Учебники / Operative Techniques in Laryngology Rosen 2008

tis. Some of these patterns are seen in other disorders as well such as adductor SD or even in normal voices and these are not pathognomonic.

MTD can present as a primary problem often associated with post-URI onset, inappropriate pitch use, reflux, or significant voice demands. It can also present in a secondary form as excessive compensation for glottal insufficiency. Circumlaryngeal massage has been used in conjunction with voice therapy to assist in reducing laryngeal height, as these patients frequently hold their larynges in an abnormally elevated position secondary to increased muscular tension. In the most severe or refractory patients, topical anesthetization of the endolarynx has assisted in decreasing laryngeal tension because of altered

7 sensation and proprioception.

Functional dysphonia or aphonia is a separate term that should be used for psychogenic dysphonia or conversion disorder. Those with conversion disorder have experienced significant psychological trauma from an event that causes the aphonia; as such, these patients require intense psychiatric treatment in addition to voice therapy. “Malingering” or “factitious dysphonia” would be included under this term.

7.6.5Paradoxical Vocal Fold Motion Disorder

Paradoxical vocal fold motion disorder (PVFMD) is a disorder marked by desynchronized or paradoxical adduction of the vocal folds during inspiration and/or expiration. As a result, the patient exhibits inspiratory stridor and/or experiences a sensation of airway restriction. This is often confused with the wheezing of asthma that, in contrast, occurs in the expiratory phase. Symptoms also include choking, aphonia or dysphonia, and chronic cough.

Many terms have been used in the past to describe this condition, including vocal cord dysfunction, factitious asthma, psychogenic asthma, irritable larynx syndrome, and episodic paroxysmal laryngospasm. The differential diagnosis is bilateral vocal cord paralysis, hereditary abductor paralysis, posterior glottic stenosis, or cricoarytenoid joint fixation. PVFMD has many causes and has been classified into five organic and two nonorganic categories, based on etiology. These include brainstem compression, severe cortical or upper motor neuron injury, nuclear or lower motor neuron injury, movement disorder, gastroesophageal reflux, factitious or malingering PVFMD, and conversion disorder PVFMD. When associated with a conversion disorder, it is seen in primarily high-achieving, perfectionistic adolescents who are usually athletes, as well as in young female professionals. Patients complain of exercise-induced episodes of airway restriction, irritant-exposure triggers, or symptoms after a meal. Flow-volume loops have been used to assist in diagnosis; however, both false positives and false negatives are generated, and there is no consistent pattern.

The gold standard in diagnosis is demonstration of PVFMD during flexible laryngoscopy, which may be seen at rest of after administration of a trigger (exercise, perfumes, etc). Treatment consists of elimination or avoidance of triggers, including reflux and allergy treatment, and respiratory retraining therapy administered by the speech pathologist. Any coexisting asthma/reactive airway disease must also be aggressively treated.

Occasionally, psychiatric treatment may also be required. Some have attempted use of heliox (80% helium, 20% oxygen) to decrease work of breathing, but results have been mixed.

7.6.6Postviral Vagal Neuropathy

Postviral vagal neuropathy (PVVN) is marked by chronic cough, with or without laryngospasm or PVFMD. The cough is thought to be a result of altered laryngeal sensitivity such as in post viral neuralgias of other cranial nerves. The trigger may be an irritant or even palpation of the larynx. Laryngeal electromyography (EMG) is used to confirm subtle neuropathic findings of paresis. These patients are frequently treated for allergies, LPR, and PVFMD and may be refractory to treatment. When faced with this situation, treatment with the anticonvulsive agent gabapentin should be considered, which decreases neural sensitivity. Treatment success ranges from 37.5 to 80%, depending on level of motor involvement of the neuropathy. A starting dose of 100 mg three times a day is recommended, increasing to 300 mg three times a day for symptom control.

7.7Allergy and Voice Disorders

Allergic diseases can manifest in the larynx in several ways. The classic description is that of laryngeal angioedema, an acute life-threatening process initiated by exposure to a specific allergen. This process is associated with immunoglobulin IgE-mediated anaphylaxis, but it is also seen in a non-IgE-me- diated anaphylactoid response. Treatment of this disorder involves immediate airway control and injection of epinephrine with use of steroids and H2 blockers after the initial episode. Food allergy may lead to milder swelling of the vocal tract with dysphonia and may actually stimulate or worsen LPR. Avoidance of the triggering allergen and antihistamines are the recommended treatment.

