ATLAS OF OPERATIVE Vol.

4
OTORHINOLARYNGOLOGY
AND HEAD & NECK SURGERY

VOICE AND LARYNGOTRACHEAL

SURGERY
 ATLAS OF OPERATIVE Vol. 4
OTORHINOLARYNGOLOGY
AND HEAD & NECK SURGERY

VOICE AND LARYNGOTRACHEAL

SURGERY
Editors

Bachi T Hathiram
Professor and Head
Department of ENT and Head and Neck Surgery
Topiwala National Medical College and
BYL Nair Charitable Hospital
Mumbai, Maharashtra, India

Vicky S Khattar
Assistant Professor
Department of ENT and Head and Neck Surgery
Topiwala National Medical College and
BYL Nair Charitable Hospital
Mumbai, Maharashtra, India

Forewords
Jatin P Shah
Milind V Kirtane

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • London • Philadelphia • Panama
 ®

Jaypee Brothers Medical Publishers (P) Ltd

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: [email protected]

Overseas Offices
J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc. Jaypee Brothers Medical Publishers Ltd
83, Victoria Street, London City of Knowledge, Bld. 237, Clayton The Bourse
SW1H 0HW (UK) Panama City, Panama 111 South Independence Mall East
Phone: +44-2031708910 Phone: +507-301-0496 Suite 835, Philadelphia, Pennsylvania, USA
Fax: +02-03-0086180 Fax: +507-301-0499 19106, USA
Email: [email protected] Email: [email protected] Phone: + 267-519-9789
Email: [email protected]

Jaypee Brothers Jaypee Brothers

Medical Publishers (P) Ltd Medical Publishers (P) Ltd
17/1-B Babar Road, Block-B Shorakhute, Kathmandu
Shaymali, Mohammadpur Nepal
Dhaka-1207, Bangladesh Phone: +00977-9841528578
Mobile: +08801912003485 Email: [email protected]
Email: [email protected]

Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com

© 2013, Jaypee Brothers Medical Publishers

All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher.

Inquiries for bulk sales may be solicited at: [email protected]

This book has been published in good faith that the contents provided by the contributors contained herein are original, and
is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the
editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the
contents of this work. If not specifically stated, all figures and tables are courtesy of the editors. Where appropriate, the readers
should consult with a specialist or contact the manufacturer of the drug or device.

Atlas of Operative Otorhinolaryngology and Head & Neck Surgery:

Voice and Laryngotracheal Surgery (Vol. 4)

First Edition: 2013

ISBN 978-93-5090-482-4
Printed at:
 Dedicated to

Shri Swami Samarth

My father, Adi Dinshaw Mistry—Who taught me the value of hard work and loyalty
My mother, Viloo Adi Mistry—For her selfless love and caring
Both my parents and mamma—For their blessings and encouragement
My husband, Tempton—Always loving, caring and encouraging
My miracle and happiness, Karishma and Khushi—For making life worthwhile
Rustom, Khushru, Firozee, Sharon, Jenaifer, Zenia,
Travis and Hazel—For believing in me and being with me
Bachi T Hathiram

My father, Subhash Chandra Gyanchand Khattar—My support

My mother, Veena Subhash Khattar—My encouragement
My grandparents, Gyanchand Khattar, Mohandevi Khattar,
Vas Dev Pawa, Tulsidevi Pawa—Who indulged me
Shalu, Sameer, Sehar and Sia—My indulgence
My family, friends, teachers and students
Vicky S Khattar
 Contributors

Ahmad Abu-Omar DOHNS MRCS Lynzee N Alworth PhD AuD Luca Autelitano MD
Educational Fellow in CCC-A F/AAA Maxillo-Facial Surgeon
Otolaryngology Assistant Professor of Audiology Smile House, San Paolo Hospital
Whipps Cross University Hospital University Audiology Associates University of Milan, via A. di Rudinì
London, UK University of Louisville Milan, Italy
Kentucky, USA
Bashar Abuzayed MD Gregor Bachmann-Harildstad MD PhD
Attending Neurosurgeron Danic Hadzibegovic Ana MD Akershus University Hospital/UIO
Department of Neurosurgery Department of Otorhinolaryngology Otorhinolaryngology
Cerrahpasa Medical Faculty and Maxillofacial Surgery Nordbyhagen, Norway
Istanbul University Istanbul, Turkey Medical School Osijek, University
Josip Juraj Strossmayer of Osijek Vincent Bachy
Rahul Agrawal Croatia Departement de Chirurgie
Department of ENT and ORL et Chirurgie Cervico-Faciale
Skull Base Surgery Miroslav Andrić DDS Msc Site Mont-Godinne: Avenue
Dr Balabhai Nanavati Hospital Clinic of Oral Surgery Docteur G Thérasse
Mumbai, Maharashtra School of Dentistry Yvoir, Belgium
India University of Belgrade
Belgrade, Serbia Mohamed Badr-El-Dine MD
Vikas Agrawal MS FCPS DORL Professor of Otolaryngology
Consultant ENT Surgeon Nebil Ark Consultant Otology
Speciality ENT Hospital, Kandivli Fatih University, Faculty of Medicine Neurotology and
Asian Heart Institue, Bandra Department of Otorhinolaryngology Skull Base Surgery
Sevenhills Hospital, Andheri Head and Neck Surgery Faculty of Medicine
BSES MG Hospital, Andheri Ankara, Turkey University of Alexandria, Egypt
Mumbai, Maharashtra President of the
India V Arora Egyptian Society of
Associate Professor Skull Base Surgery
RG Aiyer Department of ENT and Egypt
Professor and Head Head Neck Surgery
Department of ENT and University College of Yogesh Bajaj MS MD FRCS (ORL HNS)
Head and Neck Surgery Medical Sciences and Consultant ENT
Govt Medical College and GTB Hospital Barts Children’s Hospital and
SSG Hospital New Delhi, India Royal London Hospitals
Vadodara, Gujarat, India Honorary Lecturer
Katie L Austin AuD CCC-A F/AAA Anglia Ruskin University
KM Ajith Audiologist London, UK
Department of ENT Heuser Hearing Institute, and
SS Institute of Medical Sciences and Heuser Speech and Karthikeyan Balasubramanian
Research Center Language Academy Department of Surgical Oncology
Davangere, Karnataka Louisville Prince Aly Khan Hospital
India Kentucky, USA Mumbai, Maharashtra, India
 viii Voice and Laryngotracheal Surgery

Maurizio Barbara Kofi DO Boahene James A Burns

ENT Clinic, Sant’Andrea Hospital Assistant Professor Massachusetts General Hospital
Sapienza University Facial Plastic and Division of Laryngeal Surgery
Rome, Italy Reconstructive Surgery Boston, Massachusetts, USA
Johns Hopkins Facial Plastic and
Brajendra Baser MS (AIIMS) DNB Reconstructive Surgery Center Giulia Carnevali MD
Professor and Head of ENT Minimally Invasive Skullbase Surgery
Maxillo-Facial Surgeon
Shri Aurbindo Institute of Microvascular Surgery
Department of Traumatology and
Medical Sciences (SAIMS Medical Department of Otolaryngology
Maxillo Facial Surgery
College) Head and Neck Surgery
Johns Hopkins Medical Institute, USA AOUC Hospital and University of
Director Akash Hospital
Florence Largo Palagi
Indore, Madhya Pradesh
Miriam Boenisch MD PhD Florence, Italy
India
Medicent Linz, Untere
BP Belaldavar Donaulände Giorgio Carrabba MD PhD
Department of ENT, KLE University’s Linz, Austria Neurosurgery
JN Medical College and Fondazione IRCCS Ca’ Granda
Consultant ENT Surgeon, KLES Mariano M Boglione MD Ospedale Maggiore Policlinico
Dr Prabhakar Kore Hospital Pediatric Surgeon University of Milano
Belgaum, Karnataka, India General Pediatric Surgery Division Milano, Italy
Chief of Lung Transplant Program
Michael S Benninger MD Hospital de Pediatría Ricardo L Carrau MD FACS
Prof Dr Juan P Garrahan Professor
Chairman, Head and Neck Institute
Buenos Aires, Argentina Department of Otolaryngology
The Cleveland Clinic
Professor of Surgery Head and Neck Surgery
Luis A B Borba MD PhD The Ohio State University
The Learner School of
Medicine of Case Western Professor Medical Center
Chief of the Neurosurgical West 10th Avenue
Reserve University
Department Cramblett Hall, Columbus
Euclid Avenue
Evangelic Universitary Hospital Ohio, USA
Cleveland, Ohio, USA
Curitiba, Paraná, Brazil.
Neurosurgeon of the Brain and Ali Diaz Castillejos
Abir K Bhattacharyya MS DNB FRCS
Heart Institute
FRCS(ORL) FACS
Curitiba, Paraná, Brazil Fellow of Cranial Base Surgery
Consultant Otolaryngologist and Evangelic Universitary Hospital
Head and Neck Surgeon Jennings R Boyette MD Curitiba, Paraná – Brazil
Associate Director of Department of Otolaryngology—
Medical Education (Surgery) and Head and Neck Surgery CW David Chang MD
Royal College Surgical Tutor University of Arkansas for Associate Clinical Professor, Facial
Whipps Cross University Hospital Medical Sciences Plastic and Reconstructive Surgery
London, UK Arkansas Children’s Hospital Residency Program Director
Little Rock, Arkansas, USA Department of Otolaryngology
Merill Biel Head and Neck Surgery
Department of Otolaryngology Ryan F Brown MD University of Missouri
University of Minnesota Department of Head and Neck One Hospital Drive
Minneapolis Surgery Kaiser Permanente Columbia
Minnesota, USA Denver Colorado, USA Missouri, USA
 Contributors ix

Dinesh K Chhetri MD Rajib Dasgupta Akshay P Deshpande

University of California— London, UK Resident, Department of Plastic
Los Angeles Surgery TN Medical College and
Department of Danic Davorin MD PhD BYL Nair Charitable Hospital
Head and Neck Surgery Department of Otorhinolaryngology Mumbai, Maharashtra, India
CHS 62-132, UCLA and Maxillofacial Surgery
School of Medicine Medical School Osijek Snigdha Devane
Los Angeles University Josip Juraj Resident—Department of ENT and
California, USA Strossmayer of Osijek, Croatia Head and Neck Surgery, TN Medical
College and BYL Nair
Chi-Yee Choi Matteo de Notaris MD PhD Charitable Hospital
Mumbai, Maharashtra, India
Division of Head and Neck Department of Neurosurgery
Reconstruction Surgery Hospital Clinic, Faculty of Medicine
PV Dhond MS (ENT) DORL
Department of Surgery Universitat de Barcelona
Laboratory of Surgical Honorary Consultant
United Christian Hospital Bhagwati Hospital
Hong Kong Neuroanatomy (LSNA)
Faculty of Medicine Mumbai, Maharashtra, India
SAR, China
Universitat de Barcelona
Sara R Dickie MD
Tam-Lin Chow Barcelona, Spain
Section of Plastic and
Division of Head and Neck Reconstructive Surgery
Alberto Deganello MD PhD
Reconstruction Surgery University of Chicago
Department of Surgery Head and Neck Surgeon
Department of Surgery
Assistant Professor in Otolaryngology
United Christian Hospital Chicago, Illinois, USA
SOD Otolaryngology 1
Hong Kong
Department of Surgical Sciences J Dings
SAR, China
AOU-Careggi, University of Florence
Department of Neurosurgery
Vle Morgagni, Florence, Italy
Yakup Cil MD Maastricht University Medical Center
Plastic Surgeon The Netherlands
Amir R Dehdashti MD FACS
Eskisehir Military Hospital
Geisinger Clinic Gilles Dolivet MD PhD
Department of Plastic Surgery Department of Neurosurgery, USA
Eskisehir, Turkey Head and Neck Surgeon
Otolaryngologist
C E Deopujari Head of the Surgical
Joseph Curry
Department of Neurosurgery Oncology Department
Department of Otolaryngology Bombay Hospital National Cancer Institute
Head and Neck Surgery Mumbai, Maharashtra, India “Alexis Vautrin”
University of Miami Miller School of Av. de Bourgogne
Medicine, Miami Daniel G Deschler Vandoeuvre-Les-Nancy
Florida, USA Director University of Nancy
Division of Head and Neck Surgery France
Sanket Dani Department of Otology and
Resident—Department of ENT and Laryngology Adam Donne
Head and Neck Surgery Massachusetts Eye and Ear Infirmary Consultant in Paediatric
TN Medical College and Associate Professor Otolaryngology Alder
BYL Nair Charitable Hospital Harvard Medical School Hey Children’s Hospital
Mumbai, Maharashtra, India Boston, Massachusetts, USA Liverpool, UK
 x Voice and Laryngotracheal Surgery

Mark Domanski Audrey B Erman Lorenzo Gaini

Department of Otolaryngology— Department of Otology and Department of Otorhinolaryngology
Head and Neck Surgery Laryngology IRCCS Policlinico
The George Washington University Massachusetts Eye and Ear Infirmary University of Milano-Statale
USA Harvard Medical School Milano, Italy
Boston, Massachusetts, USA
Prgomet Drago Oreste Gallo MD
Clinics of Otorhinolaryngology Waleed F Ezzat Associate Professor in
Head and Neck Surgery Professor of Otolaryngology Head Otolaryngology
Clinical Hospital Centar Zagreb and Neck Surgery Head of the SOD Otolaryngology
Medical School Zagreb Ain- Shams University Department of Surgical Sciences
University of Zagreb, Croatia Cairo, Egypt AOU-Careggi
University of Florence
Yadranko Ducic MD FACS FRCS Leo FS Ditzel Filho Vle Morgagni
Clinical Professor Research Fellows Florence, Italy
Department of Otolaryngology— Department of Neurological Surgery
Head and Neck Surgery at the The Ohio State University Werner Garavello
University of Texas Southwestern Columbus, USA Department of Otorhinolaryngology
Medical Center, Dallas Texas San Gerardo Hospital
Baylor Neuroscience Skullbase Dan M Fliss MD University of Milano Bicocca
Program Dallas Fort Worth Texas Professor and Chairman Monza, Italy
Otolaryngology and Facial Plastic Department
Surgery Associates Fort Worth Otolaryngology Celeste C Gary MD
Texas, USA Head and Neck Surgery Department of Otolaryngology
and Maxillofacial Surgery Head and Neck Surgery
Jason Durel Tel-Aviv Sourasky Medical Center Louisiana State University Health
Resident Physician 6 Weizmann St, Tel-Aviv, Israel Sciences Center
Department of Otolaryngology— 533 Bolivar Street
Head and Neck Surgery Hossam MT Foda MD New Orleans, Louisiana, USA
Louisiana State University Professor and Chief of
Health Sciences Center Facial Plastic Surgery Jacques Gaudet
New Orleans, Louisiana, USA Otolaryngology Department Resident Physician,
Alexandria Medical School, Egypt Department of Otolaryngology–
Philippe Eloy Head and Neck Surgery,
Department of Otorhinolaryngology Arun K Gadre MD FACS MS(Bom) DORL Louisiana State University
University of Louvain (Belgium) HHI Professor of Otology and Health Sciences Center
Cliniques de Mont Godinne (Yvoir) Neurotology New Orleans, Louisiana, USA
Av Therasse Director of Otology, Neurotology and
Yvoir, Belgium Skull Base Surgery Panagiotis Gerbesiotis MD PhD
Associate Professor of Registrar—ENT Surgeon
Joaquim Enseñat MD PhD Otolaryngology—Head and Neck 2nd University Department of
Department of Neurosurgery Surgery Otorhinolaryngology
Hospital Clinic, Faculty of Medicine Department of Surgery Head and Neck Surgery
Universitat de Barcelona University of Louisville ATTIKON Hospital, Rimini 1
Barcelona, Spain Kentucky, USA Chaidari, Athens, Greece
 Contributors xi

Nurperi Gazioglu MD Arunesh Gupta Imtiyaz Hussain Hakeem

Professor in Neurosurgery Assistant Professor Resident
Department of Neurosurgery Department of Plastic Surgery Department of Internal Medicine
Cerrahpasa Medical Faculty TN Medical College and Florida Hospital Medical Center
Istanbul University BYL Nair Charitable Hospital Orlando, Florida, USA
Istanbul, Turkey Mumbai, Maharashtra, India
Bachi T Hathiram
Gianni Gitti MD PhD Ashok K Gupta Professor and Head
Otolaryngologist Professor and Head Department of ENT and
Centro Rieducazione Ortofonica Department of Otolaryngology Head and Neck Surgery
Piazzale della Porta al Prato (Unit II) TN Medical College and
Florence PGIMER, Chandigarh, India BYL Nair Charitable Hospital
Italy Mumbai, Maharashtra, India
Rahul Gupta
Haralampos Gouveris Biswajyoti Hazarika
Assistant Professor
Department of Otorhinolaryngology Department of ENT and Senior Consultant
The University of Head and Neck Surgery Department of Surgical Oncology
Mainz Hospitals and Clinics Govt. Medical College and Max Cancer Center
Langenbeckstr, Mainz, Germany SSG Hospital New Delhi, India
Vadodara, Gujarat, India
Cassio Zottis Grapiglia MD Barbara Henderson
Fellow of Cranial Base Surgery Mehmet Habesoglu Department of Biophysics/Cell
Evangelic Universitary Hospital Department of II-Otolaryngology— Stress Biology
Curitiba, Paraná – Brazil Head and Neck Surgery Roswell Park Cancer Institute
Haydarpasa Numune Education and Buffalo, NY, USA
Jorge Orlando Guerrissi Research Hospital, Turkey
Patrick T Hennessey MD
Head, Department of
Tulay Erden Habesoglu PGY-5 Resident
Plastic and Reconstructive Surgery
Head and Neck Surgery Department of II-Otolaryngology— The Johns Hopkins Hospital
Head and Neck Surgery Department of Otolaryngology—
Argerich Hospital
Haydarpasa Numune Education and Head and Neck Surgery, USA
Health Ministery of Ciudad
Research Hospital, Turkey
Autonoma de Buenos Aires
Argentina Björn Herman
Josef Haik MD MPH
Department of Otolaryngology
Assistant Professor of Plastic Surgery; University of Miami
Anish K Gupta
Deputy of the Division of Plastic and School of Medicine, USA
Sr Consultant Reconstructive Surgery
Department of ENT Director of the Intensive Care Burn
Fortis Hospital Yasuyuki Hinohira
Unit Sheba Medical Center
Mohali Tel-Aviv University Department of Otorhinolaryngology
Punjab, India Ramat Gan, Israel Showa University School of Medicine
Hatanodai, Shinagawa, Tokyo, Japan
Anuragini Gupta Arsheed Hussain Hakeem
Jr Resident Consultant Steven B Hopping
Department of ENT Department of Head and Neck Department of Otolaryngology—
Resident BSPH Surgery and Surgical Oncology Head and Neck Surgery
Bhilai Prince Aly Khan Hospital The George Washington University
Chattisgarh, India Mumbai, Maharashtra, India USA
 xii Voice and Laryngotracheal Surgery

Takashi Horiguchi Narayan Jayashankar Gauri Kapre

Associate Professor Department of Otorhinolaryngology Consultant ENT surgeon
Department of Neurosurgery and the Skull Base Group Neeti Clinics, Nagpur
Keio University School of Medicine Department of ENT and Clinical Fellow
Japan Skull Base Surgery Bombay Hospital
Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India
K Hörmann Mumbai, Maharashtra, India
Head and Chair of the Department of Madan Kapre
ORL and Head and Neck Surgery Deya Jourdy Director Neeti Clinics, Nagpur
University Hospital of Mannheim Honorary senior surgeon
Department of Otolaryngology
Mannheim, Germany RST Cancer Hospital Nagpur
University of Miami School of
Medicine, USA Maharashtra, India
Gilad Horowitz
Department Otolaryngology Pornthep Kasemsiri
Javier Herrero Jover MD PhD
Head and Neck Surgery and
Plastic Surgery Department Research Fellows
Maxillofacial Surgery
Centro Medico TEKNON Department of Otolaryngology and
Tel-Aviv Sourasky Medical Center
Vilana, Barcelona, Spain Head and Neck Surgery
6 Weizmann St, Tel-Aviv, Israel
The Ohio State University
Akinobu Kakigi MD Columbus, USA
Sonna Ifeacho
Department of Otolaryngology Assistant Professor
Amin B Kassam
Great Ormond Street Hospital Department of Otolaryngology
London, UK Head and Neck Surgery Professor
Faculty of Medicine Department of Neurological Surgery
Shabbir Indorewala University of Ottawa
Tokyo University, Japan
Ottawa, Canada
Department of Otorhinolaryngology
and The Skull Base Group Mohan Kameswaran DSc MS FRCS (Ed)
Daniel F Kelly MD
Dr Balabhai Nanavati Hospital FAMS FICS DLO
Mumbai, Maharashtra, India Brain Tumor Center and Pituitary
Consultant ENT Surgeon
Disorders Program
Department of Implant Otology
Ankit Jain John Wayne Cancer Institute at Saint
Madras ENT Research Foundation
Resident—Department of ENT and John's Health Center
Raja Annamalaipuram, Chennai Santa Monica, California, USA
Head and Neck Surgery, TN Medical Tamil Nadu, India
College and BYL Nair
Charitable Hospital Guy Kenyon FRCS
Tolga Kandogan MD
Mumbai, Maharashtra, India Consultant ENT Surgeon
Associate Professor of Whipps Cross University Hospital
Yong Ju Jang Otolaryngology Head and Neck NHS Trust
Surgery 69 Harley Street
Professor
Izmir Bozyaka Teaching and London, UK
Department of Otolaryngology
Asan Medical Center Research Hospital
University of Ulsan College of Department of Otol Aryngology Vicky S Khattar
Medicine, Seoul, Korea Head and Neck Surgery Assistant Professor
Izmir Bozyaka, Turkey Department of ENT and
Sharan C Jayaram Head and Neck Surgery
Head and Neck Fellow Sunita Kanojia TN Medical College and
Department of Otolaryngology Department of ENT BYL Nair Charitable Hospital
New Queen Elizabeth Hospital Bombay Hospital Mumbai, Maharashtra
Birmingham, UK Mumbai, Maharashtra, India India
 Contributors xiii

Sunil Khot Murat Küçüktaş MD Guglielmo Larotonda MD

Resident—Department of ENT and Departments of Dermatology Resident in Otolaryngology, SOD
Head and Neck Surgery Nevşehir State Hospital Otolaryngology 1
TN Medical College and Nevşehir, Turkey Department of Surgical Sciences
BYL Nair Charitable Hospital AOU-Careggi, University of Florence
Mumbai, Maharashtra, India Melda Kunduk Vle Morgagni, Florence, Italy
Assistant Professor
Ji Heui Kim Department of Otolaryngology— Georges Lawson
Department of Otolaryngology Head and Neck Surgery Otolaryngology
Asan Medical Center Louisiana State University Head and Neck Surgery Department
University of Ulsan Health Science Center Louvain University Hospital of
College of Medicine New Orleans ­Mont-Godinne, Yvoir, Belgium
Seoul, Korea Louisiana, USA
Davide Lazzeri MD
Milind Kirtane Daniel B Kuriloff MD FACS Plastic Surgeon
Professor Emeritus Seth GS Director Plastic and Reconstructive Surgery
Medical College Center for Thyroid and Unit, Santa Chiara Hospital of Pisa
Hon Surgeon at KEM Hospital Parathyroid Surgery Via Roma Pisa, Italy
Hon Consulting ENT Surgeon at PD New York Head and Neck Institute
Hinduja National Hospital Lenox Hill Hospital Eugenijus Lesinskas MD PhD
Hon ENT Consultant to his Associate Professor Clinic of Ear, Nose
Excellency the Governor of Clinical Otolaryngology Throat and Eye Diseases
Maharashtra Head and Neck Surgery Medical Faculty
Hon ENT Consultant at Columbia University Vilnius University, Lithuania
Prince Aly Khan Hospital 110 East 59th Street
Mumbai, Maharashtra, India New York, NY, USA Andreas Leunig
Professor Dr. Med. Andreas Leunig
Janusz Klatka Balagopal Kurup HNO-Zentrum Starnberg
Department of Otolaryngology and Resident Prinzenweg 1
Laryngeal Oncology Department of ENT and Starnberg, Germany
Medical University of Lublin Head and Neck Surgery
Poland TN Medical College and Roman Liscak
BYL Nair Charitable Hospital Na Homolce Hospital
Masahiro Komori Mumbai, Maharashtra, India Prague, Czech Republic
Department of Otolaryngology
Head and Neck Surgery Zekayi Kutlubay MD Marco Locatelli MD PhD
Kochi Medical School Departments of Dermatology Neurosurgery,
Okatoyo, Nankoku İstanbul University Cerrahpaşa Fondazione IRCCS Ca’ Granda
Kochi, Japan Medical Faculty, İstanbul, Turkey Ospedale Maggiore Policlinico,
University of Milano,
Shenal Kothari MS Danielle de Lara Milano, Italy
Associate Professor of ENT Research Fellows
Department of ENT Department of Neurological Surgery Kevin Lollar MD
SAIMS Medical College The Ohio State University Private Practice
Indore, Madhya Pradesh, India Columbus, USA Hannibal, Missouri, USA
 xiv Voice and Laryngotracheal Surgery

Jennifer L Long MD PhD Nayla Matar Sonal Modi

University of California-Los Angeles Otolaryngology Department of Otorhinolaryngology
Department of Head and Neck Head and Neck Surgery Department and the Skull Base Group
Surgery Hôtel Dieu de France Dr Balabhai Nanavati Hospital
UCLA School of Medicine Bellevue Medical Center Mumbai, Maharashtra, India
Los Angeles, California, USA Saint-Joseph University
Beirut, Lebanon Arash Mohebati
Claudio Macrì
Senior Fellow in Head and Neck
ENT Clinic, Sant’Andrea Hospital Nancy McLaughlin
Sapienza University Surgery
USA Memorial Sloan Kettering Cancer
Rome, Italy
Center New York, USA
Vishal Madan MBBS (Hons) MD MRCP Andrew J McWhorter
Consultant Dermatologist Assistant Professor Aliasgar Moiyadi
Laser and Dermatological Surgeon Director Associate Professor
Salford Royal NHS Foundation Department of Otolaryngology— Department of Neurosurgery
Trust Stott Lane Head and Neck Surgery Tata Memorial Center
Salford, Manchester, UK Louisiana State University Health Mumbai, Maharashtra, India
Sciences Center
Amit Magadum New Orleans Simonetta Monini
Resident—Department of Anatomy Louisiana, USA
ENT Clinic, Sant’Andrea Hospital
JN Medical College
Belgaum, Karnataka, India Madhuri Mehta Sapienza University
Rome, Italy
Department of Otorhinolaryngology
Dipesh J Malviya and the Skull Base Group
Resident—Department of Plastic Eric J Moore MD
Dr Balabhai Nanavati Hospital
Surgery, TN Medical College and Mumbai, Maharashtra, India Mayo Clinic Department of
BYL Nair Charitable Hospital Otolaryngology
Mumbai, Maharashtra, India Head and Neck Surgery
Jayakumar R Menon
200 First Street SW
Jaiganesh Manickavasagam Consultant Laryngologist, Kerala
Institute of Medical Sciences Rochester, Minnesota, USA
FRCS (ORL-HNS)
Royal Hallamshire Hospital Thiruvananthapuram, Kerala, India
KP Morwani
Sheffield, UK
Rajendra B Metgudmath Department of ENT and
Gauri Mankekar Consultant, Head and Neck Surgical Skull Base Surgery
Oncologist, KLES Dr Prabhakar Kore Dr Balabhai Nanavati Hospital
ENT Consultant
PD Hinduja Hospital Hospital and MRC Belgaum Mumbai, Maharashtra, India
Mahim, Mumbai, Maharashtra, India Associate Professor
Surgical Oncology (Head and Neck) Fabrizio Moscatiello MD PhD
Wolf J Mann JN Medical College, KLE University Plastic Surgery Department,
Department of Otorhinolaryngology Belgaum, Karnataka, India Centro Medico TEKNON
The University of Mainz Hospitals Vilana, Barcelona, Spain
and Clinics, Mainz, Germany Jignesh Mewa
Department of Surgical Oncology RS Mudhol
Alexander Margulis MD Prince Aly Khan Hospital Professor and Head, Department of
Senior Lecturer Mumbai, Maharashtra, India ENT, KLE University’s JN Medical
Hebrew University College and
School of Medicine Julie A Miller Consultant ENT surgeon, KLES
Head—Center for Pediatric and
Craniofacial Plastic Surgery Department of Surgery Dr Prabhakar Kore Hospital
Hadassah Medical Center Royal Melbourne Hospital and Belgaum, Karnataka
Jerusalem, Israel University of Melbourne, Australia India
 Contributors xv

Rajashekhar Myageri Jerzy Nyzio MD Giampiero Parrinello MD

Assistant Professor Intensive Care Unit Otolaryngologist, PhD Student
SDM Medical College St John Grande’s Hospital SOD Otolaryngology
Dharwad, Karnataka, India Kraków, Poland Department of Surgical Sciences
AOU-Careggi, University of Florence
Lalita Naik Matthew Old Vle Morgagni
Skull Base Surgery Team, Department of Otolaryngology and Florence, Italy
Dr Balabhai Nanavati Hospital Head and Neck Surgery
Mumbai, Maharashtra, India The Ohio State University Prashant Patil
Columbus, USA Associate Professor
Haralampos Gouveris JN Medical College
Department of Otorhinolaryngology, Peter D Oliver Belgaum, Karnataka
The University of Mainz Hospitals Department of Otolaryngology India
and Clinics, Mainz, Germany Head and Neck Surgery
Louisiana State University Health Amol Patil
Deepa Nair Sciences Center Department of Otorhinolaryngology
Assistant Professor Bolivar Street and The Skull Base Group
Department of Head and Neck New Orleans Dr Balabhai Nanavati Hospital
Surgical Oncology Louisiana, USA Mumbai, Maharashtra
Tata Memorial Center
India
Mumbai, Maharashtra, India
Goldan Oren MD
Attending Surgeon, Division of R N Patil
Amith Naragund
Plastic and Reconstructive Surgery Professor
Assistant Professor, Department of
Sheba Medical Center Department of ENT, KLE University’s
ENT, KLE University’s
JN Medical College and Tel-Aviv University JN Medical College and
Consultant ENT Surgeon, KLES Ramat Gan, Israel Consultant ENT surgeon, KLES
Dr Prabhakar Kore Hospital Dr Prabhakar Kore Hospital
Bradley A Otto Belgaum, Karnataka, India
Belgaum, Karnataka, India
Assistant Professor,
Chitra Nayak Department of Otolaryngology and Sultan A Pradhan
Associate Professor and Head Head and Neck Surgery Professor and Chief Oncologist
Department of Dermatology The Ohio State University Department of Surgical Oncology
TN Medical College and Columbus, USA Prince Aly Khan Hospital
BYL Nair Charitable Hospital Mumbai, Maharashtra, India
Mumbai, Maharashtra, India Sumeet Pahwa
Fellow, Surgical Oncology Rashmi Prashant
Nupur Kapoor Nerurkar
Prince Aly Khan Hospital Assistant Professor,
Laryngologist Mumbai, Maharashtra Department of ENT
Bombay Hospital
India DY Patil Medical College
Mumbai, Maharashtra, India
Pimpri, Maharashtra, India
Thomas P Nikolopoulos Prathamesh S Pai
Associate Professor—ENT Surgeon Associate Professor Alberto Prats-Galino MD PhD
2nd University Department of Department of Head and Neck Laboratory of Surgical
Otorhinolaryngology Surgical Oncology Neuroanatomy (LSNA)
Head and Neck Surgery Tata Memorial Center Faculty of Medicine
ATTIKON Hospital, Rimini 1, Mumbai, Maharashtra Universitat de Barcelona
Chaidari Athens, Greece India Barcelona, Spain
 xvi Voice and Laryngotracheal Surgery

Daniel M Prevedello Marc Remacle H Sadick

Assistant Professor Otolaryngology Head and Chair of the Department of
Department of Neurological Surgery Head and Neck Surgery Department ORL and Head and Neck Surgery
The Ohio State University Louvain University Hospital of University Hospital of Mannheim
Columbus, USA ­Mont-Godinne, Yvoir, Belgium Mannheim
Germany
Ashutosh G Pusalkar Roberta Rehder MD
Emeritus Professor, Resident Program Dariusz Sagan
Padmashree Dr DY Patil Medical Evangelic Universitary Hospital
College, Honorary Consultant Department of Thoracic Surgery
Curitiba Medical University of Lublin
Lilavati Hospital and Medical
Paraná – Brazil
Research Center Poland
Mumbai, Maharashtra, India
Gresham T Richter MD
Lucel E Salvan DA
Ullas Raghavan FRCS (ORL-HNS) Department of Otolaryngology—
Secretary
Doncaster Royal Infirmary Hospital Head and Neck Surgery
ENT-Voice Center
Doncaster, UK University of Arkansas for
Medical Sciences Yanhee International Hospital
Arkansas Children’s Hospital Bangkok
S Raghunandhan MS DNB
MRCS (Ed) DOHNS Little Rock, Arkansas, USA Thailand
Consultant ENT Surgeon
Nestor Rigual Suresh Sankhla
Department of Implant Otology
Madras ENT Research Foundation Department of Head and Neck/ Department of Neurosurgery
Raja Annamalaipuram Plastic Surgery, Dr Balabhai Nanavati Hospital
Chennai, Tamil Nadu, India Roswell Park Cancer Institute, Mumbai, Maharashtra
Buffalo, NY, USA India
Kannan Rajan
Senior Oncosurgeon Supriya Rode Zoukaa Sargi
Department of Surgical Oncology Resident – Department of ENT and Department of Otolaryngology,
Prince Aly Khan Hospital Head and Neck Surgery Head and Neck Surgery,
Mumbai, Maharashtra, India TN Medical College and University of Miami Miller
BYL Nair Charitable Hospital School of Medicine
Reema Rai
Mumbai, Maharashtra, India Miami
Resident
Department of ENT and Florida, USA
Philippe Rombaux
Head and Neck Surgery
TN Medical College and BYL Nair Department of Otorhinolaryngology Tamer Seyhan MD
Charitable Hospital University of Louvain
Assoc. Prof. of Plastic
Mumbai Maharashtra, India Cliniques Saint Luc Brussels
Reconstructive and Esthetic Surgery
Av Hippocrate, Brussels, Belgium
Adana Numune Education and
Suthee Rattanathummawat MD ENT Teaching Hospital
Phramongkutklao Hospital Sabino Russo MD
Cukurova, Adana
Medical University Consultant in Otolaryngology
Turkey
Bangkok, Thailand Head and Neck Surgery
Department of Otolaryngology
Nishit J Shah
C Rayappa Head and Neck Surgery
Department of Head and Neck and National Cancer Institute Department of ENT
Skull Base Surgery Giovanni Paolo II Bombay Hospital
Apollo Speciality Hospital Vle Flacco Mumbai, Maharashtra
Chennai, Tamil Nadu, India Bari, Italy India
 Contributors xvii

Jatin P Shah MD MS (Surg) FACS Hon FRCS Murat Songu Girish Surlikar MS (opthal)
(Edin) Hon FDSRCS (London) Hon FRACS Department of Otorhinolaryngology DOMS FCPS DNB

Professor of Surgery —Head and Neck Surgery Ophthalmologist

EW Strong Chair in Head and Neck Dr Behçet Uz Children’s Private Practice
Oncology Hospital, Izmir, Department of Mumbai, Maharashtra
Chief Otorhinolaryngology Head and India
Head and Neck Service Neck Surgery, Izmir Ataturk
Memorial Sloan Research and Training Hospital Harumi Suzaki
Kettering Cancer Center Izmir, Turkey Department of Otorhinolaryngology
New York, USA Showa University
Jonathan E Sorrel School of Medicine
Hemant Sharma Department of Otolaryngology Hatanodai, Shinagawa
Resident Head and Neck Surgery Tokyo, Japan
Department of ENT and Louisiana State University Health
Head and Neck Surgery Sciences Center and Andrew C Swift
TN Medical College and School of Medicine
Consultant ENT Surgeon and
BYL Nair Charitable Hospital New Orleans, Louisiana, USA
Rhinologist
Mumbai, Maharashtra, India Aintree University Hospitals
Giuseppe Spinelli MD
Foundation NHS Trust
Atsushi Shiraishi Maxillo-Facial Surgeon Liverpool, UK
Department of Ophthalmology Chief of the Department of
Ehime University School of Medicine Traumatology and Taizo Takeda MD
Shitsukawa, Toon, Ehime, Japan Maxillo-Facial Surgery
Emeritus Professor
AOUC Hospital and
Kochi Medical School
A M Shivakumar University of Florence Largo Palagi
Florence, Italy Kochi, Japan
Professor and Head
Department of ENT Paul A Tennant MD
SS Institute of Medical Sciences and Ornouma Sriwanishvipat MD ENT
Yanhee International Hospital Resident in Otolaryngology
Research Center, Davangere, India
Bangkok, Thailand University of Louisville
Kentucky, USA
Shy Stahl MD
Attending Surgeon, Division of Milan Stankovic MD
David J Terris MD FACS
Plastic and Reconstructive Surgery Clinic for ORL
Medical Faculty University of NIS Porubsky Professor and Chairman
Sheba Medical Center, Tel-Aviv
University, Ramat Gan, Israel Serbia Department of Otolaryngology—
Head and Neck Surgery
Michael C Singer MD Andrzej Stepulak Medical College of Georgia, Georgia
Instructor Department of Biochemistry and
Molecular Biology Alok Thakar
Department of Otolaryngology—
Head and Neck Surgery Medical University of Lublin Department of Otorhinolaryngology
Medical College of Georgia, Georgia Poland All India Institute of Medical
Sciences (AIIMS)
PP Singh RJ Stokroos New Delhi, India
Director-Professor and Head Department of Otorhinolaryngology
Department of ENT and Head and Head and Neck Surgery Kiskumar Thankappan
Neck Surgery, University College of Maastricht University Amrita Institute of Medical Sciences
Medical Sciences and GTB Hospital Medical Center Elamakkara
New Delhi, India The Netherlands Kochi, Kerala, India
 xviii Voice and Laryngotracheal Surgery

C Thomas MS FRCS FACS Gauri Vaidya Parag Watve

Senior Consultant and Department of ENT Resident
Head Plastic Surgery Bombay Hospital Department of ENT and
Service in Oman Mumbai, Maharashtra, India Head and Neck Surgery
TN Medical College and
Livnat Siman Tov MD Saurabh Varshney BYL Nair Charitable Hospital
Aesthetic and Reconstructive Professor and Head Mumbai Maharashtra
Plastic Surgeon, Jerusalem, Israel Department of ENT India
Himalayan Institute of Medical
Jagadish Tubachi Sciences, (HIHT University) Stephen Wetmore MD
Fellow Jolly Grant; Doiwala Professor and Chair
Department of Surgical Oncology Dehradun, Uttarakhand, India Department of Otolaryngology
Prince Aly Khan Hospital West Virginia University
Mumbai, Maharashtra, India B K Venkatesha School of Medicine
Department of ENT Morgantown, West Virginia, USA
Jumroon Tungkeeratichai SS Institute of Medical Sciences and
Assistant Professor Research Center Jeremy B White
Facial Plastic and Davangere, Karnataka, India Plastic Surgeon
Reconstructive Surgery ARC Plastic Surgery
Otolaryngology Head and Neck Giovanni André Pires Viana MD Stirling Road
Surgery, Faculty of medicine Cliniplast Hollywood, Florida, USA
Ramathibodi Hospital Al. Jauaperi
São Paulo, SP, Brazil Adele P Williams
Mahidol University
Bangkok, Thailand Department of Otolaryngology
Rohan R Walvekar MD Head and Neck Surgery
Prof Tuncay Ulug MD Associate Professor Louisiana State University
Department of Otolaryngology Health Sciences Center
Department of Otorhinolaryngology
Head and Neck Surgery Bolivar Street
Istanbul University-Istanbul
Louisiana State University New Orleans, Louisiana, USA
Medical Faculty
Capa, Istanbul, Turkey Health Sciences Center
Bolivar Street Eyal Winkler MD
New Orleans, Louisiana, USA Assistant Professor of Plastic Surgery
Hirohito Umeno MD
Director of the Division of Plastic
Associate professor and Reconstructive Surgery
Jeremy Warner MD
Otolaryngology Head and Sheba Medical Center
Division of Plastic Surgery
Neck Surgery Tel-Aviv University
North Shore University Health
Kurume University Ramat Gan
System, Central Street
School of Medicine Israel
Evanston, Illinois, USA
Asahi-Machi Kurume, Japan
JJ Waterval R Yadav MS (ENT) DORL FCPS
Abhishek D Vaidya Assosiate Professor
Department of Otorhinolaryngology
Fellow, Head and Neck Surgery and Head and Neck Surgery Rajawadi Hospital
Tata Memorial Hospital Maastricht University Medical Center Mumbai, Maharashtra
Mumbai, Maharashtra, India The Netherlands India
 Contributors xix

Kazunari Yoshida Alper Yüksel Diego Zanetti

Associate Professor Fatih University, Faculty of Medicine Department of Otorhinolaryngology
Department of Neurosurgery Department of Otorhinolaryngology San Gerardo Hospital
Keio University Head and Neck Surgery University of Milano Bicocca
School of Medicine, Japan Ankara, Turkey Monza, Italy

Ramzi Younis Olaf Zagólski MD PhD Maria Zisiopoulou

Department of Otolaryngology ENT Department of Otorhinolaryngology
University of Miami School of St John Grande’s Hospital The University of Mainz Hospitals
Medicine, USA Kraków, Poland and Clinics, Mainz, Germany
 Contents xxi

Foreword

In spite of significant advances made in the multidisciplinary treatment of diseases and neoplasia
in the head and neck region, surgery remains the mainstay amongst all therapeutic modalities
currently available for these conditions. Surgical techniques have however, undergone significant
evolution with major emphasis on preservation or restoration of form and function. This has resulted
in the development of minimally invasive techniques. Technological advances in endoscopic
instrumentation have ushered in the era of endoscopic surgery, replacing the well-established
techniques of open surgery of the nasal cavity and paranasal sinuses. Major strides in imaging
techniques over the past three decades, has facilitated accurate assessment of the extent of a
neoplasm and has facilitated development of computer-assisted surgical techniques with intraoperative navigation and
Robotic surgery. Thus, the surgical specialty of Otolaryngology and Head & Neck Surgery has dramatically changed over
the years, and remains a challenging and continuously evolving field.
The editors of this magnificent work, Drs Bachi T Hathiram and Vicky S Khattar have done a splendid job in putting
together a state-of-the art surgical atlas by recruiting specialists from all parts of the world who have contributed their
specific areas of expertise in demonstrating surgical techniques. The atlas is lavishly illustrated with operative pictures,
imaging studies, and superb artwork to accompany the procedural details and operative photographs. The rationale,
indications, step-by-step details of the procedure, and postoperative management and complications, makes this a
complete surgical treatise, equally useful to the trainee and the surgeon in practice.
This opus of operative surgery is presented in five volumes, covering a total of 195 operative procedures and their
variations. The compilation covers nearly all the operative procedures from the ‘Dura to Pleura’, in the repertoire of the
Otolaryngologist /Head and Neck Surgeon. This would be an essential textbook for a surgeon or surgeon in training, to
familiarize oneself with an operative procedure, and go prepared to the operating room to carry out a safe and successful
surgical procedure. The Editors and the Publishers of this excellent Atlas are to be commended for bringing about this
excellent book, and offering it at an affordable price to surgeons of all generations. I am confident that this book will be
an essential ‘read’, for Otolaryngologist / Head and Neck Surgeons, worldwide for years to come.

