Учебники / Operative Techniques in Laryngology Rosen 2008

Fig. 15.12  Straight edge of left vocal fold immediately after excision of vocal fold polyp

f)If there are some residual tags or dog-eared mucosa, then this tissue should be removed.

If this tissue is too small to be grasped, then it can be removed by opening the blades of the microcurved scissors (curved away from the surgical vocal fold), sliding the scissors down over the tissue in a way that the blades straddle the tissue to be removed. With gentle, lateral pressure at the same time that the blades are closed, this tissue will be successfully removed (Fig. 15.11).

g)After removal of the vocal fold pathology, 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).

There may be some additional fibrous or gelatinous material that should be carefully removed to prevent a rapid recurrence of the vocal fold pathology. This material can be removed with a microelevator or microcup forceps. 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. At the completion of the surgery, 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 at the surgical site (Fig. 15.12).

h)Application of 4% plain lidocaine onto the endolarynx

15.6Postoperative Care/Complications

Voice rest is typically used after surgical excision of a vocal fold polyp. This voice rest period can range from 2 to 7 days. It is wise to treat patients for perioperative laryngopharyngeal reflux, consisting of proton pump inhibitor and behavior modification.

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

■Precision microsurgical removal of a vocal fold polyp is paramount.

■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.

■Most of the mucosa of the vocal fold polyp is usually not suitable for preservation due to its thin, atrophic nature.

■However, some residual surrounding mucosa of the vocal fold polyp can be preserved and redraped to allow optimal vocal fold healing after surgery.

Selected Bibliography

1Courey MS, Garrett CG, Ossoff RH (1997) Medial microflap for excision of benign vocal fold lesions. Laryngoscopy 107:340–344

2Hochman II, Zeitels SM (2000) Phonomicrosurgical management of vocal fold polyps: the sub-epithelial microflap resection technique. J Voice 14:112–118

3Johns MM (2003) Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps and cysts. Curr Opin Otolaryngol Head Neck Surg 11:456–461

16.1Fundamental and Related Chapters

Please see Chaps. 3, 4, 8, 10, 11, and 12 for further information.

16.2Disease Characteristics and Differential Diagnosis

Vocal fold nodules are characterized as bilateral vocal fold lesions that are fairly symmetric (Fig. 16.1). On stroboscopy, the mucosal wave is normal or near normal. The stroboscopic closure pattern is an hourglass configuration. Typically, these patients have a history of vocal abuse or misuse (phonotrauma). These tend to occur in children and adult females (18–40 years of age). 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)

Vocal fold nodules are typically treated with nonsurgical methods including voice therapy, voice rest, and treatment of comorbid medical conditions. It is extremely rare that true vocal fold nodules do not respond favorably to these nonsurgical modalities. Most often, when bilateral vocal fold lesions are still present after the nonsurgical treatment modalities, these lesions are in fact not vocal fold nodules, but other benign vocal fold lesions (see above list).

16.3Surgical 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. Nonsurgical treatment options include high-quality voice therapy with good compliance by the patient—also, treatment of comorbid medical conditions such as reflux disease and allergic disease

when present. Surgery for vocal fold nodules without a thorough and properly implemented nonsurgical therapy course is not appropriate. 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.

16.4Surgical Equipment

1.Phonomicrosurgery instruments (see Chap. 10, Table 10.1)

2.CO2 laser optional (see Chaps. 10, “Principles of Phonomicrosurgery” and 13, “Principles of Laser Microlaryngo­ scopy”)

Cold-steel excision is the preferred method for vocal fold nodules removal; however, in rare instances, and with great experience and the optimal laser technical abilities, the CO2 laser can be used to remove vocal fold nodules as well.

Fig. 16.1  Vocal nodules

16.5Surgical Procedure

1.Complete exposure of the membranous vocal folds with suspension laryngoscopy (see Chap. 10, “Principles of Phonomicrosurgery”).

2.The vocal fold lesions should be palpated gently under highpower magnification.

