Учебники / Operative Techniques in Laryngology Rosen 2008

10.5.2 Patient Position

Patients undergoing phonomicrosurgery are placed in a supine position on the operating room table. The optimal head and neck position for exposure of the endolarynx with the laryngoscope is neck flexion on the body and the head extension on the neck. A shoulder roll typically places the patient in a suboptimal position for optimal laryngoscope placement (neck extension), and thus should not be used. The neck flexion can be achieved by using an articulated head of the operating table, and the head extension on the neck is done by the surgeon during laryngoscopy and secured with the suspension device (Fig. 10.7). Another method of obtaining neck flexion is to use a

10

Fig. 10.7  Optimal patient position for suspension laryngoscopy (note neck flexion and head extension)

pillow under the head to flex the neck on the body (Fig. 10.8). Dental and alveolar ridge protection prior to insertion of the laryngoscope is important. For patients who are edentulous on the maxillary teeth, the best way to protect the mucosa and the underlying alveolar ridge from laryngoscope placement and suspension injury is to place a small, high-density foam pad between the laryngoscope and the alveolar ridge. This foam padding is present in most operating rooms in the form of a headrest or pillow material (Fig. 10.9).

10.5.3 Laryngoscope Placement

Laryngoscope placement is crucial to the success of phonomicrosurgery and can be quite daunting to the novice phonomicrosurgeon. An adequate amount of time and patience should be allocated for this important step. Insuring a proper head and neck position during laryngoscopy placement is a key step, as described above. The overall goal is to place the largest diameter laryngoscope into the endolarynx. A frequent impediment to this goal is the folding inward of the epiglottis (Fig. 10.10). When this occurs, the potential space to place the distal aspect of the laryngoscope into the endolarynx is significantly reduced, and the epiglottis is traumatized (Fig. 10.11). With the use of a large-diameter laryngoscope, the positioning of the laryngoscope can be quite difficult. Instead of aborting the use of the large-diameter laryngoscope, patience and persistence should be judiciously applied.

As the laryngoscope is placed into the oral cavity, the lips and tongue should be retracted with the nondominant hand. The laryngoscope is then slid along the ventral surface of the tongue and advanced down toward the base of the tongue and posterior pharyngeal wall. At this juncture, there are a variety of techniques to place the laryngoscope under the epiglottis without folding or traumatizing the epiglottis. First, if there is adequate space, then the laryngoscope can be passed under

Fig. 10.8  Alternative method of positioning patient without the use of an articulated head of bed (note neck flexion due to pillow underneath the head)

Fig. 10.9  High-density foam for protecting the alveolar ridge in an edentulous patient during suspension laryngoscopy

Fig. 10.10  Laryngoscope advancement causing “folding” of epiglottis

direct vision underneath the epiglottis and advanced into the endolarynx. This direct approach may result in the folding of the epiglottis when attempted with a large-diameter laryngoscope (Fig. 10.11). At this stage, it best to use one of the other laryngoscope placement techniques instead of resorting to the use of a smaller laryngoscope.

The second option for laryngoscope placement is to place the laryngoscope between the posterior pharyngeal wall and the endotracheal tube and continue to advance the laryngoscope along the posterior pharyngeal wall (underneath the endotracheal tube). Once the laryngoscope is at the approximate level of the endolarynx, it can be drawn anteriorly into the en-

Fig. 10.11  “Folded” epiglottis above laryngoscope limits space for the placement of a large-diameter laryngoscope

dolaryngeal space, thus allowing the endotracheal tube to slip around the side of the laryngoscope and be positioned in the posterior glottis.

The third method to place a large-diameter laryngoscope into the endolarynx without damage or malposition of the epiglottis is to place the nondominant-hand index finger into the oral cavity and oropharynx toward the endotracheal tube and pick the endotracheal tube up off the posterior pharyngeal wall. With the endotracheal tube secured underneath the index fingertip, the laryngoscope can then be advanced along the posterior pharyngeal wall and drawn up into the endolarynx (Fig. 10.12). Using this technique, the endotracheal

Fig. 10.12  Placement of laryngoscope into endolarynx below nonfolded epiglottis while the endotracheal tube is positioned anteriorly with a finger from the nondominant hand (note initially the laryngoscope will be posterior to the endotracheal tube)

