PHONOSURGERY

Dr Vaibhav
THE LARYNGEAL MUSCULATURE
Intrinsic Muscles
Abductor Posterior Cricoarytenoid (PCA)

Adductors Lateral Cricoarytenoid (LCA)

Interarytenoid (IA)
Thyroarytenoid (TA)

Tensors Cricothyroid (CT) ---- SLN

Vocalis (internal part of TA)

Openers Thyroepiglottic (part of TA)

Closers - Interarytenoid oblique part (IA)

Aryepiglottic (AE)
Laryngeal surgery was initially concerned with merely the diagnosis
and removal of malignant disease from the larynx , whereas benign
disease and its effect on voice was considered to be of secondary
importance.

The last 50 years has seen the expansion of phonosurgery which is

defined as any surgery designed primarily for the improvement or
restoration of the voice. It was first popularized by Hans von Leden in
the late 1950s.

Phonosurgery includes ;
1. Microlaryngoscopic surgery
2. Vocal fold injection
3. Laryngeal framework surgery
4. Nerve grafting
5. Neuromuscular surgery
VOCAL FOLD INJECTION
 Historical aspects:
Bruning (1911) - the first to describe injection of vocal folds
He injected paraffin via a direct laryngoscopy
approach under LA.

Arnold (1962 ) - popularized the use of Teflon.

 Indications

Temporary correction in cases of u/l vocal cord palsy, when

prognosis for recovery is uncertain.

Immediate improvement of voice required.

Permanent correction of glottic insufficiency

Vocal fold atrophy

Adjunctive augmentation after prior surgery

Trial basis

Note: Done when there is absence of arytenoid fixation and

there is adequate residual vocal fold structure to allow for
needle placement.
IDEAL INJECTION MATERIAL
Readily available
Inexpensive

Inert

Easy to use

Completely biocompatible

Injectable materials are broadly classified into

temporary and permanent types.
 TEMPORARY INJECTABLE SUBSTANCES

Material Length of Adv. Disadv.

effect
Gelfoam 4-6 wks Long track record Short duration

Carboxymethylcellulo 2-3 months FDA approved Not long lasting

se
Bovine collagen 3-4 months Long track record Allergy test
2-4 wk delay
Human derived 3-4 months No allergy test Limited experience
collagen
Micronized Alloderm 2-3 months No allergy test More preparation
(Cymetra) Little/no inflammatory time
response.
Hyaluronic acid gel 4-6 months No allergy test Limited experience
8
 LONG TERM/ PERMANENT INJECTABLE
SUBSTANCES

Material Length of Adv. Disadv.

effect
Calcium hydroxyapatite 2-5 years FDA approved Associated with foreign body
granulomatous reaction. l/t
dysphonia, pain and VC
erythema.
Teflon Permanent Long lasting Irreversible
Vocal stiffness
Granuloma

Autologous fat Permanent Own tissue Time, morbidity from fat harvest
(harvested more
commonly from lower
abdomen and inner
thigh.)
Silicon polydimethyl Permanent Long lasting Should be placed deep inside
sialoxane body of vocal fold to prevent
migration

Note: Cymetra and autologus fat are the most commonly used injectables.
 VOCAL CORD INJECTION TECHNIQUES
It may be done under GA or LA through following routes:

Peroral : performed in selected patients.

topical 4% LA applied on laryngeal and pharyngeal mucosa.

Curved inj. device in clinical setting; under indirect visualization of larynx by

holding the tongue forward.
Bevelled end directed away from midline to minimize risk of
intramucosal injection.
 INJECTION TECHNIQUES
Percutaneous : can be performed under sedation or LA

visualization is with a flexible fibreoptic

nasopharyngoscope with digital imaging system.

For optimum results needle placed just anterior and lateral

to vocal process on a plane level with the lower border of medial edge.

11
Routes of administration are:

1. Translaryngeal through inferior half of thyroid cartilage.

performed through lateral appraoch.
level of vocal fold determined by palapting thyroid notch
and inferior border of thyroid cartilage.

2. CT membrane puncture becoming popular method.

performed through anterior approach.
vocal folds approached from below.