During this, the vocal fold lesions should be assessed for their degree of submucosal pathology and examinined for associated pathologic lesions such as vascular lesions, evidence of scar, sulcus vocalis, and other vocal fold pathologies. Special attention should be given to the anterior commissure to evaluate if there is a presence of an anterior commissure microweb. Past reports have noted an increased incidence of anterior commissure microwebs with recalcitrant vocal fold nodules that require surgical excision. If a microweb is present, then asymmetric release of the microweb can be done with scissors or a sickle knife. Mitomycin C can be applied to the operative site.

3.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. 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. After the lesion is grasped, 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.

4.Microscissors, either straight-up or curved (aimed in a direction away from the vocal fold) should be used for a sub-

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. 16.3). Without special attention to this area, excessive anterior vocal fold mucosa can be removed with the vocal fold lesion excision. 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.

5.If there are any residual mucosal irregularities at the excision site, then these should be removed in a careful, conservative fashion by either removal of the irregular abnormal mucosa with microcup forceps or by microsurgical scissors excision (Fig. 16.4).

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.

6.After removal of the benign vocal fold lesions, 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).

There may be some additional fibrous or gelatinous material at this location, which should be carefully removed to prevent a rapid recurrence of the vocal fold pathology.

7.This material can be removed with a microelevator or microcup forceps. Extreme care is required at this juncture of the surgery, 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.

8.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. 15, Fig. 15.12).

Fig. 16.2  Submucosal excision of vocal fold lesion (start)

Fig. 16.3  Submucosal excision of vocal fold lesion (finish)

Fig. 16.4  Removal abnormal mucosa from operative site

16.6Postoperative Care and Complications

Voice rest is used for a variable length of time, depending not only on the size and nature of the lesion, but also on compliance issues of the patient. In general, compared with other phonomicrosurgical procedures, 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. As an example, for an extremely compliant patient, voice rest may be needed only 1 or 2 days, proceeding to light voice use if the patient is continuing to be compliant, and the stroboscopy results are favorable.

Complications from vocal fold nodules surgery are:

■Excessive scarring

■Submucosal hemorrhage

■Residual vocal fold pathology

■Excessive removal of vocal fold tissue, 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.

Key Points

■Vocal fold nodules are bilateral, fairly symmetric, midmembranous vocal fold lesions that have normal stroboscopic or minimal impairment findings that result in an hourglass closure pattern.

■Most patients with vocal fold nodules improve with nonsurgical treatment methods, however there may be some rare cases of recalcitrant vocal fold nodules that require surgical excision.

■Surgical excision of vocal fold nodules should be extremely conservative, precise and performed in a subepithelial fashion.

■The initial retraction or grasping of the vocal fold lesion is very important. This step in large part determines the success of the procedure.

Selected Bibliography

1Akif Kilic M, Okur E, Yildirim I, Guzelsoy S (2004) The prevalence of vocal fold nodules in school age children. Int J Pediatr Otorhinolaryngol 68:409–412

2Benjamin B, Croxson G (1987) Vocal nodules in children. Ann Otol Rhinol Laryngol 96:530–533

3Benninger MS, Jacobson B (1995) Vocal nodules, microwebs and surgery. J Voice 9:326–331

4Courey MS, Shohet JA, Scott MA, Ossoff RH (1996) Immunohistochemical characterization of benign laryngeal lesions. Ann Otol Rhinol Laryngol 105:525–531

5Ford CN, Bless DM, Campos G, Leddy M (1994) Anterior commissure microwebs associated with vocal nodules: detection, prevalence, and significance. Laryngoscope 104(Pt. 1):1369–1375

6Holmberg EB, Doyle P, Perkell JS, Hammarberg B, Hillman RE (2003) Aerodynamic and acoustic voice measurements of patients with vocal nodules: variation in baseline and changes across voice therapy. J Voice 17:269–282

7Holmberg EB, Hillman RE, Hammarberg B, Sodersten M, Doyle P (2001) Efficacy of a behaviorally based voice therapy protocol for vocal nodules. J Voice 15:395–412

8Pontes P, Kyrillos L, Behlau M, De Biase N, Pontes A (2002) Vocal nodules and laryngeal morphology. J Voice 16:408–414

9Shah RK, Woodnorth GH, Glynn A, Nuss RC (2005) Pediatric vocal nodules: correlation with perceptual voice analysis. Int J Pediatr Otolaryngol 69:903–909

17.1Fundamental and Related Chapters

Please see Chaps. 3, 4, 8, 10, 11, and 12 for further information.