Jatin P Shah MD MS (Surg) FACS Hon FRCS (Edin)

Hon FDSRCS (London) Hon FRACS
Professor of Surgery
Elliot W Strong Chair in Head and Neck Oncology
Memorial Sloan Kettering Cancer Center
New York, USA
 Contents xxiii

Foreword

It is a pleasure to write the foreword for the Atlas of Operative Otorhinolaryngology and Head & Neck
Surgery. Today, the field of Medicine and especially the field of Otorhinolaryngology and Head &
Neck Surgery is advancing by leaps and bounds in expertise and technology. With evidence-based
medicine being at the forefront of our practice, mastering the skills of the surgical technique and the
rationale behind this is of equal importance to the surgeon. There are various centers of excellence
all over the world specializing in particular aspects of our field and it is common practice for the
trainee doctors as well as established surgeons to visit these from time to time to learn and to upgrade
their skills.
This exhaustive compilation by the editors, Dr Bachi T Hathiram and Dr Vicky S Khattar is an attempt to bring together
the best in the field of Otorhinolaryngology and Head & Neck Surgery under one title. With its five volumes on Otology
and Lateral Skullbase Surgery, Rhinology and Anterior Skullbase Surgery, Facial Plastics, Cosmetics and Reconstructive
Surgery, Voice and Laryngotracheal Surgery and Head & Neck Surgery, the editors have aimed to cover topics dealing
with routine procedures as also, those that are at the cutting edge of technology.
The Atlas comprises of 195 Chapters with intraoperative images and clear line diagrams/figures making it easy to
understand the surgical steps. There are contributors from all over the world, each a master in his/her own technique.
More than 30 countries have participated in this mammoth and prestigious venture thus, making it unique in our field
and one of a kind, lending to it a truly global perspective.
In addition to this pictoral step-by-step depiction of surgeries, there will follow a similarly exhaustive compilation of
teaching DVDs which will further enhance the learning process.
I am sure this academic venture will go a long way in benefitting not only the trainees but also established specialists.

Milind V Kirtane
Professor Emeritus Seth GS Medical College
Hon Surgeon at KEM Hospital
Hon Consulting ENT Surgeon at PD Hinduja National Hospital
Hon ENT Consultant to his Excellency the Governor of Maharashtra
Hon ENT Consultant at Prince Aly Khan Hospital
Mumbai, Maharashtra, India
 Preface

In today’s age of rapid advances in science and technology, there is no dearth of learning material available to the
avid learner. However, in the field of Otorhinolaryngology and Head & Neck Surgery, there seemed a lacuna between
undergoing surgical training at various places and understanding the concepts/rationale behind the surgical technique.
This book is a modest attempt by the editors to bridge this lacuna by going through each surgery in a simple step-wise
manner using intraoperative images and illustrated figures, wherever required, to help understand the technique of
surgery.
This is essentially an atlas and hence, the stress on learning through intraoperative images and illustrations, making
it easy for the trainee as well as the ENT consultant to follow the surgery. The authors are masters in the field and this is
a mammoth compilation from more than 30 countries from all over the world since knowledge cannot be bound by any
barriers.
We feel that it is never too late to learn and especially as surgeons, it is imperative to keep in touch with the recent
advances in our field and we hope to spread this message amongst our fraternity through this atlas. The Atlas discusses not
only routinely performed surgeries, such as tonsillectomy, septoplasty, tympanoplasty, thyroidectomy and tracheostomy
but also the latest advances in our field such as robotics, endoscopic skullbase surgery and sialoendoscopy. It is targeted
to young trainee surgeons as well as specialists in the field who would like to learn the techniques of surgery from the
masters.

Bachi T Hathiram
Vicky S Khattar
 Acknowledgments

We would like to express our gratitude to our publishers, M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,
India, especially Shri Jitendar P Vij for having the vision and faith in us, Ms Chetna Malhotra Vohra for her patience,
perseverance and perfection, Ms Payal Bharti, Mr Arun Sharma and the entire team for their untiring efforts in
completing this book on time. Also, we would like to thank all our students who have taught us in addition to learning
from us; Reema Rai, Harshad Nikte, Parag Watve, Harshal Sonavane, Snigdha Devane, Anjoo Choudhary, Alok Nema,
Supriya Rode, Balagopal Kurup, Hemant Sharma, Sunil Khot, Sanket Dani, Ankit Jain, Diptarka Bhattacharya, Sobhana
Chandran and Lubna Sayed. They have all contributed to the making of this Atlas in significant ways. Most importantly,
our teachers who have not only taught us surgery but, given us the drive to teach and impart knowledge.
 Contents xxix

Contents

Vol. 1: Otology and Lateral Skullbase Surgery 1–366

(Chapters 1 to 44)
Vol. 2: Rhinology and Anterior Skullbase Surgery 367–794
(Chapters 45 to 88)
Vol. 3: Facial Plastics, Cosmetics and Reconstructive Surgery 795–1106
(Chapters 89 to 111)
Vol. 4: Voice and Laryngotracheal Surgery 1107–1324
(Chapters 112 to 148)
Vol. 5: Head and Neck Surgery 1325–1654
(Chapters 149 to 195)

Volume 4
112. Principles of Phonomicrosurgery 1109
Vicky S Khattar, Bachi T Hathiram (India)

113. Leukoplakia of the Vocal Folds 1118

Nupur Kapoor Nerurkar, Gauri Kapre (India)

114. Premalignant Lesions of the Larynx and their Management 1125

Arsheed Hussain Hakeem, Imtiyaz Hussain Hakeem, Sultan A Pradhan (India)

115. Photodynamic Therapy for Laryngeal Cancers 1130

Nestor Rigual, Merill Biel, Kiskumar Thankappan, Barbara Henderson (USA)

116. Transoral Microlaryngoscopic LASER Surgery for Cancer of Larynx and Hypopharynx 1135
Jagadish Tubachi, Karthikeyan Balasubramanian, Kannan Rajan, Sultan A Pradhan (India)

117. Injection Laryngoplasty: Indications, Techniques, Injectables and Results 1147

Nayla Matar, Marc Remacle (Belgium)

118. Surgical Management of Sulcus Vocalis 1154

Tolga Kandogan (Turkey)

119. Anterior Glottic Web Management 1160

Hirohito Umeno (Japan)

120. Diagnostic Laryngo-Tracheo-Bronchoscopy 1163

Yogesh Bajaj (UK)

121. Bronchoscopy 1165

AM Shivakumar, BK Venkatesha, KM Ajith (India)
 xxx Voice and Laryngotracheal Surgery

122. The Use of the KTP LASER for Treatment of Laryngeal Papillomatosis 1171
James A Burns (USA)

123. Surgical Management of Laryngeal Papillomatosis Using Microdebrider 1176

Bachi T Hathiram, Vicky S Khattar (India)
124. Aryepiglottoplasty 1184
Yogesh Bajaj (UK)
125. Surgical Management of Posterior Glottic Stenosis 1186
Bachi T Hathiram, Vicky S Khattar (India)
126. Dilatation of a Tracheal Web Using a LASER 1191
Bachi T Hathiram, Vicky S Khattar (India)
127. LASER Arytenoidectomy 1195
Vicky S Khattar, Bachi T Hathiram (India)
128. Laterofixation of the Vocal Folds in Acute Bilateral Vocal Fold Paralysis 1199
Waleed F Ezzat (Egypt)
129. Pediatric Tracheostomy 1204
Yogesh Bajaj (UK)
130. Cricoid Split 1207
Yogesh Bajaj (UK)
131. Voice Restoration after Cordectomies: Type III Thyroplasty for
Voice Reconstruction after Laryngofissure Cordectomy 1208
T Kandogan (Turkey)
132. Botulinum Toxin for Laryngeal Dystonias 1212
Michael S Benninger (USA)
133. Selective Laryngeal Adductor Denervation-Reinnervation Surgery for
Adductor Spasmodic Dysphonia 1216
Dinesh K Chhetri, Jennifer L Long (USA)
134. Medialization Laryngoplasty (Thyroplasty) 1220
Michael S Benninger (USA)
135. Silastic Medialization Laryngoplasty (Type 1 Thyroplasty) 1226
Abir K Bhattacharyya, Ahmad Abu-Omar (UK)
136. Arytenoid Rotation 1235
Jayakumar Menon (India)
137. Type I Thyroplasty 1238
Jayakumar Menon (India)
138. Type II Thyroplasty 1243
Jayakumar Menon (India)
139. Type III Thyroplasty 1245
Jayakumar Menon (India)
 Contents xxxi

140. Type IV Thyroplasty 1249

Jayakumar Menon (India)

141. Expertise of Voice Feminization Surgery to 270 Diverse International Patients 1252
Ornouma Sriwanishvipat, Suthee Rattanathummawat, Egoy-Salvan Lucel (Thailand)

142. Decision-Making in Laryngotracheal Stenosis 1260

Vicky S Khattar, Bachi T Hathiram (India)

143. The Surgical Management of Tracheal Stenosis 1273

Danic Davorin, Prgomet Drago, Danic Hadzibegovic Ana (Croatia)

144. The Surgical Management of Tracheal Stenosis 1280

Mariano M Boglione (Argentina)

145. Tracheal Resection and Anastomosis 1290

Bachi T Hathiram, Vicky S Khattar (India)

146. Laryngotracheal Reconstruction 1298

Vicky S Khattar, Bachi T Hathiram (India)

147. Partial Cricotracheal Resection 1307

Bachi T Hathiram, Vicky S Khattar (India)

148. Extended Partial Cricotracheal Resection 1315

Vicky S Khattar, Bachi T Hathiram (India)

Index I-i-iv
 ThePrinciples
Surgical Technique of Otoplasty 1109
of Phonomicrosurgery
CHAPTER

112 Principles of
Phonomicrosurgery
Vicky S Khattar, Bachi T Hathiram

on one vocal fold at a time and angulate the microla-

INTRODUCTION ryngoscope in such a fashion
Outlined below are the basic principles of phonomi- • It must be kept in mind that often microlaryngoscopes
crosurgery, which remain regardless of the technique that are designed for the anterior commissure are
or instruments used. Adherence to these principles can angulated at the distal end, and although they may
ensure the best chance for a favorable outcome following provide excellent visualization, are not best suited
phonomicrosurgery. for instrumentation as often the angulation prevents
standard instruments from reaching anteriorly
• In patients with an anteriorly placed larynx, external
EXPOSURE pressure on the cricoid cartilage (as is used routinely,
• A variety of microlaryngoscopes are available in the during endotracheal intubation) may be applied. A
market, and one must choose the largest one that fits step further, in order to maintain a constant pressure,
the patient comfortably without trauma and gives the a linen or gauze bandage (commonly used for dress-
best exposure of the glottis. One must comfortably ing) may be tied to the operating table and around the
visualize the anterior commissure (Figs 1A and B) patient in such a manner that gives firm and constant
• The microlaryngoscope should splay apart the false pressure on the cricoid cartilage. This has been known
vocal folds and rest against the superior surface of to give an excellent exposure of the larynx
the true vocal folds. The lateral most extent of the true • It is prudent to use the highest magnification possible,
vocal fold (including the part which lies in the ventricle as it affords an optimum visual differentiation of
or saccule must be exposed). If required, one may work the various layers of the vocal fold. An easy way to

A B
Figs 1A and B: (A) This image shows the lesion on the left vocal fold exposed after fixing the microlaryngoscope; (B)
This image shows the same lesion after increasing the magnification of the microscope. For a good exposure, both the
vocal folds should be visible in the same field and both the anterior as well as the posterior commissures should be visible.
One should be able to see the superior surface laterally as far as the ventricle. Each blood vessel should be clearly visible
1110 Voice and Laryngotracheal Surgery

remember would be that the magnification may be epithelial leukoplakia will get easily elevated on
increased till one can appreciate the following: infiltration from the underlying lamina propria and
– The translucent nature of the epithelium may then be excised completely. On the other hand, if
– The superficial lamina propria the lesion is a microinvasive or invasive carcinoma, then
– The vocal ligament (seen as a white structure, with it may elevate in patches, or may not elevate at all—this
vertical fibre orientation) warrants a simple biopsy, rather than a complete excision
– Each blood vessel running across the vocal fold. of the lesion in order to plan the treatment
• While performing a superior cordotomy, this tech-
nique helps in creating a “working space” for instru-
SUBEPITHELIAL INFILTRATION mentation, and prevents damage to the underlying
• As with infiltration for any surgery, this technique lamina propria during dissection.
provides a plane for dissection (Figs 2A and B)
• It simultaneously protects the underlying lamina
propria
INCISION
• It helps to differentiate true epithelial lesions from • The incision for a superior cordotomy should be
infiltrating ones—epithelial lesions will become more planned correctly. There is no fixed site for the same,
prominent following infiltration and it should be tailor-made to suit individual lesions
• When used as a mixture of saline and adrenaline, it of the vocal folds (Figs 4A and B)
also provides some hemostasis, and may theoretically • Ideally it should be taken just lateral to the lesion so
prevent excessive vocal fold edema in the postopera- that the latter may be accessed easily, without making
tive period a “tunnel.” This also helps in accessing the lesion with
• In patients with leukoplakia, it may be the deciding a smaller incision as compared to one placed in a more
factor in converting a diagnostic procedure into a lateral position (Figs 5A and B)
curative one—many-a-time a preoperative diagnosis • It may be extended in the anterior and posterior
of leukoplakia is arrived at, based on laryngoscopic directions, with sharp dissection
images. When a biopsy is indicated, the vocal folds • Incisions on the medial vibrating edge should be
are infiltrated subepithelially (Figs 3A and B). A true avoided

A B
Figs 2A and B: (A) This image shows the infiltration needle in place in the subepithelial plane, lateral to the lesion;
(B) This image shows the same lesion after infiltration. Note that the infiltrated vocal fold appears blanched as well as
the lesion arising from the epithelium (such as this) becomes more prominent. This technique is very useful in patients
with leukoplakia, in differentiating it from microinvasive carcinoma, wherein the basement membrane is invaded and the
subepithelial infiltration does not make the lesion more prominent
 Principles of Phonomicrosurgery 1111

A B
Figs 3A and B: (A) This image shows subepithelial infiltration being performed; (B) This image
shows the lesion to become more prominent, with blanching of the right vocal fold

A B
Figs 4A and B: (A) This image shows the superior cordotomy incision being taken just laterally to the lesion on the right
vocal fold; (B) This image shows the incision completed. Note that the incision usually extends for a short distance anteriorly
and posteriorly, beyond the visible lesion—this helps in easier elevation and exposure of the lesion, with lesser traction on
the microflap and lesser chances of the latter getting torn

• Incisions on the corresponding points on the two vocal

folds should be avoided, especially for very anteriorly
ELEVATION OF THE MICROFLAP
placed lesions, to prevent synechia formation • A variety of elevators should be available in various
• Incisions should always be epithelial, and performed sizes
with a sharp instrument, in a single bold stroke, and • Sharp and clean dissection is favorable. It is important
extended only if dissection should cause undue trac- that the elevator used should be of the appropriate size
tion and pose a risk of tearing the epithelium (Figs 6A to prevent accidental flap tears
and B) • Countertraction may be provided by holding the lip of
• They should preferably be parallel to the direction of the incision with the help an atraumatic Bouchayer’s
vocal ligament as far as possible. forceps (Figs 7A and B)
1112 Voice and Laryngotracheal Surgery

A B
Figs 5A and B: (A) This image shows the superior cordotomy incision being taken just laterally to this large intracordal
cyst in the left vocal fold. Thus, the site of the incision should be tailor-made to suit the lesion; (B) This image shows the
incision (which was initially taken with a sickle knife as shown in (A) being extended with a microscissors

A B
Figs 6A and B: (A) This image shows the cordotomy incision taken just laterally to the hemorrhagic cyst on the left vocal
fold; (B) This image shows the same being extended with microscissors. Thus, the choice of instruments can vary, as long
as the dissection is sharp without any ragged edges

• While elevating microflaps over cysts, it is better to the lesion, rather than elevate a microflap after a supe-
dissect on the undersurface of the epithelial flap, rather rior cordotomy, as the latter would only cause more
than on the superior surface of the cyst—this precau- instrumentation in the subepithelial plane, with subse-
tion may help in preventing the cyst from rupturing quent potential damage to the lamina propria below.
(Figs 8A and B) This is of course in debate and the preference may be
• During elevation, undue traction or abrasions of the left to the surgeon. In the authors’ personal experience,
lamina propria should be avoided this has led to the comparable vocal outcomes. It must
• For lesions placed on the medial surface of the vocal be kept in mind that while amputating such lesions,
fold, which are either pedunculated or even sessile with the lesion should be pulled medially so as to “tent” the
a broad based epithelial attachment, but are purely epithelium prior to cutting. This ensures that no lamina
epithelial in origin, it may be prudent to simply amputate propria is accidentally injured (Figs 9 and 10).
 Principles of Phonomicrosurgery 1113

A B
Figs 7A and B: (A) This image shows the cyst being pulled medially with atraumatic Bouchayer’s forceps, so as to make
the epithelial attachment prominent and (B) also, prevent the scissors from accidentally damaging the lamina propria

A B
Figs 8A and B: (A) This image shows a large elevator incorrectly being used for dissection; (B) This image shows a
smaller dissector being used in the same patient as in (A). However, this is still abnormally large for the lesion and causes
an accidental rupture of the microflap

• For the same reason, cordotomy incisions should

PRESERVATION OF THE MEDIAL always be on the superior surface of the vocal fold
VIBRATING EDGE OF THE VOCAL • Even if it becomes necessary to work on the medial
FOLD edge of the vocal fold, one may work on the two sides
in a deferred manner (if conditions permit). This
• The medial vibrating edge of the vocal fold must be allows for reepithelialization of one cord, following
preserved at all costs, as this is the site of impact, and which the epithelium of the opposite cord may be
determines the clarity of the voice to a great extent dealt with
1114 Voice and Laryngotracheal Surgery

A B

C D
Figs 9A to D: (A) This image shows an intracordal cyst on the left vocal fold; (B) This image shows a microflap elevator
and countertraction being given by the Bouchayer’s forceps; (C) This image shows the dissection being carried out in the
plane deeper to the cyst; (D) This image shows the dissection being attempted superficial to the cyst. However, due to
incorrect traction being given on the superior surface of the cyst, rather than on the inferior surface of the epithelial flap,
the cyst accidentally ruptures

• Damage to medial surface is acoustically more • Once lost due to trauma/inflammation/surgery, it

evident when on the anterior part of the vocal folds as is difficult to replace it with any other substitute and
compared to the posterior part (Figs 11A and B). eventually leads to scar or sulcus formation
• Even if some lamina propria is lost, it is advisable
PRESERVATION OF THE to immediately replace it with a substitute, which
LAMINA PROPRIA closely resembles it in consistency and texture, such
as autologous fat so as to prevent the epithelium
• The lamina propria is the most vital part of the vocal from sinking into the subepithelial defect, and
fold, as unlike the epithelium, it cannot regenerate. It resulting in the formation of a sulcus on the vocal
must thus be preserved as far as possible fold
 Principles of Phonomicrosurgery 1115

A B
Figs 10A and B: (A) This image shows the medial lip of the cordotomy incision being held with a Bouchayer’s forceps
to give traction, during elevation of the epithelial flap; (B) This image shows the excellent exposure obtained, after giving
gentle traction with the forceps (refer A)

A B
Figs 11A and B: (A) This image shows a cystic lesion on the right vocal fold; (B) This image shows the right vocal fold
after removal of the cyst. Note that after removing the cyst, the excessive epithelium on the superior surface has been
trimmed off and the epithelium on the medial surface of the vocal fold has been draped over the defect. This ensures that
the medial vibrating surface is intact

• For the same reason, vocal fold nodules which arise at leads to synechiae formation, which greatly impacts
the basement membrane zone are most likely to cause the voice quality
lamina propria damage and loss, as the dissection • In conditions such as bilateral papillomatosis (Figs 12A
comes very close to the latter. and B), numerous options are available:
– Either one can work on one vocal fold at a time and
defer the other side after 2–3 weeks
ANTERIOR COMMISSURE LESIONS – Either one may work on both the vocal folds, but
• Lesions at the anterior commissure are the phonosur- stop just short of the anterior commissure, as a little
geons’ nightmare. Dissection in this area eventually papilloma at the anterior commissure (Fig. 13) will
1116 Voice and Laryngotracheal Surgery

A B
Figs 12A and B: (A) This image shows the papillomatous growth, arising from both vocal folds and anterior commissure;
(B) This image shows complete removal of the lesions from the left vocal fold. However, a small part has been deliberately
left behind on the anteriormost part of the right vocal fold. This will prevent adhesion formation. The residual lesion may
be tackled at a later date, after epithelization of the left vocal fold

Fig. 13: Lesions arising purely from the anterior commissure

as in this patient (seen on a rigid Hopkins telescopic
examination) pose the greatest risk for postoperative web
formation. This risk may be compounded by the presence
of blood vessels supplying the lesion, which may need to be
cauterized after removal of the lesion

cause a lesser impact on the voice as compared to a • The occasional bleeding which may occur during the
web or synechiae at the same site cordotomy incision is usually self-limiting
– One can remove all the papillomas, and insert a • Often, lesions tend to derive their own vascularity,
silicone keel which may be retrieved endoscopically and it is these vessels which can cause troublesome
after 3–6 weeks. bleeding after removal of the lesion such as a hemorr-
• The same is for cold instrumentation or light ampli­ hagic cyst
fication by stimulated emission of radiation (LASER) • Some surgeons prefer to fire a single LASER shot at
surgeries at the anterior commissure for lesions such the proximal end of such “supplying” vessels after
as leukoplakia, etc. removing the lesions
• If bleeding does occur, it should be controlled by
topical dilute adrenaline application with moist
HEMOSTASIS cottonoids
• Under normal circumstances, the vocal fold epithelium • Very rarely, one may need to use the laryngeal suction
is relatively avascular, and if planes are maintained bipolar cautery to control troublesome bleeding,
between the epithelium and lamina propria, bleeding which if done, should be as sparingly as possible
is minimal (Figs 14A to D).
 Principles of Phonomicrosurgery 1117

A B

C D
Figs 14A to D: (A) This image shows a prominent blood vessel supplying the lesion on the left vocal fold. Some surgeons
prefer to tackle such vessels after the removal of the lesion with a single shot fired from a light amplification by stimulated
emission of radiation (LASER), at the proximal end of the blood vessel, which in this case, would be on the anterolateral
part of the superior surface of the left vocal fold; (B) This image shows that after removal of the lesion, a small amount of
bleeding may be present; (C) This image shows the topical application of dilute adrenaline with a cottonoid; (D) This image
shows the appearance of the vocal folds after the topical application of adrenaline

ACKNOWLEDGMENTS
The authors are thankful to the Dean, TN Medical College
and BYL Nair Charitable Hospital for granting permission
to publish this chapter.
1118 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1118
CHAPTER

113 Leukoplakia of the Vocal Folds

Nupur Kapoor Nerurkar, Gauri Kapre

INTRODUCTION restriction of caffeine intake, increasing hydration and

minimizing vocal abuse. A short course of relaxation ther-
Leukoplakia of the vocal fold suggests that there is a white apy or speech therapy may be advised. Occasionally, fungal
patch on the vocal fold (Fig. 1). Abnormal epithelial hyper- infection of the larynx may mimic leukoplakia (Fig. 4).
trophy or dysplasia of the vocal folds can be manifested In suspected fungal infections, especially in patients who
as redundancy of the epithelial or keratotic layers of the
vocal folds resulting in hyperkeratosis, parakeratosis and
is clinically referred to as leukoplakia (Fig. 2).1 On histo-
pathology, leukoplakia may be mild, moderate or severe
dysplasia (carcinoma in situ), whereas hyperkeratosis is a
focal area of increased keratinization of squamous epithe-
lium without dysplasia (Fig. 3).
What is also commonly seen in patients of chronic
laryngitis is “red and white areas” of the vocal folds. This
is due to the presence of both erythroplasia and leukopla-
kia and can become quite a challenge to treat as targeted
biopsies may not be representative and removal of the
entire red and white area may be tantamount to stripping
of the entire length of the vocal fold.
The two challenges that face the surgeon in such a situ-
ation are, when to operate and how much to operate.
Most patients are initially advised vocal hygiene Fig. 2: Keratosis of the left vocal fold and posterior
measures which include no use of tobacco in any form, part of right vocal fold

Fig. 1: Leukoplakia over the left vocal fold Fig. 3: Histopathological slide of leukoplakia showing
hypertrophy of surface epithelium with keratosis (black oval)
 Leukoplakia of the Vocal Folds 1119

are on steroids, the authors start appropriate antifungal especially in the wake of a possibility of there being an
therapy and saline sprays. However, if the symptoms of underlying carcinoma-in-situ or invasive cancer (Fig. 5).
hoarseness persist and the size of the white patch remains
constant or increases, an excisional biopsy is the best SPECIFIC PREOPERATIVE
option.
In phonosurgery, one tries to maximally retain the
EVALUATION
layered microstructure of the vocal folds by preserving After a detailed history and clinical evaluation, the patient
as much of the normal epithelium and superficial lamina undergoes a rigid laryngoscopic examination. This
propria (SLP) as possible. Over the years, as understand- provides a magnified recording of the patient’s vocal folds.
ing of the microanatomy of the vocal folds has improved, For situations where there is an epiglottic overhang, in
lateral microflap surgery is not recommended in benign children, strong gaggers or whenever mobility of the vocal
subepithelial lesions of the vocal folds. In fact, even folds is in doubt, a flexible laryngoscopic evaluation is a
medial microflap surgery has given way to mini-micro- must. This allows the authors to visualize the vocal folds
flap surgery.2 This is to prevent disturbing the delicately during normal physiological phonation and respiration.
arranged anchoring fibrils looping from the basement Evaluation of a patient with a voice disorder is
membrane and getting intertwined with the elastin fibers never complete without a stroboscopic examination.
of the SLP. By taking the incision bang on the lesion, mini- Stroboscopy forms one of the most vital preoperative
mal elevation and thus minimal disruption of this archi- evaluation modalities in patients with vocal fold leukopla-
tecture of the basement membrane zone takes place. kia. Stroboscopy essentially gives the authors a simulated
However, in a case of leukoplakia, as the disease is mucosal wave pattern in slow motion. Here, the param-
epithelial in nature, there is no question of preserving eters studied are: absence of mucosal wave, symmetry
the involved epithelium. If frozen histopathology reveals of movement, periodicity of the wave and its amplitude.
a malignancy then a 2-mm margin of excision for onco- When a good mucosal wave is present in the region of the
logical safety is warranted in the glottis.3 As epithelium leukoplakia, it suggests that the SLP and the vocal liga-
has a good propensity for regeneration, the ultimate voice ment are free of infiltration. An adynamic area should
­quality is good if it has been possible to preserve adequate raise the clinician’s suspicion regarding the possibility of
SLP. involvement of the deeper layers of the vocal folds. A poor
mucosal wave would, by corollary, indicate a necessity for
Indications for Surgery early surgical intervention.
From the above discussion it is clear that any white patch on Though a computerized voice analysis does not help
the vocal fold, which does not subside with vocal hygiene, in the diagnosis of the vocal fold lesion, it does provide a
should be excised and examined histopathologically, qualitative and quantitative assessment of the patient’s

Fig. 4: Fungal infection causing white patches Fig. 5: Invasive glottic cancer presenting as
white patches which mimic leukoplakia
1120 Voice and Laryngotracheal Surgery

preoperative voice, which may come in useful for post- alternately be changed so that no one point in the larynx is
operative comparison, as well as from a medicolegal subjected to constant prolonged pressure.
standpoint.
SURGICAL STEPS
ANESTHETIC CONSIDERATIONS The ideal position for MLScopy is extension at the neck
Anesthesia for any microlaryngeal surgery is a very criti- and flexion at the atlantooccipital joint, which is referred
cal issue as the airway is shared by the surgeon and the to as Boyce-Jackson’s position.5 For an anterior larynx,
anesthetist. All procedures are done under general anes- the “flexion-flexion” position has been recommended.6
thesia. The Mallampati scoring system4 (grade 1 to 4) gives This involves flexion of the neck and the head by keeping
an indication about the possibility of a difficult intubation a thick pillow under the patient’s head to ease intubation
(grade 4 being the most difficult). If the anesthetist finds or introduction of the laryngoscope. Once a satisfactory
intubation difficult, it forewarns the surgeon about the exposure has been attained, the chest piece can be fixed as
possibility of difficult or inadequate exposure of the surgi- usual. A Mayo’s trolley is setup from the left side over the
cal field. chest of the patient. The chest piece of the laryngoscope
A 5, 5.5 or 6 number microlaryngoscopy (MLScopy) is placed and fixed over this trolley so as to avoid direct
endotracheal tube, depending on the size of the larynx, is pressure over the patient’s chest and to avoid movement
usually ideal for intubation as it provides adequate space of the laryngoscope with ventilation. This position allows
for the scope to expose the larynx. As the MLScopy tube is for a good exposure of the larynx (Fig. 6).
longer in length than a conventional endotracheal tube, it For a right-handed surgeon, the laryngoscope is held
allows for an adequate subglottic insertion even with the in the left hand, while keeping the patient’s mouth open
head extension. The tube also has a large volume, low pres- with the right hand, taking care not to injure the lips,
sure cuff which provides an adequate seal during ventila- tongue, etc. Once the epiglottis is seen, the laryngoscope
tion. When the authors use a CO2 LASER, a Mallinckrodt blade is used to lift up the epiglottis and visualize the vocal
double cuff tube is preferred. This flexometallic tube is folds. The level of the blade is at the level of the false vocal
LASER safe and the double cuffs provide safety even if folds, retracting them. For an anteriorly placed larynx or
one cuff gets inadvertently ruptured. For surgeries that for lesions at the anterior commissure, the laryngoscope is
last for a prolonged duration, the pressure in the cuffs can positioned slightly higher and external pressure is applied

Fig. 6: Operating room setup

 Leukoplakia of the Vocal Folds 1121

at the cricothyroid membrane level. For anterior commis- used as a supportive surface against which the lesion rests.
sure pressure, the authors apply a cotton roller gauze It may be used to push the lesion into the subglottis to see
bandage around the neck of the patient at the level of the the pedicle of the lesion more clearly. This cottonoid also
cricothyroid membrane and wrap it around the operating absorbs any trickling blood and prevents small excised
table, tightening it adequately till the anterior commissure tissue fragments from entering the subglottis. During
is satisfactorily visualized. LASER surgery, the saline-soaked cottonoid prevents
Authors recommend the subepithelial infiltration the LASER beam from accidentally hitting the normal
technique (SEIT)7 while performing leukoplakia excision subglottic tissue. In case the cuff of the endotracheal tube
surgery. There are several advantages of this technique does not adequately seal off the airway, the presence of a
other than hemostasis. As the injection enters the SLP, it cottonoid will aid in doing so.
temporarily increases the SLP volume, thereby allowing Surgical excision of a leukoplakia patch may be done
one to operate in the most superficial layers of the SLP. using cold steel instrumentation or with the help of a
The infiltration itself creates a surgical plane by way of LASER. The authors prefer to use cold steel, rather than
hydrodissection and the margins of the lesion get more LASER, for thin leukoplakia patches, especially when they
clearly demarcated. The SEIT helps in depth penetration are small. An incision is taken at the lateral edge of the
of the lesion. If the leukoplakia is involving the vocal liga- lesion with the help of a sharp sickle knife along the length
ment, then the infiltrated fluid will spread all around the of the entire white patch. A sharp microflap dissector is
leukoplakia patch but will not lift the leukoplakia patch used to elevate the epithelium off the SLP up to its medial
itself, thus forming a “doughnut effect”.8 If the leukopla- limit. Once the medial edge of the lesion has been reached,
kia is limited only to the epithelium, it will get elevated by the microflap dissector is used to make the incision on the
the infiltrating fluid entering the SLP, indicating that the medial edge and the lesion is excised by using crocodile
SLP and vocal ligament are uninvolved. When LASER is scissors to cut off the anterior and posterior attachments
being used, the infiltration fluid in the subepithelial layers (Figs 7 to 12). Bleeding is best dealt with using hemostatic
also acts as a “heat sink”, effectively absorbing the thermal patties as repeated suctioning may cause trauma to the
effects of the LASER. vocal folds.
The technique of infiltration involves injecting 1–2 cc For thick, keratotic and large lesions, the authors
of 1 in 10,000 saline in adrenaline into the SLP using a prefer to use the CO2 LASER with the acublade.
27-gauge needle. The point of injection is just lateral to the The acublade is used usually with the following
margin of the lesion. The injection should be made in such specifications—8.5 to 10 watts power in the super pulse
a way that the tip of the needle just pierces the epithelium mode with a 1 to 2 mm length of the acublade and
and is visible through it. a depth of 1 (150 microns). These specifications are
A large saline soaked cottonoid is placed in the subglot- however changed and custom-made for each situation.
tis, providing multiple advantages. The cottonoid can be The advantage of the acublade is that it can be curved

Fig. 7: Subepithelial infiltration Fig. 8: Incision being made with a sickle knife
1122 Voice and Laryngotracheal Surgery

Fig. 9: Elevation off the superficial lamina propria Fig. 10: Cutting the posterior attachment

Fig. 11: Cutting the anterior attachment Fig. 12: Lesion completely excised

to suit the shape of the lesion, the charring is minimal lesions, a 2 mm margin in all directions including depth
and the surgery proceeds faster as one can increase the must now be removed.3 It is vital to take into account the
length of the blade as desired. Once the incision has depth invasion of the malignancy along with the lateral
been made with the acublade, the edge of the lesion spread to ensure adequate oncologically safe excision.
can be held more easily with the crocodile forceps and Occasionally, the lesion excised is too small for frozen
gently pulled medially, at the same time continuing the sectioning; in which case, it is sent for conventional histo-
LASER excision of the leukoplakia. The leukoplakia may pathology. If such a lesion is reported as malignant, or if
be removed piecemeal or in toto. However, it should, a lesion which was negative on frozen histopathology
in either case, be sent for frozen section or routine is reported as malignant in the final histopathological
histopathology examination. For frozen reporting the analysis, a revision surgery is warranted at the earliest,
lesion may be fixed on a filter paper, where the vocal so as to achieve oncologically safe margins. The authors
folds are depicted diagrammatically, clearly marking recommend recording of all surgeries performed, as this
the side of the lesion and its anterior, posterior, is especially useful when performing revision surgeries, as
medial and lateral ends. If the frozen section report is the site of surgery and the amount of tissue excised can be
nonmalignant, the surgery ends here. For malignant reviewed preoperatively.
 Leukoplakia of the Vocal Folds 1123

Postoperatively, the authors use a 10% lidocaine spray 532 nm KTP LASER (potassium titanyl phosphate).13 It
for laryngotracheal anesthesia to prevent laryngeal spasm has certain advantages over the PDL LASER, like a shorter
and decrease the postoperative pain. wavelength which makes it more absorbable for oxyhemo-
globin. This leads to more effective intraluminal coagula-
tion and lesser intraoperative bleeding which may occa-
NEW TECHNIQUES IN THE sionally be a concern with the PDL LASER. Smaller fibers
SURGERY can be used to carry the flexible delivery system of the KTP
LASER which leaves a wider channel area for suction and
Recent Advances increases procedural efficiency. The KTP LASER is also
cheaper than the PDL LASER.
Other Treatment Options and Newer Techniques
The flexible 10,600 nm CO2 LASER is also being used
Contact endoscopy is a relatively new diagnostic modal- for office based procedures. As opposed to the PDL and
ity to study superficial epithelial lesions of the larynx.9 The pulsed KTP LASERS which are angiolytic, the CO2 LASER
principle is that, the very high magnification offered by targets water. It causes more immediate tissue ablation and
these endoscopes helps in detecting nucleocytoplasmic is more useful for bulky disease than the photoangiolytic
abnormalities and early diagnosis of epithelial dysplasias. LASERS. It has been shown to be equally well tolerated in
The tissue to be examined is stained with 1% methylene the unsedated patients as an office based procedure.14
blue taken on a piece of gelfoam. The specially designed
contact endoscope is then placed in such a way that its
tip gently touches the region to be examined. In cases of
COMPLICATIONS
leukoplakia, increase in the nucleocytoplasmic ratio and The complications of leukoplakia excision are no differ-
irregularities in the size, shape and color of nuclei are ent from those for any other microlaryngeal surgery. There
typical features which aid in diagnosis. In case of kerato- is the possibility of trauma to the lips, teeth, tongue, base
sis, isolated cells without nuclei are seen. The features of tongue or tonsillar pillars during introduction or maneu-
malignant dysplasia are significantly increased nucleo­ vering of the scope.
cytoplasmic ratio and increased number of mitoses and LASER safety precautions must be strictly adhered to if
inclusion bodies within the cells. a LASER is being utilized.
A newer modification of this technology is the Compact If the lesion is at the anterior commissure, there
endoscopy.10 It combines the principles of inherent tissue is always a risk of a web formation in the postopera-
fluorescence and contact endoscopy. When a suspected tive period due to formation of adhesions between raw
region of laryngeal mucosa is stained with 1% methylene surfaces. As far as possible, one should avoid damaging the
blue and then contact endoscopy is done under the “Blue anterior commissure, especially the anterior commissure
light mode”, varying degree of fluorescence of tissue can tendon.
be seen. There is a lower intensity of autofluorescence in However, if the lesion is involving the anterior commis-
tumor tissue as compared to normal tissue whereas an sure, one does not have a choice. It is better, in such
increased autofluorescene is seen in keratinized tissue. situations, to use a LASER for excision rather than cold
LASERS, which can be passed through the flexible instrumentation. This will minimize handling, pulling
laryngoscope, have offered a new treatment option to and tugging of the lesion as much as possible. In any situ-
patients as the surgery can be performed as an outpatient ation where the authors are concerned about anterior web
procedure. The 585 nm pulse dyed LASER (PDL),11,12 is formation, the patient is taken under anesthesia 7–10 days
a flexible photoangiolytic LASER, originally employed postoperatively and the region of the anterior commis-
in the treatment of vascular lesions of the vocal folds. Its sure is gently cleaned with saline soaked patties. The use
application to epithelial lesion excision is based on the of local application of mitomycin-C in minimizing fibrosis
observation that the energy delivered by the PDL results in has also been advocated by many surgeons.8
denaturation of the basement membrane linking proteins If the lesion involves nearly the entire length of the
and cleaves the epithelial layer from the underlying SLP. vocal folds, then excision may effectively mean stripping
The PDL is particularly applicable when treating lesions of the vocal folds. Using the infiltration technique, one
of the anterior commissure. The flexible delivery system attempts to preserve as much of the normal SLP as possi-
of this LASER makes it particularly useful in permitting ble and epithelium regeneration is seen to take place in
access to areas which are difficult to approach, such as the 6–8 weeks. In case of extensive bilateral lesions, a staged
ventricles. Another photoangiolytic LASER is the pulsed procedure is preferred.
1124 Voice and Laryngotracheal Surgery

