected Bibliography  . .4 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   150 Key Points  . . . . . . . . . .1 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   153 Key Points  . . . . . . . . . .   113 Surgical Equipment  . . . .   159 . . . . . . . . . . . . .   114 Postoperative Care and Complications  .   158 Anterior Glottic Web  . . . . .   135 Diagnostic Characteristics and Differential Diagnosis of Vocal Fold Varicosities  . . . . .   129 Disease Characteristics and Differential Diagnosis  . . . . . . .   112 17. . . .   107 17 Vocal Fold Cyst and Vocal Fold Fibrous Mass  . . . .   121 Key Points  . . . . . . . .   135 Fundamental and Related Chapters  . . . .   123 Surgical Procedure  . . . . . .   138 Key Points  . . . .5 25. . . . .5 24. . . . . . .6 18 18. . . . . . . . . .   123 Diagnostic Characteristics and Differential Diagnosis  . . . . . . .4 19. . . . . . . . . . . . . . . .5 20.   117 19 19. . . . . . . . . . . . . .   155 Fundamental and Related Chapters  . . . . . . . . . . . . . . . . . . .   156 Postoperative Care and Complications  . .   130 Postoperative Care and Complications  .6 25 25. .   142 Surgical Equipment  . . . . . . . . . .   155 Disease Characteristics and Differential Diagnosis  . . . . . . . . . . . . . . . .6 21 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 19. . . . .   156 Surgical Procedure for Saccular Cyst   . . .   109 Diagnostic Characteristics and Differential Diagnosis   . . . .3 22. . . . . .   135 Surgical Indications and Contraindications   . . . . . . . . . .   155 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . .   151 Surgical Indications and Contraindications  . . . . . . . . . .3 24. . . . . . . . . . .4 23.   139 22. . . . . . . . .   123 Postoperative Care and Complications  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   151 Fundamental and Related Chapters  . . . . . .   136 Postoperative Care and Complications   . . . . .4 20.   157 Key Points  . . . . . . . . . . .   121 19. . . . . .3 18. . . . . . . . . . .   109 Surgical Procedure  . .2 18. . . . .6 26 26. . . .   129   21. . . . . . . . . . . . . . . . . . . . . . . . . .   111 Key Points  . . . . . . . . . . . . . . . . .   126 Key Points  . . .1 21. . . . .3 20. . . .2 Vocal Fold Granuloma  . . . . .1 Vocal Fold Scar and Sulcus Vocalis  . . . . . . . .   143 Surgical Procedure  . . . . . . . . . .   156 Surgical Equipment  .   114 Surgical Procedure  . . . .4 21. . . . . . . . . . . . . . . . . .   134 22 Surgical Management of Vocal Fold Vascular Lesions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 18. . . . . .2 20. . . . . . . . .   158 Selected Bibliography  . . . .   136 Surgical Equipment  . .   130 Surgical Procedure  . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .   181 29. . .   189 Key Points  . . . . . . . . . . . . . . . .4 Surgical Equipment   . . . . . . . . . . . . . . .   205 Fundamental and Related Chapters  . . . . .   191 Surgical Equipment  . . . . . . . . . . . . . . . . . . . .   173 Posterior Glottic Stenosis: Endoscopic Approach  .2 Disease Characteristics and Differential Diagnosis  . . .   180 29 Subglottic/Tracheal Stenosis: Laser/ Endoscopic Management  . . . . .5. . . . . .   191 30. . . .2 28. . . . . . . . . . . . . . . . .   202 Key Points  .   199 Endoscopic Vocal Fold Injection  . . . . . . . . . . . . . .   159 Surgical Equipment  . . . . . . . . . . . . . . . . . . . .6 IV Laryngeal Injection Techniques 31 31. . . . . . . . . . . . . . . .   213 Key Points  . . . . . . . . . .4 26. . . . . . . . .   190 30 30.5 32. . . . . . . . . . . . . . . . . . . . . . . . . .2 30. . . . . . . . .5. . . . . . . . . . . . .1 28. . . .   198 Vocal Fold Augmentation via Microlaryngoscopy  . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . .2. .6 27 27.   205 Surgical Equipment  . . . . .3 Surgical Indications and Contraindications  . . . .   203 Selected Bibliography  . . . . . . . . . . . . . . . .   185 29. . . . . . . . . . . . . . . . .5 31. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 27. .3 26. . . . . . . .   205 Surgical Procedure  . . . . . . . . . . . . . . .   167 Fundamental and Related Chapters  . . . . .4 Surgical Equipment  . . . . .   197 Fundamental and Related Chapters  . . . . . . . . . . . . .1 Fundamental and Related Chapters  . . . . . . . . . . . . .   159 Surgical Procedure  . . .4 31. . . . . . . . . . . . . . . . . . . . . . . . . .   191 Surgical Procedure   . . . . . . . . . . . . . . . .  26. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 31. . . . . . .   167 Surgical Equipment  . . . . . . . . . . . . .   197 Surgical Indications and Contraindications  . . .   168 Surgical Procedure   . . . . .   176 Postoperative Care  . . . . . . .1 31. . . . . .   185 29. .   159 Surgical Indications and Contraindications  . . . . . .1 Suitability for Peroral Vocal Fold Augmentation in the Clinic Setting  . . . . . . . . . . .3 31. . . . . . .4 31. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   171 Key Points  .   185 29. . . . . . . . . . . . . . . . . . . . . . . . . .2 31. . .   189 29. . . . . . . . . . . . . . .5.1 31. . . . . . . . .   205 Postoperative Care and Complications  .   209 33. . .1 Fundamental and Related Chapters  . . . . . . . . .   203 Superficial Vocal Fold Injection  . . . . . . . . .4 28. . . . . . . . . . . . . . . . . . . . . . . . . .3 32. . . . . . . . . . .   175 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . .   205 Surgical Indications and Contraindications  . . . . . . . . .   182 29. . . . .3 31. . .   164 III Laser Microlaryngeal Surgery (Airway/Neoplastic Conditions) Bilateral Vocal Fold Paralysis  . . . . . . .4 32. . . . . . . . . . . . . .   189 Selected Bibliography  . . . . . . . . . . .5. . . . . . . . . . . . . . . . . .5 30. . . .3 28. . . . .   209 33.6 Postoperative Care and Complications  . . . . . . . . . . . . . . . . . . .4 30. . .1 Carcinoma of the Vocal Fold  . . . . . . . . . . . . . . . . . . . . . . .   200 Postoperative Care and Complications  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   191 Surgical Indications and Contraindications  . . . . . . . . . . . .   175 Diagnostic Characteristics and Differential Diagnosis  . . . . . . . . . . . .   197 Disease Characteristics   . . . . . . . . . . . . . . . . . . .2 26. . . . . . . . . . . . . . . . . . .   176 Surgical Procedure  . . . . . .6 33 Disease Characteristics and Differential Diagnosis  . . . . . . . . . . . . . . . . . . . . . . . . . .   209 33. . . . . .   164 Selected Bibliography  . . . . . . . . . . . . . .2 32. . .6 Contents Disease Characteristics and Differential Diagnosis  .11 Special Considerations in T-Tube Stenting  .10 Postoperative Care  . . .   193 Vocal Fold Augmentation via Direct Microlaryngoscopy  . . . . . . . . . . . . . . . . . . . . . . .   191 Fundamental and Related Chapters  . . . . . . .5 26. . . . . . . . . .6 Postoperative Care and Complications   . . . .   213 XXI . . . . .   209 33. .   213 Selected Bibliography  .1 27. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   181 29. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   198 Surgical Equipment  . .   179 Key Points  .   205 Disease Characteristics and Differential Diagnosis   . . . . . . . . . . . . . . . . .   210 33. . . .8 Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . .   173 Selected Bibliography  . . . .   206 Key Points  . . . . . . . .   197 Material Selection  . . . .3 30. . . . . . . . . . . . . . .   192 Key Points  . . . .   181 29. . . . .2 27. . . . .   164 Key Points  . . . .   207 Selected Bibliography  . . . .   182 29. . . . . .   192 Postoperative Care and Complications  . . . . . . . . . . . . .   175 Fundamental and Related Chapters  . . . . . . . . . . . . . . . . . . .6 32 32. . . . . . . . . . . . . .   167 Surgical Indication and Contraindications  . . . . .   179 Selected Bibliography  . . . . . . . . . . . . . . . . . . . . . . . . . .1 31. . .   168 Postoperative Care and Complications  . . . . .4 27. . . . . . . . . . . .5 Surgical Procedure  .   193 Selected Bibliography   . . . . . . . .3 Surgical Indications and Contraindications   . . . . . . .   167 Disease Characteristics and Differential Diagnosis  . . . . . . .   198 Surgical Procedure   . . . . . . . . . .   198 Principles of Deep Vocal Fold Augmentation  . . . .   210 33. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   160 Postoperative Care and Complications  . . . . .   181 29. . . . . .6 28 28. . . . . . . . . . . . . . . . . . . . . . . .2 Disease Characteristics and Differential Diagnosis  . . . . . . . . . .5 28. . . . . . .5 Surgical Procedure  .3 27. . . . . . . . . . .9 Surgical Procedure  . . . . . . . . . . . . . . . . . . . . . . . . . .   199 Lipoinjection of the Vocal Fold  . . . . . .   176 Surgical Equipment  . . . . . . .   210 33. . . . . . . . . .   207 Peroral Vocal Fold Augmentation in the Clinic Setting  . . . . . . . . . . . .7 T-Tube Stenting of SGS  . . . .1 32. . . . .   185 29. . .

. . . .   232 Patient Selection for Laryngeal Framework Surgery  . .   231 Surgical Indications and Contraindications  . . . . . . . . . . . . .3 Surgical Indications and Contraindications  . .3 Surgical Indications and Contraindications  .   221 35. . .3 Surgical Indications and Contraindications  . . . . . .6 37 42 42. . . . .3 38. . . .   215 34. . . . . . . . . . . . . . . . . .3 41.2. . . . . . .   231 Cricothyroid Subluxation  . . . . . . . . . . . . . . .3 Different Botulinum Toxin Injection Approaches  . . . . . . . . . . . . . . . . . . . . . . . . .   219 Key Points  . . . . . . . .   223 35. . . . . . . . . . . . . . . . . . . . . .   265 Bibliography  . . . . . . . . . .   255 Key Points  . . . .   253 Surgical Equipment   .4 41. . . . . . . .2 40.6 39 39. . .2. . . . . . . . . . . . . . . . . . . . . . . . .6 Arytenoid Adduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   253 Fundamental and Related Chapters  . . . .1 Fundamentals and Related Chapters  . . . . . . . . . . . . . . . . . . . . . . . . . . .   216 34. . . . . . . .4. . . . . . .   234 Selected Bibliography  . . . . .   257 Postoperative Care and Complications  . . . . . . . . . . . . . . . . .   256 40 40. .4 36. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 41. . . . . . . . . . .5 40. . . . . . .2 Spasmodic Dysphonia and Essential Tremor    221 35. . . .   250 Key Points  . .   254 Postoperative Care and Complications  . . . . . . . . . . . .4 38. . . .2 Part C Laryngeal Framework Surgery 36 36.1 36. . . . . . . . . . . . . .1 35. . . . .5 38. .6 Principles of Laryngeal Framework Surgery    231 Fundamental and Related Chapters  . . . . . . .   267 .   239 Selected Bibliography  . . . . . . . . . . . . . . . . . .5 Long-Term Surgical Issues  . . . . . . . . . . . . . . . . .   215 34. . . .   264 Key Points  . . . . . . . . . . . .2 36. . . . . . . .   267 Fundamental and Related Chapters  . . . . . .6 Postoperative Care and Complications  . . . . .   262 Key Points   . . . . . . . . .2 38. . . . . . . . . .   235 37. . .   235 37. .   216 34.   241 Surgical Equipment  . . . . . . . . . . . . . . . . . .3. . .2 36. . . . . . . . . . . . . . . . . . . .3 39. . . . . . . . . . . . .3 36. . .   220 Botulinum Toxin Injection of the Larynx  . . . . . . . . . . . . . .3. .4 40. . . . . . . . . . . . . . . . .3 36. .1 Botulinum Toxin Fundamentals  . . .   257 Surgical Equipment  . .XXII Contents 34 Percutaneous Vocal Fold Augmentation in the Clinic Setting  . . . .   231 Introduction  . . . . . .   221 35. . . . . . . . . . . . . . . . . . . .   227 35 35. . . . . . . . . .   253 Disease Characteristics and Differential Diagnosis  . . . . . . . . . . . .   263 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . . . . .4 39. . . . . . . . . . . . . . .1 Fundamental and Related Chapters  . .1 Suitability for Percutaneous Vocal Fold Augmentation in the Clinic Setting  . . . . . . . .   231 Medialization Laryngoplasty  . . . . . . . . . . . . . . . . . . . . .1 36. . . .   232 Technical Notes and Pertinent Anatomic Landmarks for Medialization Laryngoplasty    232 Key Points  . . . . . . . . . . . . .3. . . . . . . .2 39. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   257 Fundamental and Related Chapters  . . . . . . . . . . . . . . . .4 Equipment  . . . . . . . . . . . . . . . . . . .2 Perioperative Issues in Laryngeal Framework Surgery  . . .6 GORE-TEX® Medialization Laryngoplasty  . . . . . . . . .   239 Key Points  . . . . . . . . .   263 Fundamental and Related Chapters  . . . . . . . . . . . .4 Suboptimal Results/Surgical Errors  . . . . . . . . . .   241 Surgical Procedure  . . . . . . . . . . . . . . . . . . . .2 Translaryngeal Removal of Teflon Granuloma  . . . . . . . . . . . . . . . . . . . . . . .2.5 36. . . . .   242 Postoperative Care and Complications  . .   267 Disease Characteristics and Differential Diagnosis  . . . . . . . . . . . . . . . . . . . .   263 Surgical Equipment  . .   251 38. . . . . .   235 37. .1 39. . . . . . . . . . . . . . .   234 Perioperative Care for Laryngeal Framework Surgery  . . . . . . . . . . . . . . . . . .   222 35. . .   227 Selected Bibliography  . . . . . .   236 37. .1 Revision Surgery  . . . . . . . . . . . . . . . . . .   221 Fundamental and Related Chapters  . .   263 Postoperative Care and Complications  .   262 41 41. . . . . . . . . . . .   239 38 Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis  . . . . .   253 Surgical Procedure  . . . . . . .5 39. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Surgical Procedure  .   222 35. . . . . . . . . . . . . . . . . . . . .   231 Arytenoid Adduction  . . .6 Postprocedure Care and Complications  . . . . . . . . . . . . . . .   253 Surgical Indications and Contraindications  . .   237   37. . . . . . . . . . . .   223 35. . . . . . . . . .   241 Fundamental and Related Chapters  . . . . . . . . . . . . . . . . . . . .3 40. . . . . . . . . . . . . . . . . . . . . .   263 Surgical Procedure  . . . . . . .   241 Disease Characteristics and Differential Diagnosis  . . . .1 42. . . . . .   265 41. . . . .   257 Surgical Indications and Contraindications  . . . . . . . . . . . . . . . . . . .   257 Fundamentals of Arytenoid Adduction  . . . . .   232 Timing of Medialization Laryngoplasty  .   219 Selected Bibliography  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   251 Selected Bibliography  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 41. . . . . . . . . . . . . . .   257 Surgical Procedure  . .5 Procedure  . . . . . . . .   216 34. . . .   221 Disease Characteristics and Differential Diagnosis   . . . . . . . .   215 34. .4 Surgical Equipment  . . . . . . . . . . . . . . . . . . . .2 Disease Characteristics and Differential Diagnosis   . . . .   215 34. .   241 Surgery Indications and Contraindications  . . . . . . . . . . . . .   235 37. . . . . . . . . . . . . . .   262 Selected Bibliography  . . . .   263 Disease Characteristics and Differential Diagnosis   . . . . .1 38.   227 Key Points  . . . . . .   256 Selected Bibliography  . . . . . . . . .1 40. . . . . . . . . . .2 Cricothyroid Subluxation  . . . .

42.3
42.4
42.5
42.6

Contents

Surgical Indications and Contraindications   . .   267
Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . . .   268
Surgical Procedure  . . . . . . . . . . . . . . . . . . . . . . .   268
Postoperative Care and Complications  . . . . . .   271
Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   271
Selected Bibliography  . . . . . . . . . . . . . . . . . . . . .   271

46
46.1
46.2
46.3
46.4
46.5
46.6

Excision of Combined Laryngocele  . . . . . . . . .   273
Fundamental and Related Chapters  . . . . . . . . .   273
Disease Characteristics and Differential
Diagnosis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   273
43.2.1 Anatomy and Classification  . . . . . . . . . . . . . . . .   273
43.2.2 Clinical Presentation and Differential
Diagnosis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   274
43.3 Surgical Indications and Contraindications  . .   274
43.4 Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . . .   275
43.5 Surgical Procedure   . . . . . . . . . . . . . . . . . . . . . . .   275
43.6 Postoperative Care and Complications  . . . . . .   277
Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   277
Selected Bibliography  . . . . . . . . . . . . . . . . . . . . .   277

47

44
44.1
44.2
44.3
44.4
44.5
44.6

Repair of Laryngeal Fracture  . . . . . . . . . . . . . .   279
Fundamental and Related Chapters   . . . . . . . . .   279
Disease Characteristics   . . . . . . . . . . . . . . . . . . .   279
Surgical Indications and Contraindications   . .   279
Surgical Equipment   . . . . . . . . . . . . . . . . . . . . . .   280
Surgical Procedure   . . . . . . . . . . . . . . . . . . . . . . .   280
Postoperative Care and Complications   . . . . . .   282
Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   282
Selected Bibliography   . . . . . . . . . . . . . . . . . . . . .   282

48

45

Glottic and Subglottic Stenosis:
Laryngotracheal Reconstruction
with Grafting  . . . . . . . . . . . . . . . . . . . . . . . . . . . .   283
Fundamental and Related Chapters  . . . . . . . . .   283
Disease Characteristics and Differential
Diagnosis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   283
Surgical Indications and Contraindications  . .   283
Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . . .   283
Surgical Procedure  . . . . . . . . . . . . . . . . . . . . . . .   284
Postoperative Care and Complications  . . . . . .   287
Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   287
Selected Bibliography  . . . . . . . . . . . . . . . . . . . . .   288

43
43.1
43.2

45.1
45.2
45.3
45.4
45.5
45.6

47.1
47.2
47.3
47.4
47.5
47.6

48.1
48.2
48.3
48.4
48.5
48.6

Glottic and Subglottic Stenosis:
Cricotracheal Resection with Primary
Anastomosis  . . . . . . . . . . . . . . . . . . . . . . . . . . . .   289
Fundamental and Related Chapters  . . . . . . . . .   289
Diagnostic Characteristics for Open
Treatment of Subglottic Stenosis  . . . . . . . . . . . .   289
Surgical Indications and Contraindications  . .   289
Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . . .   289
Surgical Procedure   . . . . . . . . . . . . . . . . . . . . . . .   289
Postoperative Management  . . . . . . . . . . . . . . . .   292
Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   292
Selected Bibliography  . . . . . . . . . . . . . . . . . . . . .   293
Tracheal Stenosis: Tracheal Resection
with Primary Anastomosis  . . . . . . . . . . . . . . . .   295
Fundamental and Related Chapters  . . . . . . . . .   295
Background Information and Diagnosis
of Tracheal Stenosis  . . . . . . . . . . . . . . . . . . . . . . .   295
Surgical Indications and Contraindications  . .   295
Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . . .   295
Surgical Procedure  . . . . . . . . . . . . . . . . . . . . . . .   295
Postoperative Care and Complications  . . . . . .   298
Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   298
Selected Bibliography  . . . . . . . . . . . . . . . . . . . . .   298
The Gray Minithyrotomy for Vocal Fold
Scar/Sulcus Vocalis  . . . . . . . . . . . . . . . . . . . . . . .   299
Fundamental and Related Chapters  . . . . . . . . .   299
General Considerations  . . . . . . . . . . . . . . . . . . .   299
Surgical Indications and Contraindications  . .   299
Surgical Equipment  . . . . . . . . . . . . . . . . . . . . . . .   299
Surgical Procedure  . . . . . . . . . . . . . . . . . . . . . . .   299
Postoperative Care and Complications   . . . . . .   303
Key Points  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   304
Selected Bibliography  . . . . . . . . . . . . . . . . . . . . .   304

Subject Index  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   305

XXIII

Contributing Authors

Milan Amin, M.D.
Chief, Division of Laryngology
Department of Otolaryngology
New York University School of Medicine
550 First Avenue, NBV 5E5
New York, NY 10016
USA
Chapter 2: Principles of Clinical Evaluation
for Voice Disorders
Chapter 45: Subglottis Stenosis: Laryngotracheal
Reconstruction with Grafting
Michiel J. Bové, M.D.
Searle Building
Room 12-561
320 Superior
Chicago, IL 60611
USA
Chapter 2: Principles of Clinical Evaluation
for Voice Disorders
Mark Courey, M.D.
UCSF Voice & Swallowing Center
2330 Post Street, 5th Floor
San Francisco, CA 94115
USA
Chapter 28: Posterior Glottis Stenosis—Endoscopic Approach
(Laser Division with MMC)
Jonathan R. Grant, M.D.
Dept. of Otolaryngology and Communication Sciences
Medical College of Wisconsin
Milwaukee, IL
USA
Chapter 34: Percutaneous VF Augmentation
in a Clinical Setting

Patrick J. Gullane, M.D.
7-242 Eaton Wing N
Toronto General
200 Elizabeth Street, Room 3S438
Toronto, Ontario M5G 2CH
Canada
Chapter 46: Glottic and Subglottic Stenosic: Cricotracheal
resection with primary anastamosis
Rene Gupta, MD
Department of Otolaryngology
New York University School of Medicine
550 First Avenue, NBV 5E5
New York, NY 10016
USA
Chapter 29: Subglottis Stenosis: Laryngotracheal
Reconstruction with Grafting
Michael Johns, M.D.
Emory Health Care
Dept. of Otolaryngology
550 Peachtree Street, Suite 9-4400
Atlanta, GA 30308
USA
Chapter 1: Anatomy and Physiology of the Larynx
Priya Krishna, M.D.
University of Pittsburg
Voice Center
Department of Otolaryngology
200 Lothrop Street, Suite 500
Pittsburgh, PA 15213
USA
Chapter 7: Medical Treatment of Voice Disorders

XXVI

Invited Authors

Albert Merati, M.D.
University of Washington
Department of Otolaryngology
Box 356515
Health Sciences Building
Suite BB1165
Seattle, WA 98195
Chapter 34: Percutaneous VF Augmentation
in a Clinical Setting
Chapter 47: Tracheal Resection with Primary Anastomosis
Christine Novak PT
7-242 Eaton Wing N
Toronto General
200 Elizabeth Street, Room 3S438
Toronto, Ontario M5G 2CH
Canada
Chapter 46: Glottic and Subglottic Stenosic: Cricotracheal
resection with primary anastamosis
Gregory Postma, M.D.
Department of Otolaryngology
Medical College of Georgia
1120 15th Street
Augusta, GA 30912
USA
Chapter 39: Goretex Medialization Laryngoplasty

Anthony Rider, MD
Department of Otolaryngology and Communication Sciences
Medical College of Wisconsin
Milwaukee, WI
USA
Chapter 47: Tracheal Resection with Primary Anastomosis
Robert T. Sataloff, M.D.
1721 Pine Street
Philadelphia, PA 19103
USA
Chapter 22: Vocal Fold Varix
Lucian Sulica, M.D.
10 Union Square East, Suite 4J
New York, NY 10003
USA
Chapter 35: Botox Toxin Injection
Chapter 37: Peri-Operative Care for Laryngeal
Framework Surgery
Chapter 38: Principles of Laryngeal Framework Surgery
Chapter 48: Mini-Thyrotomy for Vocal Fold Scar

Part A Clinical Evaluation
of Laryngeal Disorders

Chapter 1

Anatomy and Physiology
of the Larynx

1.1

Anatomy

1.1.1

Laryngeal Cartilages

1.1.1.1 Thyroid
The laryngeal skeleton consists of several cartilaginous structures (Fig. 1.1), the largest of which is the thyroid cartilage. The
thyroid cartilage is composed of two rectangular laminae that
are fused anteriorly in the midline. The incomplete fusion of
the two laminae superiorly forms the thyroid notch. Attached
to each lamina posteriorly are the superior and inferior cornua. The superior cornua articulate with the greater horns of
the hyoid bone, while the inferior cornua form a synovial joint
with the cricoid cartilage (the cricothyroid joint). At the junction of each superior cornu with its respective thyroid ala is a
cartilaginous prominence, the superior tubercle. The superior
tubercle is of significance because it marks the point 1 cm below which the superior laryngeal artery and nerve cross over
the lamina from laterally to pierce the thyrohyoid membrane.
The sternothyroid and the thyrohyoid strap muscles attach to

1

the anterior surface of the thyroid laminae at the oblique line.
The inferior pharyngeal constrictor muscles insert on the posterior edge of each thyroid lamina.
The relationship of the internal laryngeal structures to the
surface anatomy of the thyroid cartilage is important in surgical planning, particularly in planning the placement of the
window for thyroplasty. The level of the vocal fold lies closer to
the lower border of the thyroid cartilage lamina than to the upper, and not at its midpoint, as is frequently (and erroneously)
stated. Correct placement of the window is necessary to avoid
medialization of the false vocal folds or ventricular mucosa.

1.1.1.2 Cricoid
This signet ring-shaped cartilage is the only laryngeal cartilage
to encircle completely the airway. The cricoid cartilage articulates with the thyroid cartilage’s inferior cornua on the cricothyroid joint facets. It joins the first tracheal ring inferiorly via
membranous attachments. The face of the cricoid cartilage has
a vertical height of only about 3–4 mm, while the lamina posteriorly stands about 20–30 mm high. There is a steep incline
from anterior to posterior of the superior margin of the cricoid
cartilage. This incline leaves an anterior window where the cricothyroid membrane lies.

1.1.1.3 Arytenoid
The arytenoid cartilages are paired, pyramidal cartilages that
articulate with the posterior lamina of the cricoid cartilage at
the cricoarytenoid joint. Each arytenoid has both a vocal process medially and a muscular process laterally. These processes
act as the attachment sites for the vocal ligament and the major
intrinsic muscles of vocal fold movement respectively.

1.1.1.4 Accessory Cartilages:
Cuneiform and Corniculate

Fig. 1.1  Cartilaginous and fibroelastic structures of the larynx

The cuneiform cartilages are crico-arytenoid joint paired elastic cartilages that sit on top of, and move with, the corresponding arytenoid. The soft tissue of the aryepiglottic folds covers
these cartilages. The corniculates are small, paired, fibroelastic
cartilages that sit laterally to each of the arytenoids, and are
completely embedded within the aryepiglottic folds. These



1

Anatomy and Physiology of the Larynx

likely serve to provide additional structural support to the aryepiglottic folds.

1.1.2

Laryngeal Joints

1.1.2.1 Cricothyroid Joint
1.1.1.5 Epiglottis
The epiglottis is an oblong, feather-shaped fibroelastic cartilage that is attached, at its inferior end, to the inner surface
of the thyroid cartilage laminae just above the anterior commissure. The major function of the epiglottis is to help prevent
aspiration during swallowing. The epiglottis is displaced posteriorly by tongue base contraction and laryngeal elevation. This
causes the superior free edge of the epiglottis to fall over the
laryngeal inlet, which, in conjunction with sphincteric closure
of the larynx at the glottic and supraglottic level, closes off the
laryngeal vestibule.

The cricothyroid joint is a synovial joint formed from the articulation of the inferior cornua of the thyroid cartilage with
facets on the cricoid lamina. The two major actions at this
joint are anteroposterior sliding and rotation of the inferior
thyroid cornu upon the cricoid cartilage. Cricothyroid muscle
contraction pulls the thyroid ala anteriorly with respect to the
cricoid cartilage and closes the anterior visor angle between
the thyroid and the cricoid cartilage. This motion increases the
distance between the anterior commisure and the vocal processes and serves to lengthen and tense the vocal folds. This
joint can be manipulated to assist in pitch control in cases of
paralytic dysphonia. Cricothyroid joint subluxation, resulting
in an exaggerated decrease in the anterior cricothyroid angle,
can assist in traditional medialization procedures to provide
vocal fold tightening.

1.1.2.2 Cricoarytenoid Joint

Fig. 1.2  Cricoarytenoid joint action in abduction (left) and adduction

(right). Note the lowering of the vocal process as adduction occurs

The cricoarytenoid joint is the primary moving structure of the
intrinsic larynx (Fig. 1.2). The arytenoids articulate with the
cricoid cartilage forming multiaxial joints. The action of movement at the cricoarytenoid joints changes the distance between
the vocal processes of the two arytenoids and between each vocal process and the anterior commissure. The combined action
of the intrinsic laryngeal muscles on the arytenoid cartilages
alters the position and shape of the vocal folds. Each cricoarytenoid joint sits at a surprisingly steep 45° angle with the horizontal plane on the cricoid cartilage and permits motion in a
sliding, rocking, and twisting fashion.

1.1.3

Laryngeal Musculature

1.1.3.1 Intrinsic Laryngeal Muscles
The intrinsic muscles of the larynx are responsible for altering the length, tension, shape, and spatial position of the vocal
folds by changing the orientation of the muscular and vocal
processes of the arytenoids with the fixed anterior commissure
(Fig. 1.3). Traditionally, the muscles are categorized into the
following scheme: three major vocal fold adductors, one abductor, and one tensor muscle.
Adductor Muscles
The Lateral Cricoarytenoid Muscle (LCA)

Fig. 1.3  Neuromuscular structures of the larynx

This paired laryngeal muscle is attached to the anterior part
of the muscular process medially and to the superior border
of the cricoid cartilage laterally. Contraction of this muscle
results in movement of the muscular process anterolaterally,

and posterolaterally on the lateral surface of the arytenoid. This action also results in vocal fold adduction. to cause motion in a more vertical axis (true vocal fold abduction). Tensor Muscle Cricothyroid Muscle The cricothyroid muscle is a laryngeal tensor.1. the vocal process is brought closer to the anterior commissure and the vocal folds are shortened and adducted. closure of the posterior glottis. there is a significant superior extension of the TA muscle into the false vocal folds. resulting in lengthening. the vocal folds are shortened and thickened.1 Quadrangular Membrane The quadrangular membrane is an accessory elastic support structure of the supraglottic larynx.3. The PCA muscle anatomy serves as a key landmark for arytenoid adduction surgery. it becomes the medial wall of the piriform sinus. the cricothyroid space is narrowed anteriorly. As the quadrangular membrane extends inferiorly.1. while the oblique fibers attach to each arytenoid apex and run obliquely to attach to the posterior face on the opposite side. Contraction displaces the muscular process posteriorly and caudally. its medial extent is the vocal ligament. Chapter 1 noids “upright” and has a major role in vocal fold length and tension. and wraps around posteriorly to attach to the arytenoids. and the thyrohyoid). often referred to as the ventricularis muscle. composed of two separate muscle bellies. Its fibers run diagonally to insert on the muscular process of the arytenoid. During contraction. The thyroarytenoid externus inserts anteriorly at the anterior commissure (Broyles’ ligament). while the posterior cricoid lamina and cricoarytenoid joints are forced caudally. runs obliquely from the superior arch of the cricoid to insert on the inferior cornu. Interarytenoid Muscle (IA) This nonpaired muscle consists of both transverse fibers and oblique fibers. the conus elasticus is continuous with the cricothyroid membrane.4 Fibroelastic Tissue of the Larynx 1. it is continuous with the vestibular ligament. while the vertical belly keeps the aryte- 1. while the pars obliqua. in cadaver studies. The lateral portion (vertical belly) runs in a more vertical fashion to insert on the lateral side of the muscular process. Contraction of this muscle leads to arytenoid adduction. This portion of the thyroarytenoid is also known as the vocalis muscle. 1. Anteriorly. located on the external surface of the laryngeal cartilages. and narrowing of the laryngeal inlet. and stylopharyngeus muscles all act in concert to provide laryngeal stabilization.  . In isolation. the internus and the externus. In most cases.4. geniohyoid. digastric. Some oblique fibers extend to travel along the quadrangular membrane and are referred to as the aryepiglottic muscle Abductor Muscle Posterior Cricoarytenoid Muscle (PCA) The posterior cricoarytenoid muscle arises from the posterior face of the cricoid lamina.1.1. this action serves to lower the resonant frequency of the vocal folds. During contraction of this portion of the muscle. The horizontal belly has been shown. Because of slightly different positions and orientations. At its inferior extent. the sternohyoid.  while simultaneously forcing the vocal process downward and medially. Is extends superiorly to attach to the anterior commissure and vocal processes. while the vocal process moves upward and laterally.4. Contraction of the cricothyroid muscle bellies affects motion at the cricothyroid joint. The pars recta. It attaches anteriorly to the lateral edges of the epiglottis. The superior free edge of the quadrangular membrane is the mucosa-covered aryepiglottic fold.2 Conus Elasticus The thick fibroelastic support structure of the glottis and subglottis originates inferiorly along the superior border of the cricoid cartilage. and indirectly may affect vocal fold position. The medial portion of the posterior cricoarytenoid (horizontal belly) arises from the posterior cricoid lamina and courses obliquely in a superiolateral fashion to insert on the medial aspect of the muscular process. tightening and thinning of the vocal folds and as well as increasing their resonant frequency. The result is adduction and lengthening of the vocal folds. The result is vocal fold abduction. arises laterally from the superior rim of the cricoid cartilage and inserts on the inferior rim of the thyroid cartilage. The transverse fibers insert on the posterior face of each arytenoid and run horizontally. This muscle runs lateral and in large part parallel with the thyroarytenoid muscle. 1. Thyroarytenoid Muscle (TA) The thyroarytenoid muscle consists of two main muscle bellies. the more vertical component. The posterior cricoarytenoid muscle affects motion at the cricoarytenoid joint in two planes by its two separate muscle bellies. The thyroarytenoid internus arises from the anterior commissure and inserts onto the vocal process of the arytenoid cartilage. During contraction. contraction of each muscle belly in isolation causes cricoarytenoid joint motion about a different oblique axis.2 Extrinsic Laryngeal Muscles The infrahyoid strap muscles (the sternothyroid. The posterior cricoarytenoid is the only abductor of the vocal folds and is principally responsible for control of the glottic airway. The conus elasticus rolls medially within the substance of the vocal fold. the mylohyoid.

5 Microanatomy of the Vocal Fold The complex microanatomy of the true vocal fold allows the loose and pliable superficial mucosal layers to vibrate freely over the stiffer structural underlayers (Fig. that the interarytenoid muscle is unpaired. which then exits the skull base via the jugular foramen. The vocal fold mucosa and vocal ligament cover the vocalis muscle and extend from the anterior commissure to the vocal processes of the arytenoids. which controls vocal fold lengthening and pitch. a branch of the inferior thyroid artery. which could explain the presence of false vocal fold muscular contraction in cases of RLN transection.4  Coronal section through the free edge of the vocal fold. then. The RLN innervates the ipsilateral posterior cricoarytenoid (PCA).1. The SLP is gelatinous in nature. as indicated above). is the aphonatory (respiratory). 1. and terminates in the thyroarytenoid (TA). or SLP) is mostly acellular and composed of extracellualar matrix proteins. or membranous portion. The cricothyroid artery. it can also be divided into layers. the RLN supplies all of the intrinsic laryngeal muscles with the exception of the cricothyroid muscle (and possibly the ventricularis muscle. giving off three major branches: the pharyngeal branch. The ILP and DLP together form the vocal ligament. traveling in the tracheoesophageal groove. The true vocal fold can be divided into three major layers: the mucosa. The SLN supplies sensation to the glottic and supraglottic larynx. 1. dem- onstrating the layered microanatomical structures that allow vibration 1. however. Deep to the epithelium are three layers of lamina propria. the deepest and most dense layer (DLP) is composed of tightly arranged collagen fibers. 1. The second major arterial supply to the larynx comes from the inferior laryngeal artery. Thus. The superior laryngeal artery is a branch of the superior thyroid artery. each of increasing rigidity.6   Vasculature The arterial supply to the larynx comes from the superior and inferior laryngeal arteries. The mucosa and vocal ligament extend posteriorly to cover the entirety of the vocal process. The potential space between the SLP and the intermediate layer of lamina propria is Reinke’s space.1. The most superficial layer (superficial layer of the lamina propria. It is important to remember. Lower motor neurons leave the nucleus ambiguus and travel laterally. Branches of this artery pierce the cricothyroid membrane and ascend on the internal surface of the thyroid cartilage. together with the squamous epithelium.4). known as the vagus nerve. adjacent to the cricothyroid joint (Fig. exiting the medulla between the olive and the pyramid as a series of eight to ten rootlets. and loosely arranged fibers of collagen and elastin. the superior laryngeal nerve (SLN). The nucleus ambiguus is the area within the brainstem (medulla) from which the fibers that will contribute to the vagus nerve arise. This artery then courses medially with the internal branch of the superior laryngeal nerve and enters the thyrohyoid membrane 1 cm anterior and superior to the superior tubercle.1. Fig. The most superficial layer is the squamous epithelium. or cartilaginous portion. and the underlying muscle. while the anterior two thirds of the endoscopically visualized vocal fold is the phonatory. . The nerve enters the larynx posteriorly. The intermediate and deep layers of the lamina propria (ILP and DLP) are composed mostly of elastin and collagen. and the lateral cricoarytenoid (LCA). making them possible targets during the creation of a thyroplasty window. water. runs along the inferior surface of the thyroid cartilage to supply its similarly named muscle and joint. There are some recent anatomic studies that suggest that the superior aspect of the TA muscle (the ventricularis muscle in the false vocal fold) may have SLN innervation. The gelatinous superficial layer of the lamina propria. the venous supply mirrors the arterial supply. These rootlets coalesce into a single nerve root. as well as motor input to the cricothyroid muscle. which arises directly from the external carotid. 1 Anatomy and Physiology of the Larynx 1. The superior laryngeal artery branches from the superior thyroid artery at the level of the hyoid bone. and ascends back into the neck. The RLN arises from the vagus nerve in the upper chest and loops under the aortic arch (left) or subclavian artery (right). The mucosa of the vocal fold is highly specialized for its vibratory function. one of the major branches of the superior laryngeal artery.7 Innervation Corticobulbar fibers from the cerebral cortex descend through the internal capsule and synapse on the motor neurons in the nucleus ambiguus. the interarytenoid (IA) (an unpaired muscle). 1. the vocal ligament.3). moves freely over the underlying vocal ligament and muscle to form the vibrations that produce sound. Ipsilateral RLN transection typically results in vocal fold immobility (the ipsilateral CT does not contribute to vocal fold adduction or abduction). This artery enters the larynx between fibers of the inferior constrictor muscle and anastomoses with branches of the superior laryngeal artery. The vagus nerve descends in the carotid sheath. The posterior third of the endoscopically visualized true vocal fold. and the recurrent laryngeal nerve (RLN).

The larynx has also evolved reflexes that produce cough.1. on the other hand. has been shown to have increased latency of contraction. the elastic recoil of the vocal folds. The larynx has evolved several important reflexes for the purpose of airway protection against external stimuli and foreign bodies. is required for normal laryngeal functioning. chest wall compliance. In humans. 6 As airflow continues. In a fine-wire electromyographic study of human larynges.  Chapter 1 and contralateral RLN input to the IA may lead to some adduction of the vocal fold on the paralyzed side. Accessory effects such as lung capacity. apnea. 1. but also the proper length and tension of the vocal folds.1 Phonation The most complex and highly specialized of the laryngeal functions is sound production. demon- strating mucosal wave propagation. 7 Airflow is reduced.2 Physiology 1. 8 In a zipper-like closure. and recruitment of each of the above-described laryngeal muscles in the production of sound have been studied. and the lower lips are completely approximated. with a measurable degree of fade during sustained phonation. while the posterior cricoarytenoid shows its greatest degree of activation with voluntary deep inhalation and sniff functions. but also for sound and speech production. but regular sustained tonicity during prolonged sound production. timing. There must be adequate breath support to produce sufficient subglottic pressure. myotatic. 1. The strongest of the laryngeal reflexes is that of laryngospasm—a response to mechanical stimulation. it was found that the intrinsic laryngeal muscles are not only highly specialized for their particular vector of action. The Fig. At the same time. 1. bradycardia. Actual phonation is a complex and specialized process that involves not only brainstem reflexes and the muscular actions described above. 1 Vocal folds are completely closed as subglottal pressure (arrow) builds up. The cricothyroid seems to have the greatest measurable action with increases in pitch and volume.2. sound is generated from vocal fold vibration. and Phonation interarytenoid muscle. as well as Bernoulli’s forces. and the degree of recruitment and fade during phonation.2.1 Major Laryngeal Functions: Lower Airway Protection. Phonation and precisely how it relates to laryngeal vibration has undergone many evolving theories over the years. pha- The most primitive of the laryngeal functions is protection of the airway.5  Schematic coronal section through the vocal folds. 3 Only the upper lips are in contact. Finally. there must be favorable pliability and vibratory capacity of the tissues of the vocal folds. Sound production requires that several mechanical properties be met. Respiration. 2 Lower lips separate due to rising subglottal pressure. 1. These reflex mechanisms are relayed by the mucosal (sensory afferent). 5. The detailed contribution. but high-level cortical control as well. the mucosal wave is propagated superiolaterally. There also must be adequate control of the laryngeal musculature to produce not only glottic closure. result in the lower lips of the vocal folds drawing inward.3). 4 A puff of air is released as the vocal folds separate completely. The ability to couple phonation with articulation and resonance allows for human speech. Once these conditions are met. but they are also controlled for the timing of onset of contraction. the free edge of the vocal folds come into contact from inferiorly to superiorly  . the larynx has evolved into a highly complex and specialized organ not only for airway protection and control of respiration. The thyroarytenoid and the lateral cricoarytenoid muscles have been shown to exhibit burst-like activity at the onset of phonation (as well as pre-phonatory). Precise control of all of these mechanisms. and articular receptors of the larynx via both the superior and recurrent laryngeal nerves (Fig. The RLN also supplies the glottic and subglottic mucosa and the myotatic receptors of the laryngeal musculature. and hypotension. as well as exact anatomic structure.

and cricothyroid subluxation. Distler MK (1988) Effects of electrical stimulation of cricothyroid and thyroarytenoid muscles on voice fundamental frequency. from superficial to deep: ■ Epithelium ■ Superficial lamina propria ■ Intermediate lamina propria ■ Deep lamina propria ■ Vocalis muscle 6. J Voice 2:221 Buchthal F. e. trachea. Kahane JC. speech. Curr Opinion in Otolaryngol 12:160–165 Hillel A (2001) The study of laryngeal muscle activity in normal human subjects and in patients with laryngeal dystonia using multiple fine-wire electromyography. Resp Physiol 29:223 Hirano M. University of Tokyo. 5. The process begins with inhalation and subsequent glottal closure. and bronchi. and vocal frequency. The microanatomy of the vocal folds is complex and consists of the following layers. Netterville JL (1995) Anatomy of the larynx. Maranillo E. percutaneous laryngeal injections).). Reinke’s space is a potential space between the superficial and intermediate layer of the lamina propria. 1. and swallowing. JR. Abu-Osba YK. 1. and oral anatomy. Once air passes between the vocal folds. the body-cover concept of phonation takes effect. Ann Otol Rhino Laryngol 73:118 Gay T et al (1972) Electromyography of intrinsic laryngeal muscles during phonation. more densely organized vocal ligament and vocalis muscle. Eventually. Clin Otolaryngol Allied Sci 22:362–369 Zeitels SM (2000) New procedures for paralytic dysphonia: adduction arytenopexy. 1 Anatomy and Physiology of the Larynx ryngeal. The intermediate and deep layers of the lamina propria together are referred to as the vocal ligament. Thach BT (1982) Influence of upper airway pressure changes in respiratory frequency. Arch Otolaryngol 122:1331 Kempster GB. 4. Arch Otolaryngol Head Neck Surg 122:1331–1336 Armstrong WB. tension. el-Samaa M (1991) Histo-anatomical structure of the human laryngeal ventricle. nasal. Vienna . The closure phase is also propagated rostrally. Otolaryngol Clin N Am 28:685 Mathew OP. The main abductor muscle of the larynx is the posterior cricoarytenoid (PCA). 2. Kakita Y (1985) Cover-body theory of vocal fold vibration. Dorfl J (1997) The anatomy of the inferior laryngeal nerve. and subsequent mental status also play a role. Larson CR. The relationship of the surface anatomy of the thyroid and arytenoid cartilages to the internal laryngeal structures are critical to surgical planning for laryngeal framework surgery and in-office procedures (i.   Selected Bibliography 1 2 3 4 5 6 7 Key Points 8 1. 9 10 11 12 13 14 15 16 17 Bielamowicza S (2004) Perspectives on medialization laryngoplasty. Urban & Schwarzenberg. the inferior edges become reapproximated due both to a drop in pressure at the open glottis. In: Sawashima M. Laryngoscope 109:983–87 Platzer W (ed) Atlas of topographic and applied human anatomy: head and neck. Acta Otolaryngol 111:396–402 Sanud.5). The primary adductor muscles of the larynx consist of: ■ Lateral cricoarytenoid (LCA) ■ Thyroarytenoid (TA) ■ Interarytenoid (IA) 3. Otolaryngol Clin N Am 33:841–854 Ludlow C (2004) Recent advances in laryngeal sensorimotor control for voice. Kirchner JA. The body-cover theory describes the wave-like motion of the loose mucosa of the vocal folds over the stiffer. subglottic pressure may again build and the cycle is repeated (Fig. Japan. San Diego Bryant NJ et al (1996) Human posterior cricoarytenoid muscle compartments: anatomy and mechanics. With the vocal folds fully approximated. The cricothyroid and the TA/LCA muscles control vocal fold length. Basiouny SE. Cooper F (eds) Dynamic aspects of speech production. Otolaryngol Clin N Am 37:139–160 Schwenzer V. Laryngoscope 111:1–47 Hirano M (1977) Structure and vibratory behavior of the vocal fold. Tokyo. (Pernkopf Anatomy. Ann Otol 81:401 Kotby MN.. Leon X et al (1999) An anatomical study of anastomoses between the laryngeal nerves. An increase in subglottic pressure follows until the pressure overcomes the glottal closure force and air is allowed to escape between the vocal folds. and to the elastic recoil of the tissues themselves. This motion is known as the mucosal wave.5). Speech science. The wave begins infraglottically and is propagated upward to the free edge of the vocal fold and then laterally over the superior surface (Fig. Gortex medialization laryngoplasty. Kaufman K et al (1996) Human posterior cricoarytenoid muscle compartments: anatomy and mechanics. vol 1. pp 13–30 Jones-Bryant N. 3rd edn. Woodsen GE. College-Hill Press. Faaborg-Anderson K (1964) Electromyography of laryngeal and respiratory muscles: correlation with respiration and phonation.

such as an upper respiratory infection.2 Introduction Many processes resulting in dysphonia affect the vocal folds in subtle ways. resulting in instability of the fundamental frequency. Sudden development of hoarseness (occurring over seconds or minutes) should. . Sataloff has developed a pair of questionnaires. difficulty in transition between singing registers. or paresis. in fact. on the other hand. and 5 for further information. the information derived from a careful review of the patient’s complaints provides an invaluable context within which to interpret the findings on physical exam and objective voice testing. but it may also allow preliminary differential diagnosis to be formulated in certain patients. 2. The term hoarseness. This strategy not only increases the efficiency of an office consultation. and presbylarynx. another at the professional voice user.Chapter 2 Principles of Clinical Evaluation for Voice Disorders 2. voice-related quality of life instruments should also be given to the patient prior to the start of the patient evaluation (see Sect. Although useful. 4. Standardized.4 2 History of Present Illness The exact nature of the voice patient’s chief complaint should be reviewed with care. past surgical history. for instance. Inadequate airflow production from the lungs due to pulmonary or neuromuscular pathologies can also present with vocal fatigue and/or decreased volume. 3. Early vocal fatigue can similarly result from glottal incompetence secondary to vocal fold atrophy. medications. The classic template of history of present illness. always raise suspicion of vocal fold hemorrhage or psychogenic etiologies. In addition. 2. An acute process. First. It also allows them to document comprehensively and accurately all their medications and dosages. “Listening to the Voice”). and social history provides a reliable framework for achieving a thorough medical and voice history. is often used to describe a variety of symptoms. vocal fold scar. Careful attention to the duration of each of a patient’s symptoms will thereby allow a complex symptom picture to be segregated into its component pathologies. Breathiness.1 Fundamental and Related Chapters Please see Chaps. breathiness. this hyperfunction may also represent a supraglottic compensation for glottal insufficiency. roughness. one directed at the singer. Addresses and telephone numbers of primary care and referring physicians can also be obtained. Conditions that may cause breathiness include vocal fold paralysis/paresis. Each of these symptoms can have distinct implications. Perhaps more than any other aspect of otolaryngology. essential that the laryngologic exam be supported by a careful review of the patient’s medical and vocal history. past medical history. A rough voice is often associated with abnormalities of the free edge of the vocal fold.9. may unmask or exacerbate a separate and potentially more consequential chronic process such as a vocal lesion or a pattern of vocal misuse. Raspiness refers to a disruption of the vocal harmony that usually reflects perturbation of normal mucosal wave. A strained voice is often the result of hyperfunctional glottal closure. It is. it enables patients to record accurately the symptoms they are experiencing and to chronicle the history of their problems. including loss of upper register. Determining the duration of each voice complaint will distinguish acute processes from chronic dysfunction. The exact time course of the ailment can be particularly helpful in the evaluation of rapid onset dysphonia. results from any condition preventing full approximation of the vocal folds leading to excessive loss of air during vocalization. the questionnaire cannot substitute for a thoughtful and thorough face-to-face interview with the patient. arytenoid dislocation. To this aim. 1. even when aided with sophisticated diagnostic instruments. and early vocal fatigue. as seen in laryngitis or mass lesions. pitch instability. vocal fold lesions.3 Gathering a Patient History A detailed and directed questionnaire mailed to patients before their office visits can have multiple advantages. patientbased. for instance. ankylosis of the cricoarytenoid joint. review of systems. therefore. vocal fold lesions. 2. 2. Objective evidence of vocal pathology is not always easily discernable on physical examination. Although primary glottal hyperfunction may be the result of neurological impairment or poor vocal technique. vocal fold scar. upper respiratory infection (URI) symptoms frequently precede the onset of a viral vagal neuropathy.

and palatopharyngeal myoclonus. A frequent complaint of patients with LPR is morning hoarseness that improves as the day progresses. Hyperfunctional neurologic disorders are associated with a staccato or strained voice. Sensations of something sticking in your throat or a lump in your throat. and loss of the highest notes in the voice characterize this vocal dysfunction. and globus. patient-based outcome instrument that is useful in predicting the likelihood of LPR (Table 2. Table 2. LPR is often referred to as silent reflux. muffling of the voice. making the dysphonia more difficult to diagnose. These disorders include multiple sclerosis. and an ineffective cough. Many of these changes are reflected in alterations of the   lamina propria. pseudobulbar palsy. vocal fatigue. and an RSI of greater than 10 is considered abnormal. Shy-Drager syndrome. Slight hoarseness and muffling. and abductor spasmodic dysphonia. spasmodic dysphonia. This increase draws fluid into Reinke’s space osmotically. or belching—the cardinal symptoms of gastroesophageal reflux disease. for instance. will lead to chronic laryngeal inflammation and vocal fold trauma. indigestion. These disorders include adductor spasmodic dysphonia. breathy voice. traumatic brain injury. vocal tremor can be associated with Parkinson’s disease. 012345 From: Belafsky PC. posture. Table 2. Chronic obstructive pulmonary disease (COPD) will adversely affect the power supply for the patient’s voice. indigestion. and amyotrophic lateral sclerosis. and chronic cough. Lastly. Endocrinologic changes can have profound effects on the voice. postpolio syndrome. 012345 2. and have an adverse effect on vocal fold vibration. impairing voice quality. Koufman JC (2002) Validity and reliability of the Reflux Symptom Index (RSI). Hoarseness or a problem with your voice. most patients with LPR do not present with heartburn. as many as a third of singers report menstrual related dysphonia. 012345 3. 012345 6. 012345 8. as well as over the counter medications. Heartburn.1  Reflux Symptom Index Within the last month. globus. and highly reproducible. halitosis. Surprisingly. vocal fold varices often increase in size before and during menstruation and have been associated with an increased incidence of submucosal vocal fold hemorrhages. 012345 7. Typical symptoms include chronic or intermittent dysphonia (especially in the morning). The pervasive but often overlooked nature of LPR demands that the physician evaluating the dysphonic patient consider this diagnosis in almost every case. Troublesome or annoying cough. It has been estimated that approximately half of patients presenting with laryngeal and voice disorders have laryngopharyngeal reflux (LPR) as the primary cause. or stomach acid coming up. Most of the adverse effects occur in the premenstrual phase. or as a significant etiologic factor. can affect mucosal hydration and lubrication. J Voice 16:274–277 . In addition. 012345 4. chest pain. Various rheumatological and musculoskeletal ailments can alter posture. frequent throat clearing. loss of range. a phenomenon known as laryngopathia premenstrualis.1) It is easily administered. vocal fatigue. While relatively uncommon in women without formal vocal training.5 2 Past Medical History Salient points regarding the patient’s history include any condition or medications potentially affecting pulmonary status. Breathing difficulties or choking episodes. 012345 5. Other neurologic disorders present with mixed ad.3 demonstrates symptoms suggestive of specific voice disorders. muscular dystrophy. benign essential tremor. Neurologic disorders resulting in hypoadduction of the vocal folds will present with a weak. excessive throat mucous.and abductor components. Some women report vocal changes associated with the normal menstrual cycle. Clearing your throat. Postma G. Any underlying acute or chronic inflammatory conditions can significantly affect voice. and hydration.10 Principles of Clinical Evaluation for Voice Disorders 2. ataxic (cerebellar) dysphonia. Coughing after you ate or after lying down. This pattern is not seen in most other conditions causing dysphonia.2 provides an overview of the historical elements of particular importance when obtaining a voice history. resulting in edema. how did the following problems affect you? 0 = No problem 5 = Severe problem 1. Table 2. Anticholinergic effects of prescription. Such diseases include myasthenia gravis. Excess throat mucus or postnasal drip. Consequently. liquids or pills. An increase in acid mucopolysaccharides in the submucosal tissues of the vocal fold has been demonstrated in an animal model of induced hypothyroidism. The patient may complain of dysphonia. 012345 9. Some degree of reflux is present in normal individuals. Difficulty swallowing food. and Huntington’s disease. vocal fatigue. The reflux symptom index (RSI) is a nine-item. Allergic disease manifesting as persistent postnasal drip. Parkinson’s disease. A few important generalized neurological disorders are characterized by specific patterns of dysphonia.

laryngeal stenosis. Consideration should be given to efficiency of breath support during speech. Evidence of excess rate. vocal fold paralysis/ paresis from cuff pressure on the recurrent laryngeal nerves. Both smoke and the heat produced by burning tobacco appear to contribute. paradoxical vocal fold motion Vocal tremor Parkinson’s disease. The pitch of the voice and the rate and rhythm of speech should be noted. volume. CVA Odynophonia Vocal fold granuloma. gastroesophageal reflux disease. tremors. Certain foods and alcohol predispose to gastroesophageal reflux. Vocal needs and function vary widely among these groups. vagal paralysis Globus LPR. ALS. LPR laryngopharyngeal reflux 11 . 2. and drug use Dietary habits Foods precipitating reflux esophagitis Hydration Allergy history Environmental history Climate Heating and cooling units creasing the efficiency of vocal fold vibration. Other fumes.8 Occupational History Voice disorders affecting vocal professionals have considerably greater impact on function than those affecting nonprofessional voice users. benign essential tremor. nerve injury Stridor Bilateral vocal fold paralysis.3  Symptoms suggestive of specific voice disorders Symptoms Associated diagnoses Breathiness Vocal fold paralysis (unilateral).6 Chapter 2 Past Surgical History A history of prior surgery is important to elicit with laryngeal dysfunction. ALS amyotrophic lateral sclerosis. neurologic disease. MTD Paralaryngeal pain or tension Muscular tension dysphonia (primary or secondary) Laryngospasm LPR. as well as neck and shoulder movements should be examined for evidence of excess tension. 2. or ten- Table 2. or spasms. any procedure requiring general anesthesia and endotracheal intubation—even briefly—should be identified.7 Social History The voice patient’s personal habits should be detailed. Facial movements. through dehydration and effects on judgment. Level I refers to the elite vocal performer such as singers and actors. MTD muscle tension dysphonia. a diuretic. While taking the history. MTD CVA cerebrovascular accident. neurogenic dysphonia Choking Vocal fold paralysis. Level III patients are nonvocal professionals such as teachers and lawyers and level IV users are nonvocal nonprofessionals. myoclonus Velopharyngeal insufficiency Myasthenia gravis. vocal fold mass lesion Vocal fatigue Vocal fold atrophy or paralysis. especially stage actors. and interarytenoid adhesions. In addition to questions concerning otolaryngologic procedures. vocal process granuloma.  2. Even moderate consumption of alcohol is detrimental to the voice. Injuries associated with endotracheal intubation include arytenoid dislocation. Posture and respiratory rate are important and should be noted during the encounter.9 Listening to the Voice A critical part of the clinical evaluation is a careful subjective assessment of the patient’s voice. alcohol. Koufman and Isaacson describe four levels of vocal usage based on occupation. 2. The deleterious effects of tobacco smoke on vocal fold are well documented. especially around the mouth. posterior glottic stenosis. such as stage smoke—particularly oil-based ones—can be of significance to vocal performance. Although the description of vocal usage is useful as a general categorization. evaluation and therapy must be individually tailored to a person’s specific voice use setting and demands. Level II describes professional voice users such as lecturers and clergy.2  Special topics to include within a voice history Upper respiratory infection Endotracheal intubation Time course Trauma Voice usage/demands Profession Vocal abuse Tobacco. spasmodic dysphonia. can affect the voice by thickening secretions and deTable 2. Caffeine. one should evaluate the quality of the patient’s speaking voice.

The VHI assessment is a subjective patient-based questionnaire composed of 30 questions. which is composed of every phoneme in the English language. whether more urgent intervention is needed in view of a impending important engagement. which is highly prevalent in the dysphonic population. or the assessment of air leakage through the glottis.6). have introduced an abridged version composed of ten questions. which has excellent reliability and reproducibility. with the option for additional user-defined parameters. Also. This instrument is both easily self-administered and scored quickly at the time of evaluation while preserving the original VHI’s utility and validity.12 Professional Speaking/Singing Voice A comprehensive and somewhat adapted historical background is necessary in the evaluation of the singing voice.5). The phoneme “kaa” requires good palatal lift and closure and “maa” requires mouth closure. his friends say he is looking for the pot of gold at the end of the rainbow. formal vocal testing may proceed by having the patient perform several different vocal tasks. The voice handicap index (VHI) is a quality-of-life questionnaire specific to voice disorders. The rainbow passage (Table 2. and 3 is extreme. Six salient features— overall dysphonia severity. and its two ends apparently beyond the horizon. Inc. patient-based surveys are helpful in judging quickly and accurately the patient’s perception of their degree of voice handicap. These take the shape of a long round arch. for instance. This scale is a subjective perceptual evaluation of five vocal characteristics assigned a value between 0 to 3. a description of the degree of hoarseness. This rating scale was recently created by   Special Interest Division 3 of the American Speech-LanguageHearing Association as a standardized tool for assessment of auditory–perceptual attributes of voice. with its path high above. a standardized objective. Asking the patient to recite certain phrases will assist the clinician in characterizing the disorder. breathiness. a boiling pot of gold at one end. . 2. The rainbow is a division of white light into many beautiful colors. Another widely used auditory-perceptual evaluation of dysphonia is the Consensus Auditory-Perceptual Evaluation-Voice (CAPE-V) (Table 2. Because vocal pathologies have different levels of handicap to different individuals. Nonetheless. After careful patient observation. For instance. When a man looks for something beyond his reach. is the third component of the scale. usually the result of a change in fundamental frequency or amplitude of vibration. Strain (S) reflects a perception of vocal hyperfunction. Additionally. will determine whether management of the voice problem can be conservative—designed to assure the long-term protection of the larynx—or. vocal nodules that are devastating to a professional voice user may only be a minor inconvenience to a non-professional. There is. the patient should alter pitch. People look. various words or sounds call upon the coordination of different phonatory elements. The length Table 2. instrument to characterize voice remains an important goal of voice science. sing.and hyponasality. the word “taxi” can be used to elicit signs of abductor spasmodic dysphonia. roughness (R). Breathiness (B).4  Rainbow passage When the sunlight strikes raindrops in the air. The date of the next important performance. whisper. The five elements are grade (G). or yell. To this end. such as hum. perform glissando. Hirano proposed the GRBAS scale—a widely used perceptual rating instrument used by speech pathologists and laryngologists for the evaluation of voice quality in clinical settings. pitch. For instance.12 2 Principles of Clinical Evaluation for Voice Disorders sion during speech may indicate vocal abuse. roughness. Voice-related.4). they act like a prism and form a rainbow. The Voice-related Quality of Life (VRQOL) instrument has been validated and found to be useful (see Bibliography). Rosen et al. the VHI-10 (Table 2. is used as a standardized method of recording voice in order to track clinical progress. the patient may be asked to alter his or her type of vocal output. 2. and may provide insight into the nature of the vocal dysfunction. Copyright 1960 by Harper Collins Publishers. Passage reprinted from: Fairbanks G (1960) Voice and articulation handbook. strain. the perceptual irregularity of vocal fold vibrations. Aesthenic (A) voice denotes weakness and lack of power. 2.11 Quality-of-Life Questionnaires Much work has been performed to codify and measure patient self-perception of vocal dysfunction in the form of standardized questionnaires and other metrics. according to legend. After hearing normal speech. these questionnaires are extremely important in understanding the personal impact of these disorders on daily activities. p 127. where 0 is normal. but no one ever finds it.10 Perceptual Analysis To evaluate the voice. Such vocal tasks will help the listener gain insight into how the vocal pathology is affecting the different aspects of the patient’s speech. and use rapid alternating speech. The /m/ and /n/ phonemes require good nasal resonance and are useful for testing hyper. the “trained” ear remains the most discerning instrument. and loudness—are rated by trained listeners (SLPs and laryngologists) using a 100-mm visual analogue scale for each parameter. rather.

This is especially true if stage construction is underway during rehearsals.” and vocal fatigue. or training at the hand of multiple teachers/coaches can often result in an incompatible amalgamation of techniques requiring significant time and expert instruction to rectify. can result in mucosal irritation. most prevalent among stage actors. and bronchospasm resulting in the commonly encountered complex of hoarseness. and cramped dressing room quarters are rarely cleaned. The settings in which the singer performs are of importance. especially if his or her performance career predates their formal vocal training. A history of recent or frequent airplane travel suggests an alternate source of mucosal irritation.5  Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) of time a singer has been performing is also important. intermittent training. especially oilbased ones. vocal “tickle. Moreover. Singers must therefore take care to maintain adequate laryngeal moisture by maintaining nasal breathing and constant hydration. Cabin air is dry. 13 . Finally.  Chapter 2 Table 2. Undesirable singing techniques developed by amateur singers are particularly difficult to modify. Allergies to dust and mold can become major factors in older concert halls where curtains. allergy. exposure to stage smoke presents a unique problem. backstage trappings. Most stage smoke preparations. usually at 5% or less humidity.

J Speech Hear Res 36:21 Hirano M (1981) Clinical examination of the voice. and the impact of the voice disorder on their quality of life. Osborne J. Otolaryngol Clin North Am 24:985–988 Cooper M (1973) Modern trends in voice rehabilitation. 01234 My voice makes me feel handicapped. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders (2000) Otolaryngol Head Neck Surg 123:385–8. San Diego Koufman JA. Bassich CJ. Heidelberg. the clinician should pay particular attention to the level of voice use. Folia Phoniatr (Base1) 45:76 Kreiman J et al (1993) Perceptual evaluation of voice quality: review. the importance of the voice to the patient. Amin MR. pp 727–734 8 9 10 11 12 13 14 15 16 17 18 19 20 Silverman EM. Murry T (2004) Development and validation of the voice handicap index-10 (VHI-10) Laryngoscope 114:1549–1556 Key Points 6 7 ■ A successful surgical outcome is dependent upon proper clinical evaluation of the patient’s voice disorder. 01234 I feel left out of conversations because of my voice. Selected Bibliography 1 2 3 4 5 Sataloff RT (1997) Professional voice—the science and art of clinical care. Thomas Springfield. Grywalski C (1998) Assessing outcomes for dysphonic patients. 2003. but also on evaluative and perceptual skills. Shumrick D (eds) Otolaryngology. Zullo T. J Speech Lang Hear Res 44:511–524 . This will ensure proper patient selection and make for improved surgical outcomes. J Voice 13:557–569 Ma EP-M. Panetti M. Sethuraman G (1999) Validation of an instrument to measure voice-related quality of life (V-RQOL). Yiu EM-L (2001) Voice activity and participation profile: assessing the impact of voice disorders on daily living. ■ When caring for patients with voice disorders. Charles C. Lee AS. In: Paparella M. 01234 People ask. Singular. 01234 My voice difficulties restrict personal and social life. Available at: http://www. Arch Otolaryngol Head Neck Surg 104:7–10 Courey MS. J Voice 16:274–277 Ritter FN (1973) Endocrinology.14 Principles of Clinical Evaluation for Voice Disorders   Table 2. “What’s wrong with your voice?” 01234 From: Rosen CA. Am J Speech Lang Pathol 6:66–70 Hogikyan ND. 01234 People have difficulty understanding me in a noisy room. Grywalski C et al (1997) The Voice handicap index (VHI): development and validation. It therefore behooves the serious practitioner of laryngology to focus not only on his or her surgical skills. New York. Saunders. Ill. 01234 The clarity of my voice is unpredictable. American Speech-Language-Hearing Association Special Interest Division 3: Voice and Voice Disorders. 2nd edn. Johnson A. Korovin GS et al (eds) Diagnosis and treatment of voice disorders. Erratum in: Otolaryngol Head Neck Surg 124:104 Koufman JA (1991) The otolaryngologic manifestations of gastroesophageal reflux disease. Zimmer CH (1978) Effect of the menstrual cycle on voice quality. 01234 My voice problem upsets me. New York Voice disorders: Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Koufman JA (2002) Validity and reliability of the reflux symptom index (RSI). Sataloff RT. J Voice 12:540–550 Jacobson GH.6  Voice Handicap Index 10 2 My voice makes it difficult for people to hear me. Berlin. pp 203–219 Koufman JA. Gardner G. and a framework for future research. Springer. J Speech Hear Dis 51:125 Dejonckere PH et al (1993) Perceptual evaluation of dysphonia: reliability and relevance. 01234 My voice problem causes me to lose income.asha. Ramig LO (1995) Neurological disorders and the voice. Igaku-Shoin.)53:1–78 Belafsky PC. ■ Clinical outcome instruments such as the Reflux Symptom Index (RSI) and the Voice Handicap Index 10 (VHI-10) are extremely useful tools for the evaluation of vocal complaints. Postma GN. Isaacson G (1991) The spectrum of vocal dysfunction. Ahuja AS. ■ Careful history taking and clinical evaluation are important tools in the diagnostic evaluation of the voice patient. Philadelphia. Laryngoscope 101(Suppl.org Benninger MS. 01234 I feel as though I have to strain to produce voice. In: Rubin JS. Postma GN (1996) Microvascular lesions of the true vocal folds. tutorial. NATS J May/June:45 Smith ME. Ludlow DL (1986) The use of perceptual methods by new clinicians for assessing voice quality. Curr Opin Otolaryngol Head Neck Surg 4:134 Sataloff RT (1995) Vocal fold hemorrhage: diagnosis and treatment.

Docherty GD (1999) Measuring the effectiveness of voice therapy in a group of forty-five patients with non-organic dysphonia. Rosen CA (2002) A review of outcome measurements for voice disorders. J Psychosometr Res 54:483–489 23 Hogikyan ND.  21 Carding PN. Horsley IA. Lee AS. Wilson JA. Osborne J. a patientderived voice symptom scale. Johnson A. Murray T (2004) Development and validation of the Voice Handicap Index-10. J Voice 13:76–113 22 Deary IJ. Grywalsky C et al (1997) The Voice Handicap Index (VHI): development and validation. Laryngoscope 114:1549–1556 15 . Zullo T. Otol Head Neck Surg 126:562–572 Chapter 2 24 Jacobson BH. Am J Speech Lang Pathol 6:66–70 25 Rosen CA. Carding PN et al (2003) VoiSS.

There are a variety of methods used for this visualization. ranging from indirect mirror laryngoscopy to high-speed photography. 3.1). 3. The most commonly cited and utilized closure patterns include complete. Mucosal wave as seen during stroboscopy refers to a rippling motion traveling over the vocal fold and within the vocal fold mucosa. and sulcus vocalis. This can be measured in a detailed fashion us- Fig. A periodic or nearly periodic vocal fold vibratory activity is required for stroboscopy to be successful.Chapter 3 Videostroboscopy and Dynamic Voice Evaluation with Flexible Laryngoscopy 3. 3. flexible laryngoscopy or rigid telescope). e. and excessive posterior glottic gap (Fig. 2. 4. incomplete. especially as they relate to closure pattern for exophytic lesions and defects of the lamina propria such as seen in adynamic segments of the vocal fold.1  “Representative” set of images from stroboscopy depicting “one” vibratory cycle . Vocal fold closure pattern is typically described as the global overall pattern of vocal fold closure.2). Stroboscopy is strictly the light source and not the actual equipment used for visualization of the vocal folds. (i. Areas of diminished mucosal wave represent loss of pliability or viscoelasticity of the vocal fold lamina propria and are an important aspect of voice evaluation. It is important to note that stroboscopy can be done through any type of visualization instrument including flexible laryngoscopy and rigid perioral laryngoscopy.1 Fundamental and Related Chapters Please see Chaps. The duration of vocal fold closure is also an important clinical assessment parameter. Real-time vocal fold vibration is too rapid to visualize with the unaided eye. The wave is propagated from the subglottic area and travels from underneath the vocal fold along the free edge. and high pitch and different levels of intensity. 3. The most common and relevant clinical tools for modern-day voice evaluation and care include stroboscopic visualization of vocal fold vibration and dynamic voice evaluation with flexible laryngoscopy.. then over the superior surface of the vocal fold and is dampened in the area of the ventricle. vocal fold vibratory closure should occur approximately half of the vibratory cycle. specifically at low. hourglass. anterior glottic gap. as seen during the majority of the examination specifically at modal pitch and intensity of vowel prolongation.2 Introduction Visualization of the larynx and specifically the vocal folds is paramount for the evaluation and care of patients with voice disorders. and 5 for further information. 1. This chapter focuses on these two main clinical methods. The stroboscopic light source illumination provides representative images from the entire vibratory cycle.” or synchronized illumination of the vocal folds during vocal fold vibration (Fig. This mucosal wave activity is crucial for assessing the pliability and functional characteristics of the lamina propria of the vocal folds.3 Surgical Indications and Contraindications Stroboscopy utilizes a method of “shuttering. This provides “pseudo” slow motion visualization of vocal fold vibration. vocal fold scar. The most common vocal fold vibratory characteristics that stroboscopy allows one to view are: ■ ■ ■ ■ ■ Vocal fold closure (pattern and duration) Mucosal wave movement (propagation) Symmetry of vibration Amplitude of vocal fold vibration Periodicity 3 Stroboscopy helps elucidate specific lesions of the vocal folds. At modal pitch and intensity. Mucosal wave activity should be assessed at a variety of phonatory tasks. medium. 3. These two techniques when used in a complimentary fashion can provide the clinician with detailed information on intricate vocal fold vibratory activity and phonatory and functional use of the entire vocal tract.

loss of lamina propria tissue or sulcus vocalis (see Chap. For example. amplitude and closure are two stroboscopy parameters that are directly affected by the voice intensity and pitch during the stroboscopic examination and these factors must be constantly monitored and taken into consideration when assessing these parameters. Stroboscopy of the vocal folds is helpful for visualization of a variety of vocal fold lesions.3  Vocal fold amplitude . Vocal fold vibration symmetry during stroboscopy is judged by comparing the vocal folds’ vibratory activity to one another. A typical stroboscopy examination protocol includes: ■ Modal voice (most comfortable pitch and intensity) ■ Low pitch (soft and loud to assess maximum pliability) ■ High pitch. There should be a good correlation from an auditory and visual perceptual basis. “Sulcus Vocalis and Vocal Fold Scar”).3). Of course. 4.4 Dynamic Voice Assessment with Flexible Laryngoscopy Flexible laryngoscopy is an essential evaluation technique for voice disorders-related “functional” problems such as muscle tension dysphonia.” Stroboscopy is also extremely important for visualization of seg-   ments of the vocal fold with poor vibratory characteristics due to scar. The low pitch-loud task is helpful not only for assessing overall pliability. When performing stroboscopy. Periodicity is based on the regularity of successive cycles of vibration. Even though symmetry and periodicity may be thought to assess similar behavior. 23. 3. in fact. vocal folds can have distinctly different amplitude and symmetrical activity and still be quite periodic.18 3 Videostroboscopy – Flexible Laryngoscopy ing electroglottography but can also be estimated using frameby-frame review of the recorded stroboscopic images.2  Different vocal fold closure patterns Fig. First. 3. then a repeat examination or careful examination of other factors should be undertaken. The degree of vocal fold amplitude (horizontal excursion from midline) during vocal fold vibration as seen during stroboscopy is an important assessment tool and involves both the comparative as well as overall subjective assessment of the amount of amplitude of each vocal fold during vocal fold vibration (Fig. 3. at high pitches both the amplitude and mucosal wave decrease as compared to lower pitches. Periodicity describes the regularity of vocal fold vibration. but also for patients with the most aperiodic voice. If this is not the case. The vibration of one vocal fold should be a mirror image of the contralateral fold. the vocal fold vibratory activity and characteristics should be first compared internally (to each other). subtle lesions. Stroboscopy to assess vocal fold vibratory activity should be done using a fairly consistent assessment protocol. which are discussed in detail in Chap. soft intensity phonatory task The latter is extremely helpful for identifying subtle lesions of the vocal fold as well as assessing abnormalities associated with vocal fold pliability and vocal fold vibratory activities. “Pathological Conditions of the Vocal Cords. it is essential to identify that the patient has a periodic or nearly periodic signal. paradoxical vocal fold motion disorder and Fig. 3. and then compared to the examiners experiential database and most importantly correlated with the amount and nature of dysphonia of the patient. The converse is also true where vocal folds can demonstrate aperiodic activity with normal and symmetric amplitude (as often seen with vocal fold paresis).

The advantages of recording all or portions of the laryngeal examinations include: ■ ■ ■ ■ Longitudinal comparison Preoperative planning Patient education Medical/legal uses Further justification and use of a video recording include the ability to record an audio track in conjunction with the video examination. vocal fold paralysis. essential tremor. neoplasm (benign and malignant) and infection 3. 3.1). supraglottic constriction associated with phonation.1) 2.3 Larynx (Global) 1. This examination is done in a stepwise fashion. vocal fold paresis. and illumination light source(s) (continuous halogen and preferably stroboscopy). (infectious or allergic) nasopharyngeal neoplasms 3. LPR cancer.1 Table 3. etc. sustained phonation and alternat- ing speech and respiration (see Table 3. tu- mors.1  DVA tasks. and vocal fold paresis. The two most common methods of recording portions or all of these examinations are with either still photography or video recording. vocal field paralysis and vocal fold paresis 3. tremor of the soft palate (rest and activation) and velopharyngeal incompetence (VPI) 3. “What did you do yesterday?”) Sing “Happy Birthday” Cough Laugh Nasopharynx 1. with a breath between each “hee”) and connected speech (“We were away a year ago. Patient task: rest. amyotrophic lateral sclerosis (ALS). Pathology: paradoxical vocal fold motion disorder.). nodules. Patient task: rest and tongue protrusion 2. and global laryngeal tremor 3. sinonasal disease. The subregions of the dynamic voice assessment include nasopharynx. alternating sustained phona- tion and respiration (hee-hee-hee. glottal insuf- ficiency and tremor 3. especially in a court of law. flexible laryngoscopy. and the vocal folds. decongestant and anesthetic for the nasal cavity. infections 3. secondary muscle tension dysphonia. It is essential to have a baseline or preoperative audio and/or voice recording prior to and after 19 . neurologic voice disorders (spasmodic dysphonia. as well as pyriform/vallecular lesions. At each one of these specific subportions of the dynamic voice assessment. Patient task: respiration. Pathology: essential tremor of the vocal tract. larynx (global). The specific areas of activation include vegetative functions and phonation. Parameters of evaluation: nasal disease.4 Vocal Fold (Focal) 1. sustained phonation (/ee/) and speech (/koka kola/) and prolonged fricative /s/ 2.”) 2.  Chapter 3 functional aphonia. Pathology: focal vocal fold lesions (polyp. specific tasks are elicited from the patient to look for different pathologies in the area and confirm or rule out a variety of disorders (Table 3. Equipment required includes nasal speculum. base of tongue.4. fasciculations (ALS). Pathology: velopharyngeal incompetence. vocal fold atrophy. Parameters of evaluation: tremor. primary muscle tension dysphonia. findings. etc. and correlated diagnoses: examination protocol—tasks Velum Sustained /ee/ /koka kola/ Base of tongue Evaluation of symmetry and mucosa Larynx Quiet respiration Sustained /ee/—comfortable pitch Sustained /ee/—low and high pitch /ee/ /ee/ /ee/ (with a breath between each “hee”) “We were away a year ago. Both audio and video examination can be extremely helpful for all of the above-mentioned reasons.4. Parameters of evaluation: vocal fold mobility and synchrony of mobility Paradoxical vocal fold motion.4.5 Recording of Laryngeal Examination It is highly recommended but not absolutely necessary that the stroboscopy and/or dynamic voice evaluation be recorded.”—comfortable pitch Example of connected speech (Ask.2 Base of Tongue 1.4. examining each section of the vocal tract which is outlined below from an anatomic and a physiologic perspective (at rest and then in activation).) 3. vocal tremor. masses of the naso- pharynx. Dynamic voice assessment with flexible laryngoscopy evaluates multiple parameters associated with phonation done in a dynamic and “most natural” setting. Patient task: quiet respiration. Parameters of evaluation: vocal fold lesions.” “We were away a year ago. vocal tremor.

Singular. ■ Strobe and DVA are complementary and should not be viewed in isolation. Am J Otolaryngol 25:138–141 . Singular. This is analogous to the documentation procedures for cosmetic surgical procedures. Bouchayer M. Selected Bibliography 1 2 3 4 5 Hirano M. Laryngoscope 115:423–428 Roehm PC. San Diego Stasney CR (1996) Atlas of dynamic laryngeal pathology. Key Points ■ Stroboscopy and dynamic voice assessment (DVA) with flexible laryngoscopy are essential aspects of a voice evaluation and care.20 3 Videostroboscopy – Flexible Laryngoscopy elective surgical procedures. San Diego Cornut G. Bless DM (1993) Videostroboscopic examination of the larynx. related physical exam abnormal findings. 254 min Rosen CA (2005) Stroboscopy as a research instrument: development of a perceptual evaluation tool. and stroboscopy allows the examiner insight into key vocal fold vibratory activity. specifically the physiologic and pathophysiologic activities related to the patient’s dysphonia. ■ The dynamic voice assessment and evaluation allows for a natural in vivo evaluation of the entire vocal tract during rest.   ■ The combination of stroboscopy and dynamic voice assessment with flexible laryngoscopy allows the clinician to correlate the patient’s voice symptoms. Five videocassettes. and phonation (connected and sustained). Rosen C (2004) Dynamic voice assessment using flexible laryngoscopy—how I do it: a targeted problem and its solution. Video recordings of the vibratory parameters of the vocal fold are also very helpful to refer to when surgically resecting a lesion. vegetative activities. craft an accurate diagnosis and form a successful treatment plan. Assessing dysphonia: the role of videostroboscopy.

. most of the vocal fold lesions are benign and in general should be managed with a conservative approach that involves maximizing all nonsurgical treatment methods first. and historical experience has demonstrated that external beam radiation therapy. The chapter is divided among epithelial pathology of the vocal folds. and miscellaneous vocal fold pathology.1 Recurrent Respiratory Papillomatosis of the Larynx Recurrent respiratory papillomatosis of the larynx is an epithelial growth of the larynx most commonly seen at the level of the vocal folds (Fig. likewise. many patients who suffer from keratosis of the vocal fold show no dysplasia of these lesions and are strictly burdened by the repetitive regrowth of a hyperkeratotic epithelial covering at various locations of the Fig. 4. The surgical philosophical approach for RRP should be to: (1) maintain a patent airway without using a tracheotomy.1). there is a high risk of a new papillomatous disease growth at that site. 4.2 Leukoplakia of the Vocal Fold Abnormal epithelial hypertrophy or dysplasia of the vocal folds can be manifested as redundancy of the epithelial or keratotic layers of the vocal folds resulting in hyperkeratosis. pul- monary involvement. benign midmembranous lesions. Often these cells can become dysplastic and are thought to be a precursor for malignancy. 4. such as where pseudostratified columnar and stratified squamous are juxtaposed. and then only proceeding with surgical treatment if key functional issues (i. 4.3. and alcohol exposure increase the risk of RRP malignant transformation. especially as they relate to the surgical treatment is included.2). These recurrent benign lesions grow most significantly at epithelial transition sites. However. bilateral .1  Recurrent respiratory papillomatosis. and (3) minimize chance of operative complications and sequelae such as glottic webbing and vocal fold scar formation. This is frequently demonstrated when a tracheotomy is performed on a patient with recurrent respiratory papillomatosis. 4.1 Fundamental and Related Chapters Please see Chaps. A brief overview and discussion of the key points of each of these vocal fold lesions. It cannot be overemphasized that the chance of curing patients with RRP using surgical excision alone is low. An important differentiation of this pathology relates to the anatomic structure of the cells involved in the abnormal epithelium. The most common human papilloma virus types involved with RRP of the larynx are HPV types 6 and 11.3 Epithelial Pathology of the Vocal Folds 4. e. Malignant transformation of these types of HPV infection are extremely rare. It should be stressed that with the exclusion of carcinoma and recurrent respiratory papilloma of the vocal folds. parakeratosis. there is no evidence that a more aggressive operation will increase the patient’s long-term control of his or her disease. (2) optimize functional results with respect to voice and swallowing.2 Introduction The variety of pathologic conditions that occur within the vocal fold can be separated into categories based on their anatomical location. 4.3. voice quality and vocal function) are still persistent. and is clinically referred to as leukoplakia (Fig. 2 and 3 for further information. These growths are a direct response to a human papilloma virus infection and tend to be recurrent in nature. Any time a new epithelial transition site is created in a patient who is infected with the human papilloma virus. tobacco exposure.Chapter 4 4 Pathological Conditions of the Vocal Fold 4.

4. these patients require careful monitoring and a complete surgical excision of any suspicious leukoplakic lesion. . T1 vocal cord carcinoma has a 5-year survival of 90–98% when treated with either one of these modalities (see Chap.3 Dysplasia–Carcinoma in Situ of the Vocal Folds Dysplasia or carcinoma in situ of the vocal folds represents a demonstrable change of the normal epithelial cellular structure and is thought to be a precursor toward development of malignancy of the vocal folds (Fig. It is equally important to remember that the majority of patients with keratosis of the vocal folds will not develop a malignancy and most likely will have recurrent lesions in the future. 4. 4. 30. (Fig. thus.3). Suspected risk factors for keratosis include viral infection.4  Carcinoma of the left vocal fold Carcinoma of the Vocal Fold Carcinoma of the vocal fold represents a malignant invasion of the epithelial cells into the vocal fold. There is no role for external beam radiation for these patients. Once abnormal epithelial cells have breached the basement membrane of the epithelium.4) Staging of vocal fold cancer is based on the location(s) of the disease as well as the degree of invasion and subsequent limitation of vocal fold motion due to the cancer invasion. Carcinoma in situ refers to carcinomatous transformation without basal membrane penetration. depending on the severity of the invasion. Early T1 and T2 stage cancer of the vocal folds can be successfully treated with surgical excision and/or radiation therapy. dysplasia is graded on the severity of the abnormal morphology of the epithelial cells. These lesions can be singular in nature or they can be multiple and diffuse throughout the vocal folds and arytenoid cartilages.3.4 Fig. 4.3. lamina propria.3  Dysplasia–carcinoma in situ of the right vocal fold Fig. Given that the risk of transformation of this leukoplakic biologic activity into a malignancy is present (statistically < 10%). Complete excision of dysplasia and/or carcinoma in situ of the vocal folds is crucial to preventing more serious and significant problems of carcinoma of the vocal folds. 4 Fig. the condition is then defined as a carcinoma or microinvasive carcinoma of the vocal folds. and beyond. “Carcinoma of the Vocal Fold”). principles of conservative excision and patient observation with longitudinal photo documentation are essential to the care of this patient group. 4.2  Keratosis of the left vocal fold 4. Specifically. 4. and vocal fold phonotrauma (primary or secondary to glottal insufficiency). LPR.22 Pathological Conditions of the Vocal Fold   vocal folds.

(2) characteristics of the mucosa wave of the lesion and surrounding areas as seen on stroboscopy (minimal–normal versus significant impairment). The stroboscopic pattern of a subepithelial vocal fold cyst is an hourglass closure pattern. patients with midmembranous vocal fold lesions have relatively normal epithelium overlying their pathologic process. They are thought to be “calluses” of the vocal folds and are always bilateral and fairly symmetric. and thus. then phonomicrosurgery is indicated. In general. a short period of both reduced voice use and voice therapy is implemented (2–3 weeks). This approach should be taken for most patients with midmembranous vocal fold lesions causing significant dysphonia (see Chap. The decision making on initial treatment(s). 4. duration and timing of surgery is complex and does not lend to formulaic approaches. “Vocal Cord Nodules”). and (4) intraoperative findings. with normal to minimal disruption of the mucosal wave vibratory activity (depending on Fig. “Timing.4. the concern for cancer is extremely low. pedunculated polyp). 4.6). Planning. patients should be treated with nonsurgical therapy before surgery. the patient should have a repeat comprehensive voice evaluation to determine the amount of improvement and to determine if there are any residual functional limitations to their voice use and demands.1 Overview of Midmembranous Vocal Fold Lesions Midmembranous lesions of the vocal fold are abnormalities of lamina propria of the vocal fold. with minimal or no changes of the overlying epithelium. presence or absence of a capsule wall. Exceptions include distinct lesions that are hightly unlikely to improve without surgery (i. 7. 4. These lesions are extremely common causes of voice disorders and often require surgical therapy. and both genders in children. Stroboscopic behavior of vocal fold nodules typically demonstrates an hourglass closure pattern and normal or minimally reduced mucosal wave vibratory activity (see Chap.. Often these lesions respond extremely well to nonsurgical treatment methods such as voice therapy and treatment of comorbid medical problems. This book uses a classification system utilizing four commonly used clinical modalities to differentiate seven distinct benign midmembranous vocal fold lesions. After the implementation and adequate treatment time of these nonsurgical treatment methods.4. These lesions by definition respond to a combination of voice rest and voice therapy. 16. If these functional limitations are significant to the patient and can be reasonably projected to improve with surgical excision of the vocal fold lesion(s). Vocal fold nodules are seen almost exclusively in females in adults.  Chapter 4 4. 4.5  Vocal fold nodules (bilateral) 23 .4 Vocal Fold Cyst (Subepithelial) A subepithelial vocal fold cyst represents an encapsulated lesion within the superficial aspect of the lamina propria. and Decision Making for Laryngeal Surgery”). These classification methods include (1) morphology (midmembranous vocal fold lesion). In these instances. and surgical treatment with different midmembranous vocal fold lesions differ significantly.4 Benign Diseases of the Vocal Fold Lamina Propria 4.4.5). (3) response of the lesion in the form of resolution or reduction in size to voice rest/voice therapy. and nature of the pathology. It is important for this classification to be exact. midmembranous vocal fold lesions involving most likely the most superficial aspect of the lamina propria as well as the basement membrane zone of the vocal fold epithelium (Fig. “Medical Treatment of Voice Disorders”). a large. followed by a reevaluation of the lesion(s) and patient’s vocal functional abilities (see Chap. and thus a multidimensional system has been developed and is required to classify properly the midmembranous vocal fold lesions.3 Vocal Fold Nodules Vocal fold nodules are benign. physical features. Unfortunately. 8. given that clinical outcomes and patient prognosis. visualization alone of these lesions does not properly stratify and classify these lesions. typically found in the midmembranous vocal fold (Fig.2 Approach to Midmembranous Vocal Fold Lesions In most instances. 4. 4. Significant confusion and debate exists regarding the nomenclature and classification of these lesions.4. when the patient is compliant and the voice therapy is done in an appropriate fashion. e. The latter includes location of the pathology (subepithelial or near the vocal ligament) and the physical characteristics of the lesion.

