Учебники / Operative Techniques in Laryngology Rosen 2008

42 Fig. 42.8  The patient’s voice is tested while simultaneously putting traction on the arytenoid adduction suture and depressing the depth gauge within the thyroplasty window. A Cottonoid is placed in the paraglottic space for cushioning

Fig. 42.10  Final configuration of the fat flap within the paraglottic space. Note sutures securing the flap both anteriorly and inferiorly

Fig. 42.9  Axial view of fat flap advanced into the paraglottic space

10.The lateral laryngotomy is reduced and secured with two to three 2-0 Prolene sutures. Windows are made for medialization and arytenoid adduction (both posterior and anteriorly) as described in Chaps. 38 and 40 (Fig. 42.7).

11.An arytenoid adduction suture (4-0 Prolene, doublearmed) is placed through the muscular process, secured, and the two ends are passed through separate holes in

the anterior (midline) of the thyroid lamina, similar to the technique of arytenoid adduction described in (Chap. 40).

12.A Cottonoid is then placed within the thyroplasty window to provide cushioning to the paraglottic space (approximating the effect that the fat flap will provide), while a depth gauge is used to medialize the vocal fold. The effects of medialization and tension on the arytenoid adduction suture should be used to gauge the best vocal outcome (Fig. 42.8).

13.The fat flap is tucked deep to the strap muscles and advanced into paraglottic space via the posterior thyroid cartilage window (Fig. 42.9). The flap’s apex should be brought as anteriorly as possible to reconstitute the true vocal fold at the anterior commissure. The voice should be tested as the flap is manipulated within the paraglottic space in a variety of configurations. The flap serves the important function of providing bulk to the paraglottic tissues, which is vital to the success of the primary surgery and any additional augmentative procedures attempted in

the future. The flap is secured to the thyroid and cricoid cartilages using 3- or 4-0 Prolene sutures through 1-mm drill bit holes as needed (Fig. 42.10).

14.The patient is asked to phonate, while tension on the arytenoid adduction suture is adjusted, until optimal voice result (or vocal fold positioning in the midline position) is obtained. The suture is secured over the thyroid lamina near the midline.

15.Medialization should be deferred until a later date if there is a mucosal tear, to avoid complications of foreign body contamination. However, if no mucosal defect is present, then a Silastic implant may be placed at this time. Medialization measurements are obtained by displacing the posterior/mid aspect of the window using a depth gauge. The vocal fold should be slightly overmedialized to account for inevitable fat flap atrophy. It is important to emphasize that a number of possible combinations using one or all of the three techniques (fat flap, ML, AA) can be employed at the same time to achieve the best vocal result. This takes a fair amount of trial and error to optimize the vocal results. Wound irrigation, layered closure over a closed suction drain is then performed.

42.6Postoperative Care and Complications

Postoperative care comprises:

■Overnight, 23-hour 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.

Complications include those seen in medialization laryngoplasty and arytenoid adduction (Chaps. 38 “Silastic Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis” and 40, “Arytenoid Adduction”); however, the most common

complication is encountered months after surgery. The fat flap may slowly atrophy over several month-years, resulting in glottic insufficiency eventually. Additional procedures can be attempted when this happens, including lipoinjection and/or revision Silastic medialization. In addition, implant exposure, infection, and/or extrusion are more likely in the setting of Teflon granuloma removal due to the higher risk of mucosal violation within the endolarynx.

Key Points

■Laryngotomy is the only surgical approach that allows for complete removal of granuloma in most cases.

■The ideal case for laryngotomy/fat flap reconstruction is symptomatic Teflon granuloma in a patient with UVFP in which there is sparing of the free edge of the vocal fold (vocal ligament/mucosa appear uninvolved with granuloma).

■The surgeon should master the techniques of ML and AA before attempting this procedure.

■The pedicled fat flap may atrophy over time, necessitating additional procedures to restore glottal competence, such as lipoinjection or revision Silastic ML.

Selected Bibliography

1Netterville JL, Coleman JR, Chang S et al (1998) Lateral laryngotomy for the removal of Teflon granuloma. Ann Otol Rhinol Laryngol 107:735–744

2Conoyer MJ, Netterville, Chen A et al (2006) Pedicled fat flap reconstruction of the atrophic or “empty” paraglottic space after resection of Teflon granuloma or oversized implant. Ann Otol Rhinol Laryngol 115:837–845

43.1Fundamental and Related Chapters

Please see Chaps. 25, 36, and 37 for further information.