Sometimes, there may be complications related to 3. Gallo A, de Vincentiis M, Manciocco V, et al. CO2 laser
delayed healing of the raw areas or excessive scar tissue cordectomy for early-stage glottic carcinoma: a long-term
formation, both of which interfere with the postoperative follow-up of 156 cases. Laryngoscope. 2002;112(2):370-4.
vocal outcome. 4. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to
predict difficult tracheal intubation: a prospective study.
Depending on the general health condition of the
Can Anaesth Soc J. 1985;32(4):429-34.
patient, there may be some degree of anesthetic compli-
5. Hochman II, Zeitels SM, Heaton JT. Exposure and visu-
cations. Although complications related to general anes- alization of the glottis for phonomicrosurgery. Operative
thesia are negligible nowadays, they nevertheless exist. Techniques in Otolaryngology—Head and Neck Surgery.
This is especially true in microlaryngeal surgery, as the 1998;9(4):192-5.
authors ventilate with a very small-sized endotracheal 6. Hochman II, Zeitels SM, Heaton JT. Analysis of the forces
tube and the airway is shared by the anesthetist as well as and position required for direct laryngoscopic exposure
the surgeon. Pulmonary edema, pneumothorax, cardiac of the anterior vocal folds. Ann Otol Rhinol Laryngol.
arrest and death have been reported. 1999;108(8):715-24.
7. Nerurkar N, Narkar N, Joshi A, et al. Vocal outcomes follow-
SPECIAL INSTRUMENTS USED FOR ing subepithelial infiltration technique in microflap
surgery: a review of 30 cases. J Laryngol Otol. 2007;121(8):
THE SURGERY 768-71.
8. Rahbar R, Shapshay SM, Healy GB. Mitomycin: effects on
The basic instruments required for surgery are similar to laryngeal and tracheal stenosis, benefits, and complica-
other microlaryngeal surgeries, such as sickle knife, sharp tions. Ann Otol Rhinol Laryngol. 2001;110(1):1-6.
and blunt flap elevators, scissors, crocodile forceps and 9. Andrea M, Dias O, Santos A. Contact endoscopy during
a number 27 infiltration needle which is around 24-cm microlaryngeal surgery: a new technique for endoscopic
long. However, the tips of these microflap instruments examination of the larynx. Ann Otol Rhinol Laryngol.
are around 1 mm as opposed to 3-mm tips of the conven- 1995;104(5):333-9.
tional MLScopy instruments. Sometimes, when the lesion 10. Arens C, Glanz H, Dreyer T, et al. Compact endoscopy of the
extends into the infraglottic edge of the vocal fold, a vocal larynx. Ann Otol Rhinol Laryngol. 2003;112(2):113-9.
fold retractor may be used to improve visibility. When the 11. Lin Y, Yamashita M, Zhang J, et al. Pulsed dye laser-induced
inflammatory response and extracellular matrix turnover in
LASER is being used, a LASER suction which is the same
rat vocal folds and vocal fold fibroblasts. Lasers Surg Med.
length as the laryngoscope is attached to its side to suck
2009;41(8):585-94.
away the LASER plumes. 12. Hartnick CJ, Boseley ME, Franco RA Jr, et al. Efficacy
For achieving intraoperative hemostasis, it is prefera- of treating children with anterior commissure and
ble to use hemostatic patties with long threads rather than true vocal fold respiratory papilloma with the 585-nm
a suction which is more traumatic. pulsed-dye laser. Arch Otolaryngol Head Neck Surg.
2007;133(2):127-130.
REFERENCES 13. Zeitels SM, Burns JA. Office-based laryngeal laser surgery
with the 532-nm pulsed-potassium-titanyl-phosphate
1. Rosen CA, Blake-Simpson C. Operative Techniques in laser. Curr Opin Otolaryngol Head Neck Surg. 2007;15(6):
Laryngology, Springer; 2008. 394-400.
2. Sataloff RT, Spiegel JR, Heuer RJ, et al. Laryngeal mini- 14. Halum SL, Moberly AC. Patient tolerance of the flex-
microflap: a new technique and reassessment of the micro- ible CO2 laser for office-based laryngeal surgery. J Voice.
flap saga. J Voice. 1995;9(2):198-204. 2010;24(6):750-4.
 Premalignant Lesions of
ThetheSurgical
Larynx Technique of Otoplasty 1125
and their Management
CHAPTER

114 Premalignant Lesions of the

Larynx and their Management
Arsheed Hussain Hakeem, Imtiyaz Hussain Hakeem, Sultan A Pradhan

INTRODUCTION of the European Society of Pathology re-evaluated and

further formulated the histological criteria of Ljubljana clas-
About 90% of malignant tumors of the larynx are carci- sification in November 1997 in London, United Kingdom
nomas that often develop from premalignant lesions.1 (UK). The system is divided into four grades as follows:
Therefore, early detection and prompt treatment should 1. Simple hyperplasia (SH) is benign group.
thus prevent the development of invasive cancer requir- 2. Abnormal hyperplasia (AbH) is benign group.
ing more debilitating surgical resection. World Health 3. Atypical hyperplasia (AtH) is potentially malignant.
Organization (WHO) defined premalignant lesions of 4. Carcinoma in situ is malignant.
the larynx as “morphological alterations of the mucosa Malignant transformation of these lesions is a well-
caused by chronic local irritative factors or referable to known fact. Simple and abnormal hyperplasia is consid-
local expression of generalized illnesses, presenting a ered benign forms with 0.7% and 1% risk of malignant
higher probability of degeneration into the carcinoma transformation respectively. Atypical hyperplasia is
with respect to surrounding mucosa”.2 precancerous lesion in the essential meaning of the word
However, it has been unanimously accepted that the with 9.5% of malignant alteration within 15 years.6 Some
diagnosis of a premalignant lesions of the larynx must be studies have shown that the cases with atypical and severe
based on the histological characteristics of the lesion.2 The dysplasia present the most threatening group associated
histological classification of premalignant lesions, most with the highest risk of cancer ranging from 19% to 28%.8,9
closely followed for clinical purposes, is based on the eval- Laryngeal precancerous lesions have no specific macro-
uation of the grade of hyperplasia and/or dysplasia of the scopic appearance and are variously referred to as follows:
epithelium. According to Hellquist et al.3 a distinction can • Chronic laryngitis
be made between Grade I lesions, presenting hyperplasia • Keratosis (Fig. 1)
and/or keratosis with or without mild dysplasia, Grade II • Leukoplakia, a white patch
lesions characterized by moderate dysplasia and Grade III • Erythroplakia, a red patch
lesions, in which dysplasia is severe or of such type as to • Hyperplastic and dysplastic laryngeal lesions (Fig. 2)
configure carcinoma in situ. This grading is based on the are the increase in the epithelial layers of the larynx,
classification proposed by the Kleinsasser in 19631 and which is referred to use all embracing term of kera-
later, by Delemarre,4 distinguishing a first class character- tosis. This can be associated with mild, moderate or
ized by simple squamous cell hyperplasia, a second class severe dysplasia.
represented by squamous cell hyperplasia with atypia and The surface morphology and keratin layer formation
third class represented by carcinoma in situ. of these lesions have neither specific meaning nor any
Friedmann,5 proposed that dysplastic lesions of the significant relationship with their malignant potential.6,10
larynx can be considered on the same scale as corre- Histopathological diagnosis informs a clinician, how to
sponding lesions of the uterine cervix. Thus, this classifica- treat patients with benign, potentially or actually malig-
tion distinguishes keratosis without dysplasia to keratosis nant lesions.
with mild dysplasia (laryngeal intraepithelial neoplasia or
LIN I), moderate dysplasia (LIN II) and severe dysplasia or
carcinoma in situ (LIN III).
MANAGEMENT
A classification proposed in Ljubljana, Slovenia, The surgeon is often confronted with a myriad of manage-
followed for more than 25 years, does not follow the three ment dilemmas, once the diagnosis of precancerous
grade criteria, but was devised to cater to specific clinical laryngeal lesions is made. Following questions need to be
and histological laryngeal problems.6,7 The working group addressed:
1126 Voice and Laryngotracheal Surgery

Fig. 1: Microlaryngoscopy (MLS) picture of Fig. 2: Microlaryngoscopy (MLS) picture of scattered

left vocal cord keratosis dysplastic lesions of bilateral vocal cords

• Is the lesion malignant?

• Should the lesion be biopsied or followed closely?
• How different pathological entities should be managed?
• Are there medical measures to treat them or prevent
recurrence?
• How to follow these patients and detect recurrence or
transformation early?
What adds to the confusion is a natural tendency
of such lesions to partially or completely regress, stabi-
lize without further progression or progress to invasive
malignancy.
The overall appearance of the lesion is considered to
be the most important factor in determining management.
The management decision depending mainly on whether
there are single or multiple lesions, or widespread cohe-
sive disease is as follows:
• Single (Fig. 3) and multiple foci (Fig. 4) should be Fig. 3: Microlaryngoscopy (MLS) picture of single
hyperplastic lesion right vocal cord
completely excised to all visible margins, if possible
• In the presence of widespread, confluent leukoplakia,
histopathological mapping of the lesion with multi- and change in voice quality postoperatively and about
ple biopsies should be initially performed, followed the possibility of recurrence.
by staged resection, if feasible. There should be a low It is very difficult to predict accurately, which lesions
threshold for rebiopsy in the presence of widespread will progress into invasive malignancy based only on
disease clinical appearance. Studies have proven that the clini-
• Other factors that may be important in deciding cal appearance bares little correlation with the underly-
management include the patient’s general condition ing pathology.11 What makes decision-making difficult
and fitness for surgery, physiological age, comorbidity is that SH, dysplasia and/or carcinoma can all coexist in
and the presence of other risk factors same lesions. Even, stroboscopy has not proved to be reli-
• A discussion with the patient should be undertaken to able method of determining the presence of malignancy
inform him/her about the potential risks of hoarseness or depth of invasion.12 Following features in decreasing
 Premalignant Lesions of the Larynx and their Management 1127

and alcohol) and elimination of any vocal abuse tenden-

cies. All patients should be counseled regarding measures
to reduce risk factors, especially stop smoking or ethanol
intake. Symptomatic patients with laryngopharyngeal
reflux should also be counseled about the potential risks,
and they should be offered anti-reflux treatment.

CHEMOPREVENTION
Chemoprevention with retinoids, selenium and other
agents is still controversial. However, clinical response
to retinyl palmitate for laryngeal hyperplasia with an
induction dose of at least 300,000 international unit (IU)
followed by a maintenance dose of 1,500,000 IU13 was
assessed by Issing et al. There was a complete response in
75% of the patients and a partial response in the remain-
der. None of the lesions progressed to cancer. One princi-
pal drawback to using retinoids is that the lesions tend to
recur when treatment is discontinued. Also, there may be
Fig. 4: Multifocal hyperplastic lesions right cord with
significant side effects due to mucocutaneous toxicities.
associated erythroplasia
Increased incidence of lung cancer, when beta-carotene
was used for primary cancer prevention in heavy smokers,
order of importance, ulceration, erythroplasia, surface has been reported.14,15
granulari­ ty, increased keratin thickness (verrucous Therefore, patients need to be cautioned, regarding
appearance), increased size, recurrence after excisional potential adverse effects.
biopsies and long duration have all been associated
with carcinoma.11 The initial management of such lesion MODALITY OF SURGICAL
should begin with determination, whether it is a low-risk
or high-risk lesion based on the history and clinical exami-
TREATMENT
nation. High-risk lesions are those who have: The modalities of surgical treatment are as follows:
• WHO classification severe dysplasia or carcinoma in • Cold steel or carbon dioxide (CO2) LASER resection is
situ (Ljubljana classification AtH or carcinoma in situ) or recommended
• Patients with mild or moderate dysplasia with one or • If LASER excision is contemplated, CO2 LASER is the
more of the following: preferred tool
– Continued smoking, • The use of the LASER for ablation is to be discour-
– Persistent hoarseness and aged, because no specimen is provided for diagnosis
– A lesion visible on endoscopy. and it may be associated with a possible higher risk of
Tobacco or ethanol abuse, occupational risk factors, damage and impact on voice
diet and vitamin deficiency, irradiation exposure, viral • The procedure of vocal cord stripping is not
exposure [i.e. human papillomavirus (HPV)] and laryn- recommended
gotracheal reflux have all been epidemiologically associ- • For primary lesions that have not been treated previ-
ated with laryngeal carcinogenesis. Therefore, the patient ously, radiotherapy should be offered with discretion
needs appropriate counseling regarding these risk factors only in rare circumstances and a very small numbers
as part of the overall treatment plan. of patients, e.g. poor access for resection in a high-
grade lesion
• All biopsies, including those from multiple foci, should
CONSERVATIVE MEASURES be mounted, orientated and presented on an anatomic
A one month trial of conservative measures is reasonable template to the pathologist for photodocumentation
in the absence of any worsening of vocal symptoms, an prior to histological processing.
enlarging lesion or clinical signs of invasive carcinoma. Since the introduction of endolaryngeal microsur-
Conservative measures include instructing the patient on gery, several basic microsurgical techniques have been
proper hydration, reduction of dehydrants (i.e. caffeine described for the removal of vocal fold lesions. These
1128 Voice and Laryngotracheal Surgery

techniques include conventional incision or dissection, are not smoking, should be followed up for a minimum of
bimanual retraction and cutting, microflap technique and 6 months. Following that, if the patient agrees then they
the CO2 LASER. Until recently, only a few microsurgical may be discharged with instructions to return, if there is
methods have emerged as new choices for the treatment a change in voice or other suspicious symptoms appear. It
of vocal fold lesions. Lee et al.16 introduces an innovative should be noted that there were diverse opinions, regard-
method that can precisely remove benign sessile vocal fold ing the follow-up duration of low-risk patients. Some
lesions with epithelial keratosis or hyperplasia without clinicians recommended at least a 2-year follow-up, as
jeopardizing the intermediate or deep layer of the lamina the mean duration of risk of progression has been docu-
propria. mented to be of that duration. Others recommend early
Surgeons prefer laryngeal microoperation under the discharge from clinic with open or early return should
microsuspension laryngoscope and CO2 LASER Type I patients develop anxiety, recurrence of their hoarseness
cordectomy (Fig. 5). It is an effective and safe cure proce- or “throat symptoms”.
dure. It provides a definite diagnostic method for the vocal Radiation therapy has not been shown to prevent the
cord dysplasia. progression of dysplastic lesions to carcinoma; in fact, it
may even precipitate malignant degeneration. Therefore,
radiation therapy should be reserved for invasive carci-
FOLLOW-UP noma. Due to multicentricity of the cancer in hyperplastic
All patients should be closely followed with: lesions, random biopsies are discouraged. Excision biopsy
• Use of a flexible nasendoscope or rigid Hopkins rod to is performed with special emphasis on preserving the
view the larynx on office basis structural integrity of the deeper uninvolved layers of the
• Color photodocumentation must be done and retained vocal fold and the surrounding normal mucosa (Fig. 4).11
in the notes In the absence of carcinoma, the most hyperplastic
• Stroboscopy is helpful if available, but is not really lesions occur on the superior or ventricular surface of the
essential. vocal fold.11 Therefore, dissection to the phonating edge
High-risk patients should be followed up in the same of the vocal fold is not necessary for complete excision.
manner as T1 laryngeal carcinoma: monthly for the first The lesion is carefully dissected of the deeper layers of the
year, two monthly for the second year, three monthly in lamina propria, using precise phonosurgical technique
the third year and six monthly in years 4 and 5. (Fig. 6). This minimizes the chances of adversely affect-
Low-risk lesions patients who have mild or moder- ing vocal function due to the extensive vocal fold fibrosis.
ate dysplasia with no visible lesion or hoarseness, or who At the completion of procedure, the specimen is labeled
and sent for serial section to avoid missing a focus of
carcinoma.
Difficulty in dissecting the lesions off the deeper layers
of the lamina propria or vocalis muscle suggests an invasive
carcinoma or significant fibrosis from previous surgery.

PERSISTENT OR RECURRENT
PRECANCEROUS LESIONS
The management of the recurrent or persistent premalig-
nant lesions depends mainly on their histology. They are
as follows:
• Recurrent, focal mild or moderate dysplasia should be
excised, if possible
• Recurrent, widespread mild or moderate dysplasia can
be observed or excised; excision is especially under-
taken if there is change in appearance (erythroplasia)
or texture (heterogeneous, proliferative features)
• Recurrent, focal severe dysplasia should be managed as a T1
laryngeal carcinoma with resection, where possible.
Fig. 5: Carbon dioxide (CO2) LASER resection being Radiotherapy may be considered by the multidiscipli-
performed of left cord dysplastic lesion nary team in certain circumstances, including:
 Premalignant Lesions of the Larynx and their Management 1129

REFERENCES
1. Kleinsaser O. Die Klassifikation und Differential diagnose
der Epitelhyperplasien der Kehlkopfschleimhaut auf grund
histomorphologischer Merkmale. Z Laryngol Rhinol Otol.
1963;42:339-62.
2. Kramer IR, Lucas RB, Pindborg JJ, et al. Definition of leuko-
plakia and related lesions: an aid to studies on oral precan-
cer. Oral Surg Oral Med Oral Pathol. 1978;46(4):518-39.
3. Hellquist H, Lundgren J, Oloffson J. Hyperlasia, keratosis,
dysplasia and carcinoma in situ of the vocal cords—a follow-
up study. Clin Otolaryngol Allied Sci. 1982;7(1):11-27.
4. Delemarre JFM. De betekenis van de plaveiselcellige hyper-
plasie van het larinxepitheel. Amsterdam: Thesis; 1970. p. 10.
5. Friedman I. Nose, throat and ears. Edinburgh, London,
Melborne, New York: Churchill Livingstone; 1986.
6. Poljak M, Gale N, Kambic V. Human papillomaviruses:
a study of their prevalence in the epithelial hyperplastic
lesions of the larynx. Acta Otolaryngol Suppl. 1997;527:66-9.
7. Kambic V, Lenart F. Notre classification des hyperpla-
Fig. 6: Microlaryngoscopy (MLS) picture depicting CO2 LASER sies de I’epithelium du larynx au point de vuepronostic. J Fr
cordectomy being performed with meticulously preserving Otorhinolaryngol Audiophonol Chir Maxillofac. 1971;20
vocal fold ligament (10):1145-50.
8. Crissman JD. Laryngeal keratosis and subsequent carci-
noma. Head Neck Surg. 1979;1(5):386-91.
– Patients who have had two or more recurrences 9. Blackwell KE, Calcaterra TC, Fu YS. Laryngeal dysplasia:
– Patients who continue to smoke epidemiology and treatment outcome. Ann Otol Rhinol
– Patients who have a high-risk of anesthetic Laryngol. 1995;104(8):596-602.
complications 10. Blackwell KE, Fu YS, Calcaterra TC. Laryngeal dysplasia. A
– Patients who have access problems for surgery clinicopathologic study. Cancer. 1995;75(2):457-63.
– Patient preference. 11. Zeitels SM. Premalignant epithelium and microinvasive
cancer of the vocal fold: the evolution of phonomicrosurgical
• Persistent or recurrent widespread severe dysplasia:
management. Laryngoscope. 1995;105(3 Pt 2):1-51.
radiotherapy should be considered as an option by the 12. Colden D, Zeitels SM, Hillman RE, et al. Stroboscopic
multidisciplinary team and discussed with patients assessment of vocal fold keratosis and glottic cancer. Ann
who have persistent or recurrent widespread severe Otol Rhinol Laryngol. 2001;110(4):293-8.
dysplasia, especially in patients who continue to 13. Issing WJ, Struck R, Naumann A. Positive impact of retinyl
smoke. palmitate in leukoplakia of the larynx. Eur Arch
Otorhinolaryngol. 1997;254(Suppl 1):S105-9.
14. The Alpha-Tocopherol, Beta Carotene Cancer Prevention
SUMMARY Study Group. The effect of vitamin E and beta carotene on
The classification and the most appropriate treatment the incidence of lung cancer and other cancers in male
of the precancerous lesions of the larynx continue to smokers. N Engl J Med. 1994;330:1029-35.
15. Hennekens C, Buring JE, Manson JE, et al. Lack of effect of
be controversial. It is an established fact that the dysplastic
long-term supplementation with beta carotene on the inci-
lesions of the larynx have the potential to evolve into dence of malignant neoplasms and cardiovascular disease.
malignant lesion. It is also well known that the capacity of N Engl J Med. 1996;334(18):1145-9.
this transformation significantly correlates to the grade of 16. Lee KW, Chiang FY. Current practice and feasibility in
dysplasia of the epithelium. The diagnosis, treatment and microlaryngeal surgery: microsurgical pressing exci-
prognosis of these lesions depend almost entirely on their sion technique. Curr Opin Otolaryngol Head Neck Surg.
histological abnormalities. 2009;17(6):431-5.
1130 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty
CHAPTER

115 Photodynamic Therapy for

Laryngeal Cancers
Nestor Rigual, Merill Biel, Kiskumar Thankappan, Barbara Henderson

INTRODUCTION PRINCIPLES OF PHOTODYNAMIC

Laryngeal squamous cell carcinoma (SCC) is the elev-
THERAPY
enth most common form of cancer among men world- Photodynamic therapy is a minimally invasive local treat-
wide and is the second most common malignancy of ment that utilizes a light source to activate light sensitive
the head and neck. It is the dominant pathological type drugs (photosensitizers) to produce tissue destruction.
of malignancy affecting the larynx. A clear association In addition to the photosensitizer and light, molecular
has been established between smoking, excess alcohol tissue oxygen is a critical component of PDT. The gener-
ingestion and the development of SCC of the upper ally accepted mechanism of action of PDT is that energy
aerodigestive tract.1 Currently accepted treatments for transfer occurs from the light activated and excited triplet
early stage laryngeal cancer include endolaryngeal LASER state of the photosensitizer to oxygen to produce singlet
or cold instrument excision, open partial laryngectomy oxygen, which in turn causes irreversible oxidation of
and radiotherapy.2,3 These treatment options, although essential cellular components. Cell death can occur by
effective, may be associated with considerable morbidity. apoptosis and necrosis.14 Singlet oxygen is highly reactive
Voice quality for patients, undergoing LASER resection and can diffuse only 0.02 µm.15 Tissue damage is therefore
for limited glottic lesions, has been comparable to that restricted to the penetration depth of the light used. In
of patients receiving radiotherapy, whereas open partial addition to direct cell killing, the membrane damage
laryngectomies consistently yield poor voice quality.4,5 caused by PDT is associated with the release of inflam-
Radiotherapy requires extended treatment periods and matory and immune mediators that stimulate responses
is associated with short and long-term morbidities, such in the tumor environment and systemically to further
as mucositis, xerostomia and tissue fibrosis.6-10 There are augment and tumor response. The tumor microvascula-
also constraints in repeating radiotherapy in the event of ture is also an important target of PDT, leading to vascu-
a recurrence or a second primary tumor. Head and neck lar disruption and ischemia. The combined effect of these
SCCs are associated with an annual rate of second primary actions results in the remarkable necrosis of tumor tissue
upper aerodigestive tract cancers ranging from 3% to within 2–5 days following the treatment.16,17
10%.11 The treatment of these lesions may be compro-
mised by previous radical therapies. Reirradiation carries
the risk of increased morbidity and is often restricted to
PHOTOSENSITIZERS UNDER
tertiary care centers.12 Surgical salvage is challenging due EVALUATION FOR HEAD AND
to the loss of normal tissue.13 NECK CANCER
An optimal treatment modality for early stage laryn-
geal carcinoma would be safe, effective, repeatable, mini- An ideal photosensitizer is one that is highly selectively
mally invasive and devoid of any permanent sequelae. retained by the tumor cells, is activated at a long light
Photodynamic therapy (PDT), a minimally invasive treat- wavelength, provides better tissue light penetration and
ment that uses light of a specific wavelength to activate a has minimal side effects. No agent has yet been identified
photosensitizing agent in the tumor and its microenviron- that fulfills all of these requirements, but many groups are
ment, offers some of these advantages. The purpose of this presently pursuing photosensitizer development.
review is to discuss the existing evidence for the utilization Porfimer sodium (Photofrin), a derivative of hemat-
of this modality in laryngeal cancers and to summarize the oporphyrin (HpD), is the first photosensitizer with wide
advantages and limitations. clinical use and regulatory approval in many countries,
 Photodynamic Therapy for Laryngeal Cancers 1131

including the United States.18 The absorption spectrum (a and b half-lives 7.77 h and 596 h, respectively).26 A study
of porfimer sodium has five peaks, the strongest at about of 48 patients having received graded doses of HPPH evalu-
400 nm and the weakest at about 630 nm. Light at 400 nm ated cutaneous photosensitivity up to 3 days after HPPH
will penetrate less than 1 mm in tissue and hence cannot administration. That study revealed that patients injected
be used for clinical treatment. The absorption peak at with 3 mg/m2 or 4 mg/m2 had no skin reaction, follow-
630 nm allows light penetration of 0.5–1 cm into tissues19 ing exposure of the volar part of their forearms to artificial
and hence is useful for treatment of superficial lesions. solar-spectrum light; 1 of 2 patients injected with 5 mg/m2
Although porfimer sodium has proven effective in the HPPH and 2 of 3 patients receiving 6 mg/m2 HPPH had
treatment of a wide range of solid malignancies, it induces skin reactions limited to very minimal erythema.20 HPPH
prolonged cutaneous photosensitivity in patients, which is strongly absorbs light at 665 nm and thus penetration into
a major limitation.20 tumor tissue is increased beyond what is possible at 630 nm
This limitation and the need for agents that are acti- with Porfimer sodium. Six patients have so far been treated
vated at longer wavelengths of light have stimulated the under an ongoing study of early laryngeal disease [moder-
wide ranging search for improved, “second generation” ate to severe dysplasia, carcinoma in situ (CIS), T1] with-
photosensitizers. The prodrug 5-aminolevulinic acid out any serious adverse events being observed. Temporary
(ALA, Levulan) and its methyl ester derivative (MAL) hoarseness was reported by five patients. All patients
(Metvixia), which lead to high intracellular levels of the responded to treatment, but outcomes of the data are not
photodynamically active protoporphyrin IX, is attractive yet available.
because of its rapid clearance, and therefore absence of
prolonged general photosensitivity. These agents, when
light activated at wavelength 630 nm, are highly effec-
TUMOR ILLUMINATION
tive in the treatment of superficial skin lesions, where it The activation of the tumor localized photosensitizer
is delivered topically. The 5-aminolevulinic acid (ALA), requires light of the photosensitizer specific wavelength
given orally at effective doses, is associated with nausea at sufficient power to illuminate the entire tumor volume.
and vomiting, and has caused one death due to vascular This is commonly achieved through the use of LASERS.
instability when used for the treatment of Barret’s esopha- The initially available large frame LASERS, such as tunable
gus.21 The use of orally administered ALA (60 mg/kg) in argon ion pumped dye LASERS or gold vapor LASERS, are
the treatment of premalignant and early malignant oral gradually being replaced by more user-friendly, portable
lesions was of limited effectiveness.22 diode LASERS. Light is transmitted to the tumor tissue
Meta-tetrahydrophenylchlorin (mTHPC; Foscan) is through quartz fiber optical cables fitted with appropri-
an extremely potent photosensitizer that is activated at ate light distributing tips, i.e. microlenses for flat tumor
652 nm allowing more depth of tissue penetration.23 surfaces or cylindrical diffuser fibers for luminal surfaces.
D’Cruz et al.24 have published results from a multicenter In head and neck applications, microlens equipped fibers
study using mTHPC in 128 advanced incurable head and are usually employed to distribute light in uniform fields
neck carcinomas. Overall 43% of the lesions achieved to superficial surfaces. Cylindrical diffuser tips distribute
100% tumor mass reduction, while 35% achieved a 50% light 360° along the axis of the fiber and are occasionally
or greater tumor mass reduction. Of the lesions with used in the treatment of head and neck tumors. The fiber-
complete mass reduction, 35% remained cleared 1 year based optical delivery systems are compatible with clini-
after treatment. Adverse events included local pain and cal instrumentation, such as endoscopic devices.
facial swelling. Mild to moderate photosensitivity reac-
tions were observed in 19% of patients. LARYNGEAL PHOTODYNAMIC
Mono-L-aspartyl chlorin e6 (Talaporfin sodium, NPe6)
with an activation wavelength of 664 nm has been used in
THERAPY—TECHNIQUE
more than 100 cases of early stage head and neck cancer.25 The photosensitizer is injected intravenously as an outpa-
In cases of cancer of the larynx, the initial complete tient procedure. Patients are advised to avoid exposure
response (CR) rate was reported as 100%, with a 9% recur- to sunlight after the injection. The tumor is exposed via
rence rate. No severe adverse events, including photo- direct laryngoscopy under anesthesia and the light acti-
sensitivity, have been reported. [2-(1-Hexyloxyethyl)-2- vation treatment is performed by using a pumped dye
devinyl pyropheophorbide-a (HPPH, Photochlor)] has LASER and a fiberoptic microlens fiber. It is important to
demonstrated a short duration minimal photosensitiza- keep the treatment field dry and free of blood during the
tion in preclinical and clinical studies. This is attributed to application of light. The fiber usually is passed through the
the relatively short plasma half-lives of HPPH in patients laryngoscope, keeping the lens tip at a short distance away
1132 Voice and Laryngotracheal Surgery

from the treatment field and thereby delivering uniform twenty-three patients obtained a CR with 8–53 months
tumor surface illumination. Alternatively, the fiberoptic follow-up. This series contained two patients with T1
flexible fiber may be delivered via a flexible endoscope laryngeal cancer and both obtained a CR.
with a working channel. Of note is that the light output Biel et al.31 published the results of the largest cohort
of the fiber should be measured immediately prior and treated with PhotofrinÔ PDT. Of 115 patients with CIS,
after treatment. The light dose, duration of treatment and T1 and T2 laryngeal cancers, there was durable CR in
LASER light source may vary depending on the photo- 105 (91.3%) patients after a single treatment. Notably,
sensitizer used. After the completion of PDT, the patient all the recurrences were salvaged using PDT, surgery or
receives a dose of corticosteroid and discharges the same radiotherapy to achieve a total 5 years cure rate of 100%.
day on oral analgesics. Patients are reminded to follow Biel et al. also reported on 113 patients of early carcino-
sunlight avoidance precautions. Figures 1A and B show mas of oral cavity in the same paper. In the entire series of
the pre-treatment and post-treatment video-endoscopic 276 patients by Biel et al., only two patients sustained sun
view of a T1 larynx carcinoma treated with PDT. induced photosensitivity with significant facial edema.
The degree of treatment-related pain varied with patients.
However, in all patients, the pain was adequately controlled
PUBLISHED EXPERIENCE WITH with oral analgesics and uniformly resolved within
LARYNGEAL PHOTODYNAMIC 2–3 weeks of treatment. Rigual et al.32 reported the results
THERAPY of a prospective trial, using Photofrin PDT for head and
neck dysplasia and cancers. This included six patients
Porfimer sodium (Photofrin, HpD), being the first with laryngeal pathology. All the three laryngeal dyspla-
photosensitizer with wide clinical use has been tested sias exhibited a sustained CR. Two of the three laryngeal
most extensively in the treatment of laryngeal cancer. carcinomas had a CR. One patient with a primary glottic
Freche and De Corbiere27 reported treatment in cancer had no response and progressed locally during
32 patients with T1 carcinomas of true vocal cords with radiotherapy and was salvaged by means of a total laryn-
HpD or Photofrin. A CR was achieved in 25 out of gectomy. No airway compromise was reported and all the
32 patients (78%) with 12–48 months follow-up. Feyh28 patients subjectively reported voice quality improvement
treated 12 patients with CIS-T2 laryngeal carcinomas. compared with their pretreatment status.
Eleven out of twelve patients obtained a CR (91%). Yoshida et al.33 have reported their experience with
Schweitzer29 used Photofrin PDT to treat 10 patients PDT with HpD in laryngeal cancer. The effect of PDT as a
with CIS-T2 carcinomas of the larynx of which eight primary treatment for 10 patients was classified as a CR in
had CR (80%). Gluckman30 reported on 23 patients with eight (80%) and partial response (PR) in two cases. When
early head and neck carc­inomas, including cases with evaluated only for T1 patients, the results were classified
recurrences after failed previous therapy. Twenty out of as CR in eight and PR in one. The results from these studies

A B
Figs 1A and B: Pre-treatment and post-treatment video-endoscopic view of a T1 larynx
carcinoma treated with photodynamic therapy (PDT)
 Photodynamic Therapy for Laryngeal Cancers 1133

are summarized in Table 1. To date, there is no prospective The photosensitizers can distribute in a tumor
Phase III curative intent clinical randomized trial compar- unevenly, allowing some regions to escape the effective
ing PDT versus conventional treatments in head and neck treatment. The photosensitizers can remain in the skin for
cancers, including laryngeal cancers. varying duration making the patient photosensitive. Newer
Advantages of PDT include its effectiveness in prop- photosensitizers, like HPPH, have a much shorter half-life,
erly selected cases, such as tumor in situ (TIS) and T1. Biel and hence the period of photosensitivity is limited to a few
et al. demonstrated the efficacy of Photofrin PDT with days. Finally, therapeutic effectiveness of PDT is affected
curative intent for TIS, T1 (85–91%) and T2 (72%) SCC by the depth of tissue penetration of the LASER light.
of the larynx. More importantly, if salvage treatment is
included, the curative rates are up to 100%. Photodynamic
therapy for the treatment of T1 and T2 laryngeal cancers
CONCLUSION
has cure rates that are comparable to, if not better than Photodynamic therapy as currently practiced appears
conventional therapies. Photodynamic therapy is mini- to be highly effective for early stage laryngeal cancers.
mally invasive and performed as a single outpatient Nevertheless, commercial availability of photosensitizers
procedure as compared to 6–7 weeks of radiotherapy. with limited photosensitivity remains a challenge for
Of note is that the treatment may be repeated without wide dissemination of this treatment modality. Multi-
permanent complications. Photodynamic therapy results institutional Phase II clinical trials are required to develop,
in selective tumor destruction with preservation of and incorporate PDT into the treatment algorithm of
mesenchymal tissues. This is of particular significance in laryngeal cancer. Finally, the future of PDT is promising
larynx, where tissue loss can result in functional deficits. with the development of newer photosensitizers that have
Post PDT healing results in normal mucosa and submu- reduced photosensitivity and longer light wavelength acti-
cosa.26 Histological evidence of the healing process has vation resulting in deeper tissue penetration and improved
demonstrated the preservation of cellular collagen matrix therapeutic effectiveness.
with repopulation of the normal mucosal cells into the
preserved collagen matrix scaffold. Photodynamic ther-
apy for laryngeal carcinomas results in no glottic scar-
SUMMARY
ring, even if used multiple times as compared to conven- Laryngeal SCC is a common cancer among men globally.
tional LASER or surgical resection. For limited recurrent Currently effective treatment modalities for early stage
carcinomas of the larynx that have failed radiotherapy, laryngeal cancer can associated with significant long-term
PDT, if successful, allows excellent voice preservation. morbidities. Photodynamic therapy, a minimally invasive
Importantly, the use of PDT does not interfere with other treatment that uses light of a specific wavelength to acti-
therapies. In other words, standard therapies may be used vate a photosensitizing agent in the tumor and its micro-
effectively for salvage, if necessary. environment, offers a viable alternative treatment for this
Limitations of PDT include the fact that it remains a patient population without permanent treatment related
treatment modality for local disease. sequelae.

Table 1: Summary of publications on photodynamic therapy (PDT) for laryngeal lesions

Study Number of T stage Complete Partial response No
patients response (CR) (PR) response
Feyh et al. 12 T1, T2 11 1 0
Freche et al. 32 T1 25 7 0
Gluckman et al. 2 T1 2 0 0
Yoshida et al.* 12 T1, T2, T3 10 2 0
Schweitzer et al. 10 T1 8 2 0
Biel et al. 115 CIS, T1, T2 105 10 0
Rigual et al. 6 Dysplasia, T1,T2 5 0 1

*These patients were treated with a derivative of hematoporphyrin (HpD).

1134 Voice and Laryngotracheal Surgery

Authors’ focus in this review is to discuss the existing 16. Oleinick NL, Morris RL, Belichenko I. The role of apoptosis
evidence for the utilization of PDT in treating laryngeal in response to photodynamic therapy: what, where, why,
cancers and to summarize the advantages and limitations and how. Photochem Photobiol Sci. 2002;1(1):1-21.
17. Oleinick NL, Evans HH. The photobiology of photodynamic
of this novel therapy.
therapy: cellular targets and mechanisms. Radiat Res.
1998;150(5 Suppl):S146-56.
REFERENCES 18. McCaughan JS. Photodynamic therapy: a review. Drugs
Aging. 1999;15(1):49-68.
1. Spitz MR. Epidemiology and risk factors for head and neck 19. van Gemert JC, Berenbaum MC, Gijsbers GH. Wavelength
cancer. Semin Oncol. 1994;21(3):281-8. and light-dose dependence in tumour phototherapy with
2. Steiner W. Results of curative laser microsurgery of laryn- haematoporphyrin derivative. Br J Cancer. 1985;52(1):43-9.
geal carcinomas. Am J Otolaryngol. 1993;14(2):116-21. 20. Bellnier DA, Greco WR, Nava H, et al. Mild skin photosen-
3. Garcia-Serra A, Hinerman RW, Amdur RJ, et al. Radiotherapy sitivity in cancer patients following injection of Photochlor
for carcinoma in situ of the true vocal cords. Head Neck. (2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a; HPPH)
2002;24(4):390-4. for photodynamic therapy. Cancer Chemother Pharmacol.
2006;57(1):40-5. Epub 2005.
4. Mendenhall WM, Werning JW, Hinerman RW, et al.
21. Hage M, Siersema PD, van Dekken H, et al. 5-aminolevulinic
Management of T1-T2 glottic carcinomas. Cancer. 2004;
acid photodynamic therapy versus argon plasma coagula-
100(9):1786-92.
tion for ablation of Barrett’s oesophagus: a randomised trial.
5. American Society of Clinical Oncology, Pfister DG, Laurie
Gut. 2004;53(6):785-90.
SA, et al. American Society of Clinical Oncology clinical
22. Fan KF, Hopper C, Speight PM, et al. Photodynamic therapy
practice guideline for the use of larynx-preservation strat- using 5-aminolevulinic acid for premalignant and malig-
egies in the treatment of laryngeal cancer. J Clin Oncol. nant lesions of the oral cavity. Cancer. 1996;78(7):1374-83.
2006;24(22):3693-704. Epub 2006. 23. Berenbaum MC, Akande SL, Bonnett R, et al. meso-
6. Franzmann EJ, Lundy DS, Abitbol AA, et al. Complete Tetra(hydroxyphenyl)porphyrins, a new class of potent
hypopharyngeal obstruction by mucosal adhesions: a tumour photosensitisers with favourable selectivity. Br
complication of intensive chemoradiation for advanced J Cancer. 1986;54(5):717-25.
head and neck cancer. Head Neck. 2006;28(8):663-70. 24. D’Cruz AK, Robinson MH, Biel MA. mTHPC mediated
7. Nguyen NP, Smith HJ, Sallah S. Evaluation and management photodynamic therapy in patients with advanced, incurable
of swallowing dysfunction following chemoradiation for head and neck cancer: a multicenter study of 128 patients.
head and neck cancer. Curr Opin Otolaryngol Head Neck Head Neck. 2004;26(3):232-40.
Surg. 2007;15(2):130-3. 25. Konomi U, Yoshida T, Ito H, et al. [Clinical photodynamic
8. Lambert L, Fortin B, Soulieres D, et al. Organ preservation diagnosis and therapy efficiency in oropharyngeal cancer].
with concurrent chemoradiation for advanced laryngeal Nippon Jibiinkoka Gakkai Kaiho. 2009;112(5):429-33.
cancer: are we succeeding? Int J Radiat Oncol Biol Phys. 26. Bellnier DA, Greco WR, Loewen GM, et al. Population
2010;76(2):398-402. Epub 2009. pharmacokinetics of the photodynamic therapy agent
9. Rieger JM, Zalmanowitz JG, Wolfaardt JF. Functional 2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a in
outcomes after organ preservation treatment in head and cancer patients. Cancer Res. 2003;63(8):1806-13.
neck cancer: a critical review of the literature. Int J Oral 27. Freche C, De Corbiere S. Use of photodynamic therapy in the
Maxillofac Surg. 2006;35(7):581-7. Epub 2006. treatment of vocal cord carcinoma. J Photochem Photobiol.
10. Fung K, Teknos TN, Vandenberg CD, et al. Prevention of 1990;6(3):291-6.
wound complications following salvage laryngectomy using 28. Feyh J, Goetz A, Muller W, et al. Photodynamic therapy in
free vascularized tissue. Head Neck. 2007;29(5):425-30. head and neck surgery. J Photochem Photobiol B. 1990;
7(2-4):353-8.
11. Hong WK, Lippman SM, Itri LM, et al. Prevention of
29. Schweitzer VG. PHOTOFRIN-mediated photodynamic
second primary tumors with isotretinoin in squamous-
therapy for treatment of early stage oral cavity and laryngeal
cell carcinoma of the head and neck. N Engl J Med.
malignancies. Lasers Surg Med. 2001;29(4):305-13.
1990;323(12):795-801.
30. Gluckman JL. Hematoporphyrin photodynamic therapy: is
12. Stewart FA. Re-treatment after full-course radiotherapy: is it there truly a future in head and neck oncology? Reflections
a viable option? Acta Oncol. 1999;38(7):855-62. on a 5-year experience. Laryngoscope. 1991;101(1 Pt 1):
13. Wong LY, Wei WI, Lam LK, et al. Salvage of recurrent head 36-42.
and neck squamous cell carcinoma after primary curative 31. Biel MA. Photodynamic therapy treatment of early oral and
surgery. Head Neck. 2003;25(11):953-9. laryngeal cancers. Photochem Photobiol. 2007;83(5):1063-8.
14. Dougherty TJ, Gomer CJ, Henderson BW, et al. Photodynamic 32. Rigual NR, Thankappan K, Cooper M, et al. Photodynamic
therapy. J Natl Cancer Inst. 1998;90(12):889-905. therapy for head and neck dysplasia and cancer. Arch
15. Nyst HJ, Tan IB, Stewart FA, et al. Is photodynamic therapy Otolaryngol Head Neck Surg. 2009;135(8):784-8.
a good alternative to surgery and radiotherapy in the treat- 33. Yoshida T, Saeki T, Ohashi S, et al. Clinical study of photo-
ment of head and neck cancer? Photodiagnosis Photodyn dynamic therapy for laryngeal cancer. Nippon Jibiinkoka
Ther. 2009;6(1):3-11. Epub 2009. Gakkai Kaiho. 1995;98(5):795-804.
 The Surgical Technique of Otoplasty 1135
CHAPTER
Transoral Microlaryngoscopic
116 LASER Surgery for Cancer of
Larynx and Hypopharynx
Jagadish Tubachi, Karthikeyan Balasubramanian, Kannan Rajan, Sultan A Pradhan

INTRODUCTION INDICATIONS
Recent years have seen a paradigm shift in the treatment The most widely accepted indication for transoral CO2
of early laryngeal cancer towards transoral microlaryn- LASER resection of laryngeal/hypopharyngeal cancer is
goscopic LASER resection (TOLR) because of excellent an early cancer with freely mobile vocal cords, no gross
oncologic and functional results.1-3 The coupling of the invasion of the paraglottic or the pre-epiglottic spaces and
carbon dioxide (CO2) LASER to the operating microscope good exposure on suspension laryngoscopy. Presence
has greatly simplified, even revolutionized, microlaryngo- of metastatic lymph node does not preclude endoscopic
scopic surgery.4 resection of the primary. In fact in many cases, it strength-
The use of the CO2 LASER in the endoscopic manage- ens the case for endoscopic resection of the primary prior
ment of patients with early laryngeal cancer has many to neck dissection.
advantages.4-10 Magnification of the operating micro- The following are the main indications for transoral
scope and precise cutting with the CO2 LASER helps to resection:
achieve tumor free cut margins with greater confidence • Dysplasia/carcinoma in situ (Tis) of the vocal cord
without unnecessarily sacrificing normal tissues.11,12 In • T1/T2 glottic lesion (Figs 1A to C)
transoral procedure, the laryngeal framework remains • Select cases of T1/T2 lesions of the anterior commis-
intact, so the stress on swallowing mechanism is minimal. sure (AC) with only superficial invasion and very good
Therefore so TOLR can be offered to elderly patients and exposure on laryngoscopy (Figs 2A and B).
those with chronic lung disease. Postoperative pain is • T1/T2 lesions of the supraglottic (Figs 3A to D),
less in comparison to open laryngeal surgery.13 Resection marginal zone and hypopharynx
with the CO2 LASER is almost always complete in one • Localized residual/recurrent disease following failure
sitting as against nearly 6 weeks of treatment with radia- of radiotherapy for an early cancer.
tion therapy. The resection is generally performed as a There is potential for expanding the indications of
daycare procedure. Most importantly for the patient, a transoral LASER resection to include lesions that are more
tracheostomy is not required. In case of positive resection advanced than the one’s mentioned above for e.g. super-
margins, the procedure can be repeated. Finally, should ficially invasive T3 lesions of the supraglottis/hypophar-
treatment with the LASER be found to be inadequate, use ynx. It depends on the surgeon’s experience, expertise and
of other options, namely radiotherapy and open surgery, treatment philosophy. Lesions with gross invasion of the
are still available.26,27 paraglottis and some impairment of cord mobility (T2)

A B C
Figs 1A to C: (A) T1 exophytic lesion of left glottis. Postresection view at (B) 2 months; (C) 2 years
1136 Voice and Laryngotracheal Surgery

A B
Figs 2A and B: (A) Carcinoma right vocal cord reaching till anterior commissure (AC). Lesion is superficial and
exposure of AC is adequate; (B) En bloc resection of tumor done

A B

C D
Figs 3A to D: T2 lesion of supraglottis. (A and B) Pre­operative and intraoperative view;
(C) Postoperative day 10 appearance; (D) Postoperative view after 2 years
 Transoral Microlaryngoscopic LASER Surgery for Cancer of Larynx and Hypopharynx 1137

can be resected transorally but the authors do not recom-

mend it because alternatives that are oncologically safer
and more effective are available viz the open partial laryn-
gectomy procedures.

