Учебники / Operative Techniques in Laryngology Rosen 2008

Fig. 20.8  Redraping of flap to ensure complete removal of pathology

20

Fig. 20.10  Typical orientation of excised leukoplakic specimen for pathologist (A = Anterior, L = Lateral, P = Posterior, M = Medial)

20.6Postoperative Care and Complications

Postoperative management includes:

■Complete voice rest for 3–7 days

■PPIs, pain medication

■Follow-up 1–2 weeks to review pathology results

Fig. 20.9  Final (inferior) flap incision

Complications can include:

■Chipped teeth, hypoesthesia of tongue

■Recurrence of leukoplakia

Recurrence of leukoplakia is common in those patients that continue to smoke postoperatively; therefore, this should be part of pre operatively counseling. Patients may have other cofactors leading to the recurrence of leukoplakia, such as LPR, glottic incompetence, or HPV infection. These areas should be aggressively treated if they are suspected.

Key Points

■Videostroboscopy is an important component of the preoperative evaluation of vocal fold leukoplakia.

■Loss of mucosal wave can be seen with invasive forms of leukoplakia, while noninvasive forms tend to have preservation of vibratory characteristics.

■Subepithelial infusion is a very helpful adjunct in the surgical armamentarium, as it reduces intraoperative bleeding and lifts the diseased epithelium away from the vocal ligament, thus protecting it.

■Complete excision of the area of leukoplakia should be checked by redraping the flap during the final excisional step.

■Pinning and orienting the epithelial specimen can be very helpful in guiding any additional therapy.

Selected Bibliography

1Zeitels SM, Vaughan CW (1991) A submucosal true vocal fold infusion needle. Otol Head Neck Surg 105:478–479

2Zeitels SM (1995) Premalignant epithelium and microinvasive cancer of the vocal fold: the evolution of phonomicrosurgical management. Laryngoscope 105:1–51

3Zeitels SM (1993) Microflap excisional biopsy for atypical and microinvasive cancer. Operat Tech Otolaryngol Head Neck Surg 4:218–222

4.Schweinfurth JM, Powitzky E, Ossoff RH (2001) Regression of laryngeal dysplasia after serial microflap exision. Ann Otol Rhinol Laryngeal Sep; 110(9):811–4

21.1Fundamental and Related Chapters

Please see Chaps. 4, 9, 10, 11, 12, and 13 for further information.

21.2Disease Characteristics and Differential Diagnosis

Recurrent respiratory papilloma (RRP) is characterized by benign epithelial growths that are recurrent in nature after surgical removal. The lesions often have a distinct vascular “dot” in the center of individual papilloma growth (Fig. 21.1). RRP growths can be exophytic and/or superficial “spreading.” RRP can occur anywhere in the laryngotracheal area; however, the glottis is the most common site. 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. The etiologic agent of RRP is human papilloma virus (types 6–11 are the most common). Given the recurrent nature of RRP, careful and conservative surgery is crucial to

the surgical management of this disease. Often recurrent RRP patients have 50–100 surgeries in their lifetimes, 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, web formation, etc.). With the recurrent nature of RRP disease and the need for multiple repeated surgeries, phonomicrosurgery principles, concepts, and techniques are ideal for the surgical therapy of RPP (see Chap. 10, “Principles of Phonomicrosurgery”).

Differential diagnosis for RRP is:

■Squamous cell cancer

■Verrucous carcinoma

■Leukoplakia

■Granuloma

21.3Surgical Indications and Contraindications

Indications include:

■In pediatric cases of RPP, airway considerations are primal. For this reason, parent education on the importance of compliance with doctor’s visits and monitoring of symptoms and signs of airway difficulties are essential. Adult RRP surgery is usually indicated to rule out malignancy initially and to make a pathologic diagnosis. Subsequent to establishing the diagnosis of RRP, voice disturbance is the most common indication for surgical treatment of RRP.

■A key management principle in RRP is to focus attention and efforts on preventing the need for a tracheotomy. Tracheotomy creates a new epithelial transition site in the trachea and may lead to new RRP growth at the tracheotomy site. The presence of new RRP at the tracheotomy site significantly increases the level of complexity of the surgical management of these patients.

Contraindications include surgical excision without any voice, swallowing, or airway symptoms.

