Учебники / Operative Techniques in Laryngology Rosen 2008

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Fig. 38.19  Carving a left-sided implant. A mark is made on the implant corresponding to the point of maximal medialization (“A” length from Fig. 38.17)

Fig. 38.21  A triangular implant is then created

Fig. 38.20  A line is drawn perpendicular, beginning from the “A” mark, extending the distance determined by the depth of medialization (“B” length from Fig. 38.18)

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Fig. 38.28  Trimming of excess implant

Fig. 38.29  Securing the implant to the lower strut with two 4-0 Prolene sutures

will facilitate easier placement of a large implant through the window. The A and B measurements are rechecked for accuracy.

Finally, the implant is removed from the holder, and the posterior 7 mm of the “slot” is removed from the implant (Fig. 38.27). The implant is now ready for placement.

18.Place the implant through the window using two Adson’s forceps with teeth. The posterior inferior part of the implant should be advanced into the paraglottic space first.

19.Once the implant is in place, the patient’s voice should be rechecked, and the laryngoscopic image should be observed to insure that the medialization recreates what was achieved with the depth gauge. If the voice sounds

“pressed” or “strained,” then the anterior portion of the implant should be grasped and pulled out of the window slightly. If this improves the voice, then there is too much medialization anteriorly, and the implant should be removed and reduced by an appropriate amount. On the other hand, if the voice sounds breathy, then the implant can be displaced posteriorly. One must be patient to try a variety of maneuvers to insure the implant is ideally suited to improve the voice. This may take an extra 10–15 min, but pays dividends.

20.Trim the excess implant lateral to the thyroid ala to make it flush with the cartilage (Fig. 38.28).

21.Secure the implant to the thyroid cartilage with permanent sutures (4.0 Prolene) around the inferior “strut” of cartilage (Fig. 38.29).

22.Ensure the wound is dry, and close all layers including outer perichondrium, strap muscles, platysmal, and skin. In general, a drain is not necessary, but may be placed depending on the surgeon’s preference.

38.6Postoperative Care and Complications

Postoperative care after medialization includes:

■Overnight, 23-h observation

■Pain management

■Intravenous steroids at 8-hour intervals (Decadron, 8 mg, then 4 mg)

■Elevation of the head of bed

■A return to clinic is scheduled 2–4 weeks after surgery.

■In general, the patient’s voice is poor within 6–8 h after surgery, due to edema.

Common mistakes include medialization too far superiorly within the window. In this instance, the indwelling laryngoscopic image will show a medialized false vocal fold or bulging of the ventricular mucosa—sometimes a subtle finding. Another common mistake is excess medialization of the anterior commissure. In this case, the voice has a distinctive “pressed” or “strained” quality.

Implant extrusion or exposure is another potential complication. Implant extrusion probably arises due to unrecognized tear in the ventricular mucosa and soiling of the wound with respiratory secretions. The implant may extrude through the skin incision or into the airway, possibly precipitating an airway foreign body emergency. Securing the implant with sutures significantly reduces the risk of this complication.

Yet another complication is undermedialization. This probably occurs when excessive edema of the vocal fold occurs prior placement of the implant. The patient is noted to have an excellent voice interoperative when the implant is placed, but the voice begins to fade 1–2 weeks post operatively, as the edema resolves. In cases where a prolonged period elapses between the opening of the window and final placement of the implant, one must anticipate the vocal fold will be slightly overmedialized, and the voice slightly strained to account for this edema.

Key Points

■Silastic ML is a long-lasting treatment for symptomatic UVFP.

■The procedure is performed under local anesthesia with an indwelling flexible laryngoscope so that vocal fold position and the patient’s voice can be used as feedback to optimize results.

■The inferior muscular tubercle must be exposed to define the true lower border of the thyroid cartilage; this will aid in correctly identifying the horizontal plane of the true vocal fold.

■The inner perichondrium of the thyroid cartilage must be divided to achieve unencumbered medialization.

■The paraglottic space should not be undermined anteriorly so as to avoid violation of the ventricular mucosa.

Selected Bibliography

1Koufman JA (1986) Laryngoplasty for vocal cord medialization: an alternative to Teflon. Laryngoscope 96:726–731

2Netterville JL. Stone RE. Luken ES. Civantos FJ (1993) Ossoff RH. Silastic medialization and arytenoid adduction: the Vanderbilt experience. A review of 116 phonosurgical procedures. Ann Otol Rhinol Laryngol 102:413–424

3Wanamaker JR, Netterville JL, Ossoff RH (1993) Phonosurgery: Silastic medialization for unilateral vocal fold paralysis. Oper Tech Otolaryngol Head Neck Surg 4:207–217

39.1Fundamental and Related Chapters

Please see Chaps. 5, 36, 37, 38, 40, for 41 further information.