LIMITATIONS
Certain conditions lead to inadequate exposure of the
tumor on transoral microlaryngoscopy and can make
endoscopic resection impossible or unsafe.
• Patient related factors: Trismus due to any cause such
as submucous fibrosis, inability to extend the neck Fig. 4: An ideal arrangement of instruments in
due to severe cervical spondylosis, anatomical peculi- operation theater
arities of the dental arch, anteriorly placed larynx or a
bulky tongue.
• Treatment factors: Fibrosis as a result of previous TECHNICAL CONSIDERATIONS
surgery or radiotherapy.
In all these conditions, even lesions that are seemingly Glottis is less vascular in comparison to supraglottis
easily resectable as viewed on indirect laryngoscopy, may and the hypopharynx, which are very vascular regions.
have to be offered alternative methods of treatment.26,27 Resection of tumors in the supraglottis and the hypophar-
ynx are therefore technically quite demanding. Proper
instrumentation is very important. Besides the operat-
OPERATION THEATER SETUP ing microscope and the CO2 LASER, the plume sucker,
The surgeon and the anesthetist share the same airway, so laryngoscopes of various calibers, distending laryngopha-
proper arrangement of anesthesia instruments and opera- ryngoscopes, insulated monopolar cautery with suction
tive instruments is essential to prevent discomfort during channel and tissue holding forceps with suction channel
the procedure. The operation theater should be spacious are very much essential.
because of large amount of equipment needed for the
LASER surgery. An ideal arrangement of instruments in
operation theater is represented in Figure 4.
PROCEDURE
Assessment of extent of lesion with 0° and 30° telescope
is essential before the start of procedure. The resection is
SAFETY MEASURES performed transorally using a suspension laryngoscope
When using the CO2 LASER, certain safety measures are and an operating microscope which is coupled with the
advised in order to prevent injury to the patient and to the CO2 LASER. An orotracheal tube is used for general anes-
operating room personnel. thesia. Tracheotomy is avoided. Proper exposure of the
• The endotracheal (ET) tube should be of noninflam- lesion is vital to ensure an adequate excision with onco-
mable material, preferably red rubber ET tube. Cuff logically safe margins.14 The LASER beam is now focused
of ET tube should be covered with wet neurosurgical accurately to a spot-size and is manipulated with the help
cotton to prevent cuff rupture from misdirected LASER of a micromanipulator to permit precise excision in a rela-
beam. If fire occurs, the patient is extubated at once tively bloodless field. For a small lesion that can be visu-
and reintubated. alized in its entirety, monobloc (Figs 5 and 6) resection is
• Face of patient is covered with wet cloth. performed by cutting through normal tissue around the
• Theater personnel are advised to wear goggles to margins of the tumor. A larger lesion is excised in multi-
protect the eyes from accidentally reflected LASER ple segments as determined by the field of exposure. This
beam. method of cutting through tumor tissue, though uncon-
ventional in open surgery, is the recommended technique
in TOLR. The resection is completed segment by segment,
ANESTHETIC CONSIDERATION as the tumor is excised in wedges, till the supple normal
An orotracheal red rubber tube is used for general anes- tissue is left behind.15 In such cases, orienting the speci-
thesia. Appropriate size of tube should be used without men is essential to check the adequacy of surgical cut
compromising ventilation and exposure of the lesion to margins. The CO2 LASER is an excellent cutting tool with
ensure an adequate excision. limited capability for coagulation. Minor ooze is controlled
1138 Voice and Laryngotracheal Surgery

A B
Figs 5A and B: Microlaryngoscopic picture of T1 right midcord lesion and en bloc CO2 LASER resection in process

A B C
Figs 6A to C: (A) Carcinoma in situ bilateral vocal cord; (B) Lesion with excision is
outlined with CO2 LASER and (C) mucosal stripping done

either with a defocused LASER beam or with neurosurgi- Glottic Carcinoma In Situ
cal cotton soaked in 1:100,000 adrenaline solution. For In premalignant conditions like leukoplakia or erythropla-
control of larger bleeders as encountered when resecting kia of vocal cords, the lesion may be localized or diffuse. It
lesions of the supraglottis and pyriform, an electrocautery may involve both vocal cords separately sparing the AC or
connected to an insulated suction tip is used. For glottic the two vocal cords may be involved in continuity across
lesions, hemostasis is generally much simpler. the AC. The treatment of choice is cord stripping (Figs 5A
Lesions on the AC, anterior third of the vocal cord, and B). These lesions often have a tendency to recur after
infrahyoid epiglottis, vallecula and base of the tongue, are cord stripping and may call for multiple excisions over a
very often difficult to visualize. Techniques are described period of years. Even so, radiotherapy is best avoided and
to improve the exposure and facilitate resection. For exam- reserved only for infiltrative cancer. As mentioned above,
ple, resecting the false cord to expose the growth on the the endeavor should be to excise the lesion completely
anterior third of the true cord and the AC or resecting the and prevent damage to the lamina propria so that the voice
suprahyoid epiglottis to expose the growth on the infrahy- quality remains good. Zeitels has described a phonomi-
oid region. The difficult visualization of AC was solved by crosurgical technique for this.16-18 It involves submucosal
using small caliber suspension laryngoscopes. injection of 1:100,000 adrenaline in saline with a 26-gauge
 Transoral Microlaryngoscopic LASER Surgery for Cancer of Larynx and Hypopharynx 1139

needle which will lift the mucosa and the lesion off the epiglottis. This gives a good exposure of the glottis. For the
lamina propria. If the patch is localized, conventional glottic cancer, resection margins should be 1–3 mm away
microscissors and forceps are used for excision. For diffuse from tumor. The lesion can then be resected either en bloc
lesions, the cord is stripped with the CO2 LASER using a or in segments, depending on the size of the tumor. While
microspot at low wattage. In case there is a microinvasive resecting a lesion on the AC, if it is found that the lesion
component when saline is injected, the mucosa at the site is deeply infiltrating (Figs 9A to C) or there is erosion of
of invasion will remain tethered to the lamina propria and the thyroid cartilage, the procedure is either converted to
will not be lifted off. In such a situation, only a limited an open partial laryngectomy or a LASER-assisted window
portion of the lamina propria is resected along with the partial laryngectomy is performed.20 Lesions of the AC will
entire leukoplakia to minimize damage to the quality of necessitate resection of the anterior most portions of both
voice. The saline injection helps to reduce tissue damage vocal cords. Left to itself, it will form an anterior web (Figs
due to heat generated by LASER. Addition of adrenaline 10A to C). To prevent this, it is necessary to interpose a
helps in achieving hemostasis.19 silicone keel between the two cords until the healing on
If the lesion involves both vocal cords and the AC, both sides is complete. The placement of keel is carried
the procedure may have to be staged 4–6 weeks apart out endoscopically, using the Leichtenberger needle.21,22
to prevent formation of a web. However, bilateral cord Alternate method to prevent web formation is application
lesions with uninvolved AC are tackled at the same session of mitomycin C (MMC) at the time of initial surgery. This
(Figs 7A and B). significantly lowered the incidence and extent of the web
formation. Breaking the fibrin strands formed between
T1/T2 Glottic Cancer the raw surfaces of vocal cord under general anesthesia,
Small midcord lesions are resected en bloc (Figs 5A between 7th to 10th postoperative days helps to reduce the
and B). Larger lesions are resected in segments, cutting extent of anterior glottic web.23 The other recommended
through the tumor until normal supple tissue is reached method to prevent web formation is that bilateral surgical
(Figs 8A and B). This way, as much normal tissue as possi- interventions be separated into two unilateral procedures
ble is preserved, to ensure good quality of voice. For staged at least 4–6 weeks apart. Lesions involving the true
lesions in the anterior third of the cord and the AC, if the cord, posteriorly, may necessitate resection of the vocal
exposure is inadequate, it is best to first resect the portion process of the arytenoid, retaining the main body of the
of the supraglottis, viz the false cord and the base of the arytenoid cartilage.

A B
Figs 7A and B: Bilateral cord lesions with uninvolved AC are tackled at the same session
1140 Voice and Laryngotracheal Surgery

A B
Figs 8A and B: Verrucous carcinoma involving left vocal cord. (A) Before excision;
(B) The lesion has been completely resected with a CO2 LASER

A B C
Figs 9A to C: Deeply infiltrating carcinoma right glottis involving anterior commissure (AC). Lesion is found unsuitable
for TOLR, so the procedure is converted to open partial laryngectomy

A B C
Figs 10A to C: Glottic carcinoma T1b. (A) Before; (B) After resection; (C) Patient did not turn up
for fibrinolysis and subsequently developed glottic web
 Transoral Microlaryngoscopic LASER Surgery for Cancer of Larynx and Hypopharynx 1141

Supraglottic Cancer with Mobile the CO2 LASER coupled to the operating microscope
Vocal Cords T1/T2/ Early T3 (Figs 14A to F).13
Only the cases with freely mobile vocal cords are selected In the postcricoid region, such an excision is only
for endoscopic LASER resection. Size and surface extent advisable for a small lesion confined to one wall; a
should not be the limiting factors. Even early invasion circumferential excision will lead to complete stenosis
of the pre-epiglottic space is amenable to endoscopic of the pharynx (Figs 15A and B). Lesions that extend up
resection. Tumors at the free border of the epiglottis, to the cricopharyngeal sphincter or deeply infiltrative
at the margin of ventricular fold or localized lesions lesions causing an excavating ulcer are not suitable for
on the edge of the aryepiglottic fold are easy to resect endoscopic resection.25
(Figs 11A to G). Like the supraglottis, the oropharynx and the
A tumor on the infrahyoid epiglottis needs to be hypopharynx are highly vascular regions and proper
exposed adequately before resection. A distending instrumentation is mandatory. Very large tumors may
laryngopharyngoscope is used for this purpose. This is not fit into one field and will therefore need readjust-
achieved by first resecting the suprahyoid portion of the ment of the scope from time to time.15 These lesions may
epiglottis, transecting from one pharyngoepiglottic fold at first seem formidable because of their size; however,
to the other. Thereafter, the infrahyoid epiglottis, with if the case selection is proper (mobile vocal cords, no
the tumor, is resected along with the pre-epiglottic space cartilage erosion, no parapharyngeal soft tissue inva-
(Figs 12A to C). sion and no ankyloglossia), it becomes progressively
If a supraglottic tumor has involved the mucosa over- easier as one resects the tumor, segment by segment. In
lying a mobile arytenoid, it is not necessary to resect the hypopharynx, it is recommended that one proceed
the cartilage. Under the magnification of the operating from the proximal portion of the tumor to the distal
microscope, the overlying mucosal tumor along with (craniocaudal direction). As mentioned in the earlier
sufficient submucosal margin is very easily peeled off section, the arytenoid cartilage must be preserved
with the help of the LASER, preserving the arytenoid whenever feasible in order to avoid problems of postop-
cartilage and the soft tissues covering it. This is oncologi- erative aspiration. If a pyriform cancer extends on to the
cally safe, prevents the problem of postoperative aspira- mucosa overlying a mobile, functioning arytenoid, the
tion and is therefore a major advantage over the open tumor can be resected along with the submucosal soft
procedure. Presence of metastatic neck node can be dealt tissue, preserving the arytenoids.
with by an appropriate neck dissection either at the same In case of metastatic nodes, neck dissection is deferred
sitting or 4–5 days later. Postoperative radiation therapy for about 4–5 days, particularly if the lateral pharyngeal
is only given if the resection margins are compromised wall is resected.
or if the neck nodal disease so demands. As in the case Patients undergoing LASER excision of supraglottic
of glottic cancer, the need for open partial laryngectomy and hypopharyngeal cancers need nasogastric feeding
for supraglottic cancer with freely mobile vocal cords has tube for few days before returning to normal feeding.
also significantly reduced due to progress in microlaryn-
goscopic LASER surgery.
Neuroendocrine tumors (NETs) of the larynx are the
COMPLICATIONS
second most common neoplasm of the larynx after squa- • Postoperative bleeding: Although rare, it is most danger-
mous cell carcinomas. Most commonly, it presents as ous complication. This can be prevented by meticulous
polypoidal pedunculated mass arising from aryepiglottic intraoperative hemostasis with electrocautery.
fold, arytenoid or epiglottis. NET are easily accessible and • Granuloma formation
can be treated by TOLR (Figs 13A to D).24 • Synechiae formation: Small glottic web remain asymp-
tomatic, whereas large anterior web cause dysphonia
Hypopharyngeal Cancers (Figs 16A and B).
T1/T2 squamous cancers of the pyriform and the poste- • Laryngeal stenosis
rior pharyngeal wall were generally treated with radiation • Perichondritis
therapy, largely due to the difficulty of surgical access to • Aspiration: Commonly encountered after large resec-
these regions. Using the distending laryngopharyngo- tion of supraglottic and hypopharyngeal cancers
scope, these lesions can now be excised transorally with • Surgical emphysema
1142 Voice and Laryngotracheal Surgery

A B C

D E

F G
Figs 11A to G: (A to C) Diagrammatic illustration of localized T1 supraglottic carcinoma. Black lines represent
margin of resection; (D to G) TOLR of T1 carcinoma epiglottis
 Transoral Microlaryngoscopic LASER Surgery for Cancer of Larynx and Hypopharynx 1143

A B C
Figs 12A to C: T1 supraglottic carcinoma involving infrahyoid epiglottis. (A) Before; (B) After TOLR;
(C) Diagrammatic illustration, black lines represent margin of resection

A B

C D
Figs 13A to D: Supraglottic neuroendocrine tumor (NET). (A) Tumor was adequately exposed with distending laryngoscope;
(B) Pedunculated tumor involves the laryngeal surface of the epiglottis; (C) Resection was done with CO2 LASER;
(D) Specimen
1144 Voice and Laryngotracheal Surgery

A B

C D

E F
Figs 14A to F: Postradiation recurrent carcinoma of posterior wall of hypopharynx: (A) lesion exposed with distending
laryngopharyngoscope. Incision is made around the tumor with CO2 LASER (B) incision is gradually deepened (C and D)
Postresection view (E) Postoperative wound in healing phase (F)
 Transoral Microlaryngoscopic LASER Surgery for Cancer of Larynx and Hypopharynx 1145

A B
Figs 15A and B: T2 postcricoid carcinoma extending to medial wall of right pyriform sinus.
(A) Before; (B) After 2 years of TOLR

A B
Figs 16A and B: Web (A) at anterior commissure (AC) cause minimal alteration in voice in comparison to web (B)

ACKNOWLEDGMENT 3. Steiner W. Experience in endoscopic laser surgery of

malignant tumours of the upper aero-digestive tract. Adv
The authors are thankful to Mr Prem Sonar for providing Otorhinolaryngol. 1988;39:135-44.
4. Strong MS, Jako GJ. Laser surgery in the larynx; early clini-
the help in preparing this manuscript.
cal experience with continuous CO2 laser. Ann Otol Rhinol
Laryngol. 1972;81:791-8.
REFERENCES 5. Strong MS. Laser excision of carcinoma of the larynx.
Laryngoscope. 1975;85:1286-9.
1. Sigston E, de Mones E, Babin E, et al. Early-stage glot- 6. Steiner W, Ambrosch P. CO2 laser microsurgery for laryn-
tic cancer: oncological results and margins in laser cord- geal cancer. In: Smee R, Bridger PG (Eds). Laryngeal cancer
ectomy. Arch Otolaryngol Head Neck Surg. 2006;132: proceedings of the 2nd World Congress on laryngeal cancer.
147-52. Elsevier; 1994. pp. 369-72.
2. Pradhan SA, Pai PS, Neeli SI, et al. Transoral laser for 7. Steiner W, Aurbach G, Ambrosch P. Minimally invasive
early glottic cancers. Arch Otolaryngol Head Neck Surg. therapy in otorhinolaryngology and head and neck surgery.
2003;129:623-5. Minimally Invasive Therapy. 1991;1:57-70.
1146 Voice and Laryngotracheal Surgery

8. Ossoff RH, Sisson GA, Shapshay SM. Endoscopic manage- 18. Zeitels SM. Phonomicrosurgical treatment of early glottic
ment of selected early vocal cord carcinoma. Ann Otol cancer and carcinoma in situ. Am J Surg. 1996;172:704-9.
Rhinol Laryngol. 1985;94:560-4. 19. Kass ES, Hillman RE, Zeitels SM. Vocal fold submucosal
9. Motta G, Villare G, Salerno G. The carbon dioxide laser in infusion technique in phonomicrosurgery. Ann Otol Rhinol
laryngeal and pharyngeal surgery in Functional surgery Laryngol. 1996;105:341-7.
of the larynx and pharynx. In: Singh W, Soutar DS (Eds). 20. Rebeiz EE, Wang Z, Annino DJ, et al. Preliminary clinical
Butterworth; 1993. pp. 147-54. results of window partial laryngectomy: a combined endo-
10. Zeitels SM. Laser versus cold instruments for microlaryngo- scopic and open technique. Ann Otol Rhinol Laryngol.
scopic surgery. Laryngoscope. 1996;106:545-52. 2000;109:123-7.
11. Akst LM, Strome M. Laser surgery for head and neck cancer. 21. Lang FJW, Monnier P. Le traitment endoscopique des
In: Adelstein DJ (Ed). Recent Clinical Progress and Prospects synechies glottiques. In: OR21, Problems actuels d’Otorhi­
for the Future. Series: Current Clinical Oncology. Squamous nolaryngologie. Bern: Verlag Hans Huber; 1998. pp. 314-24.
Cell Head and Neck Cancer. Springer; 2005. pp. 43-57. 22. Casiano RR, Lundy DS. Outpatient transoral laser vapori-
12. Steiniger JR, Parnes SM, Gardner GM. Morbidity of zation of anterior glottic webs and keel placement: risks of
combined therapy for the treatment of supraglottic carci- airway compromise. J Voice. 1998;12:536-9.
noma: supraglottic laryngectomy and radiotherapy. Ann 23. Roh JL, Yoon YH. Prevention of anterior glottic stenosis
Otol Rhinol Laryngol. 1997;106:151-8. after bilateral vocal fold stripping with mitomycin C. Arch
13. Rudert HH. The CO2 laser in the management of Otolaryngol Head Neck Surg. 2005;131:690-5.
hypopharyngeal cancer. Curr Opin Otolaryngol Head Neck 24. Piazza C, Giudice M, Berlucchi M, et al. Atypical carcinoid
Surg. 2002;10:118-22. tumour of the larynx treated with CO2 laser excision: case
14. Steiner W, Ambrosch P. Endoscopic Laser Surgery of the report. Acta Otorhinolaryngol Ital. 2003;23:43-6.
Upper Aerodigestive Tract. New York: Thieme; 2000. 25. Rudert HH, Hoft S. Transoral carbon-dioxide laser resection
15. Steiner W, Ambrosch P, Hess CF, et al. Organ preservation by of hypopharyngeal carcinoma. Eur Arch Otorhinolaryngol.
transoral laser microsurgery in pyriform sinus carcinoma. 2003;260:198-206.
Otolaryngol Head Neck Surg. 2001;124:58-67. 26. Pradhan S, Mehta M, Hakeem A, et al. Transoral resection
16. Myers EN, Wagner RL, Johnson JT. Microlaryngoscopic of laryngeal and hypopharyngeal cancers. Indian Journal of
surgery for T1 glottic lesions: a cost-effective option. Ann Surgical Oncology. 2010; pp. 207-11.
Otol Rhinol Laryngol. 1994;103:28-30. 27. Mehta M, Hakeem AH, Tubachi J, Kannan R, Pradhan S.
17. Zeitels SM. Premalignant epithelium and microinvasive CO2 Laser Surgery for Early Laryngeal and Hypopharyngeal
cancer of the vocal fold: the evolution of phonomicrosurgi- Cancer Otorhinolaryngology Clinics: An International
cal management. Laryngoscope. 1995;105:1-51. Journal. 2010;2(3):241-6.
 The Surgical Technique of Otoplasty 1147
CHAPTER

117 Injection Laryngoplasty: Indications,

Techniques, Injectables and Results
Nayla Matar, Marc Remacle

INTRODUCTION viscoelastic properties of tissue. Many particle sizes are

available. According to Lau et al.,10 it seems that larger
Injection laryngoplasty (IL) was introduced a century ago, particle-size make the material more durable than small
in 1911 by Bruening1 for the purpose of correcting glottic particle-size for IL.
insufficiency due to unilateral vocal fold (VF) immobility. Hydroxyapatite is a calcium phosphorus compound,
The first injectable was paraffin. However, because of naturally occurring in bone.11,12 It is the newest material
its adverse effects, such as extrusion, migration, and to be injected. It obtained the FDA approval for laryngeal
inflammation, IL was shortly abandoned. In 1955, Arnold2 use. It is vehicled by methylcellulose that can be used
reintroduced IL for the same purpose using homologous alone for a shorter duration effect.
material, such as cartilage and bone dust. The results were
not as expected due to the resorption of the material.
Between the late 1960s and early 1990s, Teflon-paste IL
INDICATIONS FOR INJECTION
was the main method of treatment for dysphonia due to LARYNGOPLASTY
unilateral VF immobility. Teflon was used to bypass the As stated earlier, IL was first used to medialize a paralyzed
resorption observed during the injection of homologous or paretic cord (Figs 1A and B). More recently and due to
material. However, the development of complications like the available new products, it has also been proposed to
Teflon granuloma associated to poor phonatory outcomes, restore a vibratory membrane in a scarred (sulcus vocalis,
led to the surgeons abandoning the use of this substance VF scar) or atrophied cord (presbylarynx) (Figs 2A and B).
too.3 Silicone paste was also used at the same period by It is generally agreed that a course of speech therapy is
Rubin and Sittel without convincing results.4,5 indicated without reaching the expected results, before
This is why collagen was introduced for IL due to performing injection for any of these conditions.13 As
its good results in esthetic surgery for the treatment of most of the injectables do not last forever, IL is used as a
wrinkles.6 Bovine collagen was first used, but due to the temporizing therapeutic intervention. It is well suited for
risk of host-graft reaction and the necessity to perform clinical situations in which the immobile vocal fold has a
skin testing to rule out hypersensitivity, human forms of good prognosis for full functional recovery. Additionally,
collagen replaced the bovine collagen.7 The most used in patients with a history of previous laryngeal irradiation
form was human collagen prepared from cadaveric or in whom an open procedure on the neck is relatively
skin and processed to remove all cells: acellular dermal contraindicated, endoscopic injection techniques have a
compound (Cymetra; Life Cell Corporation, Branchburg, distinct advantage. In cases of larger glottal gaps with a
New Jersey). None of the above mentioned material phonatory quotient superior to 300 mL/s, medialization
received FDA approval for laryngeal injections due to thyroplasty using an external approach is more indicated
the lack of controlled trials. During the late 1980s and than IL even if injectables like calcium hydroxylapatite
early 1990s, reports of clinical trials using fat injection might be used in this situation.
and others using autologous fascia emerged with a wide
variation of the results found among published series.8,9
Many of the recent advances in IL have arisen from novel
WHEN TO INJECT A PARALYTIC
materials rather than new techniques. The two newest VOCAL FOLD?
substances used for IL are hyaluronan-based compounds The standard teaching is that unilateral vocal fold paralysis
and hydroxylapatite (HA) materials. Hyaluronan is a (UVFP) recovery is unlikely after a year from paralysis.14
polysaccharide which occurs naturally in the extracellular In a review of literature on idiopathic UVFP, Sulica cites
matrix of human tissue and is responsible for many of the 12 reports that document the time to recovery. The time
1148 Voice and Laryngotracheal Surgery

A B
Figs 1A and B: Pre- and post-injection views of a left vocal fold paralysis treated by Cymetra injection

A B
Figs 2A and B: Pre- and post-injection views of a presbylarynx treated by hyaluronic acid injection

range for recovery in these studies was from 1 month to creates a more favorable vocal cord position for phonation
19 months or more.15 In a prospective study of 15 subjects that can be maintained by synkinetic reinnervation.17
with UVFP after thyroidectomy, Hydman et al. showed Some factors favor early therapeutic intervention:
that nerves with conduction block injury recovered within the presence of clinical aspiration, known nerve cut and
6 months, and those with more severe axonal injury important vocal demands of the patient.
recovered more slowly and less completely.16
In a series of 35 patients, Friedman et al. demonstrated Properties of the Perfect Injectable
that patients receiving early injection medialization for Although many substances have been used for IL,
vocal cord paralysis were less likely to require transcervical the perfect injectable is still searched for. It should be
reconstruction probably because early medialization biocompatible so that it does not produce unfavorable
 Injection Laryngoplasty: Indications, Techniques, Injectables and Results 1149

immunologic response. It should be easily injectable.

It should be readily available with minimal preparation
for optimal time efficiency. It should have similar
biomechanical properties compared to the VF to cause
minimal alteration in the natural function of the augmented
structure. It should be resistant to resorption or migration
so that the initial result is maintained. It should be easily
removable in the event of revision surgery.18

INJECTION TECHNIQUES
The site of injection depends on the etiology and the
degree of the glottal insufficiency as well as the type of
material injected. When the glottal incompetence is due
to unilateral VF motion impairment, the vibratory surface
is relatively normal. Bulking the VF by injecting foreign
substance into the medial portion of the thyroarytenoid
(TA) muscle allows the contralateral mobile fold to create
the nearly closed glottic configuration required to achieve
VF oscillation.
In the beginning, the injections were made lateral to
the TA muscle, however, it was postulated that injection
laterally into the bulk of the TA muscle or against the inner
perichondrium of the thyroid cartilage was associated
Fig. 3: Superficial injection into the region of the vocal
with early resorption of the graft material. When the ligament in case of vocal fold scarring
substances are injected into the medial portion of the
thyroarytenoid muscle, immediately deep to the vocal
ligament, they decrease the force of contraction needed the microscope. Ventilation can be done through a small
to bring the VFs into a position adequate for phonation endotracheal tube or jet ventilation. The key disadvantage
and have minimal effect on the vibratory patterns.11 If the of this technique is that the patient is unable to phonate
first injection is placed just lateral to the tip of the vocal during the procedure and provide immediate feedback
process, then the vocal process can rotate medially. The as to the vocal quality after injection. In addition, some
middle portion of the TA muscle can then be injected to laryngologists, including Ford and colleagues argue that
straighten the entire VF. proper positioning for SML distorts laryngeal anatomy
If failure of glottic closure is due to scarring of the ‘‘so that it can be difficult to precisely gauge the anatomic
mucosa or age related changes, then the injectable needs effect of injected materials.’’19
to be injected superficially into the region of the vocal Transoral techniques in the setting of an awake-patient
ligament in order to enhance graft persistence. Care are common with the use of flexible fiberoptic laryngos-
must be taken with the material used because of the copy for visualization. The advantage is a tailored place-
risk of stiffening of the vibratory mucosa that can cause ment of the injectable tailored according to the patient’s
deterioration in the voice quality (Fig. 3). voice. The disadvantages are the technical challenge and
the inability of some patients to tolerate it that make these
Operating Room versus Office Injections approaches less precise than injection under SML.
Injections can be performed in a variety of settings, Transcutaneous techniques with fiberoptic laryn-
depending on several factors, including the goal of the goscopy for visual guidance are also possible. They can
procedure, the need to overinject versus fill the defect be performed in the awake-patient in the sitting posi-
precisely, patient comfort and anatomy, choice of the tion as an office procedure, or in the supine position
substance for injection and physician skills. under general anesthesia. They are painless techniques.
The first option is suspension microlaryngoscopy Disadvantages include more limited access to the vocal
(SML). This is the least technically difficult and the cords. Two anterior approaches and one lateral approach
most precise method because the patient is positioned have been described. The transthyroid cartilage technique
optimally, and the view of the glottis is magnified through involves puncture through the ala of the thyroid cartilage
1150 Voice and Laryngotracheal Surgery

at the presumed level of the VF. Since it is a transcarti- recently, calcium hydroxylapatite has been added to this
laginous injection, sometimes, calcification of the thyroid category. Autografts include fat, fascia and autologous
cartilage precludes the use of this approach. collagen. Homografts include human collagen and finally,
For transthyrohyoid injection, the needle is inserted xenografts include bovine collagen and hyaluronic acid.
into the larynx at the thyroid notch, entering the lumen at Each of the injectables has particular properties that are
or near the petiole of the epiglottis. The transcricothyroid summarized in Table 1.
technique is similar to that of delivery of botulinum toxin. As clearly seen in Table 1, overinjection is needed in
A straight or bent needle is inserted under the inferior most of the cases. This is explained by the fact that nearly
margin of the thyroid cartilage and angled up and lateral all of the injectable materials suffer from the physical
toward the side to be injected.20 In the last two approaches, limitation of resorption over time, or the need for a carrier
significant angling of the needle superiorly/inferiorly to vehicle; for example, in humans, the percentage of fat
reach the true cords is required. remaining over time is likely highly variable and impossible
All procedures on awake-patients should be performed to predict from person to person. Individual variables,
using a combination of local and topical anesthesia. This such as blood supply, location of injection, accompanying
includes nasal anesthesia to permit flexible laryngos- comorbidities, harvest/preparation method, and amount
copy, and local anesthesia over the skin if the injection of initial fat injected likely all play a role. For hyaluronic acid,
is performed percutaneously. Mucosal topical anes­ overinjection is not necessary because it is a hydrophilic
thesia is used when the injecting needle is likely to break substance.
the mucosa, that is, in all injection techniques but trans- The inherent characteristics of the injectables create
thyroid cartilage and those transcricothyroid membrane the necessity for either reinjection or calculated over-
injections in which the needle remains entirely submu- injection to account for the projected loss of volume.
cosal. This is necessary to prevent coughing, swallowing, Consequently, the patient’s best voice result is temporally
or gagging during the procedure. delayed or transient. And even when injections are done
under local anesthesia to hear the patient’s best voice
Types of Injectables quality depending on the volume injected, the long term
Injection material can be classified into four categories. results cannot be clearly predicted because of the variable
Synthetic materials include teflon, silicone and, more resorption rate.

Table 1: Various injectables and their characteristics

Material Location of Injection Amount Duration Viscosity Needle Availability
Injected Gauge
Teflon Lateral to vocal Exact Permanent Low 18 Not recommended
ligament amount
Bovine collagen Lateral to vocal Overinject 6 months High 27 Unavailable
ligament or in deep
part of the lamina
propria
Human collagen Lateral to vocal Overinject 6 months Low 22 Unavailable
(Cymetra) ligament
Fat Lateral to vocal Overinject 3 months High 22 Available
ligament or in deep
part of the lamina
propria
Hydroxylapatite Lateral to vocal Slightly >1 year 26 Available
ligament overinject
Hyaluronic Acid In deep part of the Not >1 year 26 Available
lamina propria overinject
 Injection Laryngoplasty: Indications, Techniques, Injectables and Results 1151

How to Control the Effectiveness (possibly migration). Six implants were removed through
of the Injection? endoscopic lateral cordotomy between 2 months and
Vocal quality and mucosal vibration play a role in 24 months after injection. Mucosal wave function recov-
controlling the effectiveness of the injection. ered in five VFs after explantation. Minor complications
Maximum phonation time and phonatory quotient are were encountered in nine additional VFs. These included
precise measures of glottic efficiency and can be used to tissue inflammation marked by edema, erythema,
control the effectiveness of the injection. It does not seem and mild-to-moderate mucosal wave restriction and
that anterior neck surface electromyography is helpful to hypervascularity.
assess the changes in vocal hyperfunction associated with
glottic insufficiency.21 Direct measure of subglottic pres-
sure could be used in the future to assess vocal effort as it
RESULTS REPORTED IN THE
seems useful in medialization thyroplasty.22 LITERATURE
Short Term Results
ADVANTAGES OF INJECTION Remacle et al. conducted a prospective study on
LARYNGOPLASTY 23 patients with UVFP.26 A mean quantity of 1.05 mL
Injection laryngoplasty has several advantages when collagen was injected in the deep part of the lamina
compared with other available procedures to treat glottic propria. The mean follow-up was 8 months. Grade,
insufficiency. These advantages include avoidance of roughness and breathiness were reported on the four-
an open surgical procedure, lower procedural cost and point grading GRABS scale, showing an improvement
morbidity, as well as the potential application of these from 2.13 to 1.13 for grade, from 1.50 to 0.82 for roughness
techniques to the outpatient clinic setting with minimal and from 1.73 to 1.05 for breathiness. The parameters
anesthetic requirements. selected for videolaryngostroboscopy, glottal closure,
regularity, mucosal wave and symmetry, were measured
on a visual analog scale. These parameters showed an
COMPLICATIONS improvement from 23 to 19 for glottal closure, from 15 to
When used to manage UVFP, IL has a possible shortcom- 6 for regularity, from 15 to 11 for mucosal wave, and from
ing: the inability to address wide posterior glottic insuffi- 17 to 8 for symmetry. For the aerodynamic parameters,
ciency. This is why patients must be carefully selected. the maximum phonation time and the phonation quotient
Complications of IL have been reported in the showed an improvement from 5.8 to 8.9 and from 704.5
literature and they depend on the substance injected. to 449.7 mL/s, respectively. The acoustic parameters
The most known complications related to IL are the were improved from 5.3–3.6% for the jitter. Regarding
Teflon granuloma3 and the host-graft reaction related the subjective evaluation, the Voice Handicap Index was
to bovine collagen.7 However, complications have been improved from 65 to 37. A longer observation time showed
reported even with autografts. Sanderson et al. reported the quantitative improvement in the voice as measured by
four laryngeal complications after fat injection with three the phonation quotient was 67% for the short range and
overinjections (3.4%) leading to poor voice quality and 49% for the long range.27
one granuloma formation (1.1%).23 Laccourreye et al., in
their review of lipoinjection in 80 patients, reported early Long Term Results
complications including fat extrusion at the injection Laccourreye et al., in their review of 80 patients with UVFP,
site in one patient and dyspnea requiring short-term reported a 96.2% success rate with improvement of voice
tracheotomy in one patient. Long-term complications and swallowing immediately after surgery. These results
included intracordal cysts developing at the injection site were tempered overtime with only 62.2% of patients
in three patients.24 reporting improvement after 1 year.24 McCulloch reported
Most recently, complications have been reported a 70% success rate at 1 year and a 55% success rate after
with calcium hydroxylapatite by Defatta et al.25 Between 4 years.28
2006 and 2009, 22 injections were performed in three Few studies compare different injected substances.
institutions for glottic insufficiency. Ten major compli- Those available,29 comparing hyaluronic acid and coll­
cations were encountered. These included four VFs with agen, did not show a significant difference of voice quality
adynamic mucosa, six with a severely decreased wave, at long term between the two groups. Voice results are
and two granulomas affecting the vibratory margin. CT difficult to assess because of the possibility of recovery of
scanning confirmed six cases of implant malposition VF movement or the recovery of voice due to synkinetic
1152 Voice and Laryngotracheal Surgery

reinnervation providing VF tone and adaptation of the 2. Arnold GE. Vocal rehabilitation of paralytic dysphonia.
intact VF, thereby allowing for laryngeal compensation I. cartilage injection into a paralyzed vocal cord. AMA Arch
and effective glottic closure without actual reanimation Otolaryngol. 1955;62(1):1-17.
of the paralyzed VF or an important role of the injected 3. Dedo HH, Carlsöö B. Histologic evaluation of Teflon gran-
ulomas of human vocal cords. A light and electron micro-
material.
scopic study. Acta Otolaryngol. 1982;93(5-6):475-84.
4. Rubin HJ. Histologic and high-speed photographic obser-
INJECTABLES OF THE FUTURE vations on the intracordal injection of synthetics. Trans Am
Acad Ophthalmol Otolaryngol. 1966;70(6):909-21.
Although IL was first performed to medialize a paralyzed 5. Sittel C, Thumpfart WF, Pototschnig C, et al. Textured polydi-
VF, its indications have been broadened to treat scarred methylsiloxane elastomers in the human larynx: safety and
VFs, sulcus and so on. For these indications, a substance efficiency of use. J Biomed Mater Res. 2000;53(6):646-50.
that reduces the inflammation process in favor of a good 6. Remacle M, Marbaix E. Collagen implants in the human
cicatrization would be optimal. larynx. Pathological examinations of two cases. Arch
One of the most recent and interesting developments Otorhinolaryngol. 1988;245(4):203-9.
in IL for VF scarring has been the use of fibroblast growth 7. Charriere G, Bejot M, Schnitzler L, et al. Reactions to a
bovine collagen implant. Clinical and immunologic study in
factor (FGF) by Suehiroet al.30 According to in vitro
705 patients. J Am Acad Dermatol. 1989;21(6):1203-8.
studies, FGF seems to induce hyaluronic acid production
8. Mikaelian DO, Lowry LD, Sataloff RT. Lipoinjection for
and decrease collagen synthesis. Another development unilateral vocal cord paralysis. Laryngoscope. 1991;101(5):
is the use of mesenchymal stem cells. Svensson et al.31 465-8.
showed that human mesenchymal stem cells injected 9. Rihkanen H, Lehikoinen-Söderlund S, Reijonen P. Voice
into the rabbit VF following the excision of a chronic scar, acoustics after autologous fascia injection for vocal fold
enhanced the functional healing of the VF and restored paralysis. Laryngoscope. 1999;109(11):1854-8.
viscoelastic shear properties. If FGF or mesenchymal stem 10. Lau DP, Lee GA, Wong SM, et al. Injection laryngoplasty
cells prove to be successful in human studies, scientists with hyaluronic acid for unilateral vocal cord paralysis.
will be able to address the root causes of vocal cord Randomized controlled trial comparing two different parti-
dysfunction. cle sizes. J Voice. 2010;24(1):113-8.
11. Courey MS. Injection laryngoplasty. Otolaryngol Clin North
Am. 2004;37(1):121-38.
CONCLUSION 12. Rosen CA, Gartner-Schmidt J, Casiano R, et al. Vocal fold
augmentation with calcium hydroxylapatite: twelve-month
Performing successful IL requires an understanding report. Laryngoscope. 2009;119(5):1033-41.
of laryngeal anatomy, physiology and the physical 13. O’Leary MA, Grillone GA. Injection laryngoplasty.
characteristics of the substance to be injected. The Otolaryngol Clin North Am. 2006;39(1):43-54.
surgeon must also have an understanding of the etiology 14. Arviso LC, Johns MM 3rd, Mathison CC, et al. Long-term
and configuration of the glottic insufficiency, and keep outcomes of injection laryngoplasty in patients with
in mind the goals of the procedure and the possibility of potentially recoverable vocal fold paralysis. Laryngoscope.
adverse reactions. 2010;120(11):2237-40.
Poor tissue biocompatibility and poor persis- 15. Sulica L. The natural history of idiopathic unilateral vocal
fold paralysis: evidence and problems. Laryngoscope.
tence within the larynx are shortcomings that have to
2008;118(7):1303-7.
be addressed before the perfect injectable substance 16. Hydman J, Björck G, Persson JK, et al. Diagnosis and prog-
becomes available. nosis of iatrogenic injury of the recurrent laryngeal nerve.
Till now, few studies have compared materials or Ann Otol Rhinol Laryngol. 2009;118(7):506-11.
techniques directly with each other proving the superiority 17. Friedman AD, Burns JA, Heaton JT, et al. Early versus late
of one material or technique. This is why the laryngologist injection medialization for unilateral vocal cord paralysis.
must use the safest available material and the injection Laryngoscope. 2010;120(10):2042-6.
route where he feels the most comfortable to achieve the 18. Kwona TK, Buckmireb R. Injection laryngoplasty for
management of unilateral vocal fold paralysis. Curr Opin
best correction of glottal insufficiency and the best voice
Otolaryngol Head Neck Surg. 2004;12(6):538-42.
results. 19. Ford CN, Roy N, Sandage M, et al. Rigid endoscopy for
monitoring indirect vocal fold injection. Laryngoscope.
REFERENCES 1998;108(10):1584-6.
20. Zeitler DM, Amin MR. The thyrohyoid approach to in-office
1. Bruening W. Ubereineneue behandlungsmethode der injection augmentation of the vocal fold. Curr Opin
rekurrenslahmung. Verh Dtsch Laryg. 1911;18:23. Otolaryngol Head Neck Surg. 2007;15(6):412-6.
 Injection Laryngoplasty: Indications, Techniques, Injectables and Results 1153