21.4Surgical Equipment

1.Standard phonomicrosurgery instrument set (see Chap. 10, Table 10.1)

2.Microdebrider (optional; described in Chap. 10)

3.CO2 or pulsed KTP laser (see Chap. 13, Sect. 13.4)

21.5Surgical Procedure

1.Overview

RRP is a recurrent disease process (99% of the time), and the most aggressive surgical excision does not equal better results, cure, or longer interval between surgical treatments. Thus, conservative removal and focus of improving functional improvement (airway, voice) not complete removal of the disease is important. This chapter describes the different surgical methods for RRP removal and then discusses surgical removal of RRP by different subsites within the larynx. When cidofovir injection is being combined with surgical excision, it can be done with any of the below described techniques (see “Cidofovir Laryngeal Injection for RPP,” below).

2.Microflap Removal of RRP (see Chaps. 10, “Principles of Phonomicrosurgery” and 20, “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).

b)Submucosal infusion of epinephrine throughout the intended surgical area (see Chap. 10)

c)A sickle knife is then used to incise the epithelium immediately lateral to the recurrent respiratory papilloma disease.

Note that no margin is required in removing the recurrent respiratory papillomatosis, however, gross disease should not be left, and thus the incision should be immediately adjacent to the interface of RRP and normal mucosa.

d)Subepithelial dissection (undermining of the RRP disease is then done with curved and angled elevators and sometimes with microcurved scissors). Great care should be exercised to stay very superficial (Fig. 21.2). Not staying as superficial as possible will result in unnecessary loss of vocal fold lamina propria and scar formation.

e)Incision through the epithelium can then be made anteriorly and posteriorly to the RRP, once again, with no need for a mucosal margin.

f)The RPP that is contained within the microflap can then be held with triangular forceps or a curved alligator, and then superficial dissection underneath the RRP can then be performed until the entire RRP has been incorporated within the microflap.

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. Inferior incision underneath the area of the microflap containing the RRP can then be done with a sickle knife or microscissors. This releases the RRP completely and specimen can be sent for pathologic examination (Fig. 21.3).

h)Hemostasis can be obtained with an epinephrine-soaked pledget.

i)Inspection (visual and by palpation) for RPP at the operative site is important. This should be done with both high-power microlaryngoscopy as well as with angled telescopes (see Chap. 10).

j)If more RRP is present, then further surgical removal can be done using another microflap approach or microforceps removal technique (see below).

3.Microforceps removal of RRP

a)Inject epinephrine subepithelially throughout the intended RRP excision site. This allows for hydrodissection of the RRP from the deeper structures of the vocal fold as well as enhances hemostasis.

b)Place epinephrine-soaked pledgets on the RRP site for several minutes.

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). 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.

d)The RRP within the forceps can then be gently avulsed by pulling the tissue in either a cephalad or caudal direction. Superior or inferior direction of avulsion is the safest (Fig. 21.4).

e)Avoid pulling the RRP anteriorly or posteriorly since this may result in “stripping” of normal adjacent mucosa inadvertently.

f)These steps can be repeated until all the intended RRP has been carefully removed. It is most expedient to have two microforceps available of similar size and nature to perform this type of surgical removal. 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. This cycle can be continued until all the RRP is removed in a fairly rapid fashion.

g)Epinephrine-soaked pledgets can be applied to the operative site to obtain hemostasis on an as needed basis.

4.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.

c)Implementation of all laser safety precautions (see Chap. 13, “Principles of Laser Microlaryngoscopy”)

d)It is best to use a “defocused spot size” 0.5–0.75 mm, with a low power (2–4 W) on intermittent superpulse setting.

e)The laser is used to vaporize the RRP; care should be taken to only ablate the RRP tissue and not the deeper aspect of the vocal fold. Power, spot size, and duration of exposure can be adjusted to prevent damage to deeper structures and transmission of thermal injury to surrounding regions. This surgery should be performed at high power magnification for maximum control and precision of the RRP removal.

f)Carbonaceous material from the laser ablation site should be removed frequently with suction cannulas (5 or 7 French).

g)Surrounding areas not intended for excision (i. e., contralateral, vocal fold, anterior commissure, false vocal fold, etc.) should be retracted or covered with saline-soaked pledgets to protect inadvertent injury or damage.