10.4. 4.8 Fibrous Mass (Ligament) A ligamentous fibrous mass represents fibrous tissue accumulation in the midmembranous vocal fold near the vocal ligament (Fig. This pathology does not respond to nonsurgical treatment methods.10).24 Pathological Conditions of the Vocal Fold   rest or voice therapy. benign pathologic process that typically involves significant reduction of mucosal wave vibratory wave activity as seen on stroboscopy as well as an hourglass closure pattern (Fig. It is located in the deep aspect of the lamina propria and often better visualized within the vocal fold in abduction compared to adduction.8).6  Cyst (subepithelial) of left vocal fold A vocal fold polyp is a pathologic process of the lamina propria that involves typically an exophytic or pedunculated lesion of the midmembranous vocal fold that can be unilateral or bilateral (Fig. often under a severely thin and atrophic epithelium. “Principles of Phonomicrosurgery” and 17. The surgical approach is similar to a ligamentous vocal fold cyst. “Vocal Fold Cyst and Fibrous Mass”). 4 4.4. “Principles of Phonomicrosurgery” and 17.6 Fig. 4. A vocal fold polyp does not respond to voice therapy and rest (by definition). and the prognosis for prompt recovery of the voice after surgical excision is less when compared with a vocal fold polyp or subepithelial cyst. The stroboscopic pattern of a vocal fold polyp shows an hourglass closure pattern with normal or minimal reduction of the vibratory activity of the mucosa. 10. The surgical approach to this lesion involves a microflap (see Chaps. “Vocal Fold Polyp”). with significant reduction of the mucosal wave vibratory activity as seen on stroboscopy. but the vocal recovery is more delayed and overall prognosis reduced comparatively (see Chaps. via a microflap.5 Vocal Fold Cyst (Ligament) A vocal fold cyst found in the area near the vocal ligament is an encapsulated.7 Fig. 4. 10. 10 and 17). Stroboscopic pattern of fibrous mass in the subepithelium demonstrates an hourglass closure pattern. and the overall vocal function prognosis is worse than other midmembranous vocal fold lesions (see Chaps.9). 4. giving it a fusiform shape. This lesion does not respond to nonsurgical treatment methods. The speed of vocal recovery is reduced compared with a vocal fold cyst. Often this tissue is amorphous and has extensions anteriorly and posteriorly in the vocal fold. “Vocal Fold Cyst and Fibrous Mass”). This material is typically amorphous in nature and often has thin extensions anteriorly and posteriorly within the vocal fold. Subepithelial vocal fold cysts typically do not respond or change in any appreciable fashion to voice rest or voice therapy. This lesion does not respond to voice Vocal Fold Polyp Fibrous Mass (Subepithelial) A subepithelial fibrous mass represents an accumulation of fibrous tissue within the subepithelial aspect of the midmembranous vocal fold (Fig.7  Cyst (ligament) of left vocal fold size). 10. “Principles of Phonomicrosurgery” and 15.4.7). . 4. Surgical excision when indicated of a vocal fold subepithelial cyst is done through a microflap approach to the vocal fold (see Chaps. The surgical approach to these lesions is similar to a subepithelial vocal fold cyst. “Principles of Phonomicrosurgery” and 17. Surgical excision of the vocal fold lesion can be done through a microflap approach or truncation of the vocal fold lesion (see Chap. and the surgical approach for this lesion is through a microflap. and intraoperative exploration reveals a focal accumulation of a gelatinous material. “Vocal Fold Cyst and Fibrous Mass”). 4. 4. 4. 4. The stroboscopic pattern of fibrous mass and ligament reveals hourglass closure pattern and significant reduction of the mucosal wave vibratory activity.4.

left vocal fold Vocal Fold Granuloma A vocal fold granuloma is inflammatory tissue arising from the perichondrium of the arytenoid cartilage (Fig. in general the process occurs throughout the entire vocal fold and is also exclusively found bilaterally. “Vocal Process Granuloma”). The most common etiologic factors of Reinke’s edema involve tobacco abuse (97%). 10.5. left vocal fold Fig. 4. often found after orotracheal intubation. Surgical excision of the lesion can be done if the contralateral lesion requires surgery. 4.5 Miscellaneous Disorders of the Vocal Fold 4. and it may become asymmetric. This is a response to trauma of the arytenoid perichondrium.9  Fibrous mass (subepithelial).10  Fibrous mass (ligament). Often these accumulations can be quite severe. vocal fold cyst.. which typically lowers the pitch of the voice and causes increased vocal effort and instability.12). Once the etiologic trauma and irritants that initiated the vocal fold granuloma are removed. e. and phonotrauma.4. 4. One may also elect not to operate on the reactive lesion. 10. however. 4. 19.  Chapter 4 4. to remove the risk of an adverse surgical outcome (scar) at the operative site. “Principles of Phonomicrosurgery” and 18.5.13).8  Polyp. Each of these potential etiologic factors should be addressed in a strict and thorough fashion prior to proceeding with surgical treatment of the Reinke’s edema (see Chaps. or excessive hyperadduction of the arytenoid cartilage (found in some phonatory behaviors and chronic cough). Surgical excision of vocal fold granuloma should only be performed if there is an acute airway obstruction.2 Fig. vocal fold polyp. “Vocal Fold Polyp”). This lesion responds quite favorably to voice rest and voice therapy and typically will reduce in size with this treatment modality. 4. fibrous mass) (Fig.11).9 Reactive Lesion A reactive lesion is a submucosal. This lesion typically has a hourglass closure pattern seen on stroboscopy and has minimally reduced or normal mucosal wave vibratory activity on stroboscopy. a suspicion of malignancy or after all etiologic factors have been thoroughly addressed (see Chap. “Polyp Corditis [Reinke’s Edema]”). right vocal fold Reinke’s edema is a pathologic condition of the vocal fold that involves an accumulation of a gelatinous type of fluid throughout the superficial aspect of the lamina propria (Fig.1 Polypoid Corditis (Reinke’s Edema) Fig. 4. 25 . vocal fold granuloma disease will often spontaneously resolve over a matter of several months. LPR is thought to contribute to further inflammation and propagation of granulomatous formation. 4. laryngopharyngeal reflux disease. The surgical approach is similar to a vocal fold polyp (see Chaps. Reinke’s edema involves a demonstrable increase in size of the mass and volume of the vocal fold. pathologic process of the vocal fold in response to a contralateral vocal fold lesion (i. “Principles of Phonomicrosurgery” and 15. 4.

these lesions are often called bamboo lesions of the vocal fold (Fig. This tissue typically results in severe reduction of the vibratory activity of the vocal folds. 4. They can present and develop in a variety of different patterns. These lesions are often adjacent to the vocal fold ligament or can occupy the entire width of the lamina propria.13  Arytenoid granuloma Fig. such as vascular lakes. thus. By convention. as seen in stroboscopy. “Principles of Phonomicrosurgery”). the surgical dissection can be difficult and tedious. Vascular abnormalities of the vocal fold typically run perpendicular to the longitudinal axis of the vocal fold and are significantly greater than one millimeter in diameter.14  Rheumatological lesions of the right vocal fold (asterisks) . bilateral Fig. They have been known to form several distinct lesions within a single vocal fold. Given the intense fibrotic nature of this lesion(s).14).11  Reactive lesion of the right vocal fold (asterisk) Rheumatologic Lesions of the Vocal Folds A variety of rheumatological disorders (e.3 4 Fig. rheumatoid arthritis. This involves an abnormal vascular structure formation and vessel diameter of the subepithelial blood vessels of the vocal fold (Fig. The management and Fig. 4. g. ectasias.4 Vascular Lesions of the Vocal Folds A variety of vascular lesions of the vocal fold can occur. and varices. most commonly associated with repeated phonotrauma of the vocal folds. 4.5. the normal subepithelial vocal fold vasculature runs parallel to the longitudinal axis of the vocal fold.15).. 4.26 Pathological Conditions of the Vocal Fold   4. 10. Microflap approach to surgical excision of these lesions is warranted when there is significant dysphonia.5. 4. systemic lupus) can cause an unusual inflammatory process and deposition of abnormal tissue within the lamina propria of the vocal fold. resulting in a “bamboo” appearance of the vocal fold.12  Reinke’s edema of the vocal folds. and all attempts to control the rheumatological disease have been implemented (see Chap. 4. and postoperative vocal fold stiffness is common. 4.

Lawson L (2004) Analysis of a staging assessment system for prediction of surgical interval in recurrent respiratory papillomatosis. “Sulcus Vocalis and Vocal Fold Scar.16). Sulcus vocalis presents typically as a furrow along the free edge of the vocal fold in varying lengths and varying severity with respect to the degree of loss of the lamina propria (Fig. fibrous mass (subepithelial or ligament). Fig. Powitzky E.  Chapter 4 mation of the vocal fold epithelium onto the vocal fold ligament. Curr Opin Otolaryngol Head Neck Surg 10:492–496 27 . etc. Int J Pediatr Otorhinolaryngol 68:1493–1498 Schweinfurth JM. Rosen CA (2003) Surgical treatment of benign vocal fold lesions. Sulcus vocalis can often also have associated vocal fold pathologic entities. ■ Benign midmembranous vocal fold lesions typically occur from vocal misuse/overuse. cysts. “Surgical Management of Vocal Fold Vascular Lesions”.16  Sulcus vocalis Selected Bibliography surgical approach to these lesions are discussed in Chap. ■ Premalignant changes of the epithelium and cancer of the vocal fold require careful observation/treatment to maximize treatment success and voice preservation. Fla. The medical and surgical approaches to vocal fold scar and sulcus vocalis are discussed in Chaps. seven distinct lesions can be strictly defined: vocal nodules. 23 September 2003 Derkay CS.15  Vascular lesions of the vocal fold ■ Most pathological conditions of the vocal folds are benign and occur within the epithelium or the lamina propria. Ann Otol Rhinol Laryngol 110:811–814 Thekdi. 1 2 4. Burke B. These lesions cannot be accurately diagnosed by viewing alone. Carron J. 23. Sulcus vocalis is a loss or absence of the vocal fold lamina propria. ■ Recurrent respiratory papillomatosis of the larynx occurs from a viral (HPV) infection of the epithelium (most commonly the epithelium of the vocal folds).” and 48. Key Points Fig. Ossoff RH (2001) Regression of laryngeal dysplasia after serial microflap excision. polyp. fibrous mass.) and mucosal bridges. AAO-HNS annual meeting.5 Vocal Fold Scar and Sulcus Vocalis Vocal fold scar and sulcus vocalis represent severe abnormalities of the lamina propria of the vocal fold. 4. Using morphology. and reactive lesion.” respectively. such as vocal fold lesions (e. Orlando. The former involves replacement of the normal extracellular matrix proteins of the lamina propria with abnormal scar tissue and an altered collagen matrix structure. 4. The diffuse infection of the virus and the recurrent nature of the disease demand a conservative surgical approach. 4. g.. 22. ■ Vocal fold scar and sulcus vocalis represent severe derangement or loss of the vocal fold lamina propria (respectively). Hester RP.. “Gray’s Minithyrotomy for Vocal Fold Scar/Sulcus Vocalis. response to voice therapy and surgical findings. resulting in a direct approxi- 3 4 Rosen CA et al (2003) Benign midmembranous vocal fold lesion nomenclature paradigm. cyst (subepithelial or ligament).5. AA.

J Voice 17:571–578 Rosen CA (2000) Vocal fold scar: evaluation and treatment. Sataloff RT. Bunting GW. NJ . Bless DM (2003) Tracking outcomes after phonosurgery for sulcus vocalis: a case report. Mahwah. Ann Otol Rhinol Laryngol 108:10–16   7 8 9 Welham NV. Branski R. Vaughn T (1997) Reinke's edema: phonatory mechanisms and management strategies. Otolaryngol Clin North Am 33:1081–1086 Verdolini K. Rousseau B. Rosen CA.28 Pathological Conditions of the Vocal Fold 5 6 4 Zeitels SM. Ford CN. Hillman RE. Zeitels SM (1999) Ectasias and varices of the vocal fold: clearing the striking zone. Hillman RE. (2005) Classification Manual of Voice Disorders. Lawrence Erlbaum Associates. Ann Otol Rhinol Laryngol 106:533–543 Hochman I.

1. Unilateral vocal fold paralysis (UVFP) 2. Thus. the diagnosis of glottic insufficiency can is made through flexible laryngoscopy alone. anterior cervical disc surgery. however. but can be broken down into categories to highlight the relevant pathophysiology. and terminates in the thyroarytenoid (TA). the RLN supplies all of the intrinsic laryngeal muscles with the exception of the cricothyroid muscle.1 Introduction Glottic insufficiency is one of the most common contributing factors in patients who present with dysphonia. The vagus nerve exits the skull base via the jugular foramen and descends in the carotid sheath.2. “Videostroboscopy and Dynamic Voice Evaluation with Flexible Laryngoscopy”). fixation or subluxation) ■ Vocal fold atrophy/soft tissue deficiency due to: ■ Deinnervation (vocal fold paralysis/paresis) ■ Age-related changes (presbylaryngis) ■ Tissue loss from ablative/destructive vocal fold procedures ■ Vocal fold scar ■ Sulcus vocalis deformity ■ Myopathic disease (rare) In clear-cut clinical settings such as unilateral vocal fold paralysis. Causes of glottal insufficiency include: ■ Vocal fold immobility/partial immobility from one or a combination of: ■ Vocal fold paralysis ■ Vocal fold paresis ■ Cricoarytenoid joint derangements (e. Common iatrogenic surgical causes of UVFP include thyroidectomy/parathyroidectomy. 3. The RLN arises from the vagus nerve in the upper chest and loops under the aortic arch (left) or subclavian artery (right). thymectomy. The right vocal fold is lateralized and a visible glottic gap is present during phonation .1).1 Etiology The etiology of UVFP involves dysfunction of the brainstem nuclei. videostroboscopy is essential to evaluate for glottal insufficiency when both vocal folds appear mobile. the interarytenoid (IA) (an unpaired muscle). neck dissection. Presbylaryngis/age-related changes of the larynx 3. adjacent to the cricothyroid joint. the vagus nerve. These are shown in Table 5. and contralateral RLN input to the IA may lead to some adduction of the vocal fold on the paralyzed side (Fig.2) The causes of unilateral VFP are myriad. The nerve enters the larynx posteriorly. as is frequently the case with subtle vocal fold weakness. coronary ar- Fig. that the interarytenoid muscle is unpaired. g.Chapter 5 Glottic Insufficiency: Vocal Fold Paralysis. However. esophagectomy. and cardiothoracic surgery. giving off three major branches: the pharyngeal branch. carotid endarterectomy. Ipsilateral RLN transection usually results in complete unilateral vocal fold immobility (the ipsilateral CT does not contribute to vocal fold adduction or abduction).1  Videostroboscopy image of glottic insufficiency due to a right vocal fold paralysis. It is important to remember.. the superior laryngeal nerve (SLN). It is also one of the easiest findings to overlook in the clinical evaluation (Fig. as well as motor input to the cricothyroid muscle. Iatrogenic nerve injury likely represents the most common cause for otolaryngologic referral. 5. 5. vocal fold scar and sulcus vocalis (Chap. and ascends back into the neck. The most common causes of symptomatic glottic insufficiency and the focus of this chapter are: 1. and Atrophy 5.2 Unilateral Vocal Fold Paralysis 5. which controls vocal fold lengthening and pitch. Paresis. traveling in the tracheoesophageal groove. and the lateral cricoarytenoid (LCA). including aortic surgery. 5. and the re- 5 current laryngeal nerve (RLN). Vocal fold paresis (unilateral and bilateral) 5. The SLN supplies sensation to the glottic and supraglottic larynx. The RLN innervates the ipsilateral posterior cricoarytenoid (PCA). mediastinoscopy. or the recurrent laryngeal nerve (RLN) supplying the involved side of the larynx.

sarcoidosis. Other nonlaryngeal malignancies include thyroid. Laryngoscope 108:1346–1349   pes simplex infection (HSV1) of the vagus nerve or its branches.9) Thoracic aortic aneurysm (4. The voice may also have a watery or “gurgle-y” quality to it if secretions are retained in the pyriform sinus. and even esophageal stethoscope placement have been implicated as occasional causes of VFP. This voice can sound quite similar to a patient with primary muscular tension dysphonia.3. Such diseases include gout. A small number of case reports suggest that “idiopathic” UVFP may be due to her- Fig.7) Iatrogenic—surgical trauma (23.1) Intubation (7. as is typical in high vagal injuries. Many of these patients have severe dysphagia and aspiration due to ipsilateral laryngopharyngeal sensory and motor deficits. and deserve early intervention. With time. Nonlaryngeal malignancies are another common cause of unilateral VFP.1  Unilateral vocal fold immobility: causes Cause (%) Malignancy—nonlaryngeal (24. However. Fortunately.6) Nonsurgical trauma (11. The injury is presumed to be an inflammatory neuropathy. little scientific data have been published to demonstrate that HSV neuritis is the causative agent in “idiopathic” UVFP. Medications such as the vinca alkaloids (vincristine and vinblastine). Idiopathic UVFP is a diagnosis of exclusion. In contrast. This hyperfunctional muscular contraction leads to a characteristic rough. 5. prolonged nasogastric tube placement.1 Vocal Quality and Swallowing The primary symptom of UVFP is dysphonia. as described later in this chapter. These paralyses rarely resolve spontaneously. is used to help analyze these patients. These patients constrict the supraglottic tract either laterally. and cisplatinum. and the diagnosis of vocal fold paralysis may not be suspected.3) Pulmonary or mediastinal TB (1. and/ or in an anterior posterior dimension. and skull base (i. Endotracheal intubation. some patients will eventually progress to a stronger voice.30 5 Glottic Insufficiency tery bypass grafting. An atrophic and poorly compensated vocal fold paralysis typically presents with a breathy. tuberculosis. in these patients. and isolated UVFP in this setting is highly unlikely. and usually resolves over a 4. Laryngeal electromyography is helpful in these situations. These systemic diseases would be expected to have myriad symptoms in addition to unilateral vocal fold immobility. often females. Gillen JB. apposing the false folds. The most common scenario involves bronchiogenic carcinoma of the lung associated with a left RLN paralysis.9) Idiopathic (19. no studies exist that evaluate the benefit of systemic corticosteroids and/or antivirals in the treatment of this condition.1) Adapted from: Benninger MS.5) Neurologic (7. pitch-locked. only after a detailed history and appropriate imaging studies fail to demonstrate a cause. Other traumatic causes of VFP include blunt or penetrating injuries to the neck. Although this theory is widely regarded as true. rheumatoid arthritis. 5. The voice can vary from simple vocal fatigue in mild or well-compensated cases.3 Surgical Indications and Contraindications 5. other neurologic symptoms (such as paraplegia) or additional cranial nerve involvement are the rule. although this scenario is probably quite rare. one must be careful to rule out the possibility of arytenoid dislocation or subluxation as the true cause of an immobile vocal fold. usually of the brainstem. other patients.to 6-week period after stopping or adjusting the dose of the medication Systemic diseases can (rarely) cause vocal fold immobility. low-frequency voice. paraganglioma) tumors. Supraglottic hyperfunctional compensation is common. weak voice due to air escape. The neurologic event most commonly associated with unilateral VFP is stroke..2  Diagram depicting the dual innervation (from both the right and left RLN) of the interarytenoid muscle Table 5. In the case of endotracheal intubation leading to unilateral vocal fold mobility. using various compensatory strategies. and these conditions should not be suspected in cases of isolated VFP. are known to cause neurotoxicity of the RLN (unilateral or bilateral). to almost complete aphonia in severe cases. apposing the epiglottis to the arytenoids. The cause in these cases is usually due to mediastinal spread of the malignancy into the aortopulmonary window. Altman JS (1998) Changing etiology of vocal fold immobility. and pulmonary lobar resection. “Unloading” of the voice. Idiopathic UVFP is also seen frequently. the VFP associated with the vinca alkaloids is dose related. In addition. e. due to either paralysis or joint fixation. may . similar to the cranial neuritis observed with Bell’s palsy. Much of the quality of the voice is determined by the muscular tone and position of the affected vocal fold and each patient’s unique laryngeal compensatory strategy. as indicated below. and hypothyroidism (only in cases of myxedema). esophageal.

posterior cricoarytenoid. This is done by simply instructing the patient to take a deep breath and phonate an “ee” vowel for as long as possible. In these cases. The final position of the vocal fold after nerve injury is now thought to be due entirely to the degree of reinnervation and synkinesis present. 5. This condition is thought caused by compensatory contraction of the ipsilateral cricothyroid (CT) muscle. the palate retracts to the right). Some dysphagia for solids may also be present. “plica ventricularis”) obscure vocal fold movement. Cranial nerve X neural compression and infiltration by a neck or thyroid neoplastic process can lead to VFP in advanced cases.” This technique. in a left vagal paralysis. and median. A validated instrument. rather than the arytenoid position. when evaluating patients for laryngeal framework surgery. the palate retracts toward the uninvolved “good” side (e. where the patient alternates between phonating an “e” vowel and sniffing vigorously. Videostroboscopy is a helpful part of the workup of vocal fold movement abnormalities.. extended viewing period of the vocal folds during a variety of tasks. This theory was later disproven by both Woodson and Koufman. Stroboscopy may also provide information regarding vocal fold height differences and the status of vocal process contact during phonation. paramedian. an overhanging arytenoid obscures the observation of the underlying vocal fold. the increased amplitude seen on stroboscopy. RLN sectioning leads to paralysis of the ipsilateral thyroarytenoid. In cases of mild or moderate vocal fold paresis. such as the VHI-10 is very useful for understanding the perceived severity of the patient’s vocal disability.  Chapter 5 develop an unnaturally high-pitched voice that is breathy in quality. It is important to focus on the vocal fold movement itself. Vocal professionals rely on a serviceable voice for their livelihood. in determining vocal fold immobility. demonstrating the degree of incomplete closure present. along with a weak and ineffective cough. making it impossible to ignore its position. A complete cranial nerve exam should evaluate for other involved nerves. Swallowing difficulties are often encountered. due to the loss of ipsilateral laryngeal sensation from SLN involvement. A paralyzed vocal fold can occupy a variety of positions. Most professional voice users will opt for temporizing vocal augmentation (Chap. In many cases of VFP. Risk of aspiration is heightened in these instances as well. due to innervation from the contralateral RLN.. some residual adduction may be present in complete unilateral VFP. or an asynchronous “chasing wave” may be the only signs of vocal fold weakness. the paralyzed vocal fold shows increased amplitude of vibration due to the atrophic. It was once thought that the position of the paralyzed vocal fold had some topognostic significance (for example. or plica ventricularis. which remains innervated in isolated RLN paralysis. In some cases of vocal fold immobility. Involvement of these adjacent cranial nerves warrants a thorough radiographic evaluation of the base of the skull. and lateral cricoarytenoid. including lateral (cadaveric). the author advocates that the patient phonate with an easy onset such as a “sigh. therefore. It is important not to falsely attribute a small amount of adduction of the affected vocal fold as representing evidence of partial innervation. that lateral vocal fold position indicated complete CN X paralysis due to RLN and SLN involvement). This overhanging. Flexible laryngoscopy is the only method to view vocal fold mobility in its natural state (refer to Chap. This has been referred to as a “paralytic falsetto. When evaluating for suspected UVF paralysis/paresis. this finding is usually caused by complete denervation or poor reinnervation of the PCA muscle In some patients with UVFP.1 General Examination of the neck for adenopathy and thyroid masses should be performed. but not the interarytenoid. These parameters help determine the need for arytenoid adduction. “floppy” nature of the denervated vocalis muscle. anteriorly displaced arytenoid is sometimes mistaken for an arytenoid dislocation. “Principles of Vocal Fold Augmentation”) so that they may return to work as soon as possible. 14.4 Unilateral Vocal Fold Paralysis: Physical Examination 5. g. and these patients should be questioned regarding their upcoming work schedule to help determine the urgency of early surgical intervention.2 Laryngeal The appropriate evaluation for VFP starts with the recognition of unilateral vocal fold immobility on examination.” is useful for removing unwanted compensatory supraglottic hyperfunction that obscures vocal fold visualization. It is important to obtain a vocal inventory of the patient’s voice responsibilities (both work related and social). due to the concomitant denervation of the pharyngeal constrictors. 3. however. 5. Normal MPT for a healthy adult is approx- 31 . A simple test to evaluate the degree of vocal disability and glottic incompetence is measuring the patient’s maximal phonation time (MPT). especially in brainstem or high vagal injuries. Indirect (mirror) laryngoscopy and rigid 70 or 90° laryngoscopy are helpful but do not replace flexible laryngoscopy. This technique is invaluable in many cases of longstanding VFP that have been misdiagnosed as primary muscle tension dysphonia. In the case of palatal paralysis. a useful task is to ask the patient to perform an “ee-sniff ” maneuver.” and is characterized by a mean increase in fundamental frequency 85 Hz above “natural” pitch. however.4. compensatory supraglottic contractions (i. however. The interarytenoid is a midline muscle. especially CN XI and XII due to the close proximity these have to CN X at the skull base. and has dual innervation from both RLNs.4. Any purposeful and appropriate abduction of the affected vocal fold suggests incomplete paralysis (paresis). e. Palatal paralysis in combination with ipsilateral VFP may indicate a “high” vagal lesion. It is important to obtain an unencumbered. specifically aspiration of liquids.” or be instructed to “hum through the nose. This causes the vocal folds to alternately adduct and abduct maximally and is an excellent way to judge the degree of paresis/paralysis. “Videostroboscopy and Dynamic Voice Evaluation with Flexible Laryngoscopy”). Palatal movement when phonating /a/ should be observed. described by Koufman as “unloading.

either with injection augmentation of the vocal fold. 5. e. Early surgical intervention: a) Temporary: injection augmentation b) Permanent: laryngeal framework surgery. autoimmune panels. and not a diagnosis. or erythrocyte sedimentation rate. the etiology may be cricoarytenoid (CA) joint arthritis (rheumatoid arthritis. Therefore. thyroid. . in general. This management strategy was developed in the 1970s. gout). In cases where one cannot confidently exclude the CA joint involvement or neoplasm as the cause of unilateral vocal fold immobility. no additional radiologic workup is necessary. 5. worse voice. Referral to speech pathology for voice strengthening or swallow therapy. MPT values of 5 seconds or less indicate severe. In the vast majority of cases of unilateral vocal fold immobility. early surgical intervention is indicated.2 Imaging Studies As screening tools. directed serology tests may be indicated. the history will suggest whether CA joint derangements are the culprit. a modified barium swallow or functional endoscopic evaluation of swallowing to evaluate swallowing and aspiration risk is frequently helpful in managing patients with dysphagia in the workup of VFP. In cases where no cause can be found for the VFP. LEMG and laryngeal framework techniques. as each patient’s expectations and vocal needs are unique. along with an arsenal of injectable substances.. As Teflon injection is irreversible and sometimes associated with an unfavorable vocal outcome. imaging studies are essential. and careful flexible laryngoscopy combined with CT scan will reveal neoplastic infiltration as the cause of vocal fold immobility. Evidence of severe denervation injury on LEMG may also lead to early surgical intervention. so results need to be taken in context of the patient’s pulmonary status.1 Serology There is little yield from ordering screening laboratory tests such as chemistry panel. reserving treatment for patients with continued dysphonia 2. VFP is the cause. a “shotgun” approach to the workup of uncomplicated UVFP is unnecessary and wasteful. clergy. Evaluation outside of these parameters can render the information misleading (early). laryngeal electromyography and a laryngoscopy with palpation for passive mobility of the vocal folds is warranted. …) rarely recovers.   In cases where a clear-cut temporal relation exists between surgical iatrogenic trauma and VFP. injection augmentation Obviously. In contrast. have made early surgical intervention an excellent option in the treatment of VFP. Patients with VFP and high-level vocal demands (salespersons. In general. typically. urinalysis. its role is still yet to be determined. In a small number of cases. increase) after successful medialization surgery for VFP. or of limited usefulness (late). VDRL/FTA-ABS.6 Unilateral Vocal Fold Paralysis: Treatment The treatment of VFP can be broken into three management strategies: 1. but a management plan should be developed and followed as soon as all of the important diagnostic information is gathered. cricoarytenoid joint effusion/subluxation/dislocation (external trauma/ traumatic endotracheal intubation). Several factors should be considered when determining the best course of action. thyroid function tests. complete blood count. If additional elements of the history and physical exam point towards a systemic process as the cause of unilateral vocal fold immobility. and patients are counseled to consider early surgical intervention in these cases. LEMG can provide definitive diagnosis and prognostic information on the possibility for spontaneous recovery of VFP. uncompensated VFP that may need arytenoid adduction in addition to medialization laryngoplasty. Most investigators agree that a CT (with contrast) or MRI encompassing the base of skull through the upper chest is adequate. or neoplastic infiltration (“occult” carcinoma in the ventricle/paraglottic space). One must determine the cause of the immobility. Classical teaching for the treatment of VFP advocates a watchful waiting period of 9–12 months before surgical intervention is considered. barium swallow and thyroid scans have virtually no yield in determining the etiology of VFP and are not advocated in the diagnostic workup. Laryngeal electromyography (LEMG) undoubtedly has a place in the work up of unilateral vocal fold immobility. teachers. these treatment strategies may overlap or may be employed simultaneously. A treatment algorithm is not advocated.32 5 Glottic Insufficiency imately 25 seconds.5. the MPT is reduced to 10 seconds or less. when the only viable treatment option for VFP was injection augmentation with Teflon. MPT should be expected to improve (i. Clinical experience has shown that RLN paralysis due to carcinoma (lung. the bulk of the evaluation pertains to UVFP. or medialization laryngoplasty (ML). 5.5 Unilateral Vocal Fold Paralysis: Workup It should be noted that unilateral vocal fold immobility is a physical finding. Poor pulmonary reserve from asthma or chronic obstructive pulmonary disease may reduce MPT significantly. early surgical intervention was ill advised during this era. Observation for 9–12 months. and increased vocal fatigue. However. 5. as indicated 3. esophagus. In patients with clear-cut aspiration due to VFP.5. In cases of VFP. Useful information from LEMG is obtained between 1 and 6 months after the onset of VFP. and treatment must be individualized for each patient. Shorter MPT values indicate more severe glottic incompetence.

and is a cardinal symptom of glottic insufficiency. In this way. including the advantages and disadvantages of the three main strategies of treatment.. The “ee-sniff ” maneuver should be performed.3) ■ “Chasing”/asynchronous mucosal wave propagation 5. therefore. voice therapy with a speech language pathologist. or surgical management either with injection augmentation of the vocal fold(s) or laryngeal framework surgery. the patient can actively participate in the decision-making process. 5.7. 5. it may be necessary to intervene early (prior to 9 or 12 months) to get the patient back on the job.1 Etiology As is the case with vocal fold paralysis. stable vocal fold paresis.2.7 Unilateral/Bilateral Vocal Fold Paresis 5. treatment options include observation. as compared to UVFP. 5. Patients with significant cardiopulmonary and other medical comorbidities may not be candidates for a general anesthetic (i. In these cases.7. yet may be perfectly suitable for ML or injection augmentation performed under local anesthesia. then 33 . weak voice. and injection augmentation (lipoinjection. as outlined for UVFP in the previous sections is essential in the examination of the patient with suspected vocal fold paresis. “unloading” techniques are useful as described previously. g.7. and idiopathic causes outlined in section 5. or bilateral).2 History In contrast to patients presenting with UVFP. While the patient may complain of a breathy.. the patient should be counseled regarding the different treatment options. In most cases. the presenting symptoms of a patient with vocal fold paresis can be very subtle. When LEMG is available. then radiologic evaluation is indicated. ■ Imaging studies are not generally obtained to evaluate the course of the vagus/RLN in cases of long-standing. The medical health of the patient occasionally comes into play. e.  Chapter 5 attorneys) often have difficulty continuing their work-related duties. ■ Some consideration should be given to the possibility that the paretic vocal fold is a manifestation of a progressive neurological disorder (if no clear etiology is identified). A high index of suspicion for an underlying progressive neurologic disease (e.3 Physical Examination Flexible laryngoscopy and videostroboscopy. Neurologic consultation may be indicated. Findings are typically limited to reduced recruitment of motor units in the RLN or SLN distribution. Voice therapy is more likely to be successful. Fig 3. a less aggressive approach is used in the treatment of vocal fold paresis. Possible conditions include: ■ ALS ■ Postpolio syndrome ■ Pseudobulbar palsy 5. and establishing the “sidedness” of the vocal fold paresis (left.5 Treatment As with UVFP. and may represent a viral neuropathic process. These symptoms include: ■ ■ ■ ■ ■ Loss of volume/projection Vocal fatigue Loss of voice after extended use Odynophonia Loss of a portion of the vocal range (especially upper end of the register) ■ Problems with stamina/quality of the singing voice Vocal fatigue is usually present in patients with vocal fold paresis. If vocal fold paresis progressively worsens or the affected vocal fold becomes immobile. neoplastic. ■ Videostroboscopy plays a pivotal role in the evaluation of suspected paresis. using slow-motion review to evaluate for motion asymmetries in abduction and adduction of the vocal folds.7. Compensatory muscle tension disorders are common with vocal fold paresis. Radiesse) may be preferred over laryngeal framework surgery. more subtle forms of dysphonia are often present. right.4 Diagnostic Workup Is the same as for UVFP. with the following notable exceptions: ■ LEMG is critical to confirming the diagnosis. neurologic.7. Subtle clues include: ■ Mild bowing of the vocal fold(s) ■ Incomplete glottic closure ■ Prolonged “open phase” of vibratory cycle ■ Increased vibratory amplitude in the paretic vocal fold (see Chap. but cannot be confirmed. If the diagnosis of vocal fold paresis is suspected. In general. Idiopathic causes are much more common with vocal fold paresis. for microlaryngoscopy with vocal fold injection augmentation). postpolio syndrome) must be maintained as well. and even in some cases intermittent in nature. 3. The temporal course of the presenting vocal complaints can vary from sudden in onset. Temporary surgical procedures such as injection augmentation of the vocal fold should be considered in this population. to gradually progressive. incomplete paralysis or paresis can be due to iatrogenic. amyotrophic lateral sclerosis. it can serve as a crucial guide to the patient and surgeon regarding (1) treatment or observation and (2) temporary versus permanent treatment.

“Principles of Clinical Evaluation for Voice Disorders”) ■ Increased vibratory amplitude in the paretic vocal fold ■ Chasing/asynchronous mucosal wave propagation ■ Loss of vocal projection and voice fatigue with extended use are classic symptoms of vocal fold paresis and can easily be missed in the history.34 Glottic Insufficiency a “diagnostic” injection augmentation using a temporary filler can be done.2 Etiology. Typically. Lee-Silverman voice therapy (see Chap. age-related changes (presbylaryngis). 2.8. 5. and LEMG findings. lack of volume/projection. 5. are more likely to have vocal tremor and monotone pitch in addition. nature of neural injury. and presbylaryngis. However. it should be noted that Parkinson’s disease (PD) often has an identical clinical presentation to that of presbylaryngis. the patient complains of mild/moderate dysphonia. .3). 5 5. Vocal fold bowing is not a diagnosis. and takes into account the patient’s risk of aspiration. History.8. vocal fold paresis/ paralysis. Bilateral vocal fold bowing is the typical laryngoscopic feature on physical examination. “Medical Treatment of Voice Disorders”) is the preferred primary method of treatment for dysphonia due to PD. however. vocal demands. Subtle clues include: ■ Mild bowing of the vocal fold(s) ■ Incomplete glottic closure ■ Prolonged “open phase” of vibratory cycle (see Chap. ■ The most common causes of symptomatic glottic insufficiency are unilateral vocal fold paralysis. Patients with PD. which generally present in the fifth decade of life or later. especially at the end of the day. the vocal dysfunction related to presbylaryngis is usually addressed incompletely when “medialization” framework surgery is used to correct the glottal gap. 5. ■ Treatment of “early” unilateral vocal fold paralysis is individualized for each patient.8 Presbylaryngis/Age-Related Changes in the Larynx 5. Bowing can be due to vocal fold atrophy.3  Videostroboscopy image of bilateral vocal fold bowing due to presbylaryngis   cal fold muscular atrophy due to deinnervation. Injection augmentation and laryngeal framework surgery are reserved as an adjunctive treatment in select cases. The clinical distinction is important. and sulcus vocalis. unlike vo- Fig.3 Workup A diagnostic workup for suspected presbylaryngis is usually not necessary in most cases of elderly patients with a finding of vocal fold bowing on laryngeal examination. as PD patients are generally poor surgical candidates for treatment of glottic insufficiency. However. Improvement in the voice after injection augmentation suggests that glottic insufficiency is present. Key Points ■ Glottic insufficiency is one of the most common contributing factors in patients who present with dysphonia and one of the easiest findings to overlook in the clinical evaluation. unilateral or bilateral vocal fold paresis. presbylaryngis is a more global process that involves not only loss of muscle bulk. and Physical Findings Presbylaryngis is the condition caused by senescent changes in the larynx. due to the global bradykinetic nature of their vocal dysfunction. ■ Videostroboscopy plays a pivotal role in the evaluation of suspected vocal fold paresis. but a physical finding indicating an elliptical or scalloped contour to the membranous vocal fold (Fig. vocal fold softtissue loss/scarring. Videostroboscopic exam often reveals mild/moderate degrees of glottal insufficiency/incomplete closure. Long-term strategies can then be employed after the effects of the injection wear off. as well as CA joint changes.8.1 General Considerations It is a common misconception to use the term vocal fold bowing synonymously with presbylaryngis. 7. and vocal fatigue. 5. but also degeneration/loss of the layers of the lamina propria. For this reason.

Laryngoscope 105:368–372 Koufman JA. Ann Otol Rhinol Laryngol 105:764–769 Flowers RH. tracing the entire RLN from skull base to upper chest. Jahn AF. Murry T. Oshima K (2003) Hoarseness after cardiac surgery: possible contribution of low temperature to the recurrent nerve paralysis.  Chapter 5 ■ All unexplained vocal fold paralysis should be investigated with imaging studies (CT or MRI). Kernodle DS (1990) Vagal mononeuritis caused by herpes simplex virus: association with unilateral vocal cord paralysis. Otolaryngol Clin North Am 33:759–770 Netterville JL. In: Rubin JS. Gould WJ (eds) Diagnosis and treatment of voice disorders. as PD patients are generally poor surgical candidates. Nguyen HH (1992) Contemporary evaluation of unilateral vocal cord paralysis. Ford CN et al (1994) Evaluation and treatment of the unilateral paralyzed vocal fold. Walker FO (1998) Laryngeal electromyography in clinical practice indications. Otolaryngol Head Neck Surg 111:497–508 Benninger MS. Am J Med 1990. Green GE (1987) Left recurrent laryngeal nerve injury following internal mammary artery bypass. Crumley RL. Stuttgart Blitzer A. Aronberg DJ. Gillen JB. Thieme. Laryngoscope 103:1227–1234 35 . Koriwchak MJ. Altman JS (1998) Changing etiology of vocal fold immobility. ■ Parkinson’ s Disease (PD) often presents with dysphonia and vocal fold bowing and can be confused with presbylaryngis. 6 Selected Bibliography 10 1 2 3 4 5 Benninger MS. Brin MF. Walker FO. Sataloff RT. Keider A (1996) Semon’s law revisited: an electromyographic analysis of laryngeal synkinesis. Am J Radiol 141:527–531 Koufman JA (1995) Evaluation of laryngeal biomechanics by flexible laryngoscopy. Ken I. Joharji GM (1995) The cricothyroid muscle does not influence vocal fold position in laryngeal paralysis. Igaku-Shoin. Sasaki CT et al (eds) (1992) Neurologic disorders of the larynx. Rosen CA (2000) Laryngeal electromyography. Winkle M et al (1996) Vocal fold paralysis following the anterior approach to the cervical spine. The clinical distinction is important. and interpretation. I: Clinical study. Lee JKT. Otolaryngol Head Neck Surg 107:84–90 Woodson GE (1993) Configuration of the glottis in laryngeal paralysis. Sagel SS (1983) Extralaryngeal causes of vocal cord paralysis: CT evaluation. Arnstein DP. 88:686–688 7 8 9 11 12 13 14 15 Glazer HS. pp 122–134 Koufman JA. and should instead undergo voice therapy as primary treatment for their dysphonia. techniques. New York. Laryngoscope 108:1346–1349 Blitzer A. Ann Thoracic Surg 3:440 Shin-ichi I kKenji K. Ann Otol Rhinol Laryngol 105:85–91 Phillips TG. Korovin GS. Laryngoscope 113:1088–1089 Terris DJ. Phonoscope 1:57–70 Munin MC.

1  Subglottic stenosis 6.3 ■ ■ ■ ■ ■ ■ ■ ■ ■ Etiology of Glottic and Subglottic (Laryngotracheal) Narrowing Prolonged endotracheal intubation Complications related to tracheostomy tube placement External laryngeal trauma Thermal inhalation (burn) and caustic ingestion Autoimmune disease ■ Wegener’s granulomatosis ■ Relapsing polychondritis Amyloidosis Laryngopharyngeal reflux disease Malignancy ■ External tracheal compression (mediastinal tumor) ■ Intratracheal tumor (carcinoid. 6.Chapter 6 Glottic and Subglottic Stenosis: Evaluation and Surgical Planning 6. The other etiologies listed are much less common. once a secure airway is obtained. the medical evaluation may be limited initially. typically second or third ring ■ Suprastomal granulation tissue ■ History of radiation to neck ■ Laryngeal edema ■ Glottic stenosis/fibrosis. The endotracheal tube itself can lead to posterior glottic stenosis (PGS) from interarytenoid ulceration.3. 6. Additional medical factors may increase the risk of stenosis. g.3). 46. 26. In the case of a patient with stridor and acute airway distress. Tracheostomy tube placement (especially percutaneous dilational techniques) may narrow the airway through displacement of tracheal cartilage into the airway. pressure necrosis... as described below. 6. 28. chondrosarcoma of cricoid) Idiopathic The vast majority of patients with glottic and subglottic airway narrowing (Fig. 29. LPR. The risk of PGS increases markedly after 10 days of endotracheal intubation. Fig.2 Introduction Evaluation of airway stenosis must be performed in a systematic and thorough manner to ensure accurate diagnosis and treatment planning.1 6 Fundamental and Related Chapters Please see Chaps. 29. including hypoxia. 6. but must be considered in non-traumatic airway stenosis. 13. and other conditions. diabetes. and 47 for further information.1) are due to prolonged (at least 48–72 h or more) endotracheal intubation and complications related to tracheostomy tube placement. However. especially in advanced T3/T4 squamous cell carcinoma (SCCa) . The balloon and/or distal tip of the endotracheal tube (ETT) can likewise lead to subglottic and proximal tracheal stenosis from pressure-related effects during prolonged intubation. the Björk flap) may also lead to delayed contracture and collapse of the supporting tracheal framework (see Chap. a more detailed evaluation (as outlined in this chapter) can be obtained. 45. 9. 29.1 Common Clinical Conditions and Associated Risk Factors ■ History of prolonged mechanical ventilation ■ Posterior glottic stenosis ■ Subglottic/tracheal stenosis ■ History of prior tracheostomy ■ Tracheal collapse. g. Fig. metastatic tumor) ■ Primary tumor of airway (e. vascular disease. and cicatricial formation in the posterior glottic space. localized infection. Necrosis of tracheal cartilaginous flaps (e.

it can occur occasionally with shorter exposures.1 Local Anesthesia Techniques for Examination The patient with glottic or subglottic/tracheal stenosis typically presents with shortness of breath. which can deliver lidocaine through a peroral technique (Fig.5. In patients with a tracheotomy or a permanent tracheal stoma. this provides insight into the severity of the obstruction. The maximum recommended adult dose of lidocaine is typically 300–400 mg (7–10 ml of lidocaine 4% in a 70-kg patient). the latency to onset of airway symptoms is due to gradual maturation of scar formation in the glottis/subglottis.4 Glottic and Subglottic Stenosis: History 6. It is important to inquire specifically what level of activity the patient can tolerate before breathing difficulties are encountered (e. They may have been previously misdiagnosed with asthma or “reactive airway disease. These methods of anesthesia include: ■ Topical lidocaine (4%) drip delivered through the side channel of the endoscope or an Abraham cannula ■ Nebulized lidocaine ■ Cricothyroid (or transtracheal) puncture. In addition. one should inquire about previous intubations in the past medical history especially if they extend beyond 2–3 days. 6. and additional topical lidocaine is applied as needed only. with instillation of 4% lidocaine To begin the exam. the tracheostomy tube is removed and 2–5 ml of 4% lidocaine is dripped into the stoma. ambulating across the room.4. In some patients.4. An alternative is the use of an Abraham cannula. approximately 2–3 ml of lidocaine 4% is delivered through a side channel of the scope while the patient is phonating /ē/. The patient’s stoma should be briefly occluded manually on anesthetic instillation so that the cough will distribute the anesthetic throughout the subglottis and trachea. This can be achieved only if the patient’s upper airway is properly anesthetized. and positioned over the laryngeal inlet. one should specifically inquire whether the patient’s dyspnea is accompanied by an audible noise during inspiration. This may have to be repeated until the patient demonstrates little or no response to the presence of the lidocaine in the laryngeal inlet.1 Symptoms/Time Course 6.5. In addition. and laryngeal trauma are also important risk factors for the development of upper airway stenosis. The following conditions are not absolute contraindications to surgical treatment. With proper anesthesia. they are using bronchodilators or inhaled steroids for their presumed condition. When properly positioned. especially if steroid dependent Careful flexible laryngoscopic exam of the larynx and trachea in the clinic setting is the most important step in the evaluation of suspected glottic/subglottic stenosis.38 6 Glottic and Subglottic Stenosis   ■ Nontraumatic subglottic narrowing (CRAWLS) ■ Chondrosarcoma ■ Relapsing polychondritis ■ Amyloidosis ■ Wegener’s granulomatosis ■ Laryngopharyngeal reflux disease ■ Sarcoidosis ■ ■ ■ ■ 6. However. Although the risk of airway stenosis increases markedly after 10 days of intubation. climbing up a flight of stairs. the tracheostomy can be the direct cause of the airway obstruction due to tracheal granulation tissue proliferation or cartilage resorption/collapse after decannulation. The endoscope is then advanced through the glottis. or simply at rest). 6.2 Medical Comorbidities Medical comorbidities should be noted which can have a profound effect on determining if the patient is a surgical candidate for treatment of their airway stenosis. g. Given the strong association between prolonged endotracheal intubation and the development of airway stenosis. In many patients with airway stenosis. there is a history of tracheostomy placement and decannulation 2–3 months prior to the development of airway obstruction.2).5 Glottic and Subglottic Stenosis: Physical Examination 6. they may reduce the chances of success and/or decannulation: ■ Severe restrictive or obstructive pulmonary disease (especially if oxygen dependant) ■ Severe kyphoscoliosis Diabetes mellitus History of radiation therapy of the larynx Severe aspiration/PEG tube dependence Morbid obesity with severe obstructive sleep apnea (OSA) ■ Autoimmune disease. thermal inhalational injuries (smoke inhalation/burns).2 Documentation of Examination It is helpful to capture the flexible endoscopic airway evaluation on videotape (or digital storage device) so that a more detailed review of the airway anatomy can be carried out after the . 6. the nose is anesthetized in the standard fashion for nasolaryngoscopy (lidocaine and Neosynephrine sprays). the entire laryngotracheal airway can be examined with a standard flexible endoscope in the clinic setting. caustic ingestions. the flexible endoscope is passed transnasally. however. After this..” and in many cases.

then the length of the stenotic segment.4  Laryngeal examination in a patient with posterior glottic ste- nosis during maximal abduction. 39 .4). Vocal fold mobility testing Having the patient alternate between phonating /ee/ and sniffing will test for vocal fold adduction and abduction. Documentation of airway measurements If a stenosis is identified the approximate location should be noted (distance in mm distal to the vocal folds). Reduced abduction and narrowed glottic inlet can be due to posterior glottic stenosis and/or bilateral vocal fold paralysis/paresis (Figs. and the glottic aperture has the general configuration of an equilateral triangle. maximal abduction occurs.3. Note the limited space in the posterior glottis due to interarytenoid scarring.  Fig. Patients with paradoxical vocal fold mobility disorder may be confused with these conditions.3  Normal laryngeal exam during maximal abduction (sniffing). In these cases. The presence of tracheomalacia/cartilage collapse or suspected external compression of the airway should be also noted. the video can be reviewed in slow motion or freeze frame to insure accuracy of the examination. however. 5. and the estimated airway Fig. “Videostroboscopy and Dynamic Voice Evaluation with Flexible Laryngoscopy”). 6.1 Flexible Laryngoscopy/ Tracheoscopy Protocol The following information should be obtained during the flexible laryngoscopic airway examination: 1. This is especially true those patients where only a brief examination can be performed (due to poor respiratory status or inability to tolerate the procedure). Examination of the posterior glottic space for scar The flexible scope should be advanced into the interarytenoid space at the level of the vocal folds to evaluate for the presence of scar within the posterior glottis. into the subglottis and trachea. 2. 6. 6. 3. Retrograde flexible examination of the subglottic airway through the tracheal stoma (if present) This perspective gives an unparalleled view of vocal fold mobility and posterior glottic configuration from below. The posterior glottic space can be clearly examined for scar formation. 6. 3. which results in a glottic aperture of a more narrowed isosceles triangle diameter in mm. Scope advancement past the vocal folds.2. 6. these patients will generally have full vocal fold abduction immediately after cough or other involuntary glottic closure task (see Chap.2  Abraham cannula for peroral delivery of topical lidocaine to the laryngotracheal region Chapter 6 Fig. In general. Note the general shape of an equilateral triangle within the boundaries of the glottal aperture examination. including the main-stem bronchi 4.5. during sniffing. 6.

Audio Recording) Patients with glottic and subglottic stenosis often have varying degrees of dysphonia preoperatively and may develop worsening of their voice after surgery. . A test that is consistent with “extrathoracic airway obstruction” is typically seen in patients with glottic or subglottic/tracheal airway narrowing (Figs.1 Voice Evaluation (VHI-10.5. 6. tracheomalacia) can only be ruled out with a flexible endoscopic examination of the entire upper airway.6.6  Flow-volume loop of patient with subglottic stenosis. or neoplastic cause. 6. 6.6. 6. demonstrating “flattening” of the inspiratory limb.6.7). there is no obvious traumatic/ iatrogenic cause of the patient’s subglottic/tracheal narrowing.40 Glottic and Subglottic Stenosis   6 Fig. It is important to remember that radiographic studies of the airway only provide a static view of the airway.3 Radiographic Studies A fine-cut (1 mm) CT scan of the airway (neck and chest) with contrast is helpful in the evaluation of suspected airway obstruction.6 Additional Studies for the Evaluation of Glottic/Subglottic Stenosis 6.4 Laboratory Testing In a small handful of patients. g.2 Air-Flow Measures Pulmonary function testing with a flow-volume loop can help establish the presence of upper airway obstruction. 6.6). In these cases. Both of these conditions are contraindications for an endoscopic laser approach. For this reason. preoperative documentation of the voice is essential. 6. one must have a high degree of suspicion for an underlying inflammatory/autoimmune.6.5  Normal flow-volume loop 6. This is especially true in cases of suspected external compression or cartilage collapse (Fig. 6. Dynamic collapse of the airway (e.. This is commonly referred to as a “fixed extrathoracic obstructive pattern” 6. Fig.

7. and patients with terminal disease. the morbidity and mortality of these procedures are significantly higher than for endoscopic treatments. 29. Wall. it is not widely practiced and requires experience to achieve consistent results. if a tracheostomy tube is present. resulting in airway narrowing. which have a tendency to migrate and incite granulation tissue formation. Patients with significant comorbidities and advanced age may not be candidates for external stenosis treatment. additional information (via operative endoscopy) needs to be obtained before a definitive treatment plan can be implemented ■ Suspicion of malignancy. demon- strating collapse of the cartilaginous tracheal walls. 6.” for details in mapping the extent of the stenosis.7  Computerized tomography of the trachea (axial). auto-immune profile. (See Chap. or when all treatments fail. In general. the stenotic region ideally should not extend down to the entry point of the tracheotomy. Thus. tracheomalacia. In these cases. Examples include: ■ Incomplete office/radiographic evaluation of the airway—in this case. although not a “corrective” procedure for airway stenosis. palliative) Dumon. There is no evidence of intraluminal scar or soft tissue obstruction The mnemonic for this condition (nontraumatic subglottic narrowing) is CRAWLS (see above). it may be appropriate to perform an airway endoscopy in the operating room strictly for diagnostic purposes. anatomic mapping of the stenosis and tracheostomy location are obtained to aid in selection of the appropriate external surgical approach. may be the appropriate treatment for extensive stenosis in patients with poor medical health. These stents are better suited for palliative airway obstruction from metastatic tumor infiltration of the airway. In general. laser excision. External procedures are indicated when endoscopic treatments are contraindicated or are unsuccessful. In certain instances. Ultraflex. the least invasive procedures are attempted first (unless contraindicated). Fig. angiotensin-converting enzyme (ACE) level serum testing ■ Biopsies of the involved tissue (histopathology and culture) ■ Selective pH probe testing for LPR 6. however. Airway stenting is a “middle ground” between endoscopic and external procedures. or the systemic disease is treated medically. or significant cartilage collapse ■ Length of stenosis no more than 2–3 cm ■ Identifiable airway lumen ■ If present.7. Tracheostomy. however. however.) ■ Endoscopic (microlaryngoscopy. etc. 41 . the following protocol may be used: ■ c-ANCA. 6. rigid dilation) ■ Endoscopic with indwelling stent placement ■ T-tube stent with external limb (long term) ■ Intraluminal stent (short term. the initial microlaryngoscopy/ tracheobronchoscopy is planned as a therapeutic surgery. ■ External procedures ■ Laryngotracheoplasty with cartilage grafting (airway expansion) ■ Cricotracheal resection with primary anastomosis In general.  Chapter 6 6. Definitive treatment may need to be delayed until histologic and/or microbiologic diagnosis is obtained.2 Criteria for Endoscopic Treatment for Subglottic Stenosis Criteria include: ■ No external compression. “Subglottic Stenosis. ■ Evaluation and mapping of stenosis as an aid to planning an external procedure—in this instance the patient is known to have a stenosis that is not amendable to endoscopic treatment. saving external procedures for those cases that fail to respond to an endoscopic approach. T-tube stenting is generally more successful for long-term stenosis treatment than are intraluminal stents. or systemic disease—these cases should be evaluated with biopsy in the operating room.7 Glottic and Subglottic Stenosis: Surgical Planning In most cases.1 Corrective Surgical Procedures for Glottic/Subglottic Stenosis These procedures are listed in order from least invasive to most invasive approach. intraluminal stents are not appropriate for long-term treatment of stenosis. tracheostomy entry point not involving/adjacent to the stenotic site  Repetitive mechanical trauma from the tracheostomy tube postoperatively has an adverse effect on healing of airway stenosis.

restrictive or obstructive pulmonary disease. they simply represent general guidelines. The surgeon should use his/her judgment in determining suitability for endoscopic approach. ■ Medical comorbidities (diabetes mellitus. the least invasive surgical procedures are attempted first (unless contraindicated). ■ Radiographic airway studies are essential if external compression is suspected. Ossoff RH. and obstructive sleep apnea) may have a significant negative impact on the surgical outcome and should be carefully considered prior to undertaking these treatments. Simpson CB (2004) Office evaluation of the tracheobronchial tree. segmental resection and primary anastomosis). Ear Nose Throat J 83(Suppl. 2 3 4 5 6 Benjamin B (1993) Prolonged intubation injuries of the larynx: endoscopic diagnosis. such as Wegener’s granulomatosis and laryngopharyngeal reflux disease. The risk of airway stenosis increases markedly after 10 days of intubation.   ■ Nontraumatic subglottic narrowing should be investigated thoroughly to rule out associated inflammatory and neoplastic conditions. Duncavage JA. while conversely.to 8-mm length of “normal” airway below vocal folds ■ Accommodates proximal limb of T-tube.7. ■ In patients with laryngotracheal stenosis. and external treatments (cartilage expansion grafts vs. without impingement on vocal fold 6. classification. Ann Otol Rhinol Laryngol 107:92–97 . Courey MS. localized infection. and cicatrix formation. cartilage collapse It should be noted that the above recommendations are not absolute criteria for selecting external treatment approaches. Courey MS. Netterville JL (1998) Laryngotracheal reconstruction in the adult: a ten-year experience. length greater than 3 cm) ■ Tracheomalacia.7. Ann Otol Rhinol Laryngol 160(Suppl):1–15 Amin MR. using topical lidocaine for endolaryngeal/tracheal anesthesia. but do not replace a laryngoscopic airway evaluation. which leads to pressure necrosis. Reinisch L. ■ Tracheostomy can lead to delayed tracheal stenosis (typically 1–3 months after decannulation) and is typically due to collapse/contraction of the cartilaginous support. Hybels RL et al (1987) Endoscopic treatment for subglottic and tracheal stenosis by radial laser incision and dilation. granulation tissue. reserving external procedures for those cases that fail to respond to an endoscopic approach. Beamis JF. Certainly patients with lesser degrees of stenosis have failed endoscopic management.):10–12 Shapshay SM. those with more extensive stenosis have occasionally responded favorably to endoscopic treatment. Otolaryngol Clin North Am 28:737–750 Lano CF Jr.3 6 Criteria for T-Tube Stenting for Subglottic Stenosis ■ Tracheotomized patients with subglottic/tracheal narrowing (from any cause) who have failed serial CO2 radial incisions/dilation treatment ■ Proximal subglottic/infraglottic region free of stenosis ■ 5. Ann Otol Rhinol Laryngol 96:661–664 McCaffrey TV (1991) Management of subglottic stenosis in the adult. ■ Corrective surgical procedures for laryngotracheal stenosis include endoscopic management (microlaryngoscopy with laser radial incisions with dilation). Ann Otol Rhinol Laryngol 100:90–94 Gardner GM.4 Criteria for External Treatment of Glottic/Subglottic Stenosis Criteria include: ■ Failure of endoscopic and/or T-tube stent treatments ■ Extensive stenosis (no identifiable lumen. ■ Physical examination of a patient with suspected laryngotracheal stenosis should include a flexible laryngoscopy and tracheoscopy (down to the carina) in the clinic setting. Selected Bibliography Key Points 1 ■ Laryngotracheal airway obstruction is generally caused by trauma to the upper airway from prolonged endotracheal intubation.42 Glottic and Subglottic Stenosis 6. Ossoff RH (1995) Operative evaluation of airway obstruction. and treatment. indwelling stent placement.

resulting in vocal fold granuloma formation or recurrence. The other treatment options for granulomas are voice therapy and botulinum toxin type A injection to the thyroarytenoid muscle. interarytenoid mucosal changes. Excessive vocal fold closure pressure is applied to the arytenoids in an attempt to compensate for the glottal insufficiency. “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis”. LPR manifests in many ways: sore throat. Reinke’s edema. chronic cough. LPR plays an important role in the development of granulomas as do phonotrauma and trauma secondary to endotracheal intubation. When granulomas occur postsurgically. Vocal fold granulomas also often occur (and recur) due to an underlying glottal insufficiency that may not be recognized by the treating physician. granulomas. Though phonosurgical management of certain vocal pathologies is critical. Studies have alluded to the frequent association of LPR and/or gastroesophageal reflux disease (GERD) with subglottic stenosis in adults and children. Intubation granulomas are more common in women. Recent studies have shown that twice-a-day therapy appears to result in the highest symptom resolution. . many clinicians have noted significant improvement in LPR control with H2RAs. Most vocal fold granulomas are located in the posterior third of the vocal fold either unilaterally or bilaterally. With this study. Several controversies in the treatment of LPR include the strength of association between cough and LPR and duration of treatment. 5 and 8 for further information. It has also been linked to the development of leukoplakia and potentially. especially when given at night for the treatment of nocturnal acid breakthrough. globus. so patients typically need encouragement to remain compliant with their medication. This chapter gives a brief overview of several categories of voice disorders that are primarily treated without surgery. 2. a reflux event is defined as a 5 second drop in the intraluminal pH below 4. 4. Most clinicians and studies support duration of treatment of at least 4–6 months. It is critical to treat LPR after any type of airway reconstruction. throat clearing.Chapter 7 7 Nonsurgical Treatment of Voice Disorders 7.0. Up to 50% of voice disorder patients may have coexisting laryngopharyngeal reflux (LPR). It takes several months for affects to be noted by the patient. A few studies have confirmed that the H2RAs do not add any additional efficacy to treatment.4 Vocal Fold Granuloma Vocal fold granulomas (specifically nonintubation related) are notoriously recalcitrant to surgical therapy when underlying causative factors (such as LPR) are not controlled. The diagnosis of LPR is based on patient history and laryngeal signs noted during laryngoscopy.1 Fundamental and Related Chapters Please see Chaps. These include edema and erythema of the larynx.3 Surgical Indications and Contraindications Four to 10% of otolaryngologic visits are related to gastroesophageal reflux disease-related laryngeal complaints. contact ulcers. laryngeal cancer. and posterior pharyngeal mucosal cobblestoning.2 Introduction Many voice problems do not require surgery if properly identified and treated. many voice disorders are treated effectively by non-surgical means. The gold standard in diagnosis remains the 24-h doubleprobe (esophageal and pharyngeal) pH study. An additional point of contention is the use of histamine type 2 (H2RA) receptor antagonists in combination with PPIs. Treatment for vocal fold granuloma due to glottal insufficiency involves vocal fold augmentation and/or medialization (see Chaps. ”Vocal Fold Augmentation via Direct Laryngoscopy”. 7. up to 75% responded to clinical treatment with PPIs. which works to irreversibly inhibit the proton pumps of the gastric parietal cell. 38. Symptoms can be quantified by means of the Reflux Symptom Index and findings by the Reflux Finding Score. 31. The standard of care for the treatment of LPR is the proton pump inhibitor (PPI). “GORE-TEX® Medialization Laryngoplasty”). 21% demonstrated recurrence. The latter causes a temporary paresis of the vocal fold to reduce extensive interarytenoid contact. One study found that of patients with LPR. they can occur anywhere an operative site exists. however. dysphagia. and 39. however. It has been associated as well with paradoxical vocal fold motion disorder and asthma. 7. pseudosulcus (infraglottic edema). 7. It is felt that both the acid and pepsin contribute to the inflammation associated with LPR and/or GERD. and postnasal drip. presumably because their smaller larynx is more prone to trauma from the endotracheal tube. hoarseness.

The most common organism implicated is Candida. smoking. both of which are done via laryngoscopy or office endoscopy. heart failure. Serial laser laryngoscopy is often effective at controlling symptoms. 45. but the disease is pathologically described by three findings: necrosis.” Definitive diagnosis is based on histopathologic presence of amyloid fibrils in a twisted β-pleated sheet patter with affinity for Congo red dye. . Systemic treatment incorporates use of corticosteroids and other immunosuppressive drugs. Actual muscle bulk change due to steroid inhalers is controversial and not supported by scientific evidence. prolonged antibiotic use. inflammation of the upper airways and surrounding irritating triggers such as smoke. In addition. Subglottic stenosis is a major concern. then surgery is indicated. and dysphonia.2% of all benign tumors. and the renal system. and/or pseudohyphae within upper epithelial layers of the laryngeal mucosa by culture or biopsy. to gray epithelial nodules. The widespread use of steroid based inhalers for the treatment of obstructive pulmonary disease has been a major contributor to the increase in fungal laryngitis incidence. therefore. medullary thyroid carcinoma. “Glottic and Subglottic Stenosis: Cricotracheal Resection with Primary Anastomosis”). One study noted the following mucosal changes in patients with inhaler-related dysphonia: vascular lesions such as dilated blood vessels. Diagnosis is based on demonstration of fungal spores. 29. some have attributed dysphonia secondary to steroid inhaler use to steroid myopathy. “Glottic and Subglottic Stenosis: Laryngotracheal Reconstruction with Grafting”. of the inhaler. If the organism persists. More advanced disease may require laryngofissure with partial or total laryngectomy. Primary (localized) and secondary (systemic) amyloidosis are distinguished based on physical exam (for tender bones. Amyloid deposits or lesions are described typically as “firm.2–1. hyphae.” These changes appear to improve after cessation of the steroid inhaler. It comprises 0. however. but the presence of Aspergillus. nonulcerating. often the disease is treated clinically based on the characteristic findings. Diagnosis is based on a blood test for the identification of antinuclear cytoplasmic antibody (ANCA) and specifically c-ANCA. Treatment of fungal laryngitis rests on removal of the offending steroid when possible and antifungal medication. Blastomyces. with or without tracheostomy depending on severity of the disease (see Chaps. lower respiratory tract. The cause of WG is unknown. LPR should be optimally controlled in conjunction with reduction or discontinuation. Fungal laryngitis may be mistaken for leukoplakia. However. “Subglottic Stenosis”. mechanical irritation due to cough. Predisposing factors apart from inhaler use include radiotherapy. Systemic treatment of RA is favored to treat rheumatoid nodules. is use of an oral conazole medication as initial treatment especially in the immunocompromised patient. surgical intervention is warranted. and “areas of thickening. which is found in 90% or more of patients with active WG. and leukoplakia. orange-yellow. Rheumatoid arthritis (RA) affects 2–3% of the adult population. can cause slowly progressive dysphonia and dyspnea. Current standard of care. If the stenosis is critical however. lymphadenopathy). airway symptoms in general appear to predominate. dyspnea. the vocal folds proper are usually not involved. and immunosuppression. hepatosplenomegaly. however. and rectal biopsy. Chemical laryngitis—specifically steroid inhaler laryngitis—is another common cause of dysphonia in the inhalerusing patient. capillary ectasias and varices. if they persist and cause a functional voice problem. The disease state should be under good medical control before performing surgical procedures for airway stenosis. patients go on to either endoscopic or open surgical treatment. When the airway or voice is compromised. as both vocal folds appear atrophic and glottal closure is incomplete. Systemic lupus erythematosus (SLE) infrequently manifests itself in the larynx but can be associated with laryngeal edema in up to 28% of patients and vocal cord paralysis in 11% of patients with SLE. Autoimmune disorders are relatively rare but several of these have effects on the vocal folds and subglottis. especially cyclophosphamide. chest and bone radiography.44 Nonsurgical Treatment of Voice Disorders 7. The disease is indolent and when found in the larynx. Clinical appearance of whitish plaques surrounded by erythematous mucosa is characteristic. when possible. Some findings can overlap with those of LPR. Hoarseness is the most frequent local side effect of steroid inhalers. and vasculitis. systemic treatment frequently may not eliminate the amyloid deposits. Histoplasma. Several factors may contribute to this chemical irritation: the steroid “its preparation. “Glottic and Subglottic Stenosis: Evaluation of Upper Airway Disorders”. and small cell carcinoma. blood/serum and urine testing. and Coccidioides has also been documented in cases of fungal laryngitis. Inhalers used with a spacer decrease laryngeal deposition of the medication and can help with reduction or complete elimination of the offending agent. 6. The main two manifestations of RA at the level of the vocal folds are cri-   coarytenoid arthritis and rheumatoid lesions of the vocal fold. the drug carrier” the type of inhaler device. Laryngeal amyloidosis is a rare and benign idiopathic disease. then treatment with an oral conazole agent for 3–4 weeks is commenced. abdominal subcutaneous fat aspiration. When present in a secondary form. and 25–53% of patients have involvement of the larynx. which presents as a primary disease or secondary with other disease processes. it can be associated with multiple myeloma. Signs associated with laryngeal involvement include wheezing or stridor. CT exam of suspicious parts of the body. granulomatous inflammation. There appears to be a dose-dependent dysphonia in 34% of patients treated with beclomethasone dipropionate or budesonide when administered via pressured metered dose inhalers. and 46. The underlying condition in the secondary form requires treatment. Dysphonia may occur in 5–50% of patients using inhaled steroids. Vocal fold hypomobility associated with cricoarytenoid (CA) arthritis has resolved in some reports with systemic treatment and possibly steroid injection into or near the CA joint. irregularity.5 7 Infectious and Inflammatory Disorders Fungal laryngitis is increasingly recognized as a cause of laryngitis. Wegener’s granulomatosis (WG) is a rare disease that involves principally three anatomical areas: the head and neck.

whereas abductor SD is marked by breathy speech breaks and an overall hypophonia due to inappropriate glottal opening during speech. which may mask the true diagnosis. specifically with primidone and propranolol. with 4. Three areas of the body may be involved to varying degrees: head. Adductor SD is marked by a “strained-strangled” speech pattern caused by premature and excessive glottal closure. SD typically presents in a female patient in her mid-30s. Recently. affecting 0. and vocal tremor.6. and a head tremor in 50%. Phonatory effects include hypophonia. 7. is that multiple muscles are involved in voice tremor (both intrinsic and extrinsic laryngeal musculature).3 Parkinson’s disease (PD) affects nearly 1 million persons in the United States. Many synonyms are used in clinical practice and these include hyperfunctional dysphonia. The standard of care in the treatment of SD is injection of the affected muscle(s) with botulinum toxin (BTX). “Botulinum Toxin Injection”). bilateral thalamotomy is associated with significant vocal side effects such as hypophonia and significant data for DBS in treatment of voice tremor is pending. Voice therapy can be used as adjunctive therapy to treat compensatory behaviors or assist in differentiating SD from muscle-tension dysphonia. as patients may have associated essential tremor or actually have muscle-tension dysphonia. and if it has been present for some time. of the voice is seen in 12–30% of patients with essential tremor. Few if any medications have been successful in ameliorating symptoms of SD. Several drugs have also been associated with tremor production. hands. The “muscletension” descriptor has been applied to muscle contraction patterns seen on flexible laryngoscopy of the endolarynx. The disease is caused by neurodegeneration within the nigrostriatal tracts of the basal ganglia. however. so the benefit of simple thyroarytenoid–lateral cricoarytenoid muscle complex injection is not nearly comparable to benefit of botulinum toxin A seen in SD treatment.2 Essential Tremor Essential tremor is the most common movement disorder.to 12-kHz frequency oscillation of the affected muscles. and patients find worsening of symptoms when under psychological stress. However. Prior to this. recurrence of symptoms was typical (despite complete nerve section) and the overall voice quality worsened. Some patients find that alcohol or benzodiazepines are helpful to reduce the stress that may be the trigger for SD. which leads to decreased dopamine release. is employed as first-line treatment but is more effective for limb-based tremor than voice.4 7. Typically. There appears to be a familial association in 17–100% of individuals transmitted in an autosomal-dominant inheritance pattern with variable penetrance. There are three classic types of SD. although typically it is isolated to the larynx. such as Meige’s syndrome. Some newer surgical techniques have been developed but no long term data is available and thus are presently experimental and not validated. the disease also appears to have a bimodal age distribution. The voice takes a monotonic quality. 7.6. and tension-fatigue syndrome to name a few.6% of those over age 40. The difficulty with local treatment. The treatment of the voice component of PD involves a specialized voice therapy program. which causes a temporary chemical denervation of the thyroarytenoid–lateral cricoarytenoid muscle complex in adductor SD and the posterior cricoarytenoid muscle in abductor SD (see Chap.6. Abductor SD (2) and patients with both adductor and abductor activity. many patients develop compensatory changes. Patients may not demonstrate speech breaks during singing or laughing tasks. leads to considerable disability. Essential tremor Parkinson’s Disease Muscle Tension Dysphonia Muscletension dysphonia (MTD) is a term used to describe voice disorders that are related to excessive and poorly regulated laryngeal muscle activity during speech. some work has emerged concerning botulinum toxin A injections for treatment of voice tremor. Adductor SD (1) comprises 80% of patients with the disorder. both disorders can cause voice breaks.6. with type I being very mild constriction with an excessive posterior glottic chink. breathy dysphonia. Medically refractory cases are treated with thalamotomy or deep brain stimulation (DBS). Diagnosis rests primarily on auditory-perceptual evaluation of connected speech supplemented by flexible nasopharyngolaryngeal examination. and in severe forms. these are classified from types I–IV. Dystonias in general are disorders of central motor processing. a neural center for motor control. Lee Silverman Voice Treatment (LSVT). Many patients experience dysphagia and dysarthria. to type IV.3% of cases occurring in the first two decades of life. Essential tremor of the voice is marked by a regular 4. muscle misuse.1 Spasmodic Dysphonia Spasmodic dysphonia (SD) is a focal dystonia characterized by vocal task specific action or intention induced spasms. No data are available currently regarding the effect of DBS on the voice in PD. and muscle rigidity. and vocal tract. Treatment of PD is pharmacologic using dopamine agonists and medically refractory cases may undergo DBS or pallidotomy. 35.6–5. tremor. One study reported that 87% of PD patients demonstrated vocal fold bowing. Pharmacotherapy. and Parkinson’s disease is also considered in the differential diagnosis.6 Neurologic Disorders 7. mixed SD (3). comprise the rest of disease population. The hallmark clinical findings are bradykinesia. LSVT is sufficient alone and vocal fold augmentation is not required. and SD can be found in conjunction with other disorders.  Chapter 7 7. postural instability. a concentric closure pattern of the supraglot- 45 . however. Diagnosis can be difficult. with or without vocal fold augmentation to improve glottic configuration and closure. recurrent laryngeal nerve section was performed.4–5.

etc). topical anesthetization of the endolarynx has assisted in decreasing laryngeal tension because of altered sensation and proprioception. and episodic paroxysmal laryngospasm. MTD can present as a primary problem often associated with post-URI onset. 7. These include brainstem compression. Circumlaryngeal massage has been used in conjunction with voice therapy to assist in reducing laryngeal height. severe cortical or upper motor neuron injury.6. both false positives and false negatives are generated. nuclear or lower motor neuron injury. as these patients frequently hold their larynges in an abnormally elevated position secondary to increased muscular tension. Treatment consists of elimination or avoidance of triggers. LPR. the patient exhibits inspiratory stridor and/or experiences a sensation of airway restriction. Some have attempted use of heliox (80% helium. Some of these patterns are seen in other disorders as well such as adductor SD or even in normal voices and these are not pathognomonic. including vocal cord dysfunction. irritant-exposure triggers. and respiratory retraining therapy administered by the speech pathologist. which may be seen at rest of after administration of a trigger (exercise. but it is also seen in a non-IgE-mediated anaphylactoid response. Many terms have been used in the past to describe this condition. these patients require intense psychiatric treatment in addition to voice therapy.7 Allergy and Voice Disorders Allergic diseases can manifest in the larynx in several ways.5   Occasionally. PVFMD has many causes and has been classified into five organic and two nonorganic categories. Patients complain of exercise-induced episodes of airway restriction. VOCs include alcohols. Symptoms also include choking. Paradoxical Vocal Fold Motion Disorder Paradoxical vocal fold motion disorder (PVFMD) is a disorder marked by desynchronized or paradoxical adduction of the vocal folds during inspiration and/or expiration. When faced with this situation. and there is no consistent pattern. however. The differential diagnosis is bilateral vocal cord paralysis. psychiatric treatment may also be required. avoidance and/or removal of the source of the irritant are the mainstay of treatment. The gold standard in diagnosis is demonstration of PVFMD during flexible laryngoscopy. as such. 20% oxygen) to decrease work of breathing. Treatment of this disorder involves immediate airway control and injection of epinephrine with use of steroids and H2 blockers after the initial episode. When associated with a conversion disorder. This process is associated with immunoglobulin IgE-mediated anaphylaxis. Treatment success ranges from 37. treatment with the anticonvulsive agent gabapentin should be considered. A starting dose of 100 mg three times a day is recommended. Avoidance of the triggering allergen and antihistamines are the recommended treatment. increasing to 300 mg three times a day for symptom control. or significant voice demands. Exposure and allergy to aerosolized irritants can also lead to muscle-tension dysphonia.5 to 80%. As a result. factitious asthma. Any coexisting asthma/reactive airway disease must also be aggressively treated. Laryngeal electromyography (EMG) is used to confirm subtle neuropathic findings of paresis. posterior glottic stenosis. aphonia or dysphonia. and conversion disorder PVFMD. which decreases neural sensitivity. 7.8 Medications and Their Effects on Voice Both allergy and post-URI patients can experience dysphonia related to persistent postnasal drip. and ketones. it is seen in primarily high-achieving. It can also present in a secondary form as excessive compensation for glottal insufficiency. movement disorder. as it avoids drying effects of antihistamines in the endolarynx. with or without laryngospasm or PVFMD. Many patients also suffer from chronic postnasal drip secondary to allergic rhinitis. Food allergy may lead to milder swelling of the vocal tract with dysphonia and may actually stimulate or worsen LPR. as well as in young female professionals.6. but results have been mixed. Patients also experience . This is often confused with the wheezing of asthma that. depending on level of motor involvement of the neuropathy. Functional dysphonia or aphonia is a separate term that should be used for psychogenic dysphonia or conversion disorder. occurs in the expiratory phase. In the most severe or refractory patients. 7. 7. in contrast. perfectionistic adolescents who are usually athletes. including reflux and allergy treatment. an acute life-threatening process initiated by exposure to a specific allergen. Mold and volatile organic compounds (VOC) are the usual suspects. hereditary abductor paralysis. inappropriate pitch use. reflux. and PVFMD and may be refractory to treatment. aldehydes. psychogenic asthma. or cricoarytenoid joint fixation.46 7 Nonsurgical Treatment of Voice Disorders tis. which leads to maladaptive laryngeal muscle usage and can lead to the development of vocal fold lesions. “Malingering” or “factitious dysphonia” would be included under this term. or symptoms after a meal. The classic description is that of laryngeal angioedema. irritable larynx syndrome. These patients are frequently treated for allergies. Again. factitious or malingering PVFMD. based on etiology. Those with conversion disorder have experienced significant psychological trauma from an event that causes the aphonia.6 Postviral Vagal Neuropathy Postviral vagal neuropathy (PVVN) is marked by chronic cough. The cough is thought to be a result of altered laryngeal sensitivity such as in post viral neuralgias of other cranial nerves. and chronic cough. Flow-volume loops have been used to assist in diagnosis. These patients tend to frequently clear their throats. perfumes. Immunotherapy is an important consideration for treatment of allergy in the professional voice user. The trigger may be an irritant or even palpation of the larynx. gastroesophageal reflux.

but it is essential component of the treatment of a wide variety of voice disorders is a nonsurgical approach to voice rehabilitation with voice therapy. Nonphonatory side effects include acne. These medications. with less drying. gingko biloba. the speech–language pathologist plays a crucial role in all phases of modern voice care (diagnostic. Although some reports have stated that effects are temporary and cease with discontinuation of the medication. and medical care as needed. and rehabilitative).  cough due to direct irritation from mucus or because of altered sensitivity of the endolarynx. and licorice root also has progesteronic in addition to estrogenic effects and can change vocal pitch. One group of medications that should not be overlooked is herbal remedies.10 Role of the Speech–Language Pathologist in Voice Therapy The speech–language pathologist is instrumental in teaching the voice disorder patient about laryngeal anatomy and vocal biomechanics. 7. loss of high frequency vocal range. understanding effects of smoking. The speech–language pathologist specializes in assessing and treating behavioral issues of the speaking and singing voice. Many have anticoagulant properties and can predispose a person to vocal fold hemorrhage. feverfew. Many patients with dysphonia struggle from a variety of poor behaviors and/or speaking techniques or inappropriate use of the voice and these problems are all easily treated with the intervention of the speech–language pathologist.. Some herbal medications also may have hormonal effects. such as montelukast. leading to vocal fold hemorrhage and vocal fold lesion formation. Vocal fold hemorrhage and vocal fold lesions are the most significant concerns. and changing bad habits early in younger performers is critical to long-term vocal health. therefore. Despite widespread clinical use of oral corticosteroids for acute dysphonia in the professional voice user. echinacea. Codeine and dextromethorphan are added to many cold medicine preparations. and can lead to fungal infection. without the significant opioid side effects associated with codeine. Testosterone injections have been administered to women complaining of loss of libido or energy and have been reported in female athletes for enhanced performance. ginger. which consequently decreases edema. g. chamomile after long-term use. have been used for treatment of fibrocystic breast disease and endometriosis. alcohol. dehydration and control of postnasal drip of any cause. there is minimal scientific literature concerning this subject. may have enhanced antitussive properties. gastrointestinal and neurologic problems. 47 . These include dong quai (which actually contains coumadin). However. and hairline recession. Low-dose oral monophasic contraceptives have been shown to reduce this pitch variability and exhibit less androgenic side effects. The speech–language pathologist with special training in voice disorders is an essential member of the diagnostic and therapeutic team required for high-quality voice care. Typically.9 Vocal Hygiene A discussion of medical treatment of voice disorders would not be complete without discussing the importance of vocal hygiene. with a tapering dosage to avoid adrenocortical insufficiency and minimize long-term side effects. using the overall global term of voice therapy. This can be particularly damaging to the voice professional.” as vocal injuries are more likely to occur in the sick singer than in a healthy one. St. Histologically. systemic muscle weakness and atrophy. therapeutic. any patient on long-term oral corticosteroids should be placed on at least an H2 blocker. avoidance. For Danazol. the incidence may be as high as 10% in patients on the medication. Voice effects including lowering of fundamental frequency. and generalized dysphonia. The corticosteroid mechanism of action is to prevent capillary dilation and decrease capillary permeability. During the premenstrual period of the menstrual cycle. Chapter 7 primrose. hydration and nutrition. which are central to the voice therapy process for many disorders. Vocal hygiene involves knowledge. Leukotriene inhibitors. oral steroids are used in short bursts. Guaifenesin is the most widely used mucolytic and works best when the patient is well hydrated. and electrolyte and metabolic disorders. Intramuscular use is also reported for the acute situation. such as Danazol. fluids. and nasal corticosteroids can be used in allergic patients. A detailed description of voice therapy treatment methods for a variety of dysphonias is outside the focus of this book. and red root. garlic in high doses. so great caution must be used when considering prescribing these medications. as the drying effects on the vocal folds can be detrimental. Thus. corticosteroids can lead to fluid imbalance. The sick singer should take adequate vocal rest. Yam has progesterone-like properties. hirsutism. Antihistamines again should be used with caution in the professional voice user with allergy. John’s wort. vocal stress and vocal exercise. and general vocal hygiene. As a result. Primrose is a natural estrogen promoter. Many medications have virilizing properties and should be used with great caution in the professional voice user. vitamin E in high doses. Elements of vocal hygiene include understanding that medical problems affect the voice. Some may have crossreactivity to ragweed: goldenseal. dong quai. drugs. Corticosteroids have been linked to peptic ulcer development. glaucoma. if used for a more extended period. vocal instability with pitch breaks. which is a weak opiate. and melatonin acts as a contraceptive in high doses. e. willow bark. or reduction of irritants such as gastric juices or tobacco smoke. weight gain. Tramadol. Severe coughing can result in phonotrauma. dong quai may increase effects of ovarian and testicular hormones. yarrow. there is potential for permanent voice change as can be seen in histological studies. 7. water retention in the muscle and fiber hypertrophy are seen. A few studies have shown improvement in objective acoustic measures with use of steroids. many over the counter preparations are used for their antitussive and mucolytic properties. many women exhibit pitch lowering secondary to presumed venous dilatation and edema of the vocal folds. The patient should be made keenly aware of the danger of “singing sick. or any patient for that matter. preferably a PPI.

Otolaryngol Clin N Am 36:957–988 31 Watts CR. Emami AJ (1999) The irritable larynx syndrome. Atkins JP (2004) Laryngeal findings in advanced Parkinson’s disease. Laryngoscope 115:1230–1238 Belafsky PC. Baldwin CY. J Voice 13:496–507 33 Amir O. Ann Otol Rhinol Laryngol 107:439–445 15 Herridge MS. Rinaldo A (1998) Clinicopathological consultation: Wegener’s granulomatosis of the head and neck. J Voice 13:447–455 28 Lee B. as LPR is a common trigger for PVFMD episodes. Laryngoscope 107:1429–1435 27 Morrison M. Kamatani N (2001) Cricoarytenoid arthritis with rheumatoid arthritis and systemic lupus erythematosus. Taylor G. Schwartz SK. http://www. ■ Muscletension patterns I–IV seen in MTD are not pathognomonic for this disorder and can be seen in other voice disorders such as spasmodic dysphonia. Gadelha ME (1999) Clinical evolution of laryngeal granulomas: treatment and prognosis. Antin-Ozerkis DA (2004) Laryngeal findings in users of combination corticosteroid and bronchodilator therapy. Devaney SL. Louis ED et al (2005) Practice parameter: therapies for essential tremor. Pakiam A. Pearson FG. Balkissoon R.voiceandswallowing. Zesiewicz TA (2003) Essential tremor: epidemiology. Picolinksy DE. Kotake S. Morton RP (2004) Fungal laryngitis in immunocompetent patients. Casiano RR (2002) Cough and paradoxical vocal fold motion. Hunter BC. Koufman JA (2001) Laryngopharyngeal reflux symptoms improve before changes in physical findings. Biron-Shental T. Clin Rheumatol 19:315–317 17 Bartels H. Mendelsohn J. Hazenberg BPC (2004) Laryngeal amyloidosis: localized versus systemic disease and update on diagnosis and therapy. Elble R. 21 Sullivan KL. Woo P (2005) Chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment. Ann Otol Rhinol Laryngol 113:253–258 24 Roy N (2003) Functional dysphonia. Humphrey D (1995) Rheumatoid nodules of the larynx. Labenz J et al (2003) Prevalence of extraoesphageal manifestations in gastro-oesophageal reflux disease: an analysis based on the Pro-GERD study. Curr Opin Otolaryngol Head Neck Surg 12:543–548 20 Warrick P. Irish JC. De Biase NG. Ann Otol Rhinol Laryngol 114:369–375 Mirza N. Otolaryngol Head Neck Surg 127:501–511 26 Maschka D. Van de Heyning P. Laryngoscope 111:979–981 Vaezi MF (2003) Gastroesophageal reflux disease and the larynx. Stern Y.48 Nonsurgical Treatment of Voice Disorders Key Points 7 ■ Up to 50% of voice disorder patients may have coexisting LPR. Kishon-Rabin L (2003) Do oral contraceptives improve vocal quality? Limited trail on lowdose formulations. Aliment Pharmacol Ther 17:1515–1520 Mehanna HM. Lokhorst HM. Dromey C. Laryngoscope 110:1366–1374. Curr Opin Otolaryngol Head Neck Surg 11:144–148 25 Altman KW. Ear Nose Throat J 113:147–150 Nanke Y. Durkin L. Hauser RA. Rudolph C. Neurologist 10:250–258 22 Zesiewicz TA. Bauman NM. diagnosis. Rosen CA (2000) Vocal education for the professional voice user and singer. Hasegawa M. Koufman JA (2001) Vagal neuropathy after upper respiratory infection: a viral etiology? Am J Otolaryngol 22:251–256 30 Chadwick SJ (2003) Allergy and the contemporary laryngologist.htm 35 Murry T. Otolaryngol Clin N Am 33:967–981 . Muchnik C. Kuo T. J Thorac Cardiovasc Surg 111:961–966 16 Stappaerts I. Rammage L. Kulig M. Chest 126:213–219 Sulica L (2005) Laryngeal thrush. Van der Wal JE. Yonemoto K. Van Laer C. Laryngoscope 114:1566–1569 DelGaudio JM (2002) Steroid inhaler laryngitis: dysphonia caused by inhaled fluticasone therapy. Amina MR. Cotton RT (1998) Gastroesophageal reflux in patients with subglottic stenosis. Simpson CB. 1):289–294 Walner DL. Curr Opin Otolaryngol Head Neck Surg 10:168–172 32 Baker J (1999) A report on alterations to the speaking and singing voices of four women following hormonal therapy with virilizing agents. Abaza M. Bhalla RK. Selected Bibliography 1 2 3 4 5 6 7 8 9 10 11 12 13 Park W. Voice and Swallowing Center (2005) Herbal medications. Obstet Gynecol 101:773–777 34 Columbia University at New York Presbyterian Hospital. Arch Otolaryngol Head Neck Surg 128:677–681 Woo P.com/Voicetreat_herb. Ferlito A. ■ PVFMD is treated best with multimodality treatment that includes respiratory retraining (voice therapy) and proton pump inhibitors. Arch Otolaryngol Head Neck Surg 124:551–555 Jaspersen D. Neurology 53:2008–2020 23 Blumin JH. J Clin Gastroenterol 36:198–203 de Lima Pontes PA. Thompson LDR (2003) Larynx amyloidosis. Ann Otol Rhinol Laryngol 113:741–748 18 Akst LM. Hicks DM. J Laryngol Otol 118:379–381 Roland NJ. Chaplin J. Vermeire P (2000) Endoscopic management of severe subglottic stenosis in Wegener’s granulomatosis. Postma GN. J Rheumatol 28:624–626   14 Devaney K. Lang A (2000) Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. and treatment. and even some normal voices. College of Physicians and Surgeons. Ann Otol Rhinol Laryngol 114:253–257 29 Amin MR. ■ Twice-a-day therapy with a proton pump inhibitor results in the highest symptom resolution. Gerber ME. Dikkers FG. Ear Nose Throat J 82(11):844–845 19 Sulica L (2004) Contemporary management of spasmodic dysphonia. Deschepper K. Khandwala F et al (2005) Laryngopharyngeal reflux: prospective cohort study evaluating optimal dose of proton-pump inhibitor therapy and pretherapy predictors of response. Earis J (2004) The local side effects of inhaled corticosteroids: current understanding and review of the literature. Downey GP (1996) Subglottic stenosis complicating Wegener’s granulomatosis: surgical repair as a viable treatment option. Laryngoscope 109(Pt. 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schoolteachers have such significant vocal demands that any decision to proceed with phonomicrosurgery during the school year should be taken with great caution. the vocal recovery time before full singing is allowed is individualized to the patient situation. This is especially important for vocal performers. Furthermore. Thus. For example. surgeries for airway enlargement. Financial demands also pressure the vocalist to perform sooner than is medically appropriate. The psychological impact of phonosurgery on patients should be greatly appreciated. psychological preparation for surgery. and an appropriate and thorough informed consent process. yelling. heavy vocal demands such as singing.2 Key Components to Successful Care of Patients with Voice Disorders This chapter addresses specific issues related to phonomicrosurgery for benign lesions of the vocal fold. phonomicrosurgery to remove any type of benign lesion of the lamina propria from a schoolteacher during winter break—with expectations of resuming when school resumes at the start of the new year—is a plan fraught with danger and should be avoided. 8. comorbid medical conditions such laryngopharyngeal reflux disease and sinonasal allergic disease. or plans 8 should be made not to return for the remaining semester. The reason for avoiding temporary vocal fold edema immediately prior to phonomicrosurgery is to minimize the removal of vocal fold tissue (epithelium and/or lamina propria) that appears permanently pathological but. may represent temporary edema. This must be identified by the voice care team preoperatively. It is important to realize that these individuals (to a large degree) identify themselves by their voice.3. and minimal negative outcomes and activities during this stressful time. a short dose of oral steroids can be used to alleviate the temporary vocal fold edema associated with these conditions prior to phonomicrosurgery. Often a short period of complete voice rest immediately after phonomicrosurgery is indicated. This is an area that is frequently overlooked by surgeons. Thus. and thus the surgeon and patient have the ability to participate in maximum nonsurgical treatment modalities for the rehabilitation of the patient’s voice problem. phonosurgery for disorders of glottal incompetence. Similarly.1 Fundamental and Related Chapters Please see Chaps. Furthermore. Planning. and upper respiratory infection should be treated and may be reason to reschedule the surgery. For many of the situations in voice care. and tumor excision of the larynx. This can range from 2 to 14 days and typically averages 7 days. and thus the consideration and realization of the need for surgery induces a significant amount of anxiety and concern. 4.2 Preoperative Considerations for Phonomicrosurgery Any conditions that will create temporary vocal fold edema prior to phonomicrosurgery should be avoided or treated prior to proceeding. or lecturing should be avoided approximately 1–2 weeks before phonomicrosurgery. successful fashion. and discussed and dealt with in a positive. If this occurs. and Decision Making in Phonosurgery 8. and 7 for further information. Similarly. 8. Thus.Chapter 8 Timing. The time of voice limitation before allowing the phonomicrosurgery patient to use full speaking voice activities ranges from 7 to 30 days. especially by doctors who do not appreciate the unique relationship that professional voice users and heavy voice users have with respect to their psyche and their voice. Phonomicrosurgery on teachers should only be done at the start of summer (June) or the teacher will need to be off work for half the school year. it is important that the surgeon and patient discuss the need for an adequate amount of time for voice recovery after these procedures. In some instances. patient compliance. but typically ranges from 30 to 90 days. it is essential that the patient not feel pressured or rushed to decide on proceeding with .3. 5. screaming.1 Timing of Phonomicrosurgery The majority of patients require a significant amount of time to recover after phonomicrosurgery. the patient must cancel pending voice demands when scheduling phonomicrosurgery or delay the surgery date until there is a more appropriate time after the surgery to accommodate reduced voice demands. Preoperative voice therapy can often play a major role in addressing these issues. This will ensure maximum postoperative voice quality.3 Surgical Indications and Contraindications 8. given that they have many demands on them from management and staff. excessive excision may result. in fact. the surgical procedures are elective. 8. Similarly. most likely epithelium/lamina propria wound healing is compromised in the face of an acute inflammatory condition resulting in suboptimal postoperative voice rehabilitation.

close observation of the patient needs to be maintained to assess the patient’s response after a short time period. Thus. the patient begins to notice substantive improvement. After all nonsurgical rehabilitation methods have been employed. and this can often factor into important intraoperative decision making. When the patient resumes vocal activity. and there are various guidelines for the types of laryngeal surgery being undertaken. It is essential that the surgeon not pressure or rush the patient’s decision. 8. singing therapy. this is the case with respect to voice therapy. reduced range. If there is any possibility of the nonsurgical treatment options making a substantive difference. accepting the possibility a small number of patients may require repeat phonomicrosurgery for persistent or recurrent disease. The optimal role of the patient should be as the primary decision maker and the surgeon should serve as the educator in this process. For patients with cancer. 8. surgery should not be delayed if the following are present: ■ Dysphagia associated with aspiration ■ Impending airway embarrassment ■ Risk for malignancy The majority of voice-related procedures in the category of phonomicrosurgery. reduced clarity. and the decision-making process must be individualized. then it is often wise to obtain conservative margins and delay the surgical procedure until permanent pathology is available. On the other hand. For patients undergoing phonomicrosurgery for benign lesions of the lamina propria. This approach avoids excessive resection of nonmalignant tissue. However. Patience should be exercised by the voice care team waiting for the patient to become comfortable with the decision to have phonosurgery. then it is worthwhile having the patient undergo these treatments. if the surgeon is not comfortable with margins on frozen sections. medical therapy) if they have no reasonable expectation to make a significant improvement in the patient’s voice limitations and/or symptoms. An important component to this decision-making process is to encourage the patient to resume his/her voice activities after nonsurgical rehabilitation has been completed. phonosurgery is an elective procedure. the patient should be well equipped to be the primary decision maker for elective phonosurgery. With this information. This will significantly improve the patient’s coping ability during this stressful process.50 Timing of Phonosurgery phonomicrosurgery. as well as to discuss reasonable expectations of elective phonosurgery. intraoperative decision making is dictated by the location and nature of the cancer. and thus. This allows the surgeon to review and see the most recent status of the vocal fold pathology. Often patients with benign vocal fold lesions or with conditions of glottal incompetence will be treated with one or two sessions of voice therapy and then reassessed for progress and potential for significant improvement. Generally for most elective phonosurgeries.5. this dictum must be utilized within reason.4 8 Decision Making in Phonosurgery In most situations. the patient and surgeon are afforded an amount of time for nonsurgical treatment of the voice condition. Specifically. Difficult decisions regarding how much to resection of epithelium and/or lamina propria should be done on the conservative side. However. resulting in severe (and potentially irreversible) postoperative dysphonia from vocal fold scar. It is recommended that the surgeon review the recent stroboscopy examination either the day of the surgery or preferably immediately prior to (or during) the patient’s phonomicrosurgical procedure. The amount of time it takes any patient to decide to proceed with phonosurgery is highly variable. a formal reevaluation by the voice care team should be performed to decide if elective phonosurgery is indicated. These repeat phonomicrosurgery procedures are a small price to pay for minimizing the risk of overaggressive resection of epithelium and/or lamina propria. vocal fatigue)?” This assessment of functional ability is crucial in prompting the patient to decide if he/she should proceed with phonosurgery.) The decision to proceed with elective phonosurgery should be a joint decision between the patient and the surgeon. and then are able to make a joint decision to proceed with surgery. they should be asked to answer the simple (but essential) question: “Can you do what you need to with your voice?” or “Do you still have significant functional limitations (e. the intraoperative decision making process should be approached in a very conservative fashion. allergy therapy. and thus all surgery should be delayed until voice therapy and possibly singing voice therapy is completed. Specifically. A formal reevaluation   of their functional abilities and limitations should follow (see below. Then. the decision making and preparation prior to surgery should be undertaken on a reasonable timetable that should be predominantly patient driven. . it is unreasonable and poor use of resources to force all patients to undergo multiple nonsurgical rehabilitative measures (voice therapy. It is essential for patients undergoing phonomicrosurgery to have had a recent voice evaluation.” below). a laryngo­ video­stroboscopy should be performed in the period shortly before surgery (1–3 weeks). and vocal fold injection for benign lesions of the vocal fold/glottal incompetence are in fact non–life threatening. if there is a positive margin. “Informed Consent Regarding Phonosurgery. The surgeon’s most important role is to educate the patient on his/her specific voice condition and on the risks and benefits of the surgical procedure (see Sect. Often after the initiation of voice therapy. the decision to proceed with phonomicrosurgery can be confidently made pending the outcome and progress after one or two sessions of voice therapy. a return to the operating room can be undertaken. With a compliant patient and a skilled speech–language pathologist. the patient should be offered and undergo nonsurgical rehabilitative measures prior to proceeding with surgery. g. Thus.. Intraoperative decision making can be quite challenging for the phonosurgeon. laryngeal framework surgery. given that there are instances when the patient’s medical condition (large exophytic vocal fold polyp or lateralized vocal fold paralysis) dictate that nonsurgical treatment methods do not have a reasonable chance for significant improvement. Of course.

results.  Chapter 8 Intraoperative decision making regarding laryngeal framework procedures should follow this guideline: The best chance for a good outcome is with the first surgical procedure. Ossoff RH (1995) Endoscopic vocal fold microflap: a three-year experience. Stone RE. 1):267–273 51 . staged approach) to surgery for the enlargement of laryngeal airway should be the guiding principle for intraoperative decision making in this area. A combination of all these factors should be synthesized and presented to the patient so he/she is offered the appropriate level of expectation. so that realistic goals of postoperative voice quality and function are clearly understood. ■ With respect to microsurgery for benign lesions of the lamina propria. and vocal demands. ability/training of the patient. ■ The key principle of decision making with respect to phonomicrosurgery is the use of nonsurgical rehabilitative treatment options (when appropriate) prior to proceeding with surgery. total arytenoidectomy) should be done in a conservative fashion. The surgeon serves as educator. the most important question that must be answered before deciding for or against proceeding with phonomicrosurgery is: “Can the patient do what they need to do with his/ her voice after undergoing maximum of nonsurgical rehabilitation?” ■ Informed consent process for phonomicrosurgery should be individualized due to the specific pathologic condition present and the surgical approach recommended. medial arytenoidectomy. The reversibility and adjustability of revision laryngeal framework procedures may be limited. Appropriate informed consent for phonosurgeries involving patients with glottal incompetence should involve the specific expectations. This risk is quite small (1–2%). It is important to inform the patient that there is a risk of postoperative scarring and permanent postoperative dysphonia that could even worsen his/her condition compared to preoperative status. technique. voice improvements. the greater is the risk for decreased vocal function.5 Informed Consent Regarding Phonosurgery The most important aspect of informed consent is education of the patient regarding the salient details of the surgical procedure. Typically. there is a risk that significant improvement in vocal function will not be obtained despite the surgeon’s and the patient’s best efforts (1–2% incidence of “no improvement”). The factors that play an important role in defining reasonable expectations of successful phonomicrosurgery include the patient’s vocal abilities and/or voice training and his/her postoperative vocal demands and expectations. Cornut G (1992) Microsurgical treatment of benign vocal fold lesions: indications. the greater the likelihood of diminution of the patient’s vocal function. the decision to proceed with surgery should be patient driven. It is important for the surgeon to make the distinction between voice improvement and restoration to the patient’s premorbid vocal capabilities. all attempts. Due to this voice–airway equation and the need for conservative removal of glottic narrowing. providing reasonable expectations. these types of surgical procedures have a very high degree of success with respect to increasing volume. appropriately performed phonomicrosurgery for benign lesions of the lamina propria in a compliant patient should have a success rate of > 95%. specifically identified from stroboscopy and/ or from prior operative findings. regardless of the chosen method. the patient should be informed of the likelihood of the need for repeat surgery. Gardner GM. Selected Bibliography 1 2 Bouchayer M. Ann Otol Rhino Laryngol 104(Pt. the informed consent process should involve the patient’s individual pathology. 8. Thus. Key Points ■ Most phonosurgical procedures are elective. should work to achieve the best possible voice quality from the first surgical procedure. Folia Phoniatr 44:155–184 Courey MS. These limitations exist because of the persistent underlying pathologic condition such as vocal fold paralysis. clarity. and endurance with normal speaking-voice use and normal speaking demands. Patients with airway problems preoperatively that do not have a tracheotomy should also be consented for a possible tracheotomy depending on a variety of intraoperative situations. Success is defined as an improvement in voice quality and function. Documentation of the most important aspects of this process is also strongly advised. and vocal fold paresis. With phonomicrosurgery procedures for benign vocal fold lesions. There are often limitations af- ter this type of surgery that persist involving loud speech and/ or singing. vocal fold scar. Informed consent for airway procedures must involve discussion that as the surgical procedure obtains an increased airway for the patient. and similarly. All patients should be counseled that the greater the laryngeal airway that is created. The goal of the surgery is to obtain an adequate airway while at the same time minimizing the negative impact on the voice. a conservative (and. Intraoperative decision making for airway cases. and persistent limitations after surgery. Thus. In general. especially for glottic enlargement procedures (transverse cordotomy. and thus. and discussing risks and benefits of the procedure. if needed. Informed consent for surgical removal of laryngeal cancer should include reduction of vocal and swallowing function as well as the risk for additional surgery depending on permanent pathology results after surgery. The success rate to achieve the latter goal is going to be lower and will be directly related to the pathology of the vocal folds.