Many patients also suffer from chronic postnasal drip secondary to allergic rhinitis. These patients tend to frequently clear their throats, which leads to maladaptive laryngeal muscle usage and can lead to the development of vocal fold lesions. Exposure and allergy to aerosolized irritants can also lead to muscle-tension dysphonia. Mold and volatile organic compounds (VOC) are the usual suspects. VOCs include alcohols, aldehydes, and ketones. Again, avoidance and/or removal of the source of the irritant are the mainstay of treatment. Immunotherapy is an important consideration for treatment of allergy in the professional voice user, as it avoids drying effects of antihistamines in the endolarynx.

7.8Medications and Their Effects on Voice

Both allergy and post-URI patients can experience dysphonia related to persistent postnasal drip. Patients also experience

cough due to direct irritation from mucus or because of altered sensitivity of the endolarynx. Severe coughing can result in phonotrauma, leading to vocal fold hemorrhage and vocal fold lesion formation. As a result, many over the counter preparations are used for their antitussive and mucolytic properties. Guaifenesin is the most widely used mucolytic and works best when the patient is well hydrated. Codeine and dextromethorphan are added to many cold medicine preparations. Tramadol, which is a weak opiate, may have enhanced antitussive properties, without the significant opioid side effects associated with codeine. Antihistamines again should be used with caution in the professional voice user with allergy, as the drying effects on the vocal folds can be detrimental. Leukotriene inhibitors, such as montelukast, and nasal corticosteroids can be used in allergic patients, with less drying.

Despite widespread clinical use of oral corticosteroids for acute dysphonia in the professional voice user, there is minimal scientific literature concerning this subject. The corticosteroid mechanism of action is to prevent capillary dilation and decrease capillary permeability, which consequently decreases edema. Typically, oral steroids are used in short bursts, with a tapering dosage to avoid adrenocortical insufficiency and minimize long-term side effects. Intramuscular use is also reported for the acute situation. A few studies have shown improvement in objective acoustic measures with use of steroids. However, if used for a more extended period, corticosteroids can lead to fluid imbalance, systemic muscle weakness and atrophy, gastrointestinal and neurologic problems, glaucoma, and electrolyte and metabolic disorders, and can lead to fungal infection. Corticosteroids have been linked to peptic ulcer development; therefore, any patient on long-term oral corticosteroids should be placed on at least an H2 blocker, preferably a PPI.

Many medications have virilizing properties and should be used with great caution in the professional voice user, or any patient for that matter. These medications, such as Danazol, have been used for treatment of fibrocystic breast disease and endometriosis. Testosterone injections have been administered to women complaining of loss of libido or energy and have been reported in female athletes for enhanced performance. Nonphonatory side effects include acne, hirsutism, weight gain, and hairline recession. Voice effects including lowering of fundamental frequency, vocal instability with pitch breaks, loss of high frequency vocal range, and generalized dysphonia. For Danazol, the incidence may be as high as 10% in patients on the medication. Histologically, water retention in the muscle and fiber hypertrophy are seen. Although some reports have stated that effects are temporary and cease with discontinuation of the medication, there is potential for permanent voice change as can be seen in histological studies. This can be particularly damaging to the voice professional, so great caution must be used when considering prescribing these medications. During the premenstrual period of the menstrual cycle, many women exhibit pitch lowering secondary to presumed venous dilatation and edema of the vocal folds. Low-dose oral monophasic contraceptives have been shown to reduce this pitch variability and exhibit less androgenic side effects.

One group of medications that should not be overlooked is herbal remedies. Many have anticoagulant properties and can predispose a person to vocal fold hemorrhage. These include dong quai (which actually contains coumadin), willow bark,

primrose, garlic in high doses, vitamin E in high doses, gingko biloba, ginger, feverfew, and red root. Some may have crossreactivity to ragweed: goldenseal, chamomile after long-term use, echinacea, St. John’s wort, yarrow, dong quai. Some herbal medications also may have hormonal effects, e. g., dong quai may increase effects of ovarian and testicular hormones. Yam has progesterone-like properties, and licorice root also has progesteronic in addition to estrogenic effects and can change vocal pitch. Primrose is a natural estrogen promoter, and melatonin acts as a contraceptive in high doses.