43.2Disease Characteristics and Differential Diagnosis

43.2.1 Anatomy and Classification

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 laryngocele represents an abnormal dilation or herniation of the saccule. In contrast to a saccular cyst (Chap. 25, “Endoscopic Excision of Saccular Cyst”), a laryngocele communicates with the lumen of the larynx and is distended with air. Any factor that increases intralaryngeal pressure can lead to development of a laryngocele:

■Coughing

■Straining

■Playing wind instruments

■Glass blowing

Another etiology in the development of laryngoceles may be air trapping due to ball-valve closure of the neck of the saccule, allowing for entry of air into the saccule, but preventing its egress. This “valve-like” effect can occur from inflammatory or neoplastic processes in the ventricle or false vocal fold. For this reason, neoplastic causes should be ruled out, especially in high-risk patients (tobacco/alcohol users). Laryngoceles occur predominantly in males, most often in the fifth or sixth decade of life.

Laryngoceles are categorized based on anatomic extension of the lesion:

1.Internal laryngoceles are contained entirely within the endolarynx. They originate in the anterior ventricular membrane, and extend posteriorly–superiorly into the paraglottic space (Fig. 43.1). This creates are characteristic bulge in the false vocal fold and aryepiglottic fold. The lesions can usually be managed endoscopically, similar to the treatment of a saccular cyst (see Chap. 25).

2.Combined (external and internal) laryngoceles originate in the endolarynx as with internal laryngoceles, but extend through the thyrohyoid (TH) membrane, into the neck (Fig. 43.2). A foramen in the TH membrane where the superior laryngeal nerve (internal branch) and vessels enter provides the pathway for extension of the laryngocele into the neck. This constriction at the TH membrane gives combined laryngoceles their characteristic “dumbbell” appearance (Fig. 43.3). These lesions are usually removed externally through a transthyroid approach, as described in this chapter.

Fig. 43.1  Coronal representation of internal laryngocele

Fig. 43.2  Coronal representation of combined laryngocele

43.2.2Clinical Presentation

and Differential Diagnosis

Most laryngoceles are asymptomatic and may be incidental findings on radiographic studies of the neck. When symptoms arise, hoarseness is the most common clinical presentation, although cough or globus sensation are also seen. Patients with combined laryngoceles may present with a neck mass. The neck mass often appears only intermittently, and may be reproduced by asking the patient to valsalva.

Office laryngoscopy will typically reveal a submucosal fullness or bulge in the false vocal fold/ aryepiglottic fold region. If a neck mass is present it is typically located at the superior/lateral aspect of the thyroid cartilage, and is soft and easily compressible.

Differential diagnosis of a laryngocele includes:

■Saccular cyst

■Mucous retention cyst

■Hemangioma

■Laryngeal neoplasm (e. g., squamous cell carcinoma, neuroendocrine/neural tumors)

A CT scan should be obtained to define the extent of the lesion (internal versus combined), and to delineate the internal content of the mass. Laryngoceles will contain air (black), while saccular cysts will contain mucous (gray/soft tissue signal). A biopsy is rarely indicated due to the unique nature of the lesion. However, a ductal lavage/biopsy may be indicated in the anterior ventricular region, if malignancy is suspected.

43.3Surgical Indications and Contraindications

Absolute indications are symptomatic combined laryngocele (hoarseness/airway compromise) and suspicion of malig­ nancy.

A relative indication is cosmetic concerns (especially in large combined laryngoceles in horn players).

Contraindications include asymptomatic lesions found incidentally/radiographically

Caution should be exercised in the rare case of bilateral combined laryngoceles. Bilateral injury to the internal branch of the superior laryngeal nerve can lead to aspiration. The surgeon may wish to “stage” their resections, insuring intact sensation (via functional endoscopic evaluation of swallowing and sensory testing) on the operated side before proceeding with the contralateral laryngocele.

