F081 Coclia 75 Phonosurgery

COCLIA Laryngology:

PHONOSURGERY

Samuel OstrowerJanuary 14, 2008

Recurrent Laryngeal Nerve

Cricoarytenoid Joint

Intrinsic Musculature

Intrinsic Musculature

1. A patient is referred from your favorite thoracic surgeon for hoarseness after aortic aneurysm repair. On exam, you find an immobile vocal fold. How can you determine the etiology?

Patient Evaluation

• Subjective assessment

• Phonatory function tasks

• Acoustic parameters

• Phonatory airflow

• Videostroboscopy

• Electromyography (EMG)

Videostroboscopy

• Illusion of slow motion created using a strobe light to illuminate the vocal folds at different points of different vibration cycles

• Evaluates:– Glottic closure

– Symmetry

– Undersurface of vocal fold edges

– Stiffness, scar, submucosal injury

– Relative depth of tumor invasion

– Mucosal wave• Vocal fold vibration

patterns/amplitude

• Mucosal pliability

Laryngeal Electromyography (EMG)

• Only test available for evaluating integrity of laryngeal motor unit.– Voluntary action potentials, fibrillation potentials,

electrical silence

• Percutaneous or transoral placement of concentric bipolar needles– Thyroarytenoid m. – Posterior cricoarytenoid m.– Cricothyroid m.

2. Vocal fold injectional medialization Vs. Intrachordal injection. What is the difference?

Medialization vs Intrachordal Injection

• Vocal fold medialization injection– Material injected lateral to vocalis m. in

paraglottic space

• Vocal fold intrachordal injection– Material is injected superficially, just deep to

lamina propria, avoiding Reinke’s space– Used for elimination of soft tissue defects

3. Unilateral vocal fold medialization by injection – what materials are available? Indications and advantages?

Injection Materials

• Teflon (Polytef)• Human micronized alloderm (Cymetra)• Autologous fat• Gelfoam• Collagen• Hydroxyapatite• Hyaluronic acid formulations/Hylan B

(Hylaform)

Teflon Paste (Polytef®)

• Permanent, non-reabsorbable material

• Viscous

• Poor vibratory/phonatory results

• Must be injected laterally

• Migration, extrusion, progressive inflammatory response– Granuloma formation

Human Micronized Dermis/AlloDerm (Cymetra®)

• Most commonly used injectable

• Excellent phonatory results

• Low viscosity

• Temporary (effects last 6-12 months)

• Acellular, non-antigenic material causing minimal inflammatory response

Autologous Fat

• No inflammatory response

• Excellent phonatory results

• Requires additional incision

• Viscous, requiring Bruening syringe

Bovine Collagen

• Effective for management of vocal fold paralysis, sulcus vocalis and soft tissue deficits

• Temporary material• Low viscosity• Delayed hypersensitivity possible

– Skin testing recommended– May lead to inflammatory changes leading to

increased vocal fold stiffness, but unlikely permanent sequelae

Cross-Linked Hyaluronic Acid Gel (Hylaform®)

• Temporary

• Low viscosity

• Good phonatory results

Calcium Hydroxyapatite Gel (Radiance FN®)

• Permanent, non-reabsorbable material

• Phonatory results less well studied

• Relatively large particles not taken up by macrophages (no granuloma formation)

4. Discuss the management of Teflon granulomas.

Teflon Granuloma

• Foreign body giant cell reaction

• Variable onset– May occur between 4 months and 18 years

following injection

• Therapeutic options

Teflon Granuloma Therapeutic Options

• Endoscopic with superior fold wedge resection/suction technique (Dedo, 1992)

• Midline thyrotomy/”hemilaryngectomy” technique (Russell, et al. 1995)

• Endoscopic with CO2 laser and superior VF microflap reconstruction (Ossoff, et al. 2003)

Lateral Laryngotomy• Lateral laryngotomy (Netterville, 1998)