7.9Vocal Hygiene

A discussion of medical treatment of voice disorders would not be complete without discussing the importance of vocal hygiene. Elements of vocal hygiene include understanding that medical problems affect the voice, understanding effects of smoking, alcohol, drugs, hydration and nutrition, vocal stress and vocal exercise, and general vocal hygiene. Vocal hygiene involves knowledge, avoidance, or reduction of irritants such as gastric juices or tobacco smoke, dehydration and control of postnasal drip of any cause. The patient should be made keenly aware of the danger of “singing sick,” as vocal injuries are more likely to occur in the sick singer than in a healthy one. The sick singer should take adequate vocal rest, fluids, and medical care as needed. Vocal fold hemorrhage and vocal fold lesions are the most significant concerns, and changing bad habits early in younger performers is critical to long-term vocal health.

7.10Role of the Speech–Language Pathologist in Voice Therapy

The speech–language pathologist is instrumental in teaching the voice disorder patient about laryngeal anatomy and vocal biomechanics, which are central to the voice therapy process for many disorders. The speech–language pathologist with special training in voice disorders is an essential member of the diagnostic and therapeutic team required for high-quality voice care. The speech–language pathologist specializes in assessing and treating behavioral issues of the speaking and singing voice. Many patients with dysphonia struggle from a variety of poor behaviors and/or speaking techniques or inappropriate use of the voice and these problems are all easily treated with the intervention of the speech–language pathologist, using the overall global term of voice therapy. A detailed description of voice therapy treatment methods for a variety of dysphonias is outside the focus of this book, but it is essential component of the treatment of a wide variety of voice disorders is a nonsurgical approach to voice rehabilitation with voice therapy. Thus, the speech–language pathologist plays a crucial role in all phases of modern voice care (diagnostic, therapeutic, and rehabilitative).

Key Points

■Up to 50% of voice disorder patients may have coexisting LPR.

■Twice-a-day therapy with a proton pump inhibitor results in the highest symptom resolution.

■Muscletension patterns I–IV seen in MTD are not pathognomonic for this disorder and can be seen in other voice disorders such as spasmodic dysphonia, and even some normal voices.

■PVFMD is treated best with multimodality treat-

ment that includes respiratory retraining (voice 7 therapy) and proton pump inhibitors, as LPR is a

common trigger for PVFMD episodes.

Selected Bibliography

1Park W, Hicks DM, Khandwala F et al (2005) Laryngopharyngeal reflux: prospective cohort study evaluating optimal dose of proton-pump inhibitor therapy and pretherapy predictors of response. Laryngoscope 115:1230–1238

2Belafsky PC, Postma GN, Koufman JA (2001) Laryngopharyngeal reflux symptoms improve before changes in physical findings. Laryngoscope 111:979–981

3Vaezi MF (2003) Gastroesophageal reflux disease and the larynx. J Clin Gastroenterol 36:198–203

4de Lima Pontes PA, De Biase NG, Gadelha ME (1999) Clinical evolution of laryngeal granulomas: treatment and prognosis. Laryngoscope 109(Pt. 1):289–294

5Walner DL, Stern Y, Gerber ME, Rudolph C, Baldwin CY, Cotton RT (1998) Gastroesophageal reflux in patients with subglottic stenosis. Arch Otolaryngol Head Neck Surg 124:551–555

6Jaspersen D, Kulig M, Labenz J et al (2003) Prevalence of extraoesphageal manifestations in gastro-oesophageal reflux disease: an analysis based on the Pro-GERD study. Aliment Pharmacol Ther 17:1515–1520

7Mehanna HM, Kuo T, Chaplin J, Taylor G, Morton RP (2004) Fungal laryngitis in immunocompetent patients. J Laryngol Otol 118:379–381

8Roland NJ, Bhalla RK, Earis J (2004) The local side effects of inhaled corticosteroids: current understanding and review of the literature. Chest 126:213–219

9Sulica L (2005) Laryngeal thrush. Ann Otol Rhinol Laryngol 114:369–375

10Mirza N, Schwartz SK, Antin-Ozerkis DA (2004) Laryngeal findings in users of combination corticosteroid and bronchodilator therapy. Laryngoscope 114:1566–1569

11DelGaudio JM (2002) Steroid inhaler laryngitis: dysphonia caused by inhaled fluticasone therapy. Arch Otolaryngol Head Neck Surg 128:677–681

12Woo P, Mendelsohn J, Humphrey D (1995) Rheumatoid nodules of the larynx. Ear Nose Throat J 113:147–150

13Nanke Y, Kotake S, Yonemoto K, Hara M, Hasegawa M, Kamatani N (2001) Cricoarytenoid arthritis with rheumatoid arthritis and systemic lupus erythematosus. J Rheumatol 28:624–626