21. Stepp CE, Heaton JT, Jetté ME, et al. Neck surface electro- collagen: short-term results. Eur Arch Otorhinolaryngol.
myography as a measure of vocal hyperfunction before and 2006;263(3):205-9.
after injection laryngoplasty. Ann Otol Rhinol Laryngol. 27. Remacle M, Dujardin JM, Lawson G. Treatment of vocal
2010;119(9):594-601. fold immobility by glutaraldehyde-cross-linked collagen
22. Matar N, Remacle M, Bachy V, et al. Objective measure- injection: long-term results. Ann Otol Rhinol Laryngol.
ment of real time subglottic pressure during medicalization 1995;104(6):437-41.
thyroplasty: a feasibility study. Eur Arch Otorhinolaryngol. 28. McCulloch TM, Andrews BT, Hoffman HT, et al. Long-term
2011. [Epub ahead of print]. follow-up of fat injection laryngoplasty for unilateral vocal
23. Sanderson JD, Simpson CB. Laryngeal complications after cord paralysis. Laryngoscope. 2002;112(7 Pt 1):1235-8.
lipoinjection for vocal fold augmentation. Laryngoscope. 29. Hertegård S, Hallén L, Laurent C, et al. Cross-linked
2009;119(8):1652-7. hyaluronan versus collagen for injection treatment of
24. Laccourreye O, Papon JF, Kania R, et al. Intracordal injection glottal insufficiency: 2-year follow-up. Acta Otolaryngol.
of autologous fat in patients with unilateral laryngeal nerve 2004;124(10):1208-14.
paralysis: long-term results from the patient’s perspective. 30. Suehiro A, Hirano S, Kishimoto Y, et al. Effects of basic fibro-
Laryngoscope. 2003;113(3):541-5. blast growth factor on rat vocal fold fibroblasts. Ann Otol
25. Defatta RA, Chowdhury FR, Sataloff RT. Complications Rhinol Laryngol. 2010;119(10):690-6.
of injection laryngoplasty using calcium hydroxylapatite. 31. Svensson B, Nagubothu SR, Cedervall J, et al. Injection
J Voice. 2011. [Epub ahead of print]. of human mesenchymal stem cells improves healing
26. Remacle M, Lawson G, Jamart J, et al. Treatment of of vocal folds after scar excision—a xenograft analysis.
vocal fold immobility by injectable homologous Laryngoscope. 2011;121(10):2185-90.
 The Surgical Technique of Otoplasty
CHAPTER

118 Surgical Management of

Sulcus Vocalis
Tolga Kandogan

DEFINITION Medialization of the affected cord through thyroplasty

or vocal fold augmentation techniques and/or restoring
The term sulcus vocalis has been applied to a spectrum the sliding motion of the affected mucosal cover are the
of disorders ranging from minor vocal fold indentations goals of surgical therapy.3
to destructive lesions causing severe dysphonia. The One of the most important factors in the selection
condition is characterized by a groove of mucosa along of the surgical method is whether the surgeon is able to
the surface of the vocal folds.1 The longitudinal extent achieve proper direct microlaryngoscopic exposure in
of the furrow is variable, as is its depth.2 The symptoms the operating room or not. If the surgeon cannot achieve
of the patients with sulcus vocalis are hoarseness, vocal full laryngoscopic exposure, remaining options are open
fatigue, voice weakness, and increased effort, which are medialization thyroplasty, injection thyroplasty and voice
mostly the signs of glottal insufficiency.3 This deformity therapy. If an endoscopic approach is possible and appro-
causes organic dysphonia due to glottic leakage as well as priate, then the decision whether to incise and redrape the
to mucosal stiffness.4 The pitch of the voice may be lower epithelium or to place an implant is the next step.6
than normal, and the loudness may be reduced.2 Voice
range would be expected to be reduced. The frequency
and amplitude perturbation may be greater than normal.
SPECIFIC PREOPERATIVE
EVALUATION
INDICATIONS FOR THE SURGERY Diagnosis
Besides breathy and hoarse voice, if low voice volume and Laryngoscopically, a sulcus will be seen as a depression
loss of projection are major complaints, surgery is often or line along the upper medial edge of the vocal fold. The
indicated. depression may extend the entire length of the vocal fold.
Nevertheless, the best method in the diagnosis of sulcus
Surgical Management of Sulcus Vocalis vocalis is stroboscopy, with particular attention to vocal
Treatment of sulcus vocalis needs to achieve anatomical fold mobility; glottic closure; and the presence, ampli-
and functional improvements that satisfy the behavior of tude, and symmetry of the mucosal wave. Disruption of
the larynx and vocal quality.5 There is no consensus on the the mucosal wave where the sulcus resides, are to be seen
treatment of sulcus vocalis. As a rule of thumb, anatomic for the confirmation of the diagnosis. Sulcus significantly
changes in the vocal folds are difficult or impossible changes the physical properties of the vocal fold and
to treat with medication or voice therapy alone. In the alters the relationship between the body of the fold and
management of sulcus vocalis, any concomitant condi- its cover and inhibits normal propagation of the mucosal
tion, such as reflux laryngitis or allergy, etc. affecting the wave.4 The mass of the cover was decreased and the stiff-
voice should be evaluated and treated. Misuse and/or ness is increased.2 The main features of sulcus vocalis are
abusive behaviors in voice should be treated or at least “bowed” or “curved” aspect on the free edge of the vocal
reduced before considering a surgical therapy to maxi- folds, enhanced stiffness of the fold, glottic incompetence
mize the benefits of surgery. In the surgical management and hypertonia of the ventricular folds.4
of sulcus vocalis, since there are multiple approaches, it is After the diagnosis is confirmed, before the surgical
important to consider the various factors that may influ- management, objective and subjective voice measure-
ence the selection of repair by the patient and surgeon.6 ments should be obtained. It may include RBH (auditive
It’s worth to remember that the goal is to improve analysis), roughness (R), breathiness (B) and hoarse-
glottic efficiency, reduce vocal effort and improve vocal ness (H), Voice Handicap Index (VHI), acoustic analysis,
quality.6 e.g. analysis of jitter (%) and shimmer (%), Voice Range
 Surgical Management of Sulcus Vocalis 1155

Profile (VRP) and Disphonia Severity Index (DSI). These patients since the sulcus has not been directly addressed.
examinations were performed according to the recom- But since the vocal efficiency is improved and the effort
mendations of the Union of European Phoniatricians for phonation is reduced, the patients are able to speak
(UEP).7 louder, more understandable and they do not feel any
voice fatigue.3
We believe that medialization surgery of any kind is
SURGICAL STEPS (FIGS 1 to 10) unfortunately unable to return the patients’ voice to normal
levels. The glottic gap can be closed through surgery but
Medialization Thyroplasty (Type 1)
since the mucosal wave will stop where the sulcus resides,
Medialization thyroplasty (Figs 1 to 10) is an approved there will not be a clear voice either.3 Hovever, from the
technique for the closure of glottal gaps.8 Thyroplasty type patients’ point of view, that is VHI, though voice is not
3 may be added as an option to medilization thyroplasty clear, it is satisfactory. Surgery resulted in diminished
(type 1), aimed reducing the tension in the vocal cord.3 voice fatigue, elaborated breathiness, voice weakness and
Medialization laryngoplasty also may be combined with increased effort (There is not a gap postoperatively and
lipoinjection in an attempt to reestablish the mucosal subglottic pressure can be now established).3
wave. On the other hand, medialization thyroplasty alone Thyroplasty can bring patient satisfaction in the surgi-
may not significantly impact vocal quality in sulcus vocalis cal management of sulcus vocalis. In the evaluation of
patients’ voices, success should be based not only on
acoustic (computed) analysis, but also on subjective
measurements, such as VHI.3

Fig. 1: The landmarks during thyroplasty type 1 are the

thyroid notch, the lower margin of the thyroid, the midway
point between these two marks is the position of the anterior
commissure. In order to design the correct position of the
cartilage window, it is important to take notice of the lower
thyroid ala margin. A straight line, drawn from the anterior
commissure parallel to an imaginary line along the lower
thyroid margin, marks the upper limit of the cartilage window.
Four to 5 mm’s paramedian, a vertical line marks the anterior
limit of cartilage window. A horizontal line just above the lower
margin marks the lower limit of the cartilage window. The
posterior limit of the window is 10 to 12 mm from the anterior
limit. So the design of the cartilage window is determined by
the thyroid notch, the lower margin, the anterior commissure
level in the middle and the lower thyroid margin. The
cartilage window design runs parallel to lower thyroid margin.
In females and males; the window dimensions are about
5 x 10 mm and 6 x 12 mm, respectively. While designing the
cartilage window, be aware of the upper margin of the cricoid,
which is coming up posteriorly medial to the inner thyroid
surface. This can interfere with medialization, because the Fig. 2: To secure the optimal degree of medialization, a
lower posterior part of the cartilage window will be pressed silicon wedge is designed. Many different ways of fixation
against the lateral surface of the cricoid cartilage9 of this wedge are possible10
1156 Voice and Laryngotracheal Surgery

Fig. 3: The final position of the silicon wedge in larynx. Fig. 4: The final position of the Gore-Tex in larynx
A clear voice is not the target of intraoperative adjustment.
Medialize the vocal fold a little more until the voice sounds
slightly rough or at least clear and loud10

As a premedication, tranquilizer and atropine sulfate Hemostasis is established with the application of
can be administered. Posture is supine, with the neck epinephrine impregnated small sponge. It should be
extended. The thyroid notch and lower margin of the done immediately to prevent edema and swelling of
thyroid cartilage should be identified. It should be remem- the soft tissue inside. In such a case, slight overcorrec-
bered that in women, the thyroid cartilage may lie unex- tion is required. In the adjustment of medial displace-
petedly high. Incision line is horizontal 4 to 6 cm, at the ment of the window, a fiberoscope may help, but not
midpoint between the notch and lower margin. A subcu- an obligation. Head position must be returned to
taneous injection of 0.5% Xylocaine with epinephrine normal. Pressing the window medially at various sites
5 to 10 cc is administered for local anesthesia. Since voice and with varying forces for finding the condition for the
monitoring is essential in thyroplasty type 1, general anes- optimal voice is necessary. If a silicone plug is used,
thesia is almost always contraindicated. From the same suture fixation is required. In the closure of the wound,
reason, premedication shouldn’t be too sedative. After hemostasis is to be confirmed. Dressing with a sponge
skin incision and exposure of the thyroid ala, the thyroid pad and gentle pressing of the wound. In the postop-
notch and lower margin are identified. The perichon- erative care, vocal rest and antibiotics are to be given
drium may be utilized as a soft tissue for suture fixation of for a week. There are no reported major complication
a silicone plug in the window. The success of the surgery of thyroplasty type 1. Minor complications consist of
lies in design, cutting, adjustment and fixation of the seroma, hematoma, tears in inner perichondrium, frac-
window. The most frequent error in designing the window ture of the thyroid alar cartilage, under/over correction,
is to make it too cranial a position, resulting in bulging of local infection and extrusion of the implant.10
the false vocal fold instead of the true fold. Window must Medialization thyroplasty with Gore-Tex implants
be designed parallel to a line along the lower border of has been also described and this techique is becoming
thyroid ala. populer in recent years (Figs 1 and 4)
In cutting the cartilage window, first cut with a knife. The design of the window is same as thyroplasty type 1
In patients with advanced calcification of the thyroid ala, with silicon wedge.
cutting with a knife is followed with a fine burr. Pay atten-
tion not going too deep beyond the inner perichondrium, Medialization Thyroplasty (type 1) with
which may cause bleeding. Sufficient elevation of the Relaxation Thyroplasty (type 3)
inner perichondrium is essential for a satisfactory medial- There are no reported major complication of thyroplasty
ization. It’s worth to remember that the cartilage is always type 1 and 3 combined. In addition to above mentioned
thin anteriorly. After complete freeing of the window carti- complications of thyroplasty type 1, thyroid cartilage
lage, undermine between the cartilage and inner peri- instability, thyroid cartilage fracture and entering the
chondrium around the window frame in a width of 1 to airway, mostly at the level of the ventricle are possible
2 cm or more posteriorly and caudally with the elevator. other complications.
 Surgical Management of Sulcus Vocalis 1157

Fig. 5: Vertical incision line is located in the ala at the Fig. 6: The cartilages are fixed with multiple sutures
anterior-middle one-third and line should be modified not to
cross the middle of the window of type 1 thyroplasty. Second
vertical incision is parallel to and posterior to the first incision. high resorption rate and a moderate risk of local immune
Lower frame of the window should not be narrow and flimsy10 reaction. Autologous collagen has good short-term results,
but information about long-term survival is limited.11
Collagen is administered transorally in the clinic and can
Vocal Fold Augmentation Techniques offer substantial improvement for patients who cannot or
will not undergo surgery. The patient should be informed
(Injection Laryngoplasty)
that collagen resorbs and repeat injections may be
Several materials are still being injected for medialization necessary.6
purposes, such as Gelfoam, Collagen, fat, AlloDerm, fascia
and calcium hyroxiapetite.9 Fat Injection
Injection of fat into the paraglottic space for correc-
Collagen Injection tion of glottic insufficiency has been advocated, based
Injectable collagen has a long record of safety and efficacy upon the known staying power of autologous fat (20% to
in the treatment of glottic insufficiency for sulcus vocalis.6 40% take rate).6 Harvesting with liposuction and free fat
Collagen is in liquid form and it is designed for superficial grafts injected through a Brunings gun under laryngo-
injection into the vocal fold margin. A special 25 to 27 or scopic exposure have become more popular. Sometimes,
30-gauge laryngeal needle is inserted through the mucosa repeated injections were necessary because of variable fat
overlying the vibratory margin until the resistance of the resorption.6 Autologous fat probably is the best augmenta-
vocal ligament is felt. Usually a 0.03 to 0.08 cc injection of tion material currently in widespread use. More forgiving
collagen is necessary. A peroral technique is best for super- placement of autologous fat within the larger muscle bed
ficial injection. Office injection is performed perorally is possible and longevity has improved through the devel-
using a Brünings syringe with a curved needle.9 Injectable opment of viable adipocytes.11
collagen is believed to have an ability to soften scar tissue,
since it is found in the larynx at the lamina propria, in the Hyaluronic Acid Injection
submucosa and in the vocal ligament, which makes it Injectable hyaluronic acid may also have an application
popular in the management of sulcus vocalis. The physical in the treatment of patients with sulcus vocalis. Because
injection of the substance aids in the closure of the glot- hyaluronic acid makes up the gel-like space of the superfi-
tic gap and the collagen is postulated to alter the nature cial lamina propria, replacing it has long been considered
of the adjacent scar and makes it more pliable by lamina the holy grail of therapy for vocal scarring. Although the
propria remodeling.6 Bovine collagen has a comparatively usefulness of hyaluronic acid is unknown, early reports
1158 Voice and Laryngotracheal Surgery

Fig. 7: Vocal fold injection under general anesthesia, Fig. 8: Vocal fold injection under topical anesthesia with
suspension laryngoscopy. The material is injected anterior stroboscopy. The material is injected to the midpoint of the
1/3 and posterior 1/3 of the vocal fold vocal fold

suggest that maintaining sufficient volume of material in

the desired location is problematic. Studies into the use of
this material are ongoing.11

Cold Instrument Excision

For patients who have type 3 or pitlike sulcus deformities,
formal endoscopic excision to the depth of the lesion has
been performed.6

Slicing Technique
In this unique approach, where cuts of varying lengths
are made in the coronal plane of the vocal fold to release
the longitudinal scar band, was reported by Pontes and
Behlau.5

Fascia Implant (Superficial or Deep)

Current opinion holds that placing a biocompatible mate-
rial between the vocal ligament and cover or within the
layers of the lamina propria could compensate for lost
tissue and restore sliding movement of the mucosal cover.
Temporalis fascia may be implanted a superficial and
deep implant into the vocal fold (into Reinke’s space).11

POSTOPERATIVE DETAILS AND

FOLLOW-UP
Patients are placed on strict voice rest for 2 weeks follow- Fig. 9: Dissecting the cover where the sulcus resides
ing microflap surgery. Patients with more extensive from the body using forceps
 Surgical Management of Sulcus Vocalis 1159

Open and endoscopic procedures with or without vocal

fold fillers must be tailored to the needs of the individual
patient. Often, combined and repeated treatments are
necessary to enhance vocal outcomes.6

REFERENCES
1. Hsiung MW, Woo P, Wang HW, et al. A clinical classifica-
tion and histopathological study of sulcus vocalis. Eur Arch
Otorhinolaryngol. 2000; 257(8):466-8.
2. Raymond H Colton, Janina K Casper. Voice misuse and
abuse: Effects on laryngeal physiology. In: Understanding
Voice Problems: A Physiological Perspective For Diagnosis
and Treatment, 2nd edition. Lippincott Williams & Wilkins.
pp. 79-111.
3. Kandogan T. The role of thyroplasty in the management of
sulcus vocalis. Kulak Burun Bogaz Ihtis Derg 2007;17(1):13-7.
4. Giovanni A, Chanteret C, Lagier A. Sulcus vocalis: a review.
Eur Arch Otorhinolaryngol. 2007; 264(4):337-44.
5. Pontes P, Behlau M. Treatment of sulcus vocalis: auditory
perceptual and acoustical analysis of the slicing mucosa
surgical technique. J Voice. 1993; 7:365-76.
Fig. 10: Incision is sutured through the epithelium 6. Dailey SH, Ford CN. Surgical management of sulcus vocalis
and vocal fold scarring. Otolaryngol Clin North Am. 2006;
39(1):23-42.
dissections may be placed on a short course of corticoster- 7. Schutte HK, Seidner W. Recommendation by the Union of
oids. All patients receive antibiotics for 7 days and a mild European Phoniatricians (UEP): standardizing voice area
narcotic for pain relief. Patients with symptoms or findings measurement/phonetography. Folia Phoniatr (Basel). 1983;
of laryngopharyngeal reflux are medically treated with a 35(6):286-8.
proton pump-inhibiting agent. Patients are re-examined 8. Su CY, Tsai SS, Chiu JF, et al. Medialization laryngoplasty
with intervals postoperatively. Gradual return to voice use with strap muscle transposition for vocal fold atrophy with or
over the first few weeks is recommended, increasing by without sulcus vocalis. Laryngoscope. 2004; 114(6):1106-12.
5-minute intervals twice daily. Surgical candidates must 9. Sataloff RT. Voice Surgery. In: Treatment of voice disorders.
be willing to postpone speaking and singing engagements Plural Publishing; 2005. pp. 179-256.
for at least 3 months postoperatively.11 10. Isshiki N, Mahieu HF. Laryngeal Framework Surgery Course.
The Netherlands: Amsterdam; 2001. pp. 25-7.
11. Schweinfurth J, Ossoff RH. Sulcus Vocalis: Treatment.
CONCLUSION Available on http://emedicine.medscape.com/article/
Treatment of sulcus vocalis is linked intimately to a 866094-treatment Treatment Surgical Therapy [Accessed on
stiffened and volumetrically deficient lamina propria. September 2010].
1160 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1160
CHAPTER

119 Anterior Glottic Web Management

Hirohito Umeno

INDICATIONS FOR THE SURGERY Step II

After removal of an anterior glottic web, an 18 G disposable
A patient having an anterior glottic web (AGW) is good needle is inserted into the upper and lower points of the
indication for silicone tube placement to the anterior anterior commissure through the upper and lower edge
commissure after the resection of AGW. An anterior glottic of the midpoint of the thyroid cartilage (Fig. 1). Figure 2
web in infants commonly occurs inherently and an AGW shows glottis before surgery with an anterior glottic web.
in adults comprises a bridge of scar tissue between the
vocal folds, which is covered by epithelium and involves Step III
the anterior commissure. Both ends of a 3-0 nylon suture are threaded through a
Anterior glottic stenosis commonly occurs second- 0-sized, 10 mm length of silicone tube, which is inserted
ary to laryngeal injury resulting from laryngeal surgery.1 into the upper and lower holes of 18 G disposal needles
The presence of an anterior glottic web induces severe to fix the silicone tube at the anterior commissure (Fig. 3).
dysphonia caused by disturbance of vocal vibration.
Traditionally, repair has been achieved with procedures, Step IV
such as a transcervical midline thyrotomy and resection of In addition, both ends of the 3-0 nylon thread are sutured
the scar band with the reconstruction of a linear vocal fold at the subcutaneous anterior portion of the thyroid
edge and anterior commissure involving keel placement. cartilage (Fig. 4).
In this procedure, patients are not able to speak during
keel placement.

SPECIFIC PREOPERATIVE
EVALUATION
Laryngeal fiberscopy is required to evaluate how extending
to membranous portion of the vocal fold before operation
and vocal function should be examined before surgery.

ANESTHETIC CONSIDERATIONS
General anesthesia is required to conduct silicone tube
placement therapy under the suspension laryngoscopy.

SURGICAL STEPS
Step I
A transverse incision is made at the midpoint of the thyroid Fig. 1: An 18 G disposable needle is inserted into the upper
cartilage on the anterior neck, and the anterior portion of and lower points of the anterior commissure through the
the thyroid cartilage is exposed. upper and lower edge of the midpoint of the thyroid cartilage
 Anterior Glottic Web Management 1161

Fig. 2: Glottis before surgery with an anterior glottic web

Fig. 4: Both ends of the 3-0 nylon thread are sutured at

the subcutaneous anterior portion of the thyroid cartilage

term is prolonged, laryngeal granuloma will disappear at

the upper and lower portion of the anterior commissure
through 3-0 nylon thread.

SPECIAL INSTRUMENTS USED FOR

THE SURGERY
Fig. 3: 10 mm length of silicone tube is inserted into the No special instruments are used for the surgery without
upper and lower holes of 18 G disposal needles to fix the silicone tube.
silicone tube at the anterior commissure

NEW TECHNIQUES IN THE OTHER TREATMENT OPTIONS

SURGERY AVAILABLE FOR THE SAME
CONDITION
One site hand edge of the web should incise using a scal-
pel to shaping straight. The other side of the web should The rationale for a less complicated, endoscopic approach
incise using micro-scissors while grasping the web with a to AGW repair (and one involving less morbidity) is based
grasper to shaping straight too. After removal of the web, on the original 1924 work of Haslinger, who described a
both free edges of each vocal fold should be sutured with a technique of web excision followed by placement of a
fine absorbable thread to provide sufficient coverage. silver plate between the vocal folds in the anterior glottis.2
The plate was held by a wire that was passed through the
Complications thyroid cartilage, above and below the vocal fold level, and
A fixed silicone tube should be removed within one anchored on the skin surface externally. In Haslinger’s first
month after the fixation surgery. Because, if a fixation case, the thyroid cartilage was cut because of too much
1162 Voice and Laryngotracheal Surgery

tension between the skin and wire and the plate therefore 2. Haslinger F. A case report of membrane formation in the
had to be removed from beneath the skin through a small larynx. A new method of treatment [in German]. Manatschr
external incision. Since then, many authors have modified Ohrenheilk. 1924; 58:174
the Haslinger technique of transoral, endoscopic place- 3. Alonso JM, Regules JE. Treatment of innate membranes
ment of a laryngeal keel.3-6 Dedo developed the technique and synechiens in the anterior commissure of the larynx [in
German]. Z Laryngol Rhinol. 1956; 35:53.
using a 26-gauge wire puller and a series of triangular
4. Pennington CL. The treatment of anterior glottic webs: a
keels.5 Recently, Lichtenberger and Toohil and Roy, et al. reevaluation of Haslinger’s technique. Laryngoscope. 1968;
reported that transoral placement of a glottic keel is safe 78:728-41.
and does not significantly interfere with respiration.7,8 5. Dedo HH. Endoscopic teflon keel for anterior glottic web.
However, one disadvantage of using keel placement ther- Ann Otol Rhinol Laryngol. 1979; 88:467-73.
apy to repair an anterior glottic web is that the patient is 6. Mouney DF, Lyons GD. Fixation of laryngeal stents.
unable to speak during the procedure. Laryngoscope. 1985; 95:905-7.
7. Lichtenberger G, Toohil RJ. New keel fixing technique
for endoscopic repair of anterior commissure webs.
REFERENCES Laryngoscope. 1994; 104(6):771-4.
1. Roh JL, Yoon TH. Prevention of anterior glottic stenosis 8. Edwards J, Tanna N, Bielamowicz SA. Endoscopic lysis of
after bilateral vocal fold stripping with mitomycin C. Arch anterior glottic webs and silicone keel placement. Ann Otol
Otolaryngol Head Neck Surg. 2005; 131(8):690-5. Rhinol Laryngol. 2007; 116(3):211-6.
 The Surgical Technique of Otoplasty 1163
CHAPTER

120 Diagnostic Laryngo-Tracheo-

Bronchoscopy
Yogesh Bajaj

INDICATIONS FOR THE SURGERY the right side of the patient to see the images, and another
monitor for the scrub nurse and rest of the team to see.
For upper airway assessment in a child with significant The anesthetist hands over the patient to the surgeon with
airway morbidity, the common conditions diagnosed are nasotracheal tube positioned just above the larynx, with
laryngomalacia, subglottic stenosis, vocal cord paralysis, the child breathing spontaneously. Benjamin laryngo-
tracheomalacia, foreign body bronchus, respiratory papil- scope is usually used at this stage to visualize the larynx.
lomatosis, subglottic hemangioma and laryngeal cleft. With the tip of the laryngoscope in the vallecula, the laryn-
goscope is suspended in position using the laryngoscope
stand on to a Mayo table. Depending on the age of the
SPECIFIC PREOPERATIVE child, a 2.7-mm or 4-mm 0° endoscope is used to assess the
EVALUATION larynx. The examination starts at assessing the supraglottis
Laryngo-tracheo-bronchoscopy is the gold standard (Fig. 1). With a blunt-ended probe, mobility of cricoaryt-
in upper airway assessment in a child. The procedure enoid joint is checked passively and the presence of laryn-
is performed under general anesthetic and allows a geal cleft is looked for. The endoscope is then advanced
complete view of the larynx, subglottis, trachea and the to assess the glottis, subglottis, trachea and the bronchi
proximal bronchi. The procedure should be performed by (Figs 2 to 4). For all patients, still photographs are taken
an experienced pediatric otolaryngologist and pediatric during the procedure for records and future comparison.
anesthetist. It should be performed in a center with pedi- A minimum of four photos are taken (glottis, subglot-
atric intensive care facilities on site. tis, trachea and bronchi), and video recordings are done
for dynamic conditions like laryngomalacia. A 30o or 70o
endoscope can be used for more angled views if required.
ANESTHETIC CONSIDERATIONS Dynamic assessment for laryngomalacia, and to assess
The procedure is performed under general anesthetic with
spontaneous ventilation. A close liaison is required at all
times between the surgeon and the anesthetist during the
procedure. The anesthetists use atropine as premedica-
tion to dry the airway secretions. Induction of anesthesia
is done with sevoflurane. The anesthetist sprays the airway
with topical 4% lidocaine to minimize airway irritation with
the endoscopes. Nasotracheal intubation is performed
and the tip of the tube is positioned in the oropharynx at
the level of the vallecula to maintain oxygenation. Close
monitoring of oxygen saturations is done throughout the
procedure.

SURGICAL PROCEDURE
The child is positioned with a shoulder roll under the
shoulders to achieve neck extension. The surgeon is posi-
tioned at the head end of the patient with a monitor on Fig. 1: Endoscopic view of supraglottis
1164 Voice and Laryngotracheal Surgery

Fig. 2: Endoscopic view of glottis and subglottis Fig. 3: Endoscopic view of trachea

vocal cord movements, is done either at the beginning or

toward the end of the procedure when the anesthesia is
not deep.

COMPLICATIONS
• Airway obstruction is a potential risk with this proce-
dure, as the patient already has a compromised airway
which could get worse as a result of edema because of
the airway instrumentation.
• Tracheostomy is a possibility during the procedure
Fig. 4: Endoscopic view of carina and main bronchi and consent should always be taken for this.
 The Surgical Technique of Otoplasty 1165
CHAPTER

121 Bronchoscopy
AM Shivakumar, BK Venkatesha, KM Ajith

PREOPERATIVE PREPARATION PREOPERATIVE ASSESSMENT

• Counseling about the procedure • Dyspnea (±), severity of respiratory obstruction and O2
• Risks involved saturation determine the urgency for procedure
• Complications anticipated • Level of consciousness determines the further use of
• Failure sedatives
• Mortality (0.5%) • Nature and location of FB: Distal/proximal and moving/
• Informed written consent. fixed
• Secondary changes in the lungs: Atelectasis, air ­trapping—
to avoid nitrous oxide, mediastinal shift and pneumonia
INDICATIONS FOR • In severe respiratory distress and semiconscious points—
BRONCHOSCOPY to avoid sedatives
• Anticholinergic: To prevent bradycardia and decrease
Positive History of Foreign Body Aspiration secretions
• Choking/gagging/spasmodic cough/apneic episodes • Adequate nil-per-oral (NPO) status:
while eating or playing with objects. – Ideally for 4–6 hours NPO in the elective cases
– Nil-per-oral status secondary when patient is in
Suspicion of Foreign Body in the Airway severe respiratory distress ® intubation with cricoid
• Unresolving pneumonia, chronic cough, segmental pressure or aspiration of gastric contents.
bronchiectasis, respiratory distress, cyanotic spells.
GENERAL ANESTHESIA
Symptoms
CONSIDERATIONS
• Apneic episodes, chronic cough, breathlessness/dysp-
nea cyanotic spells, stridor and fever. • General anesthesia (GA) is better than topical anes­
thesia. In fact, in children it is the only choice
Signs • Spontaneous respiration is safer than apneic tech-
• Decreased chest movements, decreased or absent nique with complete neuromuscular paralysis (but the
breath sounds on one particular side or lung field and author begs to differ)
rhonchi. • Positive pressure ventilation (PPV) drives the FB
• Palpable thud and audible slap, biphasic stridor classi- further peripherally.
cally in tracheal.
Monitoring the Child during Bronchoscopy
Radiological Signs • Pulse oximetry
• Obstructive emphysema, atelectasis bronchiectasis • Precardial stethoscope
consolidation or radiopaque FB in airway. • Temperature
The above symptoms, signs and radiological features • End tidal CO2
can occur in varying combinations in different cases. • Blood pressure (BP)
1166 Voice and Laryngotracheal Surgery

• Electrocardiogram (ECG) chest leads: Continuous • Periods of hypoventilation should not exceed more
cardiac monitoring. than 1 minute during bronchoscopy
• During active ventilation, the anesthetist must ensure
Anesthesia in a Stable Child that the telescope/forceps are removed and the distal
Intravenous (IV) access end of the bronchoscope, pulled to mid-trachea and
¯ proximal end, occluded with thumb/obturator.
Atropine premedication (±) steroids
¯
Induction: IV thiopentone (4–6 mg/kg) (±) IV fentanyl
SURGICAL STEPS
(0.5 µg/kg) or IV propofol Prior to inducing the patient one should have all the instru-
¯ ments as well as forceps anticipated to be requried in the
Relaxation of atracurium/vecuronium/mivacurium— removal of the foreign-body close at hand (Figs 1 and 2).
choice depending on the duration of surgery • Position of patient—supine and flat
¯ Since occipital protuberance is prominent in children,
Maintenance—sevoflurane/isoflurane pillow underneath the head is not required.

In a Child with Respiratory Introduction of Bronchoscope

Distress and Hypoxia • Mcintosh laryngoscope, introduced from right corner of
the mouth till the tip of the scope, reaches the vallecula,
Hundred percent O2 while shifting from and the tongue is pushed to the left side (Fig. 3) Larynx
emergency to operation theatre (OT) will be partially visualized at this point (Fig. 4)
¯ • Gradually, lift the scope till the vocal cords are
Induction: Sitting position with ­visualized (Fig. 5)
sevoflurane and O2 by mask • Never put the laryngoscope blade underneath the
¯ epiglottis anytime during the procedure (Fig. 6)
Intravenous access ≥ IV atropine • Appropriately sized bronchoscope is introduced with
No muscle relaxant given, unless the airway is secured the beveled edge toward the left
and manual ventilation possible. • It is easier to pass the bronchoscope from the right
angle of the mouth than from the midline (Fig. 7).
In a Child with Respiratory
Distress and Full Stomach Holding the Bronchoscope
Intravenous access ≥ IV atropine • Once the tip of the scope is in the trachea, take out
¯ the laryngoscope and hold the bronchoscope with the
Preoxygenation
¯
Rapid sequence induction with thiopentone
and s-choline with cricoid pressure
¯
Airway secured with endotracheal tube
¯
Aspiration of gastric
contents with Ryle tube
¯
Bronchoscope introduction after
removing endotracheal tube

INTRAOPERATIVE MONITORING
• Attention on breath sounds by precardial stethoscope,
O2 saturation and end tidal CO2 Fig. 1: Bronchoscopy tray
 Bronchoscopy 1167

Fig. 2: Forceps Fig. 3: Mcintosh laryngoscopy

Fig. 4: Right position of laryngoscope blade in vallecula, Fig. 5: Lifting the tongue base with laryngoscope to
visualizing the epiglottis visualize the glottis

Fig. 6: Wrong position of the laryngoscope blade distorting Fig. 7: Introduction of bronchoscope
the shape and position of the laryngeal inlet from right angle of mouth
1168 Voice and Laryngotracheal Surgery

thumb and index finger of the left hand. The middle Entering Main Bronchi
finger is in the oral cavity on the hard palate control- • Scope is taken to the left corner of the mouth,
ling the head movements (Figs 8A and B) and head is slightly turned to the left so that the
• Occasionally the scope is introduced into the esophagus, scope is in line with the right main bronchus
which has to be recognized immediately by the following (Fig. 13)
points (Figs 9 to 11): • Similarly, entry into the left main bronchus is done by
– Collapsed lumen of the esophagus (Fig. 11) pushing the scope to the right corner of the mouth and
– Gurgling noise when ventilated and desaturation turning the head till the opening is visualized (Fig. 14).
• Confirm the position of bronchoscope in the airway: Once the foreign body is visualized, the size and shape,
Visualization of tracheal rings and patent round lumen nature and space between FB and the wall are noted
(Fig. 12) before attempting removal.
• Push the bronchoscope till carina (which looks like keel When the FB is seen, the following points are noted,
of the upturned boat) is visualized. Scope should always before attempting the removal of: Size and shape, nature,
be in the middle of the lumen. and space between FB and the wall.

Fig. 8A: Holding the bronchoscope Fig. 8B: Controlling head position and scope position with
thumb, index and middle finger

Fig. 9: Laryngeal inlet anteriorly and scope wrongly Fig. 10: Scope passing through laryngeal inlet anteriorly
entering cricopharyngeal opening posteriorly with cricopharyngeal opening posteriorly
 Bronchoscopy 1169

Fig. 11: Esophageal lumen and cricopharyngeal Fig. 12: Tracheal lumen
opening seen inferiorly

Fig. 13: Position of head and scope for entering right Fig. 14: Position of head and scope for
main bronchus entering left main bronchus

• Foreign body is grasped with appropriate forceps • At the glottis, try to be near the posterior commissure,
firmly and extracted. The FB is taken out through the because the space is wider (Fig. 15)
scope, if it is small • After removal of FB, bronchoscope is reintroduced to
• Otherwise, the scope with the forceps holding the look for remaining fragments of the FB, second FB and
FB is removed as a single unit. to clear the secretions
• In case of large FB, occasionally, when the scope and
the forceps holding the FB are removed together as
TIPS FOR EASY REMOVAL a single unit, the FB may not be found in the forceps.
• Let the tip of the scope be 1–1.5 cm away from the FB In such instances, laryngoscope is introduced and FB
• Never hold the FB very tight searched in the pharynx. If not found (due to sub­glottic
• After grasping the FB, request the anesthetist for impaction/slipping in the trachea while removal),
complete relaxation of the laryngeal muscles for easy bronchoscope is introduced and FB is pushed into the
removal through the glottis bronchus to relieve complete obstruction.
1170 Voice and Laryngotracheal Surgery

• Bronchospasm—oversized scope—appropriate sized

scope and avoid instrumentation over bronchial wall
Procedure preferably finished in 30 minutes
• Hemorrhage: Long standing/sharp FB and injury while
grasping a large FB—adrenaline soaked gauze
• Persistent hypoxia post-procedure requiring ventila-
tory support
• Arrhythmias
• Pneumothorax: Chest tube
• Pneumomediastinum
• Chemical pneumonitis.

OTHER SURGICAL OPTIONS

• Foreign body extraction through tracheotomy
• Thoracotomy and FB extraction
• Segmental resection for distal FB.

POSTOPERATIVE CARE
• Intravenous steroids
• Humidified O2 with nebulized racemic epinephrine
(2.25% solution in 1:6 to 1:10 dilution)
• Continuous pulse oximetry and ECG monitoring.