Doyle PB (2002) Phonomicrosurgery in singers and performing artists: treatment outcomes.):21–40 . Hillman RE. Ann Otol Rhino Laryngol 190(Suppl. A review of 116 phonosurgical procedures. Desloge R. and future directions. Stone RE.52 Timing of Phonosurgery 3 4 5 8 Dejonckere PH (2000) Committee on Phoniatrics of the European Laryngological Society. Civantos FJ (1993) Silastic medialization and arytenoid adduction: the Vanderbilt experience. Luken ES. San Diego Zeitels SM. management theories. Mauri M. Assessing efficacy of voice treatments: a guideline. Plural. J Voice 18:534–544   6 7 8 Netterville JL. Paul Moore lecture: lessons in phonosurgery. Ann Otol Rhino Laryngol 102:413–424 Sataloff RT (2005) Professional voice: the science and art of clinical care. 3rd edn. Rev Laryngol Otol Rhinol 121:307–310 Ford CN (1999) Advances and refinements in phonosurgery. Laryngoscope 109:1891–1900 Ford CN (2004) G.

9. as well as one or two alternate strategies (plans B and C) should be established so that the airway management is automatic and algorithmic. 13.5 MLT (microlaryngoscopy tube) (Fig. and Fig. 28.). Fla.0 endotracheal tube below (ETT) and 5. b) Jet Venturi ventilation using one of the following methods: i. The following general principles should always be observed: 1. A preoperative management plan for securing the patient’s airway must be discussed with the anesthesiologist prior to proceeding with surgery. or b) Jet Venturi needle 4. The patient should be placed in the “sniffing positioning. “Principles of Phonomicrosurgery”). 29. 2. Subglottic Mon-Jet/Hunsaker jet ventilation tube (Fig.0 and smaller) are not long enough to adequately span the distance between the oral commissure and the subglottic/tracheal airway. Rigid bronchoscopes 7. resting on top of the laryngoscope . 27. 40.0 or 5. and 47 for further information. Tracheostomy tube/surgical tray 6. Laser-safe ETT a) MLT 5. Most “regular” ETT (size 5.5 or smaller 5. Jet ventilator device (preferably high frequency) 3.3) 4.5 or smaller ETT. 10. Lesions of the posterior third of the larynx (vocal processes and posterior commissure/arytenoids region) require one of the following approaches: a) Jet ventilation b) Apneic technique c) ETT placement anteriorly.Chapter 9 Anesthesia and Airway Management for Laryngeal Surgery 9. Jacksonville.2) ii.3 Surgical Indications and Contraindications Sharing the airway with our anesthesia colleagues is one of the most important (and often neglected) aspects of successful laryngeal surgery. and “ready to go” if alternative plans become necessary. In general.1 9 Fundamental and Related Chapters Please see Chaps. as opposed to chaotic/reactive.” with the head extended (at the atlanto-occipital joint).2 Equipment Airway management requires the following: 1. lesions located on the anterior two thirds of the larynx (membranous vocal folds) can be adequately exposed/treated with a 5. both the surgeon and anesthesiologist should have the proper equipment in the room. 9.0/5. 9. Lack of collaboration and preoperative planning with the anesthesiology team can turn an otherwisesimple microlaryngoscopy case into a chaotic. Ventilating laryngoscope a) Ossoff-Pilling b) Pilling subglottiscope 2.0 MLT above (note longer length of MLT) the neck flexed (along the cervicothoracic vertebrae) for optimal laryngoscopic exposure (see Chap. Jet ventilation conduit a) Hunsaker Mon-Jet jet ventilation tube (MedtronicXomed. 3. 9. open. Supraglottic jet Venturi needle (via port within laryngoscope or attached to laryngoscope) (Fig. 9. MLT (microlaryngoscopy) endotracheal tube is a small-diameter ETT with an extended length.1). life-threatening airway crisis. 4% lidocaine (LTA) 9. Prior to bringing the patient into the operating room. An ideal plan (plan A).1  Standard 5. 46. Microlaryngoscopic surgery generally employs one of the following methods for maintaining the airway: a) Oral intubation using a small diameter endotracheal tube of adequate length: 5. 45. 39.

9. jet ventilation (containing 100% oxygen) must be suspended during firing of the laser.4 Principles of Airway Management: Subglottic and Tracheal Stenosis 1. then air trapping results. 2. Subglottic/tracheal stenosis presents a unique anesthetic challenge. using reinsertion of stomal ETT intermittently to restore oxygenation between treatment cycles. This allows the anesthesia team to monitor end-tidal CO2 to ensure adequate exhalation time during jet ventilation. the vocal folds are not as affected by ventilatory forces. laser protected when appropriate b) Apneic technique may be employed if airway surgery is carried out distal to the tracheal stoma site. Jet ventilation can proceed even while the laser is being fired. The potential drawback of subglottic jet ventilation is the increased risk of air trapping from the “ball-valve” phenomenon. and if egress (escape) of air is prevented by the obstructed region. 9.4  Laser protected ETT (Medtronic-Xomed)   Fig. Ideally.5–6. Subglottic/tracheal stenosis in a stable airway should generally proceed as follows: a) Mask induction is performed using inhalational agents (sevoflurane): .2  Subglottic jet ventilation tube (Medtronic-Xomed) Fig. an appro- priate laser-protected tube must be in place (Fig. The only exception to this rule is when jet ventilation or apneic technique is used (both are also safe for the laser). Another important advantage of the Hunsaker subglottic jet ventilation tube is the built-in CO2-monitoring port. In instances where the patient has an indwelling tracheostomy tube: a) 5. In addition. as opposed to subglottic) However. and emergent ventilatory compromise. Jet ventilation is safest when used proximally (supraglottic. 9. 5. In all cases where a surgical laser is employed.4). passive movement of the vocal folds due to ventilatory air movement limits the 9. 8. 9. the airway is not instrumented by the anesthesiology team. 6.54 9 Airway Management for Larygeal Surgery Fig. Subglottic jet ventilation is more efficient when used for glottic laser surgery.3  Jet Venturi needle and jet ventilation tubing/pressure gauge precision of fine surgical maneuvers. endotracheal intubation can result in traumatic injury to the subglottic mucosa and may precipitate an emergency in a patient with a marginal (but otherwise stable) airway. Increased vigilance must be practiced when this ventilation technique is employed. 7. pneumomediastinum. Often. subglottic jet ventilation is performed distal to the airway obstruction.0 reinforced ETT placed through the stoma into the trachea. Complications of this include pneumothorax (possibly bilateral).

The airway is obtained by performing a tracheostomy under local (alternate method: rigid bronchoscopy to secure the airway. 47. especially in a patient with a “difficult surgical airway” due to coexisting anatomic conditions (retrognathia. or if CO2 retention is excessive. the patient’s airway is returned to the care of anesthesia. d) Subglottic/cervical tracheal narrowing due to cartilaginous collapse. and tracheostomy can be avoided. 3. iv. In these cases. The tracheostomy should be placed at least 1 cm inferior to the stenotic region. This step minimizes the length of trachea that must be excised when a tracheal resection/cricotracheal resection is performed at a later date (Fig. viii. emergent airway case should observe the following general guidelines: a) The surgical approach to the treatment of emergent/ urgent SGS should be individualized for each patient. After surgical treatment of the stenotic region. base-of-tongue hypertrophy. or by passing a ventilating bronchoscope past the stenotic region. tracheostomy is not a viable option. Rigid dilation/laser treatment can then proceed as indicated. then 55 . If the larynx cannot be exposed through the oral route using rigid laryngoscopy/bronchoscopy. In some patients. if expert anesthesia and intensive care monitoring are available. limited neck flexion). as it is ineffective. 9. trismus. Induction should be gradual (no “rapid sequence”). Muscle relaxation must be present (via sevoflurane or propofol). then endoscopic treatments are generally preferable.5 Special Circumstances: Difficult Exposure of the Larynx 1. v. vi. ix.5) (see Chap. 2 above (jet ventilation without endotracheal intubation). unfavorable anatomy and difficult laryn- geal exposure may render all of the previously mentioned principles moot. The surgical bed is rotated to the surgeon. 2 above.5  Illustration of ideal tracheostomy entry point for cartilagi- nous collapse of the airway (indicated by arrow A) The length of tracheal resection is reduced (segment A).  Chapter 9 i. This condition cannot always be anticipated preoperatively. then ventilation through a rigid bronchoscope (as employed during rigid dilation of the stenotic region) can be used intermittently. Tracheostomy is the most conservative and safe option (exceptions noted below). and breathing spontaneously without assistance. ii. as the tracheotomy tube will not interfere with healing of the stenotic site after subsequent laser/dilation procedures. because it is unlikely to bypass (enter below) the stenotic segment. The airway should be exposed by the surgeon using an laryngoscope as described in no. vii. Another viable alternative is placement of indwelling stent at the stenotic site. compared with the amount that would need to be resected (segment B1) if the tracheostomy were placed more distally (arrow B) iii. and not through the stenotic segment. This will facilitate endoscopic treatment at a later date. The tracheotomy entry point should be through the collapsed segment. “Tracheal Stenosis: Tracheal Resection with Primary Anastomosis”) e) Intrathoracic tracheal stenosis. Reintubation at the end of the case should be avoided due to the risk of unnecessary mucosal trauma and/ or reactive airway edema. tracheostomy under local is also a reasonable choice. but once recognized should be treated in the following manner: i. Oxygenation is achieved via jet ventilation. Paralytics are not used (especially succinylcholine). Suspension laryngoscopy/subglottoscopy is ob- tained. ii. followed by tracheostomy placement) Fig. However. Jet ventilation is employed through the laryngoscope or with a ventilating tube (Hunsaker Mon–Jet catheter). however. iii. 9. and the patient is mask ventilated until reversed. Subglottic/tracheal stenosis in an unstable. iv. with placement of the tip of the scope just proximal to the stenotic region. 9. If oxygenation cannot be maintained by jet ventilation. Endoscopic laser treatment is avoided. b) The location and nature of the stenosis is critical in determining the method of securing and maintaining the airway during surgical treatment: c) “High” SGS (confined to infraglottis/cricoid) can be treated as described in no.

i. In close to 99% of surgical patients.6  Illustration of anatomic features in a patient with “difficult airway exposure” 9 Fig.9  Laryngeal cup forceps are used to grasp the ETT Fig. 9.56 Airway Management for Larygeal Surgery   or smaller should be used alternative means of securing the airway must be employed. The following conditions may predict a “difficult exposure” perorally (Fig. Specialized techniques: a) Intubation using Ossoff-Pilling laryngoscope In patients in whom difficulty with rigid transoral airway exposure is anticipated/encountered. slightly distal. Sliding Jackson laryngoscope plus curved ETT with stylet e) Laryngeal mask anesthesia (LMA) 3. A suspension device (Lewy) can also be used to achieve additional Fig. The OP laryngoscope is passed perorally and advanced to the level of the vocal folds (or ideally.0 ETT tube through the laryngoscope . the Ossoff–Pilling (OP) laryngoscope is extremely valuable. A 5. The patient is pre-oxygenated. When the patient achieves the desired level of anesthesia. and spontaneous ventilation (or assisted mask ventilation) is maintained. Paralytics are avoided. the OP laryngoscope allows successful transoral exposure of the glottis. 9. the surgical table is turned 90°. into the infraglottis). thick neck e) Limited neck extension 2.7  Intubation through an Ossoff–Pilling laryngoscope.6): a) Retrognathia b) Lingual hypertrophy/Poor palatal visualization c) Trismus/reduced interincisor opening d) Short.8  Removal of connector from ETT to facilitate passage of the Fig. Ossoff–Pilling laryngoscope d) Laryngoscopy and intubation without visualization of vocal folds i. facing the surgeon. flexible laryngoscopy with nasotracheal intubation c) Laryngoscopy and intubation using specialized “anterior” laryngoscope i. and mask induction is utilized. 9. Alternative methods of obtaining an airway in a “difficult exposure” case: a) Tracheostomy under local b) Awake. 9. 9. ii.

iv.11). and ventilation/ oxygenation established until the patient is stabilized (Fig. leaving the ETT in place: i. This curve allows the tip of the ETT to extend further anteriorly. 9. A 5. 9.” A stylet must be used. beyond the exposure provided by the laryngoscope. The balloon can be inflated. When the intraoral portion of the tube can be visualized. 9. b) Sliding Jackson laryngoscope In patients in whom it is impossible to visualize the vocal folds with the above (OP laryngoscopic) technique. a Sliding Jackson (SJ) laryngoscope can be used for peroral intubation in select cases.10  As the laryngoscope is removed. The cup forceps can be used to push this device through the scope. In cases where the glottis cannot be visualized with the OP laryngoscope. The laryngoscope can then be removed over the tube (with a pseudo-Seldinger technique).12  Intubation using a Sliding Jackson laryngoscope. iv. iii. While the SJ scope does not provide superior visualization of the glottis in difficult.  Chapter 9 anterior rotation of the laryngoscope in particularly difficult cases. iii. it can be used as a “familiar” intubation laryngoscope (analogous to the Miller blade used by anesthesiologists).10). and into the glottic inlet.12). 9. 9. The cup forceps is released. and the OP scope is pulled back until the entire ETT and trailing cuffinflation tubing are passed through its lumen (Fig. with an exaggerated curve at the distal end of the ETT. 9. it is secured by an assistant (Fig. may get caught within the narrow distal lumen of the OP scope.11  The cup forceps are released as the entire laryngoscope is removed Fig. v. Larger cuff-inflation ports (especially the liquid-filled variety used in laser-protected ETTs). The ETT is advanced into the oral cavity lateral to the laryngoscope (entering at the oral commissure) and is guided toward the midline of the airway (from right to left) (Fig. It should Fig. position confirmed. however. the SJ is used to displace the base of tongue and provide a pathway for placement of an ETT “blindly. 9. ii. The surgeon backs the OP scope out of the oral cavity while holding the ETT stationary to prevent extubation. 9. Note the acute bend at the distal end of the tube 57 . the intraoral portion of the ETT is manually secured Fig. “anterior” patients. 9. but is not often necessary.9). The plastic connector is removed from the proximal end of the ETT (Fig.8).0 MLT (or smaller) is placed directly through the laryngoscope to secure the airway.7). A medium–large laryngeal cup forceps is used to grasp the proximal ETT (Fig.

propofol is poorly suited for framework surgery performed under local anesthesia for the following reasons: ■ There is tendency for an “all-or-none” phenomenon. or completely awake/alert and uncomfortable. ■ Due to the rapid nature of “emergence” from the sedated state. ■ If tracheostomy is performed in a patient with subglottic/tracheal stenosis due to intraluminal scar formation. the patients is either deeply sedated (often snoring). In terms of local anesthesia. 9. Laryngoscope 104(Suppl. lesions located on the anterior two thirds of the larynx (membranous vocal folds) can be adequately exposed/treated with a 5. the patient often becomes disinhibited/combative when “awakened” and asked to phonate. In general. Tracheostomy entry through the area of narrowing is ideal (though not essential) if cartilaginous collapse is present. In addition. One must be careful to avoid injection into the paraglottic space and/or thyroarytenoid muscle. 1% lidocaine with epinephrine is infiltrated into the subcutaneous and deep tissues from the hyoid to the upper cricoid cartilage on the side of the proposed surgery. and results in a more relaxed. thick neck ■ Limited neck flexion ■ Alternative methods of obtaining an airway in a “difficult exposure” case include: ■ Tracheostomy under local ■ Awake. due to its ease of rapid titration. ■ The following conditions may predict a “difficult exposure” perorally: ■ Retrognathia ■ Lingual hypertrophy/poor palatal visualization ■ Trismus/reduced interincisor opening ■ Short.):1–30 . All necessary equipment should be opened and readily available in the operating room before proceeding. Midazolam (Versed) is much better suited for sedation in framework surgery patients. is a “court of last resort” for peroral intubation when all other options have failed. This is likely exacerbated by the presence of a noxious stimulus (indwelling flexible transnasal laryngoscope). it should be noted that substantial experience with intubation/difficult laryngeal exposure is required before attempting this technique. and cooperative patient.6 9 Anesthesia for Laryngeal Framework Surgery Monitored anesthesia care for patients undergoing framework surgery is often suboptimal due to a lack of communication between the surgeon and the anesthesiologist. at the end of the surgical case. However. then the airway should be entered at least 1 cm inferior to the area of the stenosis.58 Airway Management for Larygeal Surgery be emphasized that this type of “blind” intubation is not a preferred method of securing the airway. Lesions of the posterior third of the larynx (vocal processes and posterior commissure/ arytenoid region) require jet ventilation. however. faster wake-up times. The anesthetic solution should be infiltrated down to the depth of the thyroid cartilage. Propofol is felt to be superior to midazolam (Versed). ventilation distal to the stenosis carries an increased risk of air trapping and pneumothorax. Endotracheal intubation should be avoided in these cases. aware. successful medialization and layered closure of the skin can be achieved without the need for further anesthesia at the incisional site. commonly referred to as “LTA”) should be applied to the laryngotracheal region prior to instrumentation of the larynx.5 or smaller ETT.   ■ In general. and better quality of sedation. “monitored anesthesia care” for a patient undergoing a local procedure involves sedation via a propofol (Diprivan) drip. which could result in an inadvertent “injection augmentation. followed by jet ventilation is the preferred method of airway management for endoscopic treatment of subglottic/tracheal stenosis. or apneic technique. displacement of the ETT anteriorly. ■ Mask induction with inhalational agents. Key Points ■ A preoperative management plan for securing the patient’s airway must be discussed with the anesthesiologist prior to proceeding with surgery.” In most cases. fiberoptic nasotracheal intubation ■ Laryngoscopy and intubation using a specialized “anterior” laryngoscope ■ Ossoff–Pilling laryngoscope ■ Laryngoscopy and intubation without visualization of vocal folds ■ Sliding Jackson laryngoscope plus curved ETT with stylet ■ LMA ■ Topical 4% lidocaine (laryngotracheal anesthesia. as needed. Additional supplemental injections are usually required during the surgical dissection. 15–20 ml of solution is required. Selected Bibliography 1 Hunsaker DH (1994) Anesthesia for microlaryngeal surgery: the case for subglottic jet ventilation. Instead. as well as 1 cm past the midline. another application may be repeated (if greater than 45–60 min after the initial lidocaine treatment). To most anesthesiologists. Lidocaine reduces the incidence of laryngospasm. ■ Jet ventilation is safest when used proximal to the stenotic region. Also.

Ann Otol Rhinol Laryngol 108:715–724 59 . Laryngoscope 107:1476–1481 3 Hochman II. Spencer RF (1997) Lost airway during anesthesia induction: alternatives for management. Heaton JT (1999) Analysis of the forces and position required for direct laryngoscopic exposure of the anterior vocal folds. Zeitels SM. Johnson DL.  2 Chapter 9 Sofferman RA.

Part B Phonomicrosurgery for Benign Laryngeal Pathology I Fundamentals of Phonomicrosurgery .

The optimal situation for this preoperative stroboscopy review is to have the stroboscopy examination available for review in the operat- . 16. 1.3 Surgical Indications and Contraindications Phonomicrosurgery is an elective surgery. 11. and thus. 22. The surgeon should review the patient’s most recent stroboscopy (last exam should be within previous 15–20 days) prior to phonomicrosurgery. The overarching goal is to limit dissection to the most superficial plane possible and maximize epithelial and lamina propria preservation. dental injury. The latter tenet is important to facilitate primary wound healing versus secondary wound healing. Preferably. This is theorized to allow maximal functional recovery (vocal fold mucosal vibration) after surgery. “Timing. Discussion should involve the small but real risk of either no improvement of the voice quality (~1–2% incidence) or a reduction in vocal function or voice quality (~1–2% incidence). 8. The risks and benefits of the surgery should be detailed to the patient and most importantly. nonsteroidal anti-inflammatory medications or other anticoagulation medications ■ Avoiding significant vocal abuse and misuse immediately before surgery ■ Avoiding operating during the premenstrual period of a woman’s menstrual cycle. 8. When all nonsurgical treatment modalities have been exhausted and significant vocal functional limitations exist. the setting is appropriate for proceeding with phonomicrosurgery (see Chap. The latter has been shown to be temporary in nature and lasts on average 2 weeks. Preoperative consent for phonomicrosurgery should involve the risks of general anesthesia. Often this review process should be done over several weeks and involve the patient. family members. phonomicrosurgery was born and has evolved to advocate the minimal disruption to the normal microarchitecture of the vocal fold while removing dysphoniainducing pathology. 10. due to the slight edema occurring at this time as well as some increased fragility of the microvasculature of the vocal fold Preoperative voice therapy (one to two sessions) is extremely important in preparation for phonomicrosurgery for a variety of reasons: ■ Psychological preparation for surgery ■ Education regarding postoperative voice rest and voice use ■ Modification and improvement of improper speaking techniques and habits ■ Laying the foundation for postoperative voice therapy. both psychologically as well as from a behavioral perspective Preoperative voice therapy stresses to the patient the importance of changing inappropriate vocal techniques and implementing healthy voice behaviors in the postoperative period. and injury to the lingual nerve. and 23 for further information. “Anatomy and Physiology of the Larynx”). Prior to phonomicrosurgery. a realistic and thorough evaluation of the patient’s functional voice limitations and abilities (speech and singing) should be reviewed. This is to ensure that the patient has adjusted his/her voice use to be compliant with the surgeon’s voice rest and reduced voice use limitations. with a maximum duration of 1 month. this review is done the day of surgery or 1–2 days before the surgery.2 Introduction Phonomicrosurgery encompasses a variety of operations that has the primary goal of improving voice quality. 17. 4. Given the importance of the interaction between the epithelium–superficial layer of the lamina propria (cover) and the underlying deep layer of the lamina propria and muscle (body).1 Fundamental and Related Chapters Please see Chaps. temporal mandibular joint injury. A discussion regarding postoperative voice quality after phonomicrosurgery should be taken seriously and done by the surgeon. 12. These are elective operations that involve precision microsurgical removal of benign vocal fold pathology—most often from the subepithelial space of the vocal fold. The surgical procedures and principals are based on vocal fold physiology. the patient must realize he/she will be on voice rest and reduced voice use for a variable period (from 3 to 30 days). physician. 15. a speech–language pathologist and possibly a singing voice specialist. Planning. and Decision Making in Phonosurgery”). specifically Hirano’s coverbody theory of vocal fold vibration (see Chap. 10 Important preoperative measures before phonomicrosurgery include: ■ Avoiding aspirin. 18. pressure should not be placed on the patient to proceed with surgery. 10. 1.Chapter 10 Principles of Phonomicrosurgery 10.

10.5 × 2 cm) • 1:10. 10. Richard Wolf ) Specialized laryngoscopes for unique situations • Ossoff–Pilling for difficult exposure (Pilling) • Posterior-commissure laryngoscope (Pilling) 10 Suspension system • Boston University suspension (Pilling or Endocraft) (Figs.).011. Instrumentarium (Montreal.).I. Pilling (Research Triangle. This allows the surgeon to correlate stroboscopic findings with surgical findings and make important decisions on location of pathology. 10.17) Operating chair with arm supports (Fig. 10. 30.5) designed for microlaryngoscopy (Mallinckrodt) Tracheal jet ventilation tube (Hunsaker jet ventilation tube. extended-length endotracheal tube (5. length: 20 cm or more • 0. and 70° Microdebrider—skimmer blade (Medtronic ENT) Subepithelial infusion needle (25 or 27 g) • Zeitels needle (Endocraft) • Orotracheal injector (Medtronic ENT) Small-diameter.5) • Straight alligator forceps • Microlaryngeal suctions (3. 10. This is by no means a complete list of all the vendors who make these products: Endocraft (Providence.000 epinephrine • Velcro strap or cloth/silk tape • Mouth guard (maxillary. 5. Medtronic ENT (Jacksonville. Calif. R. Mo.16. Karl Storz (Culver City. Medtronic ENT.4) • Curved (left and right) • Up angled • Curved alligator forceps (left and right) (Fig. Canada). 10.22) Instrumentation (Karl-Storz. Medtronic ENT) The listed equipment/vendors are those the authors have utilized.3) • Microscissors (Fig.1) • Microcup forceps (1–2 mm in diameter) (Fig. Instrumentarium) • Specialized blunt microelevators (Fig.).)   . location of placement of incisions.9) Optical telescope • Diameter: 4–5 mm. 10.). right and left micro-ovoid cup forceps (Fig.20) • Fulcrum suspension: Lewy suspension and table-mounted Mayo stand (Pilling) (Fig.1  Standard microlaryngeal instrumentation High-quality operating microscope with 400-mm lens Large-bore laryngoscope (largest diameter possible) Examples include: • Universal modular glottalscope (Endocraft) • Sataloff laryngoscope (Medtronic ENT) • Lindholm (Karl Storz) • Operating laryngoscope for anterior commissure (model #8458.). N.C. Richard Wolf (Vernon Hills. ± mandibular) • Acrylic—custom made by dentist • Molded “athletic” tooth protector • Plastic “anesthesiologist” tooth guard. Quebec.0 or 5. 10.6) • Microlaryngeal knife (sickle or spear) Miscellaneous equipment • Cotton surgical pledgets (0.2) • Up-angled.64 Principles of Phonomicrosurgery ing room immediately before as well as during the procedure. 10. and the degree Table 10. Fla. 10. Ill. Mallinckodt (Hazelwood. 10. reinforced with layers of cloth tape (Fig.18) • Foam from operating room headrest or “doughnut” (edentulous patients only) (Fig. 10. and 7 French) • Triangular (Bouchayer) forceps (left and right) (Fig.

) and Instrumentarium (Montreal. Most of the instruments described below are available from several manufacturers of phonomicrosurgery equipment. The most useful micro cup forceps is angled-up and has a 1-mm diameter. a specialized set of instruments has been developed for microflap retraction. Fla. cup forceps. 10. given that this results in significantly improved exposure and access to the surgical site(s). and the Ossoff-Pilling laryngoscope for microlaryngeal surgery on patients with restricted upper aerodigestive tract anatomy (Table 10. In addition.2) ■ Several small special cup forceps have been developed over the last 5–10 years to facilitate several specific situations that are encountered in phonomicrosurgery. 5.4 Equipment for Phonomicrosurgery Specialized laryngoscopes are required for phonomicrosurgery. dissecting the vocal fold lesion off the overlying microflap. 10. Fig. g. These are called triangular forceps or Bouchayer forceps. Fig.3) ■ Ovoid-shaped microcup forceps are also essential for removing small pieces of pathologic mucosa and papilloma (see Chaps. Canada).). ■ Micro-ovoid cup forceps (Fig. “Vocal Fold Polyp” and 21. Multiple large and specialized laryngoscopes exist and a wide variety of laryngoscopes are necessary to manage all different types of phonomicrosurgical lesions and procedures. scissors. 10. Specialized laryngoscopes for individualized laryngoscopy needs are important.1) ■ The microelevators should be blunt and have several different angles and sized to allow the surgeon to work in various angles in different positions within the vocal fold.. 10. Quebec. including Medtronic ENT (Jacksonville. 10. and 7 French).  Chapter 10 of dissection and excision using the preoperative stroboscopy and the operative findings as guides.1  Angled elevators for phonomicrosurgery ■ Microcup forceps (Fig. 15. The core set of instruments utilized for phonomicrosurgery includes specialized blunt microelevators. e. specifically. These forceps have a sharp cutting edge but a very limited cutting surface. These elevators are often used to palpate submucosal pathology at the start of surgery. 10. This instrument comes in two sizes and is valuable for precision removal of small amounts of tissue. Key microlaryngoscopy instruments utilized for phonomicrosurgery involve: ■ Specialized blunt microelevators (Fig. curved alligators.3  Micro-ovoid cup forceps 65 . Calif.2  Microcup forceps (1 mm) cutting surface limited to distal 180° Fig. only the most distal 180º of the forceps cut. “Recurrent Respiratory Papillomatosis of the Larynx”). and small suctions (3. posterior commissure laryngoscope for difficult posterior glottic exposure.1). 10. Karl Storz (Culver City. The larger the laryngoscope. the better for phonomicrosurgery.

6) ■ These instruments are designed to retract the microflap to allow vocal fold visualization and dissection while minimizing trauma to the microflap.5) ■ Epinephrine (1:10. The disadvantages of microdebrider for laryngeal surgery include the powered instrument shaft is relatively large. ■ Curved alligators (Fig. curved and angled up Suspension of the laryngoscope is a fundamental aspect of phonomicrosurgery. given that they are the primary cutting tool for phonomicrosurgery. and sometimes visualization can be limited. 10. 10. 10. A dull knife can result in tearing of the mucosa and can significantly limit the efficacy of phonomicrosurgery ■ Microdebrider ■ The microdebrider is a powered instrument that provides simultaneous suction and cutting activity used for rapid removal of exophytic lesions in the larynx such as recurrent respiratory papillomatosis (RRP) (see Chap. Fig..4) ■ The most commonly used microscissors are right and left curved as well as “straight up.66 Principles of Phonomicrosurgery ■ Microscissors (Fig.000) and cotton pledget (0. and the risk that the powered instrument may be too strong and injure delicate subepithelial tissues of the vocal fold or other endolaryngeal structures. “skimmer blade”) ■ Aggressive ■ The conservative blade is the most commonly used for laryngeal surgery. 10   ■ Sickle knife (or spear-shaped knife) ■ These knives tend to become dull very quickly. less pain after surgery (compared with the CO2 laser).4  Microscissors. 10. They are made in a variety of sizes and designs for different situations. 5. Two basic designs for placing the laryngoscope into a fixed and stable position exist. given the risks of laser laryngeal surgery. The gallows suspension laryngoscope is favorable.5 × 2 cm) ■ Microlaryngeal suctions (3.5  Curved alligators for phonomicrosurgery Fig. These scissors should be maintained at all times to appropriate surgical precision and sharpness.” or angled scissors. and potentially even safer. There are two different types of cutting blades: ■ Conservative (i. 21. or fulcrum device. which can provide optimal exposure of the en- Fig. 10. and a rotation. and thus it is recommended that this knife be replaced with every case or at least on a very frequent basis. e. less expensive than the laser. and 7 French) ■ Triangular forceps or Bouchayer forceps (for microflap retraction) (Fig. given that there is more appropriate upward vector of the laryngoscope. 10. These are categorized as a gallows suspension device.6  Triangular (Bouchayer) forceps . “Recurrent Respiratory Papillomatosis of the Larynx”). The advantages of the microdebrider are expedient removal of a significant amount of laryngeal pathology.

Furthermore. which is important for lengthy phonomicrosurgery cases as well as for the long-term health of the phonomicrosurgeon.5. this allows for optimal surgeon ergonomics. or apneic methods. which are approximately 4–5 mm in diameter and 30 cm long. jet ventilation. Typical length of the lens used on the surgical microscope for phonomicrosurgery is 400 mm. The CO2 laser with the micromanipulator has also been used for making vocal fold incisions or removing free-edge lesions. The large majority of phonomicrosurgery is best performed using endotracheal intubation with a small (5. and Methods 10. Jet ventilation for phonomicrosurgery should be done only on an as-needed basis and is best done when the jet ventilation is delivered from a small jet ventilation catheter placed in the mid-tracheal region. This microscope should be the same microscope that is used for precision otologic procedures such as stapes surgery and other middle ear operations.v. This provides a still operating field and complete control of the airway. (see Chap. Hunsaker tube. and the risks of thermal injury and costs of the instrument outweigh any potential benefits. and all measures should be used to reduce the likelihood of the patient coughing after extubation. there are no distinct advantages of the use of this laser in this setting. Another important feature of the surgical microscope is articulated eyepieces. 9. Placement of the endotracheal tube is extremely important. “Principles of Laser Microlaryngoscopy”). and allows end-tidal CO2 monitoring. Rarely is the surgery performed utilizing these telescopes. “Anesthesia and Airway Management for Laryngeal Surgery”). specialized endotracheal tube. An exception to this may be for bronchoscopy (flexible or rigid) and diagnostic laryngoscopy prior to the placement of an endotracheal tube. Fig. Extubation should be done in a controlled fashion. The ventilation options for phonomicrosurgery are endotracheal intubation. However. the microscope should have the capability of being compatible with the CO2 laser micromanipulator attachment. Preoperatively. which can be used for cautery of vascular ectatic lesions.1 Anesthesia A working relationship based on mutual respect. Techniques.  dolarynx with minimal risk of dental injury.. This device is not the most common due to traditional and historical use of rotation-fulcrum devices (i. 67 . However. crowded surgical space. and complete muscle relaxation should be implemented after the induction of general one and continuously monitored throughout the surgery. Sometimes the endotracheal tube can be in the way for the surgical procedure and may need to be repositioned or removed in its entirety. given they are used regularly for cystoscopy. Recently. There should be significant adjustment as well as control over many different articulated angles of the microscope. e. etc. and in a very small.5 Phonomicrosurgery Procedures. Long Hopkins rod telescopes with various visualization angulations are an essential component to phonomicrosurgery. The majority of phonomicrosurgery can and should be done with “cold-steel” instrumentation. the otolaryngologist should be present during the intubation to monitor the situation and be available to assist with intubation when the situation is required.0 or 5. steroids and Robinol™ (unless contraindicated).5). for most phonomicrosurgical situations this is not a major problem. This allows adequate space between the proximal end of the laryngoscope and the microscope for hand instruments to be used for phonomicrosurgery. controlled extubation at the end of phonomicrosurgery is another important aspect of the necessary teamwork between the anesthesia team and the phonomicrosurgeon. Telescopes used for sinus surgery are too short to be effectively used for laryngeal imaging. and no stylet should be used for the placement of the endotracheal tube. However. 13. especially to the maxillary teeth. should be utilized immediately prior to phonomicrosurgical incision and are often used during phonomicrosurgery as well as at the end of the surgery to ensure that all appropriate pathology has been removed. and thus the CO2 laser is rarely indicated for this reason alone. The microscope used for phonomicrosurgery should be of the highest quality and provide the surgeon with a stable visualization method of the endolarynx. 9. The microscope that is routinely used for the placement of pressure equalizing tubes is typically not appropriate for phonomicrosurgery. Appropriate and successful phonomicrosurgery can rarely be performed using an apneic technique for anesthesia. polyp. The 30 and 70° telescopes.). but they may be complementary when dealing with vascular lesions associated with other vocal fold lesions (cyst. but these telescopes are used to provide the surgeon a “three-dimensional visualization” of the vocal folds and their related pathology. Lasers have a limited role in phonomicrosurgery surgical procedures (see Chap. Medtronic ENT) Tracheal jet ventilation is preferred compared with supraglottic jet ventilation. 9. given that the time between ventilations is too short for most phonosurgical procedures. given that a misplaced or traumatic placement of the endotracheal tube can cause injury to the vocal folds and may result in cancellation of surgery and/ or injury to the vocal folds. The most commonly used laser is the CO2 laser. The CO2 laser does offer an “instrument-free” approach to surgery of the vocal folds. Furthermore. one should administer i. communication. Chapter 10 10. and teamwork with your anesthesia colleague(s) is essential for successful phonomicrosurgery (see Chap. Phonomicrosurgery involves general anesthesia. Lewy suspension). this can be an advantage. the pulsed-dye (PDL) and pulsed-KTP lasers have been advocated for phonomicrosurgery. Similarly. benefits over cold-steel surgery have not yet been demonstrated.1. These angled telescopes are readily available in most operating rooms. The placement of the endotracheal tube should be under complete controlled conditions. given that the former provides the surgeon with less vibration and desiccation of the vocal fold tissues while phonomicrosurgery is being performed.

For patients who are edentulous on the maxillary teeth. then the laryngoscope can be passed under Fig.5. the best way to protect the mucosa and the underlying alveolar ridge from laryngoscope placement and suspension injury is to place a small. and the epiglottis is traumatized (Fig. high-density foam pad between the laryngoscope and the alveolar ridge.2 Patient Position Patients undergoing phonomicrosurgery are placed in a supine position on the operating room table.68 Principles of Phonomicrosurgery 10.11). When this occurs. 10. A shoulder roll typically places the patient in a suboptimal position for optimal laryngoscope placement (neck extension). At this juncture. 10. First. As the laryngoscope is placed into the oral cavity. A frequent impediment to this goal is the folding inward of the epiglottis (Fig. as described above. Another method of obtaining neck flexion is to use a 10 Fig. With the use of a large-diameter laryngoscope.3 Laryngoscope Placement Laryngoscope placement is crucial to the success of phonomicrosurgery and can be quite daunting to the novice phonomicrosurgeon. 10. the lips and tongue should be retracted with the nondominant hand. the potential space to place the distal aspect of the laryngoscope into the endolarynx is significantly reduced. and thus should not be used. Dental and alveolar ridge protection prior to insertion of the laryngoscope is important. The optimal head and neck position for exposure of the endolarynx with the laryngoscope is neck flexion on the body and the head extension on the neck.9). The overall goal is to place the largest diameter laryngoscope into the endolarynx.7  Optimal patient position for suspension laryngoscopy (note neck flexion and head extension) Fig. Insuring a proper head and neck position during laryngoscopy placement is a key step. there are a variety of techniques to place the laryngoscope under the epiglottis without folding or traumatizing the epiglottis.7).8  Alternative method of positioning patient without the use of an articulated head of bed (note neck flexion due to pillow underneath the head)   pillow under the head to flex the neck on the body (Fig. 10. The laryngoscope is then slid along the ventral surface of the tongue and advanced down toward the base of the tongue and posterior pharyngeal wall. An adequate amount of time and patience should be allocated for this important step.8).5. the positioning of the laryngoscope can be quite difficult. Instead of aborting the use of the large-diameter laryngoscope.10). 10. 10. and the head extension on the neck is done by the surgeon during laryngoscopy and secured with the suspension device (Fig. 10.9  High-density foam for protecting the alveolar ridge in an edentulous patient during suspension laryngoscopy . if there is adequate space. 10. 10. The neck flexion can be achieved by using an articulated head of the operating table. patience and persistence should be judiciously applied. This foam padding is present in most operating rooms in the form of a headrest or pillow material (Fig.

This direct approach may result in the folding of the epiglottis when attempted with a large-diameter laryngoscope (Fig.13  Anterior deflection of endotracheal tube with the nondom- folded epiglottis while the endotracheal tube is positioned anteriorly with a finger from the nondominant hand (note initially the laryngoscope will be posterior to the endotracheal tube) placement of a large-diameter laryngoscope inant hand to allow placement of laryngoscope into endolarynx 69 . 10. it best to use one of the other laryngoscope placement techniques instead of resorting to the use of a smaller laryngoscope. 10.11).10  Laryngoscope advancement causing “folding” of epiglottis Fig. 10. Once the laryngoscope is at the approximate level of the endolarynx. The second option for laryngoscope placement is to place the laryngoscope between the posterior pharyngeal wall and the endotracheal tube and continue to advance the laryngoscope along the posterior pharyngeal wall (underneath the endotracheal tube). The third method to place a large-diameter laryngoscope into the endolarynx without damage or malposition of the epiglottis is to place the nondominant-hand index finger into the oral cavity and oropharynx toward the endotracheal tube and pick the endotracheal tube up off the posterior pharyngeal wall. 10.12  Placement of laryngoscope into endolarynx below non- Fig. the laryngoscope can then be advanced along the posterior pharyngeal wall and drawn up into the endolarynx (Fig.11  “Folded” epiglottis above laryngoscope limits space for the direct vision underneath the epiglottis and advanced into the endolarynx.12). 10.  Chapter 10 Fig. With the endotracheal tube secured underneath the index fingertip. 10. thus allowing the endotracheal tube to slip around the side of the laryngoscope and be positioned in the posterior glottis. the endotracheal Fig. it can be drawn anteriorly into the en- dolaryngeal space. Using this technique. At this stage.

down toward the proximal tip of the laryngoscope and used to grab the tip of the epiglottis firmly. A tooth protector can be fashioned by using a standard thin plastic tooth guard commonly found in anesthesiology carts. the suture is removed from the epiglottis. 10. With the epiglottis being held anteriorly. 10. in general.70 10 Principles of Phonomicrosurgery   Fig. 10. if used. The laryngoscope is completely removed from the body and then replaced above the epiglottis. and reinforcing it with multiple layers of cloth tape (Fig. without too much difficulty. 10. the suture can be removed at the end of the case. a 4. the cup forceps can be used to pull or direct the epiglottis in an anterior direction (Fig.0 silk suture is placed through the tip of the epiglottis. the endotracheal tube can be drawn gently and carefully down into the more appropriate posterior glottic position.. the forceps are opened and the epiglottis is released. Care should be taken to avoid contacting the superior surface of the vocal fold given that this will significantly alter the anatomic orientation and nature of the vocal fold and often distort the vocal fold pathology. Tension can be applied to the epiglottis suture to control and stabilize the epiglottis as the laryngoscope is passed underneath it into position. resting directly on the endotracheal tube position of the epiglottis.15). Fig.) The optimal position of the laryngoscope within the endolarynx is determined by the vocal fold pathology and pending surgical procedure. 10. a large up-cup forceps is passed outside the laryngoscope. specifically resulting in retraction of the false vocal fold tissues. Once good position of the laryngoscope is achieved. the laryngoscope should be positioned immediately above (superior to) the vocal fold pathology. 10. Working through the microscope. Once the laryngoscope is successfully placed in the endolarynx. with the suture through the epiglottis being kept outside the laryngoscope.14). This is especially important given that as the fulcrum holder is adjusted. The fifth option for laryngoscope placement involves placement of temporary suture through the epiglottis. (Alternatively. using upward pressure of the suspended laryngoscope or the nondominant hand’s index finger (Fig.14  Laryngoscope positioned above the epiglottis. This special angulation of the laryngoscope will provide optimal laryngoscopic visualization and minimal adjacent tissue injury or damage. When the laryngoscope is successfully placed in the endolarynx but the endotracheal tube is anterior to the laryngoscope. 10. the laryngoscope is then advanced into the endolarynx on top of the endotracheal tube. floppy) starts with positioning the laryngoscope immediately above the tip of the epiglottis (Fig. it is of the utmost importance to remember to provide special care and attention to the maxillary teeth as the laryngoscope holder is put into place. . large. A large-diameter laryngoscope is positioned by hand or suspension above the epiglottis.16). With firm control of the epiglottis.18).13). which is Fig. 10.15  Cup forceps placed outside the laryngoscope to control the tube may be initially positioned anterior to the laryngoscope.17). However. and the two ends of the suture are brought out through the laryngoscope. The fourth technique for the placement of a large-diameter laryngoscope in a patient with difficult epiglottis anatomy (i. each amount of upward rotation at the distal tip of the laryngoscope results in an equal amount of downward pressure at the proximal aspect of the laryngoscope on the maxillary alveolar ridge. With this visualization. For a rotation or fulcrum laryngoscope device holder (such as a table-mounted Mayo stand. allowing placement of the laryngoscope into the endolarynx without “folding” of the epiglottis 10.5.4 Suspension Device The gallows suspension device (Fig. should be positioned to provide upward and slightly forward (caudal) suspension of the laryngoscope in the endolarynx. e.

10.5.6 Telescopic Evaluation of Vocal Fold Pathology Using the 0. 10. which is often essential to optimal exposure of the endolarynx. puts the patient at risk if the patient were to move unexpectedly as the anesthesia wears off. 10.20).5. It is extremely important that the surgeon remember this type of external counter pressure.19  Velcro strap applied to anterior neck region (near the cri- coid) to optimize vocal fold visualization during suspension laryngoscopy 10. 30.18  Tooth protector fashioned from a plastic tooth guard and layers of cloth tape Fig.16  Gallows-type suspension device Chapter 10 Fig. 10.  Fig. The surgeon should look down the laryngoscope while applying external counter-pressure to judge the location and amount of external counter-pressure required. 70° (and as needed.17  Fulcrum type suspension device (Lewy apparatus suspend- ed from a table-mounted Mayo) Fig.19). 10. 120°) telescope for visualization in a “three-dimensional” fashion of the endolarynx is of 71 . 10. A small amount of gauze or a foam pad can be positioned between the tape or strap and the neck skin to prevent any injury to the overlying skin of the larynx (Fig.5 External Counter-Pressure A Velcro strap or silk tape can be applied to the external neck (in the area of the cricoid or trachea) in a downward and slightly cephalad vector to improve the endolaryngeal exposure on an as needed basis (Fig. 10. If this occurs. the first duty of the surgeon is to release the external counter pressure and secondly take the patient out of suspension laryngoscopy.

but patience and practice will allow success. The Mayo stand is placed between the surgeon and the head of bed (Fig. This brings the laryngoscope lower—into the surgeon’s lap—and the eye pieces of the surgical microscope should be utilized to allow the surgeon to sit with his/her back completely straight and upright (Fig. these telescopes provide great visualization of the ventricles. photodocumentation. This is done after the laryngoscope is suspended. This is a very important component to phonomicrosurgery. and surgical planning (Fig. 10. 10. 10. The majority of phonomicrosurgical procedures should be done using the microscope’s highest magnification setting. and thus some type of surgical support should be identified (an ophthalmologist’s or plastic surgeon’s operating room chair with arm supports.22).72 Principles of Phonomicrosurgery Fig. Patient positioning should allow the surgeon’s upper arms to be held in a vertical position.7 Operating Microscope and Surgeon Ergonomics After suspension of the laryngoscope and telescopic examination.22  Proper support of surgeon’s arms for phonomicrosurgery attention should be drawn to the position of the laryngoscope in relation to the microscope and the surgeon. to facilitate optimal phonomicrosurgery ergonomics. or a Mayo stand) that will allow the most steady and stable hand and wrist motions. This allows for unique visualization of the vocal fold pathology. subglottis. and back position during the surgical procedure is important for his/her longstanding neck and back health. . and angle of Velcro strap positioning the larynx into an optimal viewing path of the laryngoscope Fig. specifically with the 30 and 70° angled telescopes. head. Optimal hand control of instrumentation during phonomicrosurgery occurs when the forearms can be supported with a stable device. The novice phonomicrosurgeon will initially struggle with this task. 10. such as an operating room chair with arm supports. Binocular vision at high-power magnification must be achieved during all aspects of the procedure. Specifically. Often.20  Patient positioned for phonomicrosurgery. The wrists are the best location for precise control.21). decisions are often made about the optimal location for an incision when evaluating the vocal fold pathology. anterior and posterior commissure. Note neck flex- 10 ion.22). An alternative to these custom surgical chairs is to use a Mayo stand with pillows/foam padding. and   Fig. 10. the operating room table should be placed in a reverse Trendelenburg position. head extension. but supporting the arms at the level of the forearms (Fig. 10. the surgical microscope is brought in to position. and it should not be overlooked. 10.21  Visualization of vocal fold pathology during suspension laryngoscopy with angled telescopes great value. 10. This will require minor but important adjustments of the position of the microscope and laryngoscope to ensure that the viewing access of the microscope is perfectly coaxial with the longitudinal aspect of the laryngoscope. thus allowing binocular vision.23). Paying attention to the surgeon’s neck.5. with elbows and hands as low as possible to the surgeon’s lap. In addition.

“Vocal Cord Cyst and Fibrous Mass”) Hemostasis is extremely important. 10. e. which is described below.5. small cotton pledgets should be utilized to quickly and successfully provide surgical hemostasis without 73 . or immediately lateral to the vocal fold pathology. the vocal fold pathology may be able to be palpated and directly visualized through the Fig. Often. fine blunt elevator (curved or angled) is performed to complete the elevation and creation of the microflap (Fig.25). Over the years. and mini-microflap. This prevents the sickle knife accidentally causing any type of injury to the submucosal pathology or deep vocal fold tissues. There may be instances where small. the surgeon is initially working on the upper lip of the free edge of the vocal fold medially. and it should be performed with great patience and caution. an incision is then made with a sharp sickle knife. the surgeon is working in the exact opposite direction on the inferior lip of the vocal fold laterally. 10. This plane is the single most difficult step of phonomicrosurgery. different curved elevators are often required to work in different directions.24). and then the tip of the sickle knife can be drawn slightly superiorly. us- ing a padded Mayo stand 10. Then as the microflap is carefully elevated and dissected from the submucosal pathology. 17. philosophical microflap approach to submucosal pathology. and if bleeding is causing an obstruction of visualization. After the vocal fold pathology is palpated and an incision is planned.  Chapter 10 Fig. tenting up the epithelium as the incision is made in an anterior or posterior direction (Fig.24  Microflap incision placed lateral to the lesion with epithe- lium tented up by the sickle knife incision and a small curved elevator can be used to begin the elevation of the microflap in the plane between the vocal fold pathology and the overlying epithelium (i. Once a plane is developed anterior and posterior to the lesion. The incision for the microflap should be directly overlying.8 Microflap Approach to Submucosal Pathology The microflap approach to submucosal pathology is a key aspect to most phonomicrosurgery operations. The core principles of the microflap approach to submucosal pathology include: ■ Making an incision through the epithelium at the closest possible location to the submucosal pathology ■ Disrupting the minimum of surrounding tissue to the vocal fold pathology ■ Staying in as a superficial plane as possible ■ Preservation of overlying normal mucosa (epithelium plus superficial lamina propria) There are multiple descriptions of various forms of microflaps. 10. and thus. 10. This results in minimal disruption of normal adjacent vocal fold mucosa. various angulated or curved elevators will be required to perform this aspect of the procedure. then the surgery should be temporarily stopped and the application of epinephrine (1:10. medial to the lesion). especially to ensure minimizing the risk of microflap penetration or injury.23  Alternative method for support of the surgeon’s arms. microcurved scissors need to be used to release fibrous bands off the overlying microflap in adherent areas of the submucosal pathology or in a similar manner when the submucosal pathology is adherent to the deeper aspects of the vocal fold in the area of the vocal ligament (see Chap. After the incision has been made.000)-soaked. It is often easiest to initiate and develop this plane anteriorly and posteriorly to the vocal fold lesion. then careful submucosal dissection with a small. given that at the very start of the development of the microflap. many of these microflap approaches have merged into a single. medial microflap. specifically lateral microflap. It is important to note that the tip of the sickle knife should be used to penetrate the epithelium.

Note 10 Fig.26  Elevated microflap reveals that the pathology (fibrous Fig. always erring on the side of the pathology (in a superficial fashion). In this situation. creating a plane between the vocal fold pathology and the vocal ligament is quite difficult. “Pathological Conditions of the Vocal Fold”). It is often helpful to place an epinephrine (1:10. These bands can be released with blunt dissection or microcurved scissors. the deeper aspect of the dissection. however. 10. 4.25  Elevation of microflap off vocal fold lesion beneath mass) is on the vocal ligament and not in the subepithelial space copatation of the mucosa at the incision site and smooth free edge of the vocal fold . the surgeon will notice that the microflap elevation is quite easy. great care should be taken to use either a blunt dissection technique or microscissors to release the adherent bands between the vocal fold ligament and the pathology. This is true for ligamentous vocal fold cyst and fibrous mass (see Chap. palpation of the vocal fold should be performed to determine if there is any residual submucosal pathology that can be palpated and removed. After the superficial and deep planes around the submucosal pathology have been elevated. The microflap is then redraped with either the triangular forceps or a curved elevator (Fig. 10.26).27  Redraped microflap after removal of vocal fold lesion. there may be some additional connections to the vocal fold pathology within the vocal fold anteriorly and posteriorly. usually without covering the thumb port.27). there will be situations where the pathology is not adherent to the overlying microflap and instead located deeper within the vocal fold (in the area of the vocal fold ligament) (Fig. The majority of benign vocal fold submucosal pathology is located in the immediate subepithelial plane and is often. Suctioning blood and secretions from this area should be done with a 3-French suction. When these pathologies are encountered. to a varying degree. 10. however. After the microflap has been redraped. adherent to the overlying epithelium. 10. Fig.74 Principles of Phonomicrosurgery   much difficulty. This allows the submucosal pathology to be removed and sent for pathologic examination.000)-soaked Cottonoid over the operative site for 1–2 min to reduce edema before making further surgical decisions. 10. Great care should be taken not to tear or fenestrate the microflap as it is tediously and carefully elevated off the submu- cosal pathology. This is the case in approximately 80–90% of cases.

Lippincott Williams & Wilkins. Extreme care is required at this juncture of the surgery because overly-aggressive removal of this material can result in significant scar formation as well as a permanent deformity of the free edge of the vocal fold. Laryngoscope 109:1891–1900 Hirano M (1977) Structure and vibratory behavior of the vocal fold. compliance of the patient. the vocal fold will heal adequately on its own with appropriate time and care. stroboscopy should be performed to evaluate the recovery and healing process of the vocal fold. Laryngoscope 107:340–344 Courey MS.” which is usually defined as speaking using a breathy. ■ Phonomicrosurgery utilizes small. this typically occurs when the microflap is overly traumatized or injured during the surgical procedure.” Key Points ■ Phonomicrosurgery is elective. This period can range from as short as 2 days and extend to possibly 14 days. surgical skill. Additional complications related to phonomicrosurgery are discussed in Chaps. Light voice use is often used for an additional 7–10 days after the period of strict voice rest. 10. ■ Conservative removal of submucosal pathology with preservation of overlying normal epithelium and superficial lamina propria allows healing by primary intention and optimal voice quality after phonomicrosurgery. Often. When this occurs. and experience. then the patient can be transitioned to “light voice use. the free edge of each vocal fold should be completely straight without exophytic mucosal tags and without a soft tissue defect at the free edge of the surgical site. appropriate instrumentation. Some surgeons may use immediate intravenous. There is rarely an indication for antibiotics associated with phonomicrosurgery or long-term steroid use. precise surgery aimed to improve vocal function based on principles of vocal fold physiology. and experience. Dias O (1995) Rigid and contact endoscopy in microlaryngeal surgery: technique and atlas of clinical cases. Cornut G (1992) Microsurgical treatment of benign vocal fold lesions: indications. intramuscular. In addition to voice rest. Folia Phoniatr 44:155–184 Courey MS. depending on the specific nature of the surgery.6 Postoperative Care and Complications Almost all phonomicrosurgical procedures are followed by some period of voice rest. epithelial ingrowth underneath the microflap occurs. “airy” type of voice (not a whisper) for 5–10 min per hour. and surgical excision of the microflap is mandated. Scheffel L. In: Sawashima M. pp 13–30 Rosen CA. Garrett CG. “Management and Prevention of Complications Related to Phonomicrosurgery. Gardner GM. Cooper F (eds) Dynamic aspects of speech production. and thus the patient should be informed that these postoperative changes resolve on their own within the first month after surgery. technique. the surgeon’s philosophy. ■ Microflap approach to submucosal pathology of the vocal fold is an essential component of most phonomicrosurgical procedures and is a challenging surgical task that requires patience. and maintain GERD behavior modification. Complications from phonomicrosurgery include failure of the microflap to appropriately redrape and adhere to the vocal fold. J Voice 10:389–404 Bouchayer M. This is a rare complication. when this occurs. then this tissue should be removed in a conservative and reasonable fashion. Andrade Filho PA. Laryngoscope 115:1681–1684 75 . the patient should be encouraged to stay well hydrated. If there is any residual pathologic tissue such as fibrous material or scar. Philadelphia Bastian RW (1996) Vocal fold microsurgery in singers. or intralesional steroids perioperatively to minimize postoperative edema. Buckmire RA (2005) Oropharyngeal complications of suspension laryngoscopy: a prospective study. “Perioperative Care for Phonomicrosurgery” and 12. This material can be removed with a microelevator or microcup forceps. 11. If there is adequate epithelial coverage.  Chapter 10 The free edge of the vocal fold should be straight after the pathology is removed. continue treatment for laryngopharyngeal reflux disease with a proton pump inhibitor. These symptoms are usually transitory. At the end of the prescribed strict voice rest period. results. delicate surgical instrumentation and is performed with maximum control via high-powered microlaryngoscopy for optimal results. further investigation into either the under surface of the microflap or the deeper aspect of the vocal fold should be performed. Excessive edema and even necrosis can occur to a microflap. Dental injuries after phonomicrosurgery should be repaired to the patient’s satisfaction in a prompt fashion to minimize negative feelings of the patient toward the surgeon. Lingual nerve injuries such as numbness of the tongue and/or a change in taste sensation occur in approximately 10–20% of patients after phonomicrosurgery. University of Tokyo. Stone RE. Selected Bibliography 1 2 3 4 5 6 7 8 Andrea M. Ossoff RH (1997) Medial microflap for excision of benign vocal fold lesions. At the completion of the vocal fold lesion(s) excision. if not. It is advisable to involve a speech–language pathologist to assist the patient in transitioning from strict voice rest to light voice use to ensure that the patient is using the optimal postoperative voice technique to facilitate healing and prevent injury in this important time. Ossoff RH (1995) Endoscopic vocal fold microflap: a three year experience. Ann Otol Rhinol Laryngol 104:267–273 Ford CN (1999) Advances and refinements in phonosurgery.

Barody MM. Rosen CA (2003) Surgical treatment of benign vocal fold lesions. Ann Otol Rhinol Laryngol 98:821–823 11 Thekdi AA. Healy GB (1990) New microlaryngeal instruments for phonatory surgery and pediatric applications. Spiegel JR. Doyle PB (2002) Phonomicrosurgery in singers and performing artists: treatment outcomes. Rosen DC (1995) Laryngeal mini-microflap: a new technique and reassessment of the microflap saga. Mauri M. Emerich KA. Hawkshaw MJ.76 Principles of Phonomicrosurgery 9 Sataloff RT. Heuer RJ. Hillman RE. management theories. Vaughan CW (1994) External counter-pressure and internal distension for optimal exposure of the anterior glottal commissure. Desloge R. Ann Otol Rhinol Laryngol 190(Suppl.):21–40 . Curr Opin Otolaryngol Head Neck Surg 10:492–496 10   12 Zeitels SM. J Voice 9:198–204 10 Shapshay SM. and future directions. Ann Otol Rhinol Laryngol 103:669–675 13 Zeitels SM.

The reason for avoiding the premenstrual time period when engaging in phonomicrosurgery is to avoid vocal fold edema and vascular fragility thought to be associated with premenstruation affect the surgical decision making and the surgical outcome. and Decision Making in Phonosurgery”). the patient and the physician must be comfortable with the decision to proceed with surgery. First and foremost.Chapter 11 11 Perioperative Care for Phonomicrosurgery 11. GERD behavior modification and proton pump inhibitor therapy is typically started prior to phonomicrosurgery and extended for 1–2 months after surgery. Voice therapy prior to phonomicrosurgery is important for a variety of factors. and education regarding use of the silent cough ■ Laying a foundation for healthy voice use technique after surgery ■ Discussing alternative communication options during the complete-voice rest phase Fig. and should have established reasonable expectations for the timing of recovery and voice outcomes (see Chap. There are a variety of important aspects with regard to the timing and scheduling of phonomicrosurgery. Even if the patient does not have any active symptoms of LPR. 8. 11.2 Timing of Phonomicrosurgery Phonomicrosurgery involves the surgical manipulation of the delicate epithelial and sub-epithelial tissues of the vocal fold (Fig. and individuals involved in sales and business (see Chap. It is important for the patient to stop all anticoagulation medication such as nonsteroidal anti-inflammatories. herbal supplements etc. These medications should be stopped 7–10 days prior to surgery.1 Fundamental and Related Chapters Please see Chaps. It is also wise to avoid scheduling phonomicrosurgery during a woman’s premenstrual period (approximately 5 days before the onset of menses). Lastly. “Timing. the patient and surgeon should have a clear understanding of the voice demands for the next 2–3 months after phonomicrosurgery. This is extremely important for singers. 11. aspirin. Planning.and postoperative voice use plans ■ Voice rest. 8). and 12 for further information.). 10. . and other medications that may affect coagulation (over-the-counter medications. It is also advisable prior to phonomicrosurgery to begin the patient on medical therapy for LPR treatment prophylactically.1  Microscopic dissection of the epithelial flap using a 30° flap elevator If the patient has not had any voice therapy prior to surgery.3 Surgical Indications and Contraindications It is important for the patient prior to phonomicrosurgery to minimize his/her voice demands for approximately 7 days before the scheduled surgery (see Chap. Coumadin. given the risk of reflux and its possible negative effects on wound healing of the vocal folds. “Timing. 11. 8. This is especially important for singers and for patients with very small vocal fold lesions. having had a detailed discussion regarding the nature of the surgical procedure. and Plavix. including: ■ Pre.1). and Decision Making in Phonosurgery”). Thus a variety of steps should be implemented to minimize edema and bleeding at the surgery sites(s) to maximize the surgeon’s precision and the voice outcome post-operatively. 8. perioperative treatment plan. schoolteachers. 11. Planning. then one to two sessions of voice therapy is optimal.

11. 11.78 Perioperative Care for Phonomicrosurgery 11. this treatment is done on a monthly basis for 3 months.6 Postoperative Voice Care At the completion of strict voice rest. The duration of this voice rest is controversial and should be based on the nature of the pathology treated during surgery. There is no indication for antibiotics or prolonged steroid use with most phonomicrosurgery cases. airflow. breathy voice (this is not whispering) for approximately 5–10 min per hour. and minimizes the risk of whispering or falsetto voice use.5 11 Postoperative Voice Rest After phonomicrosurgery. They include the following: ■ ■ ■ ■ ■ ■ E-mail Pen-and-paper notes A wipe-off board Bell Whistle Text messaging Silent cough is a helpful way to deal with the mucous sensation that sometimes occurs after phonomicrosurgery. When significant vocal fold stiffness after phonomicrosurgery is identified. During this session. Voice therapy after phonomicrosurgery is extremely important aspect of vocal recovery for almost all patients undergoing phonomicrosurgery. and the degree of dissection performed at the time of the surgical procedure.4 Considerations for the Day of Phonomicrosurgery Psychological reassurance of the patient on the day of surgery is extremely important. Stroboscopy is an important monitoring tool after phonomicrosurgery and should be used to guide and assist in the graduation of the patient from total voice rest to light voice use to full voice use. it is optimal for the patient to work with a speech–language pathologist for a short period as they reinitiate voice production. This involves seeing the patient outside the operating room before surgery. and reviewing the surgical plans as well as the postoperative voice rest and recovery issues. discussing any last-minute questions. the speech– language pathologist can be helpful working with the patient on these issues. The steroid injection can often be done in the office under local anesthesia (see Chap. Most frequently. Singing voice therapy is also an important adjunctive treatment to the vocal rehabilitation of singers and nonsingers alike. Light voice use often allows the patient to use a soft. Often. the speech–language pathologist emphasizes proper breath support. . light voice is   usually used for approximately 7–10 days. Silent cough involves the patient taking a large inhalation and performing a rapid. “Peroral Vocal Fold Augmentation in the Clinic Setting”). but typically. using Decadron 10 mg/ml. can be initiated approximately 3–4 weeks after surgery. resulting in better pliability. Total voice rest includes no: ■ ■ ■ ■ ■ ■ Speaking Singing Whispering Humming Clicking Throat clearing Alternative methods of communication should have been reviewed preoperatively and should be reviewed immediately postoperatively. The typical duration for voice rest after phonomicrosurgery procedures ranges from 2 to 10 days. vocal fold closure and voice quality. Intravenous steroids should be used (10–20 mg Decadron) prior to the induction of general anesthesia for phonomicrosurgery. there are also psychological aspects associated with the patient transitioning from total voice rest to voice use and thus. Appropriate timing for initiation of singing voice therapy after phonomicrosurgery is highly variable. This in combination with frequent sips of water should address any issues patients have associated with mucous sensation and mucous build up in the throat while avoiding the use of phonotraumatic throat clearing activity. The optimal time for initiation of voice therapy after phonomicrosurgery is approximately 7–14 days after surgery. without any sound production during the exhalation. resonant voice production. the patient should tuck his/her chin and perform a hard swallow. Kenalog should be avoided due to the risk of particle deposits within the vocal fold. a period of total voice rest is indicated in most situations. compliance of the patient. conversational. starting approximately 2–4 weeks after phonomicrosurgery. After the period of complete voice rest. Patients should be reminded that this voice use limitation is not cumulative and should not be violated for any reason. minimizing trauma to the recently operated vocal folds. often superficial steroid injections to the vocal folds are helpful to reduce permanent scar tissue formation and enhance wound healing of the vocal folds. 33.7 Intralaryngeal Steroid Injection to Soften Postoperative Scar in the Vocal Fold A variety of factors known and unknown can contribute to significant postoperative stiffness and scarring of the vocal fold after phonomicrosurgery. Immediately after the exhalation. It should be emphasized to the patient and family members that total voice rest involves no sound production whatsoever. forced exhalation. 11.

Sulica L (2003) Voice rest after microlaryngoscopy: current opinion and practice. Ito J (2004) Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Laryngoscope 116:1735–1739 79 . Park HJ (2000) Influence of phonation on basement membrane zone recovery after phonomicrosurgery: a canine model. ■ A short period of strict postoperative voice rest is typically indicated and helpful. Hirano S. Laryngoscope 113:2182–2186 Cho SH. Kaneko K. Woo P (2006) Office steroid injections of the larynx. 1 2 3 4 Behrman A. Kim HT. ■ It is important that the patient understand the importance of clearing their future voice demands for the 2–3 months after phonomicrosurgery to maximize the chances of successful recovery after surgery. Ann Otol Rhinol Laryngol 109:658–666 Tateya I. Euro Arch Otorhinolaryngol 261:489–4923 Mortensen M.  Chapter 11 Key Points Selected Bibliography ■ The importance of involving the patient in the decision making for phonomicrosurgery cannot be overemphasized. and then graduated voice use can be implemented under the care of the speech–language pathologist to maximize vocal recovery. Kim MS. ■ Use of the speech–language pathologist for the preoperative and postoperative care of patients undergoing phonomicrosurgery is an important aspect of successful phonomicrosurgery and the patient’s optimal vocal recovery. Lee IJ. Omori K.

It is extremely rare for suspension microlaryngoscopy to induce temporomandibular joint disease. Multiple studies have shown that patient satisfaction after medical care is related in large part to the patient’s perception of the health care provider’s interest in their care. these complications are related to the size of the laryngoscope and the duration of suspension of the laryngoscope. People have hypothesized that intermittently taking the laryngoscope off suspension to allow blood flow to the lingual area and remove pressure off the adjacent nerves may prevent or minimize these types of complications. the natural clinical course. Thus.1 Fundamental and Related Chapters Please see Chaps. the lines of communication between the patient and the voice care team are extremely important. 12. dependent edema of the vocal fold. The sections below discuss the nature of the complications. Several overriding principles associated with the management and care of patients experiencing complications should be kept in mind as individual complications are discussed. and prevention of these complications. poor postoperative compliance with voice rest) and others unknown (i. e. some laryngologists believe that these are not complications. the most essential aspect of managing complications associated with phonomicrosurgery is to establish and maintain excellent lines of communication between the patient and the voice care team members. 8. failure of the . Most likely. but expected aspects of phonomicrosurgery. prior to phonomicrosurgery. it is common that suspension microlaryngoscopy will aggravate preexisting temporomandibular joint pathology. and that they may require medical or oromaxillofacial intervention postoperative to assist their recovery from this condition. which in turn is directly related to the provider’s ability to communicate with the patient. granulation tissue at the operative site. the phonomicrosurgery procedure will exacerbate his/ her disorder. Thus. some of which are known (i. e. These include vocal fold scar. Most importantly. 10. and throat pain will be temporary in nature. In fact.2 Overview of Management and Prevention of Complications Related to Phonomicrosurgery There are a host of complications related to phonomicrosurgery that range from mild to serious and involve multiple factors. it is wise to advise that most likely. this has not been proven scientifically. Dental injuries should be cared for by a dentist in a prompt fashion to shorten and minimize the patient’s aggravation and frustration. remedies for the complications. dysgeusia. unknown wound-healing phenotype). comparable to abdominal pain after an appendectomy. For this reason. These include: ■ ■ ■ ■ ■ Dental injuries Temporomandibular joint disorder aggravation Lingual anesthesia Dysgeusia Throat pain 12 All of these complications are associated with the positioning and placement of the laryngoscope. Optimal management strategy for these complications includes pre.4 Postoperative Dysphonia There are varieties of aspects related to postoperative healing that can result in postoperative dysphonia after phonomicrosurgery. however. However.Chapter 12 Management and Prevention of Complications Related to Phonomicrosurgery 12. 12. A great majority of the time. 12. Given that much of the success of phonomicrosurgery is based on precision of surgery—which is directly related to the adequacy of the exposure of the vocal folds with a large bore laryngoscope—many of these complications are difficult to avoid completely.. Dental injuries can also be minimized by taking great care of the dentition during placement of the laryngoscope and use of tooth guards over the mandibular and maxillary teeth.3 Surgical Indications and Contraindications A variety of minor to major complications associated with phonomicrosurgery can occur in the oropharyngeal region. and 11 for further information. the patient needs to be reassured that the symptoms that he/she experiences after phonomicrosurgery resolve with time. if the patient has temporomandibular joint disease. lingual anesthesia.and perioperative communication with the patient regarding the possibility of these problems occurring and their subsequent management..

and feeling for persistent vocal fold pathology within the microflap or deep to the microflap. It is also important to maximize the lines of communication between the patient and the voice care team members by including family members. Prevention of the latter can be done by carefully examining the vocal fold at the time of microflap excision to ensure that all aspects of the vocal fold pathology have been completely removed. and failure of the microflap to adhere are typically related to uncontrolled LPR. Difficulties with the microflap adhering are rare. ensuring that the patient is compliant with regard to voice rest and light voice use after surgery. singing teachers and speech–language pathologists involved in the decision making process to proceed with phonomicrosurgery and to avoid pressuring the patient into consenting to phonomicrosurgery (see Chap. and finally. especially accounting for unsuspected vocal fold pathology found during phonomicrosurgery. They include airway compromise.5 Medical Complications Associated with Phonomicrosurgery Fortunately. Physical complications after phonomicrosurgery of dependent edema of the vocal fold. leaving the microflap nonadherent to the underlying vocal fold. poor compliance with postoperative voice rest. Infection rarely occurs after phonomicrosurgery. This is most commonly treated with systemic steroids and careful observation. and a foreign-body implantation associated with the surgical procedure. ■ Many significant complications associated with phonomicrosurgery can be prevented by strictly adhering to principles of conservative tissue handling and excision. it usually indicates incomplete removal of the recurrent respiratory papillomatosis disease. “Principles of Phonomicrosurgery”). patients complain of a persistent postoperative dysphonia or even an exacerbation of their dysphonia after phonomicrosurgery. This can be associated with uncontrolled LPR. when there is significant bleeding after phonomicrosurgery for recurrent respiratory papillomatosis. considering the use of postoperative. When this occurs. intra-vocal fold steroid injections to minimize permanent vocal fold scar after phonomicrosurgery (see Chap. Great care of the soft tissues of the microflap is essential for preventing these complications. especially in the case of poor vocal fold abduction (unilateral with a contralateral vocal fold paralysis or bilateral) can result in airway compromise. “Perioperative Care for Phonomicrosurgery”). Reducing the risk of granulation tissue at the operative site can be accomplished by reducing postoperative vocal abuse. In fact.. plan. The surgeon should be completely forthright and honest when discussing with the patient potential and real complications of phonomicrosurgery and their subsequent management. granulation tissue at the operative site. for this reason antibiotics are rarely indicated for this surgery. it is important for the surgeon to perform careful visual inspection of the operative site for persistent pathology. 10. and the ultimate outcome of their phonomicrosurgical procedure. The last aspect of poor voice results associated with phonomicrosurgery involves the formation of recurrent vocal fold   pathology after phonomicrosurgery. Prevention of vocal fold scar formation after phonomicrosurgery can be optimized by adhering to conservative tissue handling techniques during phonomicrosurgery. even though this may not in fact be the case. . bleeding from the operative site. This can be enhanced by using a special consent form for phonomicrosurgery. Key Points ■ The lines of communication and relationship between the surgeon and the patient are absolutely essential for the management and prevention of complications related to phonomicrosurgery. and in fact. and infection. treating LPR perioperatively and ensuring that there is no char from the laser or extraneous foreign bodies (e. which results in nonadherent epithelial coverage at the operative site. Overly aggressive vocal fold injection. Another related complication contributing to postoperative dysphonia is a patient with unreasonable expectations of voice quality and function after phonomicrosurgery. especially regarding the typical postoperative clinical course in rehabilitation. ■ It is imperative for the surgeon to establish reasonable expectations regarding voice quality and timeline of recovery with the patient to optimize vocal recovery and achieve patient satisfaction from a voice quality perspective. Difficulties with dependent edema of microflap can be solved with time. Unreasonable expectations after phonomicrosurgery stem from poor communication between the voice care team and the patient. overly traumatic handling of the microflap. voice abuse. These include poor compliance with voice rest. g. and recurrence of the vocal fold pathology.82 12 Prevention of Phonomicrosurgery Complications microflap to adhere. significant medical complications after phonomicrosurgery are extremely rare. and fenestration of the microflap inferiorly. Bleeding from the vocal folds after phonomicrosurgery is extremely rare and most notably occurs after removal of recurrent respiratory papillomatosis. 11. 12. The most important prevention method for minimizing the risk of patients developing unreasonable expectations associated with phonomicrosurgery is to establish an excellent line of communication between the patient and the voice care team members. This can also be achieved by a performing careful vocal fold palpation with the back of a curved instrument. In addition. which details in plain language the risk of exacerbating their dysphonia or failure to improve their dysphonia due to a variety of factors. minimizing vocal abuse and treating concurrent LPR. it is most likely from varieties of issues. metal flakes from instrumentation) implanted at the operative site during phonomicrosurgery. and/or incomplete excision of the vocal fold pathology. but when they occur.

Colton R. Diagnosis and treatment of persistent dysphonia after laryngeal surgery: a retrospective analysis of 62 patients.  Chapter 12 Selected Bibliography 1 2 Anderson TD. Scheffel L. J Voice 18:392–397 Rosen CA. Sataloff RT (2004) Complications of collagen injection of the vocal fold: report of several unusual cases and review of the literature. Casper J. Ear Nose Throat J 80:623–624 Woo P. Villagomez VJ (2001) A unique complication of microflap surgery of the vocal fold. Laryngoscope 104:1084–1091 83 . Andrade Filho PA. Buckmire RA (2005) Oropharyngeal complications of suspension laryngoscopy: a prospective study. Laryngoscope 115:1681–1684 3 4 Rosen CA. Brewer D.

the CO2 laser has been of the most use for laryngologists. Micromanipulators are used to couple laser operation and microscopy. the larger the specific target. 21. or a combination both will take place.1 Fundamental and Related Chapters Please see Chaps.2. thin beam of homogeneous energy. This process by which laser energy is restricted to a particular site is a result of the selective absorption of the chromophores at that site and was first described by Anderson et al. the surgeon can maximize the desired effects. if the pulse width is too short. vaporization. the power settings should be kept quite low. Generally.000 nm. an articulating arm is required for the delivery of CO2 laser energy to the treatment site. energy setting.2 Tissue Interaction While appropriate wavelength determination is critical for specific tissue targeting. This delivery system requires a hollow tube with several joints or articulations that allow some maneuverability. . Extreme temperature differences between target tissue and collateral structures have been shown to cause vaporization and shock wave damage. However. Temperatures above 100°C will cause vaporization through rapid volumetric expansion of intracellular water stores. and covalent bonds found in major structural proteins. Thus. subcellular organelles achieve photolysis within a nanosecond domain.3 Delivery Systems While recent advancements in the field have provided more options for delivery systems. when working with the typical very small spot sizes found with the CO2 laser micromanipulators.2. water-containing soft tissue. 22. as heat transfers uniformly to surrounding tissues. 13.2 Laser Physics The modern challenge of using medical lasers is the surgeon’s ability to deliver the right amount of energy at the right wavelength to the right tissue while minimizing damage to collateral tissue. 24–30 for further information. 6. the greater the energy delivered per unit area. melanin. The micromanipulators can control laser spot size. all of these interactions occur concomitantly. cellular disruption occurs on a microsecond scale. 13 13. and pulse duration. The challenge of laser surgery is finding a wavelength in which energy is absorbed by target tissue and scattered or transmitted by surrounding structures. a set of mirrors are positioned to reflect the beam around the corner. near 2. In actual practice. The smaller the spot size.” The following section will consider the major concerns confronting surgeons when using lasers in a clinical setting. Traditionally. the absorbing tissue may heat rapidly. When laser light is delivered to the chromophores within the target.1 Wavelength Unlike the energy emitted from ambient light sources. laser type is still the major determinant. 10. Some common chromophores targeted by surgical lasers are hemoglobin.2. as “selective photothermolysis. Under prolonged exposure times. Thus. Tissues heated to 80–100°C will suffer plasma denaturation. resulting in vessel closure and hemostasis. Laryngologists have also benefited from the addition of several attachments used at the end of articulating arms. nonspecific thermal damage occurs when the pulse width exceeds the thermal relaxation time for the tissue. as jarring or vibrations may cause misalignment within the internal mirror system. Therefore. A laser’s wavelength also correlates with the depth at which the energy is delivered. Consequently. A greater amount of precision and beam control can be managed by hand-manipulated devices. power. At each articulation. and hemostasis is achieved within millisecond exposure times. with all photons collimating into a single. photothermal effects cause collateral coagulation necrosis. Spot size. laser light is monochromatic and usually of a single wavelength. Depending on the chosen wavelength. intensity. and duration have a major role in the effect of the laser on the tissue. a technique that is useful for separating or ablating tissues. energy is absorbed within that tissue. but by selecting the proper wavelength. the larger the thermal relaxation coefficient. greater depths of tissue disruption are achieved at longer wavelengths until reaching the wavelength specific for the absorption of water. either coagulation. 13. commonly referred to as a photomechanical effect. the time in which the energy is delivered is also of consequence. Traditionally. 13. This is an essential variable from an ultimate tissue interaction perspective. Great care must be taken when using such a system.Chapter 13 Principles of Laser Microlaryngoscopy 13.

ablate.4 Types of Laser 13 Although a myriad of lasers are employed in the treatment of head and neck pathology. resulting in less mechanical damage to endoscopic channels.3 Surgical Indications and Contraindications Ideal indications for CO2 laser are: ■ Glottic/posterior glottic stenosis ■ Subglottic/tracheal stenosis ■ Bilateral vocal fold paralysis (arytenoidectomy. Normally. continuous and pulsed modes are delivered via fiber optic cables. and has found specific laryngologic application in laser incisions and dilation for the treatment of subglottic stenosis. laryngologists are able to use endoscopes. allowing for low-powered delivery with minimal ther-   mal diffusion. which can be focused into a thin beam and used to cut like a scalpel or defocused to vaporize. The KTP laser is the newest addition to the laryngologist armament. utilize no-touch technology.100 nm. Sapphire probes create a cutting and vaporization effect similar to that of CO2 lasers. contributing to its widely accepted clinical use. which corresponds with the oxyhemoglobin absorption band. or shave tissue. microlaryngeal cold instrumentation are superior to microspot laser technology in terms of precision. Traditionally the CO2 laser is the workhorse of laryngologic lasers. such as the flexible laryngoscope with a working channel to gain access. including shorter pulse width and less nonspecific tissue damage. The difference in the chemical properties of each element gives the laser a specific wavelength and thus a different surgical application.064 or 1. All YAG lasers may be continuous. This wavelength penetrates the mucosa well. or bipolar cautery. 13. The CO2 laser’s ability to deliver energy endoscopically. while articulating arms use Q switching.064nm YAG laser filtered through a KTP crystal that effectively halves its wavelength to 532 nm. 13. much like forceps. The potassium–titanyl–phosphate (KTP) laser uses a 1.600 nm is absorbed by water found in soft tissues and is independent of tissue color. Normally a 1. while avoiding collateral heat damage that can be associated with laser use. …) ■ Teflon granuloma of the larynx ■ Squamous cell carcinoma of the glottis (T1–select T2) Additional indications for CO2 laser include: ■ Papillomatosis (especially with extensive disease) ■ Vocal fold varix (select cases) ■ Saccular cyst of the larynx Relative contraindications for CO2 laser are: ■ Most benign lesions of the vocal folds: ■ Nodules ■ Vascular lesions ■ Cysts ■ Polypoid corditis Indications for Nd:YAG laser comprise: ■ Large hemangioma of the larynx ■ Glottic/subglottic stenosis (CO2 laser generally preferred) Indications for pulse dye laser/pulsed-KTP laser are: ■ Papillomatosis . The neodymium-coupled YAG (Nd:YAG) laser is one of the most clinically diverse lasers in current use. and offers excellent selective absorption by microvasculature. as spot size rapidly increases with distance from tissue. A lasing medium of rhodamine dye is excited by flash lamps and is delivered with a pulse width just under the thermal relaxation time of small vessels. transverse cordotomy. A near infrared light is emitted at 1. much like a capacitor in a circuit. while at the same time increasing peak energy power. Recent studies have shown great promise in the surgical use of this solid-state laser. and provide a marked reduction in postoperative swelling. there are only a few types in the field of laryngology. causing a great reduction in laser energy delivered and lack of precision. microscissors.to 2-mm distance from target tissue is optimal. As with the articulating arm. relative small pulse width and the cost of replacement dye medium have detracted from the benefits of such technology. Q switching. Its specific wavelength of 10.2. or Q-switched.320 nm. producing a brilliant green light. In fact. The holmium:YAG (Ho:YAG) laser uses an active medium of YAG crystal with holmium dispersion. well within the visible spectrum. is the ability to pulse the laser. minimizes absorption by melanin in the overlying mucosa. Its 532-nm wavelength corresponds to a greater specific absorption for oxyhemoglobin. It is a common misconception that microspot CO2 lasers allow increased precision over cold techniques. and improving the consistency of the lasers output throughout the pulse. Its beam falls near the infrared region of the electromagnetic spectrum at 2. With the advent of this technology. Its principle use is to ablate bone and cartilage. shortening pulse width. pulsed. Nd:YAG lasers may be delivered fiber optically to coagulate tissue or through sapphire probes. YAG lasers use a yttrium–aluminum–garnet crystal rod that is manufactured with specific rare earth elements dispersed within the crystal rod. fiberoptics is used in a noncontact manner. CO2 lasers emit continuous or pulsed waves. It is important to recognize that a laser is nothing more than a tool in the surgeon’s armamentarium.86 Principles of Laser Microlaryngoscopy Many of the other lasers used in the field are delivered via fiberoptic cables. While pulse dye lasers have been employed in many areas of laryngology. The KTP laser also can deliver energy through a small diameter fiber optic. Pulse dye lasers (PDL) emit radiation at a 585-nm wavelength.