14Devaney K, Ferlito A, Devaney SL, Hunter BC, Rinaldo A (1998) Clinicopathological consultation: Wegener’s granulomatosis of the head and neck. Ann Otol Rhinol Laryngol 107:439–445

15Herridge MS, Pearson FG, Downey GP (1996) Subglottic stenosis complicating Wegener’s granulomatosis: surgical repair as a viable treatment option. J Thorac Cardiovasc Surg 111:961–966

16Stappaerts I, Van Laer C, Deschepper K, Van de Heyning P, Vermeire P (2000) Endoscopic management of severe subglottic stenosis in Wegener’s granulomatosis. Clin Rheumatol 19:315–317

17Bartels H, Dikkers FG, Lokhorst HM, Van der Wal JE, Hazenberg BPC (2004) Laryngeal amyloidosis: localized versus systemic disease and update on diagnosis and therapy. Ann Otol Rhinol Laryngol 113:741–748

18Akst LM, Thompson LDR (2003) Larynx amyloidosis. Ear Nose Throat J 82(11):844–845

19Sulica L (2004) Contemporary management of spasmodic dysphonia. Curr Opin Otolaryngol Head Neck Surg 12:543–548

20Warrick P, Dromey C, Irish JC, Durkin L, Pakiam A, Lang A (2000) Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. Laryngoscope 110:1366–1374.

21Sullivan KL, Hauser RA, Zesiewicz TA (2003) Essential tremor: epidemiology, diagnosis, and treatment. Neurologist 10:250–258

22Zesiewicz TA, Elble R, Louis ED et al (2005) Practice parameter: therapies for essential tremor. Neurology 53:2008–2020

23Blumin JH, Picolinksy DE, Atkins JP (2004) Laryngeal findings in advanced Parkinson’s disease. Ann Otol Rhinol Laryngol 113:253–258

24Roy N (2003) Functional dysphonia. Curr Opin Otolaryngol Head Neck Surg 11:144–148

25Altman KW, Simpson CB, Amina MR, Abaza M, Balkissoon R, Casiano RR (2002) Cough and paradoxical vocal fold motion. Otolaryngol Head Neck Surg 127:501–511

26Maschka D, Bauman NM, McCray PB et al (1997) A classification scheme for paradoxical vocal cord motion. Laryngoscope 107:1429–1435

27Morrison M, Rammage L, Emami AJ (1999) The irritable larynx syndrome. J Voice 13:447–455

28Lee B, Woo P (2005) Chronic cough as a sign of laryngeal sensory neuropathy: diagnosis and treatment. Ann Otol Rhinol Laryngol 114:253–257

29Amin MR, Koufman JA (2001) Vagal neuropathy after upper respiratory infection: a viral etiology? Am J Otolaryngol 22:251–256

30Chadwick SJ (2003) Allergy and the contemporary laryngologist. Otolaryngol Clin N Am 36:957–988

31Watts CR, Early SE (2002) Corticosteroids: effects on voice. Curr Opin Otolaryngol Head Neck Surg 10:168–172

32Baker J (1999) A report on alterations to the speaking and singing voices of four women following hormonal therapy with virilizing agents. J Voice 13:496–507

33Amir O, Biron-Shental T, Muchnik C, Kishon-Rabin L (2003) Do oral contraceptives improve vocal quality? Limited trail on lowdose formulations. Obstet Gynecol 101:773–777

34Columbia University at New York Presbyterian Hospital, College of Physicians and Surgeons, Voice and Swallowing Center (2005) Herbal medications. http://www.voiceandswallowing.com/Voicetreat_herb.htm

35Murry T, Rosen CA (2000) Vocal education for the professional voice user and singer. Otolaryngol Clin N Am 33:967–981

8.1Fundamental and Related Chapters

Please see Chaps. 4, 5, and 7 for further information.

8.2Key Components to Successful Care of Patients with Voice Disorders

This chapter addresses specific issues related to phonomicrosurgery for benign lesions of the vocal fold, phonosurgery for disorders of glottal incompetence, surgeries for airway enlargement, and tumor excision of the larynx. For many of the situations in voice care, the surgical procedures are elective, and thus the surgeon and patient have the ability to participate in maximum nonsurgical treatment modalities for the rehabilitation of the patient’s voice problem, psychological preparation for surgery, and an appropriate and thorough informed consent process.