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. This can be achieved by moving the

laser beam in a smooth, controlled, and expedient fashion, thus preventing the same location from receiving repeated laser energy, which may result in deep tissue injury.

5.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, especially at the start of the case. This is especially true for the subglottis, glottis, and posterior glottis.

e)The microdebrider starting setting should be 800–1200 and then can be adjusted accordingly.

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. It is often helpful to “pin” the vocal fold in a stationary position with an adjacent blunt probe to prevent the deeper tissues (e. g., ligament) from being suctioned into the microdebrider chamber (Fig. 21.5).

g)As the settings are adjusted and comfort level of the surgeon is increased, the microdebrider can be placed closer to the RRP tissue, always attempting to apply minimal pressure to the RRP tissue with the microdebrider hand piece. Controlled removal of the RRP can be done in a fairly expedient fashion due to the rapid RRP removal afforded by the microdebrider.

h)Apply epinephrine-soaked pledget to the surgical site to obtain hemostasis after removal of the RRP.

i)To “capture” the RRP tissue for pathologic examination, a suction trap can be placed “inline” with the microdebrider suction and at the end of the procedure sent for pathologic examination.

6.Recurrent respiratory papilloma sites: technical aspects and methods for surgical removal: telescopic RRP surgery

Standard microlaryngoscopy visualization can be limited 21 in several locations (ventricle, 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. 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.

a)Supraglottis

The anatomic components of the supraglottis include laryngeal ventricles, false vocal fold, anterior face of the arytenoid cartilage, supraglottic portion of the arytenoid cartilages and the laryngeal surface of the epiglottis. The laryngeal ventricles are clearly the most difficult anatomic area to visualize and operate on within the larynx. 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). Surgical removal of gross

Fig. 21.6  Removal of RRP at the anterior commissure. (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). Cold-steel surgical excision of papilloma of supraglottic or CO2 laser area also all reasonable options for this region. Care should be taken to avoid demucosalization of the anterior aspect of the free edge of each false vocal fold to prevent supraglottic stenosis.

b)Glottis

The region of the glottis incorporates the superior surface of the vocal fold, the free edge of the vocal fold, and the infraglottic region. It also encompasses the anterior commissure. 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 preferred surgical removal of RRP in this region is a cold-steel approach (microflap, microforceps or microdebrider usually after submucosal infusion). It must be stressed and remembered that RRP is a superficial disease, and thus only epithelium needs to be removed. If RRP is extensively located on the superior surface of the vocal fold, then the complete visualization and subsequent removal can be further facilitated with submucosal infusion to medialize the disease for better visualization.

Specifically in the anterior commissure, the importance of precise and conservative surgical removal of disease in a unilateral nature to prevent glottic web formation is paramount. Telescopic examination is of further value for complete assessment of the disease at the anterior com-

missure and in the infraglottic regions. When working at the anterior commissure, in addition to not violating the contralateral mucosal or RRP covered tissue, careful retraction of the vocal fold for full exposure of the anterior commissure is essential (see Fig. 21.6). This can be done with a contralateral hand instrument or a self-retaining retraction instrument. When surgically removing RRP from only one side of the anterior commissure, it is wise to make an initial “incision” or “cut” through the RRP at the anatomic midline. Then unilateral RRP removal can proceed with little chance of accidental bilateral RRP removal.

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. Optimal surgical technique and removal of disease in this area involves either cold steel excision or mi-

crodebrider. If visualization is particularly difficult, 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. It must be stressed that

the CO2 laser must be used in a conservative fashion, including protection of surrounding laryngeal tissues and using the laser in a low-power and intermittent delivery mode.

d)Posterior commissure

The posterior commissure is the region of the larynx extending from the arytenoid region down into the subglottis. 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). To facilitate further exposure in this region, often instrumentation is required to retract the arytenoid cartilages to examine fully this region. Telescopic examination (30 and 70° telescopes) is helpful to visualize this area and determine the nature and extent of the RRP disease. 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. Microforceps or microdebrider are good methods for unilateral, staged excision of RRP to prevent posterior glottic stenosis.