3. TH membrane puncture: usually not done routinely.

danger of injection into Reinkes space.
Laryngoscopic Injection(telescopic visualization):

Indications:
1. Patients who do not tolerate flexible fibreoptic examination.
2. During ablative procedures where RLN or Vagal nerve resection is
anticipated.This provides temporary medialization decresing immidiate post
operative symptoms.

Position: Supine

Anaesthesia: GA or LA

Instruments:
1.0/30 degree 5mm laryngeal telescope
2.Digital video system
3.23-gauge butterfly needle for Cymetra
Injection gun(Brunings syringe) for Autologus fat

Needle is inserted anterior and lateral to vocal process appr. 2 mm deep or at the
plane level with the lower margin of the true folds. After injection massage is done
over vocal fold to distribute the material.
 PRECAUTIONS - VOCAL CORD INJECTION
Avoid unnecessary tension at the anterior commisure.

Superior laryngeal nerve block should be avoided as it alters vocal fold tension
by paralyzing cricothyroid muscle.

The appropriate amount of overcorrection used for most injectables (1530%,

or an additional 0.10.2 ml of material).

Injection into the superficial lamina propria (Reinkes space) is to be avoided

l/t granuloma formation in space hampering mobility.

For vocal fold medialization materila is placed in paraglottic space lateral to

vocalis muscle and For intracordal injection , site is superficial , just deep to
lamina propria avoiding Reinkes space.
COMPLICATIONS OF VOCAL FOLD INJECTION-
1. Under injection requiring repeat procedures

2. Over injection causing airway compromise

Immediate m/n incise mucosa and remove excess materialwith suction
Late m/n CO2 laser or cupped forcep removal or thyrotomy.

3. Improper placement causing subglottal extension and stenosis.

4. If given in Reinkes space cause granuloma formation leading to

impaired VC vibrations.
Laryngeal Frame Work Surgery
INTRODUCTION
Payr in 1915 first described medialyzing paralyzed
vocal fold by inward displacement of overlying
thyroid cartilage with cartilage wedge.
Isshiki in 1974 first described the 4 types of
thyroplasty.
1990s: Medialization Thyroplasty was a well-
accepted commonly-performed operation
CLASSIFICATION
1. Approximation Laryngoplasty-
Medialization thyroplasty (Type I)
Arytenoid Adduction
Roatation (pull) technique (Lateral cricoarytenoid
pull technique)
Fixation technique (Adduction arytenopexy)
2.Expansion laryngoplasty
Laterlization Thyroplasty
Lateral approach (Thyroplasty type II a)
Medial approach (Type II b) or Midline lateralization
thyroplasty.
Vocal fold abduction
Suture technique.
Resection Technique. (Thyroarytenoid myectomy)
 3. Relaxation Laryngoplasty-
Shortening Thyroplasty
- Lateral approach (Type III)
- Medial approach ( Anterior commissure
retrusion)
4.Tensioning Laryngoplasty
Cricoid Approximation (Type IV a)
Elongation Thyroplasty
- Lateral approach (Type IV b)
- Medial approach (Springboard
advancement or Anterior commissure
advancement)
TYPE I THYROPLASTY

Indications:
- Symptomatic glottic insufficiency (dysphonia, aspiration).
- U/L vocal fold paralysis.
- Vocal fold atrophy, including age related atrophy.
- Vocal fold bowing d/t ageing and cricothyroid joint fixation.
- Sulcus vocalis
- Soft tissue defect resulting from excision of pathological
masses.

Contraindications:
-Malignant disease overlying laryngotracheal complex.
-Poor abduction of C/L vocal fold.
-h/o radiation therapy to larynx.
TYPE I THYROPLASTY: INDICATIONS
Dysphonia due to
Dysphonia or aspiration due to Vocal Fold Atrophy
Vocal Fold Paralysis/Paresis
MANUAL COMPRESSION TEST

this test results in a preoperative improvement in voice suggest that

surgery will be successful
TYPE I THYROPLASTY: THEORY
In paralyzed or atrophic vocal fold, the medial bulge
from the Thyroarytenoid (TA) muscle contraction
is inadequate.
The thyroplasty implant medializes the
midmembranous vocal fold to mimic the activity of
the TA muscle.
Goals: To improve voice quality and prevent
aspiration.
SET-UP
PRE- OP
Surgery done under local anaesthesia with
patient AWAKE
-patient need to phonate
-Use 1% lignocaine with Epi 1:100,000
with an amp of bicarbonate as bicarbonate
makes it hurt less.
-Inject broadly EVERYWHERE you are going to dissect!