39.2Disease Characteristics and Differential Diagnosis

Gore-Tex® medialization laryngoplasty is an effective treatment option for many conditions that cause glottal imcompetence. This can be due to vocal fold atrophy, paresis or paralysis. Often patients will be found to have a “bowed” appearance of the vocal fold with these conditions.

Vocal fold “bowing” is a term referring to a scalloped contour to the vocal fold. Bowing is a descriptive term, not a diagnostic one. Vocal fold bowing is most often due to age-re- lated changes, or deinnervation of the vocal folds (complete paralysis, or partial paresis). A differential diagnosis of vocal fold bowing includes:

■Deinnervation (vocal fold paralysis/paresis)

■Age-related changes (presbylaryngis/vocal fold atrophy)

■Tissue loss from ablative/destructive vocal fold procedures

■Vocal fold scar

■Sulcus vocalis deformity

■Myopathic disease (rare)

39.3Surgical Indications and Contraindications

The use of GORE-TEX® as a medialization laryngoplasty (ML) implant material was first reported by McCulloch and Hoffman in 1998 and its ease of handling has made it use in this procedure increasingly common. Many surgeons prefer GORE-TEX for ML, especially in the bowed, mobile vocal fold. For some, it is faster than using Silastic, creates less edema, and therefore decreases the chance of overcorrecting the anterior commissure (particularly if performing a bilateral ML) and allows placement of the implants closer to the vocal process without limiting their abduction.

GORE-TEX ML provides an excellent option for surgical treatment of symptomatic patients with moderate to severe vocal fold atrophy/bowing or paresis (glottal gap > 1 mm), as well as unilateral vocal fold paralysis.

Unilateral GORE-TEX ML can be used in cases of symptomatic glottal insufficiency due to:

■Unilateral vocal fold immobility, paralysis paresis, or atrophy

■Unilateral vocal fold scarring or soft tissue loss

Bilaterally, GORE-TEX ML can be used to correct mild to severe degrees of glottal insufficiency in cases of:

■Presbylaryngis (vocal fold atrophy)

■Bilateral vocal fold paresis

■Select cases of Parkinson’s disease with vocal fold atrophy

Contraindications for GORE-TEX ML include:

■Previous history of radiation therapy to the larynx (relative)

■Malignant disease overlying the laryngotracheal complex

■Poor abduction of the contralateral vocal fold (due to airway concerns)

■Presence of lesion on the vocal folds

39.4Surgical Equipment

Needed equipment comprises:

■Drill with 2- to 3-mm cutting burr

■Kerrison rongeurs tray (1- to 3-mm-sized tips)

■Ruler

■Flexible laryngoscope

■C-mount camera with videocart/monitor

■Overdrape for laryngoscope (1010 drape)

■Local anesthetic (nasal and subcutaneous)

■GORE-TEX strip

The implant itself is a GORE-TEX cardiovascular patch (0.4 mm in thickness) cut in strips 3- to 4-mm wide (as described by McCullough) and soaked in 50,000 U of bacitracin in saline. Creating the GORE-TEX ribbon prior to patient contact allows the remainder of the patch to be reprocessed for future use. Preformed GORE-TEX ribbon for thyroplasty (0.6-mm thickness) is also available (Medtronic ENT, Jacksonville Fla.).

and acoustically evaluated using vocal feedback from the patient.

11.The GORE-TEX implant is placed as a stacked strip using jeweler’s forceps (or middle ear alligator forceps), and its shape can be easily adjusted for optimal vocal fold medialization (Fig. 39.5). Care is taken to insert the ribbon into the window and when possible, medial to the edge of the anterior, inferior, and posterior edges of the cartilage. This helps maintain the implant’s position. Once the optimum voice is obtained, the vocal folds are slightly overcorrected to compensate for intraoperative edema and implant compression (Fig. 39.6).

12.The implant is stabilized by suturing the outer perichondrial flap back into place using 4-0 nylon sutures. The wound is closed in layers, and drains are rarely required.

39.6Postoperative Care and Complications

Postoperative care after medialization includes:

■Overnight, 23-hr observation

■Pain management

■Oral antibiotics for 7 days

■Intravenous steroids at 8-hour intervals (Decadron, 8 mg, then 4 mg)

■Elevation of the head of bed

■A return to clinic is scheduled 2–4 weeks after surgery.

■In general, the patient’s voice is poor within 6–8 h after surgery, due to edema.