7.Cidofovir laryngeal injection for RPP

Cidofovir is an antiviral agent that has been used extensively recently as an adjunct treatment for RPP. 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. Presently, the most common method of cidofovir use is laryngeal injection of cidofovir after conservative surgical removal of the RRP. The best RRP disease control occurs with repeated cidofovir injection at the same time that staged surgical excision is performed. Typically, patients receive intralesional cidofovir injection on a monthly basis for three or more total injections times. There is no standard dose of concentration of cidofovir for injection, however, 5 mg/ml is a reasonable dose used by many.

The surgical technique associated with cidofovir injection involves a two key principles. First, it is important to remember that the etiologic viral agent of RRP, human papilloma virus, is known to be present throughout the mucosa of the entire upper airway. For this reason, it is prudent to inject cidofovir in normal appearing mucosa in a wide region around and inside the larynx. Secondly, cidofovir can be injected submucosally prior to a surgical excision as well as immediately after the surgical excision. 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. Cidofovir injection can be done with a fine-gauge needle (25–27 g) and should be done in a superficial (subepithelial) fashion. Cidofovir injection is done in this location, given that past research has identified the human papilloma virus in the epithelium of the upper airway.

Cidofovir intralaryngeal injection after surgical excision can be done in anatomic subunits to insure wide mucosal distribution of the antiviral agent. Cidofovir injection should be done in a caudal to cephalad direction. The typical sequence of intralaryngeal cidofovir injection will cover the following areas in this order: subglottis, posterior commissure (bilateral), free edge of vocal fold (bilateral), superior surface of vocal fold and ventricle (bilateral), false vocal fold (bilateral), and supraglottic larynx on an as-needed basis. When there is mucosa present in the area to be injected, the injection needle should be placed in the subepithelial plane. Often cidofovir can be infused submucosally in a large area of the laryngeal subunits described above with a single injection.

Cidofovir injection into areas without mucosa, due to recent RRP removal, should be done in the most superficial plane possible. In these settings, multiple superficial injections are required since the tissue planes are absent or distorted, negating the ability to distribute cidofovir over a large area with a single injection.

21.6Postoperative 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

Key Points

■RRP is a recurrent disease that requires precise and conservative surgical removal.

■RRP surgical removal often requires different surgical methods (microflap, microforceps, laser, or microdebrider).

■Angled telescopes especially (30 and 70°) are helpful in evaluating laryngeal RRP immediately prior to excision, during surgical excision, and at the completion of RRP removal.

Selected Bibliography

1Kashima H, Mounts P, Leventhal B et al (1993) Sites of predilection in recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol 102:580–583

2Lee AS, Rosen CA (2004) Efficacy of cidofovir injection for the treatment of recurrent respiratory papillomatosis. J Voice 18:551–556

3Mounts P, Sha KV, Kashima H (1982) Virtual etiology of juvenile and adult onset squamous papilloma of the larynx. Proc Natl Acad Sci USA 79:5425–5429

4Steinberg B, Topp W, Schneider P et al (1983) Laryngeal papilloma virus infection during clinical remission. N Engl J Med 308:1261–1264

5Zeitels SM, Sataloff RT (1999) Phonomicrosurgical resection of glottal papillomatosis. J Voice 12:1323–1327

22.1Fundamental and Related Chapters

Please see Chaps. 4, 8, 10, 11, 12, and 13 for further information.

22.2Diagnostic Characteristics and Differential Diagnosis of Vocal Fold Varicosities

In healthy vocal folds, blood vessels run parallel to the vibratory margin and are somewhat tortuous. The parallel arrangement helps prevent obstruction of the microcirculatory system of the vocal fold mucosa during high-pressure shearing movement during phonation; the tortuosity helps the vessels maintain functional patency when the vocal fold length is altered during pitch changes. Although there are numerous arteriovenous anastomoses, there is little or no direct connection between the microvasculature of the superficial lamina propria of the vocal fold, and the thyroarytenoid muscle. This arrangement helps optimize the mucosal cover’s flexibility during shearing, permitting the shearing motions required for normal mucosal wave motion without vasculature accidents. Considering the delicacy of vocal fold blood vessels and the force to which they are subjected, it is not surprising that vascular pathologies occur.

