22 - Vocal Fold Surgery Flashcards
When is VF Surgery the best option?
4
Therapy does not yield desired results
Therapy cannot yield desired results
Suspicious lesion to find pathology
Maintain airway
What are two Office-Based VF Treatments?
Indirect Laryngoscopy
Botox Injections
What are the two types of Indirect Laryngoscopy?
Mirror Laryngoscopy
Flexible Laryngoscopy
What are the two types of Flexible Laryngoscopy?
KTP Laser
Injection Laryngosplasty
What is an Indirect Laryngoscopy Using Mirror?
When is this normally used? (3)
Laryngoscopy using a long handled mirror and head light/ head mirror with light source
For injections, biopsies or foreign body removal
What is Flexible Laryngoscopy?
Laryngoscopy using a flexible scope
Often used with the use of topical or local anesthesia
What might a Flexible Laryngoscopy be equipped with?
4
Operating channels
Small flexible instruments
Laser fibers
Injection needles
Why might anesthesia not be used in Flexible Laryngoscopy when diagnosing swallowing?
It can impair trigger reflexes
How does a KTP Laser with Flexible Laryngoscopy work?
3
Laser fibers target the lesions
They emit energy that is absorbed by the lesion,
Lesion eventually falls off
What can a KTP Laser with Flexible Laryngoscopy be used to treat?
(4)
Dysplasia
Leukoplakia
VF cancer
Papilloma
What are the Pros of Office Based Procedures?
5
Does not require anesthesia
Cost-effective
Patients can typically transport themselves
Faster return to normal voice use
Ability to assess phonation/ glottal competency during procedure
What are the Cons of Office Based Procedures?
3
Tissue can onlybe manipulated or cut so far
Not an option for more advanced cases
Can be uncomfortable for patient
What are eight Office-Based VF Treatments?
Microexcision
Microflap Dissection
Laser
Microdebrider Dissection
Injection Laryngoplasty
Thyroplasty
Unilateral/ Bilateral Cordotomy
Complete Cordectomy
What is typically involve in a Surgical Approach?
3
General anesthesia
Intubation with a small endotracheal tube
Suspension
What is a Microlaryngoscopy?
1+4
Excision of a lesion using…
- Suspension
- Binocular microscope
- Forceps (retract)
- Microscissors (excise)
What is Microlaryngoscopy typically used for? (2)
How long does it normally take?
Nodular lesions
Polypoid lesions
10-20 minutes
What is Microflap Dissection?
3
Incision on the vocal fold surface followed by dissection into Reinke’s space
Removal of firm pathology and/or swelling
Tissue is draped over itself to heal (excising any excess)
What is Microflap Dissection typically used to treat?
4
Removal of a larger or submucosal lesions
Polyps
Reinke’s edema
Cyst
How long does Microflap Dissection usually take?
20-30 minutes
What is Laser Laryngoscopy?
2
Focused beam of energy is used to burn/ vaporize tissue
CO₂ laser most commonly since the energy is absorbed by water
What is Laser Laryngoscopy typically used to treat?
4
Papilloma
Vascular lesions
Hemilaryngectomy
Cordotomy
How long does Laser Laryngoscopy usually take?
30-40 minutes
What are Pros of Laser Laryngoscopy?
3
More precise cut or excision
Less burn injury to surrounding tissue
Keeps the surgical field more free of obstruction
What are Cons of Laser Laryngoscopy?
4
CO₂ laser can only be delivered to line of sight
Risk of thermal injury or scarring to adjacent
tissue
Risk of airway fire (O₂)
Increase in cost, personnel, and time
What is the SLP’s Role in Surgery?
4
Educate about the need for voice rest
Educate about vocal hygiene and discuss ways of implementing this in patient’s daily life
Voice therapy after surgery as needed
Repeat videostroboscopy to show successive improvements
What are the Surgical Intervention in Unilateral Vocal Ford Paralysis?
(2)
Injection
Thyroplasty (Implants)
When can Injection be used to treat Unilateral Vocal Ford Paralysis?
(3)
Up to 1 year of initiating event
If there is no known permanent damage to RLN
If paralysis negatively affects voice and/or swallowing
How is Office-Based Injection used to treat Unilateral Vocal Ford Paralysis?