8.3Surgical Indications and Contraindications

8.3.1Timing of Phonomicrosurgery

The majority of patients require a significant amount of time to recover after phonomicrosurgery. Thus, it is important that the surgeon and patient discuss the need for an adequate amount of time for voice recovery after these procedures. Often a short period of complete voice rest immediately after phonomicrosurgery is indicated. This can range from 2 to 14 days and typically averages 7 days. The time of voice limitation before allowing the phonomicrosurgery patient to use full speaking voice activities ranges from 7 to 30 days. Similarly, the vocal recovery time before full singing is allowed is individualized to the patient situation, but typically ranges from 30 to 90 days. Thus, the patient must cancel pending voice demands when scheduling phonomicrosurgery or delay the surgery date until there is a more appropriate time after the surgery to accommodate reduced voice demands. This is especially important for vocal performers, given that they have many demands on them from management and staff. Financial demands also pressure the vocalist to perform sooner than is medically appropriate. Similarly, schoolteachers have such significant vocal demands that any decision to proceed with phonomicrosurgery during the school year should be taken with great caution, or plans

should be made not to return for the remaining semester. For example, phonomicrosurgery to remove any type of benign lesion of the lamina propria from a schoolteacher during winter break—with expectations of resuming when school resumes at the start of the new year—is a plan fraught with danger and should be avoided. Phonomicrosurgery on teachers should only be done at the start of summer (June) or the teacher will need to be off work for half the school year.

8.3.2Preoperative Considerations for Phonomicrosurgery

Any conditions that will create temporary vocal fold edema prior to phonomicrosurgery should be avoided or treated prior to proceeding. Thus, heavy vocal demands such as singing, screaming, yelling, or lecturing should be avoided approximately 1–2 weeks before phonomicrosurgery. Similarly, comorbid medical conditions such laryngopharyngeal reflux disease and sinonasal allergic disease, and upper respiratory infection should be treated and may be reason to reschedule the surgery. In some instances, a short dose of oral steroids can be used to alleviate the temporary vocal fold edema associated with these conditions prior to phonomicrosurgery. The reason for avoiding temporary vocal fold edema immediately prior to phonomicrosurgery is to minimize the removal of vocal fold tissue (epithelium and/or lamina propria) that appears permanently pathological but, in fact, may represent temporary edema. If this occurs, excessive excision may result. Furthermore, most likely epithelium/lamina propria wound healing is compromised in the face of an acute inflammatory condition resulting in suboptimal postoperative voice rehabilitation.

The psychological impact of phonosurgery on patients should be greatly appreciated. This is an area that is frequently overlooked by surgeons, especially by doctors who do not appreciate the unique relationship that professional voice users and heavy voice users have with respect to their psyche and their voice. It is important to realize that these individuals (to a large degree) identify themselves by their voice, and thus the consideration and realization of the need for surgery induces a significant amount of anxiety and concern. This must be identified by the voice care team preoperatively, and discussed and dealt with in a positive, successful fashion. This will ensure maximum postoperative voice quality, patient compliance, and minimal negative outcomes and activities during this stressful time. Preoperative voice therapy can often play a major role in addressing these issues. Furthermore, it is essential that the patient not feel pressured or rushed to decide on proceeding with

phonomicrosurgery. The amount of time it takes any patient to decide to proceed with phonosurgery is highly variable, and the decision-making process must be individualized.

Patience should be exercised by the voice care team waiting for the patient to become comfortable with the decision to have phonosurgery. This will significantly improve the patient’s coping ability during this stressful process.

8.4Decision Making in Phonosurgery

In most situations, phonosurgery is an elective procedure, and thus, the patient and surgeon are afforded an amount of time for nonsurgical treatment of the voice condition, and then are

8 able to make a joint decision to proceed with surgery. On the other hand, surgery should not be delayed if the following are present:

■Dysphagia associated with aspiration

■Impending airway embarrassment

■Risk for malignancy

The majority of voice-related procedures in the category of phonomicrosurgery, laryngeal framework surgery, and vocal fold injection for benign lesions of the vocal fold/glottal incompetence are in fact non–life threatening. Thus, the decision making and preparation prior to surgery should be undertaken on a reasonable timetable that should be predominantly patient driven.