Fig. 10.13  Anterior deflection of endotracheal tube with the nondominant hand to allow placement of laryngoscope into endolarynx

10

Fig. 10.14  Laryngoscope positioned above the epiglottis, which is resting directly on the endotracheal tube

tube may be initially positioned anterior to the laryngoscope. When the laryngoscope is successfully placed in the endolarynx but the endotracheal tube is anterior to the laryngoscope, the endotracheal tube can be drawn gently and carefully down into the more appropriate posterior glottic position, without too much difficulty, using upward pressure of the suspended laryngoscope or the nondominant hand’s index finger (Fig. 10.13).

The fourth technique for the placement of a large-diameter laryngoscope in a patient with difficult epiglottis anatomy (i. e., large, floppy) starts with positioning the laryngoscope immediately above the tip of the epiglottis (Fig. 10.14). With this visualization, a large up-cup forceps is passed outside the laryngoscope, down toward the proximal tip of the laryngoscope and used to grab the tip of the epiglottis firmly. With firm control of the epiglottis, the cup forceps can be used to pull or direct the epiglottis in an anterior direction (Fig. 10.15). With the epiglottis being held anteriorly, the laryngoscope is then advanced into the endolarynx on top of the endotracheal tube. Once the laryngoscope is successfully placed in the endolarynx, the forceps are opened and the epiglottis is released.

The fifth option for laryngoscope placement involves placement of temporary suture through the epiglottis. A large-di- ameter laryngoscope is positioned by hand or suspension above the epiglottis. Working through the microscope, a 4.0 silk suture is placed through the tip of the epiglottis, and the two ends of the suture are brought out through the laryngoscope. The laryngoscope is completely removed from the body and then replaced above the epiglottis, with the suture through the epiglottis being kept outside the laryngoscope. Tension can be applied to the epiglottis suture to control and stabilize the epiglottis as the laryngoscope is passed underneath it into position. Once good position of the laryngoscope is achieved, the

Fig. 10.15  Cup forceps placed outside the laryngoscope to control the position of the epiglottis, allowing placement of the laryngoscope into the endolarynx without “folding” of the epiglottis

suture is removed from the epiglottis. (Alternatively, the suture can be removed at the end of the case.)

The optimal position of the laryngoscope within the endolarynx is determined by the vocal fold pathology and pending surgical procedure. However, in general, the laryngoscope should be positioned immediately above (superior to) the vocal fold pathology, specifically resulting in retraction of the false vocal fold tissues. Care should be taken to avoid contacting the superior surface of the vocal fold given that this will significantly alter the anatomic orientation and nature of the vocal fold and often distort the vocal fold pathology.

10.5.4 Suspension Device

The gallows suspension device (Fig. 10.16), if used, should be positioned to provide upward and slightly forward (caudal) suspension of the laryngoscope in the endolarynx. This special angulation of the laryngoscope will provide optimal laryngoscopic visualization and minimal adjacent tissue injury or damage. For a rotation or fulcrum laryngoscope device holder (such as a table-mounted Mayo stand; Fig. 10.17), it is of the utmost importance to remember to provide special care and attention to the maxillary teeth as the laryngoscope holder is put into place. This is especially important given that as the fulcrum holder is adjusted, each amount of upward rotation at the distal tip of the laryngoscope results in an equal amount of downward pressure at the proximal aspect of the laryngoscope on the maxillary alveolar ridge. A tooth protector can be fashioned by using a standard thin plastic tooth guard commonly found in anesthesiology carts, and reinforcing it with multiple layers of cloth tape (Fig. 10.18).

Fig. 10.16  Gallows-type suspension device

Fig. 10.18  Tooth protector fashioned from a plastic tooth guard and layers of cloth tape

10.5.5 External Counter-Pressure

A Velcro strap or silk tape can be applied to the external neck (in the area of the cricoid or trachea) in a downward and slightly cephalad vector to improve the endolaryngeal exposure on an as needed basis (Fig. 10.19). The surgeon should look down the laryngoscope while applying external counter-pressure to judge the location and amount of external counter-pressure required. A small amount of gauze or a foam pad can be positioned between the tape or strap and the neck skin to prevent any injury to the overlying skin of the larynx (Fig. 10.20). It is extremely important that the surgeon remember this type of external counter pressure, which is often essential to optimal exposure of the endolarynx, puts the patient at risk if the

Fig. 10.17  Fulcrum type suspension device (Lewy apparatus suspended from a table-mounted Mayo)

Fig. 10.19  Velcro strap applied to anterior neck region (near the cricoid) to optimize vocal fold visualization during suspension laryngoscopy

patient were to move unexpectedly as the anesthesia wears off. If this occurs, the first duty of the surgeon is to release the external counter pressure and secondly take the patient out of suspension laryngoscopy.