It is convenient to divide common vascular lesions into three categories. A varix is an enlarged vein, or a large, acutely tortuous vessel. Varices may be parallel to the vibratory margin (normal orientation) or more perpendicular to the edge of the vocal fold (Fig. 22.1). A papillary ectasia is a blood-filled venous enlargement that appears similar to a spheroid hemangioma. Papillary ectasias may occur in small clusters and appear similar to coalescent hemangiomas (Fig. 22.2). A spider telangiectasia is a delicate network of inappropriately oriented blood vessels (Fig 22.3). Diagnosis is generally based on visual inspection. Examination should include high-quality, magnified visualization of the vocal fold. Strobovideolaryngoscopy is helpful not only in defining the extent of a lesion and its mobility or fixation to underlying tissues, but also the presence of surrounding stiffness that may have resulted from previous traumatic hemorrhage. Most varicosities and ectasias occur on the superior surface of the vocal fold, particularly near the mid portion of the musculomembranous portion of the vocal fold, where shearing forces are greatest. However, these lesions may occur on the vibratory margin and below the vibratory margin, as well. Hence, it is helpful to view the vocal fold tangentially

Fig. 22.1  Vocal fold varix (see arrow)

Fig. 22.2  Vocal fold papillary ectasia

with a laryngeal telescope during office evaluation, and to observe the vocal folds using 0, 30, and 70° laryngeal telescopes intraoperatively in order to map the vasculature accurately.

True hemangiomas of the vocal fold are rare, but have occurred. In addition, other structures that may be mistaken for varicosities or ectasias include:

Fig. 22.3  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, premenstrual hormonal influences, pregnancy, recent extensive voice use, and other factors

■Hemorrhagic vocal fold polyp

Relative contraindications include:

■Vascular abnormalities that occur only premenstrually and are unassociated with hemorrhage

■It is usually possible to control these with hormonal manipulation.

■Lesions associated with Osler–Weber–Rendu syndrome.

■Minimally symptomatic lesions that have not bled, in high sopranos (coloraturas), because of increased risks of adverse effects on performance from even minimal postoperative stiffness.

■Asymptomatic lesions that pose no significant risk of hemorrhage

22.4Surgical Equipment

1.Standard phonomicrosurgery set (Chap. 10, Table 10.1).

2.Sataloff vascular knife (Medtronic-ENT, Jacksonville, Fla.), or custom-made vascular knife, fashioned by bending a 30mm laryngeal injection needle

3.CO2 laser with a microspot delivery system (Chap. 13)

4.Pulsed dye laser or pulsed-KTP laser (Chap. 13)

22.5Surgical Procedure

There are three primary approaches to vascular lesions including operative resection, operative CO2 laser coagulation or vaporization and pulsed laser therapy. This chapter concentrates on intraoperative resection, but all three options are addressed at least briefly below.

1.Operative resection

a)Intubation with a 5.0 laser-safe endotracheal tube Although the laser will not be required in most cases, it is appropriate in some patients; and it is prudent for it to be available, and for appropriate airway precautions to be in place (see Chap. 13, “Principles of Laser Microlaryngoscopy”).

b)Expose the larynx with suspension laryngoscopy.

Use the largest laryngoscope that exposes the entire vocal fold adequately (see Chap. 10, “Principles of Phonomicrosurgery”) Anterior laryngeal pressure (stabilized with silk tape) can be used to bring the anterior commissure into view, if necessary. However, this maneuver alters vocal fold tension, slackens, and distorts the blood vessels, and can make blood vessel resection more difficult. It is preferable to obtain anterior commissure exposure through optimal laryngoscope selection.

c)Careful evaluation of the vocal fold should be done with the 30 and 70° telescope through the suspended laryngoscope. Care should be taken to identify abnormal vascular lesions at the anterior commissure, midmembranous vocal fold region and near the vocal process. These are the areas in which vascular lesions are most commonly seen. The angled telescopes are especially useful for identifying vascular lesions arising in the infraglottic portion of the vocal folds.

d)Vocal fold palpation should be done under high-power magnification looking for associated vocal fold pathology (sulcus vocalis, scar, polyp, etc.).

e)Incision

A superficial epithelial incision should be made immediately adjacent to the blood vessel. This can be made with a laryngeal sickle knife, but use of the knife is rarely required. The tip of the vascular knife is a sharp point. If the vascular knife is oriented parallel to the blood vessel and placed adjacent to it, 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. 22.4).