– Allows full granuloma excision with preservation of uninvolved lamina propria

– Sternothyroid muscle flap or silastic implant medializes remaining vocal fold after excision to optimize voice production

5. Describe transcutaneous vs. laryngoscopic injection in vocal fold medialization

Transcutaneous Injection Thyroplasy

• Lateral approach– Through thyroid ala at level of vocal fold (midway

between thyroid notch and inferior margin of ala)– Local anesthesia– Direct visualization

using flexible

laryngoscopy

Transcutaneous Injection Thyroplasy

• Anterior approach – Through cricothyroid membrane– Local anesthesia– Direct visualization

using flexible

laryngoscopy

Transcutaneous Injection Thyroplasy

• Luer Lock 1-cc syringe with 1-inch, 23-gauge needle

• Injection placed just anterior and lateral to vocal process on a plane level with lower border of medial edge of VF

• Use 0.5 – 1cc of Cymetra®

Laryngoscopic Injection Thyroplasty

• Patients who do not tolerate flexible fiberoptic exam with percutaneous approach

• Used during ablative procedures when RLN or vagus sacrifice anticipated

• Performed under general anesthesia with spontaneous ventilation, apnea or jet ventilation

6. Discuss the management of overinjection during vocal fold medialization

Overinjection

• Teflon overinjection– Immediate mucosal incision and suctioning of

excess material– Delayed removal is problematic due to migration,

scar and granuloma

7. Medialization thyroplasty–indications, advantages. Otolaryngol Head Neck Surg 1997;116:349

Type I Thyroplasty• Term coined by Isshiki in the 1970’s

• External medialization technique

• Immediate & reversible results

• Improves both voice & aspiration

• Local anesthesia

Indications

• Procedure of choice for the paralyzed vocal fold when recovery unlikely

• Vocal fold bowing from aging or cricothyroid joint fixation

• Sulcus vocalis

• Soft tissue defects from excision of pathologic tissue

Timing of Surgery

Otolaryngol Head Neck Surg 1997; 116:349-54

Medialization Thyroplasty Materials

• Silastic– Carved– Prefabricated (Montgomery)

• Hydroxyapatite– VoCom

• Gore-Tex– Composed of Teflon

Surgical Technique

Surgical Technique

Surgical Technique

Surgical Technique

Surgical Technique

9. Goal of Arytenoid Adduction. Indications

Arytenoid Adduction (AA)• Surgical therapeutic option for correction of significant glottal incompetence in patients with laryngeal paralysis• Mimics lateral cricoarytenoid m. to rotate the arytenoid vocal process medially• Correct for asymmetries in vertical height

10. Would you perform an arytenoid adduction without medialization procedure? Otolaryngol Head Neck Surg 2003;129:305-310

Arytenoid adduction combined with medialization thyroplasty: an evidence-based review (Otolaryngol

Head Neck Surg 2003;129:305-310)

• 219 articles

• Majority of articles discussed the benefits of MT or AA as a single intervention

• Only 3 articles directly evaluated the voice outcomes of MT plus AA versus MT alone

• There was no clear benefit in subjective or objective outcomes for AA plus MT

11. How do you do an arytenoid adduction?

Arytenoid Adduction Technique

12. What is the success of reinnervation procedures?

Reinnervation Techniques

• Neuromuscular pedicle (NMP)

• Ansa cervicalis-to-recurrent laryngeal nerve (ansa-RLN) anastomosis

Neuromuscular Pedicle Technique

Ansa Cervicalis-to-Recurrent Laryngeal Nerve (ansa-RLN) Anastomosis Technique

13. Bilateral vocal fold paralysis in midline position. Patient refuses tracheostomy. What other surgical options can you offer? Ann Otol Rhinol Laryngol 1991; 100:717

Bilateral Vocal Fold Paralysis - Surgical Options

• Arytenoidectomy

• Arytenoidopexy

• Cordotomy

• Cordopexy

• Nerve-muscle transposition