7. For the purposes of this chapter. and 70° CO2 laser Micromanipulator with 250-μm spot size (coupling device between microscope and laser) Jet Venturi needle or Hunsaker Mon-Jet tube Fig. length 30cm or more – 0. Fig. 10. all laser settings described are used in the context of a micromanipulator with a 250-μm spot size.3) Microscissors – Curved.2) Micro-ovoid cup forceps (see Chap. including wrapping the patient’s head and upper body with moistened towels.. Quebec. 10. superpulse) allows some thermal relaxation time in between laser delivery. and 8 French (if no trach present) • • Laryngeal rigid dilators: 20–50 French (if trach present) Pneumatic balloon dilator Jet ventilation machine 13.1) Suspension laryngoscope with suction channel and jet ventilation port if operating on subglottis/trachea • Ossoff–Pilling effective for subglottis/upper trachea (proximal) • Subglottiscope for upper/mid-trachea (distal) Suspension system • • Gallows suspension Fulcrum suspension (e.]. 10. Medtronic ENT) • • • • • • Small (0. using an intermittent or superpulse mode.1  Intraoperative photograph illustrating the key laser safety concepts. 13.000 epinephrine Velcro strap or cloth/silk tape Microcup forceps (see Chap. Fla.5. left and right – Up angled • • • • • Curved alligator forceps Straight alligator forceps Microlaryngeal suctions Triangular (Bouchayer) forceps Hopkins Telescopes – Diameter 4–5mm. thus minimizing collateral heat damage.1) In the vast majority of laryngeal laser surgery. 1:10.1 General Guidelines (Fig. 6. Intermittent delivery or pulsed delivery (e.5 CO 2 Laser Safety Guidelines 13. g. due to the substantial power delivery in this mode. 10. 30. the use of a laser-safe endotracheal tube. and eye protection for operating room personnel 87 . Lewy apparatus and table-mounted Mayo) Operating chair with arm supports • Alternative: Mayo stand with pillow/foam Instrumentation (available from Karl-Storz (Culver City. Table 10. Fig. Continuous firing mode is rarely employed and can sharply increase the chances of immediate (laser fire) or late complications (glottic web/stenosis). 13. CA). 10.4 Equipment: Laser Microlaryngoscopy Setup High-quality operating microscope with 400-mm lens Large-bore laryngoscope (largest diameter possible if operating on vocal folds/supraglottis) (see Chap. low-O2 settings. Medtronic ENT [Jacksonville. Laser settings are generally set below 10 W. Instrumentarium [Montreal. Canada]) • Injection device for hydrodissection (Orotracheal injection device.  ■ ■ ■ ■ Chapter 13 Leukoplakia Granuloma Vascular lesions Polypoid corditis Dilation equipment: • Ventilating bronchoscopes: 5. g.5 × 2 cm) cotton pledgets Laser safety materials • • • • Moistened eye pads Moistened towels/surgical drapes Laser-safe endotracheal tube (if applicable) Eye protection for operating room personnel 13.. relatively lowpower settings are employed to minimize collateral heat damage.

which provides not only smoke evacuations.2  Platform suction device Surgical Principles 13. but also protects the distal tissues from inadvertent laser damage.2 CO2 Laser Settings (For most applications in the larynx. Are the OR personnel protected? a) Eyeglasses or plastic goggles with side protectors for all personnel b) Laser warning signs on all OR doors 13.2) is often employed. continuous ■ Maximum laser ablation: useful for cartilage ablation (arytenoidectomy)   13. and must be rapidly removed to maintain visualization. Suction tubing should be connected to a side channel of the laryngoscope to maintain continuous smoke evacuation.3 Maintenance of a Clean Surgical Field The CO2 laser causes the accumulation of carbonaceous debris (Fig. Fig. 13.1 Smoke Evacuation Laser vaporization results in significant smoke accumulation at the operative site.3).5. intermittent mode (0. Therefore. then suspend ventilation during firing of the laser. 13. This desiccated debris is resistant to laser penetration due to the low water content. It should be noted. 3.88 Principles of Laser Microlaryngoscopy 13. as indicated above. or char at the surgical site. Platform suction (Fig. 13. The surgeon must answer affirmatively to the following questions before firing the laser: 1. however.2 Protecting Surrounding Tissue from Laser Damage Platform suction can be used.5 s “off ”) ■ Best for precision work at the vocal fold level ■ Least collateral damage ■ 4–8 W. it must be removed periodically by wiping the tis- 13. superpulse mode ■ Increased tissue ablation ■ Use sparingly near vocal folds to minimize collateral damage ■ 4–6 W. that supplemental smoke evacuation may be necessary. This must be removed for efficient treatment of tissue with the CO2 laser .3  Carbonaceous debris from laser ablated tissue. 13. the following range of laser settings can be employed): ■ 4–8 W. Is the patient’s body protected? a) Moistened eye pads b) Soaked surgical towels around the face and upper chest 2.6.6. Is the endotracheal tube/airway protected? a) Laser-protected tube must be used b) Saline filled ETT balloon c) Moist Cottonoid covering/protecting the balloon d) O2 concentration of 30–35% or less If jet ventilation is used. right vocal fold. or a moistened Cottonoid can be placed over the area to be protected. 13. A simple yet effective protocol is to fully address three areas of safety prior to proceeding (Fig.5.3 Safety Protocol 13 The key to laser safety in the operating room (OR) is consistent and methodical adherence to an established protocol.6 Fig.6.1 s “on” and 0.1). 13.

Key Points ■ The key components that determine a laser’s interaction with tissue are wavelength. intensity. pp 190–199 Ossoff RH (1989) Laser safety in otolaryngology—head and neck surgery: anesthetic and educational considerations for laryngeal surgery. San Diego.7 Complications and Their Treatments 13. or cysts. and is most appropriate for cartilage ablation. Bielamowicz SA (eds) Textbook of laryngology. Mattox ED. although it is quite rare today.7. ■ A laser safety protocol should be employed in all cases where the CO2 laser is used. Parrish J (1983) Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Laryngoscope 91:1417–1426 Zeitels S. or nodules. as well as improved laser-safe endotracheal tube design. ■ The CO2 laser is the workhorse laser for laryngotracheal work. The key concepts are protection of the patient (moist towels). Plural.  Chapter 13 sues with a saline-soaked Cottonoid. transverse cordotomy) ■ Teflon granuloma of the larynx ■ Squamous cell carcinoma of the glottis (T1–select T2) ■ Papillomatosis (especially with extensive disease) ■ Vocal fold varix (select cases) ■ Saccular cyst of the larynx ■ The CO2 laser is generally not a good choice for the removal of benign lesions of the vocal fold. The continuous-beam setting should be used sparingly.):1–26 Schramm VL. Anderson R et al (2006) Office-based 532-nm pulsedKTP laser treatment of glottal papillomatosis and dysplasia.7. the following steps should be followed: ■ ■ ■ ■ ■ Immediate removal of ETT Turn off anesthetic gas/oxygen delivery Mask patient with 100% O2 Intubate with small 4. Also. with O2 concentration of 35% or less). Hemostasis must be achieved before proceeding (by either defocusing the laser beam. In: Merati AL. This is likely due to better education and awareness of laser safety issues. Laryngoscope 99(Suppl. or applying epinephrinesoaked Cottonoids for 1–3 min to the area of bleeding). or suction removal. which can result in scarring and dysphonia. Chapman and Hall. Either condition should be evaluated with a chest x-ray and consultation with cardiothoracic surgery/pulmonology specialists.0–5. such as polyps. and unintended collateral heat damage.2 Tracheal Perforation This can lead to tracking of air into the neck and down into the mediastinum. Science 220:524–527 Absten GT. treat with corticosteroids/antibiotics ■ Tracheostomy 13. ■ CO2 laser settings generally employ low-wattage settings (4–8 W) in an intermittent or superpulse mode to minimize collateral damage to the tissues. and protection of operating room personnel (safety glasses). protection of the endotracheal tube (laser safe. active bleeding at the surgical site usually prevents laser vaporation. 13. Selected Bibliography 1 2 3 4 5 6 Anderson R. due to decreased precision. London Buckmire R et al (2006) Lasers in laryngology. In the unlikely event of a laser fire with an indwelling endotracheal tube. Ann Otol Rhinol Laryngol 115:679–685 89 . spotsize and pulse duration. Further dissection can lead to pneumothorax. Joffe SN (1985) Lasers in medicine.0 ETT Evaluate trachea with rigid bronchoscopy with carbon debris removal ■ Flexible bronchoscopy to evaluate more distal tracheobronchial tree ■ Manage airway after extent of injury is established (options to be considered): ■ Extubate. Stool SE (1981) Acute management of laser-ignited intratracheal explosion. observe in monitored setting ■ Remain intubated.1 Laser Fire A laser fire is the most feared complication in laryngology. and the ideal indications include: ■ Glottic/posterior glottic stenosis ■ Subglottic/tracheal stenosis ■ Bilateral vocal fold paralysis (arytenoidectomy.

a similar problem is encountered in ML when factoring in perioperative vocal fold edema during the implant placement. Conversely. The overcorrection of injection issue is especially true with lipoinjection. Permanent correction of mild-to-moderate glottic in­suf­fi­ ciency a) Vocal fold atrophy (as seen in presbyphonia) b) Vocal fold paralysis c) Vocal fold paresis d) Adjunctive augmentation of the vocal fold(s) after prior laryngeal framework surgery (“touch up”) Patients with minor degrees of glottic insufficiency (<1mm glottic gap on phonation) are usually better suited for vocal fold augmentation rather than framework surgery. . and scarring of the vocal fold after partial laser cordect­ omy. However.. when the prognosis for recovery is uncertain Vocal fold augmentation results in immediate improvement of voice and/or swallowing. Temporary correction in cases of unilateral vocal fold paralysis/paresis. ML with AA for a lateralized. and Clinical Utility There are primarily two treatment modalities that are used for the surgical treatment of glottic insufficiency: 1. 31. The vocal outcome is rendered even more uncertain in those patients who require a general anesthetic for injection. ■ Vocal fold augmentation can be less precise than laryngeal framework surgery. This especially true in the case of a large posterior glottal gap in some patients with unilateral vocal fold paralysis (UVFP). 40. and whose voice result cannot be immediately assessed. “Vocal Fold Augmentation via Direct Laryngoscopy”. “Cricothyroid Subluxation”) There is a lack of consensus among laryngologists regarding the role of these two surgical approaches in the treatment of glottal closure problems. A glottic gap of 3 mm or greater (during phonation) is generally better suited for a laryngeal framework surgical approach. “Arytenoid Adduction”. in general. 31.3 Surgical Indications and Contraindications ■ Vocal fold augmentation is not as effective at closing large (3 mm or greater) glottal gaps compared with framework techniques. 5. 14. Most vocal fold augmentation procedures require some degree over-injection to allow for reabsorption. and 34. thus while some patients may be well served with either approach (i. not all forms of glottic insufficiency are the same. the temporary augmentation is done on a “trial” basis. 14. However. “GORE-TEX® Medialization Laryngoplasty”. 39.2 Vocal Fold Augmentation: Advantages. After a period of weeks to months. Laryngeal framework surgery (medialization laryngoplasty [ML]. other patients are clearly better served with a specific approach (i.1 Fundamental and Related Chapters Please see Chaps. rendering fine adjustments to vocal fold position somewhat difficult. Disadvantages. Furthermore. severe degrees of glottic incompetence appear to be more difficult to correct with vocal fold augmentation. e. If the patient re- 14 sponds to the surgery. 33. and 34 for further information. Glottic insufficiency due to loss of soft tissue in the vocal fold Examples of this clinical situation include sulcus vocalis. vocal fold augmentation is used in the following settings: 1. e. 2. and 41. 33. shortened immobile vocal fold). “Peroral Vocal Fold Augmentation in the Clinical Setting”..1). 38. 3. temporary vocal fold augmentation can be done in cases in which it is not clear that the glottal insufficiency is the main communication deficit and thus. Also. arytenoid adduction [AA]) (see Chaps. Vocal fold augmentation (see Chaps. “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis”. while allowing a period for recovery of vocal fold function. the injected substance is typically resorbed (see Table 14. “Percutaneous Vocal Fold Augmentation in the Clinic Setting”) 2.Chapter 14 Principles of Vocal Fold Augmentation 14. these cases are best suited for ML and AA. then permanent correction can be done. The choice of procedure is often a reflection of the surgeon’s own preference. The scarcity of comparative studies for these two treatments has resulted in a lack of evidence to clearly support one over the other. mild–moderate gap with mobile vocal folds).

The original injection material was paraffin. This material is quite viscous and thus requires a large bore injection needle (18 or 19 g) and pressurized injection device (e. thyroarytenoid and lateral cricoarytenoid muscle).4. Injectable preparations of this substance are composed of crosslinked chains of hyaluronic acid that take on a viscous. as the powder must be mixed with saline to form a paste. Irvine.v. and although it has been reported to last up to 9 months or more. Newer collagen-based products include Cymetra (micronized cadaveric dermal tissue) and Cosmoplast/Cosmoderm (laboratory-engineered human collagen). Due to these limitations. many patients with acute/subacute UVFP may not be good candidates for laryngeal framework surgery. sedation. “Percutaneous Vocal Fold Augmentation in the Clinic Setting”) 14. Cymetra has been used extensively for vocal fold augmentation. 1. Hyaluronic acid gels (Hyalan gels) (Restylane. i. These substances have been widely used as injectable fillers in rhytid treatment for over 10 years in Europe. although Cymetra has the potential for infectious transmission due to the use of cadaveric tissue as the source. Although these substances have been rarely used for vocal fold augmentation in the United States. clinical reports in the European literature support their safety and efficacy in the temporary treatment of glottal insufficiency. The search for such a material has been ongoing for almost 100 years. the patient with an iatrogenic UVFP is unwilling to return to the operating room for another surgery.1 and 14. These substances are polysaccharide-based. inexpensive. and thus the . and the risk of reactive airway edema postoperatively. Zyplast has been found to last as long as 4–6 month.2. yet may be perfectly willing to undergo a vocal fold augmentation in a clinic-based setting (see Chaps. “Peroral Vocal Fold Augmentation in the Clinic Setting” and 34. Most laryngeal framework surgery requires a trip to the operating room. Collagen-based products Collagen-based products have been used for vocal fold augmentation for over 20 years. The product with the longest track record is the bovine-derived cross-linked form of collagen.4. the patient is usually required to lie supine for an extended period of time during the surgical procedure. g.92 Principles of Vocal Fold Augmentation ■ Vocal fold augmentation is a more minimally invasive approach compared to laryngeal framework surgery. Gelfoam has been widely used in the larynx for over 25 years with good success. which can delay treatment for 2–4 weeks. 33. 3.3 Description of Vocal Fold Augmentation Materials Characteristics General characteristics of the current materials available for vocal fold augmentation are listed in Tables 14. Neither product carries the risk of allergic response. which resulted in a significant foreign body response and rejection. Hyalaform— Allegan-Inamed. Cymetra™) ■ Carboxymethylcellulose (Radiesse Voice Gel™) ■ Hyaluronic acid gel (Restylane™. the authors believe 2–3 months is more accurate. An additional requirement of all future vocal fold injection materials will be a matching of the biomechanical properties of the material with the biomechanical properties of either the superficial aspect of the vocal fold (superficial layer of the lamina propria) or the deep aspect of the vocal fold (vocalis.4 Characteristics of Vocal Fold Augmentation Materials 14.1 Overview 14 The ideal vocal fold injection material would be readily available. Zyplast. Similar responses have occurred with Silicone injections as well as most recently with Teflon™ vocal fold injections. skin testing is recommended prior to the use of Zyplast. Temporary injection substances include: ■ Bovine gelatin (Gelfoam™.4. but have potential advantages over the other collagen-based substances due to the low likelihood of allergic response or infectious risks. and completely biocompatible. Cosmoplast™/Cosmoderm™. 14. CA) Hyaluronic acid is a naturally occurring glycosaminoglycan that is abundant in human tissue extracellular matrix. Hyalaform™) Long-lasting injection substances include: ■ Autologous fat   ■ Calcium Hydroxylapatite (Radiesse™) ■ Teflon 14. Often. Although no serious adverse reactions have been linked to bovine collagen use in the larynx. easy to use. The disadvantage of these products is the short duration of activity (4–6 weeks) and the inability to inject the substance through a fine-gauge needle. and significant advances in vocal fold augmentation material availability and design have occurred in the last 10 years. inert. In addition.2 Categories of Vocal Fold Augmentation Materials In general. Bovine gelatin Gelfoam and Surgifoam come as a gelatin powder that is derived from a bovine source. Bruning syringe). water-insoluble form. there is a potential for an allergic response in up to 2% of the population. For this reason. augmentation substances can be divided into temporary and long-lasting (sometimes permanent) materials. Cosmoplast/Cosmoderm are relatively new substances that have not been used in the larynx. A moderate amount of preparation is required prior to injection. 2. Surgifoam™) ■ Collagen-based products (Zyplast™..

  Chapter 14 chance of immunogenicity is eliminated. Hylaform) 4–6 months (?) No allergy testing Limited experience 27 Table 14. morbidity from fat harvest Performed in OR Unpredictable duration 18 or 19 . Rare instances of hypersensitivity (0. However. Food and Drug (FDA) approved for vocal fold augmentation. although some reports suggests slightly longer effect of up to 9 months (see Table 14. a long-acting injectable. and Restylane (manufactured by bacterial fermentation). with varying levels of reported success. which is the carrier substance in Radiesse. Because of this significant complication of Teflon vocal fold augmentation.2  Long-term/permanent injectable substances Material Length of effect Advantages Disadvantages Needle gauge Ca Hydroxylapatite (Radiesse) 2–5 + years (?) FDA-approved Long lasting New product No long-term track record 25 Teflon Permanent Long lasting Irreversible May cause vocal fold stiffness Risk of granuloma 18 or 19 Autologous fat Several years– permanent (?) Patient’s own tissue used “Forgiving” (defect over-correction rarely occurs) Time. Calif. The foreign-body response is quite intense and often requires surgical removal of the Teflon. San Mateo.k. 93 5.S. 24. “Endoscopic Treatment of Teflon Granuloma” and 42.1). Polytetrafluoroethylene (Teflon) Teflon vocal fold injection has been performed for over 40 years and was initially touted as an excellent vocal fold augmentation material. Radiesse Voice Gel typically lasts 2–3 months. 6. this substance presently has very limited utility. This removal results in vocal fold tissue loss. Radiesse Voice Gel (carboxymethylcellulose) Radiesse Voice Gel (Bioform Medical. 4. The voice quality and vocal fold vibration after vocal fold augmentation are good. The hyalan gels include Hyalaform (manufactured from rooster combs).to 4-week delay 27 Human-derived collagen (Cosmoplast/Cosmoderm) 3–4 months No allergy testing New product/limited experience 27 Micronized AlloDerm (Cymetra) 2–3 months No allergy testing More preparation time Unpredictable duration 18–23 recommended Hyaluronic acid gels (Restylane. The duration of effect for these substances is comparable to the collagen-based products. vocal fold lipoinjection) has been widely used for the last 10–15 years. long term follow up of Teflon vocal fold augmentations revealed a significant complication of a foreign-body granulomatous response occurring up to 5–10 years after injection. “Translaryngeal Removal of Teflon Granuloma”). Autologous fat Autologous fat vocal fold augmentation (a. generally 4–6 months.6%) are reported. leaving a severe deficit and morbidity at the vocal fold augmentation site(s). and are related to low levels of protein impurities in the manufacture of the product.a. The principle material in this substance is carboxymethylcellulose. resulting in significant destruction of the surrounding vocal fold (see Chaps. depending on the volume injected.) is currently the only temporary injectable substance that is U. Vocal fold lipoinjec- Table 14. There is an extremely low risk of allergic response to this substance.1  Temporary injectable substances Material Length of effect Advantages Disadvantages Needle gauge Gelfoam 4–6 weeks Long track record Short duration 18 Radiesse Voice Gel 2–3 months FDA approved No allergy testing Not as long lasting as collagen/hyaluronic acid gels (?) 27 Bovine collagen (Zyplast) 3–4 months 20-year track record Allergy test required 2.

Translaryngeal (through thyroid cartilage) ii. 34.94 14 Principles of Vocal Fold Augmentation tion obviously has the advantages of using a material that is autologous and usually readily available. 14. Cricothyroid membrane puncture iii. illustrating the correct depth of needle placement for injection. In addition. 31. Fig. Calcium hydroxylapatite (Radiesse) Calcium hydroxylapatite (CaHA) microspheres represent a new vocal fold injection material that has been extensively tested in laboratory animals and used clinically as an augmentation material in other parts of the body (nonlaryngeal). however. Ideal injection locations are identified at a point where a transverse line from the tip of the vocal process laterally intersects the superior arcuate line. 33. Currently. Radiesse is a naturally occurring substance in the human body. “Vocal Fold Augmentation via Direct Laryngoscopy”) b) Percutaneous (Chap.5   3. although long-term augmentation has been demonstrated in other organ systems. 14. carboxymethylcellulose). This material is composed of microspheres of CaHA (25–45 μm in diameter) suspended in a temporary gel carrier (water. 2. Straight injection device via direct laryngoscopy in the operating room (Chap. the variable survival in the immediate postoperative period (2 months) is disconcerting to many surgeons. 14. resulting in a lack of consensus regarding whether autologous fat is a good long-term or “permanent” correction option for glottic insufficiency. However. Efficacy up to 12 months has been demonstrated in a multi-institutional clinical trial at the time. which allows for easy injection through a needle as small as 25 g. The clinical efficacy and long-term results are still pending in the larynx. A notable exception to the rule is vocal fold lipoinjection. it is likely due to improper harvesting and preparation of the material as well as incorrect injection techniques. The success of lipoinjection appears to be operator dependent and the reasons for this have not been clearly identified.1  Illustration showing the correct injection site(s) for vocal fold augmentation General Principles of Vocal Fold Augmentation 1. 14. (Fig. therefore. Long-term animal studies and a short-term human study have demonstrated excellent host acceptance of the CaHA material in the larynx. so that the patient’s voice can be monitored during the procedure. Thyrohyoid membrane puncture Fig. it is the only FDA-approved potentially long-lasting glottic injectable. In contrast to Teflon. Local anesthesia is generally preferred in most cases. the risk of chronic granulomatous formation is theoretically small. Vocal fold augmentation is generally directed at the poste- rior and mid-membranous vocal fold in the treatment of glottic insufficiency.1). “Percutaneous Vocal Fold Augmentation in the Clinic Setting”) i. Sustained results in the correction of glottic insufficiency (>1 year) have been demonstrated in patients treated with lipoinjection for glottic insufficiency. glycerin. “Peroral Vocal Fold Augmentation in the Clinic Setting”) ii. radiographic presence of fat up to 2 years after lipoinjection has been demonstrated in a number of patients. 7. A second injection site is sometimes needed at the mid-membranous vocal fold along the superior arcuate line. slightly inferior to the free edge of the vocal fold . which is performed under general anesthesia to facilitate fat harvesting and preparation.2  Coronal section of the larynx. Injection techniques include: a) Peroral i. Curved injection device in the clinic setting (Chap.

The exception to this rule is autologous fat injection. 14. ■ Augmentation is directed at the posterior and midmembranous vocal fold.3  The appropriate amount of overcorrection used for most injectables (15–30%. The overcorrection usually results in a slightly rounded. Cymetra) ■ Carboxymethylcellulose (Radiesse Voice Gel) ■ Hyaluronic acid gel (Restylane. 14. Surgifoam) ■ Collagen-based products (Zyplast. vocal fold paresis (unilateral and bilateral). In general. Hyalaform) ■ Long-lasting injection substances include: ■ Autologous fat ■ Calcium hydroxylapatite (Radiesse) ■ Teflon ■ Local anesthesia is generally preferred with vocal fold augmentation (peroral or percutaneous approach). Aggressive overcorrection (100%) is recommended in these cases to account for the substantial resorption of fat that generally occurs within the first 6–8 weeks after lipoinjection (Fig. so that the patient’s voice can be used as a constant source of feedback during the procedure (Chaps. convex contour to the injected vocal fold (Fig. and can be carried out in a clinic-based setting. to compensate for resorption of the water-based component present in commercially manufactured injectables. 33 and 34).4  The appropriate amount of overcorrection used for vocal fold lipoinjection.4). as depicted in this right vocal fold augmentation The depth of injection is generally 3–5 mm. along the lateral vocal fold (superior arcuate line). which translates to an additional 0. Overinjection in recommended. 4. Cosmoplast/Cosmoderm. ■ Temporary injection substances include: ■ Bovine gelatin (Gelfoam. and at a depth of 3–5 mm.2 ml of substance for unilateral procedures. 14.1–0. Chapter 14 Fig. or an additional 0. especially in the posterior membranous region of the vocal folds ■ Vocal fold augmentation may be less precise than framework surgery ■ Vocal fold augmentation is however.  Fig. Injection into the superficial layer of the lamina propria (Reinke’s space) should be avoided. and can be categorized into temporary (2–6 months) and long-acting/permanent (2 years or more). a 15–30% overcorrection is recommended (exception noted below). ■ Key differences between vocal fold augmentation and laryngeal framework surgery: ■ Vocal fold augmentation is less effective at closing large (3 mm or greater) glottal gaps. slightly inferior or at the level of the inferior lip of the free edge of the vocal fold (Fig. 95 . as this will result in loss of mucosal pliability and poor vocal quality 5.2 ml of material). as demonstrated in this left vocal fold ■ Vocal fold augmentation is appropriate in a variety of clinical settings. unilateral vocal fold paralysis ■ Adjunctive vocal fold augmentation after laryngeal framework surgery (“touch up”) ■ Glottic insufficiency due to vocal fold scarring/ soft tissue loss ■ A variety of injectable substances are available for vocal fold augmentation.3). a more minimally invasive approach. Key Points ■ Vocal fold augmentation is a commonly used surgical treatment for glottic insufficiency.1–0. but is commonly used in the following situations: ■ Temporary correction for unilateral vocal fold paralysis ■ Trial correction for glottal insufficiency (as a diagnostic measure) ■ Permanent correction of vocal fold atrophy (as seen in presbyphonia).2). 14. 14.

Selected Bibliography 1 2 3 14 Brandenburg JH (1992) Vocal cord augmentation with auto­gen­ ous fat. Otol Clinics North Am 33:1087–1096 7 Rosen C. McFarlane SC. Hamoir M. Laurent C et al (2004) Cross-linked hyaluronan versus collagen for injection treatment of glottal insufficiency: 2-year follow-up. Acta Otolaryngol 124:1208–1214 5 Remacle M. Laryngoscope 88:1268–1273 9 Simpson CB. Casiano R et al (2007) Vocal fold augmentation with calcium hydroxylapatite (CaHA). Laryngoscope 102:495–500 Ford CN. Ear Nose Throat J 83(Suppl. Otolaryngol Head Neck Surg 136:198–204 8 Schramm VL.96 Principles of Vocal Fold Augmentation ■ Injection into the superficial lamina propria (Reinke’s space) is to be avoided. Laryngoscope 96:863–869   4 Hertegar S. Martin DW. Laryngoscope 94:513–518 Ford CN. Hallen L. Ann Otol Rhinol Laryngol 99:438–444 6 Rosen CA (2000) Phonosurgical vocal fold augmentation: procedures and materials. Gartner-Schmidt J. Lavorato AS (1978) Gelfoam paste injection for vocal cord paralysis: temporary rehabilitation of glottic incompetence. which requires substantial overcorrection. Menicucci AL (1990) Vibratory characteristics of Teflon-injected and noninjected paralyzed vocal folds. Bless DM (1986) Clinical experience with injectable collagen for vocal fold augmentation. Amin MR (2004) Office-based procedures for the voice. Warner TF (1984) Injectable collagen in laryngeal rehabilitation. May M.):6–9 10 Watterson T. van den Eeckhaut J (1990) Correction of glottic insufficiency by collagen injection. ■ Overinjection (15–30%) is recommended to compensate for resorption of the water-based component present in most injectable substances. The exception to this rule is autologous lipoinjection. Bertrand B. J Speech Hear Disord 55:61–66 . Marbaix E.

Part B Phonomicrosurgery for Benign Laryngeal Pathology II Phonomicrosurgical Voice Procedures .

The vocal fold polyp can be associated with increased vascularity around the lesion. 13. 15. Differential diagnosis associated with vocal fold polyp includes: ■ ■ ■ ■ ■ ■ Reinke’s edema Vocal fold cyst Pseudocyst Vocal fold fibrous mass Localized edema of the vocal fold (temporary) Vocal nodules 15. 15. “Vocal Fold Varix”). then it will be clear and may even have a translucent nature to it. Standard phonomicrosurgical equipment (see Chap. there will be a hemorrhagic nature to the polyp. Physically.1 Fundamental and Related Chapters Please see Chaps. 11. Often. Typically. The lesion is typically unilateral but can be bilateral.1  Vocal fold polyp vocal fold varix as needed (see Chaps. 22. a disorganized gelatinous material is found within the subepithelial space in patients with a vocal fold polyp. “Surgical Management of Vocal Fold Vascular Lesions”) . giving it a maroon or bloodcolored appearance. at the time of surgery. Table 10. 10. 8. If the vocal fold polyp is not hemorrhagic. 15. and 12 for further information. a vocal fold polyp is associated with misuse or heavy use of the voice. medical management) ■ A vocal fold polyp that is associated with a significant vocal fold varix that is at risk for vocal fold hemorrhage Contraindications for surgery comprise: ■ Patients medically unable to tolerate general anesthesia ■ Inability to obtain proper visualization of vocal folds during microlaryngoscopy ■ A patient without vocal functional limitations 15.1). The stroboscopic features of a vocal fold polyp include minimal dampening of the overall mucosal wave and an hourglass closure pattern.1) 2. often noted as a varix feeding the lesion (see Chap. and typical features involve an exophytic lesion with quite-thin mucosa (Fig.2 Disease Characteristics and Differential Diagnosis A vocal fold polyp can have a variety of different features and presentation characteristics.4 Surgical Equipment 1. These behaviors can result in a vocal fold polyp in a gradual/progressive fashion or in a sudden fashion often associated with an acute vocal fold hemorrhage. “Principles of Laser Microlaryngoscopy” and 22. such as in a variety of phonotraumatic behaviors. 4. Bipolar or laser equipment for the treatment of associated Fig. 10.3 Surgical Indications and Contraindications Indications for surgery for vocal fold polyp include: ■ A combination of dysphonia and lack of significant response to nonsurgical treatment methods (voice therapy.Chapter 15 15 Vocal Fold Polyp 15.

15. 1. preferably the entire membranous vocal fold i. 15. The decision on which approach to select is based on the amount of healthy mucosa associated with the polyp. Subepithelial infusion for vocal fold polyp is contra- Fig. Application of topical epinephrine (1:10. a truncation approach. “Principles of Phonomicrosurgery”). 15. First. using a microflap approach and second.5  Dissection of polypoid material medially. There are two main methodological approaches to the surgical removal of a vocal fold polyp. 15. 10.000) to the vocal fold lesion via a Cottonoid ii.4  Removal of polyp contents Fig.100 Vocal Fold Polyp   Vocal fold polyp is best surgically removed via a phonomicrosurgical approach (see Chap.2  Cordotomy at junction of polyp and vocal fold Fig.5 Surgical Procedures 15 glottic mucosa . Microflap approach for vocal fold polyp removal a) Exposure of lesion.3  Microflap elevation Fig. preserving infra- 15.

4% Lidocaine is sprayed onto the larynx (commonly referred to as a LTA [laryngotracheal anesthesia]) Fig. Fig. 22.9). 15. then a 1-mm microcup forceps can be used to remove this tissue.7). An alternative removal technique involves grasping of the “dogeared” mucosa with a microcup forceps or small triangle forceps and excising the material with a microcurved scissors (Fig. Truncation of the vocal fold polyp a) Application of topical epinephrine to the vocal fold le- sion b) Subepithelial infusion for vocal fold polyp is contraindi- cated. 15. along the superior surface of the vocal fold (Fig. v.10). 15. Redrape the remaining microflap mucosa. vi. 15. The vocal fold lesion should be grasped in a location and manner that is perpendicular to the longitudinal axis of the vocal fold. 15. Epithelial cordotomy is planned and made through the epithelium at the junction of the lateral aspect of the vocal fold polyp and the normal vocal fold mucosa.6). careful control and gentle application of tension should be applied to the vocal fold polyp.6  Redrape and evaluate viability of microflap mucosa 2. given that this could blur the demarcation of the junction between the vocal fold polyp and the normal vocal fold tissue.5). 15. 15.3). d) Microscissors that are either slightly curved (away from the vocal fold) or straight up-cutting scissors are then used to incise the vocal fold polyp at the junction of the polyp and the vocal fold (Fig. given that this could blur the demarcation of the junction between the vocal fold polyp and the normal vocal fold tissue. use a blunt instrument (curved elevator) to palpate the operative site to ensure there is no remaining pathology under the flap (Fig. or is excessive and will not serve as normal mucosa during the postoperative healing (Fig. or is extremely thin and atrophic. the lesion can be dissected medially with a 30° flap elevator. With the nondissecting hand. an epinephrine-soaked Cottonoid can be placed on the operative site for several minutes. c) Grasp the vocal fold polyp with small triangular forceps in a medial direction (Fig. “Surgical Management of Vocal Fold Vascular Lesions”). If there is residual abnormal mucosa. vii.7  Trim abnormal microflap mucosa 101 . Once the flap is redraped. 15. x.  Chapter 15 indicated. viii. Redrape the microflap back over the vocal fold and evaluate the nature and status of the microflap mucosa (Fig.8). Treat the associated vascular lesion if needed (see Chap. Alternatively. 15. 15. The nature and approach to grasping the vocal fold polyp is extremely important and is a key determinant of the success of the procedure. careful examination and palpation should be performed to see if there is any residual abnormal mucosa at the vocal fold polyp site that should be removed. preserving additional inferior microflap mucosa (Fig. e) After removal of the majority or the entire vocal fold polyp. iii. The microflap elevation is performed medial to the incision to expose the subepithelial pathologic contents of the vocal fold polyp (Fig.2). 15. 15.4). iv. Vocal fold polyp material is removed via either microsuction or direct removal of the abnormal material with small microcup forceps (1 mm) (Fig. To help with this assessment. ix.9). Trim abnormal mucosa that appears to have adherent polyp material.

. Dashed line indicates proposed line of excision 15 Fig. 15. 15.10  Microscissors removal of residual mucosa Fig. 15.9  Traction applied to polyp and truncation of polyp.11  Removal of residual mucosa with outside curve of curved microscissors.102 Vocal Fold Polyp Fig.8  Redrape microflap and palpate with curved probe   Fig. 15.

15. atrophic nature. At the completion of the surgery. Complication of surgical excision of vocal fold polyp can be: ■ Excessive vocal fold scar formation ■ Granulation tissue at the operative site ■ Vocal fold hemorrhage in the region of the surgery Key Points Fig. this tissue will be successfully removed (Fig. Laryngoscopy 107:340–344 Hochman II. 15. consisting of proton pump inhibitor and behavior modification. h) Application of 4% plain lidocaine onto the endolarynx ■ Precision microsurgical removal of a vocal fold polyp is paramount. This material can be removed with a microelevator or microcup forceps. ■ Most of the mucosa of the vocal fold polyp is usually not suitable for preservation due to its thin. some residual surrounding mucosa of the vocal fold polyp can be preserved and redraped to allow optimal vocal fold healing after surgery. then it can be removed by opening the blades of the microcurved scissors (curved away from the surgical vocal fold).12). without exophytic mucosal tags and without a divot or concavity of the free edge at the surgical site (Fig. careful examination visually as well as on palpation (using the outside curve of curved elevator or curved alligators) should be performed on the operative site(s). It is wise to treat patients for perioperative laryngopharyngeal reflux. Zeitels SM (2000) Phonomicrosurgical management of vocal fold polyps: the sub-epithelial microflap resection technique. sliding the scissors down over the tissue in a way that the blades straddle the tissue to be removed. because overly aggressive removal of this material can result in significant scar formation as well as a permanent deformity of the free edge of the vocal fold. Selected Bibliography 1 2 3 Courey MS. Extreme care is required at this juncture of the surgery. With gentle. There may be some additional fibrous or gelatinous material that should be carefully removed to prevent a rapid recurrence of the vocal fold pathology. polyps and cysts. 15. then this tissue should be removed.  Chapter 15 15. the free edge of each vocal fold should be completely straight. If this tissue is too small to be grasped. Curr Opin Otolaryngol Head Neck Surg 11:456–461 103 . g) After removal of the vocal fold pathology.6 Postoperative Care/Complications Voice rest is typically used after surgical excision of a vocal fold polyp. J Voice 14:112–118 Johns MM (2003) Update on the etiology.11). lateral pressure at the same time that the blades are closed. and treatment of vocal fold nodules. Garrett CG. ■ Great care should be taken to avoid a “cookiebite” defect into the substance or main component of the vocal fold after surgical removal of a vocal fold polyp.12  Straight edge of left vocal fold immediately after excision of vocal fold polyp f) If there are some residual tags or dog-eared mucosa. Ossoff RH (1997) Medial microflap for excision of benign vocal fold lesions. This voice rest period can range from 2 to 7 days. diagnosis. ■ However.

1  Vocal nodules . The differential diagnosis of vocal fold nodules includes: ■ Vocal fold polyp (bilateral or with a contralateral reactive lesion) ■ Fibrous mass (bilateral or with a contralateral reactive lesion) ■ Cyst (bilateral or with a contralateral reactive lesion) ■ Pseudocyst (bilateral or with a contralateral reactive lesion) when present. and 12 for further information. 16. in rare instances. these lesions are in fact not vocal fold nodules. “Principles of Laser Microlaryngo­ scopy”) Cold-steel excision is the preferred method for vocal fold nodules removal. Phonomicrosurgery instruments (see Chap.1). 10.1 Fundamental and Related Chapters Please see Chaps. Vocal fold nodules are typically treated with nonsurgical methods including voice therapy. but other benign vocal fold lesions (see above list).1) 2. and treatment of comorbid medical conditions. the mucosal wave is normal or near normal. The stroboscopic closure pattern is an hourglass configuration.Chapter 16 16 Vocal Fold Nodules 16. 10. These tend to occur in children and adult females (18–40 years of age). Nonsurgical treatment options include high-quality voice therapy with good compliance by the patient—also. “Principles of Phono- microsurgery” and 13.2 Disease Characteristics and Differential Diagnosis Vocal fold nodules are characterized as bilateral vocal fold lesions that are fairly symmetric (Fig. however. A relative contraindication to surgery for vocal fold nodules is a patient that has not been compliant with voice therapy nor changed the habitual phonotraumatic behavior that most likely led the formation of the lesions. the CO2 laser can be used to remove vocal fold nodules as well. 4. when bilateral vocal fold lesions are still present after the nonsurgical treatment modalities. treatment of comorbid medical conditions such as reflux disease and allergic disease Fig. 16. 10. It is extremely rare that true vocal fold nodules do not respond favorably to these nonsurgical modalities. Typically. Most often. 16. 3. voice rest. Table 10. CO2 laser optional (see Chaps. and with great experience and the optimal laser technical abilities. 11.4 Surgical Equipment 1. 8. Surgery for vocal fold nodules without a thorough and properly implemented nonsurgical therapy course is not appropriate.3 Surgical Indications and Contraindications Surgery for vocal fold nodules is reserved for persistent and significant dysphonia (with functional limitations) after all nonsurgical treatment options are exhausted. these patients have a history of vocal abuse or misuse (phonotrauma). On stroboscopy. 16. 16.

16. If a microweb is present. The former is best done with the microcup forceps being used to grab the intended mucosa for removal and allowing the sharp edge of the forceps to come through the mucosa without any forceful stripping of the mucosal tag. 8.106 Vocal Fold Nodules suspension laryngoscopy (see Chap. “Principles of Phonomicrosurgery”). the vocal fold lesions should be assessed for their degree of submucosal pathology and examinined for associated pathologic lesions such as vascular lesions. The approach to the grasping of the lesion should be as close to perpendicular to the longitudinal axis of the vocal fold as possible and as superficially as possible. 4. As the excision is performed from posterior to anterior. Complete exposure of the membranous vocal folds with 16   . Fig. Microscissors. Special attention should be given to the anterior commissure to evaluate if there is a presence of an anterior commissure microweb. 10. Extreme care is required at this juncture of the surgery. 2.12). After removal of the benign vocal fold lesions. 15.2).2  Submucosal excision of vocal fold lesion (start) Fig. 16.3  Submucosal excision of vocal fold lesion (finish) 16. then these should be removed in a careful. This material can be removed with a microelevator or microcup forceps.4). then asymmetric release of the microweb can be done with scissors or a sickle knife. 16. If there are any residual mucosal irregularities at the excision site. conservative fashion by either removal of the irregular abnormal mucosa with microcup forceps or by microsurgical scissors excision (Fig. After the lesion is grasped.5 Surgical Procedure 1. care should be taken to ensure that the tips of the vocal fold scissors do not extend deep into the vocal fold nor past the anterior border of the vocal fold lesion (Fig. because too-aggressive removal of this material can result in significant scar formation as well as a permanent deformity of the free edge of the vocal fold. Fig. 16. 6. 5. The vocal fold lesions should be palpated gently under highpower magnification. 15. 7. Past reports have noted an increased incidence of anterior commissure microwebs with recalcitrant vocal fold nodules that require surgical excision. There may be some additional fibrous or gelatinous material at this location. excessive anterior vocal fold mucosa can be removed with the vocal fold lesion excision. and other vocal fold pathologies. 3. At the completion of the vocal fold lesion(s) excision the free edge of each vocal fold should be completely straight without exophytic mucosal tags and without a divot or concavity of the free edge of the surgical sites (see Chap. evidence of scar. 16. which should be carefully removed to prevent a rapid recurrence of the vocal fold pathology. either straight-up or curved (aimed in a direction away from the vocal fold) should be used for a submucosal excision of the vocal fold lesion (Fig. During this. It is best to watch carefully the path of the tips of the scissors to ensure that they are aimed purposely to finish the cut just anterior to the lesion and come through the free edge of the vocal fold anterior to the lesion. careful examination visually as well as on palpation (using the outside curve of curved elevator or curved alligators) should be performed at the operative site(s). sulcus vocalis. The surgical removal of vocal fold nodules starts with a very careful grasping of one of the lesions with a small triangular or curved alligator instrument. Without special attention to this area.3). the lesion is drawn to the midline gently and very careful observation of the demarcation between vocal fold pathology and the normal vocal fold free edge should be identified. Mitomycin C can be applied to the operative site.

Bless DM. Nuss RC (2005) Pediatric vocal nodules: correlation with perceptual voice analysis. J Voice 15:395–412 Pontes P. but also on compliance issues of the patient.4  Removal abnormal mucosa from operative site 1 2 16. Ann Otol Rhinol Laryngol 105:525–531 Ford CN. Doyle P. Kyrillos L. In general. Okur E. voice rest may be needed only 1 or 2 days. midmembranous vocal fold lesions that have normal stroboscopic or minimal impairment findings that result in an hourglass closure pattern. Glynn A. Sodersten M. Hillman RE. Scott MA. Perkell JS. 1):1369–1375 Holmberg EB. Behlau M. J Voice 17:269–282 Holmberg EB. 16.6 Postoperative Care and Complications Voice rest is used for a variable length of time. precise and performed in a subepithelial fashion. J Voice 16:408–414 Shah RK. Int J Pediatr Otorhinolaryngol 68:409–412 Benjamin B. and significance. ■ Most patients with vocal fold nodules improve with nonsurgical treatment methods. Woodnorth GH. Guzelsoy S (2004) The prevalence of vocal fold nodules in school age children. Campos G. Doyle P (2001) Efficacy of a behaviorally based voice therapy protocol for vocal nodules. De Biase N. Ann Otol Rhinol Laryngol 96:530–533 Benninger MS. Ossoff RH (1996) Immunohistochemical characterization of benign laryngeal lesions. for an extremely compliant patient. a shortened amount of voice rest can be used after vocal fold nodules removal if the patient will be compliant with light voice use instead of total voice rest. Pontes A (2002) Vocal nodules and laryngeal morphology. however there may be some rare cases of recalcitrant vocal fold nodules that require surgical excision. Shohet JA. Hammarberg B. Croxson G (1987) Vocal nodules in children. microwebs and surgery. J Voice 9:326–331 Courey MS. Laryngoscope 104(Pt. Jacobson B (1995) Vocal nodules. 3 4 5 6 7 8 9 Akif Kilic M. resulting in a “cookie bite” defect of the vocal fold The latter complication can be prevented with very careful submucosal excision of the vocal fold lesion and utilizing great precision and control to prevent the surgical excision from entering into the deeper aspects of the lamina propria or vocal ligament. ■ The initial retraction or grasping of the vocal fold lesion is very important. fairly symmetric. prevalence. ■ Surgical excision of vocal fold nodules should be extremely conservative. This step in large part determines the success of the procedure. As an example. and the stroboscopy results are favorable. Int J Pediatr Otolaryngol 69:903–909 107 . Complications from vocal fold nodules surgery are: ■ ■ ■ ■ Excessive scarring Submucosal hemorrhage Residual vocal fold pathology Excessive removal of vocal fold tissue. Leddy M (1994) Anterior commissure microwebs associated with vocal nodules: detection. compared with other phonomicrosurgical procedures. Hammarberg B. Yildirim I.  Chapter 16 Key Points ■ Vocal fold nodules are bilateral. proceeding to light voice use if the patient is continuing to be compliant. Hillman RE (2003) Aerodynamic and acoustic voice measurements of patients with vocal nodules: variation in baseline and changes across voice therapy. Selected Bibliography Fig. depending not only on the size and nature of the lesion.

Microflap approach to a cyst or fibrous mass in the subepithelial location a) Intubation with 5. “Principles of Phonomicrosurgery”).Chapter 17 Vocal Fold Cyst and Vocal Fold Fibrous Mass 17. . and videostroboscopy is usually needed to make the diagnosis (see Chap. Stroboscopy shows significantly reduced mucosal wave where the lesion is present. 10. 4. in a posterior-to-anterior direction or anteriorto-posterior direction. Differential diagnosis for vocal fold cyst or fibrous mass is: ■ ■ ■ ■ Vocal fold polyp Rheumatologic lesion of the vocal fold Vocal nodules Reactive lesion 17.0 microlaryngeal endotracheal tube b) Expose larynx with laryngoscope i. typically yellow or white in color (Fig.1  Vocal fold cyst (left) 17. 1. 10. It can be quite difficult to detect in some cases. The technique described below applies to both lesions unless otherwise noted. vocal fold fibrous masses are more diffuse and often have extensions anteriorly and/or posteriorly within the vocal fold. and 12 for further information. 17. 11. 3.1 17 Fundamental and Related Chapters Please see Chaps. Both lesions are usually found in the midmembranous vocal fold and can be either in the subepithelial (SE) space or near the ligament (lig) of the vocal fold. Make incision just lateral to. “Principles of Phonomicrosurgery”). 3.5 Surgical Procedure The surgical approach to a vocal fold cyst or vocal fold fibrous mass uses a microflap (see Chap.4 Surgical Equipment The surgical equipment required is a standard phonomicrosurgery instrument set (see Chap.2 Diagnostic Characteristics and Differential Diagnosis A vocal fold cyst is a sac-like structure within the lamina propria of the vocal folds. “Videostroboscopy and Dynamic Voice Evaluation with Flexible Laryngoscopy”).1). 17. 10. Table 10.3 Surgical Indications and Contraindications Indications for surgery are symptomatic dysphonia and lack of resolution with maximum nonsurgical treatment (voice therapy). 10.1). and in contrast. There is little difference in the surgical technique for a cyst or fibrous mass. Use the largest laryngoscope that will adequately expose the entire vocal fold (see Chap. Vocal fold cysts have a distinct and confined sac-like boundary. or directly over the lesion. c) Incision i. Vocal fold fibrous mass is an accumulation of fibrous material within the lamina propria of the vocal fold. 17. Contraindications for surgery comprise: ■ Patients medically unable to tolerate general anesthesia ■ Inability to obtain proper visualization of vocal folds during microlaryngoscopy ■ A patient without vocal functional limitations Fig. 17. 8.

17. It is important to perform the medial aspect of the dissection first. i.4). The tip of the elevator should be pointing medially.   d) Separate the epithelial cover from the cyst/fibrous mass (Fig. The dissection is continued to the inferior-most portion of the lesion. If the epithelial cover is separated as the last step. ii. then this dissection becomes much more difficult.2). 17. Use caution with the flap elevator inferiorly. protecting the deeper layers (Fig.3). Keep the incision superficial by maintaining a slight pull on the knife superiorly (toward yourself).2  Mucosal cordotomy with sickle knife. when natural “counter-traction” is provided by adherence of the lesion wall to the vocal ligament. ii. Use the 30° flap elevator to develop a plane as superficially as possible between the overlying epithelium and the cyst/fibrous mass. The incision should be slightly longer than the actual lesion to afford adequate space in which to work. It is best to start creating the dissection in undistorted tissue planes anterior and posterior to the lesion before dissecting directly over the lesion. semitranslucent flap (0.2-mm thick) during this step. 17. which “tents” up the mucosa. gentle pressure laterally with the “back” of the flap elevator helps avoid perforation.3  Dissection between the epithelial cover and the cyst Fig. iii. with little vascularity. Dissect between the cyst/fibrous mass and the vocal ligament with a 30° flap elevator (Fig. Often there is adherence between the flap and cyst wall. iii. i.4  Dissection of plane deep to the vocal fold cyst. Great care should be taken to Fig.110 Vocal Fold Cyst and Vocal Fold Fibrous Mass ii. adjacent to the vocal ligament . The fibers of the vocal ligament run parallel to the long axis of the vocal fold and are white in color. 17. 17. Note how tip of knife 17 “tents up” mucosa to prevent possible injury to deep structures in the vocal fold Fig. 17. as the tip of the instrument may perforate the delicate epithelial flap. e) Separate the lesion from the vocal ligament. iv. vi. The instrument can usually be visualized through the thin. v.

vi. The vocal fold should be palpated. When ligamentous pathology is present. ii. The lesion is removed and the microflap redraped into its anatomic position. 17.6  Redraping of microflap 111 . 17. the lesion is removed and the flaps are replaced and allowed to coapt (Fig.5  Release of fibrous attachments to the vocal fold cyst g) Special considerations for vocal fold cyst/fibrous mass near the vocal ligament i.  Chapter 17 avoid violation of the vocal ligament. then careful and meticulous dissection and removal of all the cyst wall contents should be done. Fig. feeling for persistent pathology causing irregularity of the vocal fold. A triangular forceps can then be used to retract the microflap medially while a fine-angled elevator is used to dissect off the vocal fold cyst/fibrous mass from the vocal ligament (see Fig. It is often best to cut these extensions at the location(s) of their attachment to the fibrous mass and then redrape the microflap to determine by palpation and visual inspection if any additional excision is required. begin graduated voice use under supervision of SLP (if possible) Fig. v. Once all attachments of the lesion are freed. If there is penetration of the cyst. f) Removal of lesion i. and should be preserved. iv. Some scant gelatinous-appearing material (SLP) can often be seen. Epithelial resection is normally not necessary. iii. ii. Often a fibrous mass will have fibrous extensions anteriorly and/or posteriorly. These fibrous connections are most commonly present anterior and posterior to the vocal fold cyst/fibrous mass and will need to be carefully lysed before the lesion can be removed (Fig. After cordotomy and the start of the microflap elevation. iii. the microflap is usually quite easily elevated. iv. and then dissection can be continued. if fibrous connections between the lesion and ligament cannot be bluntly dissected with the flap elevator. iii. 17. pain medications as needed (tongue pain from suspension) ■ Follow-up in 1 week.6). 17. these extensions can be left alone or removed. then an attempt to prevent complete evacuation of the cyst should be done by grabbing the cyst at the penetration site with a small microalligator. Microscissors are sometimes required to complete the dissection of the lesion off the vocal ligament. given that the lesion is deep to the area of dissection. the vocal fold cyst/fibrous mass will be clearly visible in the “deep” portion of the vocal fold near or on the vocal ligament. as cyst dimensions may be difficult to define after rupture occurs.5). 17. Avoidance of cyst wall rupture is tantamount to a successful surgery. Some sharp dissection with scissors may be necessary.7). Depending on the thickness.6 Postoperative Care and Complications Postoperative care includes: ■ Complete voice rest for 1 week ■ Proton pump inhibitors (PPIs). If the cyst is ruptured completely. 17.

1):19–26 Thekdi AA. diagnosis. which will complicate the removal.7  Retraction of microflap demonstrating vocal fold fibrous mass on vocal ligament Complications can include (see Chap. Ossoff RH (1996) Immunohistochemical characterization of benign laryngeal lesions. Laryngoscope 106(Pt. Selected Bibliography 1 2 3 4 5 6 7 8 Courey MS. especially if cyst rupture has occurred prior to surgery. Laryngoscope 107:340–344 Courey MS. 17. and reassurance. and future directions. Ossoff RH (1996) Value of videostroboscopic parameters in differentiating true vocal fold cysts from polyps. ■ Surgical dissection between the epithelial covering and cyst wall (medial dissection) should precede dissection between the lesion and vocal ligament (lateral dissection). oral corticosteroid taper. ■ Cyst recurrence ■ This is unusual except in the case of anterior commissure mucous retention cysts or type III sulcus vocalis. Ann Otol Rhinol Laryngol 190(Suppl. requiring dissection into the ligament and in some cases resection of vocal ligament fibers to remove the entire cyst wall. Ossoff RH (1997) Medial microflap for excision of benign vocal fold lesions. Curr Opin Otolaryngol Head Neck Surg 10:492–496 Zeitels SM. Garrett CG. Scott MA. ■ Postoperative recovery may be slower for vocal fold cyst and vocal fold fibrous mass lesions that are on or near the vocal ligament compared to lesions in the subepithelial space. ■ Delicate handling of the cyst is necessary to avoid rupture. Nikkels PG (1995) Benign lesions of the vocal folds: histopathology and phonotrauma. Mauri M. this may require limited vocal ligament fiber resection in some cases. with meticulous detail paid to the removal of all cystic wall remnants. management theories. Often exploratory cordotomy is required to differentiate between the diagnoses of a fibrous mass versus vocal fold cyst. Fig. Rosen CA (2003) Surgical treatment of benign vocal fold lesions. and treatment of vocal fold nodules. Courey MS.):21–40 . 1):698–703 Johns MM (2003) Update on etiology. polyps and cysts. The use of steroids is especially indicated if erythema is present at the operative site. Ann Otol Rhinol Laryngol 105:525–531 Dikkers FG. Occasionally. Hillman RE. however. may persist for 3 months or more ■ Minimize by keeping suspension time to less than 2 hours ■ Prolonged postoperative dysphonia ■ Seen in cases where extensive scarring/adhesions are present. “Management and Prevention of Complications Related to Phonomicrosurgery”): 17 ■ Chipped teeth (typically maxillary) ■ Anesthesia/hypoesthesia of tongue. loss of taste ■ Due to pressure neuropathy of lingual nerve from suspension laryngoscope ■ Resolves in 2–3 weeks typically. Murry T (2000) Acoustic. where the cyst extends into the vocal ligament. Ann Otol Rhinol Laryngol 104(Pt. Curr Opin Otolaryngol Head Neck Surg 11:456–461 Rosen CA. We recommend intensive voice therapy. videostroboscopy greatly improves the chances of detection. Shohet JA. Lombard LE. a sulcus vocalis deformity is seen.112 Vocal Fold Cyst and Vocal Fold Fibrous Mass   Key Points ■ Diagnosis of vocal fold cyst and vocal fold fibrous mass may be difficult preoperatively. Revision phonomicrosurgical removal can be carried out after the third postoperative month. In these cases. aerodynamic and videostroboscopic features of bilateral vocal fold lesions. Doyle PB (2002) Phonomicrosurgery in singers and performing artists: treatment outcomes. Recurrence is generally seen within 6–12 weeks after surgery. 12. Ann Otol Rhinol Laryngology 109:823–828 Shohet JA. prolonged hoarseness and slow recovery in voice quality can be expected. Desloge R.

1 Fundamental and Related Chapters Please see Chaps. Concern of malignancy Some cases of polypoid corditis have overlying epithelial changes (e. the diseased epithelial must be treated as displayed in Chap. and vocal instability (Fig. 4. with growth of the lesions. 18. which will almost assuredly result in a recurrence of the disease postoperatively—though it may take months to years to recur. preservation of vibratory parameters does not guarantee benign disease because a microinvasive process can be camouflaged by the deep layer of gelatinous pliable material. and involves expansion of Reinke’s space by an inflammatory gelatinous amorphous material that extends from anterior commissure to the vocal process. Initially.1). gravelly voice tends to be more easily identified in females because it is gender incongruous. process of the vocal folds. However. This is a relative contraindication. but does halt its progression. suspicion of malignancy or airway concerns overrides this contraindication.3 Surgical Indications and Contraindications Indications for surgical intervention include: 1. one side at a time. or upper airway edema from an additional inflammatory process such as an upper respiratory infection. Airway obstruction due to advanced disease This may occur when a patient has a preexisting severe polypoid corditis and develops unilateral vocal fold immobility. 18. In these cases. “Vocal Fold Leuko­ plakia. 97% of patients with polypoid corditis are smokers. vibratory characteristics can be dampened and/or absent due to mass effect.2) can be used with bilateral surgery to avoid formation of an anterior glottic web.” Contraindication for surgical intervention include continued smoking. 18. One of the distinctive characteristics of polypoid corditis is the “saddle-bag” appearance the vocal folds take on. however. 10. 20. Obviously. In these cases.Chapter 18 18 Polypoid Corditis 18.1). 3. The inability to improve the airway via abduction can lead to airway compromise. 11. lowered pitch. and 12 for further information. voice therapy. and must be exercised on a case-by-case basis.. It is a condition commonly associated with smoking—in fact. A carefully planned incision (Fig.1  Polypoid corditis (bilateral) 18. In contrast to most other benign laryngeal lesions. as the heavy. 8. 18. g. leukoplakia) and can be worrisome for malignancy. as opposed to focal. but over a period of years can grow to such proportions that the airway is compromised.2 wave is often amplified or increased due to the pliable nature of the gelatinous material in the SLP. rounded vocal folds prolapse inferiorly with inspiration (Fig. the mucosal Fig. The characteristic low-pitched. 7. The condition is almost exclusively bilateral. Special consideration should be given (either preoperatively or intraoperatively) to whether to operate on both vocal folds or to stage the surgeries. The disease can be quite subtle in the early stages. 18. polypoid corditis is a global. In addition. LPR and phonotrauma are thought to be important contributing cofactors. Symptomatic dysphonia (generally more noticeable in females) 2. if this is not . Lack of response to anti-reflux management with PPIs. and smoking cessation Smoking cessation does not lead to resolution of the disease. 4. Disease Characteristics Polypoid corditis (commonly referred to as Reinke’s edema) is an alteration of the lamina propria that results in dysphonia.

Table 10. The larger suction tubing used in the units can be adapted to the smaller suction tubing using a “Christmas tree” adaptor.or 7-French microsuction with closed thumb port is used (Fig. As the dissection extends inferiorly. 18. high-powered suction (typically a liposuction device). 10. and the liposuction units are generally employed. it is necessary to put lateral pressure on the flap elevator to get adequate visualization of the flap. 18.114 Polypoid Corditis possible. 18. Raise a plane between the vocal ligament and the overlying polypoid material (Fig.6). 2. Expose larynx with suspension laryngoscope. due to the limited space that is available for tube placement. the epithelium is separated from the underlying polypoid tissue. 18. Routine operating room suction units are frequently inadequate. Frequently.5) Again.4 Surgical Equipment Standard phonomicrosurgery instrument set (see Chap. in these cases. extending well into the infraglottis. One must allow a few seconds for the maximum pressure to be achieved after placing the suction into the polypoid material. 3. and that voice therapy postoperatively will usually be required. 18.5 MLT Special care must be exercised to avoid vocal fold injury or damage. Once the material has been freed. taking great care not to perforate the epithelial flap. 5.4). Patients should be counseled preoperatively that the pitch of the voice will increase. where unilateral surgeries are performed to avoid complications. 18. an extensive flap is required. 18.2  Planned bilateral incisions in a typical case of polypoid corditis.1). and a plane is developed between the vocal ligament and the diseased polypoid tissue. Using a 30° flap elevator. it is ready for removal.3  Sickle-knife incision running in an anterior-to-posterior di- rection at the superior/lateral aspect of the vocal fold . which can be quite thin. the vocal ligament is identified at the superior/lateral aspect of the vocal fold.5 Surgical Procedure 1. Note the lack of anterior extension on the left side. and from “stem-to-stern” of the entire membranous vocal fold. It should be noted that some mild-tomoderate cases of polypoid corditis might not require much flap elevation (as described in this and step 4). there are loculations of more fibrous material mixed in with 18 Fig.3) a) Use a fresh sickle knife b) Incision at the superior/lateral aspect of the vocal fold. In general. a 5. which is designed to minimize the chances of anterior glottic web formation postoperatively Fig. Intubation with a 5 or 5. using a 30° flap elevator. Raise the microflap between the epithelium and the polyp- oid material (Fig. beginning at the vocal process and extending to within 3 mm of the anterior commissure   4. the material may aspirate more readily without the need for extensive flap elevation. Removal of polypoid material Much of the polypoid tissue can be removed with suction. Incision (Fig. suction with a strong negative pressure is essential. then a conservative approach is advocated. 6. Care is taken to retract the flap so it is not caught in the suction. however. 18. In some cases. they will likely have a short period of breathiness.

Fig. which cannot be removed by suction.7  Supplemental cup forceps removal of disease from the epithelium polypoid disease 115 . 18. which can be quite extensive in advanced cases of polypoid corditis. the epithelial removal will be the last portion of the case.4  A 30° flap elevator is used to separate the polypoid disease Fig.8).5  Elevation is carried out between the vocal ligament and the Fig. This material must be manually extracted with a straight or up cups forceps (Fig. In cases of massive polypoid corditis. it is not infrequent to sacrifice this mucosa with a large excisional removal of polypoid material. 18. One must resist the temptation to remove all the polypoid material. 18.7). It is best to try to trim the mucosa conservatively at first. as some SLP must be left behind to regenerate Reinke’s space. 18. It is best to redrape the flap prior to planning the trimming of mucosa.  Chapter 18 the gelatinous polypoid material. 18. Trimming of redundant mucosa There is usually a certain amount of redundant mucosa. This mucosa should be conservatively trimmed so that the epithelial edges coapt at the end of the case. more mucosa can always be removed later if needed. however. (Fig. and maintain vibratory properties. 18.6  Suction removal of polypoid disease Fig. In many cases. 7.

and lack of projection.6 Postoperative Care and Complications Postoperative care should include PPIs. ■ Complications are generally related to technical errors in the surgical procedure. ■ Surgical indications for polypoid corditis include symptomatic dysphonia despite medical management. which can occur when raw surfaces are left at the anterior free edge of both vocal folds. Key Points ■ Polypoid corditis is a bilateral process characterized by expansion of Reinke’s space with gelatinous inflammatory material throughout the entire vocal fold. and voice rest for 5–7 days. but incisions should not extend to the anterior vocal fold to avoid web formation. ■ Removal of the polypoid material may require a high-vacuum suction device and/or manual extraction of loculated portions of the disease.116 Polypoid Corditis Fig. recovery and stabilization of voice takes longer than with most other benign lesions. the pitch of the voice will be significantly higher due to the loss of mass after the surgery. 18 18. Expected postoperative course: ■ The patient will experience a breathy voice postoperatively. The most serious complication is anterior glottic web. Alternatively. The incised edges of the flap should coapt closely. typically 6–8 weeks. The result is stiffness/loss of vibratory properties with rough.8  Trimming of redundant epithelium with up-cutting scissors Long cuts across the mucosa are preferable to short cuts. In addition. pain medicine. ■ It is critical that some gelatinous material in the SLP should be left behind to reconstitute Reinke’s space and preserve vibratory characteristics.9). 18. breathy dysphonia. and not to extend the incisions to the anterior most aspect of both vocal folds. and these tend to give a jagged contour to the cut edge. without a significant mucosal dehiscence (Fig. ■ Microflap surgery can be performed bilaterally. A risk factor for unfavorable scarring is the removal of excessive amounts of the SLP/gelatinous material. In general. . 18. it is acceptable to operate unilaterally and stage the second procedure. primarily due to the preoperative high subglottal pressures that are used to drive the vibration of the polypoid material. Smoking should be discontinued or significantly reduced in the postoperative period.   Fig. and is seen almost exclusively in smokers. airway encroachment/partial obstruction. 18. The best way to avoid this complication is to make the incisions on the lateral aspect of the vocal fold. vocal fatigue. or concern of malignancy.9  After epithelial removal with minimal mucosal dehiscence ■ Scarring of the vocal folds can also occur.

Ann Otol Rhinol Laryngol 104:267–273 Zeitels SM. Bishop SG. Bunting GW. Bennett S (1987) Comparison of surgical techniques in the treatment of laryngeal polypoid degeneration. Laryngoscope 100:399–402 3 4 Courey MS. Ossoff RH (1995) Endoscopic vocal fold microflap: a three-year experience. Ann Otol Rhinol Laryngol 106:533–543 117 . Gardner GM. Stone RE. Bennett S.  Chapter 18 Selected Bibliography 1 2 Lumpkin SM. Bishop SG (1990) Postsurgical followup study of patients with severe polypoid degeneration. Ann Otol Rhinol Laryngol 96:254–257 Lumpkin SM. Hillman RE et al (1997) Reinke’s edema: phonatory mechanisms and management strategies.

3 Surgical Indications and Contraindications Indications for vocal fold granuloma surgical removal include: ■ To rule out malignancy or infectious etiologies (e. If the vocal fold granuloma is extremely large. Vocal fold granulomas are thought to occur from a perichondritis of the arytenoid cartilage. then shortness of breath and dyspnea on exertion and other airway related symptoms can be present.4 Fig. The most common causes of vocal fold granulomas are thought to be laryngopharyngeal reflux. these lesions can be treated expectantly as long as the LPR is controlled. Table 10. For perichondritis of the arytenoid cartilage to occur. 19.1). 19. and subsequent injury to the perichondrium can occur from persistence of the endotracheal tube or LPR. tuberculosis. glottal incompetence with severe hyperfunction often associated with vocal fold paresis. This patient subgroup will do quite well and often not require surgical excision of the vocal fold granuloma. and a posteriorcommissure laryngoscope (as needed).1  Vocal fold granuloma Surgical Equipment The surgical equipment required is a standard phonomicrosurgery instrument set (see Chap. Differential diagnosis for vocal fold granuloma include: (It should be noted that all of the below diagnoses almost never present as isolated lesions at the vocal process/arytenoid): ■ ■ ■ ■ ■ Squamous cell carcinoma Carcinoma in situ Dysplasia Amyloidosis Tuberculosis of the larynx 19.Chapter 19 19 Vocal Fold Granuloma 19. . 4. Klebsiella) ■ Airway obstruction ■ Symptoms of persistent disease despite nonsurgical treatment methods ■ Growth of lesion despite medical treatment Contraindication of vocal fold granuloma surgery comprise surgical removal without addressing the possible underlying etiologic conditions preoperatively (LPR. vocal fold atrophy. Granulation tissue can form on other locations of the vocal folds. and chronic cough. dysphonia. 19. Vocal fold granuloma is classically seen after endotracheal intubation. The granuloma typically arises in the area where the vocal process adjoins the body of the arytenoid cartilage.1). voice misuse and/or glottal insufficiency). vocal fold paralysis.2 Disease Characteristics and Differential Diagnosis Vocal fold granuloma is inflammatory tissue arising from the perichondrium near the arytenoid cartilage (Fig. however. 5. 10.1 Fundamental and Related Chapters Please see Chaps.. Typically. Patients with a vocal fold granuloma can experience globus sensation. The intubation or endotracheal tube causes mucosal injury. 11. it is thought that there needs to be a two-step process of (1) mucosal injury and (2) subsequent injury to the perichondrium of the arytenoid cartilage. these are different clinical entities and are not discussed in this chapter. The postintubation granulomas typically occur in females more than in males and are often associated with a comorbid condition of laryngopharyngeal reflux disease. and 12 for further information. and/or odynophonia. 19. Vocal fold granuloma can occur unilaterally or bilaterally. vocal misuse or hyperfunction. 10. vocal fold scar. g. 1.

3). it is important that all aspects of the surgical removal of the vocal fold granuloma are aimed at: a) Maintaining as much normal mucosa surrounding the surgical site as possible b) Minimizing all possible irritation or trauma to the underlying arytenoid cartilage perichondrium 2. thus allowing the removal of the vocal fold granuloma (Fig. the alligator will grasp the stalk on its most medial aspect. then the patient will not have a recurrent granuloma. This will allow an unfettered view of the posterior commissure. examine the lesion at high-powered magnification. which is required for this surgery. 19. it is best to use a curved alligator (curved in the opposite direction of the side that the vocal fold granuloma is on) and gently grab the stalk that runs between the vocal fold granuloma and the arytenoid cartilage. With this in mind. however. 4. 19 Fig. and gain a sense of the size and location of the stalk. 19. Exposure and preparation for vocal fold granuloma excision If the vocal fold granuloma is large or the anesthesiologist refuses to use a small endotracheal tube (5. For removal of the vocal fold granuloma. Application of epinephrine-soaked pledgets (1:10. 19. This can also be done by passing a small curved alligator between the vocal fold granuloma and the arytenoid cartilage. then a recurrent granuloma is highly likely. Philosophical overview for vocal fold granuloma removal The overall goal for surgical removal of vocal fold granuloma is to remove the vocal fold granuloma lesion in as an atraumatic fashion as possible. and a curved microscissors (curved in the same direction as the curved alligator) is then used to release or cut the stalk immediately lateral to the curved alligator.5 Surgical Procedure 1.2  Nonparallel placement of the laryngoscope and endotra- cheal tube Fig. success of the operation (no recurrent granuloma disease) is dependent on the race between the underlying inflamed perichondrium and the surrounding normal mucosa. If the mucosa “wins” this race. with a   net result of keeping the endotracheal tube in an anterior location while the surgeon works in the posterior glottis (Fig.2). After the laryngoscope is suspended and adequate exposure of the posterior glottis is achieved. The Pilling posterior-commissure laryngoscope facilitates the anterior displacement of the endotracheal tube because it has a slight notch to hold the endotracheal tube anterior during laryngoscope suspension.000 dilution) will achieve hemostasis without any difficulty. The other method to keep the endotracheal tube in an anterior position is to slightly alter the angle of the endotracheal tube as it goes through the larynx so it lays nonparallel to the longitudinal axis of the laryngoscope. 19. The vocal fold granuloma stalk can then be gently retracted towards the midline. The ideal exposure for vocal fold granuloma surgery is to have exposure and good visualization of the posterior aspect of the midmembranous vocal fold and the entire arytenoid and posterior glottic area on the side of the lesion. then the surgeon should position the endotracheal tube anterior to the laryngoscope during laryngoscope suspension.0). Preferably.3  Retraction of vocal fold granuloma stalk with curved alliga- tor and cutting of stalk . this will allow the surgeon to identify the exact location and nature of the vocal fold granuloma stalk. 3. specifically gently retracting the lesion from its attachment from the arytenoid to view. The slight angulation of the laryngoscope also keeps the endotracheal tube anterior and provides optimal exposure of the arytenoid and posterior membranous vocal fold.120 Vocal Fold Granuloma 19. It is important recognize that after vocal fold granuloma removal. 5. if the perichondrial inflammation continues.

Am J Otol 26:101–107 Ylitalo R. If this tissue is present. Hammarberg B (2000) Voice characteristics. ■ Surgery should be performed if concern exists regarding a malignancy or infection. then vocal fold augmentation should be strongly encouraged and performed simultaneously to the vocal fold granuloma excision (see Chap. and long-term follow-up of contact granuloma patients. Complications after vocal fold excision surgery include: ■ Recurrent lesion ■ Severe cartilaginous or membranous vocal fold defects from excessive or overly aggressive surgical excision of the vocal fold granuloma To address the problem associated with a recurrent vocal fold granuloma. etc. Another adjunctive treatment option especially for recurrent vocal fold granuloma surgery is to consider a vocal fold Botox injection to chemically “splint” or put the voice “at rest” after the vocal fold granuloma excision. Acta Otolaryngol 120:655–659 Ylitalo R. ideally Botox injection should be done 3 days prior to the surgical excision of the granuloma (see Chap.6 Postoperative Care and Complications Postoperative care typically involves voice rest for a variable number of days (6–10 days). Laryngoscope 109:433–436 Ylitalo R. Oral Oncology 41:666–669 Hoffman HT. 35. Key Points ■ Vocal fold granuloma is a perichondritis of the arytenoid cartilage from various insults (voice misuse. effects of voice therapy. depending on the exact clinical situation. J Voice 14:557–566 Ylitalo R. “Vocal Fold Augmentation via Direct Laryngoscopy”).). including sclerosis of the arytenoid cartilage: radiographic findings. Ann Otol Rhinol Laryngol 102:756–760 Devaney KO. 19. Botox can be done during microlaryngoscopy by injecting into the TALCA muscle complex—direct the Botox needle lateral and slightly outward from the vocal process on the side of the vocal fold granuloma. Kendall K (2005) Effects of voice therapy on vocal process granuloma: a phonoscopic approach. LPR treatment (despite the clinical history) should be implemented. Adjunctive procedures to vocal fold granuloma surgery After the successful removal of the vocal fold granuloma. If vocal fold augmentation is warranted. Selected Bibliography 1 2 3 4 5 6 7 8 Benjamin B. This includes speech–language pathology evaluation and voice therapy. McCulloch TM (2001) Vocal process granuloma. one should fully evaluate the size and nature of the vocal fold to consider if the patient requires vocal fold augmentation. 7. Careful examination and palpation of the operative site will reveal if there is any residual granulation tissue or inflammatory tissue. the vocal fold is “at rest” at the time of the excision. and assessment and treatment for glottal insufficiency. Ramel S (2002) Extraesophageal reflux in patients with contact granuloma: a prospective controlled study. differential diagnosis and treatment. Head Neck 23:1061–1074 Leonard R. Overholt E. and patients should be carefully evaluated for the most common causes of glottal insufficiency and treated at the same time as vocal fold granuloma excision if appropriate. endotracheal intubation. it is important that all different etiologic possibilities are carefully and systematically reviewed prior to proceeding with a repeated surgical procedure. Voice rest is indicated to maximize the chance of successful healing of the operative site and minimize a chance for recurrent vocal fold granuloma formation. LPR. ■ Underlying glottal insufficiency is a common cause of recurrent vocal fold granuloma. it is best to remove it very carefully and conservatively with l-mm cup forceps or the micro-ovoid cup forceps. Roche J (1993) Vocal granuloma. or all nonsurgical treatment options have been exhausted. ■ Careful surgical excision of the vocal fold granuloma with minimal trauma to the underlying perichondrium and surrounding mucosa is essential to successful surgery for vocal fold granuloma. Ann Otol Rhinol Laryngol 111(Pt. Rinaldo A. Thus. 1):441–446 121 . Great care should be taken at this juncture to fully remove obvious exophytic tissue and not remove any surrounding normal mucosa or to reach deeply into the operative site. However. This will minimize the risk of traumatizing the underlying arytenoid perichondrium. including behavior modification and PPI therapy. In addition. Lindestad PA (1991) A retrospective study of contact granuloma. 31. Karnell M. “Botulinum Toxin Injection”). LPR treatment. Lindestad PA (2000) Laryngeal findings in patients with contact granuloma: a long-term follow up study.  Chapter 19 6. Ferlito A (2005) Vocal process granuloma of the larynx: recognition.

 e. Infiltrate into the submucosal space—superficial lamina pro- Fig. Invasive areas of mucosa can sometimes be noted to remain adherent to the underlying vocal ligament. noninvasive leukoplakia will be noted to lift up from the underlying vocal ligament. In this example. Histopathologically.1) and keratosis are clinical disease processes of the vocal fold epithelium.3). tenacious mucous. 0. The patient typically presents with a rough or coarse voice.3 Surgical Indications and Contraindications Indications include: ■ Leukoplakia of the vocal folds. Table 10. 10. so that air is not infiltrated under the flap. and generally. Notable exceptions to this rule are the presence of coexisting polypoid corditis and microinvasive carcinoma of the vocal fold. creating a depression. and 10 for further information.2). 20.).Chapter 20 20 Vocal Fold Leukoplakia and Hyperkeratosis 20. etc. Expose larynx with suspension laryngoscope. other inflammatory conditions may contribute to the development of this epithelial change. the mucosal wave may be preserved due to extensive expansion of the SLP. 20. however. generally.3 ml is all that is necessary.4 Surgical Equipment The surgical equipment required is a standard phonomicrosurgery instrument set (see Chap. 20. where histopathology has not been established (especially in cases where mucosal wave is reduced or absent at the lesion site) ■ Change in the appearance or nature of preexisting leukoplakia A (relative) contraindication is a patient who is high-level vocal professional (i. 3.5 microlaryngeal endotracheal tube 2. such as LPR or possibly viral infection. 8. PPIs.1). fungal infections (especially candidiasis) and occasionally.1  Leukoplakia of the vocal fold pria or Reinke’s space—using a 27-g needle (Fig. 20. . 20. 20. as noninvasive pathology tends to preserve mucosal wave. 7.1 Fundamental and Related Chapters Please see Chaps. The physical findings consist of a white plaque on the surface of the vocal fold. or “divot” (Fig. but vocal fold leukoplakia may be found in an “asymptomatic” patient on routine flexible laryngoscopy. b) The infiltration should be done slowly.0 or 5. 3. videostroboscopic characteristics give valuable information regarding the potential for malignant invasion.5 Surgical Procedure 1. Videostroboscopy is essential in the evaluation of leukoplakia of the membranous vocal folds. More importantly. Tenacious mucous can easily be distinguished from a leukoplakic plaque by observing the characteristic movement of the mucous during vibratory activity. c) Ensure that the needle is primed. 20. a) The mucosa will be distended. leukoplakia can vary from the very benign (hyperkeratosis of the epithelium) to frankly malignant (microinvasive squamous cell carcinoma). singer) before attempting conservative management (antifungals.1– 0. 20. The differential diagnosis of leukoplakia includes papillomatosis.. Intubate with 5. 4. whereas invasive disease leads to the loss of vibratory characteristics. Patients with vocal fold leukoplakia are typically smokers.2 Diagnostic Characteristics and Differential Diagnosis Vocal fold leukoplakia (Fig.

which may result in anterior glottic web formation. Make posterior. This can be accomplished by placing the epithelial specimen on a tongue blade. one must push the back end of the flap elevator against the vocal ligament laterally. 20. c) Caution must be exercised when extending the dissection inferiorly. but instead extends laterally. b) Very early in the dissection. i Note that if a diagnosis of malignancy has not been established. This is especially true in cases of re-excision for recurrent leukoplakia and inflammatory leukoplakic processes.9) Special consideration should be given to: ■ Pinning and orienting the specimen for the pathologist can be very helpful in guiding future therapy. Undermine the diseased epithelial layer from the underlying structures (Fig. indicating the medial/lateral and anterior/ posterior orientation (Fig. then anterior epithelial incisions (Fig. future endoscopic treatment can be directed to the specific region of the vocal fold that is involved. 20. 20.4) a) Use a fresh sickle knife. 20. 20. It is relatively easy to place the flap elevator into of the fibers of the vocal ligament. in a posterior-to-anterior direction. if one is not careful. and begin the plane too deep. which “tents up” the mucosa. ii Keep the incision superficial by maintaining a slight pull on the knife superiorly (toward you). 5. as the surgical plane does not continue in the same direction.000 epinephrine in vocal fold 4. Incision (Fig. 20. however. 7. taking care to be as superficial as possible. one must identify the vocal ligament.8) and rechecking the incisional line. one must be cautious to avoid bilateral anterior epithelial removal. Using this information. Complete the excision by making the inferior epithelial cut. Because of this. ■ Multiple patches of leukoplakia can be addressed in the same setting. taking note of any anatomic regions that are severely dysplastic/and or invasive. It is recommended that the surgeon review the histopathology personally with the pathologist. 20. a) It is often helpful to check that the microflap incision encompasses the entire diseased epithelium by periodically redraping the flap (Fig. which improves exposure for inferior flap elevation (Fig. a) Use the 30° flap elevator to develop a plane in the subepithelial space.7) a) Using an up-cutting scissors held sideways in one hand and a flap elevator in the other. it is easy to perforate the epithelial flap.6a. b) The epithelial lesion is retracted with a microflap using a triangular forceps. This is done by visualizing the flap elevator through the flap as the dissection proceeds.10).3  Invasion of epithelial lesion into the vocal ligament. while an up-cutting scissor is used to excise the lesion in a posterior to anterior direction. b) Make the initial incision just lateral to the area of leuko- 20 plakia. 20. To avoid this tendency. b) d) Ensure that the entire extent of the leukoplakia is undermined freely prior to proceeding. (Fig. 20. . the leukoplakic flap is lifted up and the posterior boundary of epithelium is incised.124 Vocal Fold Leukoplakia and Hyperkeratosis   Fig. followed by the anterior.2  Submucosal infusion of 1:10. protecting the deeper layers. a focal depression or “divot” within the otherwise distended SLP after submucosal infiltration 6.5). creating Fig. no “margins” are required.

6  Coronal section of vocal fold depicting lateral pressure on Fig.7  Anterior flap incision is made after the posterior incision the flap elevator to improve visualization of infraglottic flap 125 .4  Sickle knife incision immediately lateral to leukoplakia Fig.5  Flap elevation (undermining) of leukoplakic lesion Fig.  Chapter 20 Fig. 20. 20. 20. 20.

20. ■ Loss of mucosal wave can be seen with invasive forms of leukoplakia. These areas should be aggressively treated if they are suspected.9  Final (inferior) flap incision Complications can include: ■ Chipped teeth. 20. while noninvasive forms tend to have preservation of vibratory characteristics. ■ Subepithelial infusion is a very helpful adjunct in the surgical armamentarium. ■ Complete excision of the area of leukoplakia should be checked by redraping the flap during the final excisional step. P = Posterior. hypoesthesia of tongue ■ Recurrence of leukoplakia Recurrence of leukoplakia is common in those patients that continue to smoke postoperatively.10  Typical orientation of excised leukoplakic specimen for pa- thologist (A = Anterior. L = Lateral. glottic incompetence.126 Vocal Fold Leukoplakia and Hyperkeratosis Fig. thus protecting it.8  Redraping of flap to ensure complete removal of pathology   Fig. 20. M = Medial) 20. . ■ Pinning and orienting the epithelial specimen can be very helpful in guiding any additional therapy. such as LPR.6 Postoperative Care and Complications Postoperative management includes: ■ Complete voice rest for 3–7 days ■ PPIs. therefore. this should be part of pre operatively counseling. 20 Key Points Fig. as it reduces intraoperative bleeding and lifts the diseased epithelium away from the vocal ligament. pain medication ■ Follow-up 1–2 weeks to review pathology results ■ Videostroboscopy is an important component of the preoperative evaluation of vocal fold leukoplakia. or HPV infection. Patients may have other cofactors leading to the recurrence of leukoplakia.

110(9):811–4 127 . Zeitels SM (1993) Microflap excisional biopsy for atypical and microinvasive cancer. Operat Tech Otolaryngol Head Neck Surg 4:218–222 Schweinfurth JM. Otol Head Neck Surg 105:478–479 Zeitels SM (1995) Premalignant epithelium and microinvasive cancer of the vocal fold: the evolution of phonomicrosurgical management. Ossoff RH (2001) Regression of laryngeal dysplasia after serial microflap exision. Ann Otol Rhinol Laryngeal Sep.  Chapter 20 Selected Bibliography 1 2 Zeitels SM. Vaughan CW (1991) A submucosal true vocal fold infusion needle. Powitzky E. Laryngoscope 105:1–51 3 4.

however. Differential diagnosis for RRP is: ■ ■ ■ ■ Squamous cell cancer Verrucous carcinoma Leukoplakia Granuloma 21. parent education on the importance of compliance with doctor’s visits and monitoring of symptoms and signs of airway difficulties are essential.3 Surgical Indications and Contraindications Indications include: ■ In pediatric cases of RPP. 9. voice disturbance is the most common indication for surgical treatment of RRP. 12. Often recurrent RRP patients have 50–100 surgeries in their lifetimes. Tracheotomy creates a new epithelial transition site in the trachea and may lead to new RRP growth at the tracheotomy site. Contraindications include surgical excision without any voice. or airway symptoms. 11. Subsequent to establishing the diagnosis of RRP. and thus the surgeon must constantly remember that the primary goal for surgery is to remove the disease and minimize the sequela of surgery (vocal fold scar. The lesions often have a distinct vascular “dot” in the center of individual papilloma growth (Fig. With the recurrent nature of RRP disease and the need for multiple repeated surgeries. 4. “Principles of Phonomicrosurgery”). Fig.1).Chapter 21 Surgical Treatment of Recurrent Respiratory Papillomatosis of the Larynx 21. and 13 for further information. the glottis is the most common site. web formation.). concepts.2 Disease Characteristics and Differential Diagnosis Recurrent respiratory papilloma (RRP) is characterized by benign epithelial growths that are recurrent in nature after surgical removal. RRP growths can be exophytic and/or superficial “spreading. careful and conservative surgery is crucial to 21 the surgical management of this disease. and techniques are ideal for the surgical therapy of RPP (see Chap. Adult RRP surgery is usually indicated to rule out malignancy initially and to make a pathologic diagnosis. ■ A key management principle in RRP is to focus attention and efforts on preventing the need for a tracheotomy. It has been found that RRP tends to favor growth at the epithelial transition sites such as at the level of the glottis where the epithelium changes from stratified squamous epithelium to pseudostratified columnar epithelium. 21. 10. phonomicrosurgery principles. 21. swallowing. airway considerations are primal. For this reason.1 Fundamental and Related Chapters Please see Chaps. etc.1  Recurrent respiratory papilloma . Given the recurrent nature of RRP. 21. 10. The etiologic agent of RRP is human papilloma virus (types 6–11 are the most common). The presence of new RRP at the tracheotomy site significantly increases the level of complexity of the surgical management of these patients.” RRP can occur anywhere in the laryngotracheal area.

it can be done with any of the below described techniques (see “Cidofovir Laryngeal Injection for RPP. 2. “Vocal Fold Leukoplakia and Hyperkeratosis”) a) Place the largest laryngoscope over the RRP site (note that the surgeon may have to reposition the laryngoscope multiple times to work on several different locations within the larynx to address all RRP locations on an as needed basis). and thus the incision should be immediately adjacent to the interface of RRP and normal mucosa. 21. 21. 10. When cidofovir injection is being combined with surgical excision. This chapter describes the different surgical methods for RRP removal and then discusses surgical removal of RRP by different subsites within the larynx. Note that no margin is required in removing the recurrent respiratory papillomatosis. Sect.2  Microflap removal of RRP Fig. d) Subepithelial dissection (undermining of the RRP disease is then done with curved and angled elevators and sometimes with microcurved scissors). 10. 21 Fig. gross disease should not be left. Table 10. e) Incision through the epithelium can then be made anteriorly and posteriorly to the RRP. CO2 or pulsed KTP laser (see Chap. once again. This releases the RRP completely and specimen can be sent for pathologic examination (Fig. 13. voice) not complete removal of the disease is important. conservative removal and focus of improving functional improvement (airway.” below).1) 2. Thus.130 Surgical Treatment of Papillomatosis 21. and the most aggressive surgical excision does not equal better results. “Principles of Phonomicrosurgery” and 20.2).4) 21.5 Surgical Procedure 1. 21. g) Immediately redraping the microflap to assess the extent of the dissection and to determine if the entire papilloma area is included within the microflap is extremely helpful. Standard phonomicrosurgery instrument set (see Chap. and then superficial dissection underneath the RRP can then be performed until the entire RRP has been incorporated within the microflap. 10) 3. with no need for a mucosal margin. Microflap Removal of RRP (see Chaps. however. Microdebrider (optional. or longer interval between surgical treatments.3  Release of microflap containing RRP . 10) c) A sickle knife is then used to incise the epithelium im- mediately lateral to the recurrent respiratory papilloma disease. Great care should be exercised to stay very superficial (Fig. h) Hemostasis can be obtained with an epinephrine-soaked pledget.   b) Submucosal infusion of epinephrine throughout the in- tended surgical area (see Chap. 13. f) The RPP that is contained within the microflap can then be held with triangular forceps or a curved alligator. described in Chap.3). 21.4 Surgical Equipment 1. cure. Not staying as superficial as possible will result in unnecessary loss of vocal fold lamina propria and scar formation. Inferior incision underneath the area of the microflap containing the RRP can then be done with a sickle knife or microscissors. Overview RRP is a recurrent disease process (99% of the time).

g) Epinephrine-soaked pledgets can be applied to the operative site to obtain hemostasis on an as needed basis. 21. This should be done with both high-power microlaryngoscopy as well as with angled telescopes (see Chap. Note blunt probe adjacent to disease. false vocal fold. 21.4  Cup forceps removal of RRP Fig. e) The laser is used to vaporize the RRP. This allows for hydrodissection of the RRP from the deeper structures of the vocal fold as well as enhances hemostasis. with a low power (2–4 W) on intermittent superpulse setting. c) Gently and precisely grab a part of the RRP to be removed (depending on size of lesion) with 1–2 mm microforceps (cup/or ovoid). h) Laser ablation should be done in a controlled fashion and great care is required to insure that repeated “doses of laser energy” are not delivered to the same exact location consecutively. e) Avoid pulling the RRP anteriorly or posteriorly since this may result in “stripping” of normal adjacent mucosa inadvertently. 4.75 mm. anterior commissure. g) Surrounding areas not intended for excision (i. j) If more RRP is present. e. care should be taken to only ablate the RRP tissue and not the deeper aspect of the vocal fold. 3.. 13. spot size. Microforceps removal of RRP a) Inject epinephrine subepithelially throughout the intended RRP excision site.) should be retracted or covered with saline-soaked pledgets to protect inadvertent injury or damage. This allows the surgeon to hand the RRP-laden instrument to the surgical assistant and receive the second instrument to continue the RRP removal while the assistant removes the RRP from the first instrument.4). Superior or inferior direction of avulsion is the safest (Fig.5  Microdebrider removal of RRP. f) Carbonaceous material from the laser ablation site should be removed frequently with suction cannulas (5 or 7 French). It is most expedient to have two microforceps available of similar size and nature to perform this type of surgical removal. then further surgical removal can be done using another microflap approach or microforceps removal technique (see below). Make sure that the forceps are only holding on to the most superficial aspect of the RRP and not any deeper part of the mucosa or vocal fold.  Chapter 21 i) Inspection (visual and by palpation) for RPP at the op- erative site is important.5–0. and duration of exposure can be adjusted to prevent damage to deeper structures and transmission of thermal injury to surrounding regions. c) Implementation of all laser safety precautions (see Chap. 21. d) The RRP within the forceps can then be gently avulsed by pulling the tissue in either a cephalad or caudal direction. which is used to “pin” the vocal fold so that deeper structures are not drawn into the microdebrider 131 . Power. This surgery should be performed at high power magnification for maximum control and precision of the RRP removal. etc. f) These steps can be repeated until all the intended RRP has been carefully removed. Laser surgery for RRP a) Exposure of RRP with the largest possible laser laryngoscope b) Submucosal infusion of epinephrine to intended area of RRP excision. vocal fold. “Principles of Laser Microlaryngoscopy”) d) It is best to use a “defocused spot size” 0. This cycle can be continued until all the RRP is removed in a fairly rapid fashion. 10). contralateral. b) Place epinephrine-soaked pledgets on the RRP site for several minutes. This can be achieved by moving the Fig.

i) To “capture” the RRP tissue for pathologic examination. false vocal fold.6  Removal of RRP at the anterior commissure. It also encompasses the anterior commissure.5). and expedient fashion. supraglottic portion of the arytenoid cartilages and the laryngeal surface of the epiglottis. and the infraglottic region. Angled telescopic examination of this area is absolutely essential at the end of each surgical procedure for RRP to ensure thorough removal of gross disease in this region. f) The safest method for RRP removal is to hold the microdebrider “blade or port” 1–2 mm over the RRP disease and allow the suction from the instrument to draw the RRP tissue away from the deeper aspects of the laryngeal tissue and be removed by the internal blades of the microdebrider. h) Apply epinephrine-soaked pledget to the surgical site to obtain hemostasis after removal of the RRP. and posterior glottis. 21. Microdebrider removal of RRP a) Placement of the largest laryngoscope to expose the area of RRP removal b) Submucosal injection of epinephrine c) Epinephrine-soaked pledgets placed on the area of the RRP intended for excision and then removed d) The smallest and most conservative microdebrider blade should be placed on the microdebrider handle. 6. then the complete visualization and subsequent removal can be further facilitated with submucosal infusion to medialize the disease for better visualization. glottis. Cold-steel surgical excision of papilloma of supraglottic or CO2 laser area also all reasonable options for this region. g) As the settings are adjusted and comfort level of the surgeon is increased. e) The microdebrider starting setting should be 800–1200 and then can be adjusted accordingly.132 21 Surgical Treatment of Papillomatosis laser beam in a smooth. (Note that the blue shaded region should be preserved to prevent anterior glottic webbing) papilloma disease from all other areas in the supraglottis can be done in an expedient and safe fashion using a microdebrider (preferred technique). a suction trap can be placed “inline” with the microdebrider suction and at the end of the procedure sent for pathologic examination. Surgical removal of gross   Fig. especially at the start of the case. thus preventing the same location from receiving repeated laser energy. This area is of prime importance given the phonatory dependent nature of these tissues and because of the known predilection of RRP to occur in this zone. the free edge of the vocal fold. subglottis) Angled telescopes can be used for telescopic removal of the RRP utilizing a 30 or 70° telescope and angled cup forceps and/or a micro­ debrider. Telescopic examination is of further value for complete assessment of the disease at the anterior com- . This is especially true for the subglottis. the microdebrider can be placed closer to the RRP tissue. 21. g. Controlled removal of the RRP can be done in a fairly expedient fashion due to the rapid RRP removal afforded by the microdebrider. It is often helpful to “pin” the vocal fold in a stationary position with an adjacent blunt probe to prevent the deeper tissues (e. and thus only epithelium needs to be removed. ligament) from being suctioned into the microdebrider chamber (Fig. b) Glottis The region of the glottis incorporates the superior surface of the vocal fold. Thirty and 70° telescopes are important adjuncts for visualization of this area and sometimes may need to be used for surgical removal of a papilloma in this area (see above telescopic RRP surgery). Specifically in the anterior commissure. If RRP is extensively located on the superior surface of the vocal fold. The laryngeal ventricles are clearly the most difficult anatomic area to visualize and operate on within the larynx. Care should be taken to avoid demucosalization of the anterior aspect of the free edge of each false vocal fold to prevent supraglottic stenosis. It must be stressed and remembered that RRP is a superficial disease. 5. the importance of precise and conservative surgical removal of disease in a unilateral nature to prevent glottic web formation is paramount. controlled. anterior face of the arytenoid cartilage. Recurrent respiratory papilloma sites: technical aspects and methods for surgical removal: telescopic RRP surgery Standard microlaryngoscopy visualization can be limited in several locations (ventricle. microforceps or microdebrider usually after submucosal infusion). a) Supraglottis The anatomic components of the supraglottis include laryngeal ventricles.. which may result in deep tissue injury. The preferred surgical removal of RRP in this region is a cold-steel approach (microflap. always attempting to apply minimal pressure to the RRP tissue with the microdebrider hand piece.

the most common method of cidofovir use is laryngeal injection of cidofovir after conservative surgical removal of the RRP. 21. it is wise to make an initial “incision” or “cut” through the RRP at the anatomic midline. 7. This is strictly up to the surgeon’s preference and based on the total dose of cidofovir to be used and the specific nature and location of the RRP. including protection of surrounding laryngeal tissues and using the laser in a low-power and intermittent delivery mode. posterior commissure (bilateral). 21. given that past research has identified the human papilloma virus in the epithelium of the upper airway. When there is mucosa present in the area to be injected. Then unilateral RRP removal can proceed with little chance of accidental bilateral RRP removal. Cidofovir injection into areas without mucosa. superior surface of vocal fold and ventricle (bilateral). a CO2 laser can have an advantage given that hand instruments can be used for retraction while the CO2 laser is used for excision or ablation of the RRP. multiple superficial injections are required since the tissue planes are absent or distorted. false vocal fold (bilateral). negating the ability to distribute cidofovir over a large area with a single injection. This antiviral agent has been used as sole therapy without removal of disease and has been used at the same time as recurrent respiratory papillomatosis is surgically removed. patients receive intralesional cidofovir injection on a monthly basis for three or more total injections times. is known to be present throughout the mucosa of the entire upper airway. Chapter 21 The surgical technique associated with cidofovir injection involves a two key principles. and supraglottic larynx on an as-needed basis. 5 mg/ml is a reasonable dose used by many. Typically. Careful examination of this region is mandatory during all operative procedures relating to RRP and typically will require anterior displacement of the endotracheal tube for complete and detailed examination of this region (if an endotracheal tube is being used). When surgically removing RRP from only one side of the anterior commissure. If visualization is particularly difficult. For this reason. Presently. To facilitate further exposure in this region. The best RRP disease control occurs with repeated cidofovir injection at the same time that staged surgical excision is performed. human papilloma virus. First. Cidofovir laryngeal injection for RPP Cidofovir is an antiviral agent that has been used extensively recently as an adjunct treatment for RPP. In these settings. it is important to remember that the etiologic viral agent of RRP. should be done in the most superficial plane possible. however. staged excision of RRP to prevent posterior glottic stenosis. in addition to not violating the contralateral mucosal or RRP covered tissue. When working at the anterior commissure. often instrumentation is required to retract the arytenoid cartilages to examine fully this region. free edge of vocal fold (bilateral). Cidofovir injection should be done in a caudal to cephalad direction. Microforceps or microdebrider are good methods for unilateral. Secondly. Cidofovir injection is done in this location. careful retraction of the vocal fold for full exposure of the anterior commissure is essential (see Fig. d) Posterior commissure The posterior commissure is the region of the larynx extending from the arytenoid region down into the subglottis.  missure and in the infraglottic regions. Often cidofovir can be infused submucosally in a large area of the laryngeal subunits described above with a single injection. There is no standard dose of concentration of cidofovir for injection. the injection needle should be placed in the subepithelial plane. Cidofovir intralaryngeal injection after surgical excision can be done in anatomic subunits to insure wide mucosal distribution of the antiviral agent. it is prudent to inject cidofovir in normal appearing mucosa in a wide region around and inside the larynx. cidofovir can be injected submucosally prior to a surgical excision as well as immediately after the surgical excision. c) Level of the subglottis RRP disease in the subglottis is of great concern due to the airway limitations and minimal dimensions of this region. Surgical removal in this area should be in a conservative fashion given that excessive surgical removal by any technique can lead to significant posterior glottic stenosis.6). due to recent RRP removal. This can be done with a contralateral hand instrument or a self-retaining retraction instrument. It must be stressed that the CO2 laser must be used in a conservative fashion. The typical sequence of intralaryngeal cidofovir injection will cover the following areas in this order: subglottis.6 Postoperative Care and Complications Postoperative care includes: ■ Intravenous and oral steroids can be used as clinically indicated ■ LPR treatment if necessary (proton pump inhibitor and behavior modification) ■ Pain medicine on an as-needed basis ■ Limited or no voice rest as indicated Complications include: ■ Laser fire and thermal injury to larynx ■ Glottic web (anterior/posterior) ■ Excessive vocal fold scar formation or tissue destruction 133 . Optimal surgical technique and removal of disease in this area involves either cold steel excision or microdebrider. Telescopic examination (30 and 70° telescopes) is helpful to visualize this area and determine the nature and extent of the RRP disease. Cidofovir injection can be done with a fine-gauge needle (25–27 g) and should be done in a superficial (subepithelial) fashion.