Positioning: Shoulder roll with neck extended

TECHNIQUE
A paramedian
horizontal incision over
the middle aspect of
thyroid lamina.

Superior and inferior

flaps elevated in
subplatysmal plane
 CONT
Sternohyoid muscle is
elevated off the thyroid
Cartilage.
 CONT
The muscle is
retracted posterior to
thyroid lamina.
A cautery template
marks the fenestra (6 x
10 mm), and the
superior aspect of the
window is at the vocal
fold level.
TYPE I THYROPLASTY: WINDOW
Outline before cutting.
Goal: Window at the level of the TVF, to medialize
only the TVF.
If carving the implant, or using Gore-Tex can be
free-hand.
If using pre-formed implant (i.e. Montgomery or
titanium), use window sizer to mark window.
TYPE I THYROPLASTY: WINDOW
Superior edge of
window most important
(because if too high will
medialize false VF)
Half way between the
thyroid notch and the
inferior border of the
thyroid cartilage,
parallel to the inferior
border
 -The size of the window is
dependent on the size of the
larynx, men > women
- Anterior border should be
about 5-7mm posterior to
midline in female and 8-10mm in
male.
- Posterior border should be
just anterior to the oblique line
(width usually about 10-13mm)
- Inferior border should be
about 2-3 mm superior to the
inferior border to prevent
fracturing (height usually 4-
6mm)
 Cuttingthe window
- Marks are made
with electrocautery
and gentian violet
 If cartilage is soft use #15
blade
If calcified:
use oscillating saw.
or use otologic drill 2mm
burr to outline window
and then a Kerrison bone
punch to remove
remaining cartilage.

- inner perichondrium
elevated in circumferential
fashion by means of
laryngeal elevator.
 Video Window
TYPE I THYROPLASTY: IMPLANT
Pre-formed
Montgomery,
Titanium
Calcium Hydroxylapatite)
Hand carved

silicone.
layered Gore-Tex.
 Originally, after the window
was cut, the cartilage of the
window was pushed in by a
cartilage shim or later an
implant.
It was later found that the
cartilage migrated or
degraded over time causing
the voice to worsen as it
gets smaller.
Now, we remove the
cartilage before placing an
implant.
TYPE I THYROPLASTY: IMPLANT
Montgomery
Set window size
for men and
women, 5 implants
sizes for each
window.
Use an implant
sizer to decide
which implant to
use
Has inner and
outer phalanges
securing in place.
 Features :
Eliminates need to hand-
fashion Implants.
Self-retaining implant.

No suturing is necessary.

Reduced trauma and

surgery time
Reversible
TYPE I THYROPLASTY: IMPLANT
TitaniumVF
medialization
Implant:
Secured in place
at varying
depths
depending on
voice with
titanium screw
system.
TYPE I THYROPLASTY: IMPLANT
Free-form: Gore-Tex (ePTFE)
- Homopolymer of polytetrafluoroethylene
in
minute beads in a fine fiber mesh.
- Minimal tissue reaction
- Cut into long 3mm wide sheet for use
- Undermining of
perichondrium
4-5mm posterior and inferior
to window prior to insertion
TYPE I THYROPLASTY: IMPLANT
Hand-carved: Silastic:
Firm silicone block
carved by the surgeon
during operation to
appropriate shape.
Hand-carved: one
technique with inner
phalanges.
 Hand-Carved: with
outer phalanges
Carved based on
window size, and
amount of
medialization
needed.
Bevel medial surface
to be divergent.
IMPLANTS
Calcium
Hydroxylapatite
(VoCoM implant):
- Osteogenesis occurs
in fenestra
- Firm in nature,
modification by
diamond drill.
- Not used in individuals
in removal is
anticipated
 Depending upon shin
used, the implant can be
variably placed along the
anterior/posterior and
superior/inferior axis of
fenestra.
 Place implant external to
inner perichondrium.
Rotate implant into four
orientation to determine the
optimal position.
Most common position :
inferior posterior quadrant
in vertical orientation.
Before placement, perform
valsalva maneuver. If air
bubble present, procedure is
terminated.
 TYPE I THYROPLASTY
Advantages
- under local anesthesia.
- positioning is more anatomic, better assessment of voice
- Reversible.
- prosthesis is placed lateral to the inner perichondrium of
the thyroid lamina.
- structural integrity of the vocal fold is preserved, allowing
medialization with effective closure of the prephonatory gap .