Fig. 15: Foreign body removal NEWER TECHNIQUES AND

SPECIAL INSTRUMENTS
COMPLICATIONS • Optical telescopic viewing forceps: Here whole proce-
dure of viewing, studying, grasping and retrieval under
Below mentioned are the complications: constant vision through glottis is done with great ease.
• Bradycardia However, technique of extracting by using basic FB
• Desaturation—Bring the scope back to the trachea forceps must be learnt before beginning to use optical
with the tip, just above the carina and ventilate till forceps
normal saturation achieved. • Fiber-optic scope for more distal (beyond secondary
• Bring the scope back to the trachea with the tip, just bronchi) FB
above the carina and ventilate till normal saturation • Balloon catheters (to dislodge the FB), baskets for
achieved vegetable FB and magnetic probes for metallic FB.
 The Surgical Technique of Otoplasty 1171
CHAPTER
The Use of the KTP LASER
122 for Treatment of Laryngeal
Papillomatosis
James A Burns

with topical anesthesia, the post-treatment dysphonia is

INDICATIONS FOR THE SURGERY often diminished as well. Although this treatment strategy
Photoangiolysis (microvascular ablation) using LASERS results in more frequent procedures (and therefore more
is a valuable strategy for treating many vocal fold lesions, total cases) due to limitations of the therapeutic window
including recurrent respiratory papillomatosis with a provided by topical anesthesia, patients are able to avoid
primary focus of disease within the larynx. This treatment the risks of multiple general anesthetics.
approach is based on the concept of selective photother-
molysis, wherein LASER energy is confined to the micro-
circulation that supports growth of benign and malignant
SPECIFIC PREOPERATIVE EVALUATION
laryngeal disease. Photoangiolytic LASERS target hemo- All patients undergoing operative management of laryn-
globin and one of the peaks of greatest hemoglobin absorb- geal papilloma undergo a complete history and physical
ance correlate closely with the 532 nm KTP (Potassium- examination with emphasis on their past surgical history
Titanyl-Phosphate) LASER. The selectivity of photoangio- and a focused otolaryngologic evaluation. Comprehensive
lytic LASERS leads to improved vocal outcomes by allow- voice analysis includes rigid or flexible video strobolaryn-
ing for the aggressive treatment of papilloma with maxi- goscopy and objective measures of acoustic and aero-
mum preservation of the layered microstructure of the dynamic voice parameters. This evaluation, including
vocal fold, including the superficial lamina propria (SLP). voice measurements, is repeated postoperatively when
Photoangiolysis has been shown to be an effective complete healing has occurred about 6 weeks after treat-
strategy to treat a number of lesions, including papilloma- ment. Patients often undergo multiple procedures for
tosis, dysplasia, microvascular angiomata and early glot- laryngeal papilloma and it is not practical or necessary to
tic cancer. Papillomatosis is a common indication for KTP repeat a complete evaluation before each surgery. Patients
LASER use both in the operating room and in the office. The are informed that the office-based management of this
fact that patients require multiple surgical procedures for disease, which is performed under topical anesthesia
papilloma is undoubtedly due to the unpredictably irregu- without sedation, is not always tolerated.
lar presentation and recurrence pattern of the disease. Our
current strategy is to treat patients initially in the operat-
ing room where the extent of papillomatosis and the prior
ANESTHETIC CONSIDERATIONS
surgically-induced soft-tissue changes can be adequately Operating room with general anesthesia: Patients under-
assessed. The KTP has proven its utility in ablating disease going KTP LASER surgery under general anesthesia
with maximum preservation of the underlying SLP and require complete muscle relaxation in order to obtain
this LASER is used in almost every patient with papilloma. proper endoscopic exposure. Standard LASER precau-
Subsequent treatments are done in the office depending tions mandate that patients are given low levels of oxygen
on patient tolerance and preference, extent of disease and (FIO2 < 30%) during lasering. Coordination and teamwork
location of the papilloma. Office-based KTP use for papil- between the surgeon and anesthesiologist is therefore a
loma is primarily for disease on the superior and medial must. If the patient has a significant amount of disease in
glottic surfaces, as well as in the supraglottis. Disease on the posterior glottis, an apneic technique or use of a small
the inferior surface of the vocal folds and subglottis is venture jet catheter is necessary to adequately visualize
harder to treat in the office setting. Similar to patients with the disease for treatment.
dysplasia and cancer, patients with papillomatosis require Office-based surgery with topical anesthesia: Patients
extended follow-up to detect recurrent disease. Even undergoing office-based KTP LASER surgery require opti-
though office-based pulsed-KTP LASER ablation is some- mal anesthesia of the entire upper aerodigestive tract.
times less effective than similar photoangiolytic treatment Timing is important during delivery of topical anesthe-
in the operating room, due to time constraints associated sia to ensure that treatment commences shortly after
1172 Voice and Laryngotracheal Surgery

maximum anesthesia is achieved. There is generally a techniques can be utilized to remove the disease.
small therapeutic time period during which patients can The base of disease, which is at the interface between
be treated before they start to react to the lasering with the epithelial basement membrane and normal under-
increased secretions and discomfort. In some cases, it is lying SLP, is treated again with the KTP LASER.
helpful to have patients take valium (5 mg, taken orally 6. Treatment commences until all areas of papilloma
30 minutes prior to the procedure) or the equivalent have been adequately treated.
antianxiolytic before beginning office-based surgery. 7. Papilloma in the anterior commissure can be treated
The nasal passage is decongested and anesthetized bilaterally during one procedure as long as care is
by spraying a mixture of neo-synephrine and lidocaine taken not to create adjacent raw areas. Sometimes
transnasally. Cetacaine spray is judiciously applied to surgical treatment of extensive papilloma in the ante-
the tongue base and soft palate. Patients are then asked rior commissure is staged in two procedures to avoid
to inhale an atomized solution of 4% lidocaine to begin web formation.
to directly numb the glottis. Final anesthesia at the target 8. An infusion of saline in the subepithelial plane helps
treatment site or sites within the larynx is achieved by place the epithelium on tension for complete LASER
directly dripping up to an additional 4 mL (in adult treatment of papilloma. The saline infusion also sepa-
patients) of 4% lidocaine onto the treatment site under rates the epithelial surface that is being treated from
direct visualization of the transnasal scope. Treatment the underlying SLP, thereby protecting the underly-
should begin within 5 to 10 minutes of application of the ing delicate layered microstructure of vocal folds and
topical anesthetic to ensure maximum treatment time. maximizing voice results following surgery.
The Figure 1 shows an intraoperative view of a patient
in suspension undergoing microlaryngoscopy. Tape and a
SURGICAL STEPS pad are seen across the patient’s neck to provide external
Operating room with general anesthesia: counterpressure for optimal exposure at the glottic level.
1. After achieving an adequate level of general anesthe- The surgeon is seen looking through the microscope and
sia, patients are draped in the standard fashion for placing an instrument through the glottiscope.
microlaryngoscopy. Protective wet eye pads and wet The following images (Figs 2A to D) depict the
towels are placed on the patient’s eyes and head. salient steps of KTP LASER photoangiolytic surgery of
2. The largest sized universal modular glottiscope laryngeal papilloma (primary focus of disease on the vocal
(Endocraft, LLC, Providence, RI, USA) that will fit in folds) in the operating room under general anesthesia.
the patient’s mouth is inserted and advanced to the
level of the larynx. The patient is then placed into true
suspension using a gallows suspension apparatus.
Optimal endoscopic exposure is achieved with inter-
nal distention from the scope. Sometimes, external
counter-pressure with tape across the neck is helpful
to gain better exposure.
3. Standard KTP LASER settings for papilloma treat-
ment are 450 to 525 mJ of fluence energy. This energy
output is achieved in a pulsed mode by setting for 30 to
35 watts of energy, 15 msec pulse width and 2 pulses
per second on the AuraXP LASER.
4. The LASER fiber is delivered through the glottiscope
to the larynx by placing it into a standard laryngeal
suction catheter and allowing about 2 to 3 cm of the
fiber tip to extend beyond the end of the catheter.
5. LASER energy is delivered in both a contact (touching
the disease with the laser fiber) and noncontact (hold-
Fig. 1: An intraoperative view of a patient in suspension
ing the laser fiber 5 mm away from the disease) modes. undergoing microlaryngoscopy. Tape and a pad are seen
Bulky exophytic disease is treated to the endpoint of across the patient’s neck to provide external counterpressure
characteristic white-blanching, followed by removal for optimal exposure at the glottic level. The surgeon is seen
of the disease. The papilloma can often be suctioned looking through the microscope and placing an instrument
away at this point or standard phonomicrosurgical through the glottiscope
 The Use of the KTP LASER for Treatment of Laryngeal Papillomatosis 1173

A B

C D
Figs 2A to D: Intraoperative endoscopic view of diffuse glottic papillomatosis involving the full length of the glottic surface
bilaterally, including the anterior commissure. (A) Glottic surface disease immediately prior to undergoing treatment with
pulsed KTP photoangiolytic therapy; (B) Pulsed KTP LASER treating papilloma on the anterior-superior surface of the left
glottis. White blanching of papilloma signals treatment endpoint. The 15 msec green light pulse of LASER energy is captured
in this image; (C) All visible disease at the anterior commissure is treated with the LASER. The red aiming beam light at
fiber tip indicates that the LASER is activated; (D) Phonomicrosurgical instruments are shown removing bulky papilloma
after KTP LASER treatment on the right glottis. Photoangiolysis facilitates removal of surface disease, thereby exposing the
base of the lesion, which will then be treated further

Office-based surgery with topical anesthesia: Treating laryngeal papilloma in an awake patient is
1. Patients are seated in a standard otolaryngologic less precise than when the patient is under general
examination chair and the optimal height is adjusted anesthesia due to the patients’ respiration and occa-
for the operating surgeon. It is helpful to place a pillow sional swallowing. However, the selective nature of
behind the patient’s back to provide comfortable the KTP LASER to be preferentially absorbed by the
padding against which they may brace themselves. more vascular papilloma ensures optimal treatment of
2. After adequate topical anesthesia is achieved, trans- disease.
nasal flexible laryngoscopy is done with a scope that 4. Disease is treated to the endpoint of white blanching
contains both suction and a side-port working channel. (indicating that the intralesional vasculature has been
3. The KTP LASER fiber is delivered through the side-port coagulated). Bulky exophytic disease can be suctioned
working channel of the flexible scope and used to treat away or removed with the LASER tip. The base of the treat-
papilloma in both a contact and non-contact mode. ment site can then be treated again with LASER energy.
1174 Voice and Laryngotracheal Surgery

5. Lasering continues until all visible disease has been if treatment is too aggressive or there is excessive ther-
adequately treated or until patients’ tolerance and mal trauma from the LASER. Even the highly selective
increased secretions prohibit further lasering. photoangiolytic KTP LASER can cause thermal trauma
The following images (Figs 3A and B) depict the typi- to the layered microstructure of vocal folds with resulting
cal office-based setup for the treatment of laryngeal papil- scarring and dysphonia. Unfortunately, there is no optimal
loma in an awake patient with topical anesthesia: solution for the formation of vocal fold scarring currently,
so this complication is best avoided with meticulous
technique and careful use of the LASER. It is sometimes
NEW TECHNIQUES IN THE advantageous to leave disease rather than risk excessive
SURGERY scarring.
Initially used exclusively to increase precision in microflap Even though office-based procedures are less precise,
dissection of dysplasia, the KTP LASER is now also used careful LASER technique can avoid excessive scar forma-
to involute benign laryngeal disease without resection tion. Care must be taken to avoid lasering if blood has
by ablating the intralesional and sublesional microcircu- extravasated outside of the microvasculature during
lation of papilloma. Disease at the anterior commissure vessel rupture. If this happens, KTP LASER energy will
can also be treated with minimal risk of cicatrization or be absorbed non-selectively with potential vocal fold
web formation. The use of pulsed KTP LASER to achieve scarring.
photoangiolysis is a new paradigm in the treatment of
papilloma. The fiber-based delivery of the KTP LASER
facilitates office-based management of the disease and
SPECIAL INSTRUMENTS USED FOR
saves some patients from undergoing multiple general THE SURGERY
anesthetics.
The solid-state nature of the KTP LASER makes it a reli-
able surgical tool, requiring essentially no maintenance
COMPLICATIONS over the course of time during which it has been relied
Complications associated with operating room manage- upon heavily. The fiberoptic delivery system makes the
ment of papilloma that are discussed with patients LASER suitable for the treatment of laryngeal disease in
preoperatively include damage to the teeth, pharynx and the operating room and in the office, depending upon the
tongue, including a temporary alteration in the sense of clinical indication. Beyond these technical advantages,
taste that are a consequence of placing the glottiscope the 532 nm KTP LASER has created a paradigm shift in our
transorally. Recurrent disease is possible, although not management of most laryngeal pathology involving the
necessarily a complication because of the irregular nature epithelium and especially the delicate pliable phonatory
of the disease itself. Scarring of the vocal fold can occur, mucosa.

A B
Figs 3A and B: (A) Office-based treatment of a patient with glottic papillomatosis, using pulsed KTP LASER. The LASER
fiber (green due to a pulse of 532 nm LASER energy) is passed through the side-port working channel of a flexible
laryngoscope; (B) Basic procedural setup for office-based KTP LASER procedures showing, from left to right, the KTP
LASER, video tower with flexible laryngoscope, LASER foot pedal and chair where patient is seated
 The Use of the KTP LASER for Treatment of Laryngeal Papillomatosis 1175

A B
Figs 4A and B: (A) Intraoperative view of diffuse papilloma being treated into the anterior commissure. The cord spreader
is seen separating the vocal folds to allow for complete treatment of disease; (B) Image of the cord spreader depicting the
blunt curved nature of the instrument that allows for a traumatic separation of the vocal folds

Another useful surgical tool includes a cord spreader

for gaining access to the anterior commissure, seen in the
following images (Figs 4A and B).
For office-based surgery, a flexible laryngoscope with
suction and a side-port working channel is necessary
to deliver the LASER fiber to the target tissue. A small
fiber size is desirable because the fiber lies within the
suction port and large fibers can make suctioning of thick
secretions difficult. The image below (Fig. 5) shows a
typical flexible laryngoscope with suction attached (White
tubing) and LASER fiber being inserted into the side-port
working channel.

OTHER AVAILABLE TREATMENT

OPTIONS FOR THE SAME
CONDITION Fig. 5: A typical flexible laryngoscope with suction attached

Surgical management of adult laryngeal papilloma differs

only in the tool that is used to eradicate the disease. Basic Many adjuvant therapies for recurrent respiratory
surgical principles are the maximum reduction of papil- papillomatosis with or without laryngeal involvement
loma volume with preservation of the vocal fold with have been described in the literature and include
little or no scarring. In adults, surgical intervention is photodynamic therapy (PDT), systemic retinoids, systemic
often done solely for voice-related symptoms, unlike the interferon, the use of indol-3-carbinol (found naturally
concern for airway obstruction that is the predominate in cruciferous vegetables), and intralesional Cidofovir,
reason for the surgical management of pediatric patients. mumps vaccine, HspE7 and Bevacizumab (anti-angiolytic
Various tools for the removal of papilloma include the use agent) injections. None of the adjuvant therapies have
of the carbon dioxide LASER (a non-selective LASER that (as yet) been conclusively shown to be better than
has greater potential than photoangiolytic LASERS to scar placebo in altering the natural course of papilloma. The
vocal folds), soft tissue shaver, cold instrument removal of new vaccines (Gardasil or Cervarix) against the human
papilloma using standard phonomicrosurgical techniques papillomavirus (HPV) may have promise in eradicating
and pulsed-dye LASER (PDL). recurrent respiratory papillomatosis in the future.
1176 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1176
CHAPTER
Surgical Management of

123 Laryngeal Papillomatosis Using

Microdebrider
Bachi T Hathiram, Vicky S Khattar
(Our special gratitude towards Prof Philippe Monnier, who has been our inspiration and guide for our interest and knowledge
of Laryngotracheal Stenosis surgery. A special mention of Prof Sultan Pradhan for being a constant source of encouragement).

come with either severe dyspnea, stridor or/and florid

INTRODUCTION papillomatosis obstructing the entire lumen of the airway,
Human papillomavirus (HPV) infections can occur at when a tracheostomy is performed to secure the airway,
any portion of the upper aerodigestive tract, although it prior to surgical excision of the papillomas.
is most extensively described in the larynx and trachea The goal of current surgical treatment modalities
in the form of recurrent respiratory papillomatosis (RRP). [e.g. carbon dioxide (CO2), potassium-titanyl-phosphate
Recurrent respiratory papillomatosis was first described (KTP) and flash dye LASERS, microdebrider, and ‘cold’
in the 1800s, but it was not until the 1980s when it was steel] for the management of RRP is control of the disease,
convincingly attributed to HPV. Recurrent respiratory pre­servation of the voice and prevention of major compli-
papillomatosis is categorized into juvenile onset and adult cations until the disease spontaneously resolves.3
onset depending on presentation before or after the age of Indication for surgery in RRP is a symptomatic p­ ati­ent
12 years, respectively. with respiratory compromise. In a patient under­going
Morrell Mackenzie in 1880 first described juvenile multiple surgeries a year, a lesion may only need to
respiratory papillomatosis.1 It was not until the advent be removed because it is symptomatic and not nece­s­
of modern molecular genetic techniques in the 1990s sarily every lesion needs to be removed in every surgical
that HPV was confirmed as the causative agent of RRP. Of procedure.
more than 100 serotypes of HPV, types 6 and 11 are most
common in RRP.2
Younger age at diagnosis is associated with more SYMPTOMS AND SIGNS
aggressive disease and the need for more frequent surgical
procedures to decrease the airway burden. When sur­gical • Hoarseness without airway obstruction may indicate
therapy is needed more frequently than four times in the small lesion. A low-pitched, coarse, fluttering voice
12 months, or there is evidence of RRP outside the larynx, suggests a subglottic lesion. Aphonia or breathy voice
adjuvant medical therapy should be considered.3 suggests a larger glottic lesion
Recurrent respiratory papillomatosis is a benign • As the papilloma grows, the features of airway
disease, characterized by exophytic, wart-like lesions of ­obstruction worsen
the upper airway that tend to recur and have the potential • Stridor usually begins as an inspiratory noise consi­
to spread throughout the respiratory tract although it can stent with glottic or supraglottic disease but soon
have significant morbidity and rare mortality secondary becomes biphasic with progression of the disease
to airway obstruction. There is also a small risk of malig- • Other clinical presentations include cough, ­pneu­monia
nant transformation. The course of RRP is variable with and dysphagia
some patients experiencing spontaneous regression and • Children are often misdiagnosed as asthma, croup,
others suffering from aggressive papilloma growth requir- allergies, vocal nodules or bronchitis
ing multiple surgical procedures for management. Various • Children with papillomas of the larynx do not usually
studies have shown that infection with HPV 11 is associ- become symptomatic before age 6 months
ated with a more aggressive disease course requiring more • Signs of severe airway obstruction include:
surgical procedures for control. – Tachypnea, stridor, retractions (suprasternal, sub­­
sternal and intercostal), flaring of the nasal ala, and
use of accessory neck or chest muscles
INDICATIONS – Increasing air hunger may cause the child to sit
Surgical excision of the papillomas is the treatment of with the neck hyperextended in an attempt to
choice for this condition. However, some patients may improve airflow.
 Surgical Management of Laryngeal Papillomatosis Using Microdebrider 1177

breathing and treat airway edema. Careful monitoring for

PREOPERATIVE CONSIDERATIONS several hours prior to discharge is necessary.
• A Hopkins’ rigid laryngoscopic evaluation is manda-
tory prior to planning surgery. It is important to discuss
and plan the surgery with anesthesiologist and, if
SURGICAL STEPS
possible, perform the rigid laryngoscopic evaluation in Goals of surgical excision include:
the presence of anesthesiologist • Reducing the papilloma burden
• A biopsy may be performed if there is any doubt • Creating a safe airway
regarding the nature of the pathology or if there is any • Improving voice quality
coexistent pathology • Increasing the time interval between surgical
• A tracheotomy should be avoided, if possible, since it procedures
can cause a spread of disease. If necessary, this means • Removal of papilloma without sacrificing or damaging
performing surgery every 2–4 weeks. any vital structures.
The various modalities of removal of laryngeal papil-
lomatosis include the following.
ANESTHESIA CONSIDERATIONS
Various anesthetic and surgical suspension techniques Carbon Dioxide LASER
have been used for the removal of laryngeal papillomas. When using suspension microlaryngoscopy with the CO2
Excision by CO2 LASER is the most commonly LASER, this modality is associated with fewer complica-
employed removal method. Airway management for tions and less trauma to the adjacent tissues as compared
LASER laryngeal microsurgery includes the use of a with gross surgical debulking without the microscope.
“LASER safe” tube (Xomed, Mallinckrodt, Biova), jet Since this LASER is invisible to the human eye, a helium-
ventilation, an apneic technique or spontaneous breath- neon aiming beam is necessary for precise application.
ing. LASER safe tubes usually have silicon as a component. The CO2 LASER must be used precisely (performed best
Silicon is combus­tible; hence standard LASER precau- with the micro­spot micromanipulator) to prevent mucosal
tions must be used. The only reported airway fires have scarring, fibrosis and laryngeal web malformation.
been with premanufactured airway tubes by wrapping a Intraoperatively, the surgeon controls the use of LASER.
red rubber catheter with metallic tape in which a portion The surgeon must maintain good communication with the
of a catheter was exposed. operating staff or LASER technician who runs the LASER.
Jet ventilation above or below the level of the vocal Prepare the patient to prevent injury. Preparation includes
cords allows adequate ventilation with minimal risk of wet eye patches and wet towels surrounding all exposed
barotrauma, pneumothorax, pneumomediastinum and body parts. When using LASER, a smoke evacuator should
gastric insufflation. The driving pressure utilized for chil- be present because HPV particles have been recovered in
dren must be significantly lower than that used for adults. the smoke plume. Accomplish hemostasis during surgery
The use of an apneic technique involves periodic extu- with neurosurgical cottonoids soaked in vasoconstrictive
bation and reintubation. Most surgeons prefer the patient agents (e.g. oxy­metazoline). Use these cottonoids over
to have immobile vocal cords once use of the LASER or the area of bleeding, while avoiding obstruction of the
microdebrider has begun. laryngeal inlet, unless an endotracheal tube is present.
Total intravenous anesthesia (TIVA) may be a more Always consider intraoperative intravenous steroids before
effective anesthetic technique because the use of suction removing papillomas. Take care to avoid directing the
during LASER treatment can render the inspired volatile LASER beam down the airway when aiming onto papil-
anesthetic concentration quite variable. In addition, waste lomas because scattered LASER shots into the trachea can
anesthetic gas pollution is reduced. cause pneumothorax or create a squamous epithelium site.
Recovery from airway surgery may still be problematic, In children, CO2 LASER is effective for removing papil-
especially in a child. At the conclusion of the procedure, lomas on the supraglottis, glottic larynx, and subglottic
careful assessment of hemostasis and tissue edema is larynx. Tracheal lesions below the midtracheal area are
done. more difficult to LASER.
Extubation should be performed preferably when the
patient is fully awake. Humidified oxygen and racemic Microdebrider
epinephrine along with nebulization using a steroid with The microdebrider has recently been used for laryn-
a decongestant may be given in the recovery room to ease geal and tracheal papillomas. A long laryngeal blade
is now available for use in the larynx and trachea. The
1178 Voice and Laryngotracheal Surgery

microdebrider uses suction and cutting mechanisms for replication of RNA and DNA. Interferon also alters the
tissue removal, allowing the surgeon to quickly remove cell membrane, thus making them less susceptible to viral
tissue, while providing good visualization of the area penetration.
because of the suctioning of secretions and blood during
cutting. When papillomas are simultaneously present in Photodynamic Therapy
the larynx and trachea, use of the microdebrider is the best Photodynamic therapy (PDT) uses a photosensiti­ zing
method to remove them without having to reposition the agent, such as dihematoporphyrin ether (DHE) or M-tetra-
patient. In adults, however, the microdebrider is difficult hydroxyphenyl-chlorine (MTHPC), which is taken up
to use in the mid-to-distal trachea because the blade is too preferentially in rapidly dividing tissues (e.g. papillomas).
short to reach past the upper trachea. These drugs are administered intravenously, 24 hours
before photocoagulation in the operating room. At endos-
Microlaryngeal Techniques copy in the operating room, a tunable pump-dye LASER
Bulky laryngeal lesions are best treated with microlaryn- system emits a red light at 630 nanometers.
geal techniques using cold steel instruments to debulk Dihematoporphyrin ether (i.e. Actifed) produces
the lesion followed by the use of the CO2 LASER or a singlet oxygen, causing local vascular stasis and tumor
microdebrider. destruction. Most of this work has been accomplished
by Abramson, Shikowitz and Steinberg at Long Island
Jewish Medical Center, where they have observed a small
SPECIAL CONSIDERATIONS decrease in papilloma growth, especially in a more aggres-
Distal tracheal and bronchial lesions are more difficult to sive disease.4
remove with any technique. Techniques employed include
the use of optical forceps, removal by rigid bronchoscopy Indole-3-Carbinol
or use of many different types of LASER (e.g. KTP) with a Indole-3-carbinol (I3C) is a compound found in
microfiber down the side port of a bronchoscope. cruciferous vegetables (e.g. cabbage, Brussels sprouts,
Because total removal is difficult and need for future broccoli, cauliflower) and sold in health food stores.
­
surgeries unquestionable, it is prudent to leave behind Indole-3-carbinol affects the ratio of hydroxylation of
small amounts of papilloma in locations where signifi- estradiol, promoting C-2 over C-16 hydroxylation of
cant complications could occur (e.g. anterior commissure, this hormone. C-16 hydroxylation produces a genotoxic
posterior glottis). compound, promo­ting unscheduled DNA synthesis and
hyperproliferation.
NEWER TECHNIQUE OR Ribavirin
MODIFICATION Ribavirin is an analogue of guanosine (one of four basic-
building blocks of DNA). Currently, ribavirin is available
Medical Therapy only in aerosolized form. Ribavirin inhibits viral nucleic
Several medical therapies have been tried as adjuvant acid synthesis and many aspects of RNA and DNA trans-
therapy for laryngeal papillomatosis. The actual effective- mission and translation, particularly in respiratory syncy-
ness of any reported medical therapy for RRP is difficult tial viruses.
to determine because the underlying aggressiveness of the
disease is poorly understood. A patient’s disease may wax Acyclovir
and wane for no known apparent reason. Until this aspect Acyclovir (acycloguanosine) is a purine nucleoside
of the disease is more understood, any success or failure analogue used to treat herpes virus infection. Acyclovir
of medical therapy must be carefully examined. Despite binds to herpetic thymidine kinase and is phosphorylated
this problem, medical therapy for papillomas has the best and incorporated into replicating DNA molecules, where
chance of leading to a breakthrough in the treatment. it breaks replication. Human thymidine kinase does not
activate acyclovir.
Interferon Mechanism of action in RRP is unknown. In 1995, Pou,
Interferon (IFN) is a class of proteins manufactured by Rimell and Jordan showed that a coinfection of HPV and
leukocytes in response to a variety of stimuli, includ- herpes virus could occur, thus accounting for effectiveness
ing viral infections. The produced enzymes block viral of the drug.5
 Surgical Management of Laryngeal Papillomatosis Using Microdebrider 1179

Cidofovir metaplasia or dysplasia created by repeated surgical exci-

sion of the disease, is unknown.
Cidofovir is an acyclic phosphonate analogue of deoxynu- Complications of the repeated surgical procedures
cleoside monophosphate. Nephrotoxicity has been found include posterior glottic stenosis, anterior glottic web or
with IV use. Large single doses apparently are less toxic stenosis (most common, seen in approximately 20–30% of
than small doses on a repeated basis. This drug should be cases), subglottic stenosis or tracheal stenosis.
used with caution because of the risks involved. Intraoperative complications include pneumothorax
and airway fire, which could result in devastating tracheal
Vaccines and Immunostimulant Drugs or pulmonary injury. In the event of an airway fire, discon-
The most interesting and promising recent development nect the oxygen source and remove any burning material
in the prevention of RRP is the quadrivalent HPV vaccine from the airway including the ETT. Irrigate with sterile
(GARDASILTM; Merck and Co., Inc., Whitehouse Station, water or saline, and mask ventilate or reintubate imme-
NJ, USA). This vaccine is currently licensed by the FDA for diately. Evaluate the extent of the injury with laryngo/
the prevention of cervical cancer, adenocarcinoma in situ, bronchoscope and closely monitor the patient with pulse
and intraepithelial neoplasia grades 1–3; vulvar and vagi- oximetry, serial arterial blood gas (ABGs) and X-ray chest
nal intraepithelial neoplasias grades 2–3; and genital warts for at least 24 hours.
associated with HPV 6, 11, 16 and 18 (Recommendations
of the ACIP, 2007).6 Vaccines and immunostimulant drugs
such as HspE7, a recombinant fusion protein of (1) Hsp65
FOLLOW-UP AND PROGNOSIS
from Mycobacterium bovis bacilli Calmette-Guérin (BCG); Once diagnosis is made in young children, prognosis is
and (2) E7 protein from HPV type 16, are being evaluated variable. The disease must be closely monitored to deter-
in animal and clinical trials. mine its aggressiveness; various techniques have been
used to accomplish this. Some surgeons follow up patients
in the clinic, assessing the need for the next s­ urgical proce-
COMPLICATIONS dure based on the patient’s symptoms of airway obstruc-
Disease progression can occur from larynx to trachea to tion and on what is observed with flexible fiber-optic
the bronchi. Kashima et al. reported tracheal disease laryngoscopy. For young children who most likely will
spread in up to 26% of patients and bronchopulmonary have aggressive disease, initial routine bronchoscopies in
spread in less than 5%. Pulmonary disease manifests as the operating room at 4–6 week intervals can be used to
solid or cystic pulmonary masses on plain radiography or assess disease progression.
chest CT scanning.7
Progression of papilloma to squamous cell carcinoma
(SCC) can occur but is rare. SCC has most frequently
STEPS OF SURGERY
occurred with distal pulmonary spread. Whether this is The steps of surgery are shown in the images from
a transformation of the tumor or a result of squamous Figures 1 to 17.

Fig. 1: Preoperative image using a rigid Hopkins laryngoscope

showing extensive papillomas involving the entire larynx.
Posteriorly one can appreciate a small lumen in the airway
1180 Voice and Laryngotracheal Surgery

Fig. 2: Preoperative image using the rigid Hopkins laryn­ Fig. 3: Intraoperative endoscopic image showing extensive
goscope showing recurrent papillomas. Note the patches of papillomatosis, involving the supraglottis and glottis—it is
fibrosis on the supraglottis from previous surgeries difficult to appreciate the vocal folds at this stage. The patient
has been intubated with a microlaryngeal endotracheal tube.
In such patients, there is always the danger of pushing
the papillomas into the tracheobronchial tree and causing
seeding/implantation of the papillomas

Fig. 4: The intraoperative image after fixing the suspension Fig. 5: Intraoperative magnified image of the larynx of the
microlaryngoscope. Note the friable papillomas which bleed same patient as in Figure 4
on touch
 Surgical Management of Laryngeal Papillomatosis Using Microdebrider 1181

Fig. 6: It is always advisable to take a small biopsy for Fig. 7: As soon as the papillomas are begun to be removed,
histopathology and viral typing, prior to beginning the excision bleeding starts, which continues till the entire bulk is removed

Fig. 8: The angled blade of the laryngeal microdebrider is Fig. 9: Both vocal folds are now beginning to appear
introduced. The papillomas are frond-like, and are easily
drawn into the suction of the blade, facilitating their removal

Fig. 10: The free edges of both the vocal folds are delineated
1182 Voice and Laryngotracheal Surgery

Fig. 11: A vocal fold retractor is introduced to visualize the Fig. 12: As expected, one can appreciate the residual
superior surface of the vocal folds and the ventricle. Note papillomas that are now visible on the superior surface of
that one has to start working upward from the distal-most the vocal fold
papillomas (in this case on the vocal folds), and gradually
coming outward onto the supraglottis. This is to prevent the
operative field from getting stained with blood repeatedly and
to avoid seeding deeper into the airway

Fig. 13: One may intermittently require the use of moist Fig. 14: Once the vocal folds have been dealt with, the
cotton pledgets soaked in a mixture of saline and adrenaline microlaryngoscope is withdrawn slightly so as to visualize
for better visualization the supraglottis. Here one can appreciate the papillomas on
the right false vocal fold coming into view
 Surgical Management of Laryngeal Papillomatosis Using Microdebrider 1183

Fig. 15: The final look of the larynx after removal of all Fig. 16: A final wait with moist cottonoids, to ensure
papillomas. Some surgeons at this stage prefer to inject complete cessation of all bleeding
cidofovir locally

REFERENCES
1. Goon P, Sonnex C, Jani P, et al. Recurrent respiratory papil-
lomatosis: an overview of current thinking and treatment.
Eur Arch Otorhinolaryngol. 2008;265:147-51.
2. Dickens P, Srivastava G, Loke SL, et al. Human papillo-
mavirus 6, 11, and 16 in laryngeal papillomas. J Pathol.
1991;165:243-6.
3. Derkay CS, Wiatrak B. Recurrent respiratory papillomatosis:
a review. Laryngoscope. 2008;118(7):1236-47.
4. Abramson AL, Shikowitz MJ, Mullooly VM, et al. Variable
light-dose effect on photodynamic therapy for laryn-
geal papillomas. Arch Otolaryngol Head Neck Surg.
1994;120(8):852-5.
5. Pou AM, Rimell FL, Jordan JA, et al. Adult respiratory papil-
lomatosis: human papillomavirus type and viral coinfec-
Fig. 17: The appearance of the larynx at the end of the tions as predictors of prognosis. Ann Otol Rhinol Laryngol.
procedure, just before reversal of the patient from anesthesia 1995;104:758-62.
6. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent
human papillomavirus vaccine: recommendations of the
ACKNOWLEDGMENTS Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep. 2007;56:1-24.
The authors are thankful to the Dean, TN Medical College 7. Kashima H, Mounts P, Leventhal B, et al. Sites of predi-
and BYL Nair Charitable Hospital for granting permission lection in recurrent respiratory papillomatosis. Ann Otol
to publish this chapter. Rhinol Laryngol. 1993;102(8 Pt 1):580-3.
1184 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1184
CHAPTER

124 Aryepiglottoplasty
Yogesh Bajaj

INDICATIONS FOR THE SURGERY to the surgeon with nasotracheal tube positioned just
above the larynx, with the child breathing spontane-
Aryepiglottoplasty is indicated in patients with severe ously. Diagnostic endoscopic examination of the larynx
laryngomalacia. The diagnosis is confirmed by diagnostic and trachea is performed first to rule out any other
laryngo-tracheo-bronchoscopy. Nearly 90% of children pathology. After the diagnosis of laryngomalacia is
with laryngomalacia do not need any surgical interven- confirmed (Fig. 1), with the tip of the laryngoscope in the
tion. Children with severe laryngomalacia indicated by vallecula, the laryngoscope is suspended in position using
failure to thrive are selected for this procedure. the laryngoscope stand on to a Mayo table. This allows the
surgeon to use both hands for the procedure. Depending
on the age of the child, a 2.7-mm or 4-mm 0° endoscope
ANESTHETIC CONSIDERATIONS attached to the monitor is used throughout the proce-
The procedure is performed under general anesthetic, dure. Severe laryngomalacia is caused by tight aryepiglot-
with child breathing spontaneously and the airway tic folds, excessive mucosa and cartilage in the region of
sprayed with topical lidocaine. arytenoid, cuneiform, and corniculate cartilages. The
surgical procedure involves dividing the tight aryepiglot-
tic fold at the edge of the epiglottis (Fig. 2), on one or both
SURGICAL PROCEDURE sides depending on the severity. The redundant mucosa
The child is positioned as for laryngo-tracheo-bronchos- over the arytenoid cartilages can be trimmed if required.
copy with a shoulder roll under the shoulders to achieve Both these steps can be done using cold steel laryngeal
neck extension. The anesthetist hands over the patient instruments (cup forceps and microscissors) or hand-held

Fig. 1: Typical appearance of laryngomalacia Fig. 2: Blue lines indicate site of incision for
aryepiglottoplasty
 Aryepiglottoplasty 1185

A B
Figs 3A and B: (A) Pre- and (B) post-aryepiglottoplasty appearance of larynx

LASER under endoscopic vision. The surgeon needs to be

COMPLICATIONS
conservative rather than radical for these steps. It is much
easier to repeat the procedure in future than to deal with • Aspiration can occur postoperatively, if the surgeon
an incompetent larynx. Also, make sure to preserve the has excised excessive mucosa. To prevent this, it is
bridge of interarytenoid mucosa at all costs to prevent advisable to perform the procedure unilaterally and
scarring, leading to supraglottic stenosis. Bleeding at the review the situation.
end of the procedure is controlled using topical 1:1000 • Supraglottic stenosis is a distinct possibility as a result
adrenaline on neuropatties. Figures 3A and B illustrate the of scarring. This is more commonly seen if the proce-
appearances of the larynx, before and after the procedure. dure has been done using LASER.
1186 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1186
CHAPTER

125 Surgical Management of

Posterior Glottic Stenosis
Bachi T Hathiram, Vicky S Khattar
(Our special gratitude towards Prof Philippe Monnier, who has been our inspiration and guide for our interest and knowledge
of Laryngotracheal Stenosis surgery. A special mention of Prof Sultan Pradhan for being a constant source of encouragement).

INTRODUCTION STEPS OF SURGERY

Isolated posterior glottis stenosis commonly results from The images in Figures 1 to 18 show the steps in the surgi-
prolonged intubation and is seen in patients who have had cal management of an isolated posterior glottic stenosis
a long stay of more than 5–7 days in the Intensive Care Unit. where the distal airway is normal.
This is common in adults since the glottis is the narrowest
portion of the airway in adults unlike in infants where the
subglottis is the narrowest. Such patients more often than
not, would present more commonly with a change of voice
following extubation, which lasts for more than 3 days.
Some of these would have an additional component of
dyspnea depending on the grade of stenosis. A rigid laryn-
goscopy using the Hopkin’s laryngoscope would confirm
the diagnosis. Prior to undertaking surgical management
one should exclude bilateral vocal fold immobility and
cricoarytenoid joint fixation on 0° telescopic laryngeal
examination under general anesthesia. However, these
may coexist in some cases.

Fig. 1: The endoscopic image of a patient with

posterior glottic stenosis

Fig. 2: Intraoperative view. The microlaryngoscope has been Fig. 3: The LASER beam is aimed and fired at the scar.
fixed in position. The false vocal fold spreader is used to Note that the beam follows an imaginary line extrapolated
splay apart the false vocal folds, and expose the dense scar from the vocal folds, backwards towards the scar tissue. This
in the posterior glottis will help in defining the medial edge of the vocal fold that
has been involved in the scar
 Surgical Management of Posterior Glottic Stenosis 1187

Fig. 4: The left vocal fold is now delineated Fig. 5: The excessive mucosa is grasped with a
Bouchayer’s forceps, and held aligned to the LASER beam

Fig. 6: Both the vocal folds are now delineated Fig. 7: Now the interarytenoid area is being enlarged

Fig. 8: The microscope focus is changed to a lower power

1188 Voice and Laryngotracheal Surgery

Fig. 9: Gum elastic bougies are used to dilate the stenosis, Fig. 10: The largest size bougie which is negotiated
beginning with the smallest size, and gradually increasing without trauma to the mucosa
the size, till the largest possible bougie can be negotiated
(see Fig. 10)

Fig. 11: A cottonoid soaked with 2 mg/mL of mitomycin C is Fig. 12: Moist cottonoids used to wash away the
applied topically to the raw area for a period of 3 minutes, and then excess mitomycin C
washed away with moist cottonoids soaked in saline (see Fig. 12)

Fig. 13: A silicone stent (Easy LT mold) is used to stent

the expanded airway, and also hold the vocal folds in
the maximally abducted position, this will ensure that the
posterior glottis should mucosalize in the maximum possible
distance, and thus preventing a recurrence of the posterior
glottic stenosis. A prolene suture is being passed through
the stent, following which it is loaded into the Litchenberger’s
needle carrier. The needle carrier is now introduced into the
airway, and the prolene suture fixed at a point distal to the
vocal folds
 Surgical Management of Posterior Glottic Stenosis 1189

Fig. 14: Endoscopic view of the first suture in place. Note Fig. 15: The needle is retrieved externally by an assistant
the Litchenberger’s needle carrier still in position

Fig. 16: The second (proximal) suture is also Fig. 17: The stent is now gradually lowered into the larynx,
placed endoscopically making sure that the two sutures securing it are not coiled
or entangled in the airway as this is being done

Fig. 18: The endoscopic view after the stent is secured in

place, by tying off the two sutures that have been retrieved
externally in a subcutaneous tunnel. This stent will stay in
place for at least 6 months, following which it can be retrieved
endoscopically, by simply cutting the knots eternally, and
removing the stent orally. This is a great advantage of the
endoscopic placement of laryngeal stents, as this procedure
avoids a laryngofissure, and thus decreases the morbidity,
hospital stay, and most importantly the complications
associated with a laryngofissure
1190 Voice and Laryngotracheal Surgery

FOLLOW-UP ACKNOWLEDGMENTS
The patient is followed up on a regular basis with a The authors are thankful to the Dean, TN Medical College
0 degree endoscopy and the laryngeal stent is removed and BYL Nair Charitable Hospital, for granting permission
once the mucosa has healed (approx. 6–10 weeks, the to publish this chapter. Demonstrated cases have been
duration may be more in revision cases). operated during numerous laryngotracheal surgery work-
shops by the authors along with Prof Philippe Monnier.
 The Surgical Technique of Otoplasty 1191
CHAPTER

Dilatation of a Tracheal
126 Web Using a LASER
Bachi T Hathiram, Vicky S Khattar
(We express our special gratitude towards Prof Philippe Monnier, who has been our inspiration and guide for our interest
and knowledge of laryngotracheal stenosis surgery. A special mention of Prof Sultan Pradhan for being a constant source
of encouragement).

due to increased vascularity of the neighboring tissues.