134 Surgical Treatment of Papillomatosis Key Points ■ RRP is a recurrent disease that requires precise and conservative surgical removal. laser. Leventhal B et al (1993) Sites of predilection in recurrent respiratory papillomatosis. J Voice 12:1323–1327 . and at the completion of RRP removal. during surgical excision. Topp W. Sha KV. Sataloff RT (1999) Phonomicrosurgical resection of glottal papillomatosis. Schneider P et al (1983) Laryngeal papilloma virus infection during clinical remission. N Engl J Med 308:1261–1264 Zeitels SM. Rosen CA (2004) Efficacy of cidofovir injection for the treatment of recurrent respiratory papillomatosis. Mounts P. or microdebrider). Proc Natl Acad Sci USA 79:5425–5429 Steinberg B. J Voice 18:551–556 Mounts P. Ann Otol Rhinol Laryngol 102:580–583 Lee AS. ■ RRP surgical removal often requires different surgical methods (microflap. Kashima H (1982) Virtual etiology of juvenile and adult onset squamous papilloma of the larynx.   Selected Bibliography 1 2 3 4 5 21 Kashima H. microforceps. ■ Angled telescopes especially (30 and 70°) are helpful in evaluating laryngeal RRP immediately prior to excision.

permitting the shearing motions required for normal mucosal wave motion without vasculature accidents. 8. Considering the delicacy of vocal fold blood vessels and the force to which they are subjected.1). acutely tortuous vessel. True hemangiomas of the vocal fold are rare.Chapter 22 Surgical Management of Vocal Fold Vascular Lesions 22. 4. there is little or no direct connection between the microvasculature of the superficial lamina propria of the vocal fold. particularly near the mid portion of the musculomembranous portion of the vocal fold. 22. Papillary ectasias may occur in small clusters and appear similar to coalescent hemangiomas (Fig. Examination should include high-quality. Strobovideolaryngoscopy is helpful not only in defining the extent of a lesion and its mobility or fixation to underlying tissues. 22. Most varicosities and ectasias occur on the superior surface of the vocal fold. magnified visualization of the vocal fold. In addition. It is convenient to divide common vascular lesions into three categories. but have occurred. However.1  Vocal fold varix (see arrow) Fig.2  Vocal fold papillary ectasia with a laryngeal telescope during office evaluation.2). these lesions may occur on the vibratory margin and below the vibratory margin.2 Diagnostic Characteristics and Differential Diagnosis of Vocal Fold Varicosities In healthy vocal folds. Varices may be parallel to the vibratory margin (normal orientation) or more perpendicular to the edge of the vocal fold (Fig. Although there are numerous arteriovenous anastomoses. the tortuosity helps the vessels maintain functional patency when the vocal fold length is altered during pitch changes. 12. and 70° laryngeal telescopes intraoperatively in order to map the vasculature accurately. A spider telangiectasia is a delicate network of inappropriately oriented blood vessels (Fig 22. 22. 22. 11. it is not surprising that vascular pathologies occur. but also the presence of surrounding stiffness that may have resulted from previous traumatic hemorrhage. The parallel arrangement helps prevent obstruction of the microcirculatory system of the vocal fold mucosa during high-pressure shearing movement during phonation.1 22 Fundamental and Related Chapters Please see Chaps. other structures that may be mistaken for varicosities or ectasias include: . Diagnosis is generally based on visual inspection. and to observe the vocal folds using 0.3). blood vessels run parallel to the vibratory margin and are somewhat tortuous. and 13 for further information. 22. 10. as well. or a large. 30. This arrangement helps optimize the mucosal cover’s flexibility during shearing. where shearing forces are greatest. Hence. and the thyroarytenoid muscle. A varix is an enlarged vein. A papillary ectasia is a blood-filled venous enlargement that appears similar to a spheroid hemangioma. it is helpful to view the vocal fold tangentially Fig.

scar. slackens. and it is prudent for it to be available. particularly recurrent hemorrhage ■ Dysphonia caused by a lesion on or near the vibratory margin. 1. polyp. 13. in high sopranos (coloraturas). CO2 laser with a microspot delivery system (Chap.4 Surgical Equipment 1.3 Surgical Indications and Contraindications Indications for surgery comprise: 22 ■ Hemorrhage from the lesion. ■ Asymptomatic lesions that pose no significant risk of hemorrhage Surgical Procedure There are three primary approaches to vascular lesions including operative resection. “Principles of Phonomicrosurgery”) Anterior laryngeal pressure (stabilized with silk tape) can be used to bring the anterior commissure into view. operative CO2 laser coagulation or vaporization and pulsed laser therapy. Fla. The tip of the vascular knife is a sharp point. “Principles of Laser Microlaryngoscopy”).). b) Expose the larynx with suspension laryngoscopy. and distorts the blood vessels. However. or custom-made vascular knife. Standard phonomicrosurgery set (Chap. recent extensive voice use.5 Fig. 10. 13) 4. Operative resection a) Intubation with a 5. e) Incision A superficial epithelial incision should be made immediately adjacent to the blood vessel. fashioned by bending a 30mm laryngeal injection needle 3. Table 10. but all three options are addressed at least briefly below. Care should be taken to identify abnormal vascular lesions at the anterior commissure. ■ Minimally symptomatic lesions that have not bled. Use the largest laryngoscope that exposes the entire vocal fold adequately (see Chap. ■ Lesions associated with Osler–Weber–Rendu syndrome. This chapter concentrates on intraoperative resection. and for appropriate airway precautions to be in place (see Chap. premenstrual hormonal influences. and other factors ■ Hemorrhagic vocal fold polyp 22. Sataloff vascular knife (Medtronic-ENT.0 laser-safe endotracheal tube Although the laser will not be required in most cases.3  Vocal fold spider telangiectasia ■ ■ ■ ■ Limited acute hemorrhage Posthemorrhagic vocal fold cyst Vocal fold fibrous mass Normal blood vessels that are dilated from causes such as inflammation. if necessary. . 13) 22. then slight downward pressure with the back surface of the vascular knife tip is usually sufficient to create a small incision (2–3mm) adjacent to the varicosity (or other vascular lesion) (Fig. etc. 22. This can be made with a laryngeal sickle knife. Pulsed dye laser or pulsed-KTP laser (Chap. interfering with vibration or glottic closure ■ Dysphonia or fatigue caused by a vascular lesion that engorges (“pumps up”) during heavy voice use. It is preferable to obtain anterior commissure exposure through optimal laryngoscope selection. but use of the knife is rarely required. If the vascular knife is oriented parallel to the blood vessel and placed adjacent to it. 2. because of increased risks of adverse effects on performance from even minimal postoperative stiffness. 22. pregnancy. d) Vocal fold palpation should be done under high-power magnification looking for associated vocal fold pathology (sulcus vocalis.136 Surgical Management of Vocal Fold Vascular Lesions   22. The angled telescopes are especially useful for identifying vascular lesions arising in the infraglottic portion of the vocal folds. midmembranous vocal fold region and near the vocal process. 10. and can make blood vessel resection more difficult. this maneuver alters vocal fold tension. it is appropriate in some patients. c) Careful evaluation of the vocal fold should be done with the 30 and 70° telescope through the suspended laryngoscope.1). Jacksonville.4).). These are the areas in which vascular lesions are most commonly seen. altering the mass and vibratory characteristics of the vocal fold Relative contraindications include: ■ Vascular abnormalities that occur only premenstrually and are unassociated with hemorrhage ■ It is usually possible to control these with hormonal manipulation.

h) If topical anesthetic was not applied to the larynx at the beginning of the case. forceps and Cottonoid (see Chaps. In performing this maneuver. hugging the vessel as closely as possible. 22.6). this author prefers not to use the laser for lesions on the vibratory margin or on the medial half of the vocal fold. then great care should be taken to be certain that the laser beam is tangential to the vibratory margin. – Separate the vessel. further resection if the bleeding vessel is superficial. dividing the vessel with a brief CO2 laser burst is equally acceptable. 30–40 mJ. “Principles of Phonomicrosurgery” and 13. above. the vascular knife is advanced anteriorly and posteriorly under the vessel.5  Dissection underneath vascular lesion 137 . this technique can be used safely when necessary. 2. – Although there are no deep.5). it is resected and preserved for histopathologic analysis. This is not desirable near the vibratory margin.  Chapter 22 f) Elevate the vessel Turn the vascular knife 90° and insert it underneath the vessel. isolating and elevating it. Once the vessel has been elevated beyond the limits of abnormality. Thermal injury in this area can cause stiffness that impairs vibration and can lead to permanent scarring. it can be controlled with one of the methods described in step f). – With gentle downward pressure (toward the vocal fold). an alligator or heart-shaped forceps should be used to gently retract the Fig. 22. the point of the instrument is brought up through the epithelium on the other side of the blood vessel. Fig. The principle is similar to that used when placing a right angle clamp under a jugular vein to isolate and resect it during radical neck dissection. it should be applied at the end of the case. 13). CO2 lasers are not effective at controlling vessels larger than 0. g) There is usually no bleeding. or CO2 laser cautery (1 or 2 W. penetrating vessels in normal anatomy. The lesion is removed and sent for histopathologic analysis. d) In general. – Either the anterior or the posterior limit can be divided first.4  Incision immediately lateral to vascular lesion – The specimen is grasped gently with a microlaryngeal alligator forceps. Operative CO2 laser cautery/vaporization a) Intubation and exposure are performed as described in above b) Instrumentation includes a CO2 laser with a microspot.1 s. slightly defocused). If the laser is used in the medial half of the musculomembranous vocal fold. The undersurface of the vascular knife is blunt and should not damage underlying tissues. 0. The crook of the vascular knife is a right angle. such vessels occur occasionally during resection of varicosities and ectasias. More severe hemorrhage can also be controlled with cautery or the laser. However. If there is mild hemorrhage. Simply cutting the vessel with the scissors is usually sufficient and bleeding from the normal vessel stops spontaneously. 22. it is best to allow them to bleed until resection of the vessel is completed. but in the lateral half of the vocal fold. suction. 10. If possible. c) All laser safety precautions should be implemented including wet Cottonoids or wet gauze strips over the cuff of the endotracheal tube (see Chap. allowing epithelial isolation with little or no epithelial resection (Fig. “Principles of Laser Microlaryngoscopy”). When possible. and the vessel should rest in the crook of the instrument.6 mm in diameter. and the second end of the vessel is resected in a similar manner (Fig. and then to control them using a Cottonoid with topical epinephrine (ideally). 22.

After voice rest has been completed.1 second exposure time. The disadvantage of this technique is a fairly substantial recurrence rate (the vessel is found present a few months after surgery). 11. so that the laser impact on the vessel is occurs not over the medial portion of the vocalis muscle. 22. voice rest generally is limited to 2–3 days. where the shearing forces are much less likely to disrupt a blood clot than they are in the middle third of the vocal fold). and using submucosal infusion of saline/adrenaline 1:10. They have an affinity for vascular structures. 30–40 mJ. Pulsed dye laser/pulsed-KTP laser The pulse dye and pulsed KTP laser are relatively new instruments. to permit firm healing of the blood vessels before they are subjected to the phonatory forces of loud phonation or singing.138 Surgical Management of Vocal Fold Vascular Lesions Fig. If the surgery has been limited to the superior surface of the vocal fold. voice rest is not prescribed at all (particularly if the cut ends of the offending vessel are in the anterior and posterior thirds of the vocal folds. As additional research is completed and clinical experience is acquired. “Perioperative Care for Phonomicrosurgery”) If the lesion is on the vibratory margin. Other laser surgeons (including Abitbol) use a focused beam and divide the vessel completely at several points. For lesions on the superior surface. but it decreases the likelihood of recurrence. or replacement for.7). 22. then voice rest for up to approximately 1 week is recommended. 3. Lesions that occur laterally on the vocal fold (beyond the halfway point) can be treated effectively either by resection or vaporization.6  Excision of isolated vascular lesion 22 vibratory margin vessel into the glottis. For patients placed on voice rest. the options detailed above. 22. The classic approach is cautery using 1–2 W. Chilling the vocal fold with ice. This creates superficial cauterization of the vessel and minimizes thermal transfer to underlying tissues. gentle voice use is employed for at least 3–6 weeks from the time of surgery. slightly defocused. 22. 0. e) There are two approaches to CO2 laser management of varicosities and ectasias. the mu- cosa/varix is manipulated laterally with the alligator forceps by lateral traction sias. a session with a speech– language pathologist is arranged to bring the patient off voice rest at the appropriate time. laryngologists should consider this technology as a possible adjunct to. to be followed by gentle voice use. but rather lateral to the midline of the superior surface vocal fold. so that the laser contact point is as far as possible from the vocal ligament (Fig. Preliminary experience suggests that these lasers may be an excellent tool for management of varicosities and ecta-   Fig. They are utilized in an outpatient setting through a flexible endoscope with a working channel or passed peroral during simultaneous flexible laryngoscopy.7  Vascular lesion along free edge of the vocal fold. currently being evaluated for safety and efficacy in the treatment of various vocal fold lesions. an alligator and small Cottonoid can be used to gently retract the mucosal laterally. In some cases. . also help limit thermal injury. This may increase the risk of deeper thermal injury and stiffness.000 solution.6 Postoperative Care and Complications (See also Chap.

Ann Otol Rhinol Laryngol 115:571–580 139 .  Postoperative care includes anti-reflux medications that were started prior to surgery and are continued after surgery. It occurs more commonly after laser treatment of vascular lesions. particularly after resection with cold instruments but may occur. recovery occurs within 2–3 weeks. anesthesia/hypoesthesia of the tongue Dysgeusia Recanalization or recurrence of the vessel (particularly after laser cauterization) ■ Vocal fold stiffness. Akst LM. ■ Some vascular lesions respond to hormonal manipulation or are asymptomatic and do not require surgical intervention. Ann Otol Rhinol Laryngol 108:10–16 Hsiung MW. Wang HW (2003) Clearing microvascular lesions of the true vocal fold with the KTP/523 laser. Scarring may produce disruption of the mucosal wave and substantial dysphonia when it occurs near the vibratory margin. However. scarring. Drugs that do affect clotting are discontinued prior to surgery (the patient is provided with a list). Anderson RR (2006) Pulsed angiolytic laser treatment of ecstasies and varices in singers. Burns JA. Hillman RE. Yamashita M. Antibiotics and steroids are not used routinely. Adhesion of the mucosa to underlying tissues along the superior surface prevents the normal excursion and reflexion of the mucosal wave. Zeitels SM (1998) Ectasias and varices of the vocal folds: clearing the striking zone. Ann Otol Rhinol Laryngol 115:253–259 Hochman I. scarring that occurs laterally also may impair voice function and be troublesome. ■ Postoperative dysphonia is not common. Su WF. but it adds an additional risk of thermal injury. particularly those not in the medial half of the vocal fold. Sataloff RT. Selected Bibliography 1 2 3 4 5 Hirano S. Broadhurst MS. All patients receive preoperative and postoperative voice therapy. Most commonly. Kitamura M. and consequent dysphonia Postoperative pain and neurologic dysfunction usually resolves spontaneously. Precautions must be used to minimize these risks if CO2 laser treatment is utilized. Ossoff RH (1998) Microvascular lesions of the true vocal fold. Pain medications that do not alter coagulation are prescribed. using cold or laser techniques. Hillman RE. Courey MS. Key Points ■ Vocal fold vascular lesions may occur at any location on the vocal fold and are categorized as: ■ Varix ■ Papillary ectasia ■ Spider telangiectasia Chapter 22 ■ Only vascular lesions that have caused bleeding or other symptoms should be treated surgically in most cases. especially in singers. ■ Resection of vascular lesions with minimal disturbance of surrounding tissues provides the best chance to avoid scarring and recurrence. ■ The CO2 laser can be used for varicosities. ■ Office-based treatment using pulsed dye laser/ pulsed KTP laser treatment is possible and should be considered in appropriate clinical settings. and not resumed until at least 1 week after surgery. Complications can include: ■ ■ ■ ■ Dental injury Pain. Takagita S (2006) Photocoagulation of microvascular and hemorrhagic lesions of the vocal fold with the KTP laser. but recovery may take 3 months. Care should be exercised to minimize operative trauma at any point along the vocal fold. Kang BH. especially to high-performance voice users. unless there is compelling medical necessity to start medications sooner (such as Coumadin). and patients should be counseled accordingly. Ann Otol Rhinol Laryngol 107:472–476 Zeitels SM. Vocal fold scarring is extremely rare with excision of vascular lesions. Pai L. Ann Otol Rhinol Laryngol 112:534–539 Postma GN.

The etiology of sulcus vocalis is usually associated with an acquired condition due to excessive voice use or trauma to the vocal folds.2 (Fig. is phonotraumatic behavior characterized by misuse. The symptoms of patients with vocal fold scar and sulcus vocalis include dysphonia. 23. however. 23. 23. 23. this mucosal bridge causes diplophonia and severe dysphonia because of its separate vibratory characteristics from the main vocal fold. this is a much rarer condition.Chapter 23 23 Vocal Fold Scar and Sulcus Vocalis 23. increased pitch. Sulcus vocalis is characterized by an absorption or loss of the lamina propria resulting in a deep. effortful phonation. Frequently. “Pathological Conditions of the Vocal Fold”). The primary difference between vocal fold scar and sulcus vocalis is the type of alteration that occurs within the lamina propria. severe. 23. glottic insufficiency. There are also reports of a congenital deformation of the vocal fold resulting in sulcus vocalis. and severe abnormality in the pliability of the vocal fold. Disease Characteristics and Differential Diagnosis Vocal fold scar (Fig. 8.3). diplophonia. A variety of associated lesions can occur with sulcus vocalis and vocal fold scar. A mucosal bridge is a thin band of mucosa that runs parallel to the vocal fold.2) are two similar pathologic processes that involve derangement and abnormalities of the lamina propria resulting in dysphonia. typically thick. linear furrow along the free edge of the vocal fold. intubation injury.1 Fundamental and Related Chapters Please see Chaps. harsh voice quality. resulting in either absorption of the lamina propria (sulcus vocalis) or deposition of abnormal tissue within the lamina propria (vocal fold scar). most notably. external laryngeal trauma. fibrous tissue. Vocal fold scar is characterized by a deposition of abnormal tissue within the lamina propria. 4. 4.2  Vocal fold scar . Unique to sulcus vocalis is the formation of a mucosal bridge. This typically occurs over a prolonged period.1) and sulcus vocalis (Fig.1  Sulcus vocalis Fig. decreased volume. vocal fold cyst and fibrous mass. It is connected anteriorly and posteriorly but not attached to the free edge of the vocal fold Fig. and 48 for further information. or inappropriate use of the voice. overuse. and a breathy. 23. and excessive laser or cold-steel phonomicrosurgery. 10. and most likely sulcus vocalis. 7. The most common cause of vocal fold scar. 32. This can occur from repeated vocal fold hemorrhage. These two lesions can occur in a subepithelial or ligamentous area (see Chap. Vocal fold scar is an acquired condition from some type of traumatic activity of the vocal folds.

etc. After maximum nonsurgical therapeutic applications. a careful evaluation of the functional limitations associated with the patient’s voice disorder should be undertaken. Augmentation or medialization of the vocal folds if warranted . maximum nonsurgical approach should be utilized for the treatment of voice disorders for patients with sulcus vocalis and vocal fold scar.. especially by using a multidisciplinary approach with a medical and a speech–language pathology evaluation. “Vocal Fold Cyst and Vocal Fold Fibrous Mass”) 2. a comprehensive approach to patients with sulcus vocalis and vocal fold scar involves the following: 1. Surgery is indicated if the significant functional limitations remain after nonsurgical treatment (see Chap. As in the approach to most voice disorders. Excision of associated lesion (Chaps. e. and 39. 31. Excision of associated lesions 5. as well as optimizing speaking and singing techniques with voice therapy and singing voice therapy (see Chap. “Vocal Fold Augmentation via Direct Laryngoscopy”. a vocal fold augmentation procedure or medialization procedure is often the appropriate first step for patients with vocal fold scar and sulcus vocalis (see Chaps. This is important for planning purposes and to determine the severity of the vocal fold pathology and the severity of the condition as well as to remove associated lesions such as fibrous mass. and Decision Making in Phonosurgery”). “Timing. “Peroral Vocal Fold Augmentation in the Clinic Setting”. 38. 7. “Gray Minithyrotomy for Vocal Fold Scar/Sulcus Vocalis”) Contraindications comprise: 23. Proper assessment of functional voice limitations and establishment of reasonable goals with surgical therapy 4. complete resumption of normal voice) ■ Persistent phonotraumatic behavior ■ Untreated LPR ■ Active rheumatologic disease (rheumatoid arthritis. 34.142 Vocal Fold Scar and Sulcus Vocalis Fig. Detailed. often a direct approach to the lamina propria deficit associated with vocal fold scar and sulcus vocalis is indicated. For patients with a significant amount of glottal insufficiency and the primary symptoms of vocal fatigue and decreased volume. Planning. Wegener’s granulomatosis. “Superficial Vocal Fold Augmentation via Microlaryngoscopy”) 5. ■ Unreasonable expectations regarding voice quality improvement (i. 33. Vocal fold fat graft reconstruction (see below) 4. 23. Excision of sulcus vocalis/vocal fold scar and mucosal reapproximation (see below) 3. 48. 10. Superficial vocal fold injection of collagen based materials (Chap. cysts.3 23 Surgical Indications and Contraindications The medical and surgical approaches to patients with vocal fold scar and sulcus vocalis are very similar. This can be achieved with the following different approaches: 1. After the patient’s glottal insufficiency has been addressed by vocal fold augmentation or medialization if needed.   Often the first surgical step is a diagnostic microlaryngoscopy. “Principles of Phonomicrosurgery” and 17.) ■ Anatomic factors resulting in poor laryngoscope visualization (relative) In summary. 8.3  Mucosal bridge associated with sulcus vocalis Differential diagnosis of vocal fold scar and sulcus vocalis include: ■ ■ ■ ■ Fibrous mass Polyp Vocal fold cyst Rheumatologic lesions of the vocal folds Vocal fold atrophy due to muscle loss and a thinned lamina propria can have a similar appearance on laryngeal exam to sulcus vocalis. and/or mucosal bridge. Maximum nonsurgical rehabilitation 3. “Percutaneous Vocal Fold Augmentation in the Clinic Setting”. “Nonsurgical Treatment of Voice Disorders”). This typically includes treatment of medical conditions such as LPR and allergic disease. The difference between vocal fold atrophy and sulcus vocalis is the lamina propria stiffness that occurs in sulcus vocalis but is not present in vocal fold atrophy. multidisciplinary evaluation (may include diagnostic microlaryngoscopy) 2. 32. “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis”. Gray minithyrotomy (Chap. “GORE-TEX® Medialization Laryngoplasty”). given that in both entities the vocal fold will have a “bowed” appearance. One of the key aspects of the indications for surgery and the surgical approach for the treatment of patients with vocal fold scar/sulcus vocalis is to ascertain the degree of glottal insufficiency associated with the vocal fold scar and sulcus vocalis as well as the symptoms of vocal fatigue and decreased volume.

000 epinephrine in attempt to hydrodissect and clearly delineate the area of the sulcus vocalis/vocal fold scar d) Mucosal cordotomy at the junction of normal vocal fold epithelium and the sulcus vocalis deformity at both the upper and lower aspect of the deformity e) Submucosal excision of the sulcus vocalis f) Subepithelial dissection of a superiorly based flap (back elevation) and subepithelial elevation of an inferiorly based mucosal flap in preparation for reapproximation g) Suture reapproximation of cut edges of the mucosa resulting in approximation of the mucosal cut surfaces (see part 4. which is often a preparatory step for later reconstruction using fat graft reconstruction or Gray’s minithyrotomy or superficial vocal fold injection with collagen based material. 23. using a microflap approach. which is achieved by the resultant displacement of a more flexible and bulky tissue from the free edge of the vocal fold. 48. Contraindications a) Lack of patient understanding of the procedure b) Lack of acceptance of aphonia for 4 months c) Limitations for receiving postoperative voice therapy Surgical procedure: methods and techniques The main principle of this technique is to “break” the tension caused by the ligamental alteration in order to obtain vibration and to reduce the glottal gap. 10) b) Endoscopic visualization with angled endoscopes and vocal fold palpation with high-powered microlaryngoscopy assessing the severity and nature of the vocal fold pathology c) Subepithelial infusion of 1:10. parallel to the free edge of the vocal fold The cordotomy should be made 3–4 mm lateral to the free edge of the vocal fold (Fig. smooth vocal fold edge. Fig. “Superficial Vocal Fold Augmentation via Microlaryngoscopy”) b) Fat graft reconstruction via microlaryngoscopy (see below) c) Gray minithyrotomy (Chap.  Chapter 23 6. The advantage to this approach is that it will result in a straight. a) General anesthesia and orotracheal intubation b) Endolaryngeal exposure with suspension microlaryngoscopy c) Incision on the superior surface of the vocal fold (anterior–posterior). below) 2. Thus. this approach is indicated when there is only small epithelial defects or when there has been no mucosal excision required as part of the approach. A concern regarding this approach should be the eventual “rounding” of the vocal fold morphology.0.4).. Vocal fold slicing technique via microlaryngoscopy (as described by Paulo Pontes) The objective of the vocal fold slicing technique is to reduce the glottal gap and to increase vocal fold vibration in order to improve phonation in cases presenting with severe sulcus vocalis and vocal fold scar.4  Sulcus vocalis with proposed incision lines (dashed) for the slicing technique of Pontes 143 . especially along the free edge of the vocal fold. 32.0. This approach can also be used with vocal fold scar. excising abnormal vocal fold scar in the subepithelial plane and then reapproximating adjacent normal mucosa with microsutures. a) Complete exposure of vocal folds with a large laryngoscope (see Chap.1) Knot pusher Regular insulin (100-U bottle) Lactated ringers (l liter) 5. 6.4 Surgical Equipment Surgical equipment includes the following: ■ ■ ■ ■ ■ Standard phonomicrosurgery set (Table 10.0 absorbable suture with a variety of small microsurgical needles (often found in ophthalmology operating room supplies) ■ Microlaryngoscopy needle holder 23. 23.5 Surgical Procedure 1. Direct reconstruction of lamina propria using: a) Superficial vocal fold injection (Chap. Excision with reapproximation via microlaryngoscopy The goal of this procedure is to remove invaginated epithelial tissue associated with sulcus vocalis and reapproximate adjacent normal mucosa with sutures. “Gray Minithyrotomy for Vocal Fold Scar/Sulcus Vocalis”) 23. and 7.

initially with vibration exercises to make tissues flexible and to help remove fibrin. g) The central microflaps should be of different lengths and should pass over the ligament in the inferior lip.5  Raising deep flap with flap elevator 23 Fig. h) The technique should be done bilaterally when there is bilateral disease not dependent on the sulcus asymmetry. Postoperative care a) Prophylactic oral antibiotics b) Voice rest for 3 days c) Vocal exercise. 23. caudally oriented.5). 23. e) The dissection should extend inferiorly to approximately 3 mm beneath the inferior border of the sulcus.7  Asymmetric superior-inferior incisions through the vocal fold microflap   Fig. in the superior margin of the flap to create three or four smaller flaps (inferiorly based) (Fig. thus avoiding adherences. 23.144 Vocal Fold Scar and Sulcus Vocalis Fig. j) Glue or sutures are not useful or needed. Gradually deepen the incisions to avoid retraction of the initial flap (Fig. a portion of the muscle may be also included to preserve arterial supply (Fig. . Vocal exercises should begin around the seventh postoperative day. i) Care is taken to preserve intact mucosa on both sides around the anterior commissure.7). 23.6). 23. Different lengths are useful to maintain ligament fragments in different heights. f) Place small incisions. if it remains thin. which must be intraoperatively observed as soon as the microflaps retract themselves. 23.6  Slicing of deep flap d) Deep dissection to create a mucosal flap The vocal ligament is included inside this flap and. speech therapy i.

in both the anterior–posterior dimension as well as the superior–inferior dimension. This should be done in a slow. f) Remove any associated lesion or scar once the microflap elevation is performed.8). 23.9  Elevation of pocket in preparation for fat graft implantation ii.) b) Angled visualization of the vocal fold pathology via telescopes (see Chap. 3. b) Granulomas can occur but can be left intact because spontaneous remission typically occurs. “Principles of Phonomicro­ surgery”) c) Vocal fold palpation to assess vocal fold scar and sulcus overlying microflap for vocal fold fat graft reconstruction vocalis pathology and severity (during the palpation and angled visualization steps. careful fashion. avoiding the creation of depressions. 23. The glottic gap disappears or is dramatically reduced. Each free end of the suture can be secured outside the laryngoscope with a small bulldog clamp (see below section on placement of sutures in vocal fold.10). When healing has completed (~4 months). potential surgical incisions on the vocal folds should be considered) d) An incision is then made with a microknife (sickle) through the mucosa immediately lateral to the area of the vocal fold scar/sulcus vocalis. The pocket should be filled with the maximum amount of fat graft 145 . making great effort to avoid fenestration of the overlying mucosa.8  Placement for incision and area of proposed elevation of Fig. g) Verify that there is a wide pocket in the area of the vocal fold scar/sulcus vocalis. They should only be resected if too large and/or fibrotic. h) Place suture through the cut mucosal edges both medial and lateral but not tying or throwing any knots with this suture now (Fig. Voice quality will remain poor for 3–4 months. 10. The placement of the incision should be carefully done to allow enough mucosa medial and lateral to the incision for microsuture placement. This will significantly hamper the success or ability to perform fat graft reconstruction (Fig.  Chapter 23 Fig. a) Place largest possible laryngoscope for allowing full visualization of the vocal fold. The fat graft harvest technique is discussed separately (see below). e) Carefully elevate the mucosa off the ligament and underlying vocal fold scar. Vocal fold fat graft reconstruction via microlaryngoscopy This procedure is aimed at developing a pocket in the pathologic lamina propria with or without excision of the associated vocal fold scar and laying small grafts of autologous fat into the pocket for “reconstruction” of the lamina propria and improved lamina propria function postoperatively. (Note: This procedure is difficult to perform via a small laryngoscope because of the complexity of the dissection and the need for placement of sutures within the vocal fold. Complications a) Thin adherences can occur and should be cut in 2–3 weeks. 23. This entire procedure is done via microlaryngoscopy with simultaneous fat graft harvest. It is wise to make this incision longer in the anterior–posterior dimension than typically required to have complete exposure of the area of vocal fold scar/sulcus vocalis (Fig. the vocal fold surfaces appear more regular compared to the preoperative pattern.9). 23.) i) Directly implant fat grafts into the pocket. 23. The vocal folds exhibit greater flexibility and vibration in spite of the reduction or absence of the mucosal wave.

146 Vocal Fold Scar and Sulcus Vocalis Fig. If too “aggressive” placement of a suture on either side of the mucosal 23 Fig. 23. allowing complete or close approximation of the mucosal edges at the incision location (fat harvest techniques as described below) (Fig. k) Palpate free edge of vocal fold to ensure the fat graft implants are stable in the pocket and do not easily come out of the mucosal incision with a moderate amount of pressure along the free edge of the vocal fold.10  Pocket in area of vocal fold scar elevated and sutures placed through mucosal edges possible.11  Placement of fat grafts into pocket of previously elevated vocal fold scar 4.12  Postoperative result after fat graft reconstruction Fig. Placement of sutures should be carefully planned to allow adequate mucosal closure of the vocal fold without distortion of the shape of the vocal fold. 23. 23.11). Placement of sutures in the vocal fold Placement of sutures in the vocal fold is intended to assist the reapproximation of mucosal flaps in the vocal fold. 23. 23.12). j) Tie three knots of the previously thrown suture through the mucosal cut edges (see below) (Fig.   Fig.13  Placement of needle through mucosa during suturing of the vocal fold mucosa . 23. This is most commonly used for fat graft reconstruction but can also be used for a variety of microflaps associated with glottic web surgery.

14a).15b). d) The loose knot assembly is advanced down the laryngoscope by pushing distally with microalligator forceps while pulling back on the other (black) suture. this step prevents the knot from forming prematurely and subsequently breaking. thus allowing the knot to be slipped down into position at the vocal fold (Fig. c) A moderate amount of tension should be placed on the suture during high-powered microlaryngoscopy visualization to ensure that the suture has been placed through the free edges of the mucosa in the appropriate fashion. c) The free ends of the left (white) suture are used to create a slipknot around the open loop adjacent to the distal stationary hemostat. j) The knot should be tightened enough to allow close approximation of the mucosal edges.12). Alternate method of suture placement/knot tying a) Both ends of the suture are grasped with mosquito hemostats.14b). When the level of the vocal folds is reached. 23. it is difficult to backhand the suture via a microlaryngoscopy approach and thus. the knot assembly is released. 5. a “pinching” of the vocal fold will occur at the suture site and this will be counter productive to the surgical procedure at hand. the curve of the needle should be continued in a careful and gentle fashion to avoid applying undue stress or trauma to the vocal fold. the microsuture is placed through each mucosal edge in a separate pass of the needle and thus. k) Scissors can be used to cut the ends of the suture. a) Typically. If the knot is too tight. a simple knot can be tied using a straight alligator and a free hand (Fig. 23. both ends of the suture are brought out through the proximal portion of the laryngoscope. 23. g) Once the knot is close to the vocal fold.15c). the surgeon should plan not to pass the needle through both cut edges in one movement of the needle. 23. 23. 23. 23. then the suture should be removed and the process repeated. The needle should be placed within 1–1. with great care taken to not overtighten the knot. The end of the suture is marked with a pen for easier identification under the microscope during knot tying (Fig. An approximately 1-mm gap should be preserved between the mucosal surface of the vocal fold and the tied knot (Fig. and the other end can be loosely held by an assistant. however. b) After the needle is passed through each side of the free edge of the mucosa. 23. which will hold the needle in a more stable fashion and allow better control of the needle as it passes through the mucosal flap.13). b) The left (white suture in Fig. 23. close to the opening of the laryngoscope (Fig. The fat 147 . After the first part of the needle has penetrated and passed completely through the mucosal surface.5 mm of each mucosal edge. which is essential.  incision is done. As the knot pusher moves the knot down the laryngoscope. i) The knot is then slowly tightened with the alligators. or prior scar location. e) The microscope is then brought into the field and the free end of the left (white) suture is grasped with microalligator forceps and advanced distally.15e). In general.15d). the assistant and the surgeon’s other hand can be used Chapter 23 to maintain a “relaxed” tension on the suture arms. the mucosal free edge does usually not need to be held with another instrument while the needle is placed. As the needle is drawn through the mucosal edge. The direction of passing from right to left or left to right depends on which vocal fold is being sutured and the handedness of the surgeon. d) Using the two ends of the suture outside the laryngoscope. Microlaryngeal alligator forceps are used to grasp the left (white) suture at its final “crossing”. after two more additional knots have been thrown in the exact same fashion. umbilicus. Another option is using a straight alligator. the microlaryngoscopy suture holder has somewhat broader jaws. If the surgeon is dissatisfied with the suture location. 23. h) The two strands of the suture coming off the knot near the knot are then grasped with a straight and/or curved alligator under visualization with high-powered microlaryngoscopy.15a). The harvest locations can be the ear lobe. Furthermore. and an additional hemostat is placed between sutures distal. it will pass quite easily through the mucosal flap. while providing counter-tension with the opposite (black) suture. 23. The free end of the left (white) suture is advanced toward the initial (distal) crossing of the two strands of suture (Fig. but not strangulation of the associated tissue and deformation of the morphology of the vocal fold. which may tear the mucosal flap (Fig.15a) suture is looped around the right suture a total of three times clockwise. one end of the suture is held with the surgeon’s nondominant hand outside the laryngoscope. approximately 2–3 mm away from the knot. e) After a single knot has been tied. A secure knot will form at the level of the vocal folds. then the vocal fold morphology will be significantly distorted and will then result in a poor vocal outcome (Fig. as depicted (Fig. f) The knot pusher is then placed around the knot outside of the laryngoscope and slowly used to pass the knot down the laryngoscope towards the vocal fold. This allows for more control of the placement of the needle through the mucosal edge. a right-handed surgeon will typically pass the suture through the cut edges of the mucosa right to left (vice versa for a lefthanded surgeon). axilla. the suture holder is released and either the suture holder or a curved alligator is used to complete the passing of the needle through the mucosal edge. The needle is typically held and passed through the mucosal flap using a microlaryngoscopy needle holder. Fat graft harvest and preparation A small amount of fat of various sizes is required for fat graft vocal fold reconstruction. the free ends of the suture are released by the surgeon and the assistant.14c). taking care not to allow the loose knot assembly to untie (Fig. given that with the proper angle preparation of the microsurgical needle.

d) Harvest fat with scissors. taking care not to include any as- sociated dermis. b Knot pusher passing knot down the laryngoscope. f) Rinse the harvested fat with approximately 1 liter of sa- line. The axilla is the author’s preferred site. hair follicles. b) Prepare the skin with antiseptic. g) Soak the fat in regular insulin for 5 min (see Chap. c Final position and 23 tension applied to the knot with bimanual control of the two suture ends is typically taken from subcutaneous area. because this area is easily accessible during microlaryngoscopy and the incision is hidden in the axilla. c) A small skin incision is used to expose the subcutaneous fat (approximately 5 mm). “Vocal Fold Augmentation via Direct Laryngoscopy”) . 31. a) Inject local anesthesia at the proposed harvest site. making a small incision at the anterior axillary line. or to use electric cautery e) Cut fat into small pieces approximately 1 × 1 × 1 mm.148 Vocal Fold Scar and Sulcus Vocalis   23.14   a Tying of suture outside proximal end of the laryngoscope.

  Chapter 23 Fig. d The knot assembly is advanced down the laryngoscope.15a–e  Initial configuration of alternate knot tying method. while the end of the suture is marked. c Addition loop is passed proxi- mally. 23. e Final tying of knot under the micro­ scope 149 . b Counterclockwise looping of suture.

Behlau M (1993) Treatment of sulcus vocalis: auditory perceptual and acoustical analysis of the slicing mucosa surgical technique. Colton R. ■ Patients with vocal fold scar and sulcus vocalis with significant glottic insufficiency related symptoms (vocal fatigue. 12. This is a theoretical complication and has not been seen. Abaza MM.   Selected Bibliography 1 2 3 4 5 6 7 8 Key Points 9 23 ■ Surgery for vocal fold scar and sulcus vocalis can be very rewarding to the severely impaired voice patient. Bless DM. Reasonable expectations and willingness to have several surgeries are required in most cases. Reiter D. Hawkshaw M. J Voice 9:332–339 . Khidr A.) should strongly consider having vocal fold augmentation or medialization as the first step of treatment and potentially the only treatment needed. J Voice 11:238–246 Woo P. decrease volume. Ann Otol Rhinol Laryngol 110:707–12 Ford CN. ■ Maximum nonsurgical therapy should be done prior to proceeding with surgery for vocal fold scar/sulcus vocalis. Otolaryngol Clin N Am 33:1081–1086 Sataloff RT. Spiegel JR. Simpson CB (2001) Comparison of microflap healing outcomes with traditional and microsuturing techniques: initial results in a canine model. Inagi K. Hawkshaw MJ. excision of the vocal fold scar/sulcus vocalis and reapproximation. Brewer D (1995) Endoscopic microsuture repair of vocal fold defects. Gilchrist KW (1996) Sulcus vocalis: a rational analytical approach to diagnosis and management. Pontes P (2002) Escala de avaliação perceptive da fonte glótica: RASAT. “Management and Prevention of Complications Related to Phonomicrosurgery”): ■ Fat extrusion at the mucosal cut edge ■ Fat reabsorption ■ Further vocal fold scar at the operative site. Heuer RJ (1997) Autologous fat implantation for vocal fold scar: a preliminary report. Fleming DJ. Vox Brasilis 8:11–13 Pontes P.150 Vocal Fold Scar and Sulcus Vocalis 23. Casper J. etc. J Voice 15:295–304 Pinho SR. Spiegel JR (2001) Management of vocal fold scar with autologous fat implantation: perceptual results. McGuff S. J Voice 7:365–376 Pontes PAL. Sataloff RT. Griffin B. Behlau M (1993) Treatment of sulcus vocalis: auditory perceptual and acoustical analysis of the slicing mucosa surgical technique. Ann Otol Rhinol Laryngol 105:189–200 Neuenschwander MC. J Voice 7:365–376 Rosen CA (2000) Vocal fold scar: evaluation and treatment. ■ Direct rehabilitation of the injured lamina propria can be done via superficial vocal fold injection. fat graft vocal fold reconstruction or a Gray’s minithyrotomy.6 Postoperative Care and Complications To avoid possible complications postoperatively: ■ Strict voice rest for 6–7 days and subsequently graduated voice use ■ Perioperative antibiotic use is appropriate ■ There is no indication for prolonged use of perioperative steroids ■ Continue LPR treatment. which is optimally started perioperatively and continued postoperatively for a short period Complications associated with vocal fold fat graft reconstruction microlaryngoscopy include (see Chap. Rosen DC.

revealing a stiff.1  Photo of Teflon granuloma on the left vocal fold. In most cases. ventricular mucosa and/or the true vocal fold (Fig. Often this occurs years after the initial injection..1). fairly well-circumscribed mass in the paraglottic space. the inflammatory response remains localized. It is helpful to obtain a CT scan of the neck with contrast to assess the location of the Teflon and the extent of granuloma formation. 24. 10. especially if the granuloma is subglottic. 24. and 42 for further information. Palpate involved vocal fold. 24.4 Surgical Equipment Equipment comprises standard laser microlaryngoscopy set (Chap.1 Fundamental and Related Chapters Please see Chaps. Glottic incompetence is commonly present. ETT. and OR personnel. Note con- vex bulge due to expansile granuloma . Typical CT appearance is a brightly enhancing. Teflon granuloma is typically a submucosal smooth mass that presents as a bulge in the false vocal cord.2 Disease Characteristics and Differential Diagnosis In every Teflon injection. (see Chap. This is due to either mass effect (stretching of vocal fold mucosa with dampening of wave) or. 2. Occasionally. The granuloma may grow inferiorly resulting in a subglottic bulge as well. Anecdotal evidence suggests that subsequent laryngeal trauma (i. “Principles of Laser Microlaryngoscopy”).5 Surgical Procedure The procedure is performed as follows: 1. 24. and examine with angled telescopes to define the extent of the granuloma in a vertical plane.. However. and no significant clinical complications are noted. the infiltration of the granuloma into the lamina propria and/or mucosa. the patient’s airway is compromised. intubation) may contribute to growth of the granuloma. after a prolonged period of good voice. an inflammatory response to the Teflon occurs.3 Contraindications are: ■ Attempted complete removal of granuloma—this is not possible endoscopically with these lesions ■ Severe medical comorbidities that preclude surgery 24. e. superficial Teflon granulomas can be distinguished from granulomas that are more extensive. 13. “Principles of Laser Microlaryngoscopy”). more commonly. Intubate patient with laser-protected tube. In this way. 8. 13. 13. Surgical Indications and Contraindications Indications include: ■ Dysphonia due to expanding Teflon granuloma.Chapter 24 24 Endoscopic Management of Teflon Granuloma 24. nonvibratory vocal fold mass. Protect patient. 24. Videostroboscopy is quite consistent in these patients. there is a risk of clinically evident expansile granuloma formation in these patients. secondary to the mass lesion. especially if the granuloma appears to extend to the medial edge of the vocal fold ■ Airway compromise due to expanding granuloma ■ Desire for subtotal removal of granuloma Fig.

2).3).2  Planned incision for Teflon granuloma removal Fig. The most medial portion of the granuloma should be first obliterated in an even fashion from superior to inferior. 24.5  Diagram depicting the area of proposed removal of the 3. 24.1 s/off time of 0. from superior to inferior. 24. 24. granuloma (pink) at the medial edge of the vocal fold. 24. Outline the incision (using spaced laser marks) at the lateral aspect of the superior surface of the true vocal fold (Fig.4  Coronal diagram of Teflon granuloma Fig. The mucosa/lamina propria portion of the vocal fold that is retracted for preservation and exposure purposes can be intermittently redraped to assess the morphology of the infraglottic and true vocal fold. . 6. Dissection with the CO2 laser and/or microlaryngeal instrumentation is performed until the Teflon is encountered—recognized by its characteristic “sparkle” when vaporized by the laser.5 s. The laser can be used to ablate the Teflon mass in the para- 24 on a setting between 4 and 8 W superpulse or intermittent with an on time of 0. Note the lateral extension of the excision infraglottically glottic space (Fig.152 Endoscopic Management of Teflon Granuloma   Fig. The CO2 laser with the micromanipulator should be placed 5. 24. 4.3  Laser ablation of Teflon mass Fig.

Completion of the procedure is achieved when the vocal fold soft tissue is redraped over the residual Teflon mass operative site. Preserving intact mucosa on the free edge and infraglottic surface of the vocal fold will minimize this complication.6 Postoperative Care and Complications ■ The most feared complication is a laser fire. depending on the clinical situation. ■ PPIs and pain medicine. 9. This is managed conservatively with PPIs and observation. Laser precautions must be followed. 8.7. ■ Although complete removal of Teflon granuloma is frequently not possible using an endoscopic approach. 24. Fig. ■ Voice rest should be between 3 and 7 days. 24. 24. especially the use of a laser-protected tube and oxygen concentrations of 35% or less. 24.7  Postoperative result 7. but this is minimized to a negligible level using lower-power setting. ■ Because the Teflon is often exposed with this approach. 24. symptomatic improvement can be achieved.5. It should resolve over several weeks. this is usually not necessary.1) and intact tissue at free edge of vocal fold 24. 153 .  Chapter 24 Fig. Key Points ■ Teflon granuloma typically present many years after injection.6  Immediately after CO2 laser ablation. ■ The goal of endoscopic treatment for Teflon granuloma of the larynx is to recontour a straight edge to the involved vocal fold. showing infraglottic contour granuloma removal. Completed excision. there can granulation tissue formation post operatively. Antibiotics are optional.8). 24. ■ There is a small risk of igniting the granuloma with the CO2 laser. however. showing relatively symmetric appearance of the operated an uninvolved vocal fold (Figs. An adequate amount of Teflon should be removed to create an anatomically correct infraglottic anatomy (inverted cone) and a straight free edge of the vocal fold (Fig. Note reduction of convex bulge compared to preoperative (Fig. 24. Sutures can be place at the cordotomy site as needed. 24.6). Fig. with slowly worsening dysphonia that may progress to airway difficulties.8  Postoperative photograph after typical endoscopic Teflon Fig.

Ann Otol Rhinol Laryngol 101:81–86 Nakayama M. Koriwchak MJ. Netterville JL et al (1993) Difficulties in endoscopic removal of teflon granulomas of the vocal fold. Bless DM (1993) Teflon vocal fold augmentation: failures and management in 28 cases. Ann Otol Rhinol Laryngol 102:405–412 .154 Endoscopic Management of Teflon Granuloma   Selected Bibliography 1 2 24 Dedo HH (1992) Injection and removal of Teflon for unilateral vocal cord paralysis. Ford CN. Otolaryngol Head Neck Surg 109:493–498 3 Ossoff RH.

Chapter 25 Endoscopic Excision of Saccular Cyst 25.5 mm) CT scan of the larynx with contrast is recommended to confirm the diagnosis. 25. 25. (Figs.2) In rare cases. 25.2 increased incidence of dilated saccules in patients with squamous cell carcinoma of the larynx. anterior 25 Fig. and can be categorized as congenital or acquired. Two anatomic types of saccular cysts exist: anterior and lateral. lateral Fig. 25. and acts as a reservoir. although this is more typical of a laryngopyocele.3  CT scan of bilateral saccular cysts . Fine cut (1–1. It is sandwiched between the false vocal fold medially and the aryepiglotticus muscle and thyroid cartilage laterally. 12. 13. expressing secretions onto the vocal folds due to the squeezing action of the surrounding supraglottic musculature. A saccular cyst is a mucous-filled dilation of the laryngeal saccule. Disease Characteristics and Differential Diagnosis The normal saccule arises as a diverticulum originating at the anterior portion of the ventricle. the cyst can extend into the neck through the thyrohyoid membrane. and extending upward into the supraglottis. and project into the laryngeal lumen in the anterior ventricular region.2  Saccular cyst.1  Saccular cyst. 25.1 Fundamental and Related Chapters Please see Chaps.1. 25. and to define the extent of the cyst (Fig. 10. Anterior saccular cysts tend to be smaller in size. there is an Fig. 11.3). Although most saccular cysts are benign in nature. 25. The saccule contains numerous mucus-secreting glands. Lateral saccular cysts are typically larger and present as a bulge in false vocal fold and/or aryepiglottic fold. and 43 for further information.

“Principles of Laser Microlaryngoscopy”) a) Moist eye pads. Airway compromise 3.4 Surgical Equipment Equipment needed includes: ■ Standard laser microlaryngoscopy set (Chap. 25 Fig. 6. as the laser may be ineffective in stopping bleeding from larger vessels such as these. retracting the mucosa medially. and medically infirm patients for whom elective surgery is contraindicated. 25.5 Surgical Procedure for Saccular Cyst The following procedure is adapted from Hogikyan et al.7). A lateral relaxing incision may be required into the aryepiglottic fold in some cases. The lateral extension of the cyst is dissected. if lateral extension is extensive (Fig. Germany) Fig. Tuttlingen. 13. Periodic reexamination of the larynx with photodocumentation and/or CT scanning may be warranted to monitor for any changes of the cyst.6). Quebec.5). 5.3 Surgical Indications and Contraindications Indications for excisional intervention include: 1. The dissection is continued around the inferior aspect of the cyst. 25. Intubation with 5 or 5. The distal tip of the Lindholm laryngoscope rests in the vallecula to achieve wide supraglottic exposure. which may complicate the resection) (Fig.5 laser-protected ETT 2. 25. 25. Hoarseness 2. and towels covering patient fully b) Moist Cottonoid placed above ETT balloon c) O2 concentration 35% or less d) Protective eyewear for OR personnel 4. but is likely to cause perforation of the cyst. This lateral dissection can extend to the thyroid ala.5  Incision locations . Observe standard laser precautions (see Chap.: 1. 3.4) and place in suspension. A curvilinear laser mucosal incision is made over the lateral aspect of the false vocal fold. Suction and bipolar laryngeal cautery are often useful.156 Endoscopic Excision of Saccular Cyst 25.4  Lindholm laryngoscope (Karl Storz. Montreal. observation is acceptable. Expose supraglottis on involved side widely (Lindholm or bivalve laryngoscope often needed) (Fig. using blunt dissection with 5-French suction. and using blunt dissection with a 5French suction (a 30° dull flap elevator can be used. and scissors as needed (Fig. Relative contraindications include: ■ Pediatric cases (external approach favored) ■ Extension of the cystic mass into the neck (external approach recommended) 25. 25. Concern of malignancy (especially in patient with smoking history) In nonsmoking asymptomatic patients. 25. and branches of the superior laryngeal vasculature may cause troublesome bleeding. Canada) ■ Lindholm or bivalue type laryngoscope ■ CO2 laser   25. 13) ■ Laryngeal bipolar device (Instrumentarium.

25. 25. 25. and great care must be taken to include all of the ventricular mucosa with the specimen by removing the entire inferior FVF and ventricle.7  Blunt dissection of cyst with suction Fig. ■ Adverse outcomes ■ Cyst recurrence is a risk with endoscopic excision.8). including inferior false vocal fold 157 . but trimming of redundant mucosa is often all that is needed. A suture is occasionally needed to reattach the false vocal fold laterally. Fig. 25. These cuts encompass the full extent of the cyst. an open approach is indicated for re-excision.6  Exposed cyst after initial incisions Fig.8  Final cuts of cyst.6 Postoperative Care and Complications ■ Consider overnight admission for airway observation/ precautions in cases where extensive dissection and suspension were used. These lesions are usually easier to remove because of their size and favorable location. Taking care to protect the underlying true vocal fold using platform suction. ■ In cases of recurrence. 8. ■ Postoperative care should include PPIs (to reduce the chance of granuloma formation). 25. and include the attached mucosa of the ventricle and false vocal fold (FVF) with the specimen. Excision of anterior saccular cysts utilizes the same ap- proach and techniques as described above. and a normal diet as tolerated. the anterior and posterior cuts are made with the laser (Fig. Care should be taken to avoid dissection into the paraglottic space at or below the level of the true vocal fold. to prevent recurrence.  Chapter 25 7. pain medicine.

Abbarah TR (1998) Laryngeal obstructing saccular cysts: a review of this disease and treatment approach emphasizing complete endoscopic carbon dioxide laser excision. to reduce the chance of recurrence. Arch Otolaryngol Head Neck Surg 124:593–596 DeSanto LW. Meleca RJ. Weiland LH (1970) Cysts of the larynx: classification. Laryngoscope 107:260–265 .158 Endoscopic Excision of Saccular Cyst Key Points ■ Saccular cysts of the larynx in the adult can usually be managed endoscopically. Devine KD. ■ The dissection should include a complete removal of the FVF and underlying ventricle. Laryngoscope 80:145–176 Hogikyan ND. ■ Saccular cysts in infants and children are generally approached externally. 25   Selected Bibliography 1 2 3 Danish MN. Dworkin JP. Bastian RW (1997) Endoscopic CO2 laser excision of large or recurrent laryngeal saccular cysts in adults. ■ Two anatomic types of saccular cysts occur ■ Anterior ■ Smaller in size ■ Presents as a ventricular mass in the anterior half of the larynx ■ Lateral ■ Larger ■ Presents as a bulge in the FVF/ aryepiglottic fold ■ Endoscopic CO2 laser and cold dissection are used to remove the cyst.

Obviously. thyroid cartilage constriction resulting in glottic stenosis. iatrogenic. the symptoms.3 Surgical Indications and Contraindications Indications include: ■ Airway restriction ■ Abnormally elevated phonatory pitch ■ Dysphonia Contraindications include: ■ No functional voice limitations and no airway restriction ■ Uncontrolled LPR ■ Active RRP without any airway restriction 26.2 Disease Characteristics and Differential Diagnosis An anterior glottic web formation (Fig. Smaller congenital webs are often identified later in life and are associated with exercise restriction and/or dysphonia. severity. 4. 10. A variety of conditions are associated with anterior glottic webs. 26.1  Anterior glottic web . Anterior glottic webs range in size from being extremely small (a microweb) to encompassing the entire length of the membranous vocal folds.1 Fundamental and Related Chapters Please see Chaps. Vocal fold scar is frequently associated with an anterior glottic web because of the traumatic nature of the etiology of most of these conditions. A congenital anterior glottic web is quite rare.1) ■ Standard laser microlaryngoscopy set (see Chap. causing stridorous breathing. Table 10. 13) ■ Silastic sheet and/or premade laryngeal keel Fig.4 Surgical Equipment Equipment needed includes: ■ Standard phonomicrosurgery set (see Chap 10. be it surgical. Acquired anterior glottic webs are the most common type of glottic web.Chapter 26 26 Anterior Glottic Web 26. and the symptoms are usually identified at birth or in a young child if the web is large. specifically. external trauma. and subglottic stenosis from cricoid cartilage deformation and loss of normal dimensions. Differential diagnosis for an anterior glottic web is: ■ Wegner’s granulomatosis ■ Sarcoidosis ■ Amyloidosis 26. This can involve supraglottic stenosis. laryngeal framework stenosis should be carefully examined and considered when evaluating a patient with an anterior glottic web. and surgical procedures will vary significantly based on the etiology and size of the web. or intubation related. and 13 for further information. Anterior glottic webs should be evaluated in two specific dimensions: from an anterior–posterior dimension and in a superior–inferior plane. 1. 26. 26. and these typically occur from a traumatic injury to the larynx. The latter can often involve web formation from the glottis to the supraglottis and/or web formation from the glottis into the subglottis. specifically in the anterior–posterior plane.1) can occur from either congenital or acquired causes.

For larger anterior glottic webs and for patients that do not have adequate tissue for an endoscopic flap.3).2). 26. Fig. with utilization of the web for mucosal coverage on one side of the anterior commissure.160 Anterior Glottic Web ■ Endo-extra laryngeal needle passer (Richard Wolf Medical.to 10-day period that the keel is in position.4  Elevation of the anterior glottic web flap and release of web/ web 26 scar up to inner aspect of the thyroid cartilage . 10. 26. 26. Endoscopic flap for anterior glottic web a) Laryngoscopic exposure of the anterior glottic web and the anterior commissure region with suspension laryngoscopy (see Chap. The endoscopic flap approach is best used for smaller anterior glottic webs and involves the asymmetric division of the anterior glottic web. Germany) or 18-g angiocatheter/2-cm 18-g needle (Fig 27. Elevation and preservation of the anterior glottic web mucosa is performed.2  Endoscopic assessment of superior–inferior extent of glottic The two approaches most often used for the release and removal of an anterior glottic web are endoscopic flap or endoscopic placement of a keel. 1. release of the anterior glottic web and endoscopic placement of a keel is required. Patients undergoing this procedure need to be informed of the need for two surgical procedures (placement of keel and removal of keel. c) Incise the anterior glottic web in an asymmetric fashion at either the free edge of the vocal fold or onto the superior surface of the vocal fold that will then be incorporated into the flap (Fig. 26. “Principles of Phonomicrosurgery”) b) Visualize and assess superior and inferior depth of anterior glottic web and plan incision location(s) using angled telescopes (Fig. 26.) They also need to be prepared for moderate pain and discomfort as well as globus sensation for the 7.5 Surgical Procedure Fig. This operation involves delicate surgical handling. Knittingen.3  Incision for asymmetric division of anterior glottic web Fig. and then the flap is sutured over one side of the anterior commissure.7) ■ 0 Prolene suture ■ Silicone surgical button(s) ■ Mitomycin C (optional)   26.

g) The application of mitomycin C onto the contralateral anterior commissure and anterior third of the vocal fold in the demucosalized area is optional (see Chap.7).4). It is a rare endoscopic flap that does not need suturing to stay in the proper location. complete release of the an- terior glottic web all the way up to the anterior commissure/thyroid cartilage is then performed using cold-steel instrumentation or the CO2 laser (Fig 26. the CO2 laser can then be used to make an approximately 1-mm deep groove into the inner aspect of the thyroid cartilage. 26. Cold-steel excision is preferable to minimize laser surgery-related scar formation (Fig. 26.0 absorbable suture. When visualizing this area with a 30 or 70° telescope. extending 3–4 mm above the anterior commissure and 4–5 mm below the anterior commissure. the telescope should be passed to the superior-most location to which the keel will need to be secured.6  Inferior reflection of flap to cover one side of the anterior commissure 161 . Tissue glue has not been adequate. 26. This groove will be used for placement of the keel in an anterior-most location (Fig. and then the telescope shaft can be marked at the location of the junction of the shaft and the proximal laryngoscope. Fig. 29). When incising the anterior glottic web.5).5  Demucosalization of the undersurface of the flap c) Release or excision of the anterior glottic web can be done either with a CO2 laser (smallest spot size and low power) or with straight-up scissors and/or a sickle knife. Fig. During this visualization it is important to evaluate the web in a cephalocaudal dimension given that this will determine the minimum length of the planned keel (Fig.0 or 6.8). 26. The telescope is held at this position.10). 26. It can be done with either cold steel or a CO2 laser using a defocused beam on low-power settings (Fig. 26. b) Visualize the anterior glottic web with 30 and 70° telescopes. in the authors’ past experience. a mark on the telescope shaft can be placed at the junction of the shaft and the proximal laryngoscope. The distance between the two marks on the telescope shaft is measured and this distance will be used to determine the superior–inferior length of the keel (Fig. Release of the anterior glottic web with endoscopic keel placement a) Suspend the laryngoscope with adequate false vocal fold retraction and complete exposure of the anterior glottic web and anterior commissure. to secure the endoscopic flap into location (Figs. 2. 26.6. e) Thirty and 70° telescopes can then be used to visualize the superior and inferior extent of the anterior glottic web release and determine the superior–inferior extent of the intended keel. e) Often demucosalization of the undersurface of the flap and the subglottis in the region of the anterior commissure and anterior third of the vocal fold is then required. The 30° telescope is then moved to the inferior limit of the planned keel location.  Chapter 26 d) Preservation of flap mucosa. It is important to suspend the laryngoscope with adequate space above the anterior commissure for placement of the superior position of the planned keel (approximately 3–4 mm above the level of the glottis). d) After excision or release of the anterior glottic web up to the anterior commissure. it is important to put tension on the vocal folds with lateral retraction and stay in the midline between the two vocal folds to minimize any further lamina propria damage.2). f) The endoscopic flap can now be draped down into the subglottis and secured in place with a single 5. 26.9). 26.

7  Securing the endoscopic flap with suture placement   Fig.11). g) A 0 Prolene suture can then be passed from the subglottis to the anterior neck with the Lichtenberger endo-extralaryngeal needle passer. i) Load the suture coming from the keel into the endo-extra laryngeal needle passer and place down the laryngoscope to pass the suture from the region superior to the anterior commissure to the anterior neck (Fig. Alternative Method i. . 26. Have an assistant pass an 18-g angiocatheter or 2. h) Pass the free end of the suture through the laryngoscope. 26. Secure the keel at two locations along the spine of the keel with the suture. 26.8  Midline division of the anterior glottic web down to inner aspect of the thyroid cartilage rior dimension as well as the anterior–posterior dimension.5cm needle from the anterior neck to the desired location in the anterior subglottis during simultaneous microlaryngoscopy or telescopic visualization of the larynx. Once the needle is in the proper location into the subglottis. This can be done with microlaryngoscopy or endoscopically with a 30° telescope. it is helpful to place the keel into the appropriate location and obtain endoscopic visualization with the 70° telescope of where the fixation sutures should be placed onto the keel.11). The placement of the suture through the keel will ultimately determine the exact location of the keel in the larynx. 26. A clamp should be placed on the free end of the suture that comes out of the anterior neck (Fig.9  CO2 laser vaporization of a 1-mm thyroid cartilage groove at the anterior commissure f) After trimming the keel to the required superior–infe- 26 Fig. then a 0 Prolene suture can be passed in through the tip of needle and out through the neck where it is secured with a clamp. Thus. 26.162 Anterior Glottic Web Fig. the keel can be placed with a heavy cup forceps into the larynx to evaluate the appropriate size and fit.

26. the anterior neck sutures can be cut and the keel can then be removed via the laryngoscope. Pass a 0 Prolene suture into the shaft of the angiocatheter/needle until an assistant can see the suture emerging from the angiocatheter. c) After adequate mask ventilation of the patient. Once the endoscopist is confident that he has a firm grasp of the keel. Fig. place the 18-g angiocatheter or 2.10  30° telescope is used to measure the length of the keel from superior to inferior Fig. specifically the superior portion of the keel. Keel removal (10–14 days post-placement) a) Apneic anesthesia is the preferred method of anesthesia for this procedure. 26. then the endoscopic glottic web procedure can be repeated. b) Direct laryngoscopy is then performed. A large cup forceps is then used to grasp the keel.11  Passing inferior fixation suture from endolarynx through the anterior neck and place- ment of suture through keel 163 . inferior. ii. 26. given that endotracheal intubation can complicate the endoscopic keel removal and injure the operative site. and a 0° telescope is used to visualize the endolarynx. j) Guide the keel into position in the endolarynx as an assistant applies equal tension to the sutures coming out of the anterior neck. If there is severe granulation tissue or a reformation of the anterior glottic web.  Chapter 26 Alternative Method i. or lateral perspective.5-cm needle through the anterior neck into a location above the anterior commissure with simultaneous microlaryngoscopy or telescopic visualization. then the passing of the sutures and placement of the sutures through the keel should be repeated. 3. m) Secure the endoscopic keel in place by tying the sutures coming out of the anterior neck over surgical buttons with a simultaneous visualization of the keel during the suture tying procedure (Fig. a repeat direct laryngoscopy and endoscopic visualization of the operative site is performed.12). l) If the keel is not in the proper location from either a superior. k) Place a moderate and equal amount of tension on the two sutures coming out of the anterior neck and confirm the proper location of the keel using 30 and 70° telescopic visualization. The assistant can then remove the angiocatheter or needle and clamp the suture that has been passed from the larynx to the anterior neck. After passing the suture through the keel.

microwebs and surgery (1997) J Voice 11:238–246 Casiano RR. Leddy M (1994) Anterior commissure microwebs associated with vocal nodules: detection. Bless DM. 26. Smith JD. 1):467–473 Ford CN. mitomycin C can be applied at the operative site. These decisions are made based on the amount of mucosalization that has occurred at the anterior glottis. Farrell R (2006) Simple keel fixation technique for endoscopic repair of anterior glottic stenosis. 70° telescopes. Laryngoscope 109:1347–1350 Liyanage SH. Lundy DS (1998) Outpatient transoral laser vaporization of anterior glottic webs and keel placement: risks of airway compromise. J Voice 12:536–539 Dedo HH (1979) Endoscopic Teflon keel for anterior glottic web. Vocal nodules. Ann Otol Rhinol Laryngol 88(Pt. Jacobson B. ■ Release of anterior glottic web and placement of endoscopic keel requires skill from the surgeon and can be successfully performed if attention to technical details are observed. Int J Pediatr Otorhinolaryngol 52:1–9 Schweinfurth J (2002) Single-stage. Khemani S.164 Anterior Glottic Web   Complications comprise: ■ Anterior glottic web reformation ■ Dislodgement of keel ■ Scar or erosion of the vocal fold from malposition of the keel ■ Granulation at the keel suture location Key Points Fig. with keel secured together over button on the neck Also at this juncture. prevalence. Campos G. 26.6 Postoperative Care and Complications Postoperative care includes: ■ ■ ■ ■ ■ ■ 26 Intravenous antibiotics (perioperatively only) Intravenous steroids perioperatively Laryngopharyngeal reflux disease treatment Pain medicine as needed Overnight observation in the hospital Reevaluation of the patient in approximately 8–10 days in the office with flexible laryngoscopy or indirect laryngoscopy to determine the amount of mucosalization that has occurred underneath the keel Selected Bibliography 1 2 3 4 5 6 7 8 Benninger MS. if indicated.12  Visualization of proper placement of the keel with 30 and ■ Anterior glottic web most commonly is an acquired condition from surgical trauma. ■ Anterior glottic web surgery is indicated for airway restriction or symptomatic dysphonia. Laryngoscope 112:933–935 . and significance. stentless endoscopic repair of anterior glottic webs.):1369–1375 Hsiao TY (1999) Combined endolaryngeal and external approaches for iatrogenic glottic web. Everts EC (2000) Congenital laryngeal webs: surgical management and clinical embryology. Lloyd S. J Laryngol Otol 120:322–324 Milczuk HA. ■ Endoscopic flap release of anterior glottic web can be done successfully with good laryngeal exposure and a small glottic web. Laryngoscope 104(Pt 1.

Part B Phonomicrosurgery for Benign Laryngeal Pathology III Laser Microlaryngeal Surgery (Airway/ Neoplastic Conditions) .

“Posterior Glottic Stenosis”). Guillian-Barré syndrome. then laryngeal electromyography can assist in determining which side has the worst neuromuscular status and thus is the best location for the surgical procedure. and thus is rarely required. In some ways. the distinction is not essential. After these procedures.). 9. Contraindications to treatment of BVFP include: ■ Rapidly progressive neurologic disorder ■ Unrealistic patient expectations (improvement in both airway and voice) Relative contraindications to treatment include: ■ Presence of aspiration ■ Compromised pulmonary status ■ Diabetes (more true for open procedures than endoscopic) ■ Previous radiation therapy to the neck/larynx Treatment options for BVFP include: ■ Tracheotomy ■ Microlaryngoscopy with laser posterior transverse cordotomy ■ Microlaryngoscopy with laser medial arytenoidectomy ■ Microlaryngoscopy with laser total arytenoidectomy ■ Endoscopic suture lateralization ■ Open arytenoidectomy In general. an extended version of either (or a combination) can be performed. most other causes of BVFP can be treated more conservatively with endoscopic techniques. and aspiration is less likely. The most important factor for selection is presence of any purposeful motion either adductory or abductory. In contrast to unilateral vocal fold paralysis. In patients with BVFP. bilateral vocal fold paralysis (BVFP) causes airway restriction and not vocal dysfunction. Its aim is to remove all arytenoid cartilage that effects the airway. Open arytenoidectomy is reserved for cases where endoscopic techniques have failed or are impossible due to anatomic limitations. syringomelia. because posterior transverse cordotomy and/or partial arytenoidectomy are often effective for both conditions. . The most reasonable approach to patients with bilateral vocal fold paralysis is a step-wise approach to enlarge the glottic airway. and 28 for further information.2 Disease Characteristics and Differential Diagnosis Patients with bilateral vocal fold paralysis (BVFP) generally fall into two categories. Selection of the side to perform surgery for bilateral vocal fold paralysis is based on a variety of factors. Please note the procedure historically called a total arytenoidectomy does not involve complete anatomic removal of the arytenoid cartilage. etc. It can be difficult to distinguish BVFP from posterior glottic stenosis. while attempting to limit the negative effects of treatment on vocal function. (1) iatrogenic recurrent laryngeal nerve injury (typically from a thyroidectomy). treatment is directed at maximizing the airway. palpa- 27 tion of the cricoarytenoid joint as described below is helpful to determine which cricoarytenoid joint has the worst range of motion and mobility and would then be best choice for surgical procedure to widen the posterior glottic airway. or (2) progressive neurological disorder (Shy-Drager Syndrome. 10. because voice results tend to be better. therefore a careful examination to evaluate cricoarytenoid joint fixation and posterior glottic stenosis should be carried out prior to surgical intervention (see Chap. as compared with total arytenoidectomy. 28. 3. due to comorbid conditions. In addition to these methods. rapidly progressive neurologic disorders (such as Shy–Drager) tend to be treated with tracheotomy. or a total arytenoidectomy.3 Surgical Indication and Contraindications An indication for surgery is symptomatic airway obstruction. Endoscopic suture lateralization is useful if temporary treatment is warranted. 13. However. 27.Chapter 27 Bilateral Vocal Fold Paralysis 27. 27. The least aggressive and safest procedures are the posterior transverse cordotomy (PTC) or medial arytenoidectomy (MA). with which the patient principally complains of voice and swallowing difficulties. Posterior transverse cordotomy or medial arytenoidectomy are generally the ideal endoscopic treatment options. However. If there is no motion of either vocal fold. 5. a correct diagnosis greatly facilitates patient counseling and appropriate treatment.1 Fundamental and Related Chapters Please see Chaps.

168 Bilateral Vocal Fold Paralysis 27. i. 27. a subglottic jet catheter (Hunsaker tube. and that there is still good vocal process visualization with the ETT in a posterior position. Palpation of the cricoarytenoid joint is performed by using a sturdy instrument such as a large cup forceps and placing it adjacent to the vocal process and pushing the vocal process laterally swiftly. Posterior transverse cordotomy a) Intubation with 5. Fla. This would be observed in a patient with BVFP . During this maneuver.1  Palpation of a mobile (nonfixed) cricoarytenoid joint: lateral displacement of arytenoid with blunt instrument Fig. One should select the arytenoid with the worst cricoarytenoid joint mechanics to operate on. Jacksonville. 19. Knittingen. Germany) ■ Silicone buttons ■ 0 or 2.2). “Vocal Fold Granuloma”). Care should be taken to ensure that suspended laryngoscope is positioned cephalad in the larynx to avoid the laryngoscope limiting the range of motion of the arytenoid cartilages. Anesthesia should induce complete muscle paralysis and the posterior larynx is viewed with microlaryngoscopy or a 0° endoscope. If the ETT obstructs the surgical site. d) Laser incision 27 Fig. 13. ii. the surgeon can gauge the degree of effort required to displace laterally the vocal process as well as the speed of the recoil of the tissue in a medial direction   (Figs. resulting in recoil of arytenoid medi- ally.2). 19.5 laser safe endotracheal tube (ETT) Alternately. then this suggests that posterior glottic stenosis may be present. 19. It is often helpful to angle the laryngoscope toward the side where the cordotomy is being performed to maximize the exposure of the lateral aspect of the true vocal fold/false vocal fold (see Chap. c) Laser precautions are implemented (see Chap.0 or 5. 27. This maneuver can be helpful in selecting which side is optimal for surgery to improve the posterior glottic airway. 27. 2. Palpation of cricoarytenoid joint Direct laryngoscopy should be performed. careful evaluation of the posterior commissure should be done. If the entire posterior commissure moves with lateralization of the vocal process. Ensure that the ETT is in posterior commissure. It is best to perform cricoarytenoid joint palpation without an endotracheal tube in place. “Principles of Laser Microlaryngoscopy”). then the EET can be moved anteriorly with the laryngoscope securing the ETT anteriorly (see Chap. 13) Laryngeal bipolar/monopolar cautery (not essential) Mitomycin C (0.4 Surgical Equipment Equipment includes: ■ ■ ■ ■ Laser microlaryngoscopy equipment (Chap. Fig.4 mg/ml) Also for suture lateralization only: ■ Endo-extralarnygeal needle carrier by Lichtenberger (Richard Wolf Medical. b) Expose larynx with laryngoscope and place into suspension. This same procedure should be done on the contralateral side and used to compare the degree of stiffness and range of motion of both cricoarytenoid joints. 27.5 Surgical Procedure 1. With this maneuver.2  Release of arytenoid.1.0 Prolene sutures 27.) can be used. Medtronic Xomed.

4   Surgical result immediately after a right posterior transverse cordotomy. confirming that the cordotomy site is flush with the lateral subglottic wall.3. Incision is started just anterior to vocal process. iii. iv.5. v. A CO2 laser setting typically is 4 W. vii. c) Laser incision i. note how the residual vocal fold retracts anteriorly and appears very thick and shortened 169 . The CO2 laser setting should involve a small spot size (0. superpulse with a very small spot size. Suction and bipolar laryngeal cautery are effective in stopping the bleeding. 27.3  Lateral extent of transverse cordotomy at both the level of true and false vocal fold vi. f) Application of LTA i. Titration of the amount of arytenoid cartilage that is obliterated is based on the amount of airway im- Fig. Laser char (carbonaceous debris) should be removed by rubbing a saline soaked Cottonoid over the surgical site periodically. 27. iii. A complete cordotomy extends laterally 3–4 mm into the false vocal fold tissue/musculature (see Figs.4). Topical mitomycin C is placed (typically 0. “Principles of Laser Microlaryngoscopy”). All laser safety precautions should be put into place prior to starting the use of the laser (see Chap. iv. ii. The anterior–posterior dimensions of this area of obliteration should be posterior to the tip of the vocal process preserving all or most of the vocal process. 27. Once the entire vocal fold is separated from the vocal process. The CO2 laser is ineffective in a heavily charred area or bleeding operative site. 27. and troublesome bleeding can occur. An intermittent firing of 0. The residual vocal fold will retract anteriorly and ap- pears shortened (Fig 27. v.4 μm) at a setting of 2–4 W. to avoid granulation tissue postoperatively. The vocal process location is confirmed by palpation. 27. The area of the obliteration should not extend to the posterior arytenoid tissue and should spare adjacent mucosa in the intra-arytenoid area (Fig. a branch of the superior laryngeal artery is encountered. b) Laser safety precautions i. ii. being careful not to expose the cartilage. super-pulse mode.5-s off time will also minimize collateral thermal damage. Frequently. shaded portion no.1-s on/0. ii. 4% lidocaine is sprayed on the vocal folds/trachea to minimize laryngospasm postoperatively. 2).25–0.5. 13. iii. iv. and used to obliterate the medial-most portion of the arytenoid cartilage for approximately 2–3 mm in width. 1). the cordotomy is extended into the false vocal fold tissue. The degree of lateral extension of the cordotomy can be adjusted based on (1) tissue response to the initial cordotomy and (2) the amount of airway improvement needed by the patient. Confirmation of complete cordotomy is achieved via endoscopic evaluation with a 0 and/or 30° telescope. Medial arytenoidectomy a) Placement of laser laryngoscope i. e) Extension of cordotomy i. Fig. 3.4 mg/ml) via a soaked pledget for 5 min. arytenoid cartilage and posterior glottic space on the intended side of the surgical procedure. shaded portion no. Place laser laryngoscope (with built-in suction) to allow exposure of the posterior membranous vocal fold.  Chapter 27 i. A platform suction device (or a moist Cottonoid) is placed below the surgical site to protect distal structures. g) Application of mitomycin C (optional) i.

Tissue removal posteriorly should not remove any interarytenoid mucosa. v. Laser ablation of the medial arytenoid for medial arytenoidectomy is shown in shaded area no.6  Palpation of residual arytenoid overhang . b) Continuous CO2 laser ablation of arytenoid tissue until the operative defect is flush with the walls of the cricoid ring. Suction esophagus and stomach with oral gastric tube placement. 27. ideally in the first 2 months after onset. Obtain hemostasis with epinephrine-soaked (1– 10. 4. vi. 27. 27. This is a clinical judgment and should initially be done in a very conservative fashion with an expectation that some patients may require repeat surgery to further enlarge the posterior glottic airway to a satisfactory level. 3 Fig. xi.170 27 Bilateral Vocal Fold Paralysis provement that is required by the patient and tissue response after the initial aspect of the medial arytenoidectomy.4 mg/ml for 5 min) (optional). symptomatic BVFP (first 2 months) with uncertain prognosis for recovery c) Contraindications i. shaded portion no. If there is an “overhang. To further improve the posterior glottic airway. Total arytenoidectomy a) Follow the preparatory steps listed above for medial arytenoidectomy. Early. then further arytenoid lateral to the initial defect can be removed all the way to the lateral aspect of the cricoid ring resulting in a total arytenoidectomy (see below). Recent trauma to the posterior glottis from indwelling endotracheal tube ii. Laser ablation of total arytenoidectomy is shaded area no. Remove all laser char from the operative site with suction and moist cotton pledget. Evaluation of this goal can be done by: i. 2.” additional arytenoid tissue can be removed (Fig. can identify if there is any residual arytenoid overhang that needs further laser ablation to maximize the glottic airway to complete the total arytenoidectomy procedure 5. 27. Indwelling tracheostomy tube d) Procedure   Fig. viii. Placement of a curved elevator on the lateral aspect of the subglottis and then slowly drawing the instrument in a cephalad direction feeling for a glottic level “overhang” of arytenoid tissue. Apply mitomycin C to the operative site (0. This procedure is best suited as a temporizing measure for airway improvement in early BVFP cases. ix.000 concentration) pledget.5.6). b) Indications: i. 1).5  Diagram of different degrees of arytenoid removal (medial. vii. total) compared to transverse cordotomy (shaded area no. both posteriorly and laterally. x. In addition. the endoscopic evaluation of the posterior glottic airway with a 70° telescope. Spray the endolarynx with 4% plain lidocaine. If adequate surgical enlargement of the posterior glottic airway is not obtained with a conservative medial arytenoidectomy. the area of ablation can be taken anteriorly to include the vocal process and a partial posterior cordectomy to the level of the lateral ventricle (see Fig. ii. 3). Endo-extralarnygeal suture lateralization (based on the technique of Lichtenberger) a) Special consideration i.

The sutures are then pulled deep to the skin incision. Suspension laryngoscopy is performed (jet ventilation is initiated or a small 5. The most medialized vocal fold is selected in this procedure. v.0 or 0 Prolene suture. Under microscopic or telescopic visualization. 27. ii. (“Posterior Glottic Stenosis”). the needle is positioned below the posterior vocal fold at a point just anterior to the vocal process (Fig 27.13).7  Endo-extralaryngeal needle carrier device (Richard Wolf) Fig. 27.7) is loaded with a 2.11). 27.0 or 5. using a silicone button as an anchoring point (Fig 27. The needle is grasped.  Chapter 27 i. The needle is again advanced externally through the skin of the neck (Fig 27. The skin overlying the neck on the side of the proposed suture lateralization is prepped and draped in a sterile fashion. Fig 27. especially if a stable tracheotomy is present. Using the carrier device. Traction is now placed on the two sutures to create lateralization of the posterior vocal fold and expansion of the static airway dimensions (Fig 27. although these procedures can be performed on an out-patient basis. as per the surgeon’s discretion Fig. This technique is illustrated in Chap. this time at a level slightly superior to the true vocal fold (Fig 27. A permanent version of this surgery can be performed by combining this suture lateralization technique with an ipsilateral partial submucosal laser resection of the TA/LCA complex and/or a partial arytenoidectomy.8). the needle is pushed through the larynx until the tip of the needle appears externally through the skin of the neck.5 endotracheal tube can be used). A second lateralization suture is placed in a similar fashion. which is designed to be used with the endo-extralaryngeal needle carrier. vii. The proximal end of the same Prolene suture is then threaded through the free needle.12). iii. ■ Proton-pump inhibitor(s) ■ Pain medications ■ Corticosteroid taper ■ Antibiotics. The procedure as in step (iii) is performed at the same location of the posterior glottis.9). 28. 1–2 mm anterior to the first suture. and the suture is advanced through the skin and temporarily secured with a clamp (Fig 27.8  Infraglottic placement of suture just below the level of the vocal process Postoperative Care and Complications Care immediately postoperatively includes: ■ Twenty-four hour observation in a monitored setting may be indicated. vi. A 2-cm horizontal incision is made in the neck.6 Fig. The skin incision is closed in a standard fashion.9  The suture is grasped by an assistant and pulled through the skin 171 . 27. An endo-extralaryngeal needle carrier device (Richard Wolf. The two ends of the suture are then tied with a surgeon’s knot over the sternohyoid muscle. iv.10). ■ Voice rest is not essential.

which will improve over a 2. 27.14).10  The same initial suture is now placed above the vocal fold (through the ventricle) at the region of the vocal process   Fig. and should be treated by maximizing antireflux medication. The expected final result is a small posterior glottal notch in the case of posterior transverse cordotomy (Fig. and total arytenoidectomy: 1. using a silicone button Fig. Although the notch may appear to have only increased the airway 2–3 mm. 27. Followup at 2–3 week intervals for reexamination and reassurance is important during the healing phase.13  The two sutures are brought deep to the skin through a separate incision and tied over the strap muscles. the patient will experience significant worsening of the voice. and only mild worsening of the patient’s voice. Granuloma formation a) Granuloma formation at the operative site is not uncommon. . 27. Complications related to posterior transverse cordotomy.12  After completion of the suture lateralization.172 Bilateral Vocal Fold Paralysis Fig. This sequence will be repeated once more.to 3-month period and then stabilize. medial. Note lateral- ization of the vocal fold with two sutures slightly anterior to the vocal process 27 During the (expected) postoperative course. c) These granulomas may also cause return of airway symptoms. 27.11  One completed lateralization suture. but may need to be excised if still present 3–4 months after surgery. this results in significant improvement in the patient’s airway. and must be monitored carefully. slightly anterior to the previous suture placement Fig. b) The granuloma tend to resolve over time. 27.

Complications related to suture lateralization include: a) Trauma to the posterior vocal fold from excessive tension on the lateralization suture. and then further surgery and more extensive surgery can be tailored to the patient’s airway and voice needs. limited procedure should be selected initially. Ann Otol Rhinol Laryngol 102:81–84 Dennis DP. b) The suture may “cut into” the vocal fold. intra. ■ All laser char should be removed from the operative site at the end of the surgical procedure to minimize post-operative granulation tissue formation. Laryngoscope 109:995–1001 Crumley RL (1993) Endoscopic laser medial arytenoidectomy for airway management in bilateral laryngeal paralysis. Annals of Otology. Placing the first suture anterior to the vocal process. c) It is quite rare to need additional surgery after a second surgical procedure. ■ Patients undergoing glottic enlargement procedures for bilateral vocal fold paralysis must be counseled regarding the exchange of improved airway for decreased voice quality and volume. McMullin BT. Excessive scar tissue obliterating operative site a) Occasionally. thus avoiding the temptation to lateralize the vocal process/arytenoid tissue. GartnerSchmidt JL (2005) Medial arytenoidectomy versus transverse cordotomy as a treatment for bilateral vocal fold paralysis. Toohill RJ (1997) Technique of endo-extralaryngeal suture lateralization for bilateral abductor vocal cord paralysis. Hillel AD (1999) Idiopathic bilateral vocal fold weakness. Simpson CB. without the characteristic “notch. c) This complication can be avoided by: i. Not operating on vocal folds after “fresh” ETT trauma ii. Rhinology & Laryngology 114:922–926 Hillel AD. Laryngoscope 107:1281–1283 Bosley B. posterior transverse cordotomy and total arytenoidectomy are often helpful for both conditions. Blitzer A et al (1999) Evaluation and management of bilateral vocal cord immobility. ■ A variety of surgical procedures are available for treatment of bilateral vocal fold paralysis. separating the muscular vocal fold from the vocal process. The sutures must be removed promptly if significant vocal fold trauma is present. ■ Post-operative reflux treatment should be implemented to reduce post-operative granulation formation.14  Long-term postoperative result after a right transverse cor- dotomy 2. Selected Bibliography 1 2 3 4 5 6 Lichtenberger G. Kashima H (1980) Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Robinson LR. ■ Pre-. Otolaryngol Head Neck Surg 121:760–765 Dray TG. the operative site heals completely.and post-operative angled telescopic (30 and 70°) evaluation of the posterior glottic airway is an essential aspect of surgery for bilateral vocal fold paralysis. ■ Bilateral vocal fold paralysis should be differentiated from posterior glottic stenosis.  Chapter 27 Key Points Fig. Rosen CA.” b) The operation can be repeated on the same side with re- application of mitomycin C. Benninger M. even though static glottic enlargement procedures such as medial arytenoidectomy. The most conservative. 27. Ann Otol Rhinol Laryngol 98:930–934 173 .