17.2Diagnostic Characteristics and Differential Diagnosis

A vocal fold cyst is a sac-like structure within the lamina propria of the vocal folds, typically yellow or white in color (Fig. 17.1). Vocal fold fibrous mass is an accumulation of fibrous material within the lamina propria of the vocal fold. It can be quite difficult to detect in some cases, and videostroboscopy is usually needed to make the diagnosis (see Chap. 3, “Videostroboscopy and Dynamic Voice Evaluation with Flexible Laryngoscopy”). Stroboscopy shows significantly reduced mucosal wave where the lesion is present. 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. Vocal fold cysts have a distinct and confined sac-like boundary, and in contrast, vocal fold fibrous masses are more diffuse and often have extensions anteriorly and/or posteriorly within the vocal fold.

Differential diagnosis for vocal fold cyst or fibrous mass is:

■Vocal fold polyp

■Rheumatologic lesion of the vocal fold

■Vocal nodules

■Reactive lesion

17.3Surgical Indications and Contraindications

Indications for surgery are symptomatic dysphonia and lack of resolution with maximum nonsurgical treatment (voice therapy).

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. 17.1  Vocal fold cyst (left)

17.4Surgical Equipment

The surgical equipment required is a standard phonomicrosurgery instrument set (see Chap. 10, Table 10.1).

17.5Surgical Procedure

The surgical approach to a vocal fold cyst or vocal fold fibrous mass uses a microflap (see Chap. 10, “Principles of Phonomicrosurgery”). There is little difference in the surgical technique for a cyst or fibrous mass. The technique described below applies to both lesions unless otherwise noted.

1.Microflap approach to a cyst or fibrous mass in the subepithelial location

a)Intubation with 5.0 microlaryngeal endotracheal tube

b)Expose larynx with laryngoscope

i.Use the largest laryngoscope that will adequately expose the entire vocal fold (see Chap. 10, “Principles of Phonomicrosurgery”).

c)Incision

i.Make incision just lateral to, or directly over the lesion, in a posterior-to-anterior direction or anterior- to-posterior direction.

110Vocal Fold Cyst and Vocal Fold Fibrous Mass

ii.Keep the incision superficial by maintaining a slight pull on the knife superiorly (toward yourself), which “tents” up the mucosa, protecting the deeper layers (Fig. 17.2).

iii.The incision should be slightly longer than the actual lesion to afford adequate space in which to work.

d)Separate the epithelial cover from the cyst/fibrous mass (Fig. 17.3).

i.Use the 30° flap elevator to develop a plane as superficially as possible between the overlying epithelium and the cyst/fibrous mass.

ii.The instrument can usually be visualized through the thin, semitranslucent flap (0.2-mm thick) during this step. The tip of the elevator should be pointing medially.

iii.Often there is adherence between the flap and cyst wall. It is best to start creating the dissection in undistorted tissue planes anterior and posterior to the lesion before dissecting directly over the lesion.

iv.The dissection is continued to the inferior-most portion of the lesion.

v.Use caution with the flap elevator inferiorly, as the tip of the instrument may perforate the delicate epithelial flap; gentle pressure laterally with the “back” of the flap elevator helps avoid perforation.

vi.It is important to perform the medial aspect of the dissection first, when natural “counter-traction” is provided by adherence of the lesion wall to the vocal ligament. If the epithelial cover is separated as the last step, then this dissection becomes much more difficult.

e)Separate the lesion from the vocal ligament.

i.Dissect between the cyst/fibrous mass and the vocal ligament with a 30° flap elevator (Fig. 17.4).

ii.The fibers of the vocal ligament run parallel to the long axis of the vocal fold and are white in color, with little vascularity. Great care should be taken to

avoid violation of the vocal ligament. Some scant ge- latinous-appearing material (SLP) can often be seen, and should be preserved.