(4)
Local anesthesia is used (via circothyroid membrane or orally)
Flexible laryngoscopy is used
Injectable material (usually Radiesse) is used to plump up the paralyzed cord
Helps paralyzed fold “meet” the other cord creating better glottic closure
What are the PROS for treating Unilateral Vocal Ford Paralysis via Office-Based Injection?
(2)
Useful for poor surgical candidates
Gives immediate voice feedback
What are the CONS for treating Unilateral Vocal Ford Paralysis via Office-Based Injection?
Patient discomfort
How is Injection performed surgically to treat Unilateral Vocal Ford Paralysis in an Office?
(3)
Uses general anesthesia with direct visualization
Injectable material (usually Radiesse) is used to plump up the paralyzed cord
Helps paralyzed fold “meet” the other cord creating better glottic closure
What are the PROS for treating Unilateral Vocal Ford Paralysis with Injection via Surgery?
(2)
Patient comfort
Precision of injection
What are the CONS for treating Unilateral Vocal Ford Paralysis with Injection via Surgery?
No immediate feedback
When can Thyroplasty (Implants) be used to treat Unilateral Vocal Ford Paralysis?
(2)
Past 1 year of initiating event
If permanent nerve damage has been determined
Is treating Unilateral Vocal Ford Paralysis via Injection a permanent solution?
(2)
No.
It is temporary solution used during the “wait and see” period (can be up to a year)
How is Thyroplasty (Implants) used to treat Unilateral Vocal Ford Paralysis in an Office?
(2)
Paralyzed cord is medialized by placing a silicone implant under the vocal fold muscle
Goal to “push the muscle” over to the midline creating better glottal closure
Is treating Unilateral Vocal Ford Paralysis via Thyroplasty (Implants) a permanent option?
Yes
How is Thyroplasty (Implant) used to treat Unilateral Vocal Ford Paralysis?
(6)
Thyroid cartilage is exposed, with the “key point” located
Outline instrument used to imprint the window for excision of cartilage
Window is cut and cartilage is removed
Measure window size again to carve out implant
Insert implant. Patient vocalizes to assess placement/ size for adequate glottic closure
Reassess implant size if needed
What does treating Bilateral VF Paralysis surgically depend on?
(3)
How active patient is (exertion)
Timeline
Etiology
What is the goal when treating Bilateral VF Paralysis?
Assuring the patients ability to breath
What are surgical treatments used to treat Bilateral VF Paralysis?
(3)
Unilateral Transverse Cordotomy
Bilateral Transverse Cordotomy
Complete Cordectomy
What is a Unilateral Transverse Cordotomy?
3
One vocal fold is divided from the vocal process
It is allowed to retract anteriorly
This allows for a larger posterior glottic gap (improve breathing) and anterior “bunching” (goal of maintain voicing)
What is the goal in the Posterior Glottic Gap in Unilateral Transverse Cordotomy?
What is the goal in Anterior “Bunching”?
Improving breathing
Maintaining voicing
What is a Bilateral Transverse Cordotomy?
2
Both vocal folds are divided from the vocal process
This allows for a greater glottal gap but leaves minimal risk for aspiration and minimal change in voice
What is a Complete Cordectomy?
2
Complete removal of one vocal fold
This includes the vocalis muscle
When is a Complete Cordectomy usually performed?
How is it performed typically?
To treat a localized malignancy
With laser laryngoscopy
What are Isshiki four types of Phonosurgery Classification?
Type I
Type II
Type III
Type IV
What is a Type I Phonosurgery Classification?
What is the goal?
Medialization Laryngoplasty
To bring VFs together
(Can be used with arytenoid adduction)
What is a Type II Phonosurgery Classification?
What is the goal?
What does this change perceptually?
Lateralization laryngoplasty
To pull VFs apart
(Involves lateralization of thyroid cartilage)
Creates soft and breathy voice
What is a Type III Phonosurgery Classification?
What is the goal?
What does this change perceptually?
Anterior-posterior thyroid cartilage shortening
To create a lax VF
Results in pitch lowering.
What is a Type IV Phonosurgery Classification?
What is the goal?
What does this change perceptually?
Anterior-posterior elongation by crico thyroid approximation.
To create a longer, thinner VF
Results in higher pitched voice.
Who is a Type IV Phonosurgery beneficial for?
2
Patients undergoing gender reassignment (feminization)
Patients with cricothyroid muscle paralysis