A common mistake includes medialization too far superiorly within the window. In this instance, the indwelling laryngoscopic image will show a medialized false vocal fold or bulging of the ventricular mucosa—sometimes a subtle finding. Another common mistake is excess medialization of the anterior commissure. In this case, the voice has a distinctive “pressed” or “strained” quality. It is important to note that the technique of bilateral GORE-TEX ML used for the treatment of bowed (but mobile) vocal folds is not the same as the standard ML for unilateral vocal fold paralysis. The technique differs in important ways. (1) Overcorrection anteriorly must be carefully avoided, since excessive anterior medialization will cause a harsh, strained voice. This error can easily occur during bilateral ML surgery. (2) The posterior extent of the implant must not contact the vocal process of the arytenoid cartilage. Since the vocal folds are mobile, an implant projecting too far posteriorly could impinge on the arytenoid, and thus restrict arytenoid motion. In active individuals, this can result in dyspnea with exertion.

Implant extrusion or exposure is another potential complication. Implant extrusion probably arises due to unrecognized tear in the ventricular mucosa and soiling of the wound with respiratory secretions. The implant may extrude through the skin incision or into the airway, possibly precipitating an airway foreign body emergency. The implants should be fixed in place via replacement of the perichondrial flap.

Fig. 39.3  Cutting burr is used to enlarge the pilot opening

Fig. 39.4  Further enlargement of the window using a Kerrison rongeur to a final size of 3 × 6–12 mm

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Fig. 39.5  Folding in GORE-TEX ribbon through the thyroid cartilage window

Fig. 39.6  Final contour of vocal fold after GORE-TEX is layered into the window (axial view)

Key Points

■GORE-TEX laryngoplasty is a long-lasting, but readily reversible treatment for symptomatic glottal insufficiency, and can be performed bilaterally.

■The procedure is performed under local anesthesia, with an indwelling flexible laryngoscope so that vocal fold position and the patient’s voice can be used as feedback to optimize results.

■Overcorrection anteriorly must be carefully avoided (especially when bilateral ML is performed) to avoid a harsh, pressed voice.

■The posterior extent of the GORE-TEX implant must not contact the vocal process of the arytenoid cartilage, as this may restrict arytenoid motion and lead to airway difficulties.

Selected Bibliography

1McCulloch TM, Hoffman HT (1998) Medialization laryngoplasty with expanded polytetrafluoroethylene. Surgical techniques and preliminary results. Ann Otol Rhinol Laryngol 107:427–432

2Giovanni A, Gras R, Grini MN, Robert D, Vallicioni JM, Triglea JM (1997) Medialization of paralysed vocal cord by expansive polytetrafluoroethylene implant (GORE-TEX). Ann Otolaryngol Chir Cervicofac 114:158–164

3Giovanni A, Vallicioni JM, Gras R, Zanaret M (1999) Clinical experience with GORE-TEX for vocal cord medialization. Laryngoscope 109:284–288

4Zeitels SM (2000) New procedures for paralytic dysphonia: ad-

duction arytenopexy, Goretex medialization laryngoplasty, and cricothyroid subluxation. Otolaryngol Clin North Am 33:841–854

5McCulloch TM, Hoffman HT, Andrews BT, Karnell MP (2000) Arytenoid adduction combined with GORE-TEX medialization thyroplasty. Laryngoscope 110:1306–3111

6Zeitels SM, Mauri M, Dailey SH (2003) Medialization laryngoplasty with GORE-TEX for voice restoration secondary to glottal incompetence: indications and observations. Ann Otol Rhinol Laryngol 112:180–184

7Cohen JT, Bates DD, Postma GN (2004) Revision GORE-TEX medialization laryngoplasty. Otol Head Neck Surg 131:236–240

8Koufman JA (1989) Surgical correction of dysphonia due to bowing of the vocal cords. Ann Otol Rhinol Laryngol 98:41–45

9Postma GN, Blalock PD, Koufman JA (1998) Bilateral medialization laryngoplasty. Laryngoscope 108:1429–1434

10Koufman JA, Postma GN (1999) Bilateral medialization laryngoplasty. Oper Tech Otolaryngol Head Neck Surg 10:321–324

11Cashman S, Simpson CB, McGuff HS (2002) Soft tissue response of the rabbit larynx to GORE-TEX implants. Ann Otol Rhinol Laryngol 111:977–982

40.1Fundamental and Related Chapters

Please see Chaps. 5, 36, 37, 38, 39, and 41 for further information.