iii.Avoidance of cyst wall rupture is tantamount to a successful surgery, as cyst dimensions may be difficult to define after rupture occurs.

iv.If there is penetration of the cyst, 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, and then dissection can be continued. If the cyst is ruptured completely, then careful and meticulous dissection and removal of all the cyst wall contents should be done.

f)Removal of lesion

i.Some sharp dissection with scissors may be necessary, if fibrous connections between the lesion and ligament cannot be bluntly dissected with the flap elevator. 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. 17.5).

ii.Often a fibrous mass will have fibrous extensions anteriorly and/or posteriorly. Depending on the thickness, these extensions can be left alone or removed. 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. Once all attachments of the lesion are freed, the lesion is removed and the flaps are replaced and allowed to coapt (Fig. 17.6).

iii.Epithelial resection is normally not necessary.

g)Special considerations for vocal fold cyst/fibrous mass near the vocal ligament

i.After cordotomy and the start of the microflap elevation, the vocal fold cyst/fibrous mass will be clearly visible in the “deep” portion of the vocal fold near or on the vocal ligament.

ii.When ligamentous pathology is present, the microflap is usually quite easily elevated, given that the lesion is deep to the area of dissection.

iii.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. 17.7).

iv.Microscissors are sometimes required to complete the dissection of the lesion off the vocal ligament.

v.The lesion is removed and the microflap redraped into its anatomic position.

vi.The vocal fold should be palpated, feeling for persistent pathology causing irregularity of the vocal fold.

17.6Postoperative Care and Complications

Postoperative care includes:

■Complete voice rest for 1 week

■Proton pump inhibitors (PPIs), pain medications as needed (tongue pain from suspension)

■Follow-up in 1 week, begin graduated voice use under supervision of SLP (if possible)

Fig. 17.7  Retraction of microflap demonstrating vocal fold fibrous mass on vocal ligament

Complications can include (see Chap. 12, “Management and Prevention of Complications Related to Phonomicrosurgery”):

■Chipped teeth (typically maxillary)

■Anesthesia/hypoesthesia of tongue, loss of taste

■ Due to pressure neuropathy of lingual nerve from

suspension laryngoscope

17 ■ Resolves in 2–3 weeks typically, 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, especially if cyst rupture has occurred prior to surgery. Occasionally, a sulcus vocalis deformity is seen, where the cyst extends into the vocal ligament, requiring dissection into the ligament and in some cases resection of vocal ligament fibers to remove the entire cyst wall. In these cases, prolonged hoarseness and slow recovery in voice quality can be expected. We recommend intensive voice therapy, oral corticosteroid taper, and reassurance. The use of steroids is especially indicated if erythema is present at the operative site.

■Cyst recurrence

■This is unusual except in the case of anterior commissure mucous retention cysts or type III sulcus vocalis. Recurrence is generally seen within 6–12 weeks after surgery. Revision phonomicrosurgical removal can be carried out after the third postoperative month, with meticulous detail paid to the removal of all cystic wall remnants; this may require limited vocal ligament fiber resection in some cases.

Key Points

■Diagnosis of vocal fold cyst and vocal fold fibrous mass may be difficult preoperatively; however, videostroboscopy greatly improves the chances of detection. Often exploratory cordotomy is required to differentiate between the diagnoses of a fibrous mass versus vocal fold cyst.

■Delicate handling of the cyst is necessary to avoid rupture, which will complicate the removal.

■Surgical dissection between the epithelial covering and cyst wall (medial dissection) should precede dissection between the lesion and vocal ligament (lateral dissection).

■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.