Disadvantages
- open procedure.
- technically more difficult.
- closure of the posterior glottis may be limited.
 Factors affecting output of surgery

Size and shape of the implant

Position of the implant

Maintaining proper position of the implant

Limiting the duration of surgical procedure

Deterioration of voice quality after thyroplasty with implant in place

- resolving oedema in postoperative period
- surgery performed early after paralysis - d/t muscle atrophy
TYPE I THYROPLASTY: COMPLICATIONS
Penetration of endolaryngeal mucosa - assess air
leak before placement of implant in window. If air
leak is present , then terminate the procedure.
Wound infection

Chondritis

Airway obstruction most danger overnight

monitoring is required.
Implant extrusion
Can become displaced and even extrude into the airway,
more commonly with Gore-Tex and with implants without
outer phalanges
TYPE I THYROPLASTY: PITFALLS
Window is too high.
Then implant is too high, false VF is medialized and voice is poor.
Implant is too big or too small.
Makes voice either pressed or breathy.
Voice is still poor after Procedure because of posterior
glottal insufficiency.( Arytenoid adduction can correct
this.)
 Limitations of medialization
Mechanical nature of the procedure.

Imparts only static change to laryngeal framework with no effect on

dynamic function.

No effect on vocal fold muscle mass, innervation and mobility.

Closure of posterior glottis limited.

No effect on vocal fold level in vertical plane.

Incomplete glottal closure after type I thyroplasty

Occurs in patients undergoing acute implanation after paralysis of vocal cords

due to atrophy of muscles with time.

Management include ;

Revision thyroplasty
Vocal fold injection with cymetra and autologous fat
Re innervation procedure
Arytenoid adduction

Revision thyroplasty is surgically feasible and result in high rate of improvement

over the pre existing condition.
Modification of medialization thyroplasty

Modified techinque done by Nishiyama and colleagues in 1999.

Implant used: autologus temporalis fascia .

Procedure: implant harvested, dehydrated, rolled and inserted into vocal fold
under microlaryngoscopy guidence.

Indications: 1.Large glottic gaps.

2.U/l vocal fold palsy.
3.Atrophic vocal fold.
4.Post RT scar tissue.

Result: Significant improvement in phonation time.

ARYTENOID ADDUCTION
First described by Ishiki
with modifications by
Zeitels and others.
Addresses posterior
glottic gap by pulling
arytenoid into adducted
position.
Most advocate use in
combination with anterior
medialization.
Traction on muscular
process of the
arytenoid antero-
medio-inferiorly.
ARYTENOID ADDUCTION MODIFICATIONS
Suture Placed to Cricoid Cartilage
Simulates action of lateral cricoarytenoid.
Zeitels Modification Arytenopexy

More physiologic positioning of the arytenoid.

Involves suturing the arytenoid in a more
posterior and medial position to allow more tension
on flaccid cord.
 Video Arytenoid Adduction
TYPE 2 THYROPLASTY
Vocal folds are displaced laterally away from the midline
under local anaesthesia.
Management of adductor spasmodic dysphonia (AdSD) -