43.4Surgical Equipment

■Microlaryngoscopy equipment

■Neck dissection tray

■Blunt dissection instruments (Kitner/peanut)

43.5Surgical Procedure

1.Perform a direct microlaryngoscopy, examining the anterior false vocal fold, ventricular region, to rule out malignancy (note: 30 and 70° telescopes are well suited for this).

2.A horizontal incision (5–7 cm) is made at the superior aspect of the thyroid cartilage, in a skin crease.

3.Subplatysmal flaps are raised from the upper aspect of the cricoid to just superior to the hyoid. Skin retraction hooks are placed.

4.The midline raphae are identified, and divided from the hyoid down to the cricoid, exposing the thyroid ala.

5.The infrahyoid strap muscles (sternohyoid, omohyoid, and thyrohyoid) are identified on the side of the lesion, and divided superiorly near their origin. A small cuff of fascially encased muscle should be preserved at its attachment to the hyoid, to aid in reapproximation of each muscle near the end of the case (Fig. 43.4).

6.The ipsilateral hemilarynx is rotated into the field by retraction at the thyroid notch, using a single-prong hook.

7.The external component of the laryngocele is identified within the thyrohyoid region. The lateral aspect of the laryngocele is defined by carefully excising the soft tissue covering on its surface, until the glistening capsule of the laryngocele is clearly identified. A small amount of soft tissue covering is left in place at the superior aspect of the

capsule; this area is grasped with a Babcock retractor (Fig. 43.5).

8.The laryngocele is retracted gently as blunt dissection is used to define the external (extralarnygeal) portion of the laryngocele capsule (Fig. 43.6). Some sharp dissection with hemostat/15 blade is usually necessary as well. It is important to “hug” the laryngocele capsule closely during dissection. This is especially important posteriorly within the TH membrane region, where the SLN branch is immediately adjacent to the laryngocele.

9.The “back wall” of the laryngocele should be well defined before proceeding with dissection of the intralaryngeal portion of the dissection.

10.An inferiorly based flap is created from the outer perichondrium of the thyroid ala by incising at the superior

Fig. 43.4  Sectioning of strap muscles to allow exposure of the TH space

border of the thyroid lamina and using a freer elevator for dissection.

11.A triangular section of the thyroid ala is marked out, with its base superiorly, and its apex at a point half way along the vertical distance of the thyroid lamina. This segment of cartilage is removed with a 15 blade and/or Kerrison rongeurs. The inner perichondrium is then incised and removed from the triangular region, exposing the paraglottic space (Fig. 43.7). The cartilage can be discarded after removal.

12.Dissection continues inferiorly, defining the internal component of the laryngocele. Sharp dissection through the ventricularis and aryepiglotticus muscles facilitates the identification of the capsule in the paraglottic space (Fig. 43.8).

13.The termination of the laryngocele is identified at the base of the saccule. This is typically located at the anterior ventricular mucosa. This corresponds with a point 3–5 mm posterior to the midline of the thyroid lamina at the midway point along its vertical height (Fig. 43.9).

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Fig. 43.7  Inferiorly based outer perichondrial flap is raised and triangular portion of the thyroid ala is removed for exposure of the internal component of the lesion

Fig. 43.8  Sharp dissection of muscular/fibrous tissue off the internal (paraglottic) portion of the lesion

Fig. 43.9  The termination of the laryngocele is identified at the base of the saccule. The airway is entered, excising a cuff of ventricular mucosa around its entry into the endolarynx.

Fig. 43.10  A figure-eight suture is used to close the mucosal defect (4.0 chromic)

14.The airway is entered, excising a cuff of ventricular mucosa around its entry into the endolarynx. A figure-eight suture is used to close the mucosal defect (4.0 chromic) (Fig. 43.10.) If the saccular base cannot be clearly identified, then a clamp may be placed at the base of the laryngocele, and a silk ligature placed prior to removing the specimen.

15.The wound is thorough irrigated and closed in layers, along with placement of a closed suction drain:

a)Outer perichondrium to superior thyroid lamina

b)Sternohyoid, omohyoid, thyrohyoid reanastamosed

c)Skin closed

16.A close suction drain is placed.

17.A tracheostomy is rarely indicated, but may be performed at the end of the case if there are airway concerns.

43.6Postoperative Care and Complications

Postoperative care includes:

■Overnight, 23-h observation (consider pulse oximetry monitoring)

■Pain management

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

■Elevation of the head of bed

■Diet can be advanced as tolerated.