10.5.6Telescopic Evaluation of Vocal Fold Pathology

Using the 0, 30, 70° (and as needed, 120°) telescope for visualization in a “three-dimensional” fashion of the endolarynx is of

Fig. 10.21  Visualization of vocal fold pathology during suspension laryngoscopy with angled telescopes

great value. This is done after the laryngoscope is suspended. This allows for unique visualization of the vocal fold pathology, photodocumentation, and surgical planning (Fig. 10.21). Specifically, decisions are often made about the optimal location for an incision when evaluating the vocal fold pathology, specifically with the 30 and 70° angled telescopes. In addition, these telescopes provide great visualization of the ventricles, subglottis, anterior and posterior commissure.

10.5.7Operating Microscope and Surgeon Ergonomics

After suspension of the laryngoscope and telescopic examination, the surgical microscope is brought in to position, and

Fig. 10.22  Proper support of surgeon’s arms for phonomicrosurgery

attention should be drawn to the position of the laryngoscope in relation to the microscope and the surgeon. Optimal hand control of instrumentation during phonomicrosurgery occurs when the forearms can be supported with a stable device, such as an operating room chair with arm supports. The wrists are the best location for precise control, and thus some type of surgical support should be identified (an ophthalmologist’s or plastic surgeon’s operating room chair with arm supports, or a Mayo stand) that will allow the most steady and stable hand and wrist motions, but supporting the arms at the level of the forearms (Fig. 10.22). Patient positioning should allow the surgeon’s upper arms to be held in a vertical position, with elbows and hands as low as possible to the surgeon’s lap. An alternative to these custom surgical chairs is to use a Mayo stand with pillows/foam padding. The Mayo stand is placed between the surgeon and the head of bed (Fig. 10.23).

Paying attention to the surgeon’s neck, head, and back position during the surgical procedure is important for his/her longstanding neck and back health. Often, to facilitate optimal phonomicrosurgery ergonomics, the operating room table should be placed in a reverse Trendelenburg position. This brings the laryngoscope lower—into the surgeon’s lap—and the eye pieces of the surgical microscope should be utilized to allow the surgeon to sit with his/her back completely straight and upright (Fig. 10.22).

Binocular vision at high-power magnification must be achieved during all aspects of the procedure. This will require minor but important adjustments of the position of the microscope and laryngoscope to ensure that the viewing access of the microscope is perfectly coaxial with the longitudinal aspect of the laryngoscope, thus allowing binocular vision. This is a very important component to phonomicrosurgery, and it should not be overlooked. The novice phonomicrosurgeon will initially struggle with this task, but patience and practice will allow success. The majority of phonomicrosurgical procedures should be done using the microscope’s highest magnification setting.

Fig. 10.23  Alternative method for support of the surgeon’s arms, using a padded Mayo stand

10.5.8Microflap Approach

to Submucosal Pathology

The microflap approach to submucosal pathology is a key aspect to most phonomicrosurgery operations. The core principles of the microflap approach to submucosal pathology include:

■Making an incision through the epithelium at the closest possible location to the submucosal pathology

■Disrupting the minimum of surrounding tissue to the vocal fold pathology

■Staying in as a superficial plane as possible

■Preservation of overlying normal mucosa (epithelium plus superficial lamina propria)

There are multiple descriptions of various forms of microflaps, specifically lateral microflap, medial microflap, and mini-mi- croflap. Over the years, many of these microflap approaches have merged into a single, philosophical microflap approach to submucosal pathology, which is described below.