Type II a :
Lateralization thyroplasty by lateral approach -
Two paramedian vertical incisions and
interpose the anterior segment beneath the
lateral segments.
 Type II b - Lateralization
Thyroplasty By medial
approach-
a/k/a ( Midline
lateralization
Thyroplasty )
A vertical incision in
the thyroid cartilage and
lateralizing the posterior
segment over the anterior
one.
 Video- Midline lateralization Thyroplasty
 Advantages:
Optimal glottal closure can
be adjusted and readjusted
No damage of physiologic
function
Reversible
Disadvantages:
Technically difficult
Shim displacement
Does not relieve cause of
Spasmodic Dysphonia
(neuromuscular ,
parkinsons , MND , MS)
 Vocal Cord
Abduction by
1. Suture Method-
Arytenoidopexy:
Displacing the vocal fold
and arytenoid without
surgical removal of any
tissue.
Suture passed around the
vocal process of the
arytenoid and secured
laterally.
Relatively high
failure rate.
 2.Resection Method-
(Arytenoidectomy).
Removal of some or all of the arytenoid cartilage.
- Endoscopically by Microsurgical technique-
Thornell procedure
- with Laser surgery- Jakos procedure
- With Thyrotomy approach- Scheers approach)
- By lateral neck approach (Woodmans) Most
popular approach.
Woodman procedure
- Lateral neck incision.
- Exposure of the arytenoid
cartilage posteriorly with
removal of the majority of
the cartilage, sparing the
vocal process.
- Suture is then placed into
the remnant of vocal
process and fixed to the
lateral thyroid ala.
- Cause less voice deficit.
 Cordectomy:
Dennis and Kashima (1989)
Posterior partial cordectomy by carbon dioxide laser.
Excising a C-shaped wedge from the posterior
edge of one vocal cord.
If this posterior opening is not adequate, after 6-8
weeks, procedure can be repeated or a small
cordectomy can be performed on the other vocal cord.
Relief of airway obstruction with preservation of
voice quality.
TYPES
Type I: Subepithelial cordectomy,
Type II: Subligamental cordectomy, which is resection of
epithelium, or Reinkes space and vocal ligament.
Type III: Transmuscular cordectomy, which proceeds
through vocalis muscle.
Type IV: Total cordectomy, which extends from vocal
process to the anterior commissure.
Type Va: Extended cordectomy encompassing the
contralateral vocal fold.
Type Vb: Extended cordectomy encompassing the
arytenoids.
Type Vc: Extended cordectomy encompassing the
ventricular fold.
Type Vd: Extended cordectomy encompassing the
subglottis.
 Right posterior
cordectomy in cases of
bilateral abductor
paralysis.
TYPE III THYROPLASTY
Lowers the vocal pitch.
The VF is relaxed by A-P shortening of the thyroid
ala.
Indications:

1. Males with high pitch voice, resistant to voice

therapy.( Puberphonia/ Mutational falsetto)
2. Stiff VF with high pitched breathy voice.
3. Spastic dysphonia
TYPE III THYROPLASTY
Lateral approach :
( Type III)
Thyroid ala is incised
at about junction of
anterior and middle
one third, and 2-5 mm
cartilage strip is
excised.
 Medial approach:
( Anterior commissure
retrusion)
- Retrusion of the middle
portion of the thyroid
cartilage and leads to
reduction in the length of
vocal folds results in normal
adult voice
- Vertical incision was
made either side of the
midline of the thyroid
cartilage.
 Middle portion of the cartilage Free edges of the thyroid cartilage
pushed posteriorly reapproximated with 2-0 vicryl
 Video Retrusion Thyroplasty.
TYPE IV THYROPLASTY
Increases the vocal pitch.
It increases the distance between the vocal fold
attachments and thus raise the tension of vocal
fold.
Indications:

Androphonia (Abnormally low pitched voice in

female.
Male to female transsexualism
Abnormallly lax or bowed vocal folds (as in
presbyphonia)
 Cricothyroid
Approximation :
- increases vocal pitch by
simulating the contraction of
cricothyroid muscle with
sutures.
- The cricoid and thyroid
cartilage is approximated as
closely as possible because
postoperative reversion
towards a lower pitch to
some extent is inevitable.
- 4 nonabsorbable
monophilic sutures are
placed to draw the cricoid
and thyroid cartilages
together.
- In thyroid cartilage,
bolsters should be used to
prevent cutting through
sutures.
 Video- Cricoid approximation
 Advantages:
No surgery on the vocal cords themselves.
Theoretically reversible if the patient is
dissatisfied.