Complications can include:

■Laryngeal edema or hemorrhage with respiratory compromise

■Recurrence of the laryngocele

■Incomplete removal of the base of the saccule can lead to recurrence. Therefore, one must enter the airway, removing a cuff of ventricular mucosa surrounding the base of the saccule if possible.

■Damage to the internal branch of the SLN with dysphagia or aspiration

■Elderly patients are more susceptible to the effects of sensory deficits in the larynx, and may be more likely to have dysphagia as a result of SLN injury.

Key Points

■A laryngocele is an air-filled dilation or herniation of the saccule. Any factor that increases intralaryngeal pressure such as coughing, straining, playing wind instruments, or glass blowing can lead to development of a laryngocele.

■Neoplasm in the ventricle or false cord should be ruled out with microlaryngoscopy in high-risk patients (tobacco/alcohol users).

■Laryngoceles are categorized as:

■Internal: confined to the endolarynx; usually removed endoscopically (see Chap. 25, “Endoscopic Excision of Saccular Cyst”)

■Combined: extension of internal laryngocele into the neck through the TH membrane. These are usually removed through an external approach.

■During dissection of the external component of a combined laryngocele, care should be taken to avoid trauma to the SLN as it enters the TH membrane posteriorly.

■The internal dissection of the laryngocele is facilitated by removing a triangular wedge of thyroid lamina. This provides wide exposure to the paraglottic space.

■The saccular opening into the airway is located in the anterior ventricular mucosa. The saccular

opening into the airway should be included in the laryngocele resection to insure complete excision of the lesion.

Selected Bibliography

1Holinger LD, Barnes DR, Smid LJ et al (1978) Laryngocele and saccular cysts. Ann Otol Laryngol Rhinol 87:675–685

2Thome R, Thome DC, De La Cortina RAC (2000) Lateral thyrotomy approach on the paraglottic space for laryngocele resection. Laryngoscope 110:447–450

44.1Fundamental and Related Chapters

Please see Chaps. 6, 10, 36, 37, and 45 for further information.

44.2Disease Characteristics

Laryngeal fractures (Fig. 44.1) are most commonly associated with external blunt trauma, often caused by a severe or violent body trauma such as a motor vehicle accident. Laryngeal fractures can also occur from isolated or direct injuries to the larynx such as falls, gunshot or knife wounds, or traumatic emergency airway procedures (i. e., cricothyrotomy). Laryngeal fractures incorporating either the thyroid cartilage and/or the cricoid cartilage can range from minimal, (nondisplaced fractures) to severe disruption of the integrity of the larynx with avulsion of portions of the thyroid and/or cricoid cartilage. The ABC’s of emergency care must be first attended to for patients with a suspected laryngeal fracture. After the airway, circulatory, cervical spine and neurologic systems have been stabilized, the laryngeal fracture(s) can be evaluated.

The mechanism of injury and patient’s initial and present airway status are extremely important historical data to obtain when evaluating a patient with a suspected laryngeal fracture.

Fig. 44.1  Laryngeal trauma (fracture on left ala)

A “close-line” injury can suggest laryngotracheal separation; a strangulation injury can cause delayed edema in an otherwise benign appearing clinical setting. Furthermore, specific history should be found regarding intubation indications, who performed the intubation, where the intubation was performed, why it was performed, and what was seen on initial intubation. Also, initial airway and voice quality symptoms are helpful in the assessment process.

The overriding key principal to laryngeal fracture evaluation and treatment is assessment and protection of the airway, followed by assessment and preservation of voice quality and function. The former is crucial given that proper evaluation and treatment of laryngeal fractures in the acute and possibly subacute setting can prevent severe laryngeal stenosis, which is extremely difficult to treat. The key variables of assessment for a thyroid cartilage fracture are the exact location and degree of displacement of the fractures. Furthermore, laryngeal palpation should identify if the thyroid and cricoid cartilages are stable to gentle palpation. Other key variables when assessing patients with a laryngeal fracture include vocal fold mobility, tension, and length, and if there is any exposed cartilage or mucosal lacerations within the larynx. If the patient is not initially evaluated prior to intubation, then many of the endo­ laryngeal key variables mentioned above are difficult to assess until direct laryngoscopy can be performed.