40.2Fundamentals of Arytenoid Adduction

Arytenoid adduction (AA) is used in the treatment of glottal insufficiency. Unlike medialization laryngoplasty, AA acts through direct traction on the arytenoid cartilage at the muscular process, mimicking the action of the lateral cricoarytenoid muscle. AA is an important adjunct in selected cases of vocal fold paralysis. The physiologic effects of AA include the following:

■Lowers the position of the vocal process

■Medializes and stabilizes the vocal process

■Lengthens the vocal fold

■Rotates the arytenoid cartilage

In patients with vocal fold paralysis who have a lack of vocal process contact during phonation (large posterior gap), shortened immobile vocal fold, and those with vocal folds at different levels, AA should be considered in addition to ML. Videostroboscopy often provides valuable information about vocal process contact, vocal fold height and length, and therefore is useful preoperatively in assessing whether a patient may need an AA. A maximal phonation time (MPT) of less than 5 seconds has also been identified as a predictor of the need for AA in cases of vocal fold paralysis.

40.3Surgical Indications and Contraindications

Arytenoid adduction for unilateral vocal fold paralysis is indicated in the following cases:

■Large posterior glottic gap

■Lateralized vocal fold during phonation

■Vertical height differences (generally the paralyzed vocal fold is superiorly located)

■Severely foreshortened vocal fold

■Inability to achieve good voice intraoperatively with ML alone

Contraindications include:

■Intact vocal fold mobility

■Vocal fold paralysis with the chance of recovery of motion (“early” paralysis)

■Limited abduction of contralateral vocal fold

40.4Surgical Equipment

Surgical equipment needed comprises:

■Medialization instruments (see Chap. 39)

■Kerrison rongeurs

■Sewell retractors

■4-0 monofilament permanent suture

(Prolene or Tevdek) on a double-armed needle

■Straight drill bit (e. g., 1-mm wire-passing drill bit)

■Kitner dissector (peanut)

40.5Surgical Procedure

Arytenoid adduction is usually performed in conjunction with the ML procedures (see Chaps. 38, “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis” and 39, “GORE-TEX® Medialization Laryngoplasty”). The procedure is performed under local anesthesia, with an indwelling flexible laryngoscope. To prevent unnecessary duplication, the key portions of the ML up to the point of the AA are not illustrated in the chapter; however, certain additional steps that are needed to help achieve adequate exposure of the posterior laryngeal framework and arytenoid complex are included for clarity.

1.After the midline raphae are divided between the strap muscles, approximately 1 cm of the medial aspect of the sternohyoid muscle is sectioned below its insertion onto the hyoid. The step is necessary to improve posterior exposure of the laryngeal framework for AA (Fig. 40.1).

2.The outer perichondrium of the thyroid cartilage is then incised with a 15 blade, and a posteriorly based flap is raised with a cottle or freer elevator, including the inferior border of the thyroid ala.

3.A window is outlined in the thyroid cartilage, and opened as previously indicated in Chap. 38. A surgical plane is then developed in the paraglottic space (just superficial to the TA fascia) in all directions around the window except anteriorly. In general, preliminary measurements are taken for the ML portion of the case, before proceeding to the arytenoid exposure (see Chap. 38, Figs. 38.7–38.15 for details).

4.The outer perichondrial flap is then extended all the way to the posterior border of the thyroid ala. The outer peri-

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Fig. 40.1  Partial division of sternohyoid muscle 1 cm below its insertion

chondrium is incised with a 15 blade along the posterior border of the cartilage to prevent elevation of the inner perichondrium. The incision is continued to the level of the superior cornu above and the inferior cornu below (Fig. 40.2).

5.The surgical plane of the medialization window (paraglottic space) should then be connected to the posterior laryngeal dissection, so that there is one continuous surgical plane. A cottle or freer elevator is used to achieve this (Fig. 40.3).

6.A skin hook is placed on the posterior border of the cartilage to aid in retraction. Access to the arytenoid can then be achieved with one of two methods:

a)Creation of a window in the posterior thyroid ala

A window of cartilage is removed from the posterior border of the thyroid cartilage, using a 2-mm Kerrison rongeur. The cartilage is removed until the muscular process of the arytenoid is palpable and the anterior extension of the pyriform sinus can be visualized (Fig. 40.4). The size of the window ranges from 10 to 15 mm in height and extends approximately 10 mm anteriorly, although the dimensions vary. The posterior aspect of this window should be located on the same level of the ML window. It is important not to allow the anterior and posterior windows to “connect,” as this will likely lead to framework instability.

b)Separation of the cricothyroid joint

Another way to gain exposure is by separation of the cricothyroid joint along with lateral thyroid ala retraction. A small dissection scissor (tenotomy) is used to separate the cricothyroid joint. Skin hook retractors are placed, and the thyroid ala is gently retracted laterally. Often, additional muscular or perichondrial attachments along the inferior and superior cornu must be divided to facilitate lateral alar retraction (Fig. 40.5).

7.The pyriform sinus mucosa must be identified and retracted posteriorly before the muscular process of the arytenoid is identified. Great care must be taken with this step