Generally for most elective phonosurgeries, the patient should be offered and undergo nonsurgical rehabilitative measures prior to proceeding with surgery. Of course, this dictum must be utilized within reason, given that there are instances when the patient’s medical condition (large exophytic vocal fold polyp or lateralized vocal fold paralysis) dictate that nonsurgical treatment methods do not have a reasonable chance for significant improvement. Thus, it is unreasonable and poor use of resources to force all patients to undergo multiple nonsurgical rehabilitative measures (voice therapy, singing therapy, allergy therapy, medical therapy) if they have no reasonable expectation to make a significant improvement in the patient’s voice limitations and/or symptoms. If there is any possibility of the nonsurgical treatment options making a substantive difference, then it is worthwhile having the patient undergo these treatments. However, close observation of the patient needs to be maintained to assess the patient’s response after a short time period. Specifically, this is the case with respect to voice therapy. Often patients with benign vocal fold lesions or with conditions of glottal incompetence will be treated with one or two sessions of voice therapy and then reassessed for progress and potential for significant improvement. With a compliant patient and a skilled speech–language pathologist, the decision to proceed with phonomicrosurgery can be confidently made pending the outcome and progress after one or two sessions of voice therapy. Often after the initiation of voice therapy, the patient begins to notice substantive improvement, and thus all surgery should be delayed until voice therapy and possibly singing voice therapy is completed. A formal reevaluation

of their functional abilities and limitations should follow (see below.)

The decision to proceed with elective phonosurgery should be a joint decision between the patient and the surgeon. The optimal role of the patient should be as the primary decision maker and the surgeon should serve as the educator in this process. After all nonsurgical rehabilitation methods have been employed, a formal reevaluation by the voice care team should be performed to decide if elective phonosurgery is indicated. An important component to this decision-making process is to encourage the patient to resume his/her voice activities after nonsurgical rehabilitation has been completed. When the patient resumes vocal activity, they should be asked to answer the simple (but essential) question: “Can you do what you need to with your voice?” or “Do you still have significant functional limitations (e. g., reduced range, reduced clarity, vocal fatigue)?” This assessment of functional ability is crucial in prompting the patient to decide if he/she should proceed with phonosurgery. It is essential that the surgeon not pressure or rush the patient’s decision. The surgeon’s most important role is to educate the patient on his/her specific voice condition and on the risks and benefits of the surgical procedure (see Sect. 8.5, “Informed Consent Regarding Phonosurgery,” below), as well as to discuss reasonable expectations of elective phonosurgery. With this information, the patient should be well equipped to be the primary decision maker for elective phonosurgery.

It is essential for patients undergoing phonomicrosurgery to have had a recent voice evaluation. Specifically, a laryngo­ videostroboscopy should be performed in the period shortly before surgery (1–3 weeks). This allows the surgeon to review and see the most recent status of the vocal fold pathology, and this can often factor into important intraoperative decision making. It is recommended that the surgeon review the recent stroboscopy examination either the day of the surgery or preferably immediately prior to (or during) the patient’s phonomicrosurgical procedure.

Intraoperative decision making can be quite challenging for the phonosurgeon, and there are various guidelines for the types of laryngeal surgery being undertaken. For patients with cancer, intraoperative decision making is dictated by the location and nature of the cancer. However, if the surgeon is not comfortable with margins on frozen sections, then it is often wise to obtain conservative margins and delay the surgical procedure until permanent pathology is available. Then, if there is a positive margin, a return to the operating room can be undertaken. This approach avoids excessive resection of nonmalignant tissue.

For patients undergoing phonomicrosurgery for benign lesions of the lamina propria, the intraoperative decision making process should be approached in a very conservative fashion. Difficult decisions regarding how much to resection of epithelium and/or lamina propria should be done on the conservative side; accepting the possibility a small number of patients may require repeat phonomicrosurgery for persistent or recurrent disease. These repeat phonomicrosurgery procedures are a small price to pay for minimizing the risk of overaggressive resection of epithelium and/or lamina propria, resulting in severe (and potentially irreversible) postoperative dysphonia from vocal fold scar.

Intraoperative decision making regarding laryngeal framework procedures should follow this guideline: The best chance for a good outcome is with the first surgical procedure. Thus, all attempts, regardless of the chosen method, should work to achieve the best possible voice quality from the first surgical procedure. The reversibility and adjustability of revision laryngeal framework procedures may be limited.

Intraoperative decision making for airway cases, especially for glottic enlargement procedures (transverse cordotomy, medial arytenoidectomy, total arytenoidectomy) should be done in a conservative fashion. All patients should be counseled that the greater the laryngeal airway that is created, the greater is the risk for decreased vocal function. Thus, a conservative (and, if needed, staged approach) to surgery for the enlargement of laryngeal airway should be the guiding principle for intraoperative decision making in this area.