The incision for the microflap should be directly overlying, or immediately lateral to the vocal fold pathology. This results in minimal disruption of normal adjacent vocal fold mucosa. After the vocal fold pathology is palpated and an incision is planned, an incision is then made with a sharp sickle knife. It is important to note that the tip of the sickle knife should be used to penetrate the epithelium, and then the tip of the sickle knife can be drawn slightly superiorly, tenting up the epithelium as the incision is made in an anterior or posterior direction (Fig. 10.24). This prevents the sickle knife accidentally causing any type of injury to the submucosal pathology or deep vocal fold tissues.

After the incision has been made, the vocal fold pathology may be able to be palpated and directly visualized through the

Fig. 10.24  Microflap incision placed lateral to the lesion with epithelium tented up by the sickle knife

incision and a small curved elevator can be used to begin the elevation of the microflap in the plane between the vocal fold pathology and the overlying epithelium (i. e. medial to the lesion). This plane is the single most difficult step of phonomicrosurgery, and it should be performed with great patience and caution. It is often easiest to initiate and develop this plane anteriorly and posteriorly to the vocal fold lesion. Often, various angulated or curved elevators will be required to perform this aspect of the procedure, given that at the very start of the development of the microflap, the surgeon is initially working on the upper lip of the free edge of the vocal fold medially. Then as the microflap is carefully elevated and dissected from the submucosal pathology, the surgeon is working in the exact opposite direction on the inferior lip of the vocal fold laterally, and thus, different curved elevators are often required to work in different directions, especially to ensure minimizing the risk of microflap penetration or injury.

Once a plane is developed anterior and posterior to the lesion, then careful submucosal dissection with a small, fine blunt elevator (curved or angled) is performed to complete the elevation and creation of the microflap (Fig. 10.25). There may be instances where small, microcurved scissors need to be used to release fibrous bands off the overlying microflap in adherent areas of the submucosal pathology or in a similar manner when the submucosal pathology is adherent to the deeper aspects of the vocal fold in the area of the vocal ligament (see Chap. 17, “Vocal Cord Cyst and Fibrous Mass”)

Hemostasis is extremely important, and if bleeding is causing an obstruction of visualization, then the surgery should be temporarily stopped and the application of epinephrine (1:10,000)-soaked, small cotton pledgets should be utilized to quickly and successfully provide surgical hemostasis without

10

Fig. 10.25  Elevation of microflap off vocal fold lesion beneath

much difficulty. Suctioning blood and secretions from this area should be done with a 3-French suction, usually without covering the thumb port.

Great care should be taken not to tear or fenestrate the microflap as it is tediously and carefully elevated off the submu-

cosal pathology. The majority of benign vocal fold submucosal pathology is located in the immediate subepithelial plane and is often, to a varying degree, adherent to the overlying epithelium. This is the case in approximately 80–90% of cases; however, there will be situations where the pathology is not adherent to the overlying microflap and instead located deeper within the vocal fold (in the area of the vocal fold ligament) (Fig. 10.26). This is true for ligamentous vocal fold cyst and fibrous mass (see Chap. 4, “Pathological Conditions of the Vocal Fold”). When these pathologies are encountered, the surgeon will notice that the microflap elevation is quite easy; however, the deeper aspect of the dissection, creating a plane between the vocal fold pathology and the vocal ligament is quite difficult. In this situation, great care should be taken to use either a blunt dissection technique or microscissors to release the adherent bands between the vocal fold ligament and the pathology, always erring on the side of the pathology (in a superficial fashion).

After the superficial and deep planes around the submucosal pathology have been elevated, there may be some additional connections to the vocal fold pathology within the vocal fold anteriorly and posteriorly. These bands can be released with blunt dissection or microcurved scissors. This allows the submucosal pathology to be removed and sent for pathologic examination. The microflap is then redraped with either the triangular forceps or a curved elevator (Fig. 10.27). It is often helpful to place an epinephrine (1:10,000)-soaked Cottonoid over the operative site for 1–2 min to reduce edema before making further surgical decisions. After the microflap has been redraped, palpation of the vocal fold should be performed to determine if there is any residual submucosal pathology that can be palpated and removed.