27. In PGS. the EMG activity of the thyroarytenoid–lateral cricoarytenoid muscle complex will be normal. 13. 2. Laryngeal electromyography (EMG) can be used to distinguish PGS from immobility due to previous bilateral neurological injury or bilateral paralysis (see Chap. mature scar tissue develops which impairs vocal fold Fig. The diagnosis is often complicated by the presence of a tracheotomy. the effect of the granulation tissue obstructing the airway goes unnoticed until it has had a chance to mature and form a scar contracture. laser depithelialization over the CA joint was associated with a 25% reduction in vocal fold abduction after healing. Severe scarring with CA joint fixation can be distinguished from loss of mobility due to mucosal scar contraction only via an endoscopic examination and exploration. there is also a history of relatively recent intubation. the patient is often seen by the otolaryngologist. and the voice is breathy or whispered. and 29 for further information. 10. with planned palpation and potential mucosal flap elevation (see . Since the patient breathes through the tracheotomy. Therefore. autoimmune from rheumatoid arthritis) ■ Interarytenoid synchiae Severe injury with erosion of the CA joint from pressure due to prolonged intubation can lead to CA joint fusion. PGS has been reported as a complication that can occur after intubation times as short as 4 days and has been linked to LPR.. Even minimal injury to the mucosa over the cricoarytenoid (CA) joint can be associated with loss of cricoarytenoid joint function for vocal fold abduction. g. When this occurs. 28. The granulation tissue itself can grow to obstruct the glottis. which develops 4–8 weeks after extubation from a period of extended mechanical ventilation (Fig. even of chronic origin. Examination will frequently reveal granulation tissue in the area of the arytenoid cartilage or over the interarytenoid cleft. “Principles of Clinical Evaluation for Voice Disorders”). and debridement of the granulation tissue can be associated with reduction in mature scar tissue formation and lessens the overall risk of the stenosis of the airway. while in bilateral paralysis. This tissue prevents vocal fold approximation for voice production. diagnosis. This process typically occurs over 4–8 weeks. the initial management strategies in all patients with suspected PGS should include diagnostic and staging endoscopy. there will be active recruitment of additional motor units with voluntary activity. but this will not be normal in amount and the amplitude of the individual potentials will be increased. 28. Deeper injuries were associated with a greater reduction in motion and injuries into the cricoarytenoid joint capsule were associated with fusion of the arytenoids to the cricoid. In the PGS patient. The differential diagnosis of posterior glottic stenosis is: ■ Bilateral vocal fold paralysis ■ Cricoarytenoid joint ankylosis (e. Frequently.2 Diagnostic Characteristics and Differential Diagnosis Posterior glottic stenosis (PGS) presents as progressive airway obstruction. Often the patient complains of dysphonia after extubation. which increases the bacterial count in the tracheobronchial tree and may exacerbate problems with granulation tissue development. patients are not seen acutely and as the granulation tissue resolves. Often this finding can be appreciated on careful flexible laryngoscopy examination in the office under topical anesthesia. Frequently. EMG activity in bilateral paralysis will show reduced interference pattern often with reduced recruitment and large polyphasic motor unit potentials.1  Posterior glottic stenosis 28 mobility and leads to “mature” PGS. there will be evidence of old neurological injury with partial recovery.Chapter 28 Posterior Glottic Stenosis: Endoscopic Approach 28. 6. In an animal model. This is usually noted in the endoscopic exam.1). Prompt evaluation.1 Fundamental and Related Chapters Please see Chaps. 28. 9. which reveals a normal posterior glottis associated with CA joint ankylosis. however.

then it is unlikely that restoration of active CA joint function will be achieved. 27. If mobility is not restored.   a) Posterior commissure exposure is usually obtained with- out the need for anterior counter pressure. Surgical options a) Interarytenoid synchiae i. Suspension laryngoscope details The procedure is begun by obtaining exposure with the largest possible laryngoscope. 27 “Bilateral Vocal Fold Paralysis” and 46. Through palpation of the CA joints. partial arytenoidectomy. d) After exposure is obtained. and management then needs to proceed to either (1) ablative endoscopic procedures such as posterior transverse cordotomy. and the entire larynx will move. “Bilateral Vocal Fold Paralysis”). 13.3 Surgical Indications and Contraindications Indications for surgery include: ■ Airway obstruction due to PGS ■ Patient desire for tracheotomy decannulation Relative contraindications include: ■ Presence of aspiration ■ Compromised pulmonary status ■ Diabetes (more true for open procedures than endoscopic) ■ Previous radiation therapy ■ Unrealistic patient expectations (improvement in both airway and voice) ■ Uncontrolled laryngopharyngeal reflux 28. then this should be excised and removed (Fig. ii. The mucosal integrity in terms of granulation tissue and scarring is assessed. The laser or a knife is used to make an incision in the mucosa over the contralateral arytenoid starting . even palpation of uninvolved tissue needs to be minimized.176 Posterior Glottic Stenosis: Endoscopic Approach also Chap. 28.1 and 27. perform new tracheotomy. then mucosal flap elevation will be associated with at least temporary improvement in vocal fold abduction and airway. and the case should be terminated. 3. in patients without tracheotomy. Intubate with laser safe endotracheal tube through existing 28 tracheotomy. iv. If mucosal scar contraction is the sole reason for loss of vocal fold abduction.2). 27). 27. decisions regarding intervention can be made. 27. If this procedure results in restoration of passive mobility.4 mg/ml) 28. ii. c) If the patient does not have a tracheotomy. 4.4 Surgical Equipment Equipment needed for surgery includes: ■ Standard laser microlaryngoscopy set (Chap. Visualize the operative field with the binocular operating microscope. then this maneuver will result in minimal vocal process displacement. then inserting the tip of the laryngoscope through the vocal fold or over manipulation may cause postoperative edema requiring tracheotomy. or expose larynx with suspension laryngoscope and commence jet ventilation (see Chap. Mitomycin C may be applied to the raw surfaces to reduce the risk of reformation of the scar band. a) High magnification will help to evaluate mucosal integrity. Therefore. 30. then it is likely that injury process has resulted in exposure of the cricoarytenoid joint. a) Palpate the arytenoids. c) If joint mobility is impaired. Figs. Thus. suture lateralization or (2) open approaches with posterior glottic grafting (see Chaps. This needs to be done with extreme caution or not at all if the patient does not have a tracheotomy. and 70° angles telescopes. the joint with the best mobility should be identified.2). The patient will notice an immediate improvement in their ability to breathe in the recovery room. then jet ventilation can be used to support respiration. iii. 28. total arytenoidectomy. “Bilateral Vocal Fold Paralysis”). 5.5 Surgical Procedure 1. If this improvement does not occur. b) Posterior scar—microtrap-door flap i. b) To help spread the vocal folds apart. If a bridge of mucosa between the arytenoids is identified. 2. Assess passive cricoarytenoid (CA) joint mobility (see Chap. it may be beneficial to insert the tip of the laryngoscope through the vocal folds. If the patient does not have a tracheotomy. “Glottic and Subglottic Stenosis: Cricotracheal Resection with Primary Anastomosis”). 27. then the procedure is likely to be successful. d) After assessment of the posterior commissure mucosa and passive CA joint mobility. or permanent suture lateralization as described in this chapter. with remodeling and possible fusion of the arytenoid to the cricoid. Approximately 50% of patients with an interarytenoid synchiae will regain mobility after this type of intervention. the posterior commissure is examined with 0. manipulation. 13) ■ Mitomycin C (0. a glottic enlargement procedure will be needed such as a posterior transverse cordotomy (PTC) or medical arytenoidectomy (MA) (see Chap.” Principles of Laser Microlaryngoscopy”). b) Pushing lightly on the laryngeal surface of the mid body of the arytenoid should result in translocation or lateralization of the ipsilateral vocal process and vocal fold (see Chap.

  Chapter 28 Fig. Scissors or the CO2 laser is used to separate a flap of epithelium and submucosal tissue from the underlying scar. Troublesome bleeding is stopped by applying epineph- rine (1:10. iv. 177 . with CO2 laser Fig.4).3). 28. 28. 28. v. extending over the body and into the interarytenoid cleft over the interarytenoidius muscle (Fig. iii.2  Interarytenoid synchiae.5 × 3-cm Cottonoids.3  Initial incision for microtrap-door flap Fig.4  Ablation of posterior glottic scar.000) on 0. 28. The underlying scar tissue is vaporized or excised (Fig.5  Draping of microtrap-door flap plane of division near the vocal process. 28. 28. with dashed line indicating surgical Fig. These are held in place for 1–3 min until the bleeding stops.

  ix. incision in this area will usually result in scar reformation. The skin overlying the neck is prepped and draped in a sterile fashion. then identification of the vocal process will be difficult.6  Outline of extent of excision in permanent suture lateraliza- tion technique 28 Fig. Since the area is filled in with scar tissue. 28. viii. 28. is more appropriately performed in cases of BVFP. These procedures are best used when attempts at restoration of joint mobility have failed and the cartilaginous glottis is relatively well preserved. this procedure. If joint mobility is not obtained.178 Posterior Glottic Stenosis: Endoscopic Approach vi.5).7  CO2 laser excision of lateral arytenoid and lateral vocal fold tissue Fig. The flap is then repositioned over the ipsilateral CA joint (Fig. and consideration should be given to additional procedures that enlarge the posterior glottis. then it is unlikely that the procedure will be successful. Mitomycin C (0. vii. such as PTC.4 mg/ml) may be applied to the exposed CA joint to lessen scar tissue formation in this region. That being said. x. If the cartilaginous portion of the arytenoid has been resorbed by the healing process. Fig. Only in carefully selected cases. with extension of the excisional margin below the free edge of the vocal fold . or irreversible suture lateralization as depicted in this chapter. without significant airway improvement. 27). total arytenoidectomy (see Chap. as described by Lichtenberger. and when the surgeon has extensive experience in the endoscopic management of PGS should one attempt this treatment for PGS. 28. 28. xi. Sutures may be required to hold the flap in place.8  After completed excision. c) Permanent suture lateralization This technique. The flap is elevated and the scar removed until mo- bility is restored or the limits of the dissection are reached. MA. especially if performed bilaterally can be successfully used in recalcitrant cases of PGS that do not respond to other methods such as PTC and subtotal arytenoidectomy. Often the flap is elevated over the contralateral CA joint and 4–5 mm below the vocal folds in the interarytenoid cleft.

The vocal process and medial aspect of the arytenoid. Traction is placed on the sutures by an assistant. xiii. followed by a 4. Careful physical examination will document abnormalities of the cartilaginous glottis in over 80% of these patients. the same process is repeated on the contralateral side to obtain maximal airway results. As depicted in Fig.  Chapter 28 xii. as described in Chap. along with the mucosa overlying these structures are preserved (Fig. ■ Surgical success is usually associated with an immediate noticeable improvement in passive mobility of one or both vocal folds. Grasping the mucosa overlying the arytenoid. with lateralization sutures tied over a modified oral airway device external to the skin of the neck 179 . 28.8). xiv. attempts to release the posterior scar band through simple excision or mucosal flaps can be undertaken. The excision of arytenoid and lateral vocal fold musculature should continue inferiorly such that the defect extends infraglottically below the free edge of the vocal fold (Fig. traction is placed on the sutures. as well as a partial removal of lateral vocal fold musculature.10  Final result. the procedure involves a subtotal arytenoidectomy. Fig. The sutures are then secured over a silicone button. EMG will usually show normal activity in PGS patients. ■ The patient is encouraged to ambulate and plug their tracheotomy (if present) while awake if possible. with flexible laryngoscopy. while the posterior glottic scar is divided with the CO2 laser ■ The patient is reevaluated in the office at 1 month. then consideration for decannulation can be undertaken. 28.to 8-week time course of progressive airway obstruction. “Bilateral Vocal Fold Paralysis”. If mobility of one or both arytenoids has been achieved. 27. is associated with stenosis. 28. Patients will also notice improvement in respiratory status immediately after the operation. 28.9). 28. 28. the CO2 laser is used to excise the lateral aspect of the arytenoid.10).9  After suture lateralization. extending the incision anteriorly into the lateral aspect of the vocal fold for a distance of 3–4mm beyond the vocal process. ■ Laryngeal electromyography may be undertaken if the airway is safe or tracheotomy has been performed. Two sutures are used to lateralize the posterior vocal fold. Often. 28.6 Postoperative Care Relative to the postoperative course are the following: ■ Voice rest is not necessary. xv. Mitomycin C may be placed in the posterior commissure as well as conservative removal of any granulation tissue at that time. Key Points ■ PSG needs to be distinguished from bilateral true vocal fold paralysis. while the posterior glottic scar is divided with a CO2 laser (Fig. xvii.6. or a modified curved plastic oral airway device (with drill holes) (Fig. ■ At the time of direct laryngoscopy.7). ■ Regular diet may be resumed when the effects of anesthesia are resolved ■ LPR medical therapy is essential Fig. xvi. Ninety-five percent of the time a history of previous prolonged intubation. 28. ■ With the suture lateralization technique: The patient is brought to the operating room 3–4 weeks later for removal of sutures. ■ Direct laryngoscopy with palpation can be used to confirm the suspected diagnosis.

partial arytenoidectomy. or total arytenoidectomy (Chap. Eur Arch Otorhinolaryngol 256:412–414 Dedo HH. voice. Aviv JE. posterior transverse cordotomy. This is due to erosion of the posterior cartilaginous glottis with loss of the normal dimension and preexisting scar tissue. 27. Bryant GL Jr. Casiano RR. subglottic and tracheal stenosis by division or microtrapdoor flap.180 Posterior Glottic Stenosis: Endoscopic Approach ■ Endoscopic attempts to restore CA joint mobility will fail if the causative injury has resulted in cartilaginous disruption with loss of the normal arytenoid structure or fusion of the arytenoids to the cricoid ring. ■ Mitomycin C may be beneficial in reducing scar tissue reformation. Ossoff RH (1998) Posterior glottic stenosis: a canine model. 1):839–846 Lichtenberger G (1999) Endoscopic microsurgical management of scars in the posterior commissure and interarytenoid region resulting in vocal cord pseudoparalysis.   Selected Bibliography 1 2 3 4 5 28 Koufman JA. Otolaryngol Head Neck Surg 127:32–35 Courey MS. Shaw GY (2002) Laryngopharyngeal reflux: position statement of the committee on speech. J Otolaryngol 20(Suppl. Sooy CD (1984) Endoscopic laser repair of posterior glottic. “Bilateral Vocal Fold Paralysis”) may be used but are usually less successful in patients with PGS than patients with bilateral vocal fold paralysis. Laryngoscope 94:445–450 McIlwain JC (1991) The posterior glottis. and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. which predisposes to recurrent scar formation. ■ Destructive procedures such as irreversible suture lateralization. Ann Otol Rhinol Laryngol 107 (Pt.):1–24 .

29. 29. and 47 for further information. narrowing of the airway from neoplastic conditions (e. Subglottic/tracheal narrowing is usually caused by scarring within the lumen of the airway. chondrosarcoma of the cricoid) can be confused clinically with scar in the subglottis. 10.2 Disease Characteristics and Differential Diagnosis Subglottic stenosis (SGS) (Fig. 29. Arrow depicts the region of stenosis adjacent to the tracheo-esophageal party wall. 29. the “subglottic region” refers to the infraglottic airway from the free edge of the true vocal folds down to the inferior border of the cricoid cartilage.1  Subglottic stenosis tion. Strictly speaking. Cartilaginous tracheal arches are intact.3 29 Surgical Indications and Contraindications Indications include endoscopic treatment of subglottic/tracheal stenosis for cases of symptomatic cicatricial narrowing of the upper airway (Fig. 29. 6.1) and tracheal stenosis (TS) are terms that after often used interchangeably to describe symptomatic airway narrowing below the vocal folds.3).1 Fundamental and Related Chapters Please see Chaps. 45. 29. and tracheomalacia.Chapter 29 Subglottic/Tracheal Stenosis: Laser/Endoscopic Management 29.2). 13. g. Relative contraindications include: ■ Extensive length of stenosis > 2–3 cm ■ Absence of identifiable airway lumen ■ Stenosis involving the trachea at the level of the tracheostomy tube Fig. In addition. A more complete differential diagnosis is included in Chap. where care must be taken during laser radial incisions. rendering anatomic distinctions impractical. Absolute contraindications to laser excision/dilation of SGS include airway narrowing due to external compression. From a practical point of view. “Glottic and Subglottic Stenosis: Evaluation and Surgical Planning”. 29.2  Diagram of tracheal stenosis due to intraluminal scar forma- Fig. 46. or external airway compression. This must be distinguished from collapse secondary to weakened or absent cartilaginous framework (usually tracheal). 6. to avoid esophageal lumen entry .. or significant cartilage collapse (Fig. 9. many cases of upper-airway stenosis overlap the subglottis/upper tracheal boundary.

iv If jet ventilation is used.0 endotracheal tube wrapped with Cottonoid externally (for mitomycin C application) 29. b) The telescope is then advanced to the upper edge of the stenotic region.182 Laser Treatment for Subglottic Stenosis Fig. Pre-laser precautions (see Chap. and suspension laryngoscopy is established. “Mapping” of the stenosis is carried out as follows: a) The 0° telescope is advanced to the level of the vocal folds. c) The telescope is then placed at the distal edge of the stenosis for the final mark (Fig. then make sure that it is suspended during laser firing (note: 100% O2 concentrations are used with jet ventilation). 2. 1–2 cm is ideally suited for endoscopic treatment). and jet Venturi ventilation (with 100% O2) initiated through the laryngoscope channel. superpulse. and a mark is made on the telescope shaft where it intersects the proximal end of the laryngoscope (Fig.4  Mapping of the stenosis using a 0° telescope.4 “c”). Endotracheal intubation (which can be traumatic to the stenotic region) is avoided. 4.   Fig. c) Protect OR personnel i Safety eye wear 5.5 29 Surgical Procedure The example given below is typical for SGS/TS treatment in the absence of a tracheostomy tube. e) The remainder of the trachea and proximal bronchial tree is visualized (and additional sites of stenosis mapped. 29. 13) ■ 3.4. Laser radial incision (CO2 laser settings 4–8 W. The laryngoscope/subglottiscope should be positioned proximal to the vocal folds initially (for evaluation and mapping of the stenosis). b) Protect the endotracheal tube (if used) i Use a laser-safe tube. The patient is anesthetized via mask induction. and another mark is made (Fig.4. or intermittent pulse) The laryngoscope should be advanced past the true vocal folds (for protection). 1. The platform suction device is placed through the stenosis and used to protect the distal tissues while the laser . if appropriate). and positioned just above the stenotic region. ii O2 concentration of 30% or less iii Protect tube balloon by covering with a moist Cottonoid. Note the limited amount of airway expansion that could be achieved intraluminally 29. 29. 29. The marks are made on the telescope and measurements are taken directly off the telescope d) The diameter of stenotic region is estimated in millime- ters (the telescope diameter can be used as a guide). 29. The tooth guard is placed.3  Tracheal airway narrowing due to collapse of cartilaginous framework (commonly seen after tracheotomy). “Principles of Laser Microlaryngoscopy”) a) Protect the patient i. and the table is turned 90° to allow the surgical team to obtain visualization of the upper and lower airway. f) A ruler is placed along the telescope: i.5 or 4. 3. 29. 13. The measurement from “b” to “c” represents the length of the stenosis (in general. Moistened eye pads ii.4 Surgical Equipment Equipment needed for surgery includes: ■ Standard laser microlaryngoscopy set (Chap. The measurement from “a” to “b” represents the proximity of the stenosis from the true vocal folds (useful for treatment planning if external procedures are entertained). Wrap the head in moist surgical towels. “a”). “b”).

It is important to keep the incision precise (narrow).7  Example of predominantly right sided SGS with only three laser radial incisions needed at 12. so that a maximal amount of surrounding mucosa is preserved. and 9 o’ clock. it is important to maintain a strip of uninjured mucosa between the incisions to facilitate re-epithelialization. most stenotic lesions are asymmetric. The laryngoscope is advanced distally and resuspended to expose the more inferior extent of the stenosis. 29.  Fig.6). The incision should begin centrally and extend in a radial fashion. a maximum of four laser radial incisions are typically made at 12. The orientation of the incision is commonly compared to the hands of a clock. 6. 29. The platform suction device is engaged by “hooking” the stenotic “shelf ” that characterizes most upper airway stenosis (Fig. 29. Platform suction is placed underneath the stenotic shelf providing protection of distal trachea incisions are made.7). the laser incision is terminated.6  Perspective view of laser radial incisions. As most stenotic lesions are asymmetrical. 7. Additional laser radial incisions are made. the initial laser radial incision is used to open the most severely affected portion. arrow). 3. In the case of a perfectly symmetric stenosis. usually the region that has the most extensive shelf. 6 and 9 o’clock (Fig. Caution must Chapter 29 Fig. and 6 o’ clock be exercised when making laser incisions in the trachea at 6 o’clock due to the risk of esophageal entry along the party wall (see Fig. 29. Note placement of laryngoscope distal to the vocal folds for protection. When characteristic “sparking” of the tissue is encountered (indicating the presence of cartilaginous framework). The incision should be extended through fibrous scar tissue only.5). 29. with sparing of intervening mucosa Fig. Again.5  Schematic view of laryngotracheal region. Note planned inci- sions at 12. While the laser is being fired. 3. From a practical point of view. Further extension of the incision could expose cartilage leading to granulation/further scarring and/or cartilage loss. like the spokes on a bicycle wheel. jet ventilation is suspended. 29. which will promote more rapid re-epithelialization. 6. 3. and two to three strategically placed laser radial incisions in the stenotic region with preservation of a normal quadrant of airway are often all that is needed (Fig. 29.2. The 0° telescope (30° telescopes are helpful as well) is then passed through the stenosis to evaluate the extent of the 183 .

The dynamic view provided through the telescope provides a better view of this distal stenotic region. during rigid broncho- scopic dilation (center). 9.184 Laser Treatment for Subglottic Stenosis   Fig. The laser radial incisions are extended distally.4 mg/ml) Fig. which will allow passage of all bronchoscope sizes (see Fig. taking care that the entire surgical site is in contact with the pledget.4mg/ml is used. This is an important step due to the accumulation of CO2 that tends to occur during prolonged jet ventilation. placing the bronchoscope directly through the laryngoscope opening. therefore. c) Serial dilations are then carried out using progressively larger bronchoscopes. Usually a concentration of 0.9  Cottonoid-wrapped ETT segment (saturated in mitomycin C) in place. 6 and larger will not pass through most other laryngoscopes.4) Clinically successful results usually occur if dilation to #7 or greater bronchoscope is achieved. although dilation to #6 in females is sometimes adequate. Mass. bronchoscopes sized no. 25.8). The bronchoscope is then rotated 90° to achieve maximal dilation from its eccentric shape. Surgical lubricant placed on the tip of the bronchoscope is sometimes helpful. A mitomycin c–saturated Cottonoid is placed on the surgical site. and advancing past the stenosis. b) Generally. However. The time can be split up if the patient desaturates during the mitomycin-application period. Prior to dilation. Boston. Knittigen. The Cottonoid is left in place for 4–5 min. a no. under apneic conditions. and then removed. but concentrations of up to 10mg/ml (supersaturated) may occasionally be employed if a tracheostomy tube is in place. so that endotracheal ventilation can be performed during dilation.8  Schematic illustration of airway after laser radial incisions (left). A Cottonoid-wrapped 3. they may be passed using a sliding Jackson laryngoscope or “freehand” without the aid of laryngoscopic guidance. Suspension laryngoscopy with application of mitomycin C (0. 5–9) is now used to gradually dilate the airway (Fig.5 or 4.) are much easier and expeditious for dilatation compared with rigid dilatation. 29. 5 bronchoscope is used initially. Rigid dilation of stenosis Refixed-wire balloon dilators (Boston Scientific. ii. Failure to extend the laser radial incisions through the entire distal aspect of the stenosis is a common error. 29. and after serial dilations are complete (right) 29 laser incisions. This is likely due to the inherent limitations of a fixed visual field used in microlaryngoscopy. 8. stopping with the largest size that can be comfortably advanced past the stenosis. a) A series of rigid ventilating bronchoscopes (nos. A better suited alternative is the use of a large bore Lindholm laryngoscope (Karl Storz. Germany). 29. allowing jet ventilation to proceed a) Application of mitomycin C to the surgical site is an im- portant adjunct in the endoscopic treatment of airway stenosis. if indicated. Two options for mitomycin c application can be utilized: i.0 ETT segment (2– 3 cm in length) can be saturated with mitomycin and . each bronchoscope should be connected to the anesthesia circuit via flexible rubber tubing.

shortness of breath. All of the equipment listed for CO2 laser radial incisions and dilation 2.  Chapter 29 placed into the airway in contact with the surgical site (Fig. 2.5). connected to a camera/monitor to visualize the airway during the placement of the T-tube stent. 29.6 Postoperative Care and Complications Postoperatively. In general. 3. T-tube placement is indicated for tracheotomized patients with subglottic/tracheal narrowing (from any cause) who have failed serial CO2 radial incisions/dilation treatment. 1. Suspension laryngoscopy is performed. ■ Perioperative steroids are important: ■ 10 mg Decadron intravenously ■ Oral steroid-taper ■ Additional postoperative meds: ■ PPIs for at least 2 months. the detachable piece of the ETT in which you connect your ventilation circuit). The patient is returned to the care of the anesthesia team. sizes 11–14 (Hood) are used. The stent is sterilized prior to placement (Fig. until healing is complete ■ Antibiotics for 5–7 days (optional) ■ Pain medications (usually from tongue compression) ■ Cough suppressants (Tessalon Perles 100 mg three times daily.11). 29. or subcutaneous crepitance in the neck.7 T-Tube Stenting of SGS Placement of a T-tube represents an “intermediate” step between endoscopic and open treatments for SGS/tracheal stenosis. A nasogastric (NG) tube is placed through the external limb of the T-tube.5–6. chest/pleuritic pain. such as SpO2 values less than 95%.to 5-ml balloon capacity b) Hemostat/clamp c) Small-diameter ETT (4. Connector piece from a small bore (4. This seems to provide better contact with the surgical site as well as a providing an airway for jet ventilation during the 4–5 min of treatment. The tube need only be removed briefly for endoscopic viewing of the entire upper airway at the beginning of the case. in an effort to avoid any further trauma to the operative site. SGS involving the infraglottic aspect of the vocal folds (undersurface) is not well-suited for T-tube stenting (and is a relative contraindication). until an adequate airway caliber is obtained. e. ■ Chest x-rays should be obtained if the patient has any unexpected findings postoperatively. If tracheostomy is present distal to the stenotic region. 29. and to assist in positioning the stent (Fig. because the proximal limb of the T-tube will likely either interfere with vocal fold closure or lead to granulation tissue formation and obstruction of the proximal T-tube.10). A 185 . management includes: ■ The patient is observed overnight in an ICU or stepdown unit.0) ETT (i. as needed) Complications can include: ■ Laser fire ■ Tracheal penetration with pneumomediastinum/pneumothorax ■ Late postoperative edema/granulation/fibrinous exudates with airway obstruction ■ Tracheoesophageal fistula (exceedingly rare) ■ Reccurent stenosis 29.9 Surgical Procedure A preexisting tracheostomy is required to perform T-tube placement. then the case is significantly simplified—the airway is maintained with standard general anesthesia delivered through the tracheostomy site with a laser safe tube. Jet ventilation can be continued until the team is prepared to switch to mask ventilation. 29. An appropriate T-tube stent is selected according to the diameter of the airway after dilation.. and up through the proximal (shorter limb). and an assistant places a rigid endoscope. With experience. One of the following to occlude/bypass the proximal end of the T-tube for ventilation: a) Fogarty catheter with 3. Steps 1–8 of CO2 laser radial incisions and dilations are first performed (as outlined in Sect. and especially with patients who are having repeated endoscopic treatments. Intubation is not recommended at the termination of the case. such monitoring may not be necessary. An apneic technique is used during tube removal for the tracheal evaluation and dilation aspect of the procedure. although other nontraumatic techniques such as laryngeal mask ventilation are acceptable. Ensure that this piece fits snuggly into the ventilation port of the T-tube to be used. 29. 10. The patient is awakened using mask ventilation and an oral airway preferably. The open-ended design does not allow positive pressure ventilation through the external limb of the T-tube. T-tube placement is contraindicated for patients on ventilatory support. Commercially produced standard T-tube stents: a) Hood adult sizes 10–16 (size indicates outer diameter in millimeters) b) Montgomery adult sizes 10–16 (size indicates outer diameter in millimeters) 3. 29. The device is removed prior to returning the patient to the anesthesia team.0) 4. and again for dilation at the end of the case.8 Surgical Equipment Surgical equipment needed includes the following: 1. 29. 4.9).

16). and might need to be attempted a few times before the T-tube can be successfully positioned in the distal airway. or “loose” in the airway. and advanced through the stoma. 29. This step may be difficult. and clamped in place 29   airway and the NG tube is grasped by the assistant via endoscopic visualization . 29.15). seating the proximal end of the T-tube in the airway (Fig. 29. twisted. partially occluded. the assistant grasps the NG tube with a large laryngeal cup forceps/grasper.12  An NG tube is placed through the external limb of the T- Fig. Working through the laryngoscope. The tip of the NG tube is then placed through the tracheal stoma and advanced into the proximal trachea. The NG tube is pulled into the upper trachea. 5. up through the proximal (shorter limb). 6. the proximal end of the T-tube should not come within 5 mm of the undersurface of the vocal folds. The distal end of the T-tube is crimped (Fig.186 Laser Treatment for Subglottic Stenosis Fig. 29. The T-tube should not be kinked.12). 29. 29. and into the distal tracheal airway (Fig. 29. which fixes the T-tube to the indwelling NG tube (Fig. 29.13  The proximal end of the T-tube is passed into the clamp is placed at the external limb of the tube. The assistant uses the rigid telescope to visualize the entire length of the T-tube to insure patency and adequate positioning in the airway (Fig.13).11  T-tube stent prior to placement Fig.14) with a hemostat. In addition.10  An assistant provides visualization (with a 0° telescope) of Fig. The distal end should not come in contact with the airway during T-tube placement tube. 29.

and ultimately luminal obstruction of the stent. 29. 29. the patient must be ventilated until he/she is able to breathe spontaneously. 187 . as long as humidified air is used by the bedside. Chapter 29 Fig. 29.14   The distal end of the tube is crimped with a curved clamp Fig. Once the T-tube is positioned. An uncapped T-tube can lead to drying/crusting of airway secretions within the tube.15  The clamped distal end of the tube in advanced into the distal trachea through the stoma Options include: a) LMA (laryngeal mask ventilation) b) Occlusion of the proximal end of the T-tube with a endoscopically positioned Fogarty catheter. Once the patient is breathing spontaneously. without ventilatory support. Inability to cap the T-tube (for any reason) when the patient is fully awake and recovered from anesthesia. 8. A properly seated T-tube should fit snuggly in the airway and maintain its shape/patency regardless of patient position/neck movement. If the above conditions are not met. Successful maintenance of long-term T-tube stent in the airway cannot be achieved unless the tube is capped during the majority of the patient’s waking hours. c) Occlusion of the proximal end of the T-tube using a hemostat/clamp placed through the stoma at the proximal end of the T-tube (care must be taken not to also occlude the external limb). a connector from an ETT is placed into the external limb of the T-tube for ventilation distally (Fig. A good indicator of successful T-tube placement is the ability of the patient to maintain good air exchange with the T-tube capped at the end of the surgical case and in the recovery room.18).  Fig. 29. 7. Patients with coexisting obstructive sleep apnea can often uncap the T-tube at night. then T-tube placement will ultimately fail due to granulation tissue formation and occlusion of the tube. is cause for concern.16  The assistant passes the telescope through the T-tube into the distal trachea to insure good placement and patency of the lumen of the tube the carina. so that the patient is now moving air oronasally. the external limb of the T-tube should be capped (closed). Again. A connector from an ETT is placed into the external limb of the T-tube for ventilation distally (Fig.17). 29.

188 Laser Treatment for Subglottic Stenosis Fig. 29.17  Occlusion of the proximal end of the T-tube with a Fogarty catheter to allow venti­ lation 29 Fig. 29.18  Occlusion of the proximal end of the T-tube with a curved clamp to allow ventilation   .

Suctioning of the upper and lower limb of the T-tube every 8 h and as needed • An excellent nursing/patient instruction manual is included with the Hood T-tube package 7. • Come to the Emergency Department immediately. one size smaller than that of the T-tube: T-tube size Tracheotomy tube size (Shiley) 10 2 11 2 12 4 13 4 14 6 15 6 16 8 5. Key Points ■ Endoscopic treatment of subglottic and tracheal stenosis is an excellent management option. it is important to bevel and smooth the cut edges. replacement of the T-tube should be performed every 2 years. Prior to discharge from the hospital. This modification replaces the inert. page the surgeon. and in most cases. is the first method attempted before embarking on open surgical treatment. To avoid this. If transglottic extension of the superior limb of the T-tube cannot be avoided. Crusting in the external limb can be cleaned with a cerumen loop. Ten milligrams intravenous Decadron preoperatively. reactive surface—often resulting in granulation tissue formation at the tube/tissue interface. then grasp and pull firmly on external limb of T-tube to remove it.  Chapter 29 Complications include the following: 29. 8.11 Special Considerations in T-Tube Stenting T-tube stenting of the airway is intended as long-term management strategy for patients with SGS/tracheal stenosis. and must be dealt with by either removal/ cryotherapy of the granulation tissue. then suction upper and lower limb of T-tube/irrigate with 2 ml normal saline. or by replacing the stent with a more appropriate T-tube. Patients are at higher risk for this complication if the T-tube is “modified” by cutting off a portion of the proximal or distal tube. and careful postoperative monitoring should be undertaken for at least 2–3 month/hs after stent removal to check for recurrence of stenosis. then the upper limb should be located at the ventricle/inferior false vocal fold level. However. 29. if this does not improve breathing.10 Postoperative Care Postoperatively: 1. smooth “factory” edge of the tube with a sharper. The T-tube should be removed in the OR. removal of the T-tube can be attempted. in select cases. 189 . Observation of the patient in a monitored setting for 24 h (ICU or step-down unit) 2. and every 8 h (×2) during hospitalization – Consider prednisone/methylprednisone oral taper at dis­ charge 3. who have failed endoscopic laser treatments. Nine French or less is recommended for cleaning/suctioning. ■ Accidental T-tube displacement/removal ■ The use of large bore suction catheters (10 French or greater) can lead to this. using a flexible laryngoscope to insure upper and lower limb patency and to check for reactive granulation tissue. as described by Montgomery et al. until healing is complete – Antibiotics for 5–7 days (optional) – Pain medications (usually from tongue compression) – Cough suppressants (Tessalon Perles 100 mg three times a day. Humidified air at bedside. this can occur with prolonged (>3 years) T-tube placement. especially during sleep 6. • Review importance of suctioning/cleaning of tube and humidification ■ T-tube occlusion due to poor position/incorrect size of T-tube ■ Granulation tissue at proximal or distal end of T-tube ■ This presents within the first 2 months postoperatively. as needed) 4. as well as incomplete glottal closure. Tracheostomy tube at bedside. educated patient/caregivers regarding emergency measures in the event that the T-tube becomes obstructed at home: • Uncap T-tube first. Additional postoperative medications: – PPIs for at least 2 months. ■ Cracking/splintering of the T-tube ■ Although uncommon. A tracheostomy tube can be placed through the stoma as a temporizing airway until arrangements to replace the T-tube (in the OR) can be made. ■ Hoarseness/aphonia due to extension of the proximal end of the T-tube into or through the glottis ■ Edema and granulation tissue of the vocal folds can result. Follow up in the office frequently in the first 2 months postoperatively (every 1–2 weeks depending on patient’s reliability/family support/anxiety level) • The inside of the T-tube should be inspected each visit. after a minimum period of 1–2 years of stenting. • If still unable to move air adequately. If customization of the T-tube cannot be avoided.

Selected Bibliography 1 2 Montgomery WW. and is helpful for determining treatment planning. Ann Otol Rhinol Laryngol 99:2–28 Shapshay SM. and stenosis at the level of the tracheostomy. 29   ■ Placement of a T-tube stent represents a intermediate step between pure endoscopic treatment and open procedures for laryngotracheal stenosis. ■ A good indicator of successful T-tube placement is the ability of the patient to maintain good air exchange with the T-tube capped at the end of the surgical case. Beamis JF. ■ “Mapping” of the stenosis is an important part of the initial evaluation of airway stenosis. Ann Otol Rhinol Laryngol 96:661–664 . complete stenosis (no identifiable lumen). Montogomery SK (1990) Manual for use of Montgomery laryngeal.190 Laser Treatment for Subglottic Stenosis ■ Absolute contraindications for endoscopic treatment of stenosis include airway narrowing due to external compression and tracheomalacia/cartilage collapse of the airway ■ Relative contraindications for endoscopic treatment of airway stenosis include extensive length of stenosis (greater than 2–3 cm in length). Hybels RL et al (1987) Endoscopic treatment of subglottic and tracheal stenosis by radial laser incisions and dilation. ■ Laser radial incisions are used to open the stenosis. ■ Topical application of mitomycin C after endoscopic treatment greatly increases the chance for success. ■ The CO2 laser is generally the workhorse laser for endoscopic airway management. trachea and esophageal prostheses: update 1990. while simultaneously preserving surrounding mucosa for re-epithelialization. ■ Careful follow-up for cleaning and inspection of the T-tube in required in the first 2 months after T-tube placement.

10. small spot size and its hemostatic properties for excision of the vocal fold cancer. Vocal fold cancer involves epithelial migration or invasion via malignant transformation into the lamina propria and muscle of the vocal fold. A cold-steel excision is best suited for relatively superficial lesions that have neither deep muscle involvement nor cartilage involvement (arytenoid). Cold-steel excision can also be used either in combination with CO2 laser or exclusively. otalgia. The spread of the cancer to the anterior or medial border of the arytenoid cartilage is somewhat controversial regarding resectability via a microlaryngoscopy approach. Contraindications include: ■ Inadequate microlaryngoscopic exposure of the entire vocal fold lesion ■ T2N0M0 staging with > 5-mm supraglottic or intraglottic extension. Nonglottic laryngeal sites of cancer and advanced laryngeal cancer disease that spreads from the level of the vocal fold to other sites are not discussed. partial vocal fold fixation. change in pitch. 13) ■ Tongue blade with fine gauge needles . 30. the more advanced head and neck cancer related symptoms of odynophagia. 4. blastomyocosis) 30.3 Surgical Indications and Contraindications Indications for surgery include T1aN0M0 SCCa of the vocal fold. and the arytenoids. The assessment of early vocal 30 fold carcinoma prior to surgical excision should ensure that the cancer has not spread laterally into the ventricle.Chapter 30 Carcinoma of the Vocal Fold 30. For most patients with early vocal fold carcinoma (Fig. depending on the location and depth of the cancer. The most common method for excision of early vocal fold carcinoma is using the CO2 laser via a microlaryngoscopy approach. Normal vocal fold motion must be assured to confirmed early glottic disease. 30. The specific anatomic sites of the vocal fold that are important to take into consideration when assessing early vocal fold carcinoma include the anterior commissure. infraglottis. 30. 30. or the supraglottis. laryngeal ventricle. and 13 for additional information.1 Fundamental and Related Chapters Please see Chaps. or arytenoid involvement (note: patient counseling must include the treatment option of radiation therapy).4 Surgical Equipment Equipment needed includes: Fig.1  Early carcinoma of the vocal fold ■ Standard laser microlaryngoscopy set (Chap. The most common symptoms associated with vocal fold carcinoma include hoarseness.2 Disease Characteristics and Differential Diagnosis This chapter discusses the surgical treatment of squamous cell carcinoma of the glottis (T1N0M0). and roughness of the voice. the infraglottis. The CO2 laser has the advantage of precision. Early vocal fold carcinoma can occur unilaterally (T1aN0M0) or bilaterally (T1bN0M0).1). neck mass. or dysphagia are rarely present. Differential diagnosis of early vocal fold carcinoma is: ■ ■ ■ ■ ■ ■ ■ Hyperkeratosis/dysplasia Carcinoma in situ Recurrent Respiratory Papillomatosis Verrucous carcinoma Spindle cell carcinoma Tuberculosis Fungal disease (histoplasmosis.

and eye protection for all individuals in the OR (see Chap. specifically. 11. and posterior dimension. straight-up scissors or the laser can be used to release the inferior border of the excision and remove the lesion for orientation (Fig. With the cancer excision specimen retracted medially. which border and where on the border the instrument is. ■ Laryngopharyngeal reflux treatment with PPIs may reduce granuloma formation at the operative site. ■ No voice rest indicated. is essential. posterior and lateral excision borders in a fairly   even fashion (similar depth) for best exposure during the excision (Fig. looking for other areas of abnormal epithelium or tissue that would require biopsy or further excision.2). Once the anterior. deep) as indicated. Implement all laser safety procedures including protection of the endotracheal tube cuff. patient head and neck protection. it is important to make a mental note of the exact location of the retraction instrument on the specimen. it is best to incise the anterior. Using the CO2 laser on a repeat superpulse mode with a relatively small spot size (approximately 0. This lesion can be placed on a tongue blade and fixed into position with anatomic orientation. 3. outline the area of excision anteriorly. Small-gauge pins are used to secure the excision specimen to the tongue blade (Fig.3 mm). yngoscopy should allow complete visualization of the lesion.4). Detailed and angled visualization with telescopes. posterior. 4.3). it is very important to evaluate the borders of the vocal fold cancer from an anterior–posterior. and posterior borders of the excision are noted on the tongue blade. ■ Follow-up with patient. inferior. lateral. 9. depending on the results of the final pathology report .2  Vocal fold cancer seen via microlaryngoscopy with CO2 la- ser created marks for proposed excision boundaries (anterior. and infraglottic perspective. a decision should be made between using the CO2 laser and cold-steel excision. Microcup forceps can be used to take selected margins (lateral. 30. It is best to physically review the preoperative cancer excision photographs and the tongue blade orientation with the pathologist immediately after the excision in the operating room. posterior. without any medial or lateral “skiving” of the incisions. Frozen section processing of the excisional tissue is generally avoided due to inherent inaccuracies in determining margins in a small specimen.5 Surgical Procedure 1.3). 10. especially with laser artifacts. incisions can be made around the vocal fold cancer in an anterior. 6. lateral. 8. Complete the anterior. 30. and lateral borders of the excision down to the appropriate depth that will allow complete excision of the cancer without excessive removal of normal deep laryngeal tissue. The deep margin of the excision lays on the surface of the tongue blade and then the anterior. 30. Using the CO2 laser on a single-fire setting. This is very helpful for the orientation of the cancer excision immediately after the release of the inferior attachment of the excision (Fig. With vocal fold palpation. Carefully evaluate the margins of the excision via highpower microlaryngoscopy and the angled telescopes. Prior to the release of inferior excision. These can be sent for frozen section analysis or permanent pathological evaluation. Exposure of vocal fold cancer via suspension microlar2.to 2-mm margins of excision (Fig. 5.192 Carcinoma of the Vocal Fold 30 Fig. 30 and 70° telescopes. posteriorly and laterally around the vocal fold cancer with approximately 1. 30. and lateral) 30. posterior and lateral borders of the excision are completed. Using this method. posterior. 30. “Principles of Laser Micro­laryngoscopy”).6 Postoperative Care and Complications Immediately postoperatively: ■ Same-day surgery discharge on an outpatient basis is typical for this type of vocal fold cancer excision. 13. 7. the cancer excision can be retracted with a triangular forceps or curved alligator medially for exposure of the inferior border for excision. specifically. Serial sectioning (using routine histopathology processes) can be used to map the nature of the pathology throughout the specimen and especially at the margins. lateral. 30. Care should be taken to make these initial cuts perpendicular to the superior surface of the vocal fold. 30. anterior.3). Also.

Selected Bibliography 1 2 3 4 Myers EN. Laryngoscope 105(Pt. Ann Otol Rhinol Laryngol 103:28–30 Zeitels SM (1993) Microflap excisional biopsy for atypia and microinvasive glottic cancer. 2):1–51 Zeitels SM. Bunting GW (2002) Voice and treatment outcome from phonosurgical management of early glottic cancer. 30.4  Orientation and pinned vocal fold cancer excision specimen on tongue blade Fig. Ann Otol Rhinol Laryngol 190(Suppl. ■ Granulation tissue at operative site ■ This granulation tissue commonly occurs within 2–4 weeks and will slowly involute over time. causing significant dysphonia or breathing problems. Johnson JT (1993) Microlaryngoscopic surgery for T1 glottic lesions: a cost effective option. ■ Orientation of the excision specimen on a tongue blade is extremely helpful to further management of any positive margins that occur on the final pathologic analysis and to minimize the amount of tissue that is damaged or removed during the treatment of early vocal fold carcinoma. then this can be re-excised either in the operating room or in an office-based setting.  Chapter 30 Fig. Wagner RL.):3–20 193 . 30. Operat Tech Otolaryngol Head Neck Surg 4:218–222 Zeitels SM (1995) Premalignant epithelium and microinvasive cancer of the vocal fold: the evolution of phonomicrosurgical management.3  Medial retraction of vocal fold cancer excision with expo- sure of the inferior border for excision (with scissors in place for final excision) Complications include: ■ Bleeding from the deep excision location ■ This can be treated with an application of topical epinephrine on a Cottonoid and/or using the CO2 laser with a defocused beam for coagulation purposes. If the granulation tissue is slow to involute. Franco RA. ■ Residual tumor/recurrence Key Points ■ Exposure is essential to successful microlaryngoscopy excision of vocal fold carcinoma. Hillman RE.

Part B Phonomicrosurgery for Benign Laryngeal Pathology IV Laryngeal Injection Techniques .

14. easy to use and completely biocompatible. materials. An additional requirement of all future vocal fold injection materials will be a matching of the biomechanical properties of the material with the biomechanical properties of either the superficial aspect of the vocal fold (superficial layer of the lamina propria) or the deep aspect of the vocal fold (vocalis. 5. 31. 32. which resulted in a significant foreign body response and rejection.1  Deep vocal fold augmentation locations 31 Autologous fat ® Radiesse (calcium hydroxylapatite) Teflon Gelfoam® Radiesse Voice Gel® Bovine collagen–based products (Zyplast®. Similar responses have occurred with Silicone injections as well as more recently with Teflon® vocal fold injections. Zyderm®) Human collagen–based ®products (Cymetra®. Injection augmentation can be divided into two specific anatomic locations. 33. and methodologies applied to all of these locations. inexpensive. The search for such a material has been ongoing for close to a 100 years. with subsequent different indications. injection materials and methods to perform vocal fold injection (see Chap. 31. “Principles of Vocal Fold Augmentation”). The advantage of injection augmentation versus open laryngeal procedures (laryngeal framework surgery) is the endoscopic and minimally invasive nature. 10. There are different locations.Chapter 31 Vocal Fold Augmentation via Direct Microlaryngoscopy 31. Other advantages include a more direct visualization of the vocal fold pathology requiring treatment. This technique is discussed in Chap.1 Material Selection The ideal vocal fold injection material would be readily available. and significant advances in vocal fold injection material availability and design have occurred in the last 10 years. Hyalaform Plus®.1 Fundamental and Related Chapters Please see Chaps. 32. Restylane®. Cosmoplast . This injection location is used to augment globally the vocal fold for cases of significant glottal incompetence due to: ■ ■ ■ ■ ■ ■ Vocal fold paralysis Vocal fold paresis Vocal fold atrophy Sulcus vocalis Severe vocal fold scar Soft tissue loss of the vocal fold(s) 31. “Superficial Vocal Fold Augmentation via Microlaryngoscopy. A superficial or medial vocal fold injection is performed for the treatment of vocal fold scarring or focal loss of lamina propria. 14. thyro-arytenoid and lateral cricoarytenoid muscle). The original injection material was paraffin. The materials presently available for vocal fold injection include (see Chap. Perlane®) ■ Autologous fascia (minced) . and 34 for further information.2 Disease Characteristics Vocal fold injection can be an extremely useful treatment method for a variety of voice disorders. 8. “Principles of Vocal Fold Augmentation”): ■ ■ ■ ■ ■ ■ ■ Fig.” Injection augmentation can also be carried out in a deep or lateral vocal fold position.2. Cosmoderm) ■ Hyaluronic acid–based products (Hyalaform®. 14.

Often. Pilling.)   ■ Vocal fold injection needle and device ■ Zero degree Hopkins telescope (4–5 millimeters in diameter and 30 cm long) ■ C-mount camera and video monitor 31. further injection will often spread superiorly to augment the vocal fold at the level of the glottis or the injection needle can be withdrawn 1–2 mm to finish the vocal fold augmentation in the region of the midmembranous vocal fold (Fig. 31. autologous collagen. comfort level of the surgeon.and 19-g needles (Storz. Prior to vocal fold augmentation. Furthermore. 2. “Percutaneous Vocal Fold Augmentation in the Clinic Setting”). 31.1). The vocal fold injection needle should be angled slightly laterally and placed approximately 3–5 millimeters deep to the mucosa prior to the injection. “Principles of Vocal Fold Augmentation”).3 Surgical Indications and Contraindications Vocal fold augmentation is indicated for the patient with glottal incompetence. Bovine collagen. bulk. and vocal fold atrophy. The vocal fold should be injected at the intersection of two anatomic landmarks: a) At the level of the vocal process b) At the transition zone from the superior surface of the vocal fold to the ventricle (superior arcuate line). a deep vocal fold augmentation is the preferred injection approach. 10) ■ Brunings syringe vocal fold injection device with 18. and via microlaryngoscopy (see Chaps. Montreal.) Endoscopic vocal fold injection requires the following: ■ Slotted small laryngoscope (anterior commissure laryngoscope.. the vocal fold injection location. For disorders that cause global glottal incompetence and/or lack of vocal fold bulk such as vocal fold paralysis.1 Principles of Deep Vocal Fold Augmentation Principles of deep vocal fold augmentation comprise the following: 1. however. . 3. a second injection site is required along the superior arcuate line in the region of the midmembranous vocal fold (Fig. 33. 31.4 Surgical Equipment Vocal fold augmentation via microlaryngoscopy requires following: ■ Standard phonomicrosurgery equipment (see Chap.2). Injection can then be done in a graded or step-wise fashion. It is important to remember that the best deep vocal fold injection is placed lateral within vocal fold.. Incomplete vocal fold closure is divided into global or focal deficit of the vocal fold. and glottic closure. The options for vocal fold injection methodology include percutaneous. observing the immediate impact of the vocal fold injection on vocal fold size. position.1). vocal paresis. “Superficial Vocal Fold Augmentation via Microlaryngoscopy”). Fla. Canada). This can be further enhanced by purposefully positioning the laryngoscope to visualize the lateral aspect of the vocal fold ventricle as opposed to the midline of the glottis. and human-based collagen are all products that have been used in the past or are presently being used for superficial vocal fold augmentation (see Chap. Quebec.) or Instrumentarium lipoinjection device (Instrumentarium Surgical Corp.5 Surgical Procedure Selection of the vocal fold augmentation technique is determined by the underlying etiology. Optimal needle placement is confirmed when the initial augmentation is seen at the level of the infraglottis. which requires significant overinjection of the vocal fold (see Chap. St. Fort Washington. nature.198 31 VF Augmentation – Microlaryngoscopy All of these materials other than Cymetra and other collagenbased produces have been designed and used for deep vocal fold augmentation. “Peroral Vocal Fold Augmentation in the Clinic Setting” and 34. ■ Liposuction device (large bore. and the vocal fold injection material. the degree. This contraindication is especially true for vocal fold lipoinjection. Patients with poor abductory range of motion on the contralateral vocal fold or with poor bilateral vocal fold abduction are at significant risk for airway compromise postoperatively. Mo. After reasonable infraglottic augmentation. 32.5. 31. and cause of the glottal incompetence need to be further elucidated. 31. 10) ■ Vocal fold injection needle and device Lipoinjection of the vocal fold requires: ■ Standard phonomicrosurgery set (See Chap. the nature of the glottal incompetence can be identified as to either a lack of muscle bulk or of lamina propria (or both). Inc. transoral. Louis. low pressure) (Tulip™) or small “plastics” instrument tray for open harvest ■ Sterile funnel ■ Merocel™ sponges (Medtronic-Xomed. 14. endoscopic direct laryngoscopy. 31. careful evaluation and consideration of the patient’s airway is warranted. The junction of these two anatomical locations is the optimal location for a deep vocal fold injection (Fig. Jacksonville. and this is optimally achieved with a slightly angled injection needle that is not completely parallel to the longitudinal axis of the laryngoscope (thus the advantage of using a slotted laryngoscope). Pa. 4.

Preoperative anesthesia is a crucial aspect of this procedure. 1.3). The advantages of this approach are outstanding visualization and precise vocal fold injection placement.” which allows one to fully assess the lack of bulk and exact pathology that is to be corrected with the vocal fold augmentation (see Chap. “Principles of Phonomicrosurgery”). Lidocaine is sprayed on the larynx after the vocal fold in- jection is completed to help prevent postoperative laryngospasm.5. The disadvantage is the lack of an endpoint due to the inability to assess vocal fold closure. 2. 5. A surgical telescope provides endoscopic visualization for the procedure. during. This allows visualization of vocal fold motion and closure before. Additional 4% plain lidocaine can be directly applied to the oropharynx and endolarynx via indirect laryngoscopy and/or direct laryngoscopy. Endoscopic vocal fold injection is used for a deep vocal fold augmentation. with the patient awake.2  Depth of injection needle for deep vocal fold augmentation Fig.3 Endoscopic Vocal Fold Injection tion via microlaryngoscopy 199 . and after the injection. Preoperative anesthesia will allow the slotted anterior commissure laryngoscope (Pilling) to be passed through the Fig. Topical nebulized 4% plain lidocaine should be administered for 10–15 min prior to the operative procedure. 30. a large bore laryngoscope is suspended. 31. providing complete visualization of the vocal fold (see Chap.2 Vocal Fold Augmentation via Microlaryngoscopy Chapter 31 6. Over-correction as depicted on Fig. This technique allows the surgeon a magnified. 3.  31. Deep vocal fold augmentation should be performed at this vocal fold injection site approximately 3–5 mm deep to the mucosa. 10. This injection technique is also advantageous given that it allows the vocal fold injection to be performed with complete visualization of the procedure by both student and mentor simultaneously. Review of the preoperative videolaryngoscopy and/or videostroboscopy is an important start to vocal fold augmentation. To ensure a lateral vocal fold injection site. After adequate general anesthesia and complete muscle relaxation has been achieved by the anesthesiology team. 7. 2. detailed view during vocal fold augmentation. 10). Endoscopic vocal fold injection involves a deep vocal fold augmentation using a small slotted laryngoscope under a local anesthesia (with minimal intravenous sedation).5. 31. it is wise to position the laryngoscope with the suspension device angled in a lateral facing direction (Fig.3  Angled laryngoscope position for deep vocal fold augmenta- 31. Alternative anesthesia methods include trans-tracheal lidocaine injection and/or superior laryngeal nerve block (either percutaneous or via the pyriform sinus). Angled telescopes (0. 1. Suspension microlaryngoscopy with general anesthesia can be used to perform vocal fold augmentation.7 should be achieved. 31. and 70°) are used to visualize the entire larynx in a “three-dimensional fashion. and the needle should be angled as lateral as possible as it is placed through the laryngoscope. Visualization of the vocal fold during the vocal fold injection allows one to determine the ideal amount and location of the injection by observing immediate changes in the vocal fold contour during and after the injection. 31. 4.

The most reasonable location for open harvest is in the infra-umbilical region or through a preexisting abdominal scar. and tacking sutures are placed in the deeper aspect of the wound to the subdermal plane. The need for any further injection is determined. 4. and provides perfectly sized injection material. closure pattern.4  Overview of endoscopic vocal fold injection Fig. 6. For patients with only “modest” amounts of subcutaneous fat. approximately 1 × 2 × 1 mm in size. and vocal fold closure is visualized during the patient’s phonation. Fat harvest for lipoinjection can be done either through open incision with harvesting subcutaneous fat or via liposuction. Fat harvest can be done under local or general anesthesia. resulting in medialization and augmentation of the vocal fold by deposition of autologous fat.5.5. f) Hemostatis is attained with electric cautery as needed. open harvest is recommended. The injection device is then passed into the laryngoscope parallel with the endoscope.200 31 VF Augmentation – Microlaryngoscopy oral cavity and oropharynx and to pick up the tip of the epiglottis. Given the viscous nature of the fat. 31. e) The fat is sharply dissected out with cold-steel instruments. or only at the proposed incision site for hemostasis if under general anesthesia. and the glottal incompetence deficit are noted by visualization through either the endoscope or a camera attached to the endoscope (Fig. Open fat harvest a) The abdomen is prepped and draped in a sterile fashion.4 Lipoinjection of the Vocal Fold Fig. 4% plain lidocaine can be applied directly to the endolaryngeal region and intended vocal fold. Deep vocal fold injection is performed (Figs. g) The harvested fat is then carefully cut into small pieces with scissors. Liposuction is the preferred technique because it is expedient. The vocal fold motion. Once adequate vocal fold augmentation is obtained by direct visualization (Fig. 5.6). 31. the slotted laryngoscope is then advanced with the nondominant hand. 31. A 0° telescope (30 cm. b) Local injection of lidocaine with epinephrine is done as a regional block for local anesthesia. 31. a pressurized injection device such as a Brunings syringe or the lipoinjection device designed by Instrumentarium is required. 1. the needle can be retracted and kept sheathed within the laryngoscope.7). taking care not to violate the skin above or the peritoneum below. 3. With this visualization. Lipoinjection can be done via an endoscopically guided peroral approach or a microlaryngoscopy approach (see above). from approximately 4 to 8 o’clock. d) Subcutaneous elevation of the dermis proceeds in an inferior direction. (This aspect of the procedure is time consuming and laborious . 31. The laryngoscope is positioned to slightly retract the false vocal fold to allow complete visualization of the entire length of the membranous vocal fold and the ventricle of the intended site for injection. 31.5  Endoscopic vocal fold injection method Lipoinjection of the vocal fold is designed to be a deep/lateral vocal fold injection. immediately over the vocal fold to be injected and manually suspended. c) A curvilinear incision is made at the junction of the umbilicus and the infra-umbilical region. using the visualization achieved by the endoscope for guidance. 31.to 5-mm diameter) is then passed through the manually suspended laryngoscope. releasing the subcutaneous fat off the subdermal plane. less invasive.   4. After adequate laryngeal anesthesia is achieved and a small amount of intravenous sedation is given.4). The former area of the body typically has a plentiful amount of material and an incision immediately inside the umbilicus can be easily hidden.

  but important. The fat must be carefully and thoroughly rinsed and carefully handled prior to lipoinjection to maximize graft survival. 31.2 ml of material) used for most injectables previously described deep vocal fold injection techniques (see above). b) Suction tubing is applied to the downward spout of the funnel. Calif.6  Endoscopic vocal fold injection method Fig. a) The abdominal skin is prepped and draped in a sterile fashion. Pinching the skin to create “tunnels” helps develop a safe plane for fat harvest (Fig. 31. then it will not flow smoothly through the injection needle. Lipoinjection of the vocal fold The approach and exposure of the vocal fold and injection sites for Lipoinjection of the vocal folds are identical to all Chapter 31 Fig. The latter requires local anesthesia injection in the area of the intended liposuction. bilateral lipoinjection patients with mobile vocal folds will be done to the extent that after immediate completion of the procedure the membranous vocal folds will be in complete approximation. c) The liposuction cannula is passed through the skin and into the subcutaneous space.8). and 2 liters of saline is used to rinse and irrigate the blood and fatty acids from the surface of the harvested fat. lowpressure liposuction technique. Liposuction from the subcutaneous abdominal space can be done under general or local anesthesia.) h) The fat graft material is then handled in a similar manner as the liposuction harvest material (described below). and serum. An excellent liposuction cannula is made by Tulip™ (San Diego. e) The harvested material can then be loaded into the injection device in preparation for lipoinjection (Fig. Small-gauge and high-pressure liposuction devices should be avoided to minimize trauma to the fat during the harvest process. b) A small skin incision (approximately 5 mm) is made in the right upper quadrant of the abdomen.) that includes a 4. blood. Great care should be taken to avoid injection of fat material into the: a) Ventricle b) Subglottis c) Superficial planes of the lamina propria Lipoinjection of the vocal fold should be performed with the goal of substantial overinjection of the vocal fold to allow for expected fat loss during the transplantation process (Fig. The free fatty acids are from ruptured lipocytes and induce an intense inflammatory response if not removed prior to lipoinjection. and negative pressure is applied to the liposuction cannula. 31. 31. d) To remove excess moisture. 3. 31. Care should be taken to restrict lipoinjection unilaterally if the patient has vocal fold paralysis and poor abduction of the contralateral vocal fold.7  Photo demonstrating the appropriate amount of overcorrec- tion (15–30%.9). 31. or an additional 0. 201 . Liposuction fat harvest for lipoinjection Liposuction should be performed using a large bore. single-hole liposuction cannula with low-pressure suction applied to the cannula. a) Fat from either open or liposuction harvest is placed in a sterile funnel that is lined with strips of Merocel (Fig.1–0. d) The liposuction cannula is then moved rapidly in the subcutaneous space in a transverse direction across the patient’s abdomen. with great care taken to control the plane and location of the liposuction tip to avoid penetration into the peritoneum or the overlying skin. Often. the fat is then placed on a dry Merocel sponge and partially dried by air for several minutes. This inflammatory response will diminish the graft survival.6-mm diameter. 2. c) The fat is then transferred into a small dish with 100 U of regular insulin and soaked for 5 min (the insulin is theorized to stabilize the lipocyte cell membranes and thus improve cell survival during the transplantation process). Preparation of fat for lipoinjection Fat harvested by any method is covered with free fatty acids. If the fat graft is not properly prepared.11). More aggressive lipoinjection can be carried out safely when both vocal folds are mobile.10). 4.

3–6 days of voice rest. For nonautologous material injections (CaHA. After lipoinjection of the vocal fold.9  Fat in Merocel-lined funnel Fig. 31. given that a nonhuman material is placed in the body. and a course of oral steroids are recommended. Complication of over.8  Liposuction technique Fig. 31. Removal of overinjected material can be done via suspension microlaryngoscopy. then the treatment options include intubation to allow laryngeal edema to resolve or tracheotomy to bypass the airway obstruction. Teflon. If the airway obstruction is severe.202 VF Augmentation – Microlaryngoscopy 31. a single dose of antibiotics is used. Other deep vocal fold injections require significantly fewer days of voice rest or no voice rest. antibiotics. Most pain and swallowing difficulties are minor and are treated with Tylenol or nonsteroidal over-the-counter medicine. airway observation.11  The appropriate amount of overcorrection (100%) used for autologous lipoinjection . Approximately 3–6 months should be allowed for the injected vocal fold material to settle completely before deciding whether excessive vocal fold injection material has been deposited.or underinjection for deep vocal fold injection can occur. and performing a lateral cordotomy and cold steel dissection down to the injected material and removing the material partially to correct Fig. Complications of deep vocal fold injection include: ■ ■ ■ ■ ■ ■ Airway obstruction Infection at the injection site Overinjection Underinjection Allergic reaction Superficial injection   Airway obstruction is rare and can be treated with oral or intravenous steroids. 31. Swallowing difficulties can also occur from the irritation and pain associated with vocal fold injection. Gelfoam). and humidification.10  Fat from lipoinjection needle Fig. 31.6 31 Postoperative Care and Complications The voice rest requirement of postoperative care for patients with deep vocal fold injection is highly variable.

Laryngoscope 105:17–22 Nakayama M. Wang HW. Su FW. Ford CN. Laryngoscope 107:177–186 Mikus JL. Oper Tech Otolaryngol Head Neck Surg 9:203–209 Schramm VL. ■ Precise needle placement and careful attention to the vocal fold tissue during injection are critical to successful vocal fold injection. Mazzola RF. Koschkee D (1996) Vocal cord injection with autogenous fat: a long-term magnetic resonance imaging evaluation. Lavorato AS (1978) Gelfoam paste injection for vocal cord paralysis: temporary rehabilitation of glottic incompetence. Hsiung MW (2003) Fat augmentation for nonparalytic glottic insufficiency. ■ Vocal fold augmentation (deep) can be performed via microlaryngoscopy (via general anesthesia) or endoscopically under local anesthesia. A short-term study. Jamart J (1999) Correcting vocal fold immobility by autologous collagen injection for voice rehabilitation. Ann Otol Rhinol Laryngol 108:788–793 Rihkanen H (1998) Vocal fold augmentation by injection of autologous fascia. The material can usually be easily removed via a microflap approach (see Chapter 10. “Principles of Phonomicrosurgery”). Laryngoscope 106(Pt. Maraschi B (2005) Vocal fold augmentation by autologous fat injection with lipostructure procedure. One must take great care to control the depth of the injection needle. Kilpatrick SE (1995) Fate of liposuctioned and purified autologous fat injections in the canine vocal fold. Lin YS. Koufman JA. Otolaryngol Head Neck Surg 109(Pt. Lowry LD. Arnonr F. Laryngoscope 113:541–545 Mikaelian DO. May M. 2 3 4 5 6 7 8 9 10 11 Selected Bibliography 1 Brandenburg JH. Sataloff RT (1991) Lipoinjection for unilateral vocal cord paralysis. the material should be removed as soon as possible. 1):174–180 12 13 Cantarella G. long-term results from the patient’s perspective. Lawson G. Bless DM (1993) Teflon vocal fold augmentation: failures and management in 28 cases. If superficial injection occurs. Lin YS. Accidental injection of augmentation material into the superficial aspect of the vocal fold is possible when a fine gauge needle is used and the depth of the injection is not controlled. ORL J Orothinolaryngol Relat Spec 65:176–183 Hsiung MW. Otolaryngol Head Neck Surg 132:239–243 Chen YY. Laryngoscope 108(Pt. Laryngoscope101:465–468 Shaw GY et al (1997) Autologous fat injection into the vocal folds: technical considerations and long-term follow-up. Laryngoscope 88(Pt. 1):493–498 Remacle M. Pai L. Delos M. “Management and Prevention of Complications Related to Phonomicrosurgery”). Wang HW (2003) Autogenous fat injection for vocal fold atrophy. 12. ■ Vocal fold augmentation has an advantage of avoiding an open surgical procedure and involves a quick and prompt recovery.  Chapter 31 the over injection of material (see Chap. Domenichini E. Unger JM. Key Points ■ Vocal fold augmentation (deep) is a versatile and essential procedure for a variety of voice disorders associated with glottal insufficiency. 1):51–54 Rosen CA (1998) Phonosurgical vocal fold injection: Indications and techniques. Eur Arch Otorhinolaryngol 260:469–474 Laccourreye O et al (2003) Intracordal injection of autologous fat in patients with unilateral laryngeal nerve paralysis. 1):1268–1273 203 .

Jacksonville. then the saline will track to locations other than those desired. Zyplast. 1. This procedure is aimed at correcting vibra­tory deficits of the vocal fold(s). 32. then it is best to wait several minutes and/or “milk” the saline out of the vocal fold and then proceed with the superficial vocal fold injection. . vocal fold paralysis. Fla. which may be able to be delivered via a superficial vocal fold injection approach. This procedure is done with high power microlaryngoscopy and a fine-gauge injection needle (27–30 g).2 Disease Characteristics and Differential Diagnosis Superficial vocal fold injection involves placement of a lamina propria replacement substance into the superficial aspect of the vocal fold to restore pliability. If the saline-infusion trial is positive. and thus are contraindicated for this procedure.Chapter 32 Superficial Vocal Fold Injection 32. 32. If the scar is too severe in nature. 32. A saline-infusion trial involves superficial injection of saline or diluted epinephrine underneath the epithelium to determine if a substance such as collagen could be subsequently injected into the vocal fold in the area of the focal lamina propria defect or vocal fold scar.1 Fundamental and Related Chapters Please see Chaps.5 Surgical Procedure Superficial vocal fold injection via microsuspension laryngoscopy allows for the precise and controlled placement of vocal fold injection material (collagen. Cross-linked hyaluronic acid-based substances have proven not to be of any value when placed superficially. etc. there are instances of a very focal defect of the lamina propria that would be suitable for augmentation via a superficial vocal fold injection approach. These materials are all temporary in nature but can last up to 1 year. This procedure is done via highpowered microlaryngoscopy with a fine-gauge needle (27–30 g). such as seen in patients with vocal fold paresis. Review most recent preoperative videostroboscopy immediately before or during the operation to identify the specific pathology and location that requires vocal fold injection. these materials may induce new. The most commonly used materials presently available for superficial vocal fold injection are collagen based materials such as Cymetra. Superficial vocal fold injection is used in select cases of vocal fold scar. native extracellular matrix protein recruitment. an orotracheal injector with a disposable 27-g needle attached (Medtronic Xomed.) into the most superficial aspect of the vocal fold.) serves the purpose for a superficial vocal fold injection extremely well. with the wings of the needle removed and cup forceps used to deliver the needle down to the vocal fold. 10.4 Surgical Equipment Equipment needed comprises: ■ Phonomicrosurgery tray (see Table 10.3 32 Surgical Indications and Contraindications Indications include: ■ Mild-to-moderate vocal fold scar ■ Focal lamina propria defect ■ A positive saline-infusion trial Contraindications include: ■ Need for global augmentation. In addition. In addition. 8.1) ■ A fine-gauge injection needle and device (27 or 30 g) ■ Injection device can be designed from a fine-gauge butterfly needle. or Cosmoplast. and 23 for further information. It is likely that new lamina propria substitutes/replacement will be developed in the near future. vocal fold atrophy ■ Negative saline-infusion trial ■ Sulcus vocalis (relative) 32. Alternatively. The best prediction of success is a positive saline-infusion trial. and the patient will not respond well to a superficial vocal fold injection. not providing global augmentation.

32. Placement of a large-bore laryngoscope (see Chap. 32. The entry site should be 3–5 mm away from the intended vocal fold injection deposition to prevent extrusion of the injection material. Fig. Vocal fold palpation with a slightly curved blunt instru- 32 ment is helpful to identify completely the area of the vocal fold pathology and the nature of the pathology (vocal fold scar).3  Appearance after superficial vocal fold injection . 32. 4. 32. then often a preliminary injection with 1:10. 10) 3. 32. The defect to be addressed will determine the volume to be injected. 7.1  Saline-infusion trial Fig.3).2). the vocal fold injection is done using a 27. these injections only require 0.2–0.4 ml of material (Fig. If there is a concern or question about the exact nature and severity of the vocal fold scar. Typically.or 30-g needle.6 Postoperative Care and Complications Postoperatively: ■ ■ ■ ■ No need for antibiotics No indication for steroids Voice rest for approximately 6 days Voice therapy can start shortly after the resumption of voice use.2  Superficial vocal fold injection with needle tunneled to area of intended deposit Fig.1). The vocal fold injection needle should be as superficial as possible after its entry through the epithelium. It is best to have the entry site away from the proposed area of infiltration and then tunnel the needle submucosally to the intended area of injection (Fig. Under high-power magnification.206 Superficial Vocal Fold Injection 2. and is often visible through the mucosa as the needle is tunneled forward to the vocal fold pathology site. 5.000 epinephrine or saline placed superficially in the area of the pathology will clearly delineate the   area of the deficit as well as the severity of the scar (Fig. 32. There is no preset volume of material to be injected. 32. 6.

Chapter 32 Selected Bibliography 1 2 Key Points 3 ■ Superficial vocal fold injection can be done to correct mild vocal fold scar or a focal lamina propria defect. Vaughan CW (1991) A submucosal vocal fold infusion needle. ■ Collagen-based materials are presently best suited for superficial vocal fold injection. Bless DM (1995) Autologous collagen vocal fold injection: a preliminary clinical study. Hillman RE. Ann Otol Rhinol Laryngol 105:341–347 Zeitels SM. Otolaryngol Head Neck Surg 105:478–479 207 . Zeitels SM (1996) The submucosal infusion technique in phonomicrosurgery. Laryngoscope 105(Pt. Bless DM. Loftus JM (1992) Role of injectable collagen in the treatment of glottic insufficiency: a study of 119 patients. new lamina propria replacement materials may be delivered via a superficial vocal fold injection approach. ■ In the future. Staskowski PA. ■ Saline-infusion trial predicts the suitability for superficial vocal fold injection. Ann Otol Rhinol Laryngol 101:237–247 Ford CN. 1):944–948 Kass ES. 4 Ford CN. if there is an overinjection of superficial vocal fold injection that is not resolved with a short period (approximately 1–2 months) and inhibits vocal fold function and voice quality. then the superficial material can be removed by making a small incision over the most lateral aspect of the injection location and removing part or all of the material.  With regard to complications.

33.1 Fundamental and Related Chapters Please see Chaps. while allowing for spontaneous recovery of function and avoids a surgical procedure in the hospital or general anesthesia. 14. and does not have to be NPO before the surgical procedure. A typical example is a patient with idiopathic unilateral vocal fold paralysis who presents early (1–3 months after onset) in the course of the disease. and Atrophy” and “Principles of Vocal Fold Augmentation. All patients should be counseled prior to injection regarding the expected duration of augmentation from injection. The patient does not have to arrange transportation to and from the hospital nor undergo a general anesthetic. 33. Furthermore. This approach is referred to as a trial vocal fold augmentation. Vocal fold augmentation can also be offered to a patient as a minimally invasive opportunity to “test drive” their voice after correction of glottic insufficiency. the patient should be taken off any anticoagulant medication prior to any planned injection. Duration varies with technique as well as with the type of material injected. e. The most common symptoms associated with patients with glottal insufficiency include the following: ■ ■ ■ ■ ■ ■ Dysphonia Decreased volume Vocal fatigue Odynophonia Dysphagia/Aspiration of liquids Compensated falsetto Several advantages to performing peroral vocal fold augmentation in a clinic setting exist. clinical experience has shown that the procedure can be performed if medically unable to stop anticoagulant therapy. This may help the patient decide if a permanent treatment option for their glottic insufficiency is desirable. Information regarding the specific indications and nature of the current materials available for augmentation are discussed in detail in Chaps..2 Disease Characteristics and Differential Diagnosis Transoral vocal fold augmentation in the clinic setting is used to provide global vocal fold augmentation into the deep aspect of the vocal fold for patients with glottal insufficiency. Coumadin) ■ Ideally. or significantly dysphonic and has significant vocal demands. Chapters 5 and 14 (“Glottic Insufficiency: Vocal Fold Paralysis. Contraindications involve: ■ Unstable cardiopulmonary status ■ Inability to tolerate procedure under local anesthesia (i. 5 and 14. nonsteroidal anti-inflammatories. vocal fold augmentation can be tailored to optimize the patient’s voice result by intermittently testing the voice throughout and at the completion of the procedure. If the patient is aspirating. hyperactive gag response or high level of anxiety) ■ Use of anticoagulants (aspirin. then temporary augmentation via peroral vocal fold augmentation in the clinic is an excellent option. and 34 for further information.” respectively) discuss the pertinent issues regarding glottal insufficiency and their subsequent treatment with vocal fold augmentation. ■ Inability to visualize the larynx adequately during the time of injection ■ This may occur if the patient has significant hooding of the arytenoid or severe supraglottic constriction. 5. . This addresses the patient’s vocal/swallowing needs. since the procedure is performed with the patient completely awake and in the upright position. however. Paresis.Chapter 33 Peroral Vocal Fold Augmentation in the Clinic Setting 33.3 33 Surgical Indications and Contraindications Peroral vocal fold augmentation in the clinic setting is indicated in treatment of symptomatic glottal insufficiency due to any of the following factors: ■ ■ ■ ■ ■ ■ Unilateral vocal fold paralysis Vocal fold atrophy Vocal fold paresis Vocal fold scar Sulcus vocalis Soft tissue loss of the vocal fold(s) Injection in the clinic setting can be used as a temporizing treatment to correct the patient’s glottal insufficiency or for permanent correction. 31.

33.3. Patients with severe torticollis or head tremor are sometimes difficult to treat.210 Peroral VF Augmentation – Clinic 33. and additional topical applications may be indicated until the desired effect is obtained.4 Surgical Equipment Surgical equipment needed (Fig.2  “Laryngeal gargle” of 4% lidocaine delivered via an Abraham cannula . b) Four percent lidocaine drip onto larynx under flexible laryngoscope guidance (3–6 ml) The patient is bent forward at the waist with the neck extended in a “sniffing” position to maximize laryngeal exposure. b) Topical Cetacaine spray to oral cavity (palate/posterior pharynx) 2. A 3-ml syringe of 4% lidocaine attached to an Abraham cannula is passed from the oral cavity into the pharynx under flexible laryngoscopy guidance. Bioform injection needle filled with Radiesse. drip catheter)   33. However. Approximately 1 ml is deposited over the tongue base. Videomonitoring/topical anesthesia of larynx a) A video camera is attached to a flexible laryngoscope (distal chip flexible laryngoscope system preferred) is inserted through the nasal cavity (typically the side opposite the intended vocal fold to be injected) by an assistant. 4% plain lidocaine. 33. and a hyper-responsive gag may render any procedures impossible. 33. The tongue is grasped with gauze with the surgeon’s left hand.5 Surgical Procedure Peroral vocal fold augmentation comprises the following: 1.2).1 Suitability for Peroral Vocal Fold Augmentation in the Clinic Setting 33 In order to be a suitable candidate for peroral vocal fold augmentation: ■ The patient must tolerate a flexible laryngoscopy endoscopic exam. without excessive gag.1  Equipment used for transoral vocal fold augmentation in the clinic (cotton pledgets. approximately 300 mg in 70-kg patient). Absence of the laryngeal gargle and cough may indicate that the patient has swallowed the anesthetic. producing the characteristic “laryngeal gargle” (Fig. employing a “videocart system. Fig. Monitoring with a flexible endoscope is key to maintaining visualization. Neosynephrine. and 2–4 ml are dripped onto the vocal folds during phonation. The initial dose is usually followed by a brisk cough.” The scope is generally maintained slightly below the palate so that the tongue base and larynx can be easily viewed on the video monitor.5 mg/kg. 33. it should be noted that gagging with a mirror or rigid peroral endoscope is not a contraindication. Abraham cannula.1): ■ ■ ■ ■ ■ ■ ■ ■ ■ Flexible laryngoscope (fiberoptic or distal chip) C-mount camera (attaches to flexible scope) Videomonitor for visualization 3–6 ml of 4% lidocaine Curved Abraham cannula for delivery to topical lidocaine Cetacaine spray (benzocaine/tetracaine topical) Oxymetazoline and/or 2% Pontocaine (for nasal decongestant and anesthesia) Cotton nasal pledgets Disposable nebulization device Fig. 33. Topical anesthesia nasal/oropharynx a) Topical oxymetazoline/Pontocaine 2% spray to nasal cavities (medication-soaked cotton nasal pledgets placed intranasally are also very helpful). The maximum recommended dose of 4% lidocaine is approximately 7–8 ml (4. ■ The patient must be able to remain reasonably still and upright in the exam chair for the duration of the procedure (typically 5–15 min). ■ The patient must have an adequate oral opening (at least 2-cm intermaxillary distance). as the anesthetic is aspirated and then distributed over the laryngotracheal mucosa.

The assistant must be adept at manipulating the flexible scope.B. the most correction is needed. Once the posterior vocal fold is adequately medialized. Typically. The needle is passed through the oral cavity and then advanced into the oropharynx under direct visualization from the flexible laryngoscope.  Fig.7): (1) the posterior aspect (lateral to the vocal process) and (2) the midmembranous vocal fold. until the needle is visualized in the oropharynx. PW-2L-1.) The former device is curved for transoral injection. using a simple disposable nebulization device (frequently used in the hospital for respiratory therapy) and an external source of pressurized air (often from an oxygen tank). This catheter allows direct application of the anesthesia to the specific areas intended for the vocal fold injection and is very well tolerated by patients. c) The needle is then guided into the oropharynx and the endolarynx under endoscopic visualization. Calif.4). 33. respectively. Center Valley. c) The depth of injection should be into the substance of the vocal fold in a lateral position (see Chap. the vocal folds.and 25-g. well-illuminated view before. then the needle should be withdrawn slightly. In preparation for vocal fold injection.3  Nebulization of 4% plain lidocaine for laryngeal anesthesia Fig.to 10-min period to achieve anesthesia of the larynx and pharynx. b) The patient holds his/her own tongue with gauze. if needed. Fla. 33. 211 . 4. which will result in a stiff vocal fold and poor voice quality (Fig. Four percent plain lidocaine can be nebulized and inhaled peroral by the patient (Fig. and the latter is malleable and can be bent to the appropriate dimensions and curvature needed for transoral vocal fold augmentation. 33. consistent visualization of the needle can be challenging in a narrow airway with copious secretions. flexible cannula through the working channel of the flexible laryngoscope or an Endosheath™ with a working channel (Medtronic Xomed. Transoral passage of the needle into the endolaryngeal region a) The two most commonly used needles for peroral vocal fold augmentation in a clinic setting are the orotracheal injector device (Medtronic Xomed) and the injection needle developed by Bioform Medical (Bioform Medical. clearing the path into the oropharynx. the intended injection material should be attached to the injection needle and “primed” to eliminate the dead space within the needle. 4–5 ml of plain lidocaine is nebulized over a 5. “Principles of Vocal Fold Augmentation”).3). San Mateo. b) The initial injection should be at the posterior aspect of the vocal fold.). during. providing a clear. 3. Another technique to deliver anesthetic agent to the larynx is using a small Silastic.5). The flexible scope should be positioned a few millimeters above the true vocal folds. After the nebulization process. Vocal fold injection a) For unilateral vocal fold paralysis. specifically. The assistant should position the fiberoptic scope just above the palate. as the assistant follows closely behind with the flexible laryngoscope (Fig. 33.6). Each of these injection devices use fine-gauge needles (27. Jacksonville. or the surgeon grasps the tongue with the left hand. d) If the subglottis begins to bulge during injection. a smaller additional amount can be deposited at the mid vocal fold. which results in palatal raising.). This method of anesthesia provides a simple and less physician-involved method for obtaining laryngeal anesthesia. the injection should be placed at two sites (Fig. 33.4  Drip catheter for applying 4% plain lidocaine to larynx via flexible laryngoscope with a working channel An alternative method to obtain anesthesia of the larynx involves nebulization of lidocaine. Care should be taken to avoid superficial placement into Reinke’s space. where. 33. 14. The patient is instructed to phonate /a/ as the needle enters the oral cavity. Pa.) is passed through the working channel Chapter 33 of the flexible laryngoscope and used to deliver 4% plain lidocaine to the endolarynx during sustained phonation to achieve the “laryngeal gargle” as described above (Fig. a curved Abraham cannula can be used to supplement any further need for laryngeal anesthesia on an as-needed basis and to test for complete anesthesia of the larynx and. 33. and immediately after the injection (Fig.8). typically. 33. This Silastic catheter (Olympus America.

212

Peroral VF Augmentation – Clinic

33

Fig. 33.5  Transoral vocal fold augmentation in the clinic. Surgeon on

Fig. 33.6  Flexible laryngoscope image during peroral injection aug-

Fig. 33.7  Injection location(s) for deep vocal fold augmentation

Fig. 33.8  Injection depth for deep vocal fold

the left with the assistant on the right and patient holding her own
tongue

e) If the injected substance extrudes from the puncture

hole, then the material can be cleared by instructing
the patient to cough or clear their throat (this is rarely a
problem when a fine-gauge needle is used).
f) The injection should be carried out in a stepwise fashion,
checking for improvement in the patient’s voice periodically.
For most injectables, the medialized vocal fold should be
overinjected (past midline) to a variable degree, depending
on the specific nature of the material and the primary goal

mentation. The scope should be positioned a few millimeters above
the true vocal folds, providing a clear, well-illuminated view

of the procedure (long duration of the temporary agent versus immediate need for optimal voice function.) In general,
the vocal fold is medialized until the voice is maximally
improved, and then an additional 0.1–0.2 ml is injected to
achieve overcorrection. This overcorrection is necessary, because all injectables have a small aqueous component that will
be absorbed 3–5 days after injection. The total amount necessary for unilateral augmentation is typically less than 1 ml,
but amount injected should be determined by the sound of
the voice and appearance of the vocal fold, not by the volume
injected.

Chapter 33

For patients with a bowed vocal fold due to atrophy/paresis
or presbylaryngis, the injection differs slightly from the previous technique. These cases typically require injection principally in the midportion of the vocal fold, where the maximal
glottal gap usually occurs. In severe cases of muscular atrophy,
the posterior vocal fold can be augmented to fill in the atrophy
that occurs just anterior to the vocal process. Again, overcorrection is the rule, even in the case of bilateral injections. Airway compromise should not be a concern, because the posterior (respiratory) glottis remains patent and in cases of vocal
fold atrophy both vocal folds are usually fully mobile.

33.6

Postoperative Care
and Complications

Postoperative care includes:
■ Immediately after vocal fold injection in the clinic, patients should be observed for a short period to monitor
for any complications of the vocal fold injection, most
notably, airway difficulties.
■ Patients need to be instructed that they should not take
anything orally for approximately 2 hours after vocal
fold injection to allow adequate time for the local anesthesia to wear off. In addition, patients should take care
as they resume oral intake to ensure that all aspects of
the anesthesia are gone.
■ The use of strict voice rest after vocal fold injection is
not standardized and is often determined by the size
of the vocal fold injection needle used and the individual surgeon’s preferences. Given that most vocal fold
injections are now performed with a fine-gauge needle,
prolonged voice rest (exceeding 24 hours) is most likely
not indicated. Some surgeons use no voice rest; others
will use a 24-hour period of voice rest. The rationale for
voice rest after vocal fold injection is to minimize loss of
the injected material being extruded through the injection site(s) if immediate phonation is allowed.
■ Antibiotics and steroids associated with the vocal fold
injection are not typically indicated for this procedure.
■ Patients should be instructed that, because of the vocal
fold edema associated with the procedure, as well as
possibly the overinjection of the augmentation material,
optimal voice quality is typically not achieved for 1–2
weeks after vocal fold injection.
Complications of peroral vocal fold injection include inappropriate placement of the vocal fold injection material comprise:
■ Either too superficially into Reinke’s space
■ Very lateral into the paraglottic space
■ Inferior into the subglottis

If these inappropriate locations of vocal fold injection are recognized during the procedure, then often the material can be
“milked” out of the vocal fold with the use of an Abraham cannula, applying gentle lateral pressure to the vocal fold. If this is
not possible, then it would be advisable that the vocal fold material, if permanent in nature (such as calcium hydroxylapatite)
be removed under microlaryngoscopy with general anesthesia
in the near future.

Key Points
■ Peroral vocal fold augmentation in a clinic setting
provides the patient an opportunity for permanent
or temporary vocal fold augmentation under local
anesthesia, obviating a trip to the operating room
and general anesthesia.
■ Appropriate patient selection is the key to successful peroral vocal fold augmentation. Patients
should be cooperative and should not have a
hyperactive gag reflex.
■ Adequate anesthesia can be easily obtained for
peroral vocal fold augmentation, with topical
lidocaine and does not necessitate nerve blocks or
sedation (orally or intravenously).
■ Peroral vocal fold augmentation offers the unique
advantage of having the patient unsedated and
positioned in an upright position to monitor voice
quality and vocal fold closure pattern during the
injection. This allows for customization and maximum control of the vocal fold augmentation to
optimize postoperative voice quality and function.

Selected Bibliography
1

2

3

4
5

Arad-Cohen A, Blitzer A (1999) Office-based direct fiberoptic
laryngoscopic surgery. Oper Tech Otolaryngol Head Neck Surg
9:238–242
Bové MJ, Jabbour N, Krishna P, Rosen CA et al (2007) Operating
room versus office-based injection laryngoplasty: a comparative
analysis of reimbursement. Laryngoscope 117:226–230
Chu PY, Chang SY (1997) Transoral Teflon injection under flexible laryngovideostroboscopy for unilateral vocal fold paralysis.
Ann Otol Rhino Laryngol 106:783–786
Simpson CB, Amin MR (2004) Office-based procedures for the
voice. Ear Nose Throat J 83(Suppl.):6–9
Simpson CB, Amin MR, Postma GN (2004) Topical anesthesia of
the airway and esophagus. Ear Nose Throat J 83(Suppl.):2–5

213

Chapter 34

Percutaneous Vocal Fold
Augmentation in the Clinic Setting

34.1

Fundamentals and Related Chapters

Please see Chaps. 5, 14, 31, and 33 for further information.

34.2

Disease Characteristics
and Differential Diagnosis

Percutaneous vocal fold augmentation in the clinic setting is
used to provide global vocal fold augmentation into the deep
aspect of the vocal fold for patients with glottal insufficiency.
Chaps. 5 and 14 (“Glottic Insufficiency: Vocal Fold Paralysis,
Paresis, and Atrophy” and “Principles of Vocal Fold Augmentation,” respectively) discuss the pertinent issues regarding
glottal insufficiency and their subsequent treatment with vocal
fold augmentation. The most common symptoms associated
with patients with glottal insufficiency include the following:





Dysphonia
Decreased volume
Vocal fatigue
Odynophonia
Dysphagia
Compensatory falsetto

A variety of major advantages to performing percutaneous vocal fold augmentation in the clinic setting exist. Specifically,
it is a significant advantage to the patient, given that the patient does not have to arrange transportation to and from the
hospital nor undergo a general anesthetic, and does not have
to be NPO before the surgical procedure. Furthermore, since
the procedure is performed with the patient completely awake
and in the upright position, vocal fold augmentation can be
tailored to optimize the patient’s voice result by intermittently testing the voice throughout and at the completion of the
procedure. Information regarding the specific indications and
nature of the current materials available for augmentation are
discussed in detail in Chaps. 5 and 14.
Awake, percutaneous vocal fold augmentation in the clinical setting is a viable option for many patients with glottal
insufficiency. Vocal fold augmentation using a percutaneous
approach in the clinic or at the bedside has been successfully
performed with a number of different materials and can be
performed with either temporary or permanent augmentation
materials. See Chap. 14 for a discussion of different augmentation materials.

34

A variety of percutaneous vocal fold augmentation approaches exist for in-office procedures. These percutaneous
approaches include:
■ Transthyroid cartilage
■ Transcricothyroid membrane
■ Transthyrohyoid membrane
The transthyroid cartilage and cricothyroid membrane approaches are very similar. Ossification of the thyroid cartilage
can prevent passage of the injection needle through the thyroid
cartilage and thus, a cricothyroid or thyrohyoid approach may
be required. All of these approaches require anesthesia of the
overlying skin, a skilled endoscopist as an assistant, and a 23to 25-g needle (1.5 in. long).
The thyrohyoid approach can be used for vocal fold augmentation as well as for injection of therapeutic substances
such as cidofovir and Botox. The transthyrohyoid approach
was developed by Milan Amin, M.D., and is as well tolerated
as other percutaneous approaches, but provides unique visualization and precision compared to transthyroid cartilage and
cricothyroid approach.

34.3

Surgical Indications
and Contraindications

Percutaneous vocal fold augmentation in the clinic setting is
indicated in the treatment of symptomatic glottal insufficiency
(dysphonia and/or dysphagia) due to any of the following factors:





Unilateral vocal fold paralysis
Vocal fold atrophy
Vocal fold paresis
Vocal fold scar
Sulcus vocalis
Soft tissue loss of the vocal fold(s)

Injection in the clinic setting can be used as a temporizing
treatment to correct the patient’s glottal insufficiency or for
permanent correction. A typical example is a patient with idiopathic unilateral vocal fold paralysis who presents early (1–3
months after onset). If the patient is aspirating, or dysphonic
and has vocal demands, then temporary augmentation via a
percutaneous vocal fold augmentation in the clinic is an excellent option. This addresses the patient’s vocal/swallowing

216

34

Percutaneous Augmentation

needs, while allowing for spontaneous recovery of function
without having to perform a surgical procedure in the hospital
with general anesthesia.
Vocal fold augmentation can also be offered to a patient as
a minimally invasive opportunity to “test drive” their voice after correction of glottic insufficiency. This may help the patient
decide if a permanent treatment option for their glottic insufficiency is desirable. This approach is referred to as a trial vocal
fold augmentation.
Contraindications comprise:
■ Unstable cardiopulmonary status
■ Inability to tolerate procedure under local anesthesia
(i. e., high level of anxiety)
■ Use of anticoagulants (aspirin, nonsteroidal anti-inflammatories, Coumadin)
■ Ideally, the patient should be taken off any anticoagulant medication prior to any planned injection;
however, clinical experience has shown that the
procedure can be performed if medically unable to
stop anticoagulant therapy.
■ Inability to visualize the larynx adequately during the
time of injection
■ This may occur if the patient has significant hooding
of the arytenoid or severe supraglottic constriction.
■ Poorly defined or obstructing neck landmarks

34.3.1 Suitability for Percutaneous
Vocal Fold Augmentation
in the Clinic Setting
To be a suitable candidate:
■ The patient must tolerate a flexible laryngoscopy endoscopic exam without excessive gag. Monitoring with a
flexible endoscope is key to maintaining visualization,
and a hyper-responsive gag may render any procedures
impossible. However, it should be noted that gagging
with a mirror or rigid transoral endoscope is not a contraindication.
■ The patient must be able to remain reasonably still and
upright in the exam chair for the duration of the procedure (typically 5–15 min). Patients with severe torticollis or head tremor are sometimes difficult to treat.

