Учебники / Operative Techniques in Laryngology Rosen 2008

is typically taken from subcutaneous area. The axilla is the author’s preferred site, making a small incision at the anterior axillary line, because this area is easily accessible during microlaryngoscopy and the incision is hidden in the axilla.

a)Inject local anesthesia at the proposed harvest site.

b)Prepare the skin with antiseptic.

c)A small skin incision is used to expose the subcutaneous fat (approximately 5 mm).

d)Harvest fat with scissors, taking care not to include any associated dermis, hair follicles, or to use electric cautery

e)Cut fat into small pieces approximately 1 × 1 × 1 mm.

f)Rinse the harvested fat with approximately 1 liter of saline.

g)Soak the fat in regular insulin for 5 min (see Chap. 31, “Vocal Fold Augmentation via Direct Laryngoscopy”)

23.6Postoperative 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. 12, “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. This is a theoretical complication and has not been seen.

Key Points

tion or a Gray’s minithyrotomy.

Selected Bibliography

1Fleming DJ, McGuff S, Simpson CB (2001) Comparison of microflap healing outcomes with traditional and microsuturing techniques: initial results in a canine model. Ann Otol Rhinol Laryngol 110:707–12

2Ford CN, Inagi K, Khidr A, Bless DM, Gilchrist KW (1996) Sulcus vocalis: a rational analytical approach to diagnosis and management. Ann Otol Rhinol Laryngol 105:189–200

3Neuenschwander MC, Sataloff RT, Abaza MM, Hawkshaw MJ, Reiter D, Spiegel JR (2001) Management of vocal fold scar with autologous fat implantation: perceptual results. J Voice 15:295–304

4Pinho SR, Pontes P (2002) Escala de avaliação perceptive da fonte glótica: RASAT. Vox Brasilis 8:11–13

5Pontes P, Behlau M (1993) Treatment of sulcus vocalis: auditory perceptual and acoustical analysis of the slicing mucosa surgical technique. J Voice 7:365–376

6Pontes PAL, Behlau M (1993) Treatment of sulcus vocalis: auditory perceptual and acoustical analysis of the slicing mucosa surgical technique. J Voice 7:365–376

7Rosen CA (2000) Vocal fold scar: evaluation and treatment. Otolaryngol Clin N Am 33:1081–1086

8Sataloff RT, Spiegel JR, Hawkshaw M, Rosen DC, Heuer RJ (1997) Autologous fat implantation for vocal fold scar: a preliminary report. J Voice 11:238–246

9Woo P, Casper J, Griffin B, Colton R, Brewer D (1995) Endoscopic microsuture repair of vocal fold defects. J Voice 9:332–339

24.1Fundamental and Related Chapters

Please see Chaps. 8, 10, 13, and 42 for further information.

24.2Disease Characteristics and Differential Diagnosis

In every Teflon injection, an inflammatory response to the Teflon occurs. In most cases, the inflammatory response remains localized, and no significant clinical complications are noted. However, there is a risk of clinically evident expansile granuloma formation in these patients. Often this occurs years after the initial injection, after a prolonged period of good voice. Anecdotal evidence suggests that subsequent laryngeal trauma (i. e., intubation) may contribute to growth of the granuloma.

Teflon granuloma is typically a submucosal smooth mass that presents as a bulge in the false vocal cord, ventricular mucosa and/or the true vocal fold (Fig. 24.1). The granuloma may grow inferiorly resulting in a subglottic bulge as well. Videostroboscopy is quite consistent in these patients, revealing a stiff, nonvibratory vocal fold mass. This is due to either mass effect (stretching of vocal fold mucosa with dampening of wave) or, more commonly, the infiltration of the granuloma into the lamina propria and/or mucosa. Glottic incompetence is commonly present, secondary to the mass lesion. Occasionally, the patient’s airway is compromised, especially if the granuloma is subglottic.

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. In this way, superficial Teflon granulomas can be distinguished from granulomas that are more extensive. Typical CT appearance is a brightly enhancing, fairly well-circum- scribed mass in the paraglottic space.