INTRODUCTION Also, it is important to keep in mind that whenever there is
In this chapter we have shown the various intraoperative a ‘cartilage-framework collapse’ (perichondritis, cartilage
steps in the use of LASER for the dilatation of a thin tracheal necrosis or fracture, etc) the use of LASER is to be avoided
web. It is a good idea to be clear that LASER is merely a tool as this would now require a ‘laryngeal stabilization/
for surgery and not a ‘surgery’ by itself and the indications laryngeal widening’ procedure.
for the use of this sophisticated tool in the surgical
management of laryngotracheal stenosis is limited to the
management of thin membranous webs. Its use, however
STEPS OF SURGERY
tempting, should be avoided at all costs in the removal of The Intraoperative images in the Figures 1 to 12 discuss the
granulation tissue as, it would result in collateral damage steps of surgery

Fig. 1: The preoperative image showing a thin membranous Fig. 2: A moist cottonoid is inserted into the distal
web in the proximal trachea, involving a short segment trachea, to protect it from accidental LASER beam burns
(few millimeters)
1192 Voice and Laryngotracheal Surgery

Fig. 3: The incisions with the LASER begin anteriorly Fig. 4: The anterior incision is extended till
the cartilage is reached

Fig. 5: The lateral incision is begun, making sure to leave a Fig. 6: Since there is adequate residual mucosa, one may
small island if intact mucosa is present in between the two “cheat” a bit more by excising the left mucosal flap, making
incisions. This will promote faster healing, and also reduce sure that there are no corresponding raw areas on the right side
the chances of a restenosis
 Dilatation of a Tracheal Web Using a LASER 1193

Fig. 7: The mucosal bridge on the left is Fig. 8: Note the luminal gain after removing
being completely removed the mucosal bridge on the left side

Fig. 9: The airway after the excision is complete Fig. 10: The magnification of the microscope is reduced
to get a panoramic view. At this stage, one may use gum
elastic bougies to further dilate the airway till the largest
possible size of bougie can be easily passed trauma to the
tracheal mucosa
1194 Voice and Laryngotracheal Surgery

Fig. 11: A moist cottonoid soaked in 2 mg/mL mitomycin C Fig. 12: The end result obtained after applying mitomycin C
solution is applied topically for 3 minutes, before being washed
away with saline soaked cottonoids

ACKNOWLEDGMENTS permission to publish this chapter. Demonstrated cases

have been operated during numerous laryngotracheal
The authors are thankful to the Dean, TN Medical surgery workshops by the authors along with Prof Philippe
College and BYL Nair Charitable Hospital for granting Monnier.
 The SurgicalLASER
Technique of Otoplasty 1195
Arytenoidectomy
CHAPTER

127 LASER Arytenoidectomy

Vicky S Khattar, Bachi T Hathiram
(Our special gratitude towards Prof Philippe Monnier, who has been our inspiration and guide for our interest and
knowledge of laryngotracheal stenosis surgery. A special mention of Prof Sultan Pradhan for being a constant source of
encouragement.)

STEPS OF SURGERY
The steps of surgery have been discussed in Figures 1 to 17.

Fig. 1: A LASER safe tube should be used for endotracheal Fig. 2: The mucosal flap is marked out
intubation. In case such a tube is not available, a regular or
red-rubber endotracheal tube that has been wrapped with a
thin aluminium foil may be used as shown here

Fig. 3: The incision is then deepened Fig. 4: Bouchayer atraumatic forceps is used to gently
grasp the flap for providing traction during LASER dissection
1196 Voice and Laryngotracheal Surgery

Fig. 5: The mucosal flap being elevated using the LASER Fig. 6: The cuneiform cartilage is grasped using an atrau-
matic Bouchayer forceps to aid in dissection using the LASER

Fig. 7: The cuneiform cartilage is being dissected out Fig. 8: The final cut to remove the cuneiform cartilage

Fig. 9: The arytenoid cartilage is now grasped

 LASER Arytenoidectomy 1197

Fig. 10: Often one may encounter troublesome bleeding Fig. 11: The membranous vocal fold is now being detached
from the attachments of the muscular process, and this may from the vocal process. This attachment was kept intact till
require the use of an electrocautery to tackle these vessels, this stage to prevent excessive traction on the arytenoids
as the LASER is not capable of fulgurating vessels that are cartilage during its partial excision
more than 0.5 mm in diameter

Fig. 12: Even the flap is now dissected from the medial Fig. 13: The arytenoidectomy is complete, and one can
surface of the vocal fold appreciate the expansion of the airway posteriorly
1198 Voice and Laryngotracheal Surgery

Fig. 14: Fibrin glue is applied onto the raw area Fig. 15: The mucosal flap is reposited, and pressure is
applied with a moist cottonoid to help the flap to adhere to
the raw area

Fig. 16: Another technique is to carefully insert an endo­ Fig. 17: After the flap has adhered, the expanded airway
tracheal tube, and advance it till the cuff is adjacent to the shows a considerable decrease in the raw area, thus
site of surgery, then inflate the cuff of the tube, holding its promoting faster healing
pressure for a few seconds. This further helps the flap in
adhering to the raw area

ACKNOWLEDGMENTS to publish this chapter. Demonstrated cases have been

The authors are thankful to the Dean, TN Medical College operated during numerous laryngotracheal surgery work-
and BYL Nair Charitable Hospital for granting permission shops by the authors along with Prof Philippe Monnier.
 The Surgical Technique of Otoplasty 1199
CHAPTER

128 Laterofixation of the Vocal Folds in

Acute Bilateral Vocal Fold Paralysis
Waleed F Ezzat

Acute bilateral vocal fold paralysis (BVFP) is a potentially INDICATIONS FOR THE SURGERY
life-threatening condition. The most common cause of
this condition used to be encountered following thyroid The etiology should be determined; if an apparent etiology
surgery, but the incidences of such a cause has declined is present that would dictate a permanent procedure, as
in the past 15 years or so, due to refinement of surgery malignancy involving the recurrent laryngeal nerves that
and introduction of techniques that aid the preservation necessitated them to be removed in the surgical speci-
of the nerves, as use of microscope in dissection, or the men, and there is no hope for recovery, then a definitive
use of intraoperative nerve monitoring to guard against procedure should be performed. But, if the expertise or
nerve injury. The more common causes in recent prac- the patient’s consent or the definite etiology indicating
tice are usually due to laryngeal injury or intubation, neck permanent paralysis is absent, a temporary procedure is
trauma, or tumors. The role of non-laryngeal malignancies chosen.
has increased significantly, particularly in relationship to Paralysis in abduction position without compromise,
pulmonary and mediastinal tumors. A variety of systemic which goes without saying, does not need any lateraliza-
neurological disorders can also cause bilateral VFP but tion procedure; on the contrary, it may need a medializa-
despite advances in diagnostic techniques, in some tion procedure to improve voice and aspiration.
patients, the etiology remains unknown. The gold stand- So, if laterofixation of the vocal folds (VFs) is consid-
ard, initial and often emergency, treatment is tracheotomy ered, the patient should fulfill the following:
pending definitive surgery if the vocal fold paralysis (VFP) • Acute bilateral VFP with a glottic chink less than
does not resolve in due course. The prognosis of recent or 3 mm, stridor at rest, or significant limitation of physi-
acute bilateral VFP, especially those that occur postop- cal activity due to airway narrowing.
eratively, is uncertain; many cases will resolve or improve • The etiology of the paralysis is either nonpermanent,
spontaneously in the following 6 months. It would be or undetermined.
advisable to avoid destructive or anatomically disturbing • Patient is not involved in laborious efforts, as whatever
irreversible procedures during the wait and see periods of the lateralization, this is not equal to the normal widen-
6–12 months. Lateralization procedures provide an attrac- ing of the chink of the VF with effort (in such cases, a
tive alternative to tracheotomy, because the procedure is tracheostomy with a check valve would be better and
relatively simple, reliable and reversible, and preferred by safer).
patients (and surgeons conducting the original surgery).
Patient’s needs in terms of airway for physical activ-
ity and voice should be individualized, and the type and
SPECIFIC PREOPERATIVE
extent of intervention should be tailored accordingly, and EVALUATION
it goes without saying that the wider the airway achieved, True paralysis of the VF should be validated, especially in
the poorer the voice, and vice versa, but the problem with idiopathic cases; this can be done by laryngeal electromyo­
conventional laterofixation techniques is that they depend graphy (EMG). Immobility due to cricoarytenoid fixation
on the physicians judgment without any contribution or will give very poor and short-lived results with the latero-
direct feedback from the patient, to judge the balance. fixation procedure.
1200 Voice and Laryngotracheal Surgery

Tolerance to general anesthesia is usually not an issue between the upper and lower borders VF over the middle
as the procedure is usually short and no additional precau- of the thyroid cartilage ala on the side where the laterofixa-
tions are needed. tion will be performed, and a subcutaneous tiny pocket is
Ability to extend the neck is assessed as in, any case, created to bury the suture later on (Fig. 1). This step can be
doing a direct laryngoscopy. skipped if the patient and surgeon decide to fix the suture
State of the skin of the neck and surgical wound—if externally on a button.
present—should be clean and noninfected. Under direct endoscopic vision, two 14F or 16F intrave-
nous cannula are inserted into the thyroid cartilage, 0.5 cm
above and below the level of the true vocal cord (VC)—
SURGICAL PROCEDURE through the skin incision, if done (Figs 2 to 5).
The operation is performed under general anesthesia. The tips of the two cannula are then advanced just
The endotracheal tube used should not be larger than anterior to the vocal process until they extended in the
6.5 mm so as not to compromise the surgical field; a laryngeal airway for about 2–3 mm (Fig. 5).
5.5-mm or 6-mm endotracheal tube gives better exposure. The trocars of the cannula are usually kept in place to
If the patient was previously tracheostomized, anesthesia facilitate the insertion of the proline suture, but if the diam-
is administered through the tracheotomy, and this even eter is narrow and the suture is thick, they can be removed.
widens the field and facilitates the procedure, but should A 2–0 prolene suture on a straight, short needle is intro-
not be part of the procedure. duced into the lower cannula from outside and slipped till
The procedure can be performed unilaterally or bilat- its edge is seen coming out of the inferior cannula (Fig. 6).
erally whether in the same setting on sequentially. Once the edge of the needle is recognized under the
The patient is placed supine with a headrest and shoul- operative microscope, it is grasped by a regular micro-
der elevation, and the larynx is exposed by suspension laryngeal needle holder; it is then redirected to pass
microlaryngoscopy. through the upper cannula from within the airway to
After scrubbing and preparation of the neck skin, exter- the outside. A single thread forms a loop around the VF
nal surface identification of the boundaries of the thyroid (Fig. 7); piece by piece, the suture is slipped from within-
cartilage is done; a mark is placed on the superior (thyroid out till it comes out of the upper cannula externally.
notch), inferior, and posterior borders (Fig. 1). With the two ends of the suture now being external, the
As an option, 2-cm horizontal cervical skin incision is loop is pulled to assess that the VF can be sufficiently later-
created at the level of the true VF, which is about midway alized (Figs 8 and 9).

Fig. 1: Surface anatomy and identification of the Fig. 2: Endoscopic view of the larynx after exposure of the
landmarks on the larynx VF; a small endotracheal tube is used, and the arytenoids
are identified
 Laterofixation of the Vocal Folds in Acute Bilateral Vocal Fold Paralysis 1201

Fig. 3: A 14F or 16F intravenous cannula is inserted Fig. 4: Edge of the introduced cannula pushed till tip
through the incision protrudes above the vocal process

Fig. 5: The second cannula is introduced; now, one is above Fig. 6: The proline suture is introduced from the lower
and the other below the vocal process of the arytenoid cannula till its edge protrudes in the larynx; in this case,
the trocar of the cannula was left in place and the proline
suture was introduced through it

The next step depends on the preference, either the then to awaken the patient; the next day when the patient
ends of the suture are tied externally over a button, or is fully conscious and under flexible endoscopic laryngo-
they are tied and buried subcutaneously, after suitable scopy, the suture is tied to a suitable tension according to
tension is applied to obtain balance between voice and the voice and airway preferences of the patient. The suture
airway. is then buried in the subcutaneous pocket, after six to eight
The author’s personal modification and preference knots are made.
is to tie the ends of the suture over a piece of gauze, and Steri-Strips are used to approximate the skin, if opened.
1202 Voice and Laryngotracheal Surgery

Fig. 7: The proline suture is looped and reintroduced Fig. 8: The edges of the proline loop are pulled externally
through the upper cannula to assure lateralization of the VF

assessed intraoperatively, and if found to be the case,

the whole procedure can be revised.
• Loosening of the suture can be life-threatening if the
airway, initially, was severely compromised, and all
cases undergoing such procedures should have emer-
gency access near their domain if such a condition
occurs.
• Irritation by the puncture or the loop may result in
granuloma formation—this can be treated conserva-
tively or endoscopically removed, or the procedure
abandoned and other arrangements taken.
• Migration of the loop—this can occur when severe
tension is needed for the lateralization to achieve
airway, and if this occurs, it is not advisable to repeat
the procedure because, most probably, it will occur
again.
• A rather theoretical and very rarely seen complication
is some degree of aspiration, which was not encoun-
Fig. 9: Diagram representing the position of tered by the author, especially when the adjustment is
the proline loop performed while the patient is awake.
• Neck discomfort during swallowing from the suture—
this is usually trivial and the patient adapts to it.
COMPLICATIONS • Wound infection can occur, although very rarely
reported.
• The main complication is failure to achieve a suitable
airway; this is mainly attributed to two things: first,
improper assessment, i.e. the problem is not paraly-
SPECIAL INSTRUMENTS USED FOR
sis, and the second is improper positioning of the THE SURGERY
loop—if it is too anterior (far from the vocal process), The basic set for surgery involves availability of the
the pulling will not be effective, but this can be usually general instruments for microlaryngoscopic surgery. No
 Laterofixation of the Vocal Folds in Acute Bilateral Vocal Fold Paralysis 1203

special instruments are needed. In author and associates’ OTHER TREATMENT OPTIONS
personally adopted technique, only two 14F or 16F intra-
venous cannula are needed, and a 2-0 prolene suture on
AVAILABLE FOR THE SAME CONDITION
a straight, short needle, a size-10 scalpel and a mosquito Of course, the ultimate treatment option is a tracheostomy,
forceps. but this should be reserved for cases where no expertise or
An asset, but an expensive one, is to have the equipment is available for less traumatizing interventions.
Lichtenberger’s set, using the endo-extra-laryngeal needle As mentioned, the Lichtenberger’s set can be used, but is
suturing method. rather expensive.
1204 Voice and Laryngotracheal Surgery
CHAPTER

129 Pediatric Tracheostomy

Yogesh Bajaj

Tracheostomy in children has considerable implications SPECIFIC PREOPERATIVE

for the child and the parents, and should be performed
only when no other alternatives are available to secure the
EVALUATION
airway. The procedure should be performed in the presence of an
experienced pediatric ENT surgeon and a senior pedia­
tric anesthetist. Age appropriate tracheostomy tubes and
INDICATIONS FOR THE SURGERY pediatric rigid bronchoscopes should be selected and
The indications for pediatric tracheostomy can be broadly checked by the surgeon before starting the procedure.
divided into:
• Upper airway obstruction
– Acquired/congenital subglottic stenosis
ANESTHETIC CONSIDERATIONS
– Craniofacial malformations The procedure should be performed preferably under
– Bilateral vocal cord paralysis general anesthetic with endotracheal intubation. If intu-
– Large lymphangiomas bation is not possible, usually the anesthetists are able to
– Severe tracheomalacia use laryngeal mask airway, failing which the ventilation
• Long-term assisted ventilation can be maintained with a face mask.
– Neuromuscular disorders
– Central nervous system disorders
– Respiratory distress syndrome
SURGICAL PROCEDURE
• Pulmonary toilet Positioning the patient for pediatric tracheostomy is of
– Chronic aspiration (neurological disorders). utmost importance, and should be done by the surgeon
The major indications of tracheostomy in the previous himself before scrubbing. Use a shoulder roll, to extend
century used to be airway obstruction due to infections, the neck, and a head ring. Tape the chin using an elasto-
i.e. acute epiglottitis, diphtheria, laryngotracheobron­ plast to the table to further stabilize the head in midline
chitis. The more common indications at present are bilat- (Fig. 1). This brings the trachea into a more anterior and
eral vocal cord paralysis, craniofacial malformation, laryn- superior position. The neck should not be hyperextended
geal/tracheal stenosis, and tumors. to avoid mediastinal structures entering the neck.

Fig. 1: Position for pediatric tracheostomy (head is stabilized with elastoplast)

 Pediatric Tracheostomy 1205

After the patient has been cleaned and draped, the first free from bleeding as far as possible. Staying in midline,
step should be to identify laryngeal landmarks by palpa- identify and count the tracheal rings again. At this stage,
tion, which should preferably be marked with a marker two stay sutures should be placed using 3.0 nylon suture,
pen. The surgeon should mark sternomastoid muscles, at the level of the third tracheal ring on either side of the
suprasternal notch, cricoid cartilage, and the tracheal midline (Fig. 2). Tracheotomy is performed through verti-
rings. cal incision through the third and fourth tracheal rings.
Horizontal skin crease incision, approximately 1-cm Maturation sutures are done at this stage (Fig. 3). These
long, is made at the level of the third tracheal ring (vertical are sutures from the edge of the trachea to the skin edges,
incision can be done, but cosmesis is poor). Using bipo- converting the tracheotomy into tracheostomy. Two such
lar diathermy, remove the fat plug from the subcutane- sutures on either side are done with 4.0 vicryl. This is
ous plane to improve access and visualization. At every another safety measure to prevent a false tract formation
step, make sure to stay in midline and keep palpating the in the event of early accidental decannulation. The stay
laryngeal landmarks. Separate the strap muscles in the sutures are left in place at least till the first tracheostomy
midline and retract laterally with the help of an assistant. tube change, and taped to the chest with “do not remove”
Identify and divide the thyroid isthmus in the midline clearly written on the tape (Fig. 4). These sutures help to
with bipolar diathermy. The surgical field should be kept pull the trachea close to the skin for reinsertion of trache-
ostomy in the event of accidental decannulation in the first
week. At this stage, the endotracheal tube is withdrawn by
the anesthetist, so that the tip of the tube is just above the
incision in the trachea. An age-appropriate tracheostomy
tube is inserted. The anesthetic circuits are connected to
the tracheostomy tube and only after the ventilation is
established through the tracheostomy tube, the endotra-
cheal tube is completely withdrawn. The tracheostomy
tube is secured by suturing it to the skin, and with trache-
ostomy tapes.

COMPLICATIONS
The complications associated with tracheostomy are
divided into early and late complications.

Early Complications
• Bleeding—usually due to capillary oozing. The surgeon
must be aware of encountering the innominate artery
in the neck due to neck extension.
• Wound infection—is a possibility, needs treatment as
Fig. 2: Placement of stay sutures before tracheal incision
per severity.

Fig. 3: Maturation sutures Fig. 4: Stay sutures taped to chest

1206 Voice and Laryngotracheal Surgery

• Surgical emphysema—seen due to air tracking under • Respiratory arrest—can happen intraoperatively due
the skin as a result of tight closure of the tracheostomy to sudden loss of respiratory drive because of rapid fall
incision. of CO2 levels. Postoperatively, the arrest can happen if
• Pneumothorax/Pneumomediastinum—can happen if the tracheostomy tube gets dislodged.
the apex of the lung is damaged during the procedure. • Pulmonary edema—happens as a result of sudden
• Tracheostomy tube problems—the two main prob- change in airway pressures after tracheostomy, lead-
lems are tube blockade or dislodgment. Both are seri- ing to rapid influx of fluid across the alveolar walls.
ous problems and need urgent attention.
• Damage to other neck structures—injury to esopha- Late Complications
gus, recurrent laryngeal nerves and carotid arteries Tracheostomy tube problems, tracheitis, bleeding second-
can happen. To prevent this, avoid opening excessive ary to tracheal wall erosion, tracheocutaneous fistula,
tissue planes and stay in midline. tracheomalacia.
 The Surgical Technique Cricoid Split 1207
of Otoplasty 1207
CHAPTER

130 Cricoid Split

Yogesh Bajaj

INDICATIONS FOR THE SURGERY the anterior rim of the cricoid cartilage. The incision is
extended above into the inferior one-third of the thyroid
Anterior cricoid split (ACS) is indicated in patients with cartilage and inferiorly into first two tracheal rings. The
early soft subglottic stenosis. This is most commonly child is intubated with an age appropriate endotracheal
performed in neonates who have failed attempted extuba- tube, which serves the purpose of an endolaryngeal stent.
tion. The eligibility criteria for the patients to undergo this Soft silicone drain is inserted in the skin incision and left
procedure are: in situ for 48 – 72 hours to allow any air leak/ prevent surgi-
• Failed extubation on two occasions due to laryngeal cal emphysema. The incision is not closed primarily. The
pathology patient is extubated after 5 – 7 days. Successful extubation
• Child’s weight more than 1,500 gm is achieved in 70 – 80% cases.
• No assisted ventilation for at least 10 days
• Oxygen requirement less than 30% NEW TECHNIQUES IN THE
• No cardiac problems
SURGERY
• No acute respiratory tract infections.
More recently, experienced surgeons have started
performing ACS endoscopically using a sickle knife.
SURGICAL PROCEDURE
The patient is positioned supine with a shoulder roll and
a head ring. This results in laryngeal framework becom-
COMPLICATIONS
ing prominent. Cricoid cartilage is palpated and marked • Wound infection
with a skin marking pen. Horizontal skin crease incision • Surgical emphysema remains a common complica-
is done over the cricoid cartilage. Subcutaneous tissues tion, but can be avoided by allowing the incision to
are dissected and cricoid cartilage is exposed. Using a close by secondary intention and leaving a drain in the
no. 15 blade, a vertical incision is made in the midline of incision.
 Surgical Technique of Otoplasty 1208
Voice RestorationTheafter
1208 Voice and Laryngotracheal Surgery
CHAPTER

Cordectomies: Type III Thyroplasty

131 for Voice Reconstruction after
Laryngofissure Cordectomy
T Kandogan

INTRODUCTION SPECIFIC PREOPERATIVE

Voice outcome after cordectomy may not be satisfactory to EVALUATION
the patient because the missing cord is not reconstructed.
Loss of vocal fold tissue results in abnormal glottic closure, Before surgery, objective and subjective voice
which may result in a breathy and weak voice and signifi- measurements should be obtained. It may include RBH
cantly affect the quality of life of the patient. (Auditive analysis) Roughness(R), Breathiness (B) and
Thyroplasty type III was traditionally used to lower the Hoarseness (H), Voice Handicap Index (VHI), acoustic
pitch in male patients with too high vocal pitch of long analysis, e.g., analysis of jitter (%) and shimmer (%),
duration, which has proven resistant to voice therapy and Voice Range Profile (VRP) and Disphonia Severity Index
in dysphonia resulting from stiff vocal cord. (DSI).
The standard of care for T1 squamous cell carcinoma
of the vocal fold is either radiation therapy or transoral
LASER microsurgery. Laryngofissure cordectomy is a
ANESTHETIC CONSIDERATIONS
surgical modality if the endoscopic exposure is not feasi- Intubation anesthesia is required.
ble. But this reconstructive procedure could also be used
for patients having had prior endoscopic cordectomy to
improve glottic closure.
SURGICAL STEPS
The major concern doing this procedure in one stage The patient is positioned supine on the operating table
is that the vocal cord where the thyroplasty type III is under intubation anesthesia. The skin incision is made
planned, will be shorter and thicker. However, this vocal with a scalpel and the upper and lower skin flaps are
cord also resists less to subglottic pressure. Furthermore, elevated in subplatysmal plane until the hyoid and the
with thyroplasty type III, there is a theoretical possibility cricoid are exposed. The strap muscles are separated
of deterioration of the voice due to relaxed stress on vocal and are retracted laterally exposing the thyroid cartilage
cord. After the operation, it was shown that the mentioned totally. An incision is made in the perichondrium of the
concerns were not realized. thyroid lamina in the midline. Following this, the edges of
A satisfactory glottal closure and voice result will be the external perichondrium are elevated from the thyroid
achieved in a relatively short period of time by performing cartilage on both sides. This will permit sufficient expo-
a thyroplasty type III and laryngofissure with cordectomy sure of the thyroid cartilage for its division in the midline
in one stage to the patients. with an oscillating saw. After this, a midline thyrotomy
Since this reconstructive technique does not touch is performed with an oscillating saw. Double hooks are
the diseased area, recognizing early recurrences is always used to retract each hemilarynx, providing a good view of
possible without difficulty, which is important in onco- the tumor on the left side (Fig. 1A). Using a microscope,
logic surgeries. accurate surface assessment of the extent of the tumor is
provided and the tumor is resected, including the entire
true vocal cord, all the adjacent tissue and the internal
INDICATIONS FOR THE SURGERY perichondrium of the thyroid cartilage (Fig. 1B). Margins
In order to prevent glottic insufficiency and relatively are checked with frozen sections.1
rapid achievement of glottic competence, this procedure During this procedure, to provide a good view, the
is indicated. endotracheal tube has been sometimes retracted laterally.
 Voice Restoration after Cordectomies 1209

To depict the procedure better, the intubation tube has not ala, parallel to and 3 mm posterior to the first incision and
been shown in figures. the vertical strip has been excised totally. Narrow holes are
After the cordectomy has been completed, the made with a fine burr and fixation of the incised edges is
intended vertical line of incision is drawn at about the done by 3 (4-0) nylon sutures (Fig. 1D). The laryngofissure
junction of the anterior and middle one-third of the right has been closed with 3 (4-0) nylon sutures, passed through
thyroid ala (Fig. 1C, arrow). The cartilage is incised with the elevated perichondrium and the procedure has been
an oscillating saw, special care has been taken not to cut finished (Fig. 1E). Figure 1F shows anterior view of the
inner perichondrium. The second incision is made in the thyroid cartilage at the end of the surgery.

A B C

D E F

Figs 1A to F: Operative procedure for the surgical management of voice after

laryngofissure cordectomies: Type III thyroplasty

in the Reinke’s space. Furthermore fat must be injected

OTHER TREATMENT OPTIONS
between the cartilage and the vocal fold and since this
AVAILABLE FOR THE SAME is no longer possible after total cordectomy, injection of
CONDITION substances to treat glottal gap after cordectomy will not be
a useful technique.
In order to preserve best phonatory function, several Although the external medialization laryngoplasty
techniques have been proposed based on either the ster- technique with a plenty of implant materials, such as
nohyoid muscle or the ventricular band preoperatively. autologous cartilage or alloplastic materials, such as
There are also some surgical reconstructive procedures silastic, hydroxyapatite, Vitalium (miniplates), expanded
to improve the patient`s voice postoperatively; such as polytetrafluoroethylene (Gore-Tex) and titanium vocal
injection laryngoplasty (for partial cordectomies); mostly fold medialization implant, has become widely accepted
using collagen or autogenous fat and medialization laryn- for the treatment of unilateral vocal fold immobility, the
goplasty. Sittel et al. proposed a new medialization tech- indications and results in other causes of incomplete glot-
nique using autologous cartilage for patients treated with tal closure (cordectomy) have not been well described.
transoral LASER surgery for glottic carcinoma. The medialization surgery is advocated to the cord-
But since vocal cord structure no longer exists after ectomy patient only when the post-therapy voice
cordectomy, the injected collagen cannot be enclosed outcome does not meet the patient’s requirements. It
1210 Voice and Laryngotracheal Surgery

is recommended of a six-month interval after cordec- techniques often lead to unsatisfactory results because of
tomy before engaging in further surgery aiming at voice the scarred endolaryngeal tissue.
improvement. This time interval is for the formation of
fibrous neocord, that can provide also a satisfactory func-
tional outcome. Performing medialization thyroplasty to
POSTOPERATIVE DETAILS AND
the cordectomy patients is not easy, since undermining the FOLLOW-UP
fibrous tissue at the inner side of the thyroid ala is a labo- The patient never required a tracheotomy postoperatively.
rious procedure, care must be taken not to tear the inner The patient has been left in total voice rest for three days
fibrous tissue to prevent the risk of extrusion of implant in postoperative period. Some of the stroboscopic views of
material. It is also believed, that vocal fold medialization the larynx are given in Figs 2 to 3.

Fig. 2A: Stroboscopic view of the larynx at the 1st month Fig. 2B: Stroboscopic view of the larynx at the first
postoperatively. Inspiration mode month postoperatively. Phonation mode. See the near total
closure in the glottic area without supraglottic compensatory
movements

Fig. 3A: Stroboscopic view of the larynx at the 8th month Fig. 3B: Stroboscopic view of the larynx at the 8th month
postoperatively. Inspiration mode postoperatively. Phonation mode. Near total closure in the
glottic area without supraglottic compensatory movements
continued
 Voice Restoration after Cordectomies 1211

CONCLUSION REFERENCE
After the procedure, the quality of voice was found to be 1. Kandogan T. Type III thyroplasty for the treatment of
sufficient to hold a normal individual conversation, also glottic gap in a patient undergoing laryngofissure cord-
in a noisy atmosphere, since it can be raised satisfactorily. ectomy for squamous cell carcinoma of the vocal fold:
More definitive consequences will come along with more technique and outcome. Ear Nose Throat J. 2010; 89(6):
cases. 272-5.
1212 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1212
CHAPTER

132 Botulinum Toxin for

Laryngeal Dystonias
Michael S Benninger

spasm or contract in abduction. Adductor SD accounts

INRODUCTION for between 80% to 90% of all cases and abductor SD
Dystonia is a term that is used to describe an abnormal accounts for between 10% to 20%.4 There are a small group
muscle movement that is characterized by repetitive invol- of patients who have both the abductor and adductor
untary muscle contractions. It is thought to be a neurological component (<1%) and the treatment of such patients can
condition and the various contractions are described as be particularly challenging.
sustained (tonic) or spasmodic (clonic). Depending on Patients with adductor SD have pitch breaks, irregular
the size and location of the muscle contractions, there can speech and a strained or strangled voice while individuals
be gross posturing and disfigurement during the activ- with abductor SD have a breathy quality to the voice with
ity, although the muscle action is usually normal during a short duration of vocalization due to excessive air loss
rest. Typically, these dystonic contractions are induced by on phonation. This is particularly true in words that begin
conscious action to move the muscle group.1,2 with a voiceless consonant followed by a vowel (such as
Botulinum toxin injections for dystonias have proved pat or puppy). The primary treatment for SD is with Botox
to be effective treatment. The toxin targets a group of injections with a very high initial and subsequent success
proteins called the SNARE complex. This family of proteins rate in treating adductor SD.5 With abductor SD, responses
normally facilitates the docking of neurotransmitter vesi- are more variable with Botox injections.4
cles to the presynaptic membrane. Each botulinum toxin
serotype has specific molecular targets in the SNARE
complex, essentially causing an irreversible blockade of
ANATOMIC CONSIDERATIONS
cholinergic transmission at ganglionic synapses, post- The two primary muscles that are injected for SD are the
ganglionic parasympathetic synapses, and neuromus- thyroarytenoid muscle (vocalis muscle) and the poste-
cular junctions. Recovery from botulinum toxin involves rior cricoarytenoid muscle. The thyroarytenoid muscle is
two phases. During the first phase, new axons appear a primary tensor of the vocal fold and has a medial and a
and allow for limited acetylcholine release. In the second lateral belly that blend into one muscle group. Although
phase, new synthesis of the SNARE complex proteins they have slightly different effects on tensing the vocal
occurs.3 After a little more than 90 days, recovery is essen- folds, these differences are minor and do not seem to
tially complete. This is why patients require repeat injec- have an impact on the effectiveness of the botulinum
tions every few months to maintain a sustained effect. toxin injections. The muscle attaches anteriorly to the
Although there are a number of subtypes of botulinum thyroid cartilage via Broyle’s ligament in the area of the
toxin, only Type-A is routinely used in clinical care. There macula flava. When seen from anteriorly, the insertion
are two primary commercially available preparations of is usually in the midpoint of the distance between the
botulinum toxin-A, Botox and Dysport, and these have thyroid notch and the lower border of the thyroid carti-
different concentration of effects. Botox is four times lage. The medial belly of the muscle inserts posteriorly to
stronger than Dysport based on volume of injection. For the muscular process of the arytenoid cartilage medially
purposes of this presentation, only Botox is described. and the lateral belly attaches to the body of the arytenoid
The larynx is commonly involved with dystonic move- more laterally.6
ments. Although there are a number of laryngeal dysto- The posterior cricoarytenoid muscle is the only true
nias, the most commonly encountered laryngeal dystonia abductor of the vocal folds, although the cricothyroid
is spasmodic dysphonia (SD). SD is a focal dystonia of muscle may have some abductor role in deep inspiration.
the larynx. It is subdivided into an adductor type (adduc- It opens the glottis by separating the vocal folds by rotat-
tor SD) where the vocal folds spasm in adduction and ing the arytenoid cartilage laterally and tilting it. There are
an abductor type (abductor SD) where the vocal folds paired muscles on each side. The posterior cricoarytenoid
 Botulinum Toxin for Laryngeal Dystonias 1213

muscle is a broad muscle with its origin along a broad and length of postinjection breathiness and the length of
depression on the posterior surface of the posterior lamina time between the injection and the return of symptoms.
of the cricoid cartilage. The muscle fibers then converge The dose is tempered by the desire of the patient. Some
and insert on the muscular process of the arytenoid.6 individuals cannot tolerate much breathiness but are will-
ing to accept more frequent injections in which case, the
starting dose will be decreased on subsequent injections,
TECHNIQUES FOR ADDUCTOR while others may not care about the breathiness but want
SPASMODIC DYSPHONIA a more sustained effect and less frequent injections. In this
There are a number of approaches to the injection of Botox case, the dose can be left as it is or increased. There are
for adductor SD. The most common approach is through unique individuals who continue to have significant peri-
the cricothyroid membrane (Fig. 1) but the injections can ods of breathiness after injections of even small amounts
also be made through the thyrohyoid membrane (Fig. 2) or of Botox. In these cases, an option is to do a higher dose
from above through the mouth either with a long curved of Botox injected into one vocal fold. An approximate
needle (Fig. 3) or through a flexible endoscope. Injections equivalency between the doses of Botox in one vocal
can also be made into both or one vocal fold. The typical fold in comparison to both vocal folds varies slightly as the
starting dose for bilateral vocal fold injections is 2.0 or dose increases (Table 1).7
2.5 units a side into the thyroarytenoid muscle. The
patients may note a period of breathiness beginning a day Injection through the Cricothyroid Membrane
or two after the injection and this may last for 1–2 days to This injection can be performed either with electro­
up to a couple of weeks. During that time, the patient may myography (EMG) localization or observing the vocal
be more susceptible to aspiration of thin liquids and they folds from above with a flexible scope. In many cases, it
should do so cautiously if they are very breathy. Although is simpler and quicker to use EMG localization. The injec-
the length of the effect may be variable, typical results will tion can be performed in either a sitting or supine posi-
last between 3–6 months. Over the last month or so, the tion (Fig. 1). A small amount of xylocaine can be injected
individual will note gradually increasing strain and effort. into the cricothyroid space and then into the tracheal
The amount of Botox injected on subsequent visits lumen. A hollow bore elctromyographic needle is passed
will depend on a number of factors including the degree through the cricothyroid space, directed superiorly and

Fig. 1: Needle passed superiorly and laterally into the Fig. 2: Needle passed inferiorly and laterally into the vocal
vocal fold (thyroarytenoid muscle) through the cricothyroid fold (thyroarytenoid muscle) through thyrohyoid space just
membrane above the thyroid notch
1214 Voice and Laryngotracheal Surgery

Table 1: Equivalency doses for unilateral in comparison to

bilateral vocal fold injections for spasmodic dysphonia7
Unilateral Bilateral
1.25–2.5 units No equivalence
5 units 0.625 units
10–15 units 1.25 units
25–30 units 2.5 units

laterally into the vocal fold until muscle motor potentials

are identified. Position is confirmed by seeing an increase
in motor unit potentials and the Botox is injected. The
needle can then be directed superiorly and laterally into
the other vocal fold without withdrawing the needle from
the neck. The entire procedure typically can be performed
in less than a minute or two. A similar technique can be
used for the treatment of primary vocal tremor, although
the results are more variable.

