Phonosurgery

Dr. Saurabh GuptaDeptt. Of ENT

Apollo Hospitals

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Introduction Definition “any surgery designed primarily for the improvement

or restoration of the voice”

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IntroductionMicrolaryngoscopic surgery

Vocal fold injection

Laryngeal framework surgery

Nerve grafting

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Introduction

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Laryngeal framework surgery -whole group of phonosurgery

Laryngoplasty -functional aspect of framework surgery

Thyroplasty - involving modification in thyroid cartilage

Unilateral VC ParalysisPreoperative Evaluation

Speech TherapyAssess patient’s vocal requirementsDo not perform irreversible interventions in patients

with possibility of functional return for 6-12 monthsSurgery often not necessary in paramedian positioning

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Evaluation – Unilateral Paralysis

Manual Compression Test

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Evaluation – Unilateral ParalysisAssess extent of posterior glottic gapConsider consenting patient for both anterior and

posterior medialization procedures

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Management – Unilateral ParalysisType of Anesthesia

Local – allows patient to phonate Careful administration of IV sedation Internal superior laryngeal nerve block at the thyrohyoid

membrane Glossopharyngeal nerve block at the inferior pole of the

tonsils Flexible endoscope allows visualization

Laryngeal MaskGeneral

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Management – Unilateral ParalysisVocal Cord Injection

Adds fullness to the vocal cord to help it better oppose the other side

Injection technique is similar regardless of material used

Injection into thyroarytenoid/vocalisInjection can be done endoscopically or

percutaneouslyPoor correction of posterior glottic gap

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External landmarks – several mm anterior to oblique line horizontally, midpoint between thyroid notch and inferior thyroid border vertically

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Management – Unilateral ParalysisVocal Cord Injection - MaterialsTeflonFatCollagen

Autologous CollagenHomologous Micronized Alloderm Heterologous Bovine Collagen

Hyaluronic AcidCalcium Hydroxyapatite gel Silicone gel

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Teflon - the first biosynthetic material specifically designed for implantation Advantages

Inexpensive and easily administered Immediate voice improvement

Disadvantages: Irreversible Granuloma formation leads to vocal cord stiffening Migration Useful mainly in terminal patients

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FatUse first reported by Brandenberg 1987Overcorrection is necessary – about 50%Resorption in months to years

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Management – Unilateral ParalysisVocal Cord InjectionFat Injection

Hsiung et al. divided failures into two categories Early

failure of fat to soften scarred segments large glottal gap large posterior defect

Late due to absorption of fat

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Calcium Hydroxyapatite gel (Radiance FN; BioForm)Composed of small spherules of CaHydroxyapatiteNo granuloma formationCurrently under study

Silicone gel (Bioplastique)Widely used in Europe, not approved for U.S.Sustained phonatory improvement up to 7 years

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Management – Unilateral ParalysisType I Thyroplasty

First described by Payr and reintroduced by Ishiki in 1974

Variety of materials used for implantsAutologous CartilageSilasticHydroxyapatiteGore-TexTitanium

Useful for anterior glottic gap

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Management – Unilateral ParalysisType I ThyroplastyAdvantages:

Permanent, but surgically reversibleNo need to remove implant if vocal function returnsExcellent at closing anterior gap

Disadvantages:More invasivePoor closure of posterior glottic gap

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Management – Unilateral ParalysisType I Thyroplasty – Gore-Tex

Gore-TexHomopolymer of polytetrafluoroethylene in minute

beads in a fine fiber meshMinimal tissue reactionCut into long 3mm wide sheet for useThyrotomy window drilled to 6-8mm long using a 2mm

burr 1cm posterior to midline and 3 or 4mm above lower edge of thyroid

Undermining of perichondrium 4-5mm posterior and inferior to window prior to insertion

Insertion under endoscopic visualization with patient awake

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Management – Unilateral ParalysisType I ThyroplastyComplications

Extrusion/Displacement (Intraoperative vs Postop)

Misplacement – most often superiorInfectionUndercorrection – important to overcorrect by 1-

2mmControversies

Location of graft placementStatus of inner perichondrium

Many series have shown low extrusion rate with sacrificed perichondrium

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Management – Unilateral ParalysisArytenoid AdductionArytenoid Adduction

First described by Ishiki with modifications by Zeitels and others

Addresses posterior glottic gap by pulling arytenoid into adducted position

Difficult to predict which patients will benefit preoperatively.

Most advocate use in combination with anterior medialization

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Management – Unilateral ParalysisArytenoid Adduction

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Management – Unilateral ParalysisArytenoid Adduction

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Management – Unilateral ParalysisArytenoid Adduction – ModificationsEndoscopic ApproachesSuture Placed to Cricoid Cartilage

Simulates action of lateral cricoarytenoidZeitels Modification – Arytenopexy

Presumably allows a more physiologic positioning of the arytenoid

Involves suturing the arytenoid in a more posterior and medial position to allow more tension on flaccid cord

Cricothyroid subluxation mimics action of cricothyroid muscleModifications should be used selectively

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Management – Unilateral ParalysisArytenoid AdductionComplications

Sutures too tight – may displace arytenoid complex anteriorly, adversely affecting voice

Entry in pyriform sinus

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ManagementBilateral Abductor Paralysis

Patients exhibit lack of abduction during inspiration, but good phonation

Maintenance of airway is the primary goal

Airway preservation often damages an otherwise good voice

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Expiration

Inspiration

ManagementBilateral Abductor ParalysisTracheostomy

Gold standardMost adults will require thisSpeaking valves aid in phonation

Laser Cordectomy Laser CordotomyWoodman Arytenoidectomy

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Bilateral Abductor ParalysisPhrenic to Posterior Cricoarytenoid anastamosis

Allows abduction during inspirationPreserves voice when successful

Electrical PacingTimed to inspiration with electrode placed on posterior

cricoarytenoidLong-term efficacy not yet shown

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Type II ThyroplastyOpen method – lateral / Median approach

Vocal fold abduction - Suture technique - Thyroarytenoid myectomy

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Re-innervation proceduresRLN anastomosis first described by Horsely in 1909Crumly showed Ansa cervicalis to RLN anastomosis

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Management – Unilateral ParalysisReinnervation

Results in synkynetic tone of vocal cord

Ansa to Recurrent Laryngeal Nerve

Ansa to Omohyoid to Thyroarytenoid

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Management – Unilateral ParalysisReinnervationHypoglossal to recurrent laryngeal nerveCrossed nerve grafts or wire conduction prostheses

from one muscle to its paralyzed counterpart are being researched

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Take Home messageAnatomy

TVC positioned at about ½ vertical height of the anterior thyroid cartilage and is anterior to the oblique line

Causes of Vocal Cord ParalysisIatrogenic (Surgery and intubation #1)

EvaluationRealize that some function may return with time (6-12

months)

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Take Home messageManagement – Unilateral Paralysis

Anterior and Posterior Glottic gap must be addressedArytenoid adduction is irreversibleContinued improvement up to 1yr after Type I

thyroplastyManagement – Bilateral Paralysis

Preservation of airway is most important goal

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Phonosurgery

Health & Medicine

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