Selected Bibliography

1Courey MS, Garrett CG, Ossoff RH (1997) Medial microflap for excision of benign vocal fold lesions. Laryngoscope 107:340–344

2Courey MS, Shohet JA, Scott MA, Ossoff RH (1996) Immunohistochemical characterization of benign laryngeal lesions. Ann Otol Rhinol Laryngol 105:525–531

3Dikkers FG, Nikkels PG (1995) Benign lesions of the vocal folds: histopathology and phonotrauma. Ann Otol Rhinol Laryngol 104(Pt. 1):698–703

4Johns MM (2003) Update on etiology, diagnosis, and treatment of vocal fold nodules, polyps and cysts. Curr Opin Otolaryngol Head Neck Surg 11:456–461

5Rosen CA, Lombard LE, Murry T (2000) Acoustic, aerodynamic and videostroboscopic features of bilateral vocal fold lesions. Ann Otol Rhinol Laryngology 109:823–828

6Shohet JA, Courey MS, Ossoff RH (1996) Value of videostroboscopic parameters in differentiating true vocal fold cysts from polyps. Laryngoscope 106(Pt. 1):19–26

7Thekdi AA, Rosen CA (2003) Surgical treatment of benign vocal fold lesions. Curr Opin Otolaryngol Head Neck Surg 10:492–496

8Zeitels SM, Hillman RE, Desloge R, Mauri M, Doyle PB (2002) Phonomicrosurgery in singers and performing artists: treatment outcomes, management theories, and future directions. Ann Otol Rhinol Laryngol 190(Suppl.):21–40

Chapter 18

Polypoid Corditis

18.1Fundamental and Related Chapters

Please see Chaps. 4, 7, 8, 10, 11, and 12 for further information.

18.2Disease Characteristics

Polypoid corditis (commonly referred to as Reinke’s edema) is an alteration of the lamina propria that results in dysphonia, lowered pitch, and vocal instability (Fig. 18.1). The characteristic low-pitched, gravelly voice tends to be more easily identified in females because it is gender incongruous. It is a condition commonly associated with smoking—in fact, 97% of patients with polypoid corditis are smokers. In addition, LPR and phonotrauma are thought to be important contributing cofactors. In contrast to most other benign laryngeal lesions, polypoid corditis is a global, as opposed to focal, process of the vocal folds. The condition is almost exclusively bilateral, and involves expansion of Reinke’s space by an inflammatory gelatinous amorphous material that extends from anterior commissure to the vocal process. The disease can be quite subtle in the early stages, but over a period of years can grow to such proportions that the airway is compromised. Initially, the mucosal

18

wave is often amplified or increased due to the pliable nature of the gelatinous material in the SLP; however, with growth of the lesions, vibratory characteristics can be dampened and/or absent due to mass effect. One of the distinctive characteristics of polypoid corditis is the “saddle-bag” appearance the vocal folds take on, as the heavy, rounded vocal folds prolapse inferiorly with inspiration (Fig. 18.1).

18.3Surgical Indications and Contraindications

Indications for surgical intervention include:

1.Symptomatic dysphonia (generally more noticeable in females)

2.Lack of response to anti-reflux management with PPIs, voice therapy, and smoking cessation

Smoking cessation does not lead to resolution of the disease, but does halt its progression.

3.Airway obstruction due to advanced disease

This may occur when a patient has a preexisting severe polypoid corditis and develops unilateral vocal fold immobility, or upper airway edema from an additional inflammatory process such as an upper respiratory infection. The inability to improve the airway via abduction can lead to airway compromise.

4.Concern of malignancy

Some cases of polypoid corditis have overlying epithelial changes (e. g., leukoplakia) and can be worrisome for malignancy. In these cases, preservation of vibratory parameters does not guarantee benign disease because a microinvasive process can be camouflaged by the deep layer of gelatinous pliable material. In these cases, the diseased epithelial must be treated as displayed in Chap. 20, “Vocal Fold Leuko­ plakia.”

Contraindication for surgical intervention include continued smoking, which will almost assuredly result in a recurrence of the disease postoperatively—though it may take months to years to recur. This is a relative contraindication, and must be exercised on a case-by-case basis. Obviously, suspicion of malignancy or airway concerns overrides this contraindication.

Special consideration should be given (either preoperatively or intraoperatively) to whether to operate on both vocal folds or to stage the surgeries, one side at a time. A carefully planned incision (Fig. 18.2) can be used with bilateral surgery to avoid formation of an anterior glottic web. However, if this is not