24.3Surgical Indications and Contraindications

Indications include:

■Dysphonia due to expanding Teflon granuloma, 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

Contraindications are:

■Attempted complete removal of granuloma—this is not possible endoscopically with these lesions

■Severe medical comorbidities that preclude surgery

24.4Surgical Equipment

Equipment comprises standard laser microlaryngoscopy set (Chap. 13, “Principles of Laser Microlaryngoscopy”).

24.5Surgical Procedure

The procedure is performed as follows:

1.Intubate patient with laser-protected tube. Protect patient, ETT, and OR personnel, (see Chap. 13., “Principles of Laser Microlaryngoscopy”).

2.Palpate involved vocal fold, and examine with angled telescopes to define the extent of the granuloma in a vertical plane.

Fig. 24.1  Photo of Teflon granuloma on the left vocal fold. Note convex bulge due to expansile granuloma

Fig. 24.4  Coronal diagram of Teflon granuloma

24

3.The CO2 laser with the micromanipulator should be placed on a setting between 4 and 8 W superpulse or intermittent with an on time of 0.1 s/off time of 0.5 s.

4.Outline the incision (using spaced laser marks) at the lateral aspect of the superior surface of the true vocal fold (Fig.

24.2). Dissection with the CO2 laser and/or microlaryngeal instrumentation is performed until the Teflon is encoun- tered—recognized by its characteristic “sparkle” when vaporized by the laser.

Fig. 24.5  Diagram depicting the area of proposed removal of the granuloma (pink) at the medial edge of the vocal fold, from superior to inferior. Note the lateral extension of the excision infraglottically

5.The laser can be used to ablate the Teflon mass in the paraglottic space (Fig. 24.3). The most medial portion of the granuloma should be first obliterated in an even fashion from superior to inferior.

6.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.

Fig. 24.7  Postoperative result

7.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. 24.5, 24.6).

8.Completion of the procedure is achieved when the vocal fold soft tissue is redraped over the residual Teflon mass operative site. Sutures can be place at the cordotomy site as needed; however, this is usually not necessary.

9.Completed excision, showing relatively symmetric appearance of the operated an uninvolved vocal fold (Figs. 24.7, Fig. 24.8).

24.6Postoperative Care and Complications

■The most feared complication is a laser fire. Laser precautions must be followed, especially the use of a laser-protected tube and oxygen concentrations of 35% or less.

■Voice rest should be between 3 and 7 days, depending on the clinical situation.

■PPIs and pain medicine. Antibiotics are optional.

■There is a small risk of igniting the granuloma with the

CO2 laser, but this is minimized to a negligible level using lower-power setting.

■Because the Teflon is often exposed with this approach, there can granulation tissue formation post operatively. This is managed conservatively with PPIs and observation. It should resolve over several weeks. Preserving intact mucosa on the free edge and infraglottic surface of the vocal fold will minimize this complication.

Key Points

■Teflon granuloma typically present many years after injection, with slowly worsening dysphonia that may progress to airway difficulties.

■Although complete removal of Teflon granuloma is frequently not possible using an endoscopic approach, symptomatic improvement can be achieved.

■The goal of endoscopic treatment for Teflon granuloma of the larynx is to recontour a straight edge to the involved vocal fold.

25.1Fundamental and Related Chapters

Please see Chaps. 10, 11, 12, 13, and 43 for further information.

25.2Disease Characteristics and Differential Diagnosis

The normal saccule arises as a diverticulum originating at the anterior portion of the ventricle, and extending upward into the supraglottis. It is sandwiched between the false vocal fold medially and the aryepiglotticus muscle and thyroid cartilage laterally. The saccule contains numerous mucus-secreting glands, and acts as a reservoir, 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, and can be categorized as congenital or acquired. Two anatomic types of saccular cysts exist: anterior and lateral. Anterior saccular cysts tend to be smaller in size, and project into the laryngeal lumen in the anterior ventricular region. Lateral saccular cysts are typically larger and present as a bulge in false vocal fold and/or aryepiglottic fold. (Figs. 25.1, 25.2) In rare cases, the cyst can extend into the neck through the thyrohyoid membrane, although this is more typical of a laryngopyocele. Although most saccular cysts are benign in nature, there is an

increased incidence of dilated saccules in patients with squamous cell carcinoma of the larynx.