Disadvantages:
Requires neck incision.
prolonged healing process.
long-term results are inconsistent.
 Cricothyroid Subluxation : By Steve Zeitels
Indications :

U/L vocal fold paralysis with vocal fold shortening with

resultant reduced pitch range.
Poor pitch range after adequate implant positioning in
medialization laryngoplasty.
Contraindications :

Present or impending laryngeal fracture of thyroid ala

from associated medialization laryngoplasty.
 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.
- Results in rotation of anterior commissure away from
midline in a direction C/L to unilateral vocal fold paralysis.
 Separation of cricothyroid jt Placement of cricothyroid
with scissors subluxation suture
submucosally at the midline of
anterior cricoid cartilage.
 Elongation Thyroplasty:
- Lateral Approach (Type IV
b)
Vertical incision is taken at
the junction of anterior and
middle one-third of ala and
silastic implant is fixed
between cartilage edges by
two mattress sutures.
- If pitch elevation is
insufficient, the same
procedure may also be
performed on the
contralateral side.
 Medial Approach:
- By Le Jeune as springboard
advancement
- Indication : Breathy voice due to
bowed vocal folds.
- After exposure of anterior portion
of thyroid cartilage, an inferiorly
based carilage flap is formed so
as to include the anterior
commissure. The upper end of
flap is held in position by a
tantalum shim.
- Tucker modified this technique
by reversing the pedicle and
called it anterior commissure
advancement.
Laryngeal Reinnervation Surgeries
Laryngeal Reinnervation Surgeries

In 1909 , Horsely reported first successful vocal cord reinnervation.

He performed neurorraphy of RLN and obtained nearly complete
recovery of
laryngeal function.

Two most common reinnervation techniques are:

1. Neuromuscular pedicle
2. Ansa Cervicalis-RLN anastomosis
Neuromuscular pedicle

The techique attempts to transfer a nerve with a portion of its motor units
intact to denervated muscle.

Small blocks of muscle at distal end of donor nerve are included.

Successful results depend on : ability of transplanted axons to reach

receptive
sites on recipient muscle
:ability of muscle fibres to accept foreign
nerves.

Principle:Muscle reinnervation occurs from sprouts generated from

intact motor neurons of partially denervated transferred nerve to the
end plate sites of denervated muscle fibre.
 Bilateral Vocal cord plasy

Done when palsy persists for 6 months to one year.

C/I when: cricoarytenoid joint fixation present.

vocal cord palsy d/t CNS disease.

Technique:
Laryngoscopy with palpation of arytenoids
Horizontal skin incision at level of lower border of thyroid cartilage
Branch of ansa cervicalis identified by:
a) finding the main trunk as it crosses IJV and tracing proximally and distally till
appropriate branch recognized.
b)mobilizing the medial border of omohyoid near its attachment to the hyoid
bone carrying dissection in medial to lateral direction.
If nerve injured branch to sternothyroid is also acceptable.
NMP is sutured to PCA.
 Unilateral Vocal Cord Palsy

Laryngoscopy and harvesting of NMP is same as b/l palsy.

Recipient muscle is LCA.
 Complications

1.Failure to obtain satisfactory result.

2.Wound infections.
 Ansa Cervicalis-RLN anastomosis

Indicated for U/L VC palsy and offers an excellent oppurtunity for

outstanding rehabilitation.

Waiting period before reiinervation surgery is 12 months.

No motion of the reinnervated vocal fold with respiration is expected.

Advantages:

Relatively easy to perform.

Provides tone,position and bulk to vocal fold thus reducing the asymmetry
b/w two cords.
Sternothyroid muscle sacrifice is clinically insignificant which improves
vocal function.
Procedure is reversible as is primarily extralaryngeal.
No limitation for use of vocal fold injection and thyroplasty as no violation
of thyroid ala and laryngeal muscles.
No permanent implant used.
 Disadvantages:

Requires deeper neck dissection.

Lengthy procedure.
Eliminates possibility of spontaneous recovery of VC.
Delay of 5- 9 months before substantial improvement in voice occurs.
Requires one intact ansa cervicalis and intact distal stump of the RLN.

Pre-requisite:
1.Availblity of distal stump of RLN.
2.Availblity of donor nerve.
3.Patient must be able to tolerate GA
4.Pateint must be ready to wait for substantial improvement from
reinnervation.
 C/I:
1.Absolute: glottic airway compromise
B/l VC palsy
absence of distal RLN
b/l absence of ansa cervicalis
poor general health.
2.Life expectancy
3.Presence of scar,web or poylp over vocal folds.
4.VC plasy d/t CNS disease.
 Procedure:

Incision below the

level of cricoid
cartilage.

In postoperative period
after 2- 3 months voice
may deteriorate.
At 4- 6 moths after
surgery gradullay
improvement in voice
quality occurs.
 Thank You
)