8.5Informed Consent Regarding Phonosurgery

The most important aspect of informed consent is education of the patient regarding the salient details of the surgical procedure, providing reasonable expectations, and discussing risks and benefits of the procedure. Documentation of the most important aspects of this process is also strongly advised. With phonomicrosurgery procedures for benign vocal fold lesions, the informed consent process should involve the patient’s individual pathology, specifically identified from stroboscopy and/ or from prior operative findings. The factors that play an important role in defining reasonable expectations of successful phonomicrosurgery include the patient’s vocal abilities and/or voice training and his/her postoperative vocal demands and expectations. A combination of all these factors should be synthesized and presented to the patient so he/she is offered the appropriate level of expectation. In general, appropriately performed phonomicrosurgery for benign lesions of the lamina propria in a compliant patient should have a success rate of > 95%. Success is defined as an improvement in voice quality and function. It is important for the surgeon to make the distinction between voice improvement and restoration to the patient’s premorbid vocal capabilities. The success rate to achieve the latter goal is going to be lower and will be directly related to the pathology of the vocal folds, ability/training of the patient, and vocal demands. It is important to inform the patient that there is a risk of postoperative scarring and permanent postoperative dysphonia that could even worsen his/her condition compared to preoperative status. This risk is quite small (1–2%), and similarly, there is a risk that significant improvement in vocal function will not be obtained despite the surgeon’s and the patient’s best efforts (1–2% incidence of “no improvement”).

Appropriate informed consent for phonosurgeries involving patients with glottal incompetence should involve the specific expectations, voice improvements, and persistent limitations after surgery. Typically, these types of surgical procedures have a very high degree of success with respect to increasing volume, clarity, and endurance with normal speaking-voice use and normal speaking demands. There are often limitations af-

ter this type of surgery that persist involving loud speech and/ or singing. These limitations exist because of the persistent underlying pathologic condition such as vocal fold paralysis, vocal fold scar, and vocal fold paresis. Informed consent for surgical removal of laryngeal cancer should include reduction of vocal and swallowing function as well as the risk for additional surgery depending on permanent pathology results after surgery.

Informed consent for airway procedures must involve discussion that as the surgical procedure obtains an increased airway for the patient, the greater the likelihood of diminution of the patient’s vocal function. The goal of the surgery is to obtain an adequate airway while at the same time minimizing the negative impact on the voice. Due to this voice–air- way equation and the need for conservative removal of glottic narrowing, the patient should be informed of the likelihood of the need for repeat surgery. Patients with airway problems preoperatively that do not have a tracheotomy should also be consented for a possible tracheotomy depending on a variety of intraoperative situations.

Key Points

■Most phonosurgical procedures are elective, and thus, the decision to proceed with surgery should be patient driven. The surgeon serves as educator, so that realistic goals of postoperative voice quality and function are clearly understood.

■The key principle of decision making with respect to phonomicrosurgery is the use of nonsurgical rehabilitative treatment options (when appropriate) prior to proceeding with surgery.

■With respect to microsurgery for benign lesions of the lamina propria, the most important question that must be answered before deciding for or against proceeding with phonomicrosurgery is:

“Can the patient do what they need to do with his/ her voice after undergoing maximum of nonsurgical rehabilitation?”

■Informed consent process for phonomicrosurgery should be individualized due to the specific pathologic condition present and the surgical approach recommended.

Selected Bibliography

1Bouchayer M, Cornut G (1992) Microsurgical treatment of benign vocal fold lesions: indications, technique, results. Folia Phoniatr 44:155–184

2Courey MS, Gardner GM, Stone RE, Ossoff RH (1995) Endoscopic vocal fold microflap: a three-year experience. Ann Otol Rhino Laryngol 104(Pt. 1):267–273

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

Sataloff RT (2005) Professional voice: the science and art of clinical care, 3rd edn. Plural, San Diego

Zeitels 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 Rhino Laryngol 190(Suppl.):21–40

Xomed, Jacksonville, Fla.), or

b)Jet Venturi needle

4.Laser-safe ETT

a)MLT 5.0/5.5 or smaller

5.Tracheostomy tube/surgical tray

6.Rigid bronchoscopes

7.4% lidocaine (LTA)

9.3Surgical Indications and Contraindications

Sharing the airway with our anesthesia colleagues is one of the most important (and often neglected) aspects of successful laryngeal surgery. Lack of collaboration and preoperative planning with the anesthesiology team can turn an otherwisesimple microlaryngoscopy case into a chaotic, life-threatening airway crisis.