34.4



Surgical Equipment

Skilled endoscopist to assist surgeon
Flexible laryngoscope (chip-tip preferred to fiber optic)
Videomonitor for visualization
Local anesthetic (1% Lidocaine with epinephrine) to
anesthetize skin over the cricothyroid membrane and
thyroid ala on the side to be injected

■ Local anesthetic/decongestant mix (e. g., oxymetazoline
and 2% Pontocaine) for nasal passage in order to facilitate flexible laryngoscopy
■ Injection material (see Chap. 14)
■ Alcohol prep pad or topical prep solution such as povidone–iodine

34.5

Surgical Procedure

1. Percutaneous vocal fold augmentation in the clinic setting in

a transthyroid cartilage or transcricothyroid membrane approach.
a) The area overlying the injection site may be cleaned with
an alcohol prep pad or povidone–iodine prep.
b) The patient is positioned in the sitting position with the
neck in neutral position and the head slightly extended
on the neck (i. e., the sniffing position).
c) It is important to anesthetize both the skin over the area
to be injected as well as the upper airway in preparation
for flexible laryngoscopy. To anesthetize the skin and
subcutaneous tissues, approximately 0.5 ml of local anesthetic is sufficient. The skin and subcutaneous tissues
overlying the cricothyroid membrane are injected as well
as the area over the inferior aspect of the thyroid ala on
the side(s) intended for injections. Overinjection of this
area with anesthetic may transiently impair cricothyroid
function, thus clouding the picture of paresis/paralysis at
the time of injection.
d) The nasal cavity is anesthetized and decongested as is
customary for the surgeon. Topical anesthesia to the endolarynx (see Chap. 33, “Peroral Vocal Fold Augmentation in the Clinic Setting”) is helpful per the surgeon’s
preference but is usually not necessary for the percutaneous approach.
e) Flexible laryngoscopy is performed by the assistant and
the preprocedure diagnosis/diseases are confirmed. Ideally, the tip of the scope is maintained over the contralateral arytenoid, as posteriorly as possible to avoid stimulating the supraglottic structures. This position allows
for some visualization of the infraglottic surface of the
vocal fold to be injected.
f) The cricothyroid membrane is palpated by the injecting surgeon. In many patients, it is possible to see (endoscopically) the depression of the underlying mucosa
during this maneuver (Fig. 34.1). This is very helpful in
estimating the height of the vocal fold relative to the cricothyroid membrane. If the impression from the palpating finger is not seen, then this maneuver may be performed with the injection needle without penetrating
into the airway.
g) The vertical and horizontal distance from this point to
the midpoint of the membranous vocal fold is estimated
by the surgeon. The needle (23 or 25 g, or 1.5 in. long)
is placed along a vertical line approximately 6–12 mm
from the midline; this distance depends on the size of the

Fig. 34.1  Palpation of cricothyroid space during simultaneous flexible

laryngoscopy

Fig. 34.2  Transthyroid cartilage placement of injection needle into

vocal fold

Chapter 34

217

larynx. The needle should be oriented perpendicularly in
relation to the thyroid ala.
h) The needle is placed against the thyroid ala at the desired
vertical level along this line. In most females and younger males, gentle steady pressure will allow the needle to
pass through the cartilage (Fig. 34.2). Care should be
taken not to “past point” as the needle is passed through
the thyroid cartilage. This will avoid entering the airway. If the needle meets significant resistance, then the
needle is kept in the same line and “walked” down the
thyroid ala until the inferior aspect of the thyroid cartilage is reached. The needle is then advanced medially,
again perpendicular to the thyroid ala for approximately
3–4 mm through the junction of the thyroid ala and the
cricothyroid membrane. At this point, the tip of the needle is in the infraglottic vocal fold and is directed nearly
straight up, vertically (Fig. 34.3). All attempts should be
made to avoid entering the airway. The needle may be
seen indenting the infraglottic mucosa or penetrating
the floor of the ventricle. To facilitate identifying where
the needle has entered into the endolarynx, the needle
can be moved back and forth rapidly several times over a
short distance. The tip of the needle is then redirected if
found not to be located in the membranous vocal fold.
i) Once the needle location is confirmed, vocal fold injection is started slowly. Good visualization of the vocal fold
is essential at this stage. As the material is injected, the
vocal fold will swell. The endpoint for injection will be
determined by the endoscopic appearance of the vocal
fold as well as by the patient’s voice. Depending on the

Fig. 34.3  Transcricothyroid

membrane placement of injection needle into vocal fold

218

34

Percutaneous Augmentation

nature of the injectate, modest to moderate overcorrection is often desirable (see Chap. 14). The patient may
immediately notice the improvement in the voice—it is
important in most cases to overcorrect past this point, if
possible, to allow for a longer duration of overall benefit
for temporary augmentation materials (see Chap. 14).
j) If the contour is not ideal (focally overinjected) immediately after injection, then a hard cough may “straighten
out” the vocal fold as seen during the endoscopy.
k) In the case of bilateral vocal fold pathology, there is generally no limitation to treating both sides at the same setting.
2. Thyrohyoid approach to the larynx (of Milan Amin, M.D.)
a) Spray (topical 50:50 mix of oxymetazoline/Lidocaine
spray to nasal cavities)
b) Inject skin and subcutaneous tissues overlying the thyrohyoid notch using a 25-g needle with 1% lidocaine with
1:100,000 epinephrine.
c) Ensure the patient is positioned sitting upright with neck
extended to expose the thyrohyoid notch.
d) An assistant passes the flexible laryngoscope through the
nasal cavity (usually left side) and positions the scope so
the tongue base and larynx are clearly visualized.
e) A 25-g needle (1.5 in. long) and syringe with topical 4%
Lidocaine is passed into the airway above the vocal folds
via the thyrohyoid membrane. The needle is passed immediately above the thyroid notch and directed acutely
downward until the needle enters the airway in the area
of the petiole. Proper positioning is confirmed by flex-

Fig. 34.4  Needle path for the thyrohyoid approach to the larynx

ible laryngoscopic guidance and the ability to draw back
air into the syringe. Three milliliters of topical lidocaine
is deposited in the larynx. Note that absence of a laryngeal gargle or cough suggests the patient swallowed the
anesthetic, and additional 4% lidocaine may be needed.
Adequate anesthesia is achieved after 3–5 min. Alternatively, topical laryngeal anesthesia may be administered
through a working channel of the flexible laryngoscope
if this is available or a peroral approach (see Chap. 33,
“Peroral Vocal Fold Augmentation in the Clinic Setting”).
f) Prepare implant/injectable material in appropriate syringe attached to a 25- or 23-g (1.5-inch needle) and
“prime” the needle with material.
g) The needle is passed in the midline just above the thyrohyoid notch in a downward, acute angle just under the
patients’ chin. It may help to have the patient turn his/
her head slightly away from the surgeon to obtain the
proper angle. The tip of the needle passes through the
pre-epiglottic space and enters the larynx at the petiole
of the epiglottis (Figs. 34.4, 34.5).
h) Under direct guidance on the monitor, the assistant advances the flexible scope to follow the needle as it is guided to the appropriate injection site(s) (Figs. 34.6, 34.7).
If necessary, bilateral vocal fold injection is achieved by
backing the needle out slightly (without removing it)
and redirecting the needle tip under direct visualization
to the other side.

Fig. 34.5  Placement of needle through thyrohyoid membrane (endo-

scopic view)

■ Patients should be instructed that. as well as the overinjection of the augmentation material. and knowledge of multiple approaches to the vocal fold will provide the highest chance of success for vocal fold augmentation. Dramatic swelling may occur if air is inadvertently injected. others will use a 24-hours period of voice rest. ■ Antibiotics and steroids are not typically indicated for this procedure.6 Postoperative Care and Complications Postoperative care includes: ■ Immediately after vocal fold injection in the clinic.6  Injection location for deep vocal fold 34. Fig. ■ Patient positioning. ■ Identification of the needle in the mid to posterior membranous vocal fold is essential for successful percutaneous vocal fold augmentation in the clinic setting. prolonged voice rest (exceeding 24 hours) is most likely not indicated.  Chapter 34 Fig. ■ Hematoma in the skin overlying the injection site Key Points ■ Percutaneous vocal fold augmentation in the clinic setting is an excellent alternative for patients who prefer not to undergo general anesthesia or will not tolerate transoral vocal fold injection in the clinic setting for either temporary or permanent vocal fold augmentation. ■ The use of strict voice rest after vocal fold injection is not standardized and is often determined by the size of the vocal fold injection needle used and the individual surgeon’s preferences. The patient is asked to gargle (if possible) and the procedure is usually continued. optimal voice quality is typically not achieved for 1–2 weeks after vocal fold injection. most notably. ■ Providing the patient with information and supportive reassurance before and during the procedure is very important. In addition. ■ Patients need to be instructed that they should not take anything orally for approximately 2 h after vocal fold injection to allow adequate time for the local anesthesia to wear off. 219 .7  Injection depth for deep vocal fold augmentation Complications comprise: ■ Injection should be aborted at the first sign of airway embarrassment or unexpected vocal fold swelling. skilled endoscopy of the assistant. It is typically minimal though when it leads to coughing. airway difficulties. patients should take care as they resume oral intake to insure that all aspects of the anesthesia are gone. patients should be observed for a short period to monitor for any complications of the vocal fold injection. Given that most vocal fold injections are now performed with a fine-gauge needle. Some surgeons use no voice rest. 34. ■ Bleeding into the airway occurs in many patients. the endolarynx may be covered with a thin film of blood and limit visibility. The rationale for voice rest after vocal fold injection is to minimize loss of the injected material being extruded through the injection site(s) if immediate phonation is allowed. because of the vocal fold edema associated with the procedure. 34.

220

Percutaneous Augmentation

Selected Bibliography
1
2

34

3

Amin, MR (2006) Thyrohyoid approach for vocal fold augmentation. Ann Otol Rhinol Laryngol 115:699–702
Berke GS, Gerratt B, Kreiman J, Jackson K (1999) Treatment of
Parkinson hypophonia with percutaneous collagen augmentation. Laryngoscope 109:1295–1299
Chhetri DK, Blumin JH, Shapiro NL, Berke GS (2002) Officebased treatment of laryngeal papillomatosis with percutaneous injection of Cidofovir. Otolaryngol Head Neck Surg 126:642–648

4

5

6

Grant JR, Hartemink DA, Patel N, Merati AL (2006) Acute and
subacute awake injection laryngoplasty for thoracic surgery
patients. J Voice. 2006 Oct [Epub ahead of print]
Lipton RJ, McCaffrey TV, Cahill DR (1989) Sectional anatomy of
the larynx: implications for the transcutaneous approach to endolaryngeal structures. Ann Otol Rhinol Laryngol 98:141–144
Rosen CA, Thekdi AA (2004) Vocal fold augmentation with
injectable calcium hydroxylapatite: short-term results. J Voice
18:387–391

Chapter 35

Botulinum Toxin Injection
of the Larynx

35.1

Fundamental and Related Chapters

Please see Chaps. 7, 33, and 34 for further information.

35.2

Disease Characteristics
and Differential Diagnosis

35.2.1 Botulinum Toxin Fundamentals
Botulinum toxin is a naturally occurring clostridial neurotoxin
that reversibly inhibits release of acetylcholine into the synaptic cleft of the neuromuscular junction, thereby causing flaccid
paralysis. Clinically, this results in a reversible, dose-dependent
weakening of injected muscles. In addition to its muscle weakening effect, botulinum toxin has been hypothesized to have
an effect on efferent feedback to the central nervous system,
although whether this is by means of a direct effect on intramuscular gamma motor neurons or an indirect consequence
of muscle weakening remain matters of speculation. This efferent effect may be an important part of the broad success of
botulinum toxin in the treatment of dystonia, particularly in
comparison to surgical denervation.
Although seven different serotypes of botulinum toxin are
known, only two are available for clinical use, type A (Botox®,
Allergan, Irvine, Calif., and Dysport®, Ipsen, Ltd., Slough, UK)
and type B (Myobloc®, Elan Pharmaceuticals, Dublin, Ireland).
Type A appears to have a slightly longer duration of effect (approximately 90 days) than has type B, and the Botox preparation diffuses less from the point of injection than the other
two, both factors with practical clinical consequences. Dose is
expressed in mouse units (U) and differs substantially among
the commercial preparations; the reader should note that dosages discussed in this chapter refer to Botox.
Adverse effects of botulinum toxin treatment may result
from overweakening of the intended target muscle as well as
unintended weakening of surrounding muscles. Therefore,
both appropriate dosing and the tissue distribution of the
toxin are crucial. In general, dose is proportional to targeted
muscle mass, although the range of therapeutic dosing is typically highly variable. There is no standard botulinum toxin
dose for patients with spasmodic dysphonia. Some patients get
the best results from a unilateral dose and others from bilateral treatment. In bilateral injections for adductor spasmodic
dysphonia, for example, therapeutic doses range from 0.3 to
15 U per thyroarytenoid muscle, although most dysphonia is
well controlled with doses of 0.625–2.5U. The distribution of

35

the toxin is affected by accuracy of needle placement as well as
by volume of the injectate, which can be varied as necessary.
Systemic effects from botulinum toxin are very unlikely, particularly at doses used to treat laryngeal diseases.
Development of antibody resulting in clinical resistance to
toxin is very rare with recent preparations of toxin, and may
be tested for with an antibody assay, or, more practically, with
an injection into an area where muscle effect is obvious, such
as the forehead. Technical issues rather than resistance remain
the most likely reason for an ineffective laryngeal injection. For
a more in-depth description of the pharmacology of botulinum
toxin, the reader is referred to article by Aoki cited in “Selected
Bibliography,” below.

35.2.2 Spasmodic Dysphonia
and Essential Tremor
Dystonia is a chronic neurologic disorder of central motor processing characterized by task-specific, action-induced muscle
spasms. Spasmodic dysphonia is a focal dystonia involving
the larynx. It is usually classified into adductor, abductor, and
mixed forms, the first two characterized by hallmark clinical
features and the latter being a combination of the first two. Adductor spasmodic dysphonia, the more common form, causes
inappropriate glottic closure and as a result, produces strangled
breaks in connected speech. Abductor spasmodic dysphonia,
in contrast, causes inappropriate glottal opening that produces
breathy breaks and hypophonia. Although clinical features are
not always typical, the classification of spasmodic dysphonia
into adductor and abductor varieties remains essential to treatment: Botulinum toxin is injected into the thyroarytenoid/lateral cricoarytenoid muscles (TA-LCA) in adductor spasmodic
dysphonia, and into the posterior cricoarytenoid muscle in
abductor spasmodic dysphonia.
Essential voice tremor is an age-related disorder of involuntary muscle contraction, which can affect the voice to a debilitating extent in some patients. Clinical examination reveals
rhythmic, oscillatory movement of the portions of the vocal
tract (i. e., velum, base of tongue, pharynx, larynx, vocal folds),
which typically involves a wide variety of muscles of the upper
aerodigestive tract. No pharmacologic intervention has been
documented to be effective in essential voice tremor, and botulinum toxin chemodenervation has provided symptomatic
relief in selected patients. Administered much as in adductor
spasmodic dysphonia, botulinum toxin symptom control is
usually not as dramatic in essential tremor, probably due to
differences in the pathophysiology of the two diseases. The

222

Botulinum Toxin Injection of the Larynx

areas of tremor most responsive to the botulinum toxin injection from a symptom perspective are the true vocal folds and
the false vocal folds.

35.3

Surgical Indications
and Contraindications

Indications comprise:

35.2.3 Different Botulinum Toxin
Injection Approaches

35

There are a variety of injection approaches to deliver botulinum toxin to the larynx:
■ Percutaneous injection with EMG guidance (most
traditional)
■ Percutaneous with laryngoscopic guidance
■ Supraglottic botulinum toxin injection with laryngoscopic guidance
Distinct advantages and disadvantages exist for these approaches (see below). Selection of the best injection approach
is determined by surgeon’s training, equipment availability,
patient’s disease characteristics and preference.
Percutaneous injection under EMG guidance is the quickest and most precise method of botulinum toxin delivery into
the larynx. However, this technique also has a learning curve
and can take a considerable amount of time and practice to
master. In addition, the technique requires the purchase of additional equipment (EMG machine) and moderate technical
mastery of EMG interpretation. Given these barriers, some
surgeons who perform laryngeal botulinum toxin injections
on an infrequent basis may wish to consider an alternative
method, a percutaneous or peroral injection technique, using laryngoscopic (visual) guidance. Given that this approach
(without EMG guidance) is less precise, often the toxin dose
used is slightly higher than EMG-guided percutaneous injection.
Supraglottic botulinum toxin injection with laryngoscopic
guidance for spasmodic dysphonia offers the advantages of:
■ More gradual/smooth onset of action
■ Smoothing of vocal fold “peaks and troughs” associated
with true vocal fold injections
■ Less severe (minimal to none) breathy voice
■ Preserves singing voice/pitch control in many patients
The disadvantages of this approach include a shorter duration
(typically 6–8 weeks), less predictable voice results and more
involved injection procedure. The unreliable voice results most
likely occur from variable supraglottic muscular anatomy and
variable needle location during the supraglottic injection. Supraglottic botulinum toxin injection with laryngoscopic guidance may be preferred in professional voice users afflicted with
adductor spasmodic dysphonia, given the reduced number of
days with a soft, weak, breathy voice.

■ Spasmodic dysphonia
■ Essential voice tremor
■ Vocal fold granuloma
Muscle selection, injection strategies, and dosing involves the
following:
1. Spasmodic dysphonia
The standard treatment for adductor spasmodic dysphonia
(SD) is bilateral EMG-guided, percutaneous injections of
the TA-LCA muscles, using equal amounts of botulinum
toxin, based on the understanding that the motor control
disorder is bilateral and symmetric (see Blitzer et al. 1998).
In patients with abductor spasmodic dysphonia, bilateral
posterior cricoarytenoid muscles are treated, although injections are staggered for reasons of airway safety. For both
forms of SD, the dose is adjusted based on the severity of
the disease and on response to treatment, and the value of
bilateral versus unilateral treatment is reassessed. It is clear
from reports in the literature that unilateral injection may
provide essentially equivalent symptomatic relief in patients
with adductor spasmodic dysphonia, although the dose is
usually increased and may not provide the same duration of
benefit.
A reasonable initial dose in adductor spasmodic dysphonia is 1.25 U per side, which represents a low-average dose.
Dosing at subsequent treatment is adjusted based on patients response. For abductor spasmodic dysphonia, the
first posterior cricoarytenoid (PCA) muscle is injected with
5 U; voice result and vocal fold mobility is evaluated 2 weeks
later. The contralateral dose is determined in light of this,
so that the dose in inversely proportional to the degree of
muscle weakness observed. Asymmetric dosing is the rule
in abductor spasmodic dysphonia.
Botulinum toxin treatment results in an initial period of
marked muscle weakness lasting several days, followed by
a 3- to 4-month-long plateau of milder weakening, which
constitutes the principal therapeutic effect. This effect probably occurs because of the two-stage mechanism of neural
recovery from botulinum toxin administration. The transient, breathy dysphonia that usually follows bilateral TALCA injections is a clinical manifestation of this pattern,
and is to some extent inevitable. In general, the length of
the period of breathiness and the length of the therapeutic
effect are approximately proportional, so that attempts to
shorten the breathiness may compromise the duration of
therapeutic effect. Naturally, patients prefer to minimize the
frequency of their injections, but each will have a different
tolerance for the initial breathy voice phase of their treatment.
Dyspnea is the equivalent early treatment effect in abductor
SD. Because this may be life threatening, only one side is
treated at a time, to allow partial recovery of the first prior
to denervation of its counterpart. Alternate explanations

Chapter 35

for greater difficulty and less satisfactory results in abductor
SD patients are (1) the PCA muscle injection is technically
more difficult and/or (2) some patients thought to have abductor SD have mixed SD, a combination of adductor and
abductor SD. Even so, the potential for dyspnea imposes
important treatment limitations in abductor spasmodic
dysphonia, which may account for the generally less satisfactory results in these patients.
2. Essential voice tremor
Essential voice tremor is typically treated with bilateral
symmetric muscle injections of the TA-LCA muscles in the
similar manner of adductor spasmodic dysphonia. These
patients are more likely to be troubled by prolonged post­
injection breathiness; thus, a lower dose is preferred by
most patients. Essential voice tremor usually involves the
muscles of the upper aerodigestive tract more broadly, but
no systematic attempt to treat other involved muscles, such
as the strap muscles, has been made, and the functional requirements of swallowing prevent treatment of still others,
such as pharyngeal constrictors. When the tremor is found
to be predominantly at the level of the true and false vocal folds, botulinum toxin injection of the TA-LCA muscles
and/or the supraglottis can be very effective.
3. Vocal fold granuloma
Botulinum toxin injection has been advocated by some to
weaken the vocal adductory force of the arytenoid to allow better healing and resolution of vocal fold granuloma.
Botulinum toxin is injected into ipsilateral or bilateral TALCA muscles, in doses ranging from 1.25 to 20 U. Most
often 5 U injected unilaterally is adequate. In most cases,
a single application, either alone or in conjunction with
surgical removal, has been sufficient to permit resolution
of the granuloma. It should be noted that patients treated
with this approach will have a severe breathy, weak voice for
several months, and this may have a major impact on the
functional voice capacity (work and social).
Contraindications to injection include:
■ Pregnancy
■ Breast feeding
■ Impaired abduction of vocal fold for PCA injection
(relative)
■ Neuromuscular diseases (e. g., myasthenia gravis)
■ Concurrent aminoglycoside treatment

35.4

Equipment

Equipment for botulinum toxin injection:
■ EMG device (AccuGuide® [Medtronic Xomed, Jacksonville, Fla.] is a hand-held device that offers principally
acoustic output which may used as a lower-cost alternative to more expensive traditional electromyography
machines.)
■ Botulinum toxin
■ Insulated 26-g needle electrode

■ Ground and reference electrodes
■ Tuberculin syringe
■ (Optional) local anesthetic for skin (1% lidocaine with
1:100,000 epinephrine) and tracheal use
Additional equipment necessary for percutaneous injection
with laryngoscopic guidance and/or peroral supraglottic injection with laryngoscopic guidance:
■ Flexible laryngoscope (with working channel or
endosheath with channeled sheath (Vision Sciences,
Orangeburg, New Jersey)
■ C-mount camera (attaches to flexible laryngoscope)
■ Videomonitor for visualization
■ Three to 6 ml of 4% plain lidocaine
■ 27-g needle, 37 mm in length (percutaneous injection
with laryngoscopic guidance
■ Orotracheal injector device for peroral injection approach (Medtronic Xomed)
■ Cetacaine spray (benzocaine/tetracaine topical)
■ Curved Abraham cannula
■ Fine-gauge injection needle for use with working channel in flexible laryngoscope

35.5

Procedure

1. Botulinum toxin reconstitution and dilution

Botox is supplied as a freeze-dried powder in 100-U vials.
It is reconstituted with preservative-free saline. The product insert provides dilution instructions to achieve a wide
variety of concentrations (1.25–10 U/0.1 ml). Injection volume should be limited to minimize diffusion. Preferable
volume is 0.1 ml per vocal fold; however, a volume of 0.2 ml
is also acceptable. At that volume, there is virtually no risk
of airway difficulty from vocal fold engorgement. A needle
larger than 21 g should be used for reconstitution, dilution,
and transfer from vial to injection syringe. After the correct
dose is prepared, the insulated 26-g injection needle is attached to the syringe.
2. Percutaneous EMG-guided botulinum toxin injection
a) Connecting EMG electrodes
A ground and a reference electrode are attached to the
patient’s skin at a convenient site so as not to obstruct
the injection or inconvenience the injector. The insulated
injection needle, which serves as a monopolar sampling
electrode during the injection, is attached to an EMG recording device.
b) Thyroarytenoid–lateral cricoarytenoid muscle complex
localization and injection for Adductor SD
The patient is positioned in a semirecumbent position,
with the chin raised and the head back. If the neck is
thin and laryngeal landmarks are easily palpable, then
a shoulder roll may be omitted. If the neck is short and
stocky, or the larynx is canted forward, then a shoulder
roll is helpful. Alternatively, the headpiece of the chair
can be positioned to allow neck extension (Fig. 35.1).

223

224

35

Botulinum Toxin Injection of the Larynx

The patient is asked to breathe quietly and to try not to
swallow during the procedure. Both skin and intratracheal anesthetic may be injected, the latter via a cricothyroid puncture.
The anesthetic approach is highly variable among experienced clinicians. Some argue that the discomfort to the
patient from the anesthetic injection is approximately
equivalent to that from the toxin injection itself, while
others will perform the skin injection (30-g needle using
1% lidocaine with 1:100,000 epinephrine and sodium bicarbonate).

It is helpful to bend the needle upward some 30–45°, especially when injecting the female larynx, as the shorter
anterior–posterior distance requires a more acute angle
of entry under the inferior rim of the thyroid cartilage.
The needle is inserted into the cricothyroid space some
2–3 mm off the midline toward the side to be injected
and advanced superiorly and laterally (Fig. 35.2). A
more lateral entry point is used to attempt to avoid the
airway, because traversing endolaryngeal mucosa is uncomfortable for the patient and may cause cough or even
laryngospasm during the procedure. If it is possible to
remain entirely submucosal, then the patient finds the
procedure much less painful and stimulating to airway
reflexes. Entry into the airway produces a characteristic
“buzz” in the EMG signal, which should alert the injector
to redirect the needle more laterally, or even begin again.
The location where the needle penetrates the cricothyroid membrane from a superior–inferior perspective is
determined by the surgeon’s preference. Some will enter
the larynx at the junction of the inferior border of the
thyroid cartilage and the membrane while others prefer
to be at the halfway point of the membrane.
The needle is maneuvered within the tissue until the tip
lies in an area of crisp motor unit potentials. The patient is asked to phonate and a brisk recruitment and
a full interference pattern confirms placement, and the
botulinum toxin is injected. It is especially good to see

Fig. 35.1  Position of patient for percutaneous TA-LCA muscle botu-

linum toxin injection

Fig. 35.2  Insertion of needle through cricothyroid membrane into the

TA-LCA muscle complex for botulinum toxin injection

Fig. 35.3  Placement of EMG needle into the posterior cricoarytenoid

muscle, using a retrolaryngeal approach

Chapter 35

a characteristic prephonatory burst of EMG activity for
optimal injection localization.
c) Posterior cricoarytenoid muscle localization and injection for Abductor SD
i. Retrolaryngeal approach
The patient is seated upright, and the injector places
his or her thumb at the posterior border of the thyroid cartilage on the side to be injected. Using counterpressure on the opposite side of the thyroid cartilage from the other four fingers, the larynx is gently
rotated to expose its posterior aspect. The needle
pierces the skin along the lower half of the posterior
border of the thyroid cartilage and is advanced until
it stops against the posterolateral surface of the cricoid. The needle is then pulled back slightly, and the
patient is asked to sniff to confirm placement (Fig.
35.3). When this produces brisk recruitment, the
toxin is injected.
ii. Translaryngeal approach
In this approach, the needle must cross the endo­lar­
yngeal mucosa so an intratracheal injection of 4%
plain lidocaine is useful to prevent coughing and
discomfort. The needle is inserted through the cricothyroid membrane in the midline, and directed
posteriorly across the lumen of the glottis (identified
by the characteristic airway buzz on EMG) angled
toward the side to be injected. Using gentle pressure, it is pushed through the lamina of the cricoid
cartilage until the opposite side is reached (due to
cricoid cartilage calcification, this approach may not
be possible in the older patient). The first electrical
signal encountered on the far side represents posterior cricoarytenoid muscle. Placement is confirmed
by muscle activation during sniffing, and the toxin is
injected (Fig. 35.4). It is often useful (especially when
learning the technique) to employ an assistant to provide flexible laryngoscopy visualization on a monitor
during PCA injections (see Chap. 33, “Peroral Vocal Fold Augmentation in the Clinic Setting”). The
surgeon should be aware that fragments of cartilage
might plug the needle lumen as it crosses the cricoid,
and expelling them to permit injection may require
considerable force on the plunger of the syringe; a
luer-lock syringe will prevent toxin leakage around
the needle hub.
d) Botulinum toxin injection with laryngoscopic guidance
for Adductor SD
i. Local anesthesia is obtained by performing a puncture through the cricothyroid membrane, and instilling approximately 3 ml of 4% lidocaine into the airway.
ii. The nasal cavity is anesthetized and a flexible laryngoscope, attached to videomonitor, is inserted through
the nasal cavity and advanced to a level slightly above
the vocal folds. An assistant maintains the scope in
position in order to provide constant visual feedback
during the procedure.
Alternatively, the surgeon may use a rigid telescope
for laryngeal visualization (nondominant hand) while

Fig. 35.4  Placement of EMG needle into the posterior cricoarytenoid

muscle, using a translaryngeal approach

manipulating the needle with the other. The patient
(or an assistant) must stabilize the tongue to facilitate
good transoral visualization.
iii. A 1-ml syringe filled with botulinum toxin is attached to a 27-g needle. The needle is placed through
the cricothyroid membrane near the midline, using
videomonitoring to confirm the location of the needle tip in the subglottic airway.
iv. The needle is angled toward the posterior aspect
of the vocal fold, piercing the infraglottic mucosa,
and advancing the needle laterally into the adductor musculature of the vocal fold (TA-LCA complex)
(Fig. 35.2). The posterior third of the membranous
vocal fold is the targeted region for Botox placement.
A similar injection is then performed on the opposite vocal fold through the same approach via the
cricothyroid membrane. Visual confirmation, via the
flexible laryngoscopic monitoring is used to confirm
correct placement and to insure that inadvertent
“loss” of the Botox does not occur.
e) Supraglottic botulinum toxin injection with laryngoscopic guidance for Adductor SD.
Supraglottic botulinum toxin injection with laryngoscopic guidance is effective for treatment of adductor
spasmodic dysphonia as well as essential tremor involving the supraglottis. Two different injection approaches
can be used to perform supraglottic botulinum toxin injection, (1) peroral approach or (2) an approach using a
working channel of a flexible laryngoscope. Each of these
two approaches are equally efficacious, and the decision
to use one approach or the other is usually determined
by the availability of the equipment to the surgeon. From
a patient-comfort perspective, the injection through the
working channel of a flexible laryngoscope is better tolerated.

225

226

Botulinum Toxin Injection of the Larynx

35

Fig. 35.5  False vocal fold site(s) for trans-oral botulinum toxin

Fig. 35.6  Characteristic submucosal bleb immediately after transoral

1. Topical anesthesia nasal/oropharynx
a) Topical oxymetazoline/Pontocaine 2% spray to

curved needle. Disposable 27-g needles are used
with this system.
b) The needle is advanced into the oropharynx under direct visualization. The patient is instructed
to phonate /a/ as the needle enters the oral cavity,
which results in palatal raising, clearing the path
into the oropharynx. The assistant should position the flexible scope just above the palate until
the needle is visualized in the oropharynx.
c) The injector is then advanced, and the needle tip
is then guided into the hypopharynx, under endoscopic visualization, as the assistant follows closely
behind with the flexible scope The assistant must
be adept at manipulating the scope; consistent
visualization of the injector can be challenging
in a narrow airway with copious secretions. The
flexible scope should be positioned a few millimeters above the false vocal folds providing a clear,
well-illuminated, magnified view of the false vocal folds.
4. Laryngeal injection of Botox
a) The needle is guided into the posterolateral and/
or mid-lateral false vocal fold under laryngoscopic visualization (Fig. 35.5).
b) Botox is injected into a superficial (submucosal)
plane, forming a characteristic bleb (Fig. 35.6).
c) Five to 7.5 U are typically deposited in both false
vocal folds (total of 10–15 U).
An alternative way to perform supraglottic botulinum toxin injection with laryngoscopic guidance
is to use a flexible laryngoscope with a working
channel, or a flexible laryngoscope with an endosheath working channel apparatus. After adequate anesthesia to the larynx has been achieved

injection

nasal cavities

b) Topical Cetacaine spray to oral cavity (palate/pos-

terior pharynx)

2. Videomonitoring/topical anesthesia of larynx
a) A video camera is attached to a flexible laryngo-

scope or a distal chip flexible laryngoscope, inserted through the nasal cavity (typically the left side)
by an assistant, employing a “videocart system.”
The scope is generally maintained slightly below
the palate so that the tongue base and larynx can
be easily viewed on the video monitor.
b) Four percent lidocaine drip onto larynx under
flexible guidance (3–5 ml; see Chap. 33)
The patient is bent forward at the waist with the
neck extended in a “sniffing” position to maximize
laryngeal exposure. The tongue is grasped with a
4 × 4 gauze with the surgeon’s left hand. A 3-ml
syringe of 4% lidocaine (40 mg/ml) attached to an
Abraham cannula (Pilling, Fort Washington, Pa.)
is advanced into the oropharynx. Approximately
1 ml is deposited over the tongue base, and 2–4 ml
is dripped onto the vocal folds during phonation,
producing the characteristic “laryngeal gargle”.
The maximal recommended dose of 4% lidocaine
is approximately 7–8 ml (4.5 mg/kg; approximately 300 mg for a 70-kg patient).
3. Peroral passage of the needle into the endolaryngeal
region
a) The Botox is drawn up in a 1-ml syringe, and
secured into the orotracheal injector device
(Medtronic ENT, Jacksonville, FL) with the

botulinum toxin injection

Chapter 35

via the approach described above, a fine-gauge injection needle can be passed through the working
channel of the flexible laryngoscope (NM-9L-1,
Olympus America, Center Valley, Pa.) and the supraglottic larynx can be injected with botulinum
toxin as discussed above.

35.6

Postprocedure Care
and Complications

Patients may be discharged immediately after the injection.
Patients receiving TA-LCA injections should be cautioned regarding an initial period of (1) breathiness and (2) dysphagia,
especially to liquids, as discussed above. Patient receiving their
second posterior cricoarytenoid injection should be advised
regarding dyspnea and stridor.
Patients that received laryngeal anesthesia should be advised to retrain from any peroral intake for 2 hours (or until
sensation returns to the larynx/pharynx) to avoid the risk of
aspiration.

Key Points
■ Percutaneous, EMG-guided botulinum toxin injection
■ Effective administration of botulinum toxin
depends on
■ Accuracy of injection
■ Minimizing diffusion to neighboring muscles
■ Appropriate dosing
■ When using EMG, confirmation of needle placement by muscle activation during appropriate
activity (e. g., sustained “ee” or Valsalva for the
thyroarytenoid, sniffing for the posterior cricoarytenoid) is essential to accuracy.
■ Diffusion is minimized by injecting a small volume of solution, ideally 0.1 ml.
■ Approximate dosing is determined by muscle
mass and experience treating a given muscle.
Precise dosing for each patient is determined by
careful assessment of clinical result and adjustment of subsequent treatment.
■ Percutaneous injection of botulinum toxin with
laryngoscopic guidance
■ Percutaneous injection of Botox under flexible
(or rigid) laryngoscopic guidance is an ideal
technique for the practitioner who performs

laryngeal injections infrequently because it is
easier to master and relies on visual confirmation of the target, rather than blind needle
placement. However, it does require an assistant
to hold the flexible laryngoscope.
■ The response to botulinum toxin is similar with
this technique when compared to EMG guided
technique, except:
■ Higher doses are required
■ Delayed onset of action (up to 5 days) occurs
■ Toxin effect that is less consistent
■ Supraglottic botulinum toxin injection with flexible laryngoscope guidance
■ Supraglottic peroral Botox injection with flexible laryngoscopic guidance is indicated in
selected patients with adductor spasmodic
dysphonia (especially professional voice users
and supraglottic-based essential tremor).
■ Advantages of supraglottic botulinum toxin
(over EMG-guided approach) for spasmodic
dysphonia
■ Smoothing of the vocal “peaks and troughs”
associated with serial EMG-guided Botox
injections
■ Less severe (minimal-to-no) breathy voice
after injection
■ Disadvantages of supraglottic botulinum toxin
for spasmodic dysphonia
■ Shorter duration of effect (6–8 weeks)
■ Variable patient response (variable supraglottic muscular anatomy)

Selected Bibliography
1
2

3
4

5
6

Aoki KR (2004) Pharmacology of botulinum neurotoxins. Oper
Techniques Otolaryngol 15:81–85
Blitzer A, Brin MF, Stewart CF (1998) Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): a 12-year experience in more than 900 patients. Laryngoscope 108:1435–1441
Blitzer A, Sulica L (2001) Botulinum toxin: basic science and
clinical uses in otolaryngology. Laryngoscope 111:218–226
Bové M, Daamen N, Rosen C et al (2006) Development and
validation of the vocal tremor scoring system. Laryngoscope
116:1662–1668
Simpson CB, Amin MR (2004) Office-based procedures for the
voice. Ear Nose Throat J 83(Suppl.):6–9
Sulica L, Blitzer A (2004) Botulinum toxin treatment of spasmodic dysphonia. Oper Tech Otolaryngol 15:76–80

227

Part C Laryngeal Framework
Surgery

Chapter 36

36

Principles of Laryngeal
Framework Surgery

36.1

Fundamental and Related Chapters

Please see Chaps. 1, 5, 8, 37, 38, 39, 40, 41, and 42 for further
information.

36.2

Introduction

The general goal of laryngeal framework surgery is to improve
phonatory glottal closure by altering vocal fold position. Medialization laryngoplasty, also called type I thyroplasty, is the
most commonly performed laryngeal framework surgery,
typically used to correct glottic insufficiency from a variety
of causes, but most often from unilateral vocal fold paralysis.
Whereas injection augmentation techniques principally improve glottal closure by expansion of the thyroarytenoid (TA)
muscle, laryngoplasty techniques employ implant material in
the paraglottic space to displace the affected vocal fold(s) medially into a more favorable phonatory position. These materials
include Silastic, hydroxylapatite, polytetrafluoroethylene ribbon (GORE-TEX®) and titanium. Medialization laryngoplasty
may be used in conjunction with an arytenoid repositioning
procedure, an adjunctive technique that can be used to alter
vocal fold height and tension by manipulating the arytenoid
along its physiologic axis of rotation (see also Chaps. 40, “Arytenoid Adduction” and 41, “Cricothyroid Subluxation”).

36.3

Surgical Indications
and Contraindications

36.3.1 Medialization Laryngoplasty
The primary indication for medialization laryngoplasty (ML) is
symptomatic glottic insufficiency. The goals of the surgery are
to improve voice quality and protect the airway by achieving
improved glottic closure during phonation and swallowing.
Nevertheless, it is important to understand that vocal fold
medialization does not always provide a sure remedy. In the
presence of other motor or sensory deficits, as in a high vagal
nerve lesion, the ability to close the glottis does not necessarily
mean that this will occur appropriately during deglutition. Medialization is indeed likely to help, but many patients continue
to have medically significant aspiration. Due caution is war-

ranted in making feeding recommendations after medialization in such individuals. A complete reevaluation of swallowing function is prudent after medialization in such patients.
Medialization laryngoplasty has been advocated by some
as a treatment for glottic insufficiency due to soft tissue loss
in the aspect of the superficial vocal fold, such as is found in
postsurgical scarring or sulcus vocalis. However, it is not well
suited for these conditions, as it in no way addresses the lack
of tissue pliability and may not yield significant voice improvement. It is worth noting that there is considerable evidence
to suggest that at least part of the so-called “bowing” that has
been accepted as the clinical correlate of vocal fold aging may
also be due to changes in the lamina propria and loss of vocal
fold muscle bulk, and thus medialization may represent only a
partial solution.
Indications for ML include:
■ Symptomatic glottic insufficiency (dysphonia and/or
aspiration), especially if there is little chance of return of
normal neurologic function
Glottic insufficiency can be due to:
■ Unilateral vocal fold paralysis
■ Unilateral or bilateral vocal fold paresis
■ Vocal fold atrophy, including age-related atrophy
Contraindications include:
■ Previous history of radiation therapy to the larynx (relative)
■ Malignant disease overlying the laryngotracheal complex
■ Poor abduction of the contralateral vocal fold (due to
airway concerns)
■ Because medialization inevitably leads to some
narrowing of the airway, patients with moderateto-severe bilateral vocal fold paresis may not be
candidates for medialization. At least one vocal fold
should have intact inspiratory vocal fold abduction
for a medialization procedure to be considered

36.3.2 Arytenoid Adduction
Arytenoid adduction and arytenopexy as described by Zeitels is an important adjunct in selected cases of vocal fold paralysis. The physiologic effects of arytenoid adduction are not
completely understood, and some debate continues. However,
there is consensus concerning the following basic premises.

breathy dysphonia and/or dysphagia. and Atrophy”. The patient with troublesome symptoms may be treated by any of a number of temporary measures in the meantime principally injection augmentation (see Chaps.6 36. 36.3 Cricothyroid Subluxation Cricothyroid subluxation was developed by Steve Zeitels to address the problems of a shortened vocal fold frequently seen in unilateral vocal fold paralysis. The only other procedure that can lengthen a paralyzed vocal fold is arytenoid adduction (see Chap. and therefore is useful preoperatively in assessing which patients may need an arytenoid adduction. The concept of the procedure is to lengthen the vocal fold by increasing the distance from the cricoarytenoid joint (cricoid) to the anterior commissure (thyroid cartilage) by subluxing the cricothyroid joint on the side of the unilateral vocal fold paralysis.5 If the status of the nerve injury is unknown or LEMG data are equivocal or favorable for spontaneous recovery. medialization between 3 and 9 months can be considered. The inferior limit of placement is determined by the integrity of the cartilaginous strut below the window.   tion via Direct Microlaryngoscopy”. This will usually encompass the level of the vocal fold and make successful medialization possible with appropriate implant positioning. Cricothyroid subluxation is an adjunct procedure to medialization laryngoplasty. and has rarely required removal. “Percutaneous Vocal Fold Augmentation in the Clinic Setting”). and 34. most patients with minor degrees of glottic insufficiency (<1-mm glottic gap on phonation) who have minimal voice symptoms (e.3. It is worth noting that in the very rare cases of recovery of vocal fold motion after laryngoplasty that have been observed. as is frequently (and erroneously) stated. due to progressive atrophy of the vocal fold from ongoing nerve degeneration. and pediatric patients are not ideally suited for this technique. which should be at least 3 mm high to prevent fracture. certain general principles of laryngeal anatomy can be universally applied. This results in a rotation of the anterior commissure away from the midline in a direction contralateral to the side of the unilateral vocal fold paralysis. but is typically only used with medialization laryngoplasty. In select cases. Paresis. and 34. The ideal candidate for medialization laryngoplasty is a patient with moderate to severe glottic insufficiency (2–3 mm or greater glottic gap on phonation) manifested by weak. 36. anxious/uncooperative patients. The level of the vocal fold lies closer to the lower border of the thyroid cartilage lamina than to the upper. which results in a return of glottal insufficiency weeks to months after medialization. the implant does not appear to interfere with function. 33.4 Patient Selection for Laryngeal Framework Surgery Although any patient with symptomatic glottic insufficiency is technically a candidate for framework surgery. “Peroral Vocal Fold Augmentation in the Clinic Setting”. “Glottic Insufficiency: Vocal Fold Paralysis. In these cases. the patient should be counseled that the implant might need to be removed if vocal fold function returns. 31. arytenoid adduction should be considered in addition to medialization laryngoplasty. A maximum phonation time of < 5 seconds has also been identified as a predictor of the need for arytenoid adduction in cases of vocal fold paralysis. Most surgeons advocate waiting at least 3 months after a known vagal or recurrent nerve transection before performing medialization laryngoplasty. 40. “Peroral Vocal Fold Augmentation in the Clinic Setting”. 33. Conversely. especially if electromyography shows severe neuronal degeneration without evidence of neural recovery or the history strongly suggests nerve transection. 5. “Vocal Fold Augmenta- Timing of Medialization Laryngoplasty Technical Notes and Pertinent Anatomic Landmarks for Medialization Laryngoplasty Although many techniques and implant materials for medialization laryngoplasty exist. vocal fatigue) may be better suited for voice therapy and/or injection augmentation (see Chaps. As .. and not at its midpoint. Early or “primary” medialization (performed within the first 3 months after nerve injury) has fallen into disfavor. Cricothyroid subluxation addresses the commonly seen problem of a shortened vocal fold associated with unilateral vocal fold paralysis. It is important to place the thyroplasty window at the most inferior location possible. then medialization surgery is best delayed until 6–12 months after nerve injury to allow for spontaneous recovery. Because medialization laryngoplasty is performed under local anesthesia. “Percutaneous Vocal Fold Augmentation in the Clinic Setting”). which destabilizes the implant in a way that usually prevents effective medialization. Videostroboscopy often provides valuable information about vocal process contact and vocal fold height. “Arytenoid Adduction”). g. 36. This can be done with arytenoid adduction also.232 Principles of Laryngeal Framework Surgery Arytenoid adduction/re-position: ■ ■ ■ ■ 36 Rotates the arytenoid cartilage Medializes and stabilizes the vocal process Lowers the position of the vocal process Lengthens the foreshorted vocal fold In patients with vocal fold paralysis who have a lack of vocal process contact during phonation (large posterior gap) and those with vocal folds at different levels. medialization laryngoplasty is not necessarily the best approach in every case. 31. “Vocal Fold Augmentation via Direct Microlaryngoscopy”.

as do McCullough and Hoffman when using expanded polytetrafluoroethylene ribbon. while a well-defined “sweet spot” at the posterior aspect of the vocal fold is key to optimizing results. the implant often needs to be carved such that medialization occurs at the inferior limit of the window to avoid ventricular mucosa/false cord displacement. Maintaining the perichondrium intact effectively prevents medial migration and extrusion of the implant. Being able to check on the result of medialization in- traoperatively by means of flexible laryngoscopy. However. In this case. the inferior muscular tubercle (arrow) is ignored when determining the plane a result of this limit. Isshiki continues to advise its preservation in combination with Silastic and a cartilage island. the inferior tubercle should be completely exposed and excluded from the determination of the plane along the long axis of the vocal fold (Fig.2  Diagram showing the incorrect (left) and correct (right) method of exposing the inferior thyroid ala. and a monitor should be used for every case. 36. an intact perichondrium tends to distribute the vector of medialization throughout the window.1). and an incorrect. however. downwardly sloping line is used to trace the proposed horizontal plane of the vocal fold.1  Gender differences in medial- ization laryngoplasty. the leading edge of the window is placed 7 mm back from the midline of the thyroid cartilage in males and 5 mm in females (Fig. On the left. On the right. therefore. The inferior border of the thyroid lamina is the most reliable guide to determining the plane of the long axis of the vocal fold. 7 mm in males) Fig. ensuring correct window placement. To accurately identify this plane. 36. The most obvious dimension is medial/lateral. Many implants are shaped to medialize tissue in a plane exactly parallel to the long axis of the thyroplasty window. and the thyroid ala form a more acute angle when compared with the female larynx These anatomic differences require a more posterior location of the cartilaginous window in the male larynx to avoid excessive or disproportionate displacement of the anterior third of the vocal fold. Anterior displacement must be avoided.2). Another important anatomic consideration is the genderrelated differences in the configuration of the thyroid cartilage. the medial projection of many preformed implants makes their insertion impossible unless the internal perichondrium is opened. Preserving some flexibility in medialization laryngoplasty technique to allow for individual variations in laryngeal anatomy is necessary to achieve consistently satisfactory surgical results. The superior–inferior dimension is often the least discussed. because the amount of medial displacement must be precisely determined to close the glottic gap. a flexible laryngoscope. The more oblique angulation of the thyroid cartilage in females. its light source. Conflicting advice regarding the inner perichondrium has appeared in the literature. In addition. Just as important. In males.  Chapter 36 233 Fig. 36. It is important to conceptualize medialization of the vocal fold in three dimensions. and minimizes the possibility of endolaryngeal bleeding. which will result in strained or “pressed” voice. is the anterior–posterior dimension. and auditory perceptual evaluation is essential to understanding the reason for a poor phonatory result in time to correct it. along with the shorter length of the vocal folds requires that the medialization window be placed more anteriorly (5 mm in females. the cricothyroid fibers have not been divided from the inferior border. its orientation is thus an important factor for surgical success. In general. a thorough dissection of the inferior thyroid ala allows the true horizontal plane of the vocal fold to be outlined. but no less important. leading to less precise medialization. 36. This dimension is also . a camera. the vocal folds are longer.

Billante CR (2004) The immobile vocal fold. Rosen CA (1998) Complications of phonosurgery: results of a national survey. Ann Otol Rhinol Laryngol 102:413–424 Netterville JL. GORE-TEX. Postma GN (2004) Revision Gore-Tex medialization laryngoplasty. including Silastic. Conversely. Acta Otolaryngol 78:451–457 Netterville JL. Ann Otol Rhinol Laryngol 109:360–364 . A minor error in medialization within the superior–inferior plane can result in height mismatch during vocal fold closure. Yeung D et al (2000) Arytenoid adduction: controlling vertical position. ■ Early medialization can be considered in select cases including: complete nerve transec-   tion. vocal fatigue) may be better suited for injection augmentation and/or voice therapy. 38. Laryngoscope 108:1697–1703 Woo P. Otolaryngol Head Neck Surg 131:236–240 Isshiki N.. In: Ossoff RH. 39. This mismatch is difficult to detect during intraoperative flexible laryngoscopy. and may only later be discovered with videostroboscopy post operatively. Philadelphia. “Arytenoid Adduction”) Key Points ■ Medialization laryngoplasty and arytenoid adduction are the primary laryngeal framework techniques used to correct glottic insufficiency ■ The indications for laryngeal framework surgery include: ■ Unilateral vocal fold paralysis ■ Bilateral vocal fold atrophy/paresis ■ The ideal candidate for medialization laryngoplasty is a patient with moderate to severe glottic insufficiency (2. or in a clinical setting where there is little chance for recovery of vocal fold mobility (e. Okamura H. Morita H. g. a delay of 3 months from the time of injury is recommended to allow vocal fold atrophy to occur. severe neuronal degeneration as seen with laryngeal electromyography. Arytenoid adduction and medialization laryngoplasty (2000) Otolaryngol Clin N Am 33:817–839 Woodson GE. most patients with minor degrees of glottic insufficiency (<1-mm glottic gap on phonation) who have minimal voice symptoms (e. ■ Gender-related difference in the thyroid lamina requires a more posterior location for the medialization window in males. Temporary vocal fold injection can be used acutely in these patients prior to proceeding with laryngeal framework surgery ■ The level of the vocal fold lies closer to the lower border of the thyroid cartilage lamina. Selected Bibliography 1 2 3 4 5 6 7 Cohen JT. The thyroplasty window should be placed as inferior as possible. Civantos FJ. UVFP due to a malignancy). breathy dysphonia and/or dysphagia. Williams & Wilkins. g. pp 269–305. A review of 116 phonosurgical procedures. “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis”. Ossoff RH (1993) Silastic medialization and arytenoid adduction: the Vanderbilt experience. and Titanium. Picerno R. Lippincott. and not at its midpoint. Hiramoto M (1974) Thyroplasty as a new phonosurgical technique. Details of technique specific to various implant materials and steps and modifications required to perform arytenoid repositioning surgery in conjunction with medialization laryngoplasty are covered elsewhere (see Chaps. framework surgery is generally performed after a waiting period of 6–12 months to allow for spontaneous recovery. An intact inner perichondrium limits the depth and precision of vocal fold displacement. Stone RE. Hydroxylapatite. Shapshay SM.to 3-mm or greater glottic gap on phonation) manifested by weak. “GORE-TEX® Medialization Laryngoplasty”. Luken ES. Woodson GE. Netterville JL (eds) The larynx.234 36 Principles of Laryngeal Framework Surgery the most difficult to judge intraoperatively. ■ The inner perichondrium of the thyroid lamina should be incised to gain access to the paraglottic space during medialization. ■ In unilateral vocal fold paralysis (UVFP). and 40. Bates DD. In these cases.. ■ Medialization laryngoplasty can be performed with a variety of implant substances.

followed by two additional doses at 8 and 16 h postoperatively. as are those with a history of irradiation to the neck. 1. In cases of significant postoperative edema. this can result in significant airway obstruction—the Fig. If a drain is placed. Most patients have good-to-excellent voicing intraoperatively. Rare cases may persist up to 3 months. In rare instances. with pulse oximetry. Patients may be fed the evening of surgery. The period of postoperative dysphonia is variable. with arytenoid adduction a drain is prudent. 5. The patient should be warned of this before the surgery.1 Fundamental and Related Chapters Please see Chaps. 37. a patient undergoing framework surgery may develop laryngeal edema to such a degree that partial or complete airway obstruction occurs. 40. edema may continue to progress up to 72 h postoperatively in rare cases. 8. with the diet advanced to regular as tolerated. The results of a survey of American otolaryngologists performed in 1998 revealed incidences generally in line with those reported in various series. in which case a fluroquinalone may be use for 7–10 days postoperatively. 39.2 Perioperative Issues in Laryngeal Framework Surgery Vocal fold edema may have a marked effect on voice quality and prolong recovery of normal voice. 36. but develop varying degrees of postoperative dysphonia as a result of edema or submucosal hemorrhage. but may last between 2 and 6 weeks. Generally.1  Violation of ventricular mucosa at the anterior aspect of the medialization window (cross-section). total voice rest is unnecessary. All cases are admitted for overnight observation. Medialization necessarily results in a narrowing of the glottic airway. however.Chapter 37 Perioperative Care for Laryngeal Framework Surgery 37. a peroral corticosteroid taper may be used at discharge. Note the close proximity of the ventricular mucosa to the thyroid lamina at the anterior aspect of the window . and 41 for further information. In combination with postoperative edema or hematoma. Patients undergoing bilateral medialization procedures and/or arytenoid adduction are at increased risk for this complication. thus intravenous Decadron (10 mg) is given preoperatively. 37. An intravenous antibiotic such as Ancef 1 gm is given preoperatively. a good postoperative voice will become rough and hoarse. Use of a surgical drain is not necessary in most medialization cases. Voice conservation is advocated. Postoperative antibiotics are usually not necessary unless there is a history of irradiation to the neck. 37. however. Within hours. then it is typically removed the next morning before discharge. maximal airway edema occurs within the first 24 h after surgery. 38.3 37 Surgical Indications and Contraindications The principal complications specific to medialization laryngoplasty include airway obstruction and implant extrusion.

which renders height differences notoriously difficult to assess. If perforation goes unrecognized at the time of surgery. A height mismatch is often accompanied by unequal vocal fold tension. when the edema begins to resolve. The key to preventing airway entry is to avoid undermining of the paraglottic space anterior to the window and to use care when removing the anterior portion of the cartilaginous window.1). which causes the folds to react differently to phonatory air pressure.4   performed. It is likely that at least some of the airway extrusions. The implant then acts as a foreign body and may extrude. Extrusion of the implant was extremely rare (0. In addition. preoperative intravenous corticosteroids (Decadron. Surgeons surveyed reported some airway compromise in 13. particularly those that occur within a few weeks of surgery. Furthermore. and can be easily torn when working at the anterior aspect of the window (Fig. either externally or endoscopically. 37. Even mild edema can create enough medial displacement of the vibratory margin of the vocal fold to cause the surgeon to underestimate of the degree of medialization required. revision framework surgery should not be considered for at least another 3 months. as well as in the authors’ experience. The window should be probed. and tended to occur more often after medialization laryngoplasty arytenoid adduction rather than medialization laryngoplasty alone. Usually.236 37 Perioperative Care for LFS most dangerous postoperative complication of medialization laryngoplasty. and medialization measurements should be obtained as soon as the window is opened. the patient will report good voice immediately after surgery. as in the case of a so-called prolapsed arytenoid. some 0. In cases where delayed implant exposure within the airway is encountered. revision rates have been reported to be as high as 33%. When secondary procedures such as fat injection are included. the patient should be taken back to the operating room for removal of the implant. 10 mg) and application of epinephrine-soaked Cottonoids within the medialization window during implant carving can help lessen edema.6% of patients undergoing medialization laryngoplasty and 2.2% of patients undergoing medialization with arytenoid adduction required intubation or tracheostomy. 37. One can test that the closure is complete by flooding the operative field with irrigation and looking for air bubbles during a Valsalva maneuver. resulting in dysphonia. are the result of intraoperative unidentified perforations through the mucosa. In fact. reported to be 5. then the tear can usually be closed with absorbable sutures.2  Flexible laryngoscopy demonstrating prolapse of the left ventricular mucosa and false vocal fold from an implant that is placed “too high” (superior to the correct plane of the long axis of the vocal fold) . can reach 16%. as one would expect on comparison of internal and external tissue covering of the implant. with muscle traction diminished or even absent. However. then the implant is at risk for exposure and contamination. Certain causes of poor voice results occur regularly and with greater frequency than others in most reported series. There is some doubt that the vocal process of the arytenoid can be medialized effectively and consistently by a posterior extension of the medialization implant. Revision rates. If the tear is successfully closed. It is important to recognize the onset of vocal fold edema intraop- Suboptimal Results/Surgical Errors An unsatisfactory voice result rather than any airway problem or extrusion is the most common cause of revision medialization surgery. this was minor. Securing the implant to the cartilage with sutures is thought to significantly reduce the risk of airway foreign body. This is especially likely to occur in cases that last longer than usual and allow normal intraoperative vocal fold edema to accumulate. Undercorrection is another relatively frequent cause of poor results. In these cases.8%) and predominantly into the airway rather than transcutaneous. when the vocal process lies below the plane of glottic closure. If accidental mucosal violation does occur. only to fade 1–2 weeks later. A denervated vocal fold may thus rest at a different vertical position from its functioning counterpart. potentially precipitating an airway foreign-body emergency. a fact not always obvious during laryngoscopic examination. In these cases. The key to avoiding this complication is to keep the time from intralaryngeal elevation until final implant placement as short as possible.4% in the survey of complications. then an implant can be safely placed in select cases. The delicate ventricular mucosa is often located in close proximity to the inner aspect of the anterior thyroid ala. it may even lie outside of this trajectory. Simple medialization cannot remedy a height mismatch. 37.8% of cases. These include: ■ ■ ■ ■ Persistent posterior glottic gap Undermedialization Superior implant malposition Anterior implant malposition Persistent posterior glottic gap can account for up to 50% of revisions in cases in which arytenoid adduction has not been Fig. the arytenoid and its vocal process move in three dimensions.

as the most common overall cause for revision. it is more important to confirm a well-medialized vocal fold (using an indwelling flexible laryngoscope) in a patient with a mildly stained voice.  eratively. When vocal fold edema is suspected. 37. The remainder of the surgical case proceeds in a similar fashion to primary medialization laryngoplasty. Clues that vocal fold edema has developed include: ■ The patient’s baseline voice (nonmedialized) sounds significantly better than it did before the case began. The same meticulous exposure of the thyroid ala and precise measurements should be used to establish the “new” window location. subglottis) indicates an incorrect medialization plane (Fig. similar to primary medialization techniques. the reason for failure may be related to vocal fold height differences. and retest the voice. If the voice improves with this maneuver. 37. A subset of patients may be noted to have voice deterioration months to years after surgery. the unusual window dimensions do not present a problem (Figs.3  Flexible laryngoscopy demonstrating excessive medializa- tion of the anterior third of the left vocal fold after medialization laryngoplasty Chapter 37 plane of the true vocal fold prior to attempting the use of any depth-measuring devices. which results in medialization of the ventricular mucosa or the false vocal fold. 37. one must rely on visual clues more than auditory clues in determining the correct amount of medialization. glottic tissues overlying the anterior third of the window are generally not medialized. This is especially true in men. Also. As long as the revision implant occupies the new window location. 237 .7). Netterville and Billante have identified placing the implant too far superior. The location of the original cartilaginous window from the previous surgery is not taken into consideration when planning the location of the revision window. Finally. using two single-prong hooks. results in a distinctive pressed or strained vocal quality from early contact and “overclosure” of the anterior part of the membranous vocal fold during phonation (Fig. or lack of posterior glottic closure conditions that medialization surgery cannot correct. If an adequate voice quality cannot be obtained by medial displacement of the vocal fold intraoperatively.4. The image from an indwelling flexible laryngoscope is extremely useful to confirm the correct medialization plane. in whom the extremely thin glottic tissue overlying this area is prone to overmedialization from even small amounts medial displacement.6).2). reshaping of the anterior portion of the implant is necessary. the fibrous capsule that has formed deep to the implant must be incised (Fig. Most implants can be removed easily as the new window is opened. 37. even if there is some overlap between this and the original window. 37. more rarely. and is secured within this space. Implant malposition of the implant generally accounts for the balance of revisions. The new window is then created. then significant vocal fold edema may have developed. 37. or one with an irregular shape. If more than 30–45 min elapse between the opening of the cartilaginous window and placement of the implant. or bilateral age-related atrophy. It is not uncommon for a well-carved implant to cause a slight amount of unintended anterior medial displacement. This fibrous tissue creates tethering of the thyroarytenoid muscle and must be incised along the perimeter of the window (Fig. This is probably best explained by continued atrophy of the vocal fold musculature from prolonged denervation.1 Revision Surgery The approach for revision surgery does not deviate much from that taken with primary surgery. 37. This is similar to the release of the internal perichondrium that is performed in most medialization surgery. then arytenoid adduction should be performed in conjunction with medialization. rather than settling for a normal voice with a slightly undercorrected vocal fold. it is not surprising that substantial number of medialization revisions require arytenoid adduction. the paraglottic space is entered and undermined.5).4.3). This can be avoided by placing the window no more than 3 mm above the inferior border of the thyroid ala. one should carefully probe within the window to confirm the Fig. or as low as possible while maintaining a stable inferior frame of cartilage below the window. To prevent this. In many cases. a bulging ventricular fold or everted ventricular mucosa (or. forceps can be used to pull the anterior portion of the implant partially out of the window. If a pressed voice is noted after implant placement. In other words. caused by too anterior a placement of the medialization implant. Overmedialization of the anterior vocal fold. but cannot be replicated later (30 + min) in the case. ■ Good voice quality is obtained during medialization with depth gauge immediately after opening the window. Once the revised window is created. to permit unencumbered medial displacement of the vocal fold. In some cases. 37. this may result in a larger window. Therefore.

37. Note adherence of the capsule along the inner aspect of the thyroid lamina position of the implant of the window .5  Combined revision window that is created. 37.7  Sharp incision through the fibrous capsule along the margin window dimension superimposed removal.4  Original window/implant and the outline of the “new” ideal Fig. Note the secure Fig. 37. 37.6  Fibrous capsule within the paraglottic space after implant Fig.238 Perioperative Care for LFS   37 Fig.

Postma GN (2004) Revision Gore-Tex medialization laryngoplasty. Pearl AW. Som P (2001) Failed medialization laryngoplasty: management by revision surgery. Luken ES. A review of 116 phonosurgical procedures. Hsiung MW. A smaller diameter ETT (6. Ann Otol Rhinol Laryngol 102:413–424 Rosen CA (1998) Complications of phonosurgery: results of a national survey. Otolaryngol Head Neck Surg 113:671–673 Hong KH. ■ Revision surgery for medialization laryngoplasty failures often requires arytenoid adduction to achieve maximal voice results. Bates DD. Otolaryngol Head Neck Surg 124:615–621 239 . Ossoff RH. ■ Major complications/ risk factors of framework surgery include: Complication Risk factor(s) Airway compromise/ obstruction Arytenoid adduction Bilateral medialization Prior history of neck irradiation Implant extrusion/exposure Violation of airway mucosa ■ Suboptimal results with framework surgery are usually due to one or more of the following: ■ Persistent posterior glottic gap ■ Undermedialization ■ Implant malposition: ■ Anteriorly ■ Superiorly ■ Vocal fold height mismatch ■ A good voice after framework surgery that begins to “fade” or weaken 1–2 weeks postoperatively suggests undercorrection. Crary MA. Laryngoscope 111:227–232 Maragos NE (2001) Revision thyroplasty. Cassisi NJ. ■ Endotracheal intubation is safe in patients who have undergone framework surgery in the past.0 or smaller) is recommended. Silastic medialization and arytenoid adduction: the Vanderbilt experience.5 Chapter 37 Long-Term Surgical Issues Patients who have undergone successful medialization laryngoplasty. A waiting period of 6 months postsurgery (if the proposed surgery is elective) is advised. Laryngoscope 110:1082–1085 Woo P. The anesthesiologist should place the smallest endotracheal tube that he or she feels is safe—ideally. if possible. Sataloff RT (2003) Thyroplasty revision: frequency and predictive factors. Ann Otol Rhinol Laryngol 110:1087–1092 Netterville JL. Otolaryngol Head Neck Surg 131:236–240 Cotter CS. Stone RE.0 or smaller—principally to avoid inducing laryngeal edema from a slightly constricted glottic aperture. Gorham MM (1995) Laryngeal complications after type 1 thyroplasty. Laryngoscope 108:1697–1703 Weinman EC. with or without arytenoid adduction often express concerns about the safety of endotracheal intubation for surgical procedures in the future. 7 8 9 Anderson TD. size 6. Jung KS (2001) Arytenoid appearance and vertical height difference between the paralyzed and innervated vocal folds. J Voice 17:442–448 Cohen JT. Selected Bibliography 1 2 3 4 5 Key Points 6 ■ Corticosteroids should be given in the preoperative and immediate postoperative period to help minimize potential complications.  37. Spiegel JR. but should be delayed until 6 months postoperatively. Civantos FJ. Avidano MA. Maragos NE (2000) Airway compromise in thyroplasty surgery.

or if a revision surgery needs to be performed later. Cricoarytenoid joint abnormalities can be differentiated from vocal fold paralysis using laryngeal electromyography and vocal fold palpation. 1. Laryngoscopy generally shows an immobile vocal fold. 14. especially if there is little to no chance of return of vocal fold motion Contraindications include: ■ Previous history of radiation therapy to the larynx (relative) ■ Malignant disease overlying the laryngotracheal complex ■ Poor abduction of the contralateral vocal fold (due to airway concerns) ■ Presence of lesion on the vocal folds 38. Even though the implant can be removed. cricoarytenoid joint fixation (usually due to trauma or rheumatologic disease).). The position of the paralyzed vocal fold can vary from median position to lateralized. the implant can be removed if return of vocal fold mobility occurs. 39. 37. Ariz.) and VoCoM hydroxylapatite (Smith and Nephew.or 3-mm cutting burr Kerrison rongeurs tray (1. Indications comprise: ■ Symptomatic glottic insufficiency (dysphonia. generally. We advocate hand carving of a medium-grade Silastic block (available from Medtronic ENT. It is really a matter of surgeon preference and experience.) or strip GORE-TEX® (W. Bartlett. 36. Experimental and clinical evidence supports the efficacy of Silastic ML over a prolonged period. and aspiration of liquids. and almost exclusively related to severe external trauma—not intubation). This variation of the position of the vocal fold is probably related to the degree of reinnervation that has occurred subsequent to the nerve injury. it should be noted that Silastic ML is fully reversible—that is.L.3 Surgery Indications and Contraindications It is important to note that Silastic medialization laryngoplasty (ML) is designed to be a long-term treatment for symptomatic UVFP. and the height from slightly above to below the contralateral vocal fold. Gore and Associates. other systems (such as the preformed implants in the Montgomery Thyroplasty Implant System (Boston Medical Products. superior voice results. Tenn. 38. Jacksonville. However.1 Fundamental and Related Chapters Please see Chaps.2 Disease Characteristics and Differential Diagnosis Patients with unilateral vocal fold paralysis (UVFP) typically complain of breathy dysphonia. 9. 40. Flagstaff. Fla. 5. However.) can be employed successfully as well. Differential diagnosis of an immobile vocal fold includes vocal fold paralysis. 38. and a better understanding of the dynamics of vocal fold medialization.to 3-mm-sized tips) Medium-grade Silastic block (Medtronic ENT) ■ Partially preformed blocks are used in this procedure. this 38 procedure should be used as a permanent treatment not a temporary method of medialization. This leads to precise medialization. There is minimal tissue reactivity to Silastic over time. aspiration). although a slight amount of adduction can be present due to contralateral innervation of the interarytenoid muscle. The etiology of the paralysis is frequently vagal/recurrent laryngeal nerve injury secondary to iatrogenic causes or nonlaryngeal malignancy. using the surgical technique described by Netterville. and 41 for further information.4 Surgical Equipment No single implant material is superior to the others for performing ML. Mass.Chapter 38 Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis 38. ■ ■ ■ ■ ■ ■ ■ ■ ■ Netterville Medialization Tray (Medtronic ENT) Drill with 2. a thin fibrous capsule surrounding the implant is all that is seen months to years after ML. and cricoarytenoid dislocation (very rare. referred to as “silicone strips” by the manufacturer Ruler (15-mm section of plastic ruler at tip of hemostat) Flexible laryngoscope C-mount camera with videocart/monitor Clear overdrape for laryngoscope (1010 drape) Local anesthetic (nasal and subcutaneous) . vocal fatigue. as well as the differing anastomotic connections between the RLN and SLN that are variable from patient to patient. Westborough.

000 epinephrine. 8. One-inch tape is used to secure the flexible scope to a modified i.5 Surgical Procedure 7. The visual feedback of the larynx is invaluable when performing this surgery.5). .1). 38. 5.3). exposing the laryngeal cartilage (Fig.38. typically 5–6 cm in length (Fig.2). 6. Fig. so that the correct orientation of the window can be properly determined (Fig. 38.2  Horizontal skin incision: typically midthyroid cartilage and 5 cm in length 38. This requires serial release of the perichondrium superiorly and inferiorly (Fig. Placement of an indwelling flexible laryngoscope with videomonitoring of the larynx during the entire surgical case. 38. 38. from the hyoid down to the cricoid cartilage. Preoperative intravenous Decadron (10 mg) is administered. 38. This exposes the inferior border. The inferior border of the thyroid ala has muscle fibers from the cricothyroid muscle inserting onto it.242 Silastic Medialization Laryngoplasty   38 Fig. A single-prong hook is placed under the thyroid notch.6). The neck is then prepped and draped. The midline raphae is divided between the strap muscles with cautery. on the side of the intended surgery. Subplatysmal flaps are raised to the hyoid superiorly and the upper portion of the cricoid below. 1. 2. and a posteriorly-based flap is raised with a cottle or freer elevator. bringing the entire hemilaryngeal cartilage into view (Fig. 3.7). retention hooks are used to secure the flaps out of the way. so these must be divided (typically with bipolar cautery followed by 15-blade division). 4. 38.v. as the angulation of this process can cause mistaken orientation of the medialization window. The exposure of the inferior thyroid cartilage border must extend posterior to the muscular tubercle (an inferiorprojecting extension of the thyroid ala). 15 ml are used.1  Diagram of typical prep/drape for medialization laryngoplasty 4.4). pole hanging above 9. 38. The surgical region is liberally infiltrated with 1% lido- caine with 1:100. and the larynx is retracted towards the side opposite the paralysis. A horizontal incision is placed in a skin crease at the level of the midthyroid cartilage. including a clear overdrape to allow manipulation of the flexible laryngoscope during the case (Fig. Typically. the patient’s head. Four percent lidocaine and oxymetazoline nasal spray is applied to the most patent nasal cavity. The outer perichondrium of the thyroid cartilage is then incised with a 15 blade. The downward projection of the muscular tubercle must be ignored when determining the horizontal plane of the inferior border of the thyroid cartilage (Fig. 38.

The needle can usually be seen immediately or can be rapidly jostled to aid the identification of the needle location. Placement of the window any higher (superior) may result in medialization of the false vocal fold or ventricular mucosa. Care is taken to not “pass point” with the needle as it goes through the cartilage. one can pass a needle (21 gauge) through the anterior-superior corner of the proposed ML window during simultaneous flexible laryngoscopy. measuring 6 × 13 mm.6  Bipolar cautery and sharp dissection are used to expose the inferior border of the thyroid ala cal fold.5  Posteriorly based outer perichondrial flap elevation 10. which may result in “pressed” voice (Fig. 38. If 243 . thus avoiding the airway. 38. The window is placed 3 mm above the inferior border of the thyroid cartilage. with poor voice results. The window is “set back” from the midline of the thyroid cartilage by a distance of 5 mm in women and 7 mm in men. This setback helps avoid medialization of the anterior vo- Fig. 38.3  Division of midline raphae of the strap muscles Fig.4  Single-prong hook under the thyroid notch to gain exposure to thyroid ala Fig. After the window is outlined.8).  Chapter 38 Fig. A window is outlined in the thyroid cartilage. The needle location can aid in optimal window localization. 38. using the window-size gauge instrument. 38.

13).11. the cartilage is soft. When drilling the window. 38. 11. Once the entire rectangular section of cartilage is thinned. 12. On the right. exposing the thyroarytenoid muscle fascia. Kerrison rongeur. the cricothyroid fibers have not been divided from the inferior border. 38. The window-size gauge instrument is 6 × 13 mm in area the needle is seen too anteriorly or superiorly. However if it is intact. On the left.10). 38.14).12). In this case.9). . a through dissection of the inferior thyroid ala allows the true horizontal plane of the vocal fold to be outlined. depending on laryngeal calcification). In younger patients. An intact perichondrium remains tightly bound to the thyroid cartilage (even with undermining) and often provides great resistance to medialization. first outlining the perimeter of the window. the inferior muscular tubercle (arrow) is ignored when determining the plane 38 Fig. a 2. A surgical plane is then developed. or drill. 38. 38. the planned ML window can be adjusted appropriately. a Woodson elevator can be used to gain entry into the paraglottic space (Figs. downwardly sloping line is used to trace the proposed horizontal plane of the vocal fold. insuring correct window placement. 38. 5–7 mm from the midline of the thyroid ala (5 mm in females. a Kerrison rongeur can be used to complete the window (Fig. The window of cartilage is then removed (with a 15 blade. and can be removed with a 15 blade. 7 mm males). and inferiorly (Fig.7  Diagram showing the incor- rect (left) and correct (right) method of exposing the inferior thyroid ala. 38. being cautious to avoid penetration of the cartilage with resultant paraglottic bleeding. In contrast.to 3-mm cutting burr is used. Incising the inner perichondrium and establishing a surgical plane in the paraglottic space is important to successful medialization. and 3 mm above the inferior border. once the inner perichondrium is incised. then it may be incised superiorly.244 Silastic Medialization Laryngoplasty   Fig.9  A small triangle of cartilage is removed from the posterior window using a 15 blade and a Woodson elevator Fig. Once an entry point through the thyroid cartilage is established. 38. Often this inner perichondrium is removed piecemeal with the Kerrison rongeur during primary cartilage removal of the window. Dissection anterior to the window may result in perforation into the airway through the very thin (and closely adherent) ventricular mucosa and should be avoided. Often. posteriorly. the paraglottic space allows for unencumbered medialization. with the right-angle elevator within the paraglottic space (just superficial to the TA fascia) in all directions around the window except anterior (Fig.8  Correct placement of the medialization window. a triangle of cartilage can be incised and then removed from the posterior superior aspect of the window using a Woodson elevator (Fig. The inner perichondrium that lies deep to the window is removed. 38. and an incorrect. it is analogous to trying to displace a trampoline.

  Chapter 38 38. 38.11  A cutting burr is used to outline the window in cases where Fig.10  Kerrison rongeur is then used to remove the remainder of the Fig. posteriorly.13  Release of the inner perichondrium. 38.12  A Woodson elevator is then used to gain entry into the Fig. 38. when the cartilage is sufficiently thinned the cartilage is calcified riorly. and inferiorly 245 . with a 15 blade supe- cartilage paraglottic space.

17). 38. while the patient counts to “10” (Fig. An implant is then carved out of medium-grade Silastic wedge on the back table to meet the specifications provided by the depth gauge measurements. 38. 3 × 0. 38.. Once the appropriate measurements are made. 6–8 mm) (Fig. 38. to insure 13. the inferior aspect generally is the most desirable for medialization. and corresponds to the free edge of the vocal fold. a) Carving the Silastic implant The implant may be carved from a medium-grade Silastic block to meet the specifications provided by the depth gauge measurements. and results in suboptimal results in most cases. It is rare that any medialization is needed at the anterior aspect of the window. allowing for complete glottic closure and significant voice improvement. This can be achieved by undermining from below the strut.14  Undermining within the paraglottic space (deep to the in- Fig.16). and inferiorly the inferior strut of the thyroid ala.000 epinephrine are placed inside the window to aid in hemostasis while the implant is carved. A combination of visual feedback from the videolaryngoscopy monitor and the patient’s vocal quality are used to judge the correct amount of medialization needed. Within the window. The TA muscle is then displaced within the window while visualizing the effects on vocal fold displacement on the videomonitor.5-inch Cottonoids soaked in 1:10. This helps establish the correct plane of medialization. The other measurement is the depth of medialization.18). which is referred to as the “A” measurement in the corresponding illustration. Two principle measurements are obtained. Typically. 5–7 mm of medialization is needed at the posterior aspect of the window. This will allow space for the flanges of the implant to rest . This is often 10–13 mm in length.246 Silastic Medialization Laryngoplasty   38 Fig. except in females. Displacement within the superior aspect of the window usually medializes the false vocal fold or ventricular mucosa. A depth gauge is used to displace the paralyzed TA muscle medially. The first is the distance from the anterior release of cricothyroid fibers. not the outer table (Fig. A preformed 20-mm wedge block ner perichondrium) superiorly. 38. 16. posteriorly. Ideally.15  Undermining the paraglottic space from below. The inferior paraglottic surgical plane should extend below window to the point of maximal displacement (i. The measurement is taken off the inner table of the cartilage.15). using the long or a cottle elevator. 15. as posterior medialization most often is used (in women this measurement is typically closer to mid aspect of the window. the tip of the depth gauge). and is read off the depth gauge instrument. 38. 17. the paralytic vocal fold will assume a straight contour in the midline. e. 14. The TA fascia in the window should be displaced medially to avoid perforation/penetration of the TA muscle fibers (Fig.

Using a 15-blade. 38.17  Distance from the anterior window to the point of maximal displacement of the depth gauge. This creates a characteristic triangular shape of the implant. This is typically 5–7 mm. preserving an approximately 3-mm strip of material along the indicated line (Figs.  Chapter 38 Fig.24). not on the upper or lower “flange” portions Fig. The measurement should be taken of the inner (deep) aspect of the cartilage. This is generally 10–13 mm in males and 3–8 mm in females.22). From the dot. and segment D corresponding to the posterior extension of the implant that helps to hold it in place. 38. This is referred to as the “B” measurement during implant carving of the implant (Fig. and a dot is placed with a marking pen (Fig. 38.23).20). Lines are then drawn connecting the tip of line B with both the anterior and posterior portions of the block (“C” and “D. This section describes its proper preparation for implantation. removing the excess portion of the block (Fig. middle.26). 38. 38. Note the displacement is generally at the posterior. The distance from the anterior edge of the window to the point of maximal medialization (typically 11–13 mm in males and 3–8 mm in females) is measured along the block (measurement “A” on the diagram). The implant is placed in a customized implant holder for further shaping. A 10 blade is used to cut along lines C and D. inferior border of the window (“silicone strip” by Medtronic ENT) simplifies this task and shortens surgical time. 38. In general. The extreme upper and lower edges of the implant must be thinned considerably to make the flanges flexible.” respectively) (Fig. The plane of medialization (lower. with the edge C corresponding to the portion of the implant that displaces the vocalis muscle medially.18  Measuring the depth of medialization using the depth gauge. This measurement was obtained using the depth gauge and is typically 5–7 mm in most patients.25. 38. 38. One must be careful to make these cuts at 90° angles to maintain the integrity of the depth of the implant. a line is extended into the substance of the block (measurement “B” in the diagram) which corresponds to the depth of medialization (Fig.16  Displacement of TA muscle with the depth gauge. or upper portion of the window) that corresponds to the plane of the true vocal fold is marked with a line along the implant border (Fig.19). This is referred to as the “A” length during implant carving Fig. 38.21). the excess Silastic is removed superior and inferior to the plane of medialization. 38. This 247 . 38. this is the inferior or lower border of the window space. The line must be drawn along the medialization “zone” in the middle of the implant.

using a 10 blade Fig. extending the distance determined by the depth of medialization (“B” length from Fig. 38.21  A triangular implant is then created Fig.18) Fig. beginning from the “A” mark. 38.248 38 Silastic Medialization Laryngoplasty   Fig. 38.17) Fig. A mark is made on the im- plant corresponding to the point of maximal medialization (“A” length from Fig.19  Carving a left-sided implant. 38.23  Marking the plane of medialization (corresponding to the inferior border in most implants) . 38. 38.20  A line is drawn perpendicular.22  Trimming excess Silastic. 38.

38.26  Sculpting the final implant contour. 38. 38.24  Medialization should only occur within the “medialization zone” indicated. Note the line of medi- alization is at the inferior aspect of the medialization zone Chapter 38 Fig. using a 15 blade Fig. The implant material above and below this zone is strictly used as flanges to hold the implant in place Fig.  Fig.27  Posterior 7-mm slot is removed from the implant to allow placement 249 . 38.25  Removal of Silastic.

If this improves the voice. 21. This may take an extra 10–15 min. Implant extrusion probably arises due to unrecognized tear in the ventricular mucosa and soiling of the wound with respiratory secretions. Yet another complication is undermedialization. the implant is removed from the holder. then the implant can be displaced posteriorly. 38. the indwelling laryngoscopic image will show a medialized false vocal fold or bulging of the ventricular mucosa—sometimes a subtle finding. This probably occurs when excessive edema of the vocal fold occurs prior placement of the implant. 19.” then the anterior portion of the implant should be grasped and pulled out of the window slightly. platysmal. If the voice sounds Common mistakes include medialization too far superiorly within the window. 38. Implant extrusion or exposure is another potential complication. 20. strap muscles. one must anticipate the vocal fold will be slightly overmedialized.28). and the laryngoscopic image should be observed to insure that the medialization recreates what was achieved with the depth gauge. Ensure the wound is dry. 8 mg. The A and B measurements are rechecked for accuracy. Trim the excess implant lateral to the thyroid ala to make it flush with the cartilage (Fig. . In general. but pays dividends. The patient is noted to have an excellent voice interoperative when the implant is placed. The implant is now ready for placement. and skin. One must be patient to try a variety of maneuvers to insure the implant is ideally suited to improve the voice. The posterior inferior part of the implant should be advanced into the paraglottic space first. possibly precipitating an airway foreign body emergency. and the posterior 7 mm of the “slot” is removed from the implant (Fig. the voice has a distinctive “pressed” or “strained” quality. but the voice begins to fade 1–2 weeks post operatively. ■ In general. 22. the patient’s voice is poor within 6–8 h after surgery. Secure the implant to the thyroid cartilage with permanent sutures (4. if the voice sounds breathy. due to edema. 23-h observation ■ Pain management ■ Intravenous steroids at 8-hour intervals (Decadron. the patient’s voice should be rechecked. The implant may extrude through the skin incision or into the airway. Finally. but may be placed depending on the surgeon’s preference. 38. 38. In this instance.0 Prolene) around the inferior “strut” of cartilage (Fig. and close all layers including outer perichondrium. On the other hand.6 Postoperative Care and Complications Postoperative care after medialization includes: ■ Overnight. then 4 mg) ■ Elevation of the head of bed ■ A return to clinic is scheduled 2–4 weeks after surgery. then there is too much medialization anteriorly.250 Silastic Medialization Laryngoplasty 38 Fig. Place the implant through the window using two Adson’s forceps with teeth. as the edema resolves. In this case. In cases where a prolonged period elapses between the opening of the window and final placement of the implant.27).29  Securing the implant to the lower strut with two 4-0 Prolene sutures will facilitate easier placement of a large implant through the window. and the voice slightly strained to account for this edema. Once the implant is in place. 18. Another common mistake is excess medialization of the anterior commissure.28  Trimming of excess implant   “pressed” or “strained. Fig. and the implant should be removed and reduced by an appropriate amount.29). 38. 38. a drain is not necessary. Securing the implant with sutures significantly reduces the risk of this complication.

Luken ES. ■ The inner perichondrium of the thyroid cartilage must be divided to achieve unencumbered medialization. Ossoff RH (1993) Phonosurgery: Silastic medialization for unilateral vocal fold paralysis. Laryngoscope 96:726–731 Netterville JL. Silastic medialization and arytenoid adduction: the Vanderbilt experience. ■ The inferior muscular tubercle must be exposed to define the true lower border of the thyroid cartilage. Ann Otol Rhinol Laryngol 102:413–424 Wanamaker JR. this will aid in correctly identifying the horizontal plane of the true vocal fold. ■ The procedure is performed under local anesthesia with an indwelling flexible laryngoscope so that vocal fold position and the patient’s voice can be used as feedback to optimize results.  Chapter 38 Key Points Selected Bibliography ■ Silastic ML is a long-lasting treatment for symptomatic UVFP. A review of 116 phonosurgical procedures. Civantos FJ (1993) Ossoff RH. ■ The paraglottic space should not be undermined anteriorly so as to avoid violation of the ventricular mucosa. Netterville JL. Oper Tech Otolaryngol Head Neck Surg 4:207–217 251 . 1 2 3 Koufman JA (1986) Laryngoplasty for vocal cord medialization: an alternative to Teflon. Stone RE.

creates less edema.2 Disease Characteristics and Differential Diagnosis Gore-Tex® medialization laryngoplasty is an effective treatment option for many conditions that cause glottal imcompetence. Vocal fold bowing is most often due to age-related changes. 38. especially in the bowed. paralysis paresis. paresis or paralysis. 36.3 Surgical Indications and Contraindications The use of GORE-TEX® as a medialization laryngoplasty (ML) implant material was first reported by McCulloch and Hoffman in 1998 and its ease of handling has made it use in this procedure increasingly common. mobile vocal fold.to 3-mm cutting burr Kerrison rongeurs tray (1.1 Fundamental and Related Chapters Please see Chaps. A differential diagnosis of vocal fold bowing includes: ■ Deinnervation (vocal fold paralysis/paresis) ■ Age-related changes (presbylaryngis/vocal fold atrophy) ■ Tissue loss from ablative/destructive vocal fold procedures ■ Vocal fold scar ■ Sulcus vocalis deformity ■ Myopathic disease (rare) Unilateral GORE-TEX ML can be used in cases of symptomatic glottal insufficiency due to: ■ Unilateral vocal fold immobility.4 Surgical Equipment Needed equipment comprises: 39. Creating the GORE-TEX ribbon prior to patient contact allows the remainder of the patch to be reprocessed for future use. ■ ■ ■ ■ ■ ■ ■ ■ Drill with 2. as well as unilateral vocal fold paralysis. Jacksonville Fla. GORE-TEX ML can be used to correct mild to severe degrees of glottal insufficiency in cases of: ■ Presbylaryngis (vocal fold atrophy) ■ Bilateral vocal fold paresis ■ Select cases of Parkinson’s disease with vocal fold atrophy Contraindications for GORE-TEX ML include: ■ Previous history of radiation therapy to the larynx (relative) ■ Malignant disease overlying the laryngotracheal complex ■ Poor abduction of the contralateral vocal fold (due to airway concerns) ■ Presence of lesion on the vocal folds 39. For some. Bowing is a descriptive term.).4 mm in thickness) cut in strips 3. Many surgeons prefer GORE-TEX for ML. not a diagnostic one. or atrophy ■ Unilateral vocal fold scarring or soft tissue loss Bilaterally. Vocal fold “bowing” is a term referring to a scalloped contour to the vocal fold.to 3-mm-sized tips) Ruler Flexible laryngoscope C-mount camera with videocart/monitor Overdrape for laryngoscope (1010 drape) Local anesthetic (nasal and subcutaneous) GORE-TEX strip The implant itself is a GORE-TEX cardiovascular patch (0. 5. GORE-TEX ML provides an excellent option for surgical treatment of symptomatic patients with moderate to severe vocal fold atrophy/bowing or paresis (glottal gap > 1 mm).to 4-mm wide (as described by McCullough) and soaked in 50. it is faster than using Silastic. 40. 37.000 U of bacitracin in saline. or deinnervation of the vocal folds (complete paralysis. Often patients will be found to have a “bowed” appearance of the vocal fold with these conditions.Chapter 39 39 GORE-TEX® Medialization Laryngoplasty 39. or partial paresis). 39. Preformed GORE-TEX ribbon for thyroplasty (0. and therefore decreases the chance of overcorrecting the anterior commissure (particularly if performing a bilateral ML) and allows placement of the implants closer to the vocal process without limiting their abduction. This can be due to vocal fold atrophy. . for 41 further information.6-mm thickness) is also available (Medtronic ENT.

4. and posteriorly as needed. Fig. An inferiorly based cathedral arch–shaped outer perichondrial flap is elevated from the thyroid ala (Fig. Fig. A horizontal incision is placed in a skin crease at the level of the midthyroid cartilage. 39. anteriorly. A 2. The effect is observed on the video monitor .3). 9. The neck is then prepped and draped. pole hanging above the patient’s head.5 Surgical Procedure 1.254 GORE-TEX® Medialization Laryngoplasty   39. The pilot-hole technique allows the surgeon to be certain of the height of the vocal fold and avoid this. The most common technical error is placing the window too high. A small Kerrison rongeur is often helpful in removing residual cartilage (Fig. 38. This is easily observed on the monitor. The surgical region is liberally infiltrated with 1% lido- 39 Fig. 8.to 3-mm cutting burr is used to initiate this window placement (Fig. Fig. the inner perichondrium is incised along the inferior border with a scalpel. 39. Using that as a guide. 38.1). 10. The midline raphae are divided between the strap muscles with cautery.3). The visual feedback of the larynx is invaluable when performing this surgery. One-inch tape is used to secure the fiberoptic scope to a modified i. typically 3–5 cm in length (see Chap.v. A small pocket is formed using the Woodson elevator between the muscle and cartilage inferiorly. 15 ml is used.1).1  Inferiorly based perichondrial flap is raised Fig. 6. placed parallel to the lower border of the thyroid ala. An indwelling flexible laryngoscope with videomonitoring of the larynx is used during the entire surgical case. and the vocal fold is medialized with an elevator (note: there is no reason to elevate superiorly). 39. Preoperative intravenous Decadron (10 mg) is administered. 2. 39. 38. The laryngoplasty window location is determined by needle localization under direct vision with the flexible laryngoscope. from the hyoid down to the cricoid cartilage. An 18-g needle is used to bore gently only through the cartilage.2). Incising the perichondrium allows a more precise control of medialization (particularly adjacent to the vocal process) with less chance for medialization of ventricular mucosa. and then a 27-g needle or intravenous catheter is passed through the hole in the cartilage to precisely localize the level of the vocal fold (Fig. These windows are usually 3 × 6–12 mm in size. retention hooks are used to secure the flaps out of the way. 7.. 5. 38. and are created using a scalpel or a drill. Four percent lidocaine and oxymetazoline nasal spray is applied to the most patent nasal cavity. including a clear overdrape to allow manipulation of the scope during the case (see Chap. exposing the laryngeal cartilage (see Chap.2  Axial view of 27-g needle penetrating thyroid ala as a “pilot hole” caine with1:100. 39. Subplatysmal flaps are raised to the hyoid superiorly and the upper portion of the cricoid below.2). After creating the cartilage window. 39. 3. on the side of the intended surgery. a small rectangular window is then marked on the thyroid cartilage approximately 4–6 mm posterior to the midline of the thyroid cartilage and usually 2–3 mm superior to the inferior border of the thyroid ala.4).000 epinephrine. 38. Typically.