Fig. 10.26  Elevated microflap reveals that the pathology (fibrous mass) is on the vocal ligament and not in the subepithelial space

Fig. 10.27  Redraped microflap after removal of vocal fold lesion. Note copatation of the mucosa at the incision site and smooth free edge of the vocal fold

The free edge of the vocal fold should be straight after the pathology is removed; if not, further investigation into either the under surface of the microflap or the deeper aspect of the vocal fold should be performed. If there is any residual pathologic tissue such as fibrous material or scar, then this tissue should be removed in a conservative and reasonable fashion. This material can be removed with a microelevator or microcup forceps. Extreme care is required at this juncture of the surgery because overly-aggressive removal of this material can result in significant scar formation as well as a permanent deformity of the free edge of the vocal fold. At the completion of the vocal fold lesion(s) excision, the free edge of each vocal fold should be completely straight without exophytic mucosal tags and without a soft tissue defect at the free edge of the surgical site.

10.6Postoperative Care and Complications

Almost all phonomicrosurgical procedures are followed by some period of voice rest. This period can range from as short as 2 days and extend to possibly 14 days, depending on the specific nature of the surgery, compliance of the patient, the surgeon’s philosophy, and experience. In addition to voice rest, the patient should be encouraged to stay well hydrated, continue treatment for laryngopharyngeal reflux disease with a proton pump inhibitor, and maintain GERD behavior modification. At the end of the prescribed strict voice rest period, stroboscopy should be performed to evaluate the recovery and healing process of the vocal fold. If there is adequate epithelial coverage, then the patient can be transitioned to “light voice use,” which is usually defined as speaking using a breathy, “airy” type of voice (not a whisper) for 5–10 min per hour. Light voice use is often used for an additional 7–10 days after the period of strict voice rest. There is rarely an indication for antibiotics associated with phonomicrosurgery or long-term steroid use. Some surgeons may use immediate intravenous, intramuscular, or intralesional steroids perioperatively to minimize postoperative edema.

It is advisable to involve a speech–language pathologist to assist the patient in transitioning from strict voice rest to light voice use to ensure that the patient is using the optimal postoperative voice technique to facilitate healing and prevent injury in this important time.

Complications from phonomicrosurgery include failure of the microflap to appropriately redrape and adhere to the vocal fold. When this occurs, epithelial ingrowth underneath the microflap occurs, and surgical excision of the microflap is mandated. This is a rare complication. Excessive edema and even necrosis can occur to a microflap; this typically occurs when the microflap is overly traumatized or injured during the surgical procedure. Often, when this occurs, the vocal fold will heal adequately on its own with appropriate time and care. Dental injuries after phonomicrosurgery should be repaired to the patient’s satisfaction in a prompt fashion to minimize negative feelings of the patient toward the surgeon. Lingual nerve injuries such as numbness of the tongue and/or a change in taste

sensation occur in approximately 10–20% of patients after phonomicrosurgery. These symptoms are usually transitory, and thus the patient should be informed that these postoperative changes resolve on their own within the first month after surgery. Additional complications related to phonomicrosurgery are discussed in Chaps. 11, “Perioperative Care for Phonomicrosurgery” and 12, “Management and Prevention of Complications Related to Phonomicrosurgery.”

Key Points

■Phonomicrosurgery is elective, precise surgery aimed to improve vocal function based on principles of vocal fold physiology.

■Phonomicrosurgery utilizes small, delicate surgical instrumentation and is performed with maximum control via high-powered microlaryngoscopy for optimal results.

■Conservative removal of submucosal pathology with preservation of overlying normal epithelium and superficial lamina propria allows healing by primary intention and optimal voice quality after phonomicrosurgery.

■Microflap approach to submucosal pathology of the vocal fold is an essential component of most phonomicrosurgical procedures and is a challenging surgical task that requires patience, appropriate instrumentation, surgical skill, and experience.

Selected Bibliography

1Andrea M, Dias O (1995) Rigid and contact endoscopy in microlaryngeal surgery: technique and atlas of clinical cases. Lippincott Williams & Wilkins, Philadelphia

2Bastian RW (1996) Vocal fold microsurgery in singers. J Voice 10:389–404

3Bouchayer M, Cornut G (1992) Microsurgical treatment of benign vocal fold lesions: indications, technique, results. Folia Phoniatr 44:155–184

4Courey MS, Garrett CG, Ossoff RH (1997) Medial microflap for excision of benign vocal fold lesions. Laryngoscope 107:340–344