Fine cut (1–1.5 mm) CT scan of the larynx with contrast is recommended to confirm the diagnosis, and to define the extent of the cyst (Fig. 25.3).

Fig. 25.2  Saccular cyst, lateral

25.3Surgical Indications and Contraindications

Indications for excisional intervention include:

1.Hoarseness

2.Airway compromise

3.Concern of malignancy (especially in patient with smoking history)

In nonsmoking asymptomatic patients, and medically infirm patients for whom elective surgery is contraindicated, observation is acceptable. Periodic reexamination of the larynx with photodocumentation and/or CT scanning may be warranted to monitor for any changes of the cyst.

Relative contraindications include:

■Pediatric cases (external approach favored)

■Extension of the cystic mass into the neck (external approach recommended)

25.4Surgical Equipment

Equipment needed includes:

■Standard laser microlaryngoscopy set (Chap. 13)

■Laryngeal bipolar device (Instrumentarium, Montreal, Quebec, Canada)

■Lindholm or bivalue type laryngoscope

■CO2 laser

25.5Surgical Procedure for Saccular Cyst

The following procedure is adapted from Hogikyan et al.:

1.Intubation with 5 or 5.5 laser-protected ETT

2.Expose supraglottis on involved side widely (Lindholm or bivalve laryngoscope often needed) (Fig. 25.4) and place in suspension. The distal tip of the Lindholm laryngoscope rests in the vallecula to achieve wide supraglottic exposure.

3.Observe standard laser precautions (see Chap. 13, “Principles of Laser Microlaryngoscopy”)

a)Moist eye pads, 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.A curvilinear laser mucosal incision is made over the lateral aspect of the false vocal fold. A lateral relaxing incision may be required into the aryepiglottic fold in some cases, if lateral extension is extensive (Fig. 25.5).

5.The lateral extension of the cyst is dissected, retracting the mucosa medially, and using blunt dissection with a 5- French suction (a 30° dull flap elevator can be used, but is likely to cause perforation of the cyst, which may complicate the resection) (Fig. 25.6). This lateral dissection can extend to the thyroid ala, and branches of the superior laryngeal vasculature may cause troublesome bleeding. Suction and bipolar laryngeal cautery are often useful, as the laser may be ineffective in stopping bleeding from larger vessels such as these.

6.The dissection is continued around the inferior aspect of the cyst, using blunt dissection with 5-French suction, and scissors as needed (Fig. 25.7).

7.Taking care to protect the underlying true vocal fold using platform suction, the anterior and posterior cuts are made with the laser (Fig. 25.8). These cuts encompass the full extent of the cyst, and include the attached mucosa of the ventricle and false vocal fold (FVF) with the specimen, to prevent recurrence. A suture is occasionally needed to reattach the false vocal fold laterally, but trimming of redundant mucosa is often all that is needed.

Fig. 25.6  Exposed cyst after initial incisions

8.Excision of anterior saccular cysts utilizes the same approach and techniques as described above. These lesions are usually easier to remove because of their size and favorable location.

25.6Postoperative Care and Complications

■Consider overnight admission for airway observation/ precautions in cases where extensive dissection and suspension were used.

■Postoperative care should include PPIs (to reduce the chance of granuloma formation), pain medicine, and a normal diet as tolerated.

■Adverse outcomes

■Cyst recurrence is a risk with endoscopic excision, and great care must be taken to include all of the ventricular mucosa with the specimen by removing the entire inferior FVF and ventricle.

■In cases of recurrence, an open approach is indicated for re-excision. Care should be taken to avoid dissection into the paraglottic space at or below the level of the true vocal fold.