Essential components of a complete assessment for laryngeal fracture include:

■Flexible laryngoscopy (if possible) to assess vocal fold mobility and airway potency

■Fine cut CT imaging of the larynx/cervical trachea

■Microlaryngoscopy, tracheoscopy and esophagoscopy

44.3Surgical Indications and Contraindications

Indications include:

■Thyroid cartilage fracture involving:

■Displaced thyroid cartilage with airway lumen compromise and/or negative voice implications

■Exposed intralaryngeal cartilage (anterior two thirds of cartilage)

■Shortened or avulsed vocal fold(s)

■Cricoid fracture

■Displaced fracture with lumen encroachment

Contraindications comprise:

■Unstable vital systems (sepsis, head injury, etc.) or cervical spine injury

■Nondisplaced thyroid cartilage fracture

■Fracture limited to posterior third of thyroid cartilage

■Nondisplaced cricoid fracture, no encroachment of the subglottic airway

44.4Surgical Equipment

Surgical equipment needed includes:

■Standard microlaryngoscopy set up and equipment (see Chap. 10)

■Laryngeal/bronchial telescopes (0, 30, and 70°)

■Soft tissue neck surgical instrument tray

■Maxillofacial fracture plating system (microplates with emergency screws)

■Internal laryngeal stent devices

■Montgomery internal laryngeal stent (Boston Medical, Boston, Mass.)

■Rolled Silastic sheeting

■Aboulker stent

■Sterile glove and surgical foam

■T-tube stenting devices

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44.5Surgical Procedure

through any preexisting neck wound in the laryngeal area.

iii.Dissection down through the soft tissues of the neck to preserve strap muscles and expose the thyroid cartilage (strap muscles that are avulsed or dislocated should be reattached into their anatomic position as much as possible). Exploration of the thyroid cartilage fracture with minimal disruption of the surrounding tissue is then performed with the goal of reducing the fractures, if possible. With this exposure, palpation directly of the thyroid cartilage as a whole from externally can be performed to assess the three dimensional integrity of the structure, and to determine if the patient will require internal laryngeal stenting.

iv.As the thyroid cartilage fractures are explored and reduced, minimal tissue should be removed from the area. This will help reduce and stabilize the fractures.

v.0 Prolene sutures or small mini-reconstruction plates can be used across the fracture to secure the reduced laryngeal fracture into a stable position (Fig. 44.2). When noncalcified thyroid ala occurs (seen commonly in younger patients), the larger diameter “emergency” screws should be employed to improve purchase to the cartilage.

vi.A small drain is placed in the dependent portion of the wound and removed within 24 hours.

b)Displaced thyroid fracture with internal mucosal lacerations, exposed cartilage or arytenoid displacement

i.Same approach to the thyroid cartilage as described above.

ii.If there is a preexisting laryngotomy from the penetrating neck wound, then the internal laryngeal structures can be explored through this wound (it can be expanded if absolutely required). It is important to limit the size of the laryngotomy to as small as possible.

iii.A midline laryngofissure can be performed if no laryngotomy is present from the injury itself. Great care must be obtained to stay in the midline protecting the right and left anterior commissure and the vocal fold attachments to the thyroid cartilage (Figs. 44.3, 44.4).

iv.Exploration of mucosal injury is then performed.

v.Absorbable sutures (5.0 or smaller) are used to replace avulsed or lacerated mucosal flaps to obtain as

Fig. 44.3  Planned laryngofissure incision. Note lateral extension of incision superior to the thyroid ala

much cartilaginous covering as possible (Fig. 44.5). Free mucosal grafts or perichondrium can be used to resurface the internal larynx.

vi.External palpation of the thyroid cartilage can be used to determine the strength/support of the thyroid cartilage to determine if the patient will require

internal laryngeal stenting. If laryngeal stenting is required, then a stent size should be selected or created that will allow adequate internal laryngeal stenting without placing excessive pressure on the internal laryngeal mucosa.

vii.The internal laryngeal stent options in order of preference are the following:

1.Montgomery laryngeal stent (Fig. 44.6)

2.Aboulker stent

Fig. 44.4  Completed laryngofissure with exposed vertical transglottic laceration