5Courey MS, Stone RE, Gardner GM, Ossoff RH (1995) Endoscopic vocal fold microflap: a three year experience. Ann Otol Rhinol Laryngol 104:267–273

6Ford CN (1999) Advances and refinements in phonosurgery. Laryngoscope 109:1891–1900

7Hirano M (1977) Structure and vibratory behavior of the vocal fold. In: Sawashima M, Cooper F (eds) Dynamic aspects of speech production. University of Tokyo, pp 13–30

8Rosen CA, Andrade Filho PA, Scheffel L, Buckmire RA (2005) Oropharyngeal complications of suspension laryngoscopy: a prospective study. Laryngoscope 115:1681–1684

9Sataloff RT, Spiegel JR, Heuer RJ, Barody MM, Emerich KA, Hawkshaw MJ, Rosen DC (1995) Laryngeal mini-microflap: a new technique and reassessment of the microflap saga. J Voice 9:198–204

10Shapshay SM, Healy GB (1990) New microlaryngeal instruments for phonatory surgery and pediatric applications. Ann Otol Rhinol Laryngol 98:821–823

11Thekdi AA, Rosen CA (2003) Surgical treatment of benign vocal fold lesions. Curr Opin Otolaryngol Head Neck Surg 10:492–496

12Zeitels SM, Vaughan CW (1994) External counter-pressure and internal distension for optimal exposure of the anterior glottal commissure. Ann Otol Rhinol Laryngol 103:669–675

13Zeitels 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 Rhinol Laryngol 190(Suppl.):21–40

11.1Fundamental and Related Chapters

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

11.2Timing of Phonomicrosurgery

Phonomicrosurgery involves the surgical manipulation of the delicate epithelial and sub-epithelial tissues of the vocal fold (Fig. 11.1). Thus a variety of steps should be implemented to minimize edema and bleeding at the surgery sites(s) to maximize the surgeon’s precision and the voice outcome post-op- eratively. There are a variety of important aspects with regard to the timing and scheduling of phonomicrosurgery. First and foremost, the patient and the physician must be comfortable with the decision to proceed with surgery, having had a detailed discussion regarding the nature of the surgical procedure, perioperative treatment plan, and should have established reasonable expectations for the timing of recovery and voice outcomes (see Chap. 8, “Timing, Planning, and Decision Making in Phonosurgery”). It is important for the patient to stop all

Fig. 11.1  Microscopic dissection of the epithelial flap using a 30° flap elevator

anticoagulation medication such as nonsteroidal anti-inflam- matories, aspirin, Coumadin, and Plavix, and other medications that may affect coagulation (over-the-counter medications, herbal supplements etc.). These medications should be stopped 7–10 days prior to surgery.

It is also wise to avoid scheduling phonomicrosurgery during a woman’s premenstrual period (approximately 5 days before the onset of menses). This is especially important for singers and for patients with very small vocal fold lesions. The reason for avoiding the premenstrual time period when engaging in phonomicrosurgery is to avoid vocal fold edema and vascular fragility thought to be associated with premenstruation affect the surgical decision making and the surgical outcome. Lastly, the patient and surgeon should have a clear understanding of the voice demands for the next 2–3 months after phonomicrosurgery. This is extremely important for singers, schoolteachers, and individuals involved in sales and business (see Chap. 8).

11.3Surgical Indications and Contraindications

It is important for the patient prior to phonomicrosurgery to minimize his/her voice demands for approximately 7 days before the scheduled surgery (see Chap. 8, “Timing, Planning, and Decision Making in Phonosurgery”). Voice therapy prior to phonomicrosurgery is important for a variety of factors, including:

■Preand postoperative voice use plans

■Voice rest, and education regarding use of the silent cough

■Laying a foundation for healthy voice use technique after surgery

■Discussing alternative communication options during the complete-voice rest phase

If the patient has not had any voice therapy prior to surgery, then one to two sessions of voice therapy is optimal. It is also advisable prior to phonomicrosurgery to begin the patient on medical therapy for LPR treatment prophylactically. Even if the patient does not have any active symptoms of LPR, given the risk of reflux and its possible negative effects on wound healing of the vocal folds, GERD behavior modification and proton pump inhibitor therapy is typically started prior to phonomicrosurgery and extended for 1–2 months after surgery.