The following general principles should always be observed:

1.A preoperative management plan for securing the patient’s airway must be discussed with the anesthesiologist prior to proceeding with surgery. An ideal plan (plan A), as well as one or two alternate strategies (plans B and C) should be established so that the airway management is automatic and algorithmic, as opposed to chaotic/reactive. Prior to bringing the patient into the operating room, both the surgeon and anesthesiologist should have the proper equipment in the room, open, and “ready to go” if alternative plans become necessary.

2.The patient should be placed in the “sniffing positioning,” with the head extended (at the atlanto-occipital joint), and

above (note longer length of MLT)

the neck flexed (along the cervicothoracic vertebrae) for optimal laryngoscopic exposure (see Chap. 10, “Principles of Phonomicrosurgery”).

3.Microlaryngoscopic surgery generally employs one of the following methods for maintaining the airway:

a)Oral intubation using a small diameter endotracheal tube of adequate length: 5.0 or 5.5 MLT (microlaryngoscopy tube) (Fig. 9.1). MLT (microlaryngoscopy) endotracheal tube is a small-diameter ETT with an extended length. Most “regular” ETT (size 5.0 and smaller) are not long enough to adequately span the distance between the oral commissure and the subglottic/tracheal airway.

b)Jet Venturi ventilation using one of the following methods:

i.Subglottic Mon-Jet/Hunsaker jet ventilation tube (Fig. 9.2)

ii.Supraglottic jet Venturi needle (via port within laryngoscope or attached to laryngoscope) (Fig. 9.3)

4.In general, lesions located on the anterior two thirds of the larynx (membranous vocal folds) can be adequately exposed/treated with a 5.5 or smaller ETT. Lesions of the posterior third of the larynx (vocal processes and posterior commissure/arytenoids region) require one of the following approaches:

a)Jet ventilation

b)Apneic technique

c)ETT placement anteriorly, resting on top of the laryngoscope

Fig. 9.4  Laser protected ETT (Medtronic-Xomed)

5.In all cases where a surgical laser is employed, an appropriate laser-protected tube must be in place (Fig. 9.4). The only exception to this rule is when jet ventilation or apneic technique is used (both are also safe for the laser).

6.In instances where the patient has an indwelling tracheostomy tube:

a)5.5–6.0 reinforced ETT placed through the stoma into the trachea, laser protected when appropriate

b)Apneic technique may be employed if airway surgery is carried out distal to the tracheal stoma site, using reinsertion of stomal ETT intermittently to restore oxygenation between treatment cycles.

7.Jet ventilation is safest when used proximally (supraglottic, as opposed to subglottic) However, passive movement of the vocal folds due to ventilatory air movement limits the

Fig. 9.3  Jet Venturi needle and jet ventilation tubing/pressure gauge

precision of fine surgical maneuvers. In addition, jet ventilation (containing 100% oxygen) must be suspended during firing of the laser.

8.Subglottic jet ventilation is more efficient when used for glottic laser surgery; the vocal folds are not as affected by ventilatory forces. Jet ventilation can proceed even while the laser is being fired. Another important advantage of the Hunsaker subglottic jet ventilation tube is the built-in

CO2-monitoring port. This allows the anesthesia team to monitor end-tidal CO2 to ensure adequate exhalation time during jet ventilation. The potential drawback of subglottic jet ventilation is the increased risk of air trapping from the “ball-valve” phenomenon. Often, subglottic jet ventilation is performed distal to the airway obstruction, and if egress (escape) of air is prevented by the obstructed region, then air trapping results. Complications of this include pneumothorax (possibly bilateral), pneumomediastinum, and emergent ventilatory compromise. Increased vigilance must be practiced when this ventilation technique is employed.

9.4Principles of Airway Management: Subglottic and Tracheal Stenosis

1.Subglottic/tracheal stenosis presents a unique anesthetic challenge. Ideally, the airway is not instrumented by the anesthesiology team; endotracheal intubation can result in traumatic injury to the subglottic mucosa and may precipitate an emergency in a patient with a marginal (but otherwise stable) airway.

2.Subglottic/tracheal stenosis in a stable airway should generally proceed as follows:

a)Mask induction is performed using inhalational agents (sevoflurane):