22 - Vocal Fold Surgery Flashcards by Jamie Bevill

When is VF Surgery the best option?

Therapy does not yield desired results

Therapy cannot yield desired results

Suspicious lesion to find pathology

Maintain airway

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What are two Office-Based VF Treatments?

Indirect Laryngoscopy

Botox Injections

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What are the two types of Indirect Laryngoscopy?

Mirror Laryngoscopy

Flexible Laryngoscopy

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What are the two types of Flexible Laryngoscopy?

KTP Laser

Injection Laryngosplasty

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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

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What is Flexible Laryngoscopy?

Laryngoscopy using a flexible scope

Often used with the use of topical or local anesthesia

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What might a Flexible Laryngoscopy be equipped with?

Operating channels

Small flexible instruments

Laser fibers

Injection needles

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Why might anesthesia not be used in Flexible Laryngoscopy when diagnosing swallowing?

It can impair trigger reflexes

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How does a KTP Laser with Flexible Laryngoscopy work?

Laser fibers target the lesions

They emit energy that is absorbed by the lesion,

Lesion eventually falls off

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What can a KTP Laser with Flexible Laryngoscopy be used to treat?

(4)

Dysplasia

Leukoplakia

VF cancer

Papilloma

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What are the Pros of Office Based Procedures?

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

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What are the Cons of Office Based Procedures?

Tissue can onlybe manipulated or cut so far

Not an option for more advanced cases

Can be uncomfortable for patient

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What are eight Office-Based VF Treatments?

Microexcision

Microflap Dissection

Laser

Microdebrider Dissection

Injection Laryngoplasty

Thyroplasty

Unilateral/ Bilateral Cordotomy

Complete Cordectomy

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What is typically involve in a Surgical Approach?

General anesthesia

Intubation with a small endotracheal tube

Suspension

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What is a Microlaryngoscopy?

1+4

Excision of a lesion using…

Suspension
Binocular microscope
Forceps (retract)
Microscissors (excise)

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What is Microlaryngoscopy typically used for? (2)

How long does it normally take?

Nodular lesions

Polypoid lesions

10-20 minutes

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What is Microflap Dissection?

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)

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What is Microflap Dissection typically used to treat?

Removal of a larger or submucosal lesions

Polyps

Reinke’s edema

Cyst

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How long does Microflap Dissection usually take?

20-30 minutes

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What is Laser Laryngoscopy?

Focused beam of energy is used to burn/ vaporize tissue

CO₂ laser most commonly since the energy is absorbed by water

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What is Laser Laryngoscopy typically used to treat?

Papilloma

Vascular lesions

Hemilaryngectomy

Cordotomy

How long does Laser Laryngoscopy usually take?

30-40 minutes

What are Pros of Laser Laryngoscopy?

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?

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

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22 - Vocal Fold Surgery Flashcards

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