39. Fig. strained voice. since excessive anterior medialization will cause a harsh. due to edema. Care is taken to insert the ribbon into the window and when possible. the indwelling laryngoscopic image will show a medialized false vocal fold or bulging of the ventricular mucosa—sometimes a subtle finding. This helps maintain the implant’s position. Since the vocal folds are mobile. 11. the patient’s voice is poor within 6–8 h after surgery. In this instance. an implant projecting too far posteriorly could impinge on the arytenoid. The wound is closed in layers. Implant extrusion probably arises due to unrecognized tear in the ventricular mucosa and soiling of the wound with respiratory secretions. inferior. The implants should be fixed in place via replacement of the perichondrial flap. possibly precipitating an airway foreign body emergency.6). Implant extrusion or exposure is another potential complication. (1) Overcorrection anteriorly must be carefully avoided.3  Cutting burr is used to enlarge the pilot opening Fig. this can result in dyspnea with exertion. and thus restrict arytenoid motion. The implant may extrude through the skin incision or into the airway. In this case. The GORE-TEX implant is placed as a stacked strip using jeweler’s forceps (or middle ear alligator forceps). 39. 12. A common mistake includes medialization too far superiorly within the window.4  Further enlargement of the window using a Kerrison ron- geur to a final size of 3 × 6–12 mm 255 . It is important to note that the technique of bilateral GORE-TEX ML used for the treatment of bowed (but mobile) vocal folds is not the same as the standard ML for unilateral vocal fold paralysis. medial to the edge of the anterior. Another common mistake is excess medialization of the anterior commissure. The technique differs in important ways. the voice has a distinctive “pressed” or “strained” quality. and drains are rarely required. 23-hr observation Pain management Oral antibiotics for 7 days Intravenous steroids at 8-hour intervals (Decadron. the vocal folds are slightly overcorrected to compensate for intraoperative edema and implant compression (Fig.6 Postoperative Care and Complications Postoperative care after medialization includes: ■ ■ ■ ■ Overnight. and its shape can be easily adjusted for optimal vocal fold medialization (Fig.  Chapter 39 and acoustically evaluated using vocal feedback from the patient. 39. This error can easily occur during bilateral ML surgery. 39. 8 mg. In active individuals. then 4 mg) ■ Elevation of the head of bed ■ A return to clinic is scheduled 2–4 weeks after surgery. (2) The posterior extent of the implant must not contact the vocal process of the arytenoid cartilage. ■ In general. and posterior edges of the cartilage. 39. The implant is stabilized by suturing the outer perichondrial flap back into place using 4-0 nylon sutures.5). Once the optimum voice is obtained.

Vallicioni JM. Koufman JA (1998) Bilateral medialization laryngoplasty. Postma GN (1999) Bilateral medialization laryngoplasty. but readily reversible treatment for symptomatic glottal insufficiency. Blalock PD. 39. Postma GN (2004) Revision GORE-TEX medialization laryngoplasty. Laryngoscope 109:284–288 4 Zeitels SM (2000) New procedures for paralytic dysphonia: adduction arytenopexy. Hoffman HT. Triglea JM (1997) Medialization of paralysed vocal cord by expansive polytetrafluoroethylene implant (GORE-TEX). Goretex medialization laryngoplasty. Zanaret M (1999) Clinical experience with GORE-TEX for vocal cord medialization. ■ Overcorrection anteriorly must be carefully avoided (especially when bilateral ML is performed) to avoid a harsh. Gras R. Hoffman HT (1998) Medialization laryngoplasty with expanded polytetrafluoroethylene.6  Final contour of vocal fold after GORE-TEX is layered into the window (axial view) Selected Bibliography 1 McCulloch TM. Andrews BT.5  Folding in GORE-TEX ribbon through the thyroid cartilage window Fig. and can be performed bilaterally. McGuff HS (2002) Soft tissue response of the rabbit larynx to GORE-TEX implants.256 GORE-TEX® Medialization Laryngoplasty   Key Points ■ GORE-TEX laryngoplasty is a long-lasting. Ann Otolaryngol Chir Cervicofac 114:158–164 3 Giovanni A. Laryngoscope 110:1306–3111 6 Zeitels SM. Dailey SH (2003) Medialization laryngoplasty with GORE-TEX for voice restoration secondary to glottal incompetence: indications and observations. Vallicioni JM. Robert D. Grini MN. Oper Tech Otolaryngol Head Neck Surg 10:321–324 11 Cashman S. Ann Otol Rhinol Laryngol 112:180–184 7 Cohen JT. Surgical techniques and preliminary results. Otol Head Neck Surg 131:236–240 8 Koufman JA (1989) Surgical correction of dysphonia due to bowing of the vocal cords. as this may restrict arytenoid motion and lead to airway difficulties. Ann Otol Rhinol Laryngol 107:427–432 2 Giovanni A. Laryngoscope 108:1429–1434 10 Koufman JA. ■ The procedure is performed under local anesthesia. Gras R. 39. Karnell MP (2000) Arytenoid adduction combined with GORE-TEX medialization thyroplasty. Ann Otol Rhinol Laryngol 111:977–982 . and cricothyroid subluxation. Bates DD. Simpson CB. Mauri M. pressed voice. ■ The posterior extent of the GORE-TEX implant must not contact the vocal process of the arytenoid cartilage. with an indwelling flexible laryngoscope so that vocal fold position and the patient’s voice can be used as feedback to optimize results. Otolaryngol Clin North Am 33:841–854 5 McCulloch TM. 39 Fig. Ann Otol Rhinol Laryngol 98:41–45 9 Postma GN.

Unlike medialization laryngoplasty.Chapter 40 40 Arytenoid Adduction 40. 36.2 Fundamentals of Arytenoid Adduction Arytenoid adduction (AA) is used in the treatment of glottal insufficiency. AA acts through direct traction on the arytenoid cartilage at the muscular process.. AA is an important adjunct in selected cases of vocal fold paralysis.5 Surgical Procedure Arytenoid adduction is usually performed in conjunction with the ML procedures (see Chaps. 40. AA should be considered in addition to ML. 5. A maximal phonation time (MPT) of less than 5 seconds has also been identified as a predictor of the need for AA in cases of vocal fold paralysis. . After the midline raphae are divided between the strap muscles. Videostroboscopy often provides valuable information about vocal process contact. “GORE-TEX® Medialization Laryngoplasty”). 2. certain additional steps that are needed to help achieve adequate exposure of the posterior laryngeal framework and arytenoid complex are included for clarity. 37. however. approximately 1 cm of the medial aspect of the sternohyoid muscle is sectioned below its insertion onto the hyoid. 39. 1. 38. To prevent unnecessary duplication. 38. and those with vocal folds at different levels. The outer perichondrium of the thyroid cartilage is then incised with a 15 blade. g.1 Fundamental and Related Chapters Please see Chaps. and therefore is useful preoperatively in assessing whether a patient may need an AA. 40. with an indwelling flexible laryngoscope. the key portions of the ML up to the point of the AA are not illustrated in the chapter. “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis” and 39. The procedure is performed under local anesthesia. The step is necessary to improve posterior exposure of the laryngeal framework for AA (Fig. including the inferior border of the thyroid ala. and a posteriorly based flap is raised with a cottle or freer elevator.1). and 41 for further information. 40. 39) Kerrison rongeurs Sewell retractors 4-0 monofilament permanent suture (Prolene or Tevdek) on a double-armed needle ■ Straight drill bit (e.4 Surgical Equipment Surgical equipment needed comprises: ■ ■ ■ ■ Medialization instruments (see Chap. mimicking the action of the lateral cricoarytenoid muscle. 1-mm wire-passing drill bit) ■ Kitner dissector (peanut) 40.3 Surgical Indications and Contraindications Arytenoid adduction for unilateral vocal fold paralysis is indicated in the following cases: ■ Large posterior glottic gap ■ Lateralized vocal fold during phonation ■ Vertical height differences (generally the paralyzed vocal fold is superiorly located) ■ Severely foreshortened vocal fold ■ Inability to achieve good voice intraoperatively with ML alone Contraindications include: ■ Intact vocal fold mobility ■ Vocal fold paralysis with the chance of recovery of motion (“early” paralysis) ■ Limited abduction of contralateral vocal fold 40. shortened immobile vocal fold. The physiologic effects of AA include the following: ■ ■ ■ ■ Lowers the position of the vocal process Medializes and stabilizes the vocal process Lengthens the vocal fold Rotates the arytenoid cartilage In patients with vocal fold paralysis who have a lack of vocal process contact during phonation (large posterior gap). vocal fold height and length.

preliminary measurements are taken for the ML portion of the case. A cottle or freer elevator is used to achieve this (Fig. although the dimensions vary. and the thyroid ala is gently retracted laterally. and opened as previously indicated in Chap.4).2). The incision is continued to the level of the superior cornu above and the inferior cornu below (Fig. In general. 7. . 5. additional muscular or perichondrial attachments along the inferior and superior cornu must be divided to facilitate lateral alar retraction (Fig. 6. A surgical plane is then developed in the paraglottic space (just superficial to the TA fascia) in all directions around the window except anteriorly.3). 38. before proceeding to the arytenoid exposure (see Chap. b) Separation of the cricothyroid joint Another way to gain exposure is by separation of the cricothyroid joint along with lateral thyroid ala retraction. A small dissection scissor (tenotomy) is used to separate the cricothyroid joint. The cartilage is removed until the muscular process of the arytenoid is palpable and the anterior extension of the pyriform sinus can be visualized (Fig. so that there is one continuous surgical plane. It is important not to allow the anterior and posterior windows to “connect.15 for details).2  A posteriorly based flap is separating the mus- cle away from the posterior cartilaginous border. The size of the window ranges from 10 to 15 mm in height and extends approximately 10 mm anteriorly. 40. 4. A skin hook is placed on the posterior border of the cartilage to aid in retraction. 40.1  Partial division of sternohyoid muscle 1 cm below its inser- tion   chondrium is incised with a 15 blade along the posterior border of the cartilage to prevent elevation of the inner perichondrium. The outer peri- 40 Fig. 40. Skin hook retractors are placed. using a 2-mm Kerrison rongeur.5). 38. 40. 40. Often. Figs. The pyriform sinus mucosa must be identified and retracted posteriorly before the muscular process of the arytenoid is identified.258 Arytenoid Adduction 3. 38. A window is outlined in the thyroid cartilage. The surgical plane of the medialization window (paraglottic space) should then be connected to the posterior laryngeal dissection.7–38. Access to the arytenoid can then be achieved with one of two methods: a) Creation of a window in the posterior thyroid ala A window of cartilage is removed from the posterior border of the thyroid cartilage.” as this will likely lead to framework instability. Great care must be taken with this step Fig. The posterior aspect of this window should be located on the same level of the ML window. 40. The outer perichondrial flap is then extended all the way to the posterior border of the thyroid ala.

The mucosa is grasped and dissected posteriorly. Once the implant is created. By grasping the muscular process with a toothed forceps. taking great care not to inadvertently catch any tissue with the needle tips. The two ends of the suture are then clamped with hemostats. 11. The sutures are gently pulled anteriorly to adduct the Fig. 40. 40. 40. To aid in its identification. The muscular process is small (about the size of a grain of rice). at this time the effects of medialization.12). taking care to keep the AA suture lines deep to the implant (Fig. 40. 40. using the previously mentioned depth gauge instrument are tested both in isolation. and the effect on the voice is tested by having the patient count from 1 to 10. and with the addition of tension of the AA suture.  Chapter 40 Fig. In addition. 40. a 4-0 monofilament suture (double armed) is passed through the lateral edge of the muscular process in a figure of eight fashion (Fig. 13.6).13). In addition. if the cricothyroid joint is separated as in step 6b. the cricothyroid joint can be divided for poste- rior exposure arytenoid. 12. using blunt dissection with a Kitner (Fig. In order to obtain a secure purchase on the muscular process.4  Posterior “cookie-bite” window is created with a Kerrison rongeur Fig. The pyriform mucosa can be seen extending anteriorly onto the posterior cricoarytenoid (PCA) muscle. 40. The other needle is passed underneath the inferior strut and is secured anteriorly through the anterior cricothyroid membrane (Fig. 40.7). and rotating the arytenoid (anteriorly). The muscular process can then be identified using a number of landmarks.3  The paraglottic space is connected between the posterior cartilage border and the ML window to avoid perforation of this delicate mucosa. One of the needles is passed through the cartilage anterior to the medialization window. The pyriform can then be shielded under a Sewell retractor (Fig.14). the needles are passes with the dull end as the leading edge (Fig. one should be able to easily rotate the arytenoid into a medial position while confirming this with the endolaryngeal image on the monitor (Fig. 40. using a 1-mm wire-passing drill bit if the cartilage is calcified (Fig. 9. which results in distension and easy identification of the pyriform mucosa. then this can be used as a nearby landmark. as the muscular process can be reliably found within 1 cm above this point. Both needles are brought through the dissected paraglottic space into the medialization window.5  Alternately. Generally. 40. The muscular process is usually at the same vertical height of the vocal fold and found by tracing the fibers of the PCA muscle anterior/superiorly to its tendinous insertion (Fig. 40.10). 8. 40.8). 10. the patient is asked to blow against pursed lips (“blow out the birthday candles”).11). which could adversely affect the vector of pull for the AA stitch. it is placed through the window. 259 .9). but can be palpated.

9  Axial representation of manual traction on the muscular process to demonstrate adduction of the vocal fold . 40. 40.260 Arytenoid Adduction   Fig.7  Axial representation of larynx after posterior pyriform mu- cosa dissection/protection with Sewell retractor Fig. 40.6  The pyriform mucosa is dissected posteriorly using a Kitner 40 Fig. 40.10  A 4-0 double-armed Prolene suture is passed through the muscular process in a figure of eight fashion Fig. 40.8  Muscular process of the arytenoid is identified Fig.

40. 40. 40.15  Final tying of a surgeon’s knot over the thyroid ala Fig.13  After successful passage of both arms of the AA suture through the midline Fig.14  Axial representation of AA sutures deep to ML implant 261 .12  A 1-mm wire-passing drill bit is used to create an anterior passage for one arm of the AA suture near the midline Fig.  Fig. 40. 40.11  Passage of the suture through the ML window Chapter 40 Fig.

Otol Head Neck Surg 119:634–642 Woodson GE. Arytenoid adduction and medialization laryngoplasty (2000) Otolaryngol Clin N Am 33:817–839 Noordzij JP. the AA suture tension is adjusted and the knot is secured over the anterior thyroid cartilage. The sutures lie deep to the medialization implant. The pyriform mucosa must be dissected off the muscular process of the arytenoid to allow proper exposure of this structure. only a small amount of tension is required for this (Fig. the patient’s voice is poor within 6–8 hours after surgery. Hoffman HT. Key Points ■ Arytenoid adduction (AA) is a framework surgery where the pull of the LCA muscle is recreated to achieve vocal fold repositioning. Laryngoscope 110:1306–1311 Woo P. although it is quite uncommon. Perrault DF. Additional corticosteroids may be warranted in patients undergoing ML and AA. and the patient should be retested for air leakage. The additional retraction and dissection necessary for exposure and manipulation of the arytenoid complex results in increased paraglottic and arytenoid edema post operatively. 40. The physiologic effects of AA include the following: ■ Lowers the position of the vocal process ■ Medializes and stabilizes the vocal process ■ ■ ■ ■ ■ ■ Lengthens the vocal fold ■ Rotates the arytenoid cartilage AA is used as an adjuvant surgical treatment along with ML in cases of vocal fold paralysis where one of the following occurs: ■ Posterior glottic gap/lateralized vocal fold during phonation ■ Vertical height differences between vocal folds (generally the paralyzed vocal fold is superiorly located) ■ Severely foreshortened vocal fold ■ Inability to achieve good voice intraoperatively with ML alone AA requires a posterior dissection technique separate from ML. then the field can be irrigated and the patient instructed to perform the Valsalva maneuver. The needles from the AA sutures should be passed through the paraglottic space carefully (dull end as the leading edge) to avoid picking up soft tissue. due to edema. then 4 mg) ■ Elevation of the head of bed ■ A return to clinic is scheduled 2–4 weeks after surgery ■ In general. where either a posterior window in created in the thyroid ala. Bryant GL. Careful handling of the pyriform mucosa and protection of the mucosa with a retractor should prevent this complication. Sternohyoid muscle is re-attached.262 Arytenoid Adduction   14. 23-hours observation ■ Pain management ■ Intravenous corticosteroids at 8-hour intervals (Decadron. Pharyngocutaneous fistula is a possible complication with AA. therefore. The tension needed on this suture is actually minimal in most cases. Arch Otolaryngol 104:555–558 Miller FR. which may change the vector of pull. A double-armed needle is secured at the muscular process of the arytenoid and passed anteriorly near the midline of the thyroid ala to recreate the pull of the LCA muscle. Andrews BT et al (2000) Arytenoid adduction combined with Gore-Tex medialization thyroplasty. the surgeon should err on the side of light tension on the AA suture. Netterville JL (1999) Arytenoid adduction in vocal fold paralysis. In general. Only mild–moderate tension is required on the AA suture to achieve desirable arytenoid positioning. care should encompass: 40 ■ Overnight. then the pyriform mucosa should be repaired with absorbable suture. One should consider whether it is prodent to proceed with the ML and/or AA at this point. Finally. Ann Otol Rhinol Laryngol 109:360–364 Isshiki G (1978) Arytenoid adduction for unilateral vocal cord paralysis. Excessive tension on the AA suture can create over-rotation of the arytenoid and worsening of the voice. Woo P (1998) Biomechanics of combined arytenoids adduction and medialization laryngoplasty in an ex vivo canine model. If an injury to the mucosa is suspected. Drain is placed at the surgeons discretion. which is more common with framework surgery that involves AA. ■ An additional corticosteroid taper may be warranted on discharge from the hospital. 15. If air bubbles occur during this maneuver. or the cricothyroid joint is divided to allow outward retraction of the posterior thyroid ala. again assessing the voice. Picerno R. 40. Complications and common surgical errors include laryngeal edema with airway compromise. 8 mg. Wound is closed in layers. Yeung D et al (2000) Arytenoid adduction: controlling vertical position.15).6 ■ Postoperative Care and Complications Postoperatively. Selected Bibliography 1 2 3 4 5 6 McCulloch TM. Oper Tech Otolaryngol Head Neck Surg 10:36–41 .

This can be done with arytenoid adduction also. thus.2 Disease Characteristics and Differential Diagnosis Cricothyroid subluxation was developed by Steve Zeitels to address the problems of a shortened vocal fold frequently seen in unilateral vocal fold paralysis. Complete skeletonization of the inferior cornu of the thyroid cartilage should be performed using electric cautery or cold steel instrumentation. 38. 2. 4. Cricothyroid subluxation is done as a planned procedure in conjunction with medialization laryngoplasty. “Silastic Medialization Laryngoplasty for ® Unilateral Vocal Fold Paralysis” and 39. as seen on endoscopy during medialization laryngoplasty after adequate implant positioning (intraoperative) Contraindications include present or impending laryngeal fracture of thyroid ala from the associated medialization laryngoplasty procedure. Care should be taken during this step not to fracture the inferior cornu. 5. and 40 for further information.4 Surgical Equipment Surgical equipment needed for cricothyroid subluxation comprises: ■ See “Surgical Equipment” sections in Chaps. The concept of the procedure is to lengthen the vocal fold by increasing the distance from the cricoarytenoid joint (cricoid) to the anterior commissure (thyroid cartilage) by subluxating the cricothyroid joint on the side of the unilateral vocal fold paralysis. lateral aspect of the cricoid cartilage to allow the tips of the scissors to be positioned on either side of the cricothyroid joint (Fig. Separation of the cricothyroid joint This can be done using a scissors or a cottle elevator. but is typically used with medialization laryngoplasty. Further dissection than what is typically performed for a medialization laryngoplasty approach alone is required. 41. it is wise to keep dissection close to the inferior cornu of the thyroid cartilage to avoid deinnervation of the immobile but partially reinnervated vocal fold. This will involve removal of the cricothyroid muscle immediately anterior and inferior to the inferior cornu and release of the inferior constrictor muscle off the posterior aspect of the inferior cornu. This results in a rotation of the anterior commissure away from the midline in a direction contralateral to the side of the unilateral vocal fold paralysis. “GORE-TEX Medialization Laryngoplasty. 40. Cricothyroid subluxation is an adjunct procedure to medialization laryngoplasty. 41. Soft tissue overlying the superior and inferior aspect of the cricoid cartilage at the midline should be removed. 37. 41.3 Surgical Indications and Contraindications Indications for cricothyroid subluxation involve: ■ Unilateral vocal fold paralysis associated with vocal fold shortening with resultant glottal insufficiency and reduced pitch range (preoperative assessment) ■ Poor pitch range and/or significantly shortened vocal fold.1 Fundamental and Related Chapters Please see Chaps.” ■ Right-angle clamp (vascular clamp) ■ 2-0 Prolene suture with narrow diameter. care should be taken to insure the inferior cornu of the thyroid cartilage is completely free of any soft tissue attachments. semicircle needle ■ Surgical headlight 41. The use of scissors to separate the cricothyroid joint is most likely less traumatic to the inferior cornu.1). or done immediately after a medialization laryngoplasty due to a restricted pitch range despite a well-positioned medialization laryngoplasty implant. The only other procedure that can lengthen a paralyzed vocal fold is arytenoid adduction (see Chap. . The blades of the scissors are placed up against the posterior. 36. Cricothyroid subluxation addresses the commonly seen problem of a shortened vocal fold associated with unilateral vocal fold paralysis. After separation of the cricothyroid joint. 5.Chapter 41 41 Cricothyroid Subluxation 41. 41. 39. 3.5 Surgical Procedure 1. “Arytenoid Adduction”). The recurrent laryngeal nerve is at risk in this region. 38.

4). The voice and vocal fold length (endoscopically) should be evaluated as tension is applied to the knot (Fig. This anterior subluxation of the inferior. 41. A 2-0 Prolene suture is then passed around the neck of the inferior cornu. or by using a right-angled clamp (vascular clamp) to pass the free end of the suture around the neck of the inferior cornu.6 Postoperative Care and Complications Postoperative care is identical to that of medialization laryngoplasty.1  Separation of cricothyroid joint with scissors 6. ■ Fracture of the main aspect of the thyroid cartilage ala ■ If fractures of the thyroid cartilage ala occur. This can be done with a relatively narrow diameter. 44. 38. Care should be taken not to fracture the cricoid cartilage and to pass the needle in a submucosal plane under the anterior aspect of the cricoid ring (Fig. cornu of the thyroid cartilage results in vocal fold lengthening and an expanded pitch range (Fig. Fig. “Repair of Laryngeal Fracture”). only moderate tension is required to position the inferior cornu into an anterior.264 Cricothyroid Subluxation   41 Fig. semicircle needle. 41.2  Placement of cricothyroid subluxation suture submucosally at the midline of the anterior cricoid cartilage 41.2). Once an optimal tension is found (predominantly by perceptual voice assessment). The suture should be positioned as superior as possible on the neck of the inferior cornu and then tied with relatively equal lengths of the suture on both sides of the knot. . 41. then all fractures should be reduced and secured with either suture or plating and the cricothyroid subluxation procedure should be aborted (see Chap.3). 41. The arm of the suture with the needle is then passed underneath the cricoid cartilage anteriorly at the midline. a suture can be placed through the thyroid cartilage near the fracture line and then be used in a similar fashion as described above to complete the cricothyroid subluxation. 7. Typically. The reader is referred to Chaps. 41. Complications involve: ■ Fracture of the inferior cornu ■ To remedy this complication. 8. the suture is secured with several surgical knots. “GORE-TEX® Medialization Laryngoplasty” for details. The free end of the suture tied at the inferior cornu is then tied to the end of the suture passed underneath the anterior cricoid cartilage. “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis” and 39. subluxated position.

and cricothyroid subluxation. Desloge RB. Hillman RE. ■ Care should be taken not to fracture the inferior cornu of the thyroid cartilage during the procedure. 41. 41. ■ Excessive tension applied to the suture securing the cricothyroid subluxation position may worsen voice quality. thus lengthening the vocal fold. Otolaryngol Clin North Am 33:841–854 Zeitels SM.4  Axial view of vocal fold position before and after cricothyroid subluxation .  Chapter 41 265 Key Points ■ Cricothyroid subluxation is an adjunctive procedure to medialization laryngoplasty which lengthens the shortened vocal fold associated with unilateral vocal fold paralysis. Bunting GA (1999) Cricothyroid subluxation: a new innovation for enhancing the voice with laryngoplastic phonosurgery. ■ Cricothyroid subluxation rotates the anterior commissure attachment of the vocal fold away from the cricoarytenoid joint. Ann Otol Rhinol Laryngol 108:1126–1131 Fig.3  Suture fixation of cricothyroid subluxation Fig. Bibliography 1 2 Zeitels SM (2000) New procedures for paralytic dysphonia: adduction arytenopexy. Goretex medialization laryngoplasty.

Occasionally.. the patient’s airway is compromised. 42.1) ■ Desire for complete removal of granuloma Relative contraindications although these are not absolute contraindications to this approach. 38. especially if the granuloma is subglottic. fairly well-circumscribed mass in the paraglottic space. In most cases. 42. 24) Fig. The granuloma may grow inferiorly resulting in a subglottic bulge as well. It is helpful to obtain a CT scan of the neck with contrast to assess the location of the Teflon and extent of granuloma formation. In this way. Videostroboscopy is quite consistent in these patients. superficial Teflon granulomas can be distinguished from more extensive granulomas. and/or the true vocal fold.Chapter 42 42 Translaryngeal Removal of Teflon Granuloma 42. which guides the surgeon in choosing the appropriate approach (endoscopic. the infiltration of the granuloma into the lamina propria and/or mucosa.1 Fundamental and Related Chapters Please see Chaps. include the following: ■ Extensive granuloma infiltration along the medial edge of the vocal fold (vocal ligament involvement) (Fig. Anecdotal evidence suggests that subsequent laryngeal trauma (i. 42. 24. 42. intubation) may contribute to growth of the granuloma. 42. Typical CT appearance is a brightly enhancing. ventricular mucosa. nonvibratory vocal fold mass. and no significant clinical complications are noted.3 Surgical Indications and Contraindications Indications include: ■ Symptomatic Teflon granuloma in a patient with UVFP in which there is sparing of the free edge of the vocal fold (vocal ligament/mucosa appear uninvolved with granuloma) (Fig.2) ■ Minimally symptomatic patient ■ These clinical settings may be better suited for endoscopic treatment (see Chap. revealing a stiff. more commonly. an inflammatory response to the Teflon occurs.1  Coronal section of larynx with Teflon granuloma sparing the vocal fold mucosa and vocal ligament (arrow) . there is a risk of clinically evident expansile granuloma formation in these patients if long-term follow up (10 years or more) is used. 36. Glottic incompetence is commonly present. and 40 for further information. Often this occurs years after the initial injection. after a prolonged period of good voice. However.2 Disease Characteristics and Differential Diagnosis In every Teflon injection. e. 37. Teflon granuloma is typically a submucosal smooth mass that presents as a bulge in the false vocal cord. see Chap. secondary to the mass lesion. This is due to either a mass effect (stretching of vocal fold mucosa with dampening of wave) or. 24 “Endoscopic Management of Teflon Granuloma”) versus the external approach described in this chapter). the inflammatory response remains localized.

Jamison scissors. Dissection of the granuloma can now proceed (Fig. optional) 42. defects in the ventricular or subglottic mucosa may be created during dissection. with its overlying fat.6). Subplatysmal flaps are raised to the hyoid superiorly and the upper portion of the cricoid below. 3. 42 Fig. “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis” and 40.to 3-mm-sized tips) ■ Medium-grade Silastic block (Medtronic ENT) ■ 4-0 monofilament suture. allows videomonitoring of the larynx during the entire surgical case. while middle ear instruments (no. 8. The visual feedback of the larynx is invaluable when performing this surgery. 2 House knife) can be used for dissection with surgical loops. a horizontal incision is placed in a skin crease at the level of the cricothyroid membrane extending past the midline. A variety of dissection tools may be employed. 42. 42. from the hyoid down to the cricoid cartilage.4). as their integrity has proven an important prognostic indicator of postoperative voice quality. In contrast.000 epinephrine. Jacksonville. Care is taken to preserve the vocal ligament/conus elasticus and lamina propria. 5. such that complete removal may result in an “empty” paraglottic space. A single-prong hook is placed under the thyroid notch. The midline raphae is divided between the strap muscles with cautery. Fla. The surgical region is liberally infiltrated with 1% lido- 2. 42.4 Surgical Equipment Equipment includes: ■ Netterville medialization tray (Medtronic ENT. caine with1:100. The granuloma often encases most of the paraglottic laryngeal musculature (thyroarytenoid/vocalis. lateral cricoarytenoid). double-armed needle ■ Ruler (15-mm section of plastic ruler at tip of hemostat) ■ Flexible laryngoscope ■ C-mount camera with videocart/monitor ■ Overdrape for laryngoscope (1010) ■ Local anesthetic (nasal and subcutaneous) ■ High-power surgical loops (optional) ■ Middle ear instrument tray (especially a no. Four percent lidocaine and oxymetazoline nasal spray is applied to the most patent nasal cavity. using a 15 blade or a powered sagittal saw (Fig. A randomly pedicled flap is raised that is composed of the superficial layer of the deep cervical fascia covering the strap muscles. on the side of the intended surgery. “Arytenoid Adduction” before attempting this technique. 42. 2 House knife.3). The thyroid lamina is retracted laterally with hooks allowing for wide exposure of the paraglottic space (Fig.or 3-mm cutting burr ■ Kerrison rongeurs tray (1. These mucosal defects should not compromise the end result. Identification of the correct plane of dissection between the granuloma and normal paraglottic tissue is frequently difficult. 6. Typically. A vertical parasagittal laryngotomy is performed 5–7 mm posterior to the midline on the ipsilateral side. 7. retention hooks are used to secure the flaps out of the way. exposing the thyroid lamina on the involved side. Once reflected. in a cervical skin crease.268 Translaryngeal Removal of Teflon Granuloma   1. surgical loops may be helpful during this portion of the case. After sterile prep of the neck and flexible laryngoscope placement. Not infrequently.5). This is a relative contraindication for translaryngeal removal 42. bringing the entire hemilaryngeal cartilage into view. Placement of an indwelling flexible laryngoscope. typically 7–8 cm in length. and the larynx is retracted to the side opposite the paralysis.5 Surgical Procedure This advanced framework technique requires experience with the techniques of ML and AA.) ■ Drill with 2. the flap is covered with moist gauze. Freer. 38. The surgeon should be well versed in the techniques of Chaps. 42. 9. and Woodson elevators are useful for the gross dissection. This flap is posteriorly based and has a wide base lateral to the omohyoid muscle (Fig. 20–25 ml is used. . The flap should be raised with cold dissection and bipolar cautery to avoid thermal damage. The mucosa of the ventricle should be avoid anteriorly where is may be adherent to the granuloma. removal of the vocal fold mucosa and/or vocal ligament should be avoided as this has a detrimental effect on the voice result.2  Coronal section of the larynx with Teflon granuloma involv- ing the free edge of the vocal fold (arrow). 4.

42. the laryngotomy is repaired Fig.7  After removal of the granuloma.5  Axial view of parasagittal laryngofissure with 2-0 Prolene sutures. 42.  Chapter 42 Fig. 42.6  Dissection of granuloma from the paraglottic space Fig. 42. and windows are made for medialization laryngoplasty and arytenoid adduction 269 .3  Posteriorly based fat flap is raised Fig.4  Vertical laryngotomy is performed 5–7 mm off the midline for exposure of the paraglottic space Fig. 42.

40).9). 42. similar to the technique of arytenoid adduction described in (Chap. Windows are made for medialization and arytenoid adduction (both posterior and anteriorly) as described in Chaps. The voice should be tested as the flap is manipulated within the paraglottic space in a variety of configurations. 38 and 40 (Fig. The effects of medialization and tension on the arytenoid adduction suture should be used to gauge the best vocal outcome (Fig. while a depth gauge is used to medialize the vocal fold. 42. 13. A Cottonoid is then placed within the thyroplasty window to provide cushioning to the paraglottic space (approximating the effect that the fat flap will provide). 42. The fat flap is tucked deep to the strap muscles and advanced into paraglottic space via the posterior thyroid cartilage window (Fig.8).10  Final configuration of the fat flap within the paraglottic space. 42. An arytenoid adduction suture (4-0 Prolene. 12. secured. 11.7). The flap’s apex should be brought as anteriorly as possible to reconstitute the true vocal fold at the anterior commissure. A Cottonoid is placed in the paraglottic space for cushioning Fig. doublearmed) is placed through the muscular process. 42.8  The patient’s voice is tested while simultaneously putting traction on the arytenoid adduction suture and depressing the depth gauge within the thyroplasty window.270 42 Translaryngeal Removal of Teflon Granuloma   Fig. and the two ends are passed through separate holes in the anterior (midline) of the thyroid lamina. 42. The lateral laryngotomy is reduced and secured with two Fig. The flap serves the important function of providing bulk to the paraglottic tissues.9  Axial view of fat flap advanced into the paraglottic space 10. which is vital to the success of the primary surgery and any additional augmentative procedures attempted in . Note sutures securing the flap both anteriorly and inferiorly to three 2-0 Prolene sutures.

layered closure over a closed suction drain is then performed. and/or extrusion are more likely in the setting of Teflon granuloma removal due to the higher risk of mucosal violation within the endolarynx. Chang S et al (1998) Lateral laryngotomy for the removal of Teflon granuloma.6 Postoperative Care and Complications complication is encountered months after surgery. In addition. Postoperative care comprises: ■ Overnight. however. The patient is asked to phonate. Ann Otol Rhinol Laryngol 115:837–845 271 .10). Wound irrigation. Ann Otol Rhinol Laryngol 107:735–744 Conoyer MJ. The vocal fold should be slightly overmedialized to account for inevitable fat flap atrophy. AA) can be employed at the same time to achieve the best vocal result.or 4-0 Prolene sutures through 1-mm drill bit holes as needed (Fig. The fat flap may slowly atrophy over several month-years. Coleman JR. to avoid complications of foreign body contamination. 15. 42. while tension on the arytenoid adduction suture is adjusted. Netterville. including lipoinjection and/or revision Silastic medialization. It is important to emphasize that a number of possible combinations using one or all of the three techniques (fat flap. Additional procedures can be attempted when this happens. The flap is secured to the thyroid and cricoid cartilages using 3. ■ The pedicled fat flap may atrophy over time. infection. Medialization should be deferred until a later date if there is a mucosal tear. Medialization measurements are obtained by displacing the posterior/mid aspect of the window using a depth gauge. then a Silastic implant may be placed at this time. ■ The surgeon should master the techniques of ML and AA before attempting this procedure.  Chapter 42 the future. 8 mg. 38 “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis” and 40. Chen A et al (2006) Pedicled fat flap reconstruction of the atrophic or “empty” paraglottic space after resection of Teflon granuloma or oversized implant. such as lipoinjection or revision Silastic ML. implant exposure. Complications include those seen in medialization laryngoplasty and arytenoid adduction (Chaps. This takes a fair amount of trial and error to optimize the vocal results. until optimal voice result (or vocal fold positioning in the midline position) is obtained. The suture is secured over the thyroid lamina near the midline. necessitating additional procedures to restore glottal competence. 23-hour observation ■ Pain management ■ Intravenous steroids at 8-hour intervals (Decadron. ML. Key Points ■ Laryngotomy is the only surgical approach that allows for complete removal of granuloma in most cases. resulting in glottic insufficiency eventually. “Arytenoid Adduction”). However. then 4 mg) ■ Elevation of the head of bed ■ A return to clinic is scheduled 2–4 weeks after surgery. 14. if no mucosal defect is present. ■ The ideal case for laryngotomy/fat flap reconstruction is symptomatic Teflon granuloma in a patient with UVFP in which there is sparing of the free edge of the vocal fold (vocal ligament/mucosa appear uninvolved with granuloma). the most common Selected Bibliography 1 2 Netterville JL. 42.

43. most often in the fifth or sixth decade of life. and acts as a reservoir. The normal saccule arises as a diverticulum originating at the anterior portion of the ventricle. A laryngocele represents an abnormal dilation or herniation of the saccule. into the neck (Fig. a laryngocele communicates with the lumen of the larynx and is distended with air. In contrast to a saccular cyst (Chap. For this reason.2). as described in this chapter. “Endoscopic Excision of Saccular Cyst”). These lesions are usually removed externally through a transthyroid approach. 25. This constriction at the TH membrane gives combined laryngoceles their characteristic “dumbbell” appearance (Fig. They originate in the anterior ventricular membrane. This creates are characteristic bulge in the false vocal fold and aryepiglottic fold. and extend posteriorly–superiorly into the paraglottic space (Fig. Laryngoceles occur predominantly in males. This “valve-like” effect can occur from inflammatory or neoplastic processes in the ventricle or false vocal fold. but extend through the thyrohyoid (TH) membrane. 43.3). Fig. 36. similar to the treatment of a saccular cyst (see Chap. and extending upward into the supraglottis. 25). 25. The lesions can usually be managed endoscopically.1). allowing for entry of air into the saccule. and 37 for further information.Chapter 43 Excision of Combined Laryngocele 43.1 Fundamental and Related Chapters Please see Chaps. neoplastic causes should be ruled out.2 Disease Characteristics and Differential Diagnosis 43.1  Coronal representation of internal laryngocele . expressing secretions onto the vocal folds due to the squeezing action of the surrounding supraglottic musculature. 43. A foramen in the TH membrane where the superior laryngeal nerve (internal branch) and vessels enter provides the pathway for extension of the laryngocele into the neck.1 Anatomy and Classification 43 2. Internal laryngoceles are contained entirely within the endolarynx. The saccule contains numerous mucus-secreting glands. 43. Laryngoceles are categorized based on anatomic extension of the lesion: 1. 43. but preventing its egress. It is sandwiched between the false vocal fold medially and the aryepiglotticus muscle and thyroid cartilage laterally.2. Any factor that increases intralaryngeal pressure can lead to development of a laryngocele: ■ ■ ■ ■ Coughing Straining Playing wind instruments Glass blowing Another etiology in the development of laryngoceles may be air trapping due to ball-valve closure of the neck of the saccule. Combined (external and internal) laryngoceles originate in the endolarynx as with internal laryngoceles. especially in high-risk patients (tobacco/alcohol users).

insuring intact sensation (via functional endoscopic evaluation of swallowing and sensory testing) on the operated side before proceeding with the contralateral laryngocele.2  Coronal representation of combined laryngocele 43.. Bilateral injury to the internal branch of the superior laryngeal nerve can lead to aspiration. and to delineate the internal content of the mass. If a neck mass is present it is typically located at the superior/lateral aspect of the thyroid cartilage. neuroendocrine/neural tumors) A CT scan should be obtained to define the extent of the lesion (internal versus combined).274 Excision of Combined Laryngocele   Fig. The neck mass often appears only intermittently. 43. if malignancy is suspected. Differential diagnosis of a laryngocele includes: ■ ■ ■ ■ Saccular cyst Mucous retention cyst Hemangioma Laryngeal neoplasm (e.3  CT scan depicting combined laryngocele. although cough or globus sensation are also seen. A relative indication is cosmetic concerns (especially in large combined laryngoceles in horn players). 43. with characteris- tic dumbbell appearance 43 Fig. When symptoms arise. Office laryngoscopy will typically reveal a submucosal fullness or bulge in the false vocal fold/ aryepiglottic fold region. Patients with combined laryngoceles may present with a neck mass. g. and is soft and easily compressible. while saccular cysts will contain mucous (gray/soft tissue signal). The surgeon may wish to “stage” their resections. squamous cell carcinoma. .3 Surgical Indications and Contraindications Absolute indications are symptomatic combined laryngocele (hoarseness/airway compromise) and suspicion of malig­ nancy. However.2 Clinical Presentation and Differential Diagnosis Most laryngoceles are asymptomatic and may be incidental findings on radiographic studies of the neck.2. hoarseness is the most common clinical presentation. and may be reproduced by asking the patient to valsalva. Contraindications include asymptomatic lesions found incidentally/radiographically Caution should be exercised in the rare case of bilateral combined laryngoceles. Laryngoceles will contain air (black). A biopsy is rarely indicated due to the unique nature of the lesion. a ductal lavage/biopsy may be indicated in the anterior ventricular region. 43.

to aid in reapproximation of each muscle near the end of the case (Fig. The laryngocele is retracted gently as blunt dissection is used to define the external (extralarnygeal) portion of the laryngocele capsule (Fig. 43.4). in a skin crease. 10. and divided superiorly near their origin.6). The external component of the laryngocele is identified within the thyrohyoid region. This is especially important posteriorly within the TH membrane region. The ipsilateral hemilarynx is rotated into the field by retraction at the thyroid notch. A horizontal incision (5–7 cm) is made at the superior aspect of the thyroid cartilage.5 Surgical Procedure 1. 43.4 Surgical Equipment ■ Microlaryngoscopy equipment ■ Neck dissection tray ■ Blunt dissection instruments (Kitner/peanut) 43. exposing the thyroid ala. 43. until the glistening capsule of the laryngocele is clearly identified.4  Sectioning of strap muscles to allow exposure of the TH space Fig. The midline raphae are identified. A small cuff of fascially encased muscle should be preserved at its attachment to the hyoid. 6. 7. where the SLN branch is immediately adjacent to the laryngocele. examining the ante- 2. It is important to “hug” the laryngocele capsule closely during dissection. 8. Subplatysmal flaps are raised from the upper aspect of the cricoid to just superior to the hyoid. The infrahyoid strap muscles (sternohyoid. ventricular region.5). Skin retraction hooks are placed. 43. to rule out malignancy (note: 30 and 70° telescopes are well suited for this). and thyrohyoid) are identified on the side of the lesion. 3. using a single-prong hook. 43. A small amount of soft tissue covering is left in place at the superior aspect of the capsule. Some sharp dissection with hemostat/15 blade is usually necessary as well. Perform a direct microlaryngoscopy. The “back wall” of the laryngocele should be well defined before proceeding with dissection of the intralaryngeal portion of the dissection. this area is grasped with a Babcock retractor (Fig. The lateral aspect of the laryngocele is defined by carefully excising the soft tissue covering on its surface. 9. An inferiorly based flap is created from the outer perichondrium of the thyroid ala by incising at the superior Fig. 5.6  Blunt dissection of the external component of the laryngo- cele 275 . 43. 4. rior false vocal fold.  Chapter 43 43. omohyoid.5  Identification of laryngocele capsule within the TH mem- brane Fig. and divided from the hyoid down to the cricoid.

9). excising a cuff of ventricular mucosa around its entry into the endolarynx.8  Sharp dissection of muscular/fibrous tissue off Fig. This is typically located at the anterior ventricular mucosa. This segment of cartilage is removed with a 15 blade and/or Kerrison rongeurs. Dissection continues inferiorly. The inner perichondrium is then incised and removed from the triangular region. 43. and its apex at a point half way along the vertical distance of the thyroid lamina.0 chromic) . 43 raised and triangular portion of the thyroid ala is removed for exposure of the internal component of the lesion of the saccule. the internal (paraglottic) portion of the lesion (4. A triangular section of the thyroid ala is marked out. defining the internal com- Fig.7  Inferiorly based outer perichondrial flap is Fig. with its base superiorly. 43. exposing the paraglottic space (Fig. 43. 43.9  The termination of the laryngocele is identified at the base Fig.8).276 Excision of Combined Laryngocele   border of the thyroid lamina and using a freer elevator for dissection. Sharp dissection through the ventricularis and aryepiglotticus muscles facilitates the identification of the capsule in the paraglottic space (Fig. 11.10  A figure-eight suture is used to close the mucosal defect ponent of the laryngocele. The airway is entered. The termination of the laryngocele is identified at the base of the saccule. This corresponds with a point 3–5 mm posterior to the midline of the thyroid lamina at the midway point along its vertical height (Fig. 13. 43. 12. 43. 43. The cartilage can be discarded after removal.7).

Barnes DR. ■ The internal dissection of the laryngocele is facilitated by removing a triangular wedge of thyroid lamina. one must enter the airway. 15. Therefore. A figure-eight suture is used to close the mucosal defect (4. thyrohyoid reanastamosed c) Skin closed 16.  Chapter 43 14.0 chromic) (Fig. Smid LJ et al (1978) Laryngocele and saccular cysts. then 4 mg) ■ Elevation of the head of bed ■ Diet can be advanced as tolerated. 17. excising a cuff of ventricular muco- sa around its entry into the endolarynx. Selected Bibliography 1 2 Holinger LD. 25. along with placement of a closed suction drain: a) Outer perichondrium to superior thyroid lamina b) Sternohyoid. ■ During dissection of the external component of a combined laryngocele. then a clamp may be placed at the base of the laryngocele. ■ Laryngoceles are categorized as: ■ Internal: confined to the endolarynx. ■ Neoplasm in the ventricle or false cord should be ruled out with microlaryngoscopy in high-risk patients (tobacco/alcohol users). but may be performed at the end of the case if there are airway concerns. or glass blowing can lead to development of a laryngocele.) If the saccular base cannot be clearly identified. The wound is thorough irrigated and closed in layers. usually removed endoscopically (see Chap. 8 mg. and a silk ligature placed prior to removing the specimen. A tracheostomy is rarely indicated. removing a cuff of ventricular mucosa surrounding the base of the saccule if possible. De La Cortina RAC (2000) Lateral thyrotomy approach on the paraglottic space for laryngocele resection. The saccular opening into the airway should be included in the laryngocele resection to insure complete excision of the lesion. playing wind instruments. straining. These are usually removed through an external approach. omohyoid. and may be more likely to have dysphagia as a result of SLN injury. The airway is entered. Laryngoscope 110:447–450 277 . care should be taken to avoid trauma to the SLN as it enters the TH membrane posteriorly. Complications can include: ■ Laryngeal edema or hemorrhage with respiratory compromise ■ Recurrence of the laryngocele ■ Incomplete removal of the base of the saccule can lead to recurrence. Any factor that increases intralaryngeal pressure such as coughing. “Endoscopic Excision of Saccular Cyst”) ■ Combined: extension of internal laryngocele into the neck through the TH membrane. ■ The saccular opening into the airway is located in the anterior ventricular mucosa. 43. A close suction drain is placed. Thome DC. Key Points ■ A laryngocele is an air-filled dilation or herniation of the saccule.6 Postoperative Care and Complications Postoperative care includes: ■ Overnight. 23-h observation (consider pulse oximetry monitoring) ■ Pain management ■ Intravenous steroids at 8-hour intervals (Decadron. 43.10. Ann Otol Laryngol Rhinol 87:675–685 Thome R. ■ Damage to the internal branch of the SLN with dysphagia or aspiration ■ Elderly patients are more susceptible to the effects of sensory deficits in the larynx. This provides wide exposure to the paraglottic space.

44. the laryngeal fracture(s) can be evaluated. Laryngeal fractures can also occur from isolated or direct injuries to the larynx such as falls. 10. often caused by a severe or violent body trauma such as a motor vehicle accident. a strangulation injury can cause delayed edema in an otherwise benign appearing clinical setting. Essential components of a complete assessment for laryngeal fracture include: ■ Flexible laryngoscopy (if possible) to assess vocal fold mobility and airway potency ■ Fine cut CT imaging of the larynx/cervical trachea ■ Microlaryngoscopy. followed by assessment and preservation of voice quality and function. 37. circulatory. gunshot or knife wounds. or traumatic emergency airway procedures (i. If the patient is not initially evaluated prior to intubation. and length. cricothyrotomy). 36.2 Disease Characteristics Laryngeal fractures (Fig. The mechanism of injury and patient’s initial and present airway status are extremely important historical data to obtain when evaluating a patient with a suspected laryngeal fracture. which is extremely difficult to treat. and 45 for further information. e. Furthermore. Also. The former is crucial given that proper evaluation and treatment of laryngeal fractures in the acute and possibly subacute setting can prevent severe laryngeal stenosis. where the intubation was performed.3 Surgical Indications and Contraindications Indications include: Fig. and what was seen on initial intubation. 44 A “close-line” injury can suggest laryngotracheal separation. tension.Chapter 44 Repair of Laryngeal Fracture 44. and if there is any exposed cartilage or mucosal lacerations within the larynx. Other key variables when assessing patients with a laryngeal fracture include vocal fold mobility. then many of the endo­ laryngeal key variables mentioned above are difficult to assess until direct laryngoscopy can be performed. cervical spine and neurologic systems have been stabilized. After the airway. The key variables of assessment for a thyroid cartilage fracture are the exact location and degree of displacement of the fractures. laryngeal palpation should identify if the thyroid and cricoid cartilages are stable to gentle palpation. Furthermore.1 Fundamental and Related Chapters Please see Chaps. 6. 44. tracheoscopy and esophagoscopy 44. specific history should be found regarding intubation indications. The ABC’s of emergency care must be first attended to for patients with a suspected laryngeal fracture.1  Laryngeal trauma (fracture on left ala) ■ Thyroid cartilage fracture involving: ■ Displaced thyroid cartilage with airway lumen compromise and/or negative voice implications ■ Exposed intralaryngeal cartilage (anterior two thirds of cartilage) ■ Shortened or avulsed vocal fold(s) ■ Cricoid fracture ■ Displaced fracture with lumen encroachment .1) are most commonly associated with external blunt trauma. why it was performed. who performed the intubation. (nondisplaced fractures) to severe disruption of the integrity of the larynx with avulsion of portions of the thyroid and/or cricoid cartilage.. Laryngeal fractures incorporating either the thyroid cartilage and/or the cricoid cartilage can range from minimal. initial airway and voice quality symptoms are helpful in the assessment process. 44. The overriding key principal to laryngeal fracture evaluation and treatment is assessment and protection of the airway.

vi.5 Surgical Procedure 1. iii. Same approach to the thyroid cartilage as described above.280 Repair of Laryngeal Fracture Contraindications comprise: ■ Unstable vital systems (sepsis. When noncalcified thyroid ala occurs (seen commonly in younger patients). the larger diameter “emergency” screws should be employed to improve purchase to the cartilage. iv. Microlaryngoscopy and bronchoscopy are also essential features of the initial assessment. no encroachment of the subglottic airway 44.) ■ Rolled Silastic sheeting ■ Aboulker stent ■ Sterile glove and surgical foam ■ T-tube stenting devices 44 44.4 Surgical Equipment Surgical equipment needed includes: ■ Standard microlaryngoscopy set up and equipment (see Chap. 10) ■ Laryngeal/bronchial telescopes (0. Secure airway with tracheotomy or endotracheal intubation. Exploration of the thyroid cartilage fracture with minimal disruption of the surrounding tissue is then performed with the goal of reducing the fractures. the anterior commissure tendon and the arytenoid position should be carefully evaluated and documented. This palpation should assess the overall integrity and strength of the three-dimensional configuration of the thyroid and cricoid cartilage. With this exposure. In addition. the overall length and tension of the vocal folds should be carefully assessed with flexible laryngoscopy and/ or direct laryngoscopy (see Chap. Dissection down through the soft tissues of the neck to preserve strap muscles and expose the thyroid cartilage (strap muscles that are avulsed or dislocated should be reattached into their anatomic position as much as possible). ii. exposed cartilage or arytenoid displacement i. looking for exposed thyroid and cricoid cartilage. v. Fig.) or cervical spine injury ■ Nondisplaced thyroid cartilage fracture ■ Fracture limited to posterior third of thyroid cartilage ■ Nondisplaced cricoid fracture. Finally. specifically avulsion injuries. minimal tissue should be removed from the area. and 70°) ■ Soft tissue neck surgical instrument tray ■ Maxillofacial fracture plating system (microplates with emergency screws) ■ Internal laryngeal stent devices ■ Montgomery internal laryngeal stent (Boston Medical. A small drain is placed in the dependent portion of the wound and removed within 24 hours.2  Laryngeal fracture repaired with a miniplate. This assessment should include any mucosal injury. b) Displaced thyroid fracture with internal mucosal lacerations. etc. 30. Boston. This assessment is crucial for decision making regarding the need for internal laryngeal stenting of the larynx. 10. Thyroid fracture exploration and repair a) Isolated thyroid cartilage fracture i. 0 Prolene sutures or small mini-reconstruction plates can be used across the fracture to secure the reduced laryngeal fracture into a stable position (Fig. “Principles of Phonomicrosurgery”). 44. Tracheoscopy and esophagoscopy may also need to be considered. Mass. palpation directly of the thyroid cartilage as a whole from externally can be performed to assess the three dimensional integrity of the structure. Initial assessment of laryngeal fracture The most important initial surgical assessment technique for patients with suspected laryngeal fracture include gentle palpation of the thyroid and cricoid cartilage. inferiorly and superiorly . This will help reduce and stabilize the fractures. head injury. and to determine if the patient will require internal laryngeal stenting. Horizontal incision is placed in the closest deep rhytid to the inferior border of the thyroid cartilage or   through any preexisting neck wound in the laryngeal area. 44. 2.2). As the thyroid cartilage fractures are explored and reduced. if possible.

Absorbable sutures (5. vi.5).4). then a stent size should be selected or created that will allow adequate internal laryngeal stenting without placing excessive pressure on the internal laryngeal mucosa. Montgomery laryngeal stent (Fig. then the internal laryngeal structures can be explored through this wound (it can be expanded if absolutely required). Free mucosal grafts or perichondrium can be used to resurface the internal larynx.  Chapter 44 ii. It is important to limit the size of the laryngotomy to as small as possible. 44. A midline laryngofissure can be performed if no laryngotomy is present from the injury itself. v.5  Repaired laceration Fig.6  Placement of Montgomery internal laryngeal stent 281 . Aboulker stent Fig. 44.3. External palpation of the thyroid cartilage can be used to determine the strength/support of the thyroid cartilage to determine if the patient will require internal laryngeal stenting.0 or smaller) are used to replace avulsed or lacerated mucosal flaps to obtain as much cartilaginous covering as possible (Fig. Note lateral extension of laceration incision superior to the thyroid ala Fig. If laryngeal stenting is required. vii. Great care must be obtained to stay in the midline protecting the right and left anterior commissure and the vocal fold attachments to the thyroid cartilage (Figs. If there is a preexisting laryngotomy from the pen- etrating neck wound. 44.3  Planned laryngofissure incision. Exploration of mucosal injury is then performed.6) 2. The internal laryngeal stent options in order of preference are the following: 1. 44. 44. iv. 44.4  Completed laryngofissure with exposed vertical transglottic Fig. 44. iii. 44.

6 Postoperative Care and Complications Postoperative care comprises: ■ ■ ■ ■ Fig.282 Repair of Laryngeal Fracture   d) Microlaryngoscopy and telescopic examination of the larynx and upper trachea should then be performed to evaluate the structural integrity and mucosal integrity of the larynx. “Anterior Glottic Web”).7  External fixation of Montgomery stent 44 3. The internal stability of cricoid ring should be once again assessed with external palpation. e) Mitomycin C can be applied (as need. d) Suture or miniplate fracture repair can then be performed (with 0 Prolene). Rolled Silastic sheeting 4. Sterile glove finger packed with foam viii. supporting sutures that go through the stent should be drawn out through the thyroid cartilage and to the outside of the neck and secured over buttons to hold the internal laryngeal stent in place (Fig. The best and preferred laryngeal stent options are listed above. c) A large cup forceps is used to grasp the stent and then the securing sutures of the stent can be released from the neck and the stent removed. ix. 44. Int J Oral Maxillofac Surg 36:748–750 . Selected Bibliography 1 Thor A. b) Direct laryngoscopy is performed to visualize the internal laryngeal stent. After the stent has been placed. e) If the cricoid ring is unstable. cricoid ring stability should be assessed with external palpation. 44. Cricoid fracture exploration and repair a) Same exposure as described above b) Exposure and reduction of the cricoid fracture(s) c) After reduction of the cricoid fracture(s). Endoscopic replacement of the stent can be done on an as-needed basis (see Chap. ■ Internal laryngeal stenting should be performed if the lumen integrity of the laryngeal airway is compromised due to laryngeal fractures. see Chap. 26. Internal laryngeal stent removal (Two-three weeks post-operatively) a) General anesthesia is induced via the preexisting tracheotomy. after the reduction and repair of the cricoid fracture. Linder A (2007) Repair of a laryngeal fracture using miniplates. 29. Tracheotomy care and education (as needed) Intravenous antibiotics for 24 hours Removal of drain within 24 hours Maintain internal laryngeal stent for approximately 14–30 days ■ Microlaryngoscopy/bronchoscopy and stent removal (see above) Complications can include: ■ Laryngeal infection ■ Stent migration (superior–inferior dimension) ■ Stenotic laryngeal airway (anterior–posterior dimension and/or lateral dimension) ■ Anterior commissure blunting/webbing ■ Granuloma formation Key Points ■ All evaluation and treatment of laryngeal fractures should focus on: ■ Airway lumen protection ■ Voice quality and function ■ Mucosal coverage is crucial for obtaining the best possible results after laryngeal fracture and injury. 4. Suture or miniplates can be used to repair the laryngofissure/fracture sites at the laryngotomy.7). “Subglottic/Tracheal Stenosis: Laser/Endoscopic Management”). 44. then placement of an internal stent endoscopically or through an injury-induced laryngofissure can be performed. 3.

Congenital stenosis is caused by a failure of recanalization of the laryngeal lumen during embryogenesis. “Tracheal Stenosis: Tracheal Resection with Primary Anastomosis”) are commonly used. Wegener’s granulomatosis) ■ Untreated LPR 45. the trachea has C-shaped cartilage anteriorly with an intervening posterior membranous section. g. and 47 for further information. 6. external techniques such as laryngotracheal reconstruction with grafting (described in this chapter) or cricotracheal/tracheal resection with primary anastomosis (Chaps. The membranous type is marked by circumferential fibrous tissue. there are clearly cases where these methods will fail. monofilament suture with taper needle (such as Prolene or nylon) Malleable retractors Montgomery laryngeal stent of appropriate size (Boston Medical. 45. 46. Subglottic stenosis may be caused by a multitude of factors. sometimes extending upwards to include the true vocal folds. Mass. “Glottic and Subglottic Stenosis: Cricotracheal Resection with Primary Anastomosis” and 47. Boston. 45. seen as both a congenital and an acquired lesion. with a small posterior airway. A more comprehensive list of these etiologies is included in Chap. In these instances. and it is contained entirely within a nonflexible cartilaginous ring. of which 90% is intubation related.. The cartilaginous type is comprised of a sheet of cartilage extending posteriorly from the inner surface of the anterior cricoid ring.) Sterile buttons and 0 or 2-0 permanent suture to secure stent Tracheotomy tube of appropriate size . other potential internal and external disease processes may lead to the development of stenosis. Subglottic stenosis after prolonged or repeated intubations occurs in 3–8% of children and adults.” Although endoscopic methods are often employed in the treatment of subglottic and tracheal stenosis.Chapter 45 Glottic and Subglottic Stenosis: Laryngotracheal Reconstruction with Grafting 45. 29.1 Fundamental and Related Chapters Please see Chaps. “Glottic and Subglottic Stenosis: Evaluation and Surgical Planning. 46. In contrast. depending on the age of occurrence and the presence of inciting factors.4 Surgical Equipment Equipment needed for surgery includes: ■ ■ ■ ■ ■ ■ ■ ■ Standard neck dissection tray Cottle and freer elevators Drill with cutting burr (optional) Nonabsorbable. While intubation is the leading cause of stenosis.3 45 Surgical Indications and Contraindications Indications include: ■ Failed endoscopic treatment of laryngotracheal stenosis ■ Cartilage collapse/tracheomalacia with obstruction ■ Laryngotracheal stenosis> 2–3 cm in length Contraindications (relative) comprise: ■ Diabetes ■ Steroid dependency (especially in autoimmune patients) ■ Moderate–severe lung disease (COPD/restrictive disease) ■ Moderate–severe heart disease ■ Obstructive sleep apnea ■ Renal failure ■ Untreated autoimmune disease (e. This type of stenosis is divided into membranous or cartilaginous types. The subglottis is the narrowest section of the airway.2 Disease Characteristics and Differential Diagnosis Subglottic stenosis is a narrowing of the subglottic airway. Narrowing in this segment of the airway is termed tracheal stenosis. Acquired subglottic stenosis accounts for 95% of cases subglottic stenosis. 6.

It is crucial in this dissection to remain in the subperichondrial plane to avoid injury to the nerves and vessels running on the inferior surface of the rib and to avoid pneumothorax. In addition. Using a cottle or Freer elevator. 45. The airway is obtained preferably by endotracheal intubation using a small-bore tube (4. The inner perichondrium should remain intact deep to 45 Fig.5 Surgical Procedure 1. The perichondrium is then incised along the superior. 45. In this region.4  The inner perichondrium should remain intact deep to the rib.to 6-cm horizontal incision is made over the seventh or eighth rib as indicated (Fig.1). Care should be taken to preserve the overlying perichondrium. 10 blade. the rib graft is incised laterally and medially to free it from the rest of the rib (Fig. The neck and chest are prepped and draped.3  Malleable retractors are placed below the exposed rib to pro- tect the underlying pleura while sharp dissection is used to free the rib graft Fig. Malleable retractors are placed below the exposed rib to protect the underlying pleura. a) Elevation should continue around the undersurface of the rib. 4. typically the medial aspect of the seventh or eighth rib Fig. the perichondrium is elevated along the periphery of the proposed graft (Fig. a) Using a no. 45. Dissection should be carried out until an appropri-   ately sized cartilage piece is exposed. inferior. after graft removal . A 5. 45.2).1  Diagram demonstrating the site of costal cartilage harvest.2  The rib is freed circumferentially. 45. which must be dissected off the rib to expose the cartilage. they are located in a region where the diaphragm is thicker.0 ETT). the surgeon will encounter fibers from the rectus abdominus muscle. and lateral borders of the proposed graft.284 Laryngotracheal Reconstruction 45. until the rib is freed circumferentially. staying in a subperichon- drial plane on the undersurface of the rib Fig.3). 3. 5. 45. a) Both of these ribs have adequate bulk for fashioning grafts. so there is less risk of pneumothorax. 45. 2.

a tracheostomy is then performed two or more rings below the inferior-most incision through the affected airway (Fig. with extension of the incision above and below the stenotic site as well. and the strap muscles are separated and retracted laterally to expose the laryngotracheal complex (Fig. 12. a) Suture material is typically non-absorbable and monofilament (3-0 or 4-0 Vicryl). If not already present. 45. A Montgomery stent (appropriate for size/gender) is placed in the wound to help keep the lumen patent (Fig. An incision is made in the skin of the neck horizontally overlying the cricoid and trachea. then one should incorporate the superior aspect of tracheostoma into the incision (Fig. the entire length of stenosis is exposed. The graft is then soaked in a saline solution. Care should be taken to preserve the perichondrium. Elevation of subplatysmal flaps is carried out. The cricothyroid membrane is divided horizontally to facilitate retraction of the cricoid segments laterally. 7. 45. the midline raphae are divided.10).8). Sutures should be placed submucosally to reduce the incidence of granulation tissue formation.7. The wound is closed in layers over a suction drain. Having a tracheostomy site adjacent to the rib graft can lead to graft infection. 45. Using a 15 blade.  Chapter 45 the rib. a midline cricoidotomy is performed and extended into the upper two to three tracheal rings (Fig. The incision should be wide enough to allow exposure of the lower portion of the thyroid cartilage and the first few tracheal rings. and the graft is sutured into place.5  A horizontal incision is made at approximately the second Fig. 45. but this is not always possible. The perichondrial surface of the graft should sit flush with the edges of the cricoidotomy.6  Exposure of the laryngotracheal complex and proposed tracheal ring pared. 45. and coming out on the skin of the opposite side.5).11). Using this method. piercing the stent. 45. 45. after graft removal (Fig. 9. midline incision through the stenotic region 285 . a) These two suture ends are then tied over a button on the skin. Ideally. The sutures are not tied until the graft placement and position are confirmed (Fig. 13. The ideal shape is either a modified boat shape or hexagon (Fig. allowing for some postoperative edema (Fig. The beveled design prevents the graft from falling into the airway. The graft is inserted such that the perichondrium is oriented toward the lumen. 6. 45. 10. The previously harvested costal cartilage graft is now pre- Fig. a) The extent of the incision is dependent on the length of stenosis. a) The cartilage is modified to the appropriate size and shape using a scalpel and/or drill with cutting bur. and restenosis.9). 11. since this will serve as the internal lining of the reconstructed airway and a scaffold for epithelialization. granulation tissue formation.7).4). The superior aspect of the incision may be extended into the inferior thyroid cartilage as depicted in Fig. the tracheostomy site is separate from the stented region. 8. a) If there is a previous tracheostomy.6). The Montgomery stent is secured in place by passing two permanent sutures (0 or 2-0 Prolene) through the skin on one side. taking care not to tie the ends too tightly. 45. 45. 45. 45.12).

10  Montgomery stent is placed prior to suturing the graft . 45. This should be separate from the graft site to lessen the chance of infection 45 Fig.8  Location of tracheostomy.286 Laryngotracheal Reconstruction   Fig. The perichondrium should be left intact at the diamond shaped portion of the graft Fig.9  Proposed configuration of the costal cartilage graft after shaping.7  The stenotic region has been exposed prior to graft placement Fig. 45. 45. 45.

emphysema. Key Points ■ Laryngotracheal reconstruction with costal cartilage rib graft is indicated in the following cases: ■ Failed endoscopic treatment of laryngotracheal stenosis ■ Cartilage collapse /tracheomalacia with airway obstruction ■ Laryngotracheal stenosis > 2–3 cm in length 287 . insufficient duration of stenting. possibly clindamycin for coverage of anaerobes) ■ A nasogastric tube is often placed during the initial postoperative period. 45. The most common complication is failure to correct the stenosis. It later serves as a vehicle for feeding. 45. in a patient with a tracheotomy by plugging or accidental decannulation.12  The stent is stabilized with percutaneous sutures tied over buttons are also seen. particularly in its role in the development of a laryngocutaneous fistula. inappropriate stent length. Emergent airway compromise may develop. Infection is also of concern. ■ Acid-suppression medication (PPIs) ■ Routine tracheostomy care ■ Pain management ■ Return to OR in 3–4 weeks for stent removal endoscopically Complications can include: ■ ■ ■ ■ Voice alteration Pneumothorax or pneumomediastinum Loss of airway Graft failure Voice alterations can occur if a laryngofissure is performed as a part of the surgery. Even small displacements of the anterior cartilage can disrupt voice quality. persistent LPR or keloid formation. and chest or neck wound infections. including pneumothorax. including inappropriate choice of graft or stent. Finally. The most feared complication after any such surgery is loss of control of the airway. slipped stent.11  Securing of the graft with multiple sutures extraluminally 45. inadequate endoscopic follow-up.  Chapter 45 Fig. pneumomediastinum. Pulmonary complications Fig. This is attributable to several aspects of the initial surgery. This permits suctioning of the gastric contents to diminish the possibility of nausea and vomiting that put the surgical site at risk. failure of the reconstruction with the need for a revision surgery is always a possibility of which patients and their families must be aware.6 Postoperative Care and Complications Postoperative care involves: ■ Broad-spectrum antibiotics (first-generation cephalosporin.

Miller R.288 Laryngotracheal Reconstruction ■ Patients with significant co-morbid medical conditions are generally poor candidates for open laryngotracheal treatment of airway stenosis. and is removed endoscopically 3–4 weeks later in the operating room. Otolaryngol Clin N Am 33:111–130 Gray S. Ann Otol Rhinol Laryngol 96:509–513 Little FB. Marin J. This is due to a high failure rate and tendency toward restenosis. Kohut RI. as well as higher morbidity/mortality. Myer CM. Laryngoscope 114:364–367 Zalzal GH. 45   Selected Bibliography 1 2 3 4 5 6 Pena J. Cruz S. Wiatrak BJ. Laryngoscope 96(Pt. ■ The ideal shape for the costal cartilage graft is a modified boat shape or hexagon. Koufman JA. ■ A Montgomery stent is used to maintain the airway lumen during the healing process. ■ Costal cartilage is an ideal graft material for laryngotracheal reconstruction. The beveled design prevents the graft from falling into the airway. Ramirez M. Ann Otol Rhinol Laryngol 94:516–519 Simoni P. Otolaryngol Head Neck Surg 125:397–400 Cotton RT (2000) Management of subglottic stenosis. Cotton RT (1987) Adjunctive measures for successful laryngotracheal reconstruction. Navarro F (2001) Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present. 1):1039 . Marshall RB (1985) Effect of gastric acid on the pathogenesis of subglottic stenosis. The preserved perichondrium on the graft serves as the internal lining of the reconstructed airway and a scaffold for epithelia­ lization. Cicero R. Microbiology of stents in laryngotracheal reconstruction. Cotton RT (1986) A new way of carving cartilage grafts to avoid prolapse into the tracheal lumen when used in subglottic reconstruction.

low-collar incision is utilized and the flaps are developed in the subplatysmal plane.2 Diagnostic Characteristics for Open Treatment of Subglottic Stenosis Numerous surgical procedures have been described to improve airway function in patients with benign acquired subglottic/tracheal stenosis. which fails endoscopic management.Chapter 46 Glottic and Subglottic Stenosis: Cricotracheal Resection with Primary Anastomosis 46. then an ETT can be placed though a tracheostomy during the resection portion of the case.0 microlaryngeal tube (MLT). and the trachea is circumferentially mobilized to the inferior border of the cricoid cartilage (Fig. which then permits further mobilization of the trachea and a reduction of tension on the anastomosis. 46. prior radiation to the larynx or trachea and patients taking immunosuppressive agents. 46. cartilaginous collapse of the airway).4 46.3). with no consensus on the optimal treatment. 46. high-dose steroids. 4-0 Vicryl 46. a one-stage procedure that includes circumferential resection of the subglottis and tracheal region with primary thyrotracheal anastomosis has resulted in excellent outcomes. As outlined in Chaps. 3. The distal end of the stenosis is then identified. e.” endoscopic treatments are often used as a first-line treatment of glottic and subglottic stenosis. the patient is placed in a supine position. 6. In patients with cricotracheal stenosis.3 Surgical Indications and Contraindications Equipment needed for this procedure includes: ■ ■ ■ ■ ■ ■ Relative contraindications can comprise associated comorbidities including severe vascular dysfunction. The strap muscles are then retracted and the thyroid isthmus divided in the midline. In cases where this approach fails. 6. i. A Kerrison rongeur is used to excise further . or conditions in which endoscopic treatment is not possible (e. The airway is generally secured with endotracheal intuba- 2. 45. such as a 4. 45. 4. The primary indication for the procedure is laryngotracheal stenosis contained within the cervical region. poor pulmonary Standard head and neck surgery set Kerrison rongeurs Drill with 3-mm cutting burr T-tube (sizes 11–14. Wegener’s granulomatosis) ■ Stenosis that includes > 6. and the reported outcomes of these techniques vary. 29. Contraindications include: ■ Stenosis at the glottic level (within 5 mm of free edge of the vocal folds) ■ “Active” autoimmune or inflammatory process (e. Blunt dissection is used along the anterior wall of the trachea to the level of the aortic arch/carina. 46. tion using a small-caliber endotracheal tube (ETT). “Glottic and Subglottic Stenosis: Evaluation and Surgical Planning” and 29. 46. The perichondrium on the upper and lower border of the cricoid cartilage is then incised. g. minimum lateral dissection is performed.1). and 47 for further information. To maintain the vascular supply to the trachea.1 Fundamental and Related Chapters 46 reserve.2). Please see Chaps. and the anterior segment is excised (Fig.. The cricothyroid muscle is then identified and reflected superiorly. g. If this is not possible. exposing the airway from the hyoid bone superiorly to the manubrium inferiorly (Fig. Hood) 2 endotracheal tubes 35 gauge wire. “Glottic and Subglottic Stenosis: Laryngotracheal Reconstruction with Grafting”) or cricotracheal resection with primary anastomosis is indicated. Under general anesthesia.5 Surgical Procedure 1. and a shoulder roll is placed to extend the neck. A standard.5 cm of the trachea Surgical Equipment 5. “Subglottic/Tracheal Stenosis: Laser/Endoscopic Management. Dissection then continues on the inner aspect of the cricoid cartilage to protect the recurrent laryngeal nerves. open treatment with either laryngotracheal reconstruction (Chap.. which are located posteriorly and inferiorly. and replaced by a oral endotracheal tube just prior to the re-anastomosis.

4  Further intraluminal removal of the stenotic region with a 46 circumferentially mobilized to the inferior border of the cricoid cartilage that is excised.5). 46. 46. sparing the posterior third of the ring and protecting the recurrent laryngeal nerves (arrow) Kerrison rongeur.1  Wide exposure of the laryngotracheal complex Fig.290 Cricotracheal Resection   the thickened area of stenosis (Fig. sparing the outer perichondrium and underlying recurrent laryngeal nerves . The cricoid plate is thinned posteriorly using a sharp burr with preservation of 50% of the posterior aspect (Fig. 47. 46. 6. The distal and proximal margins of the stenosis are identified. preserving the outer perichondrium of the cricoid plate.4). a laryngofissure is Fig. and the stenotic segment is resected en bloc as described in Chap.2  The distal end of the stenosis is identified and the trachea is Fig. The dissection is within the lumen of the cricoid. 46. When the site of stenosis extends superiorly close to the vocal folds.3  Diagrammatic representation of the amount of cricoid ring Fig. 46. 46.

Dashed lines in- dicate the incision of posterior glottic scar (if present) and the corresponding posterior tracheal mucosa that is to be advanced into this region Fig. 46.5  A cutting burr is used to thin the posterior cricoid plate Fig.  Chapter 46 Fig.7  Cricotracheal anastomosis into the posterior glottic region Fig.8  Completed cricotracheal anastomosis. 46. 46. 46. Note how the trache- al rings are completely contained within the cricoid shell 291 .6  Prior to cricotracheal anastomosis.

8). the chin suture is removed 4–5 days after surgery. ■ This procedure should be performed only in patients with mature cricotracheal stenosis in which the acute inflammatory stage has subsided. the platysma. diabetes mellitus) are at an increased risk of complications. ■ Dysphagia ■ A moderate number of patients develop dysphagia for up to 2 weeks postoperatively. 10. especially when the tracheal resection exceeds 4 cm. This can be accomplished with a bronchial block or a Fogarty catheter placed into the proximal end of the T-tube (Chap. Posterior glottic stenosis can be treated by division of interarytenoid adhesions and advancement of posterior tracheal mucosa into the interarytenoid region (Figs. thereby minimizing the risk of dehiscence. ■ The T-tube is removed 3–6 weeks postoperatively. 7. beginning with carbonated fluids and progressed gradually as tolerated.7). Note that the proximal end of the tube extends beyond the true vocal folds into the supraglottis ■ In the authors’ experience. 9. The T-tube must be kept capped to prevent drying of secretions and obstruction of the tube. ■ A complete segmental cricotracheal resection of the stenotic tissue is essential.9  Indwelling T-tube. through a tracheostomy that is located inferior to the anastomotic site (Fig. 8. ■ Dehiscence of the anastomotic suture line ■ Restenosis of the airway ■ Recurrent laryngeal nerve injury ■ Granulation tissue from the T-tube ■ Post-operative decrease in pitch (speech) can occur and is related to cricothyroid muscle division. a T-tube is inserted and placed at least 6–7 mm cephalic to the vocal folds. During the completion of the anastomosis. 46. ■ Dietary intake is initiated 48 hours postoperatively. At the end of the procedure. 4 distal tracheostomy tube is used rather than a T-tube. Once proximal and distal clearance has been achieved. using no. . depending on the extent and complexity of the resection. 46. and these comorbidities should be treated and/or considered preoperatively to minimize this risk. “Subglottic/Tracheal Stenosis: Laser/Endoscopic Management”). A successful outcome depends on the following factors: ■ Patient selection is critical and must include the consideration of the level. site. an anastomosis is performed approximating the proximal margin of the trachea to the immediate subglottic area. and extent of the lesion and the known patient comorbidities. The skin is closed in standard fashion. 46. e. 46. ■ To protect the anastomosis. Occasionally. a heavy suture is placed from the submental area to the anterior chest wall to maintain the patient’s cervical spine in a flexed position and to eliminate tension on the tracheal anastomosis.6. a no. 46. 35 gauge wires posteriorly and 4-0 Vicryl laterally and anteriorly (Fig.6 Postoperative Management Postoperative care involves the following: ■ Airway patency is maintained and the suture line protected by a soft Silastic T-tube. Complications can comprise: ■ Patients with significant comorbidities (i.292 Cricotracheal Resection performed to provide greater visualization and to permit resection closer to the vocal folds and enables the surgeon to complete the anastomosis. and excellent airway and vocal function supports the efficacy of cricotracheal resection with primary thyrotracheal anastomosis. Key Points Fig. The closure includes reapproximation of the strap muscles. definitive decannulation of 92% of patients with no evidence of recurrence. The proximal end of the T-tube is occluded to permit ventilation distally through its horizontal arm.9). and the soft tissue in the subcutaneous plane using 4-0 Vicryl.. 29. 46   11. 46.

Bryce DP (1974) The management of subglottic laryngotracheal stenosis by resection and direct anastomosis. the use of a T-tube is superior to a tracheostomy because is provides a physiologic airway stent and is less traumatic to the airway. which decreases the risk of postoperative complications associated with T-tube misplacement. Correct placement of the T-tube is imperative to maintain a patent airway and provide support to the anastomosis in the early postoperative period. Velly JF (1988) The surgical treatment of inflammatory and fibrous laryngotracheal stenosis. Guelinckx PJ. This therefore permits excision of all pathologic tissue and meticulous anastomosis of the trachea to the immediate subglottic region in close proximity to the vocal folds. Hermans R. Brichon PY. Mark EJ. Wain JC (2003) Successful treatment of idiopathic laryngotracheal stenosis by resection and primary anastomosis. Van Nostrand AW (1975) Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. it is imperative to perform the dissection on the inner aspect of the remaining cricoid cartilage after excision of its anterior arch. Pearson FG (1992) Subglottic tracheal resection and synchronous laryngeal reconstruction. Cooper JD. Another advantage of a laryngofissure includes the accurate placement of the T-tube. Laryngoscope 84:940–947 5 Grillo HC (1982) Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Laryngoscope 106:175–181 4 Gerwat J. Kuzucu A.  Chapter 46 ■ The addition of a laryngofissure provides excellent exposure for patients with a cricotracheal stenosis that is located close to the vocal folds. J Thorac Cardiovasc Surg 104:1443–1450 9 Pearson FG. Wain JC. Wright CD. Wain JC (1993) Idiopathic laryngotracheal stenosis and its management. J Thorac Cardiovasc Surg 127:99–107 2 Couraud L. Blondeel PN. Feenstra L (1997) Use of a composite fascial carrier for laryngotracheal reconstruction. J Thorac Cardiovasc Surg 70:806–816 10 Pearson FG. Gullane PJ (1996) Subglottic resection with primary tracheal anastomosis: including synchronous laryngotracheal reconstructions. Gullane PJ. Grillo HC. Ashiku SK. Selected Bibliography 1 Ashiku SK. as it appears to exacerbate dysphagia postoperatively. Semin Thorac Cardiovasc Surg 8:381–391 293 . Mathisen DJ. ■ Release of the suprahyoid or infrahyoid muscles is not routinely performed. Ann Thorac Surg 33:3–18 6 Grillo HC. Toth JL. Ann Otol Rhinol Laryngol 112:798–800 8 Maddaus MA. Mathisen DJ (2004) Idiopathic laryngotracheal stenosis: Effective definitive treatment with laryngotracheal resection. ■ In general. Eur J Cardiothorac Surg 2:410–415 3 Delaere PR. Mathisen DJ. Ann Thorac Surg 56:80–87 7 Grillo HC. ■ To avoid injury to the recurrent laryngeal nerves. Lo B. Wright CD. Nelems JM.

particularly during tracheotomy under local anesthesia) 47. and degree of tracheal involvement. or tracheotomy under local anesthesia until safe intubation of the distal trachea is achieved.Chapter 47 Tracheal Stenosis: Tracheal Resection with Primary Anastomosis 47.2 Background Information and Diagnosis of Tracheal Stenosis Tracheal stenosis is a complex and difficult problem to manage. and propensity for restenosis need to be considered when determining the best treatment option for tracheal stenosis. 47. Patients will typically present with reports of exertional dyspnea or progressive shortness of breath along with a history of previous intubation(s) or tracheotomy. 29. 45. Positioning of patient Patients are placed in a supine position with shoulder roll for full neck extension. and 46 for further information. “Glottic and Subglottic Stenosis: Cricotracheal Resection with Primary Anastomosis” for the treatment of this condition) ■ Multiple levels of tracheal stenosis or configuration not amenable to primary anastomosis ■ Uncontrolled mucosal inflammation secondary to LPR. 2. b) Some patients with severe stenosis must be managed with bronchoscopic dilation. 6. jet ventilation.4 Surgical Equipment Surgical equipment needed includes: ■ Monopolar and bipolar electrocautery ■ Standard soft tissue or neck dissection tray ■ A no. site. c) Preserve the tracheotomy in patients that have an unrelated stenotic tracheal segment. b) If the stenotic segment involves the tracheotomy site. Incision a) A low collar or U-shaped incision is made that extends from the anterior borders of the sternocleidomastoid muscles. Diagnostic information can be obtained from CT scans to determine the length. 10 or 20 for severely scarred. 15 scalpel (occasionally no. Patient health and comorbidities. . Wegener’s disease. It is also important to determine if multilevel obstruction exists. “Glottic and Subglottic Stenosis: Laryngotracheal Reconstruction with Grafting” and 46. Most cases of benign tracheal stenosis are caused by prolonged tracheal intubation or tracheotomy. or infection 47. 45.0 MLT) if possible. then the incision should include the tracheotomy tract and will be removed with the stenotic tracheal segment. Intubation a) Patients without tracheotomy are orotracheally or naso- tracheally intubated with appropriately sized endotracheal tubes (4.5 Surgical Procedure 1.1 Fundamental and Related Chapters Please see Chaps. and the number of tracheal rings or length proximal and distal to the site of stenosis. 47.3 Surgical Indications and Contraindications Indications for tracheal resection with primary anastomosis include: ■ Symptomatic tracheal stenosis after failure of endoscopic management ■ Focal (short-segment) tracheomalacia/cartilage collapse ■ Primary tracheal neoplasm Contraindications can comprise: ■ Stenotic tracheal segment > 5 cm (without the use of additional laryngeal releasing maneuvers) 47 ■ Subglottic stenosis with involvement of vocal cords (see Chaps. This information should be used in conjunction with tracheobronchoscopy to identify the extent and length of stenosis. Flexible laryngoscopy should be performed to determine the status of vocal fold mobility. This allows for surgical planning to determine the manner and extent of the surgical resection. 3. degree and length of stenosis. calcified tracheal wall.

b) Strap muscles are separated in the midline and retracted laterally to expose the trachea (Fig. the orotracheal endotracheal tube is then withdrawn until the tip is above the proximal or superior resection line. Fig. most of the stenotic segment in these cases. 47.4  Proximal and distal division of stenotic segment .3).2). 5. The recurrent laryngeal nerves are not identified. the stenotic segment is easily identifiable by external changes. Exposure of stenosis a) Subplatysmal flaps are elevated and the strap muscles are identified. is at the tracheostomy site itself. however. f) In patients with tracheotomy site involvement. 47. Excision of stenosis a) Horizontal incisions are then made superiorly and inferiorly at the margins of the stenotic segment (Fig. 47. It is not removed completely.4). e) Dissection is then completed around the stenotic segment to be resected. 47   c) In patients without tracheotomy. It is not necessary to dissect the membranous trachea at this time.2  Dissection of stenotic segment Fig. 47. e) A vertical incision is then made in the midline of the stenotic segment and extended inferiorly and superiorly until normal mucosa and an acceptable lumen caliber is achieved (Fig. 47. c) If present. 47.296 Tracheal Resection with Primary Anastomosis 4. as it is useful later in the procedure.3  Vertical incision through stenotic region to define its bound- aries Fig.1  Wide exposure of stenotic region of trachea Fig. the trachea can be incised vertically through the stoma site inferiorly and superiorly until normal mucosa and tracheal caliber is identified. b) An endotracheal tube is then used to intubate the distal trachea through the neck. d) The superior and inferior circumferential resection incisions are then completed.1). 47. Bipolar cautery is used if necessary. 47. d) The trachea is isolated by careful sharp dissection directly on the cartilage (Fig.

Note tying of the knots extralu- minally Fig. leaving the posterior tracheal wall intact can be performed. d) The cartilaginous trachea is closed using 2-0 Prolene sutures on an SH needle (taper) in a similar fashion (Fig. Submucosal sutures are placed in the posterior midline and laterally on both sides.  Chapter 47 f) The posterior aspect of the stenotic segment is separated from the esophagus using blunt and sharp dissection. This “crowds” the closure and may be saved for the last few sutures. These techniques are Fig. suprahyoid laryngeal release.6  Posterior re-anastomosis. Sutures should be placed so that the knots will be outside of the trachea lumen both for the posterior membranous and cartilaginous closure (Fig. with complete removal of stenotic region. 47. Note placement of an endotracheal tube into the distal trachea Fig.7). This will allow for a successful the anastomotic closure and will minimize the risk for devascularization of the healthy tracheal tissue. 6. Three sutures are all that is typically required. using 3-0 Vicryl sutures on an RB-1 needle. c) Once all of the posterior sutures are placed. 47. then a wedge resection. 47. e) Additional methods for gaining extra length for a primary anastomosis include mobilization of the distal trachea from the thorax.5).6). It is also important not to dissect more than 1 or 2 cm of normal trachea above and below the resected stenotic segment. 47. g) If the posterior trachea in uninvolved and the stenotic segment does not involve more than two or three tracheal rings. Anastomosis a) The shoulder roll is then removed to allow the neck to move to a more flexed position. It is important to perform the dissection close to the tracheal wall to avoid injury to the recurrent laryngeal nerves. This is done from the endotracheal side (Fig. b) The posterior membranous trachea is closed first. 47.7  Completed anastomosis with additional sutures externally spanning two tracheal rings for additional support 297 . and infrahyoid laryngeal release. the lateral most sutures in this area are tied simultaneously by the surgeon and assistant to reduce tearing.5  Blunt dissection of posterior tracheoesophageal party wall. 47.

■ Skin sutures are removed at 1 week. Shaha A et al (1993) Resection of tracheal stenosis with end-to-end anastomosis. This will decrease the amount of devascularization and improve healing. This is minimized by the use of perioperative antibiotics and by maintaining cervical flexion. Diet is advanced as tolerated. Mark EJ. ■ Voice rest for 3–5 days to minimize glottic pressure and subsequent airflow at the site of the anastomosis. c) A 2-0 Prolene suture is placed between the submentum and anterior chest wall to keep the neck in a flexed position. 47. ■ Chin flexion suture is removed at 2 weeks. Ann Otol Rhinol Laryngol 105:944–948 Har-El G. the distal endotracheal tube is withdrawn and the oral or nasotracheal tube is passed distally to bridge the anastomosis and eventual primary closure.298 Tracheal Resection with Primary Anastomosis typically not required for tracheal stenosis segments less than 5 cm and are not included in this chapter. Closure a) A Penrose drain is used and positioned at the anastomosis. Feeding tubes are rarely required unless extensive releasing maneuvers are performed. Park DL. ■ Stenosis at site of anastomotic closure ■ Tracheobronchoscopy may be used to identify and treat. Girod D (2005) Does successful segmental tracheal resection require releasing maneuvers? Otolaryngol Head Neck Surg 133:372–376 . Mathisen DJ. The need for laryngeal release needs to be made intraoperatively and depends on the degree of anastomotic tension. Extubation a) Patients are extubated the following day in the operating room or monitored intensive care unit. f) Prior to closing the anterior and lateral portion of the anastomosis. Selected Bibliography 1 2 3 4 5 Grillo HC. b) The wound is then closed in three layers. Patel N. Wain JC (1993) Idiopathic laryngotracheal stenosis and its management. Key Points ■ Cervical flexion is necessary to decrease anastomotic tension during the initial phases of wound healing. tracheal resection with primary anastomosis can be performed without the need for additional laryngeal releasing maneuvers. ■ Minimize the amount of tracheal dissection that is performed superior and inferior to the anastomotic site. g) The anastomotic closure is then leak tested by flooding the field with saline solution and deflating the cuff on the endotracheal tube while ventilating the patient. Wain JC (2003) Successful treatment of idiopathic laryngotracheal stenosis by resection and primary anastomosis. ■ Penrose drain removal on day 3 if no complications or evidence or air leak/crepitus. One theoretical advantage to overnight intubation is to reduce air leak at the closure site in case of cough or need for ventilatory support. Postoperative management includes: 47 ■ Postoperative chest radiograph to evaluate for pneumothorax and to confirm that the endotracheal tube (if present) is below the anastomosis ■ Keep neck in flexed position. Chaudry R. The strap muscles are reapproximated. Cauchois R et al (1996) Tracheal resection with end-to-end anastomosis for isolated postintubation cervical trachea stenosis: long-term results. Ann Thorac Surg 56:80–87 Grillo HC. Rieder AA. usually postoperative day 1. Granulation tissue can be removed. ■ All sutures for closure are placed with the knots extraluminally. ■ PPIs ■ Antiemetics ■ Pain medication ■ Soft diet may begin after extubation.6 Postoperative Care and Complications   Complications can comprise: ■ Wound dehiscence/infection. Mathisen DJ. Brasnu D. 7. Ann Otol Rhinol Laryngol 112:798–800 Laccourreye O. ■ For select patients with sites of stenosis < 5 cm. ■ Empiric antibiotic coverage for 5–7 days ■ If inflammation or infection is suspected at the time of surgery. and finally skin closure. followed by platysma and dermis. then antibiotic coverage can be determined by culture of these organisms. and stenotic sites can be dilated. 8. Wright CD. Many surgeons prefer immediate extubation. Ashiku SK. Ann Otol Rhinol Laryngol 102:670–674 Merati AL.

5 Surgical Procedure 1. 10) ■ Zero degree endoscope (30 and 70° are also useful). and video monitor (Chap.D. and 36 for further information. 48. The Gray minithyrotomy is named for Steven Gray. together with his colleagues. as the implant space is limited in volume. is compromised in sulcus vocalis. such as changes associated with the sulcus vergeture deformity.3 48 Surgical Indications and Contraindications The patient with a loss of pliability of the mucosal cover of the vocal fold. The integrity of the layered structure of the membranous vocal fold. including small self-retaining retractor ■ 22-g needle ■ Powered drill with 3-mm cutting burr ■ Mastoid curette ■ Tympanoplasty instrument tray. M.4 Surgical Equipment Equipment for the Gray minithyrotomy need is: ■ Suspension microlaryngology equipment (see Chap. especially: ■ Duckbill and Gimmick elevators ■ Blunt probes ■ Bellucci scissors. camera. 1. It has also not been used to remove subepithelial lesions.2 General Considerations The Gray minithyrotomy offers: ■ Access to physiologically important subepithelial vocal fold tissue without epithelial incision ■ The ability to carry out delicate dissection of areas of adhesion/fibrosis under excellent visualization ■ A means of introducing shorter dissecting instruments into the vocal fold mucosa that may be easier to handle than the usual microlaryngoscopic tools ■ Dissection orientation in a practical direction along the long axis of the vocal fold The Gray minithyrotomy is designed for access to subepithelial tissue planes of the membranous vocal fold..Chapter 48 The Gray Minithyrotomy for Vocal Fold Scar/Sulcus Vocalis 48. Preoperative measures and anesthesia a) Anesthesia The procedure is performed under a general anesthetic. especially when associated with age-related alterations in lamina propria thickness and pliability The Gray minithyrotomy is not intended to provide subs