Injections through the Thyrohyoid Space Fig. 3: Curved needle passed into the vocal fold (thyroarytenoid
Similar to the technique above, this can be performed muscle) from above with endoscopic guidance
either with EMG guidance or with direct visualization
above with a flexible scope, although the angles make it into the posterior cricoarytenoid muscle(s). Initially, a
simpler to use a flexible endoscope to visualize the needle. unilateral injection is typically performed. There have
Local anesthesia can be performed by injection into the been concerns that bilateral injections at one sitting may
skin just above the thyroid notch and into the deeper result in poor abductor ability and may compromise the
tissues. The needle is then passed in the midline just airway. With a unilateral injection, 5 units is a good start-
above the thyroid notch, directed inferiorly and visualized ing dose. Although most people note some improvement,
as it enters into the larynx. It can be directed inferiorly to a good response is seen in about 20% of patients.4 They will
one side until it can be seen entering the vocal fold and usually require a second injection a month or so later and
the injection can be made (Fig. 2). Similarly, the needle are often done in a staged fashion, with another 5 units
is directed to the opposite side and the injection can be injected at that time. It may be helpful to evaluate the
made. larynx at the time of the second injection. Since the injec-
tions are done blindly, there is a chance that the injection
Injections from Above will be on the opposite side than expected and this should
There are two approaches to injecting Botox from above. be detected on endoscopy, so that the subsequent injec-
The first is to have the patient hold their own tongue and tion can be performed on the more active side.
a rigid endoscope can be passed through the mouth. There have been increased interest in simultaneous bilat-
A curved needle can then be passed into the vocal fold eral posterior cricoarytenoid muscle injections and the safety
and injection made into the vocal folds (Fig. 3). A similar has been well substantiated.8 In these cases, the initial dose is
approach can be made using a flexible scope. Since these approximately 2.5 units injected into each side.
are longer needles, the volume of the needle needs to be
taken into consideration. Posterior-lateral Approach to the
Posterior Cricoarytenoid Muscle
The injections need to be performed with EMG guid-
TECHNIQUES FOR ABDUCTOR ance since the posterior cricoarytenoid muscle cannot
SPASMODIC DYSPHONIA be directly visualized. An injection is made in the skin at
The success of Botox treatment in abductor SD is more approximately the midpoint of the posterior aspect of the
variable than for adductor SD. The injections are made thyroid cartilage (Fig. 4). The thyroid cartilage is rotated
 Botulinum Toxin for Laryngeal Dystonias 1215

Fig. 4: Needle passed through the lateral neck into the Fig. 5: Needle passed directly through the cricoid cartilage
posterior cricoarytenoid muscle into the posterior cricoarytenoid muscle

as much as is tolerated for patient comfort. The needle is REFERENCES

passed through the skin until the posterior portion of the 1. Cultrara A, Chitkara A, Blitzer A. Botulinum toxin injections
thyroid cartilage is encountered and the needle is then for the treatment of oromandibular dystonia. Oper Tech
passed slightly inferiorly and medially until the cricoid Otolaryngol Head Neck Surg. 2004;15:97-102.
cartilage is encountered and motor unit potentials are 2. Fahn S. The varied clinical expressions of dystonia. Neurol
identified. The patient can then tighten their neck muscles Clin. 1984;2(3):541-54.
to make sure that the needle is not in the strap muscle. 3. Wenzel RG. Pharmacology of botulinum neurotoxin sero-
They are then asked to sniff and EMG activity should type A. Am J Health Syst Pharm. 2004;61(22 Suppl 6):S5-10.
increase verifying the position in the muscle. The injection 4. Blitzer A, Brin MF, Stewart CF. Botulinum toxin management
is made. For a bilateral injection, a similar approach could of spasmodic dysphonia (laryngeal dystonia): a 12-year
be made from the opposite side. experience in more than 900 patients. Laryngoscope. 1998;
108(10):1435-41.
Injection through the Cricoid Cartilage 5. Benninger MS, Gardner G, Grywalski C. Outcomes of
botulinum toxin treatment for patients with spasmodic
This is a reasonable technique in patients who are rela-
dysphonia. Arch Otolaryngol Head Neck Surg. 2001;127
tively young and have little calcification of the thyroid
(9):1083-5.
cartilage. It is also more difficult in people with large
6. Warfel JH. The head, neck and trunk: muscles and motor
larynges and thick cricoid cartilages. The needle is passed points, 4th edition. Philadelphia: Lea and Febiger; 1978.
directly through both the anterior and posterior lamina 7. Woodson GE. Spasmodic dysphonia. In: Gates GE (Ed).
of the cricoid cartilage, directed slightly laterally until the Current Therapy in Otolaryngology Head and Neck Surgery.
muscle is entered and confirmed by EMG and the injec- St Louis: Mosby; 1998.
tion can be made (Fig. 5). One of the problems with this 8. Klein AM, Stong BC, Wise J, et al. Vocal outcome meas-
technique is that the needle can occasionally get plugged ures after bilateral posterior cricoarytenoid muscle botu-
with cartilage, and it may be necessary to make a small linum toxin injections for abductor spasmodic dysphonia.
push to eject some of the Botox or repeat the injection. Otolaryngol Head Neck Surg. 2008;139(3):421-3.
1216 Voice and Laryngotracheal Surgery
CHAPTER
Selective Laryngeal Adductor
133 Denervation-Reinnervation Surgery
for Adductor Spasmodic Dysphonia
Dinesh K Chhetri, Jennifer L Long

INTRODUCTION The operation is discouraged in elderly persons (over

75 years old) since nerve regeneration is inefficient in
Spasmodic dysphonia (SD), also referred to as focal the aged. Diagnosis of SD is made primarily based upon
laryngeal dystonia, is a neurologic disorder of unknown perceptual evaluation of voice by an experienced clinician.
etiology. Subtypes are defined according to the laryngeal Laryngeal videostroboscopy is performed to rule out other
muscle groups affected, with the adductors more often organic pathology and may demonstrate excess tension in
afflicted than the abductor muscles. The characteristic the larynx. Other causes of dysphonia must be ruled out,
sign is strained-strangled voice quality with intermittent including muscle tension dysphonia. If the diagnosis of
voice breaks during speech that results in dysfluency SD is in question, trial injections of botulinum toxin can
of speech. Affected patients may note difficulty with approximate the results after surgery.
onset of phonation or a sensation of words being
“stuck in the throat,” even in cases with minimal vocal
symptoms. The treatment is directed towards weakening
ANESTHETIC CONSIDERATIONS
the affected spasmodic intrinsic laryngeal muscles and The surgery is performed under a deep plane of general
the most common treatment is injection of botulinum anesthesia without neuromuscular paralysis. A small
toxin. However, Botox therapy needs to be repeated ­electromyographic (EMG) endotracheal tube (NIM endo­
approximately every 3 months and results in side effects, tracheal tube, Medtronic Inc., Minneapolis, Minnesota,
such as a period of breathy dysphonia and occasional USA) is used and will assist in identification of the
dysphagia. Therefore, for a lasting solution, some patients intralaryngeal recurrent laryngeal nerve (RLN) branches.
elect surgical treatment. One such operation, selective The patient is given intravenous antibiotics and steroids
laryngeal adductor denervation-reinnervation surgery intraoperatively and for at least the first postoperative day.
for adductor SD, is described here. The reader is referred Patient positioning is supine with the neck extended and
elsewhere for review of the development, rationale, and surgeons standing on both sides of the neck.
excellent outcomes of this surgery.1-3
SURGICAL STEPS
INDICATIONS FOR THE SURGERY Identical surgery is performed on both sides of the neck,
Patients with adductor-type SD, who desire relief of through a midline horizontal incision. The incision is
symptoms without repeated botulinum toxin injections, performed in a natural neck skin crease overlying the
are candidates for this surgery.3 Contraindications include larynx (Fig. 1). Subplatysmal skin flaps are elevated
abductor or mixed SD, and severe laryngeal tremor. In superiorly to the hyoid bone and inferiorly below the
those cases, the dominant features of breathy spasms or cricoid level. Bilateral ansa cervicalis nerves are identified,
tremor could become more evident. Professional singers most typically overlying the internal jugular vein at the
should not undergo this surgery as it alters the fine junction of the sternocleidomastoid muscle and the
laryngeal control mechanisms that are required for high- omohyoid muscle.4 A ansa branch to one of the strap
level vocal performance. muscles is tagged with a loose tie, dissected out, and cut
low in the neck to allow rotation to the larynx for use in
laryngeal reinnervation.
PREOPERATIVE EVALUATION Strap muscles are then retracted to expose the larynx
Patients must be in adequate overall health for an elective in the midline. The thyrohyoid and sternothyroid muscle
surgery under general anesthesia that takes about 3 hours. attachments to the thyroid cartilage are released, avoiding
 Selective Laryngeal Adductor Denervation-Reinnervation Surgery for Adductor Spasmodic Dysphonia 1217

Fig. 1: A midline horizontal neck incision is marked Fig. 2: Laryngeal thyroid cartilage showing inferiorly-based
on a skin crease overlying the larynx laryngotomy trapdoor window; view from right side

injury to the cricothyroid muscle. Using a single-prong

hook on the posterior edge of the thyroid ala, the larynx is
rotated medially to expose the lateral edge of the cartilage.
An inferiorly-based laryngotomy trapdoor is drawn on
the thyroid ala, designed to expose the intralaryngeal
course of the adductor branch of the RLN (Fig. 2). The
window extends from the inferior tubercle of the thyroid
cartilage posteriorly to the inferior cornu anteriorly, and
approximately halfway up the vertical level of the thyroid
ala about the same level as the vocal folds. The trapdoor
window is made with a scalpel or sagittal saw to cut the
cartilage, and retracted downward as an inferiorly-based
trapdoor opening along with its inner perichondrium.
The adductor branch of the RLN is identified within
Fig. 3: Intralaryngeal course of the right recurrent laryngeal
the window by fine dissection. The RLN enters the nerve (RLN) seen at the laryngotomy window level (IA:
larynx deep to the cricopharyngeus muscle at the level Interarytenoid muscle. LCA: Lateral Cricoarytenoid; PCA:
of the cricothyroid joint, sends a posterior branch to the Posterior Cricoarytenoid; TA: Thyroarytenoid; RLN: Recurrent
posterior cricoarytenoid (PCA) muscle, and then travels laryngeal nerve)
upwards and anteriorly towards the midpoint of the
thyroarytenoid (TA) muscle (Fig. 3). The nerve is noted The lateral cricoarytenoid (LCA) muscle is another laryn-
to cross diagonally within the trapdoor window, after geal adductor involved in adductor spasmodic dysphonia
sending its PCA branch, as it traverses towards the TA (ADSD), but its nerve branch is too fine and short for reinner-
muscle. After the adductor branch is found traversing vation. During posterior dissection of the adductor branch,
to the TA muscle, it is tied tightly with a 3-0 silk suture this branch is encountered and divided. Additionally,
and divided distal to the tie, so the distal nerve stump partial myotomy of the LCA muscle fibers is performed with
remains free for anastomosis with the ansa cervicalis microscissors to lessen the chances of symptom recurrence
nerve. The proximal adductor nerve stump is dissected (Fig. 5). The muscle is easily accessed just medial to the
backwards to the posterior edge of the trapdoor window divided adductor RLN within the trapdoor window as it runs
and secured out of the larynx by securing this tie using from the cricoid cartilage anteroinferiorly to the muscular
a French-eye needle to outer perichondrium. Securing process of the arytenoid cartilage posterosuperiorly (Fig. 5).
the proximal nerve branch outside the larynx is expected Typically, 15% to 50% myotomy is performed depending
to prevent it from reinnervating the larynx by the native upon the severity of ADSD (more myotomy is performed for
RLN axons (Fig. 4). more severe voice breaks symptoms).
1218 Voice and Laryngotracheal Surgery

Fig. 5: Cadaveric larynx showing arrangement of the

Fig. 4: Selective adductor denervation and reinnervation, intrinsic laryngeal muscles (left larynx). LCA myotomy is
showing the proximal adductor branch of the RLN exteriorized performed during surgery for adductor SD as described in
and the distal thyroarytenoid nerve stump anastomosed to a the text (CT: Cricothyroid; LCA; Lateral Cricoarytenoid; PCA:
branch of the ansa cervicalis nerve (LCA: Lateral Cricoarytenoid; Posterior Cricoarytenoid; RLN: Recurrent laryngeal nerve;
TA: Thyroarytenoid; RLN: Recurrent laryngeal nerve) TA: Thyroarytenoid)

Next, the nerve anastomosis from ansa cervicalis to of their abilities immediately. The duration of breathiness
distal RLN is performed (Fig. 4). The free nerve end is is 1 month to 2 months, until laryngeal reinnervation
tunneled under the strap muscles to reach the laryngeal occurs. The rare patients, with persistently breathy voice,
trapdoor. Anastomosis is performed without tension are attributed to excessive LCA myotomy or failure of nerve
using two to three epineural sutures of 8-0 nylon. Prior to regeneration. One patient developed a more generalized
replacing the trapdoor cartilage, a small cartilage piece cervical dystonia and subsequently, experienced recurrent
from the posteroinferior corner is removed by rongeur to voice spasms mediated by the ansa cervicalis nerve. Lysis
make space for passage of the ansa cervicalis nerve into of the ansa anastomosis eliminated the voice breaks.5
the larynx.
The cartilage trapdoor window flap is then replaced
and secured with 4-0 permanent suture in the outer
SPECIAL INSTRUMENTS USED FOR
perichondrium. A passive drain is typically placed and THE SURGERY
removed on the first postoperative day. Muscle and skin A sagittal saw is useful to make the laryngotomy window,
are closed in layers. especially in ossified larynges. Loupe magnification
is required for identification of the intralaryngeal
adductor RLN branch and for neural anastomosis. Some
COMPLICATIONS surgeons prefer a microscope for the neurorrhaphy. Fine
Complications, such as the usual risks of infection or microsurgical instruments, capable of handling the 8-0
bleeding when operating in the neck, are very rare. Specific suture, are needed for the neurorrhaphy and should
to this surgery, transient postoperative dysphagia is very be used only for that purpose. A French-eye needle is
common and should be anticipated by administering helpful when stitching the proximal RLN tie to the external
a modified diet (typically, nectar thick liquids and soft perichondrium of the thyroid cartilage. Intraoperative
solids) until the patient is clinically able to swallow thin laryngeal electromyographic monitoring using an EMG
liquids safely. Occasional patients may demonstrate a safe endotracheal tube assists with locating the laryngeal nerve.
swallow as early as the first postoperative day but more
commonly, a few days of thickened liquids and aspiration
precautions are required. Permanent dysphagia or
OTHER TREATMENT OPTIONS
aspiration has not occurred in the authors’ patients. Botulinum toxin injections remain the most common
The voice is expected to be very breathy postoperatively, treatment, usually administered at intervals of 2 months to
but free of spasms. Patients may resume voicing to the best 6 months.6 Other surgical treatments included complete
 Selective Laryngeal Adductor Denervation-Reinnervation Surgery for Adductor Spasmodic Dysphonia 1219

unilateral RLN sectioning,7 which has a high long-term 6. Blitzer A. Spasmodic dysphonia and botulinum toxin:
recurrence rate.8 Thyroarytenoid muscle myotomy can experience from the largest treatment series. Eur J Neurol.
reduce the adductor force leading to voice breaks but does 2010;17 Suppl 1:28-30.
risk both breathy voice and recurrent spasms.9,10 Type II 7. Dedo HH. Recurrent laryngeal nerve section for spastic
thyroplasty, to separate the vocal folds, is performed but dysphonia. Ann Otol Rhinol Laryngol. 1976;85(4 Pt 1):451-9.
has not proven effective in the authors’ experience.11-13 8. Aronson AE, De Santo LW. Adductor spastic dysphonia:
three years after recurrent laryngeal nerve resection.
REFERENCES Laryngoscope. 1983;93(1):1-8.
9. Koufman JA, Rees CJ, Halum SL, et al. Treatment of
1. Chhetri DK, Berke GS. Treatment of adductor spasmodic
dysphonia with selective laryngeal adductor denervation adductor-type spasmodic dysphonia by surgical myectomy:
and reinnervation surgery. Otolaryngol Clin North Am. a preliminary report. Ann Otol Rhino Laryngol. 2006;
2006;39(1):101-9. 115(2):97-102.
2. Berke GS, Blackwell KE, Gerratt BR, et al. Selective laryngeal 10. Su CY, Chuang HC, Tsai SS, et al. Transoral approach to laser
adductor denervation-reinnervation: a new surgical treat- thyroarytenoid myoneurectomy for treatment of adductor
ment for adductor spasmodic dysphonia. Ann Otol Rhinol spasmodic dysphonia: short-term results. Ann Otol Rhino
Laryngol. 1999;108(3):227-31. Laryngol. 2007;116(1):11-8.
3. Chhetri DK, Mendelsohn AH, Blumin JH, et al. Long- 11. Isshiki N, Tsuji DH, Yamamoto Y, et al. Midline lateralization
term follow-up results of selective laryngeal adductor thyroplasty for adductor spasmodic dysphonia. Ann Otol
denervation-reinnervation surgery for adductor spasmodic
Rhinol Laryngol. 2000;109(2):187-93.
dysphonia. Laryngoscope. 2006;116(4):635-42.
12. Isshiki N, Sanuki T. Surgical tips for type II thyroplasty
4. Chhetri DK, Berke GS. Ansa cervicalis nerve: review of the
topographic anatomy and morphology. Laryngoscope. for adductor spasmodic dysphonia: modified technique
1997;107(10):1366-72. after reviewing unsatisfactory cases. Acta Otolaryngol.
5. Deconde A, Long JL, Armin B, et al. Functional 2010;130(2):275-80.
reinnervation of the vocal cords after selective laryngeal 13. Yumoto E, Minoda R, Kadoma N, et al. Effects of type II
adductor denervation-reinnervation surgery for spasmodic thyroplasty on adductor spasmodic dysphonia. Otolaryngol
dysphonia. J Voice, in press. Head Neck Surg. 2010;142(4):540-6.
1220 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1220
CHAPTER

134 Medialization Laryngoplasty

(Thyroplasty)
Michael S Benninger

INTRODUCTION Laryngeal electromyography (EMG) is very useful in

helping to predict outcome and in aiding in trying to deter-
The management of unilateral vocal-fold immobility mine the timing of those outcomes. In general, permanent
requires an assessment of many factors including the procedures are delayed until the likelihood of recovery
degree of innervation of the vocal fold, whether or not it becomes very small. An EMG at 6 months is a good time
is fixated, the timing since injury, and the likelihood of frame. At that time, an EMG that shows no innervation,
recovery. A careful evaluation with or without imaging and minimal reinnervation, or some reinnervation with poor
the results of laryngeal electromyography all play a role in recruitment are all such poor long-term prognostic signs
clarifying the etiology and helping to predict recovery.1 that proceeding with permanent procedure is reasonable.
Similarly, complex are the considerations that are made No matter what intervention is recommended, whether
for treatment. There are multiple things that should be it is medical, functional or surgical, it is very important to
both assessed and deliberated before treatment is under- obtain reproducible data to compare preintervention and
taken. A few of the more important are the likelihood postintervention results. Although there are many tests
and potential timing of recovery, the severity of the voice that can be performed, the author and associates always
and/or swallowing disorder, the results of laboratory and obtain three evaluations: (i) Laryngeal stroboscopy which
quality of life surveys, the position of the vocal fold in is recorded in a reproducible fashion for comparison;
relationship to the other fold, the function and bulk of the (ii) Maximum phonatory time (MPT) and; (iii) Quality
normal vocal fold and, most importantly, the patient’s need of life assessment with the voice handicap index (VHI).4
and desire for improvement. As can be seen, the decision These allow the author and associates to assess vibration,
making process for the management of a unilateral vocal airflow, closure and patient perception of quality of life
fold paralysis is complex and has multiple considerations. impact. The VHI also allows for comparison with other
The treatment of these patients also requires consi­ studies. The MPT could also potentially allow for compari-
deration of multiple treatment options. There is recent and son with other studies, although the methods of obtaining
growing evidence that the early medialization of the vocal these values vary between groups which may limit some-
folds may improve long-term results, even if the vocal fold what direct comparisons. It does give a very good evalu-
does not recover.2,3 This may have to do with the ability ation between preoperative and postoperative results in
to return the immobile vocal fold to a medial position, an individual patient and allow for a good measure of the
where more normal function can occur and hyperfunc- effectiveness of medialization in a patient who is having a
tion and aberrant vocal fold motion may be prevented. procedure under local anesthesia in the operating room or
Because of this, it is common to proceed with an early with office-based injection procedures.
injection of a resorbable injectable material in order to Medialization laryngoplasty (ML) has been routinely
return the patient to more normal voice and swallowing performed since first described by Isshiki.5 There have
function while the ultimate motion of the vocal fold had been multiple different techniques described as well
not been definitively determined. This is particularly true as multiple materials used to medialize the vocal fold.
in patients who are aspirating early after loss of function. Despite the magnitude of the papers that describe these
Although this is a reasonable approach and one that we procedures, few show any objective results after medializa-
will often take, this early intervention approach has the tion. The author and associates’ results following ML show
disadvantage that final treatment may need to be delayed dramatic reduction of average VHI scores from 70.9 to 31.6
to allow for the injected material to completely resorb and improvements in average MPT scores from 9.3 to 20.6.
prior to implementing the definitive treatment. These results validate that this technique is effective in
 Medialization Laryngoplasty (Thyroplasty) 1221

improving voice and voice related quality of life. Of inter- that the voice and the position of the prosthesis can be
est, these scores would seem to gradually improve over used to make interoperative modifications and maximize
time after medialization. Although long-term follow up the results. There are different approaches to anesthesia,
was only available in a subset of patients, the author and but the author and associates elect to limit the amount
associates have seen gradual improvement of both VHI of sedation only to the very beginning of the case so that
and MPT scores over the first year postoperatively. the pain from the local anesthetic can be minimized. A
Although there are a number of materials that are small amount of a short-acting sedation, like propofol,
described to medialize the vocal folds, the author and will permit anesthesia but have the patient awake for the
associates prefer to use carved silastic (solid silicone). The remainder of the case. The author and associates use a
reasons for this are multiple. Carving prosthesis for each total of 20 mL of 1% xylocaine with 100,000 of epinephrine
patient allows for an individualization of the results based mixed 50:50 with one-fourth percent Marcaine. The skin
on the size of the thyroid cartilage and larynx, and the is injected for the suture line, in the soft tissues deep to
angle of the anterior thyroid cartilage. If the prosthesis is the incision and down to the thyroid cartilage. Since the
too large or too small, it can be modified during the opera- Marcaine is cardiotoxic, the needle is aspirated before
tion. If the window is slightly in the wrong position, there is injecting. The injections are performed prior to setting up
the ability to modify the prosthesis to allow the implanted the rest of the case.
portion to align with the vocal fold but still fit the window.
Finally, the position of the implant at the time of surgery
will be maintained after surgery as it is held in place by
SURGICAL STEPS
the inner perichondrium and muscle medially and the The approach to the surgical management with a ML may
thyroid cartilage laterally, and it cannot rotate based on vary between practices but it is best within a practice to
the way it is wedged in the window. One of the disadvan- standardize the setup, the anesthesia and the specifics
tages of carved silastic is that it truly takes significant expe- of the techniques as much as possible in order to be able
rience in carving the prosthesis to be able to judge location to maximize efficiency and to modify results as needed.
and size. If done properly, the author and associates have Repetition will also improve results over time.
found that it can often push the vocal process medialize so
that over time, they have performed less arytenoid adduc- Setup
tion (AA) procedures. The surgery is performed with the patient in a supine posi-
Although there are other implanted materials and tion. Once the patient arouses from the sedation and after
devices, there are disadvantages to silastic. Gortex is easier the local injections, the nose is sprayed with oxymeta­
to use and place, and has the similar advantages as silastic zoline and 4% xylocaine. A flexible video laryngoscope
as it can be adjusted based on the observation of the larynx is passed through the nose, preferably on the side oppo-
and the quality of voice. One major disadvantage of gortex site from the paralysis, if possible. The laryngoscope is
is that once the tunnel has been created, the position of the suspended so that the larynx can be visualized through the
gortex is determined. If it is too large or too high or low, it is entire case. After the neck is prepped, a sterile see-through
hard to hold the gortex in the preferred position. In addi- drape is used to isolate the patient’s face from the field but
tion, the author and associates have found that the results still allow for communication with the patient through-
at surgery decrease slightly over time, likely because of out the case (Fig. 1). The remainder of standard surgical
compression of the gortex with use. It may be necessary drapes are then applied.
to slightly overcorrect the implantation to allow for this
gradual change. The prefabricated implants have multiple Surgical Technique
disadvantages. They are expensive, and size specific, so All patients receive 10 mg of decadron and an antibiotic
they are difficult to modify. If the size is not correct, then prior to incision. A horizontal incision is designed usually
an additional prosthesis would need to be used, adding about 7–8 cm long, beginning just lateral to the midline
additional cost. Even with a few sizes, the implant might on the noninvolved side and extending laterally on the
not be correct for some patients. involved side to about the lateral aspect of the thyroid
cartilage. Although it is nice to look for a visible skin line
to maximize the postoperative cosmetics, the optimal
ANESTHETIC CONSIDERATIONS location is about at the midpoint of the thyroid cartilage
The best way to perform ML is under local anesthesia. (Fig. 2). The incision is carried through the skin, subcu-
This allows the patient to cooperate with the surgeon so taneous tissue and platysma until the strap muscles are
1222 Voice and Laryngotracheal Surgery

Fig. 1: The setup with the patient in position and the Fig. 2: Location of the incision at the midpoint of the thyroid
endoscope placed through the nose. This is in a sterile cartilage, extending from just lateral to the midline on the
fashion, so that the vocal folds can be visualized throughout uninvolved side and then extending 5–7 cm in length
the case

identified and are separated in the midline. The muscles

should be retracted to allow full exposure of the thyroid
cartilage on the involved side and a small amount on the
other side. In patients with significant neck musculature,
a small cut may need to be made on the muscles above
and below the thyroid cartilage. If necessary, to provide
adequate exposure, a small amount of muscle can be
resected. Once the cartilage is exposed, a vertical cut
is made in the perichondrium in the midline, from the
notch to the lower edge and then over the upper and lower
thyroid cartilage extending laterally. The perichondrium
is then elevated with a freer or Cottle elevator. If an AA is
going to be performed, then good posterior exposure is
needed.
The mid portion of the thyroid cartilage is measured
from the notch to the lower edge and at the midpoint of
this distance, a small mark is made. There is often a slight Fig. 3: Location of the window. A point is located, which is
indentation in the thyroid cartilage in this location which at the midpoint of the thyroid notch to the inferior cartilage, in
corresponds to the insertion of Broyles’ ligament. The the midline of the thyroid cartilage. The upper-medial edge of
the thyroplasty window is measured laterally to this midpoint.
upper-medial edge of the thyroplasty window is measured
This is usually 6–7 mm for a woman and 7–8 mm for a man.
laterally to this midpoint (Fig. 3). This is usually 6–7 mm
From this point, the line is carried vertically for about 5 mm
for a woman and 7–8 mm for a man depending on the size and posteriorly for about 9–10 mm
of the person and their thyroid cartilage. From this point,
the line is carried vertically for about 5 mm and poste-
riorly for about 9–10 mm. A needle tip bovie is useful in
drawing out the window. The lower edge should leave at tends to gradually extend inferiorly, the window may have
least 2–3 mm of thyroid cartilage to prevent the cartilage a slightly inferiorly-tilted angle as it extends posteriorly
from breaking as the prosthesis is placed. This is particu- (Fig. 4).
larly true in soft, noncalcified cartilage. The upper window Once the window is drawn, window needs to be
should not be above the midpoint. Since the lower edge opened until the inner perichondrium of the thyroid
 Medialization Laryngoplasty (Thyroplasty) 1223

Fig. 4: The size of the prosthesis as it Fig. 5: The position of the prosthesis at the level of the
locks into the thyrotomy window vocal fold. This is placed low enough so that it does not
prolapse the ventricle

cartilage is reached. If the cartilage is thin and not well

calcified, a beaver blade can be used to cut through the
cartilage. If more calcified, a small cutting drill may be
needed. It is important to make sure that the entire rectan-
gular window is opened. A 1-mm Kerrison rongeur may
be helpful for cutting out the corners. The inner perichon-
drium is elevated in all four directions, but only a few
millimeters in the superior, inferior and anterior direction.
Posteriorly, it needs to be opened widely enough to allow
the prosthesis to move the vocal process of the arytenoid.
Ideally, the perichondrium should be conserved and not
cut, although small tears will not cause much harm.
Carving the prosthesis is the most critical part of the
procedure. Solid silicone (silastic) is easy to carve and
holds its shape. In general, the prosthesis should be
20–22 mm long for a woman and 22–25 mm for a man. The Fig. 6: The prosthesis in position medializing the vocal
height should be about 4 mm in order for the prosthesis fold and vocal process of the arytenoid
to fit in the 5-mm window (Fig. 4). The maximal mediali-
zation is dependent on the amount of medial movement The determination as to whether the prosthesis is
necessary. Although this can vary, a good starting point appropriate should be made on a combination of assess-
is 5–6 mm of maximal medialization for a woman and ments; the quality of the voice, the appearance of the loca-
6–8 mm for a man (Figs 5 and 6). The prosthesis should be tion of the prosthesis and the amount of medialization
carved so that the outer fixed portion should fit easily but by the laryngoscopy, and the MPT. Although an excellent
snuggly in the window, so that the prosthesis cannot move voice on the operating table is an indication of a good
either in the horizontal or vertical direction (Figs 4 to 6). prosthesis size and placement, it often does not occur
In this fashion, and unlike gortex, once the prosthesis is even with a good prosthesis. Many patients have devel-
placed, it will be held firmly in position and will not move. oped compensatory behavior over a long time that are not
Two important concerns are to make sure that the pros- expected to correct in a few minutes on the OR table. In
thesis is neither too high, extending into the ventricle, nor addition, many patients have a vocal fold paralysis from
too anterior resulting in a bowed anterior segment (Figs 4 lung surgery or have reduced pulmonary reserve, where
to 6). Either of these will result in a poor outcome. the position makes it difficult for them to support the voice.
1224 Voice and Laryngotracheal Surgery

In such cases, the position can be confirmed by visualizing An AA can be performed at the same time as silastic
the larynx, where a midline position would predict a good medialization. Although many surgeons perform this rela-
outcome. A dramatic improvement of MPT, particularly if tively routinely, the author has found that there are very
it is above 20 seconds, is also a strong indication of good few cases where this is needed. A well carved and placed
long-term results. If all of these suggest that the prosthesis silastic implant will serve to correct almost all glottal gaps.
is too small or not posterior enough, the prosthesis can be In addition, there are no reported series of AA either with
removed and the initial one can be used as a template to or without silastic that are better than those described by
carve a larger prosthesis. If the prosthesis is too large, it the author’s procedure above. Nonetheless, in the rare
can be removed and trimmed to a smaller size. cases that this is needed, the silastic is carved and placed
Once it is determined that the prosthesis is adequate, as noted above, and then removed. Posterior window is
the wound is irrigated with saline, a small passive drain made in the thyroid cartilage (Fig. 8) exposing the aryt-
is placed deep to the strap muscles and above the thyrot- enoid, and a stitch is placed and pulled forward and tied
omy, and the strap muscles are loosely approximated. The in a location that will allow rotation of the vocal process to
author and associates do not close the outer perichon- rotate medially and at a vertical plane that is at the same
drium. Subcutaneous tissues are closed with interrupted level of the other side (Figs 9 and 10). An AA can be done
4-0 vicryl sutures and a 5-0 running fast absorbing gut independently, where the suture would be tied into posi-
is used to close the skin. Antibiotic ointment is applied tion after confirming the amount of tension on the suture
followed by a small strip of telfa and a pressure dressing. by both visualization and listening to the patient voice and
If it is determined that the defect is small enough, here MPT. In most cases, silastic is used with the AA and in such
gortex can be used; a smaller thyrotomy is made at the cases, the silastic is then replaced and vocal-fold position
anterior portion of the window described above of about is verified, at which time the suture can be tied through the
4 mm in height and no more than 5 mm in length. The thyroid cartilage.
elevation of the inner perichondrium is only posterior, and The patients do not go to recovery room and return
the gortex is carefully packed posteriorly, taking time after directly to the in and out center. The author and associates
each small amount is packed to make sure that the gortex reevaluate the larynx 2–3 hours after the surgery. If there
is not too high or overpacked (Fig. 7). Unlike silastic, where is no swelling or significant bruising, they are discharged
modifications can be easily made, a high gortex implant or to home. If they come from a long distance, which many
one that is overcorrected make it very difficult to correct. of their patients do, they are discharged to a local hotel.
Once placed, the gortex can be held in place with a stitch Only patients who have bilateral medializations or those
through the cartilage at the level of the window. that have an AA are admitted to hospital for 24 hours. They

Fig. 7: Gortex packing through the thyrotomy window Fig. 8: A posterior window is created to allow
medializing the vocal fold exposure to the arytenoid
 Medialization Laryngoplasty (Thyroplasty) 1225

Fig. 9: A stitch is placed in the posterior arytenoid to allow Fig. 10: With the stitch in place in the posterior arytenoid,
for rotation of the vocal process to the midline, further it can be pulled anteriorly until the medial position of the
medializing the vocal fold vocal fold is confirmed with visualization and listening to the
voice. After the silastic is placed, the suture can be tied to
hold in position

are seen back the next day for dressing and drain removal; and cut the prosthesis and to define the thyroid cartilage
steristrips are applied and a light pressure dressing is window, a small ruler and calipers will be needed.
placed for an additional 24 hours. They can get the inci-
sion wet and if there is any drainage from the drain site, a
small dressing or band aid can be applied. They are asked
REFERENCES
to use their voices carefully and with no heavy lifting or 1. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immo-
straining for 10 days. They are seen back for follow-up in bility: a longitudinal analysis of etiology over 20 years.
6 weeks if there are no problems. Laryngoscope. 2007;117(10):1864-70.
2. Friedman AD, Burns JA, Heaton JT, et al. Early versus late
injection medialization for unilateral vocal cold paralysis.
SPECIAL INSTRUMENTS USED Laryngoscope. 2010;120(10):2042-6.
FOR THE SURGERY 3. Arviso LC, Johns MM 3rd, Mathison CC, et al. Long-term
There is not much need for specialized equipment to outcomes of injection laryngoplasty in patients with
perform an ML, although there are some sets available potentially recoverable vocal fold paralysis. Laryngoscope.
to purchase. In most cases, a drill will be needed to cut 2010;120(11):2237-40.
through the thyroid cartilage, especially in men where 4. Jacobson BH, Johnson A, Grywalski C, et al. The voice hand-
calcification is common. Small Kerrison rongeurs are icap index (VHI): development and validation. J Speech-
helpful once the initial window is made and small eleva- Lang Path. 1997;6:66-70.
tors allow for elevation of the inner perichondrium. A 5. Isshiki N, Morita H, Okamura H, et al. Thyroplasty as a
typical tympanoplasty/mastoidectomy set has much of new phonosurgical technique. Acta Otolaryngol. 1974;78
the instruments that can be of value. In order to design (5-6):451-7.
1226 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1226
CHAPTER

135 Silastic Medialization

Laryngoplasty (Type 1 Thyroplasty)
Abir K Bhattacharyya, Ahmad Abu-Omar

INTRODUCTION Patients with minor degree of glottic insufficiency

(< 1 mm glottic gap on phonation) who have minimal
Medialization laryngoplasty (ML) is the most commonly voice symptoms such as vocal fatigue are better suited for
performed laryngeal framework surgery. It is typically injection augmentation and voice therapy.
undertaken to correct different etiological causes of glottic
insufficiency. The aim of this procedure is to improve voice Timing of Surgery
quality and protect the airway by achieving improved glot- In unilateral vocal fold paralysis, surgery is performed
tic closure during phonation and swallowing. An implant after 6–12 months to allow for spontaneous recovery.
material is employed in the paraglottic space to displace Early medialization, i.e., after 3 months, can be consid-
the affected vocal fold medially into a more favorable ered in patients with complete nerve transection, severe
phonatory position. neuronal degeneration identified by laryngeal electromyo­
Silastic medialization laryngoplasty (SML) is designed graphy, or when there is little chance of recovery of vocal
to be a long-term treatment. However, it should be noted fold mobility.
that this procedure is fully reversible as the implant can be
removed if vocal mobility returns.
ANESTHETIC CONSIDERATIONS
Local anesthesia is usually the preferred option to carry
INDICATIONS FOR THE SURGERY out this procedure. The main advantages are auditory
Symptomatic glottic insufficiency (dysphonia and/or feedback from the patient to fine-tune the size and
aspiration) due to: placement of the implant and to prevent overmedi-
• Unilateral vocal fold paralysis alization and airway compromise. Reported cases
• Unilateral or bilateral vocal fold paresis of airway compromise are usually carried out under
• Vocal fold atrophy. general anesthesia and the problem is only identified
in recovery as the patient awakes. It is essential to work
Contraindications with the same anesthetist regularly and to develop a
• Malignant disease of the laryngotracheal complex team approach.
• Poor abduction of the contralateral vocal fold
• Vocal fold lesion.
SURGICAL APPROACH
Relative Contraindications Infiltrate the local anesthetic generously from the hyoid
• Previous history of radiotherapy to the larynx. bone down to the cricoid cartilage on the side of the
intended surgery.
Place a horizontal skin crease incision 5–6 cm in length
SPECIFIC PREOPERATIVE at the level of the mid-thyroid cartilage after sterile prepa-
EVALUATION ration of the neck and flexible nasendoscopy assessment.
(Figs 1 to 3).
Patient Selection Raise subplatysmal flaps superiorly to the hyoid bone
The ideal patient has moderate to severe glottic insuffi- and inferiorly to the upper part of the cricoid cartilage.
ciency (≥ 2 mm to 3 mm glottic gap on phonation) mani- Divide the midline raphe of the strap muscles to expose
fested by weak, breathy dysphonia and/or dysphagia. the thyroid cartilage (Fig. 4).
 Silastic Medialization Laryngoplasty (Type 1 Thyroplasty) 1227

Fig. 1: Horizontal skin incision at the level of Fig. 2: Lateral view with minimal extension
mid-thyroid cartilage and rotation of the neck

Fig. 3: Skin incision for thyroplasty Fig. 4: Dividing the raphe between strap muscles
to expose the thyroid cartilage

Place a single prong hook through the cartilage strut below the window, which should be at least 3 mm
under the thyroid notch, rotating the larynx towards the high to prevent fracture.
contralateral side to the paralysis, bringing the entire Consider gender‐related differences in the configu-
cartilage framework of the hemilarynx into view (Fig. 5). ration of the thyroid cartilage. In males, the vocal folds
are longer and the thyroid alae form a more acute angle
Level of Vocal Fold when compared with the female larynx. Therefore, a
A critical task is to identify the level of the vocal fold in rela- more posterior location of the cartilaginous window in
tion to the thyroid lamina. The level of the cord lies closer the male larynx is required to avoid excessive displace-
to the lower border of the thyroid cartilage and not at its ment of the anterior one third of the vocal fold, which
midpoint (Fig. 6). will result in strained voice. The leading edge of the
It is important to place the thyroplasty window at the window is placed 5 mm posterolateral to the midline
most inferior location possible. The inferior limit of place- of the thyroid cartilage in females and 7 mm in males
ment is determined by the integrity of the cartilaginous (Figs 7A and B).
1228 Voice and Laryngotracheal Surgery

Fig. 5: Rotating the cartilage to visualize the hemilarynx Fig. 6: Identifying the level of the vocal fold (I: Thyroid
incisura; UM: Upper margin of the thyroid lamina; LM: Lower
margin of the thyroid lamina)

A B
Figs 7A and B: Position of the cartilaginous window in (A) females and (B) males

Incise the outer perichondrium of the thyroid cartilage thyroid cartilage. Placement of the window any higher may
with a No. 15 blade and raise a posteriorly-based flap with result in medialization of the false vocal fold or ventricular
a Cottle or Freer elevator (Fig. 8). mucosa with poor voice results. The leading edge of the
Divide the muscle fibers from the cricothyroid muscle window is placed 7 mm posterolateral to the midline of
using bipolar diathermy and a No. 15 blade to expose the the thyroid cartilage in men and 5 mm in women (Fig. 10).
inferior border of the thyroid ala. Remove the window of cartilage with a No. 15 blade,
Kerrison rongeur or drill as necessary depending on laryn-
Size and Position of the Thyroplasty Window geal calcification. In younger patients, the cartilage is soft
Outline a 6 mm by 13 mm window in the thyroid carti- and can be removed with a No. 15 blade provided that
lage using a window-size gauge instrument (Fig. 9). The no penetration of the inner perichondrium occurs with
window is placed 3 mm above the inferior border of the resultant paraglottic bleeding (Figs 11 to 13).
 Silastic Medialization Laryngoplasty (Type 1 Thyroplasty) 1229

Fig. 8: Elevating the outer perichondrium

Fig. 9: Outlining the cartilaginous window with a template

Fig. 10: The implant position marked Fig. 11: Removing the cartilaginous window
on the thyroid cartilage with a No. 15 blade

Elevate the inner perichondrium deep to the window in perforation into the airway through the very thin and
to expose the thyroarytenoid muscle fascia. An intact closely adherent ventricular mucosa (Fig. 15).
inner perichondrium remains tightly bound to the thyroid
cartilage and provides great resistance to medialization. A Implant Design
Duckbill elevator can be used for this purpose (Fig. 14). Carve the implant from a medium-grade silastic block. A
Develop a surgical plane with the “Long elevator” preformed 20-mm wedge blank (Medtronic, Xomed) can
(right-angle soft tissue elevator) within the paraglottic­ be obtained to shorten surgical time (Fig. 16).
space, just superficial to the thyroarytenoid fascia and Measure the distance from the anterior edge of the
extend it in all directions around the window except window to the point of maximal medialization (typically
anteriorly. Dissection anterior to the window may result 11–13 mm in males and 6–10 mm in females)—distance
1230 Voice and Laryngotracheal Surgery

Fig. 12: Kerrison rongeur used to remove the Fig. 13: Drill used in cases where the cartilage is calcified
window of cartilage

Fig. 14: Elevating the inner perichondrium Fig. 15: Developing a plane around the window in all
directions except anteriorly

“A” (Figs 17A and B, and 18B). Place a dot with a mark- the portion of the implant displacing the thyroarytenoid
ing pen. muscle medially. Segment “D” corresponds to the poste-
Extend a line into the substance of the block—distance rior extension of the implant, which helps to hold it in place
“B”, which corresponds to the depth of medialization. This (Fig. 19).
measurement was obtained using the depth gauge and is Use a No. 10 blade to cut along the lines “C” and “D”,
typically 5–7 mm in most patients (Figs 18A and B). removing the excess portion of the block. Make sure these
Draw a line connecting the tip of the line “B” with both cuts are performed at 90° to maintain the integrity of the
the anterior and posterior portions of the block—measure­ depth of the implant (Fig. 20).
ments “C” and “D”. This creates a characteristic triangular There may be slight variations in the design of the
shape of the implant, with the edge “C” corresponding to implant according to the individual surgeon’s preference.
 Silastic Medialization Laryngoplasty (Type 1 Thyroplasty) 1231

A small 1–2 mm edge may be left at the border between

the triangular section and the base giving thickness to the
flange for achieving a better fit (Figs 21A and B).
Mark the implant border, which corresponds to the
plane of medialization with the plane of the true vocal
fold. In general, this is the inferior border of the window
space (Fig. 22).
Draw a line along the medialization zone in the middle
of the implant and remove using a No. 15 blade. Preserve a
3-mm strip along the indicated line. The implant is ready
for placement (Figs 23A and B).

Fig. 16: The Silastic implant

A B
Figs 17A and B: Outlining distance “A”

A B
Figs 18A and B: (A) Outlining distance “B”; (B) Diagrammatic representation of distances “A” and “B”
1232 Voice and Laryngotracheal Surgery

Fig. 19: Outlining distances “C” and “D” Fig. 20: Shaping the implant by removing the
excess portion

A B
Figs 21A and B: Design and size of the Silastic implant

implant should be removed and trimmed. Conversely,

Implant Placement
if the voice sounds breathy, then the implant can be
Place the implant through the window using two Adson displaced posteriorly.
forceps. Advance the posteroinferior part of the implant Secure the implant to the thyroid cartilage with a
into the paraglottic space first. The implant is locked into permanent suture (Fig. 26).
position with the flanges (Figs 24 and 25). Achieve hemostasis and close all layers sequentially
Once in place, check the patient’s voice and observe including outer perichondrium, strap muscles, platysma
the videolaryngoscopic image to ensure that the mediali- and skin. A drain is usually not necessary.
zation recreates what was achieved with the depth gauge.
If the voice sounds “strained”, the anterior portion should Perioperative Care
be pulled out of the window slightly. If this improves the Intravenous dexamethasone should be given periop-
voice, there is too much medialization anteriorly and the eratively followed by two additional doses at 8 hours and
 Silastic Medialization Laryngoplasty (Type 1 Thyroplasty) 1233

16 hours postoperatively to prevent vocal fold edema,

which can potentially lead to partial or complete airway
obstruction. Patients undergoing bilateral medialization
as well as those with previous history of irradiation to the
neck are at increased risk of airway obstruction. Maximal
airway edema occurs within the first 24 hours after
surgery; hence, patients should be admitted for overnight
observation postoperatively. Adequate analgesia should
be prescribed and the head of the bed is elevated.

Postoperative Advice
It is important to warn the patient that the voice may dete-
riorate in the first 12–24 hours due to local edema. This
should settle after 5 days and the voice quality returns.
The voice will continue to improve up to 9 months after
Fig. 22: Outlining the medialization zone surgery as the patient gets used to the new position of the
vocal cord.

A B
Figs 23A and B: (A) Marking the medialization zone; (B) Excising the medialization zone with a No. 15 blade

Fig. 24: Placing the implant through the cartilaginous window Fig. 25: Operative photograph of the implant in situ
1234 Voice and Laryngotracheal Surgery

Fig. 26: Securing the implant with permanent sutures on

the anterior and posterior borders of the implant window
Fig. 27: Instruments used for thyroplasty

Future Operations (4) Angled (Duckbill) elevator to elevate inner perichon-

After the patient’s operation, a waiting period of 6 months drium from cartilage
is advised for elective surgical procedures. The anesthetist (5 and 6) Chisel elevator used to remove soft cartilage
should place the smallest safe endotracheal tube; ideally, for fashioning the window (male and female
size 6.0 or smaller to avoid inducing laryngeal edema from sizes)
a slightly constricted glottic aperture. (7 and 8) Window outline instrument, male and female

COMPLICATIONS OTHER TREATMENT OPTIONS

AVAILABLE
• Bleeding
• Infection Injection Medialization procedures are also employed
• Airway obstruction to correct glottal gaps particularly of the anterior and
• Implant extrusion middle third of the vocal fold. Arytenoid adduction
• Poor voice result due to: techniques and their modifications are used to correct
– Persistent posterior glottic gap posterior glottal gaps where the vocal folds may be at
– Undermedialization different levels. This can be combined with Silastic
– Superior implant malposition Medialization Laryngoplasty for optimum results in
– Anterior implant malposition. patients with significant anterior and posterior glottal
incompetence.
SPECIAL INSTRUMENTS USED
FOR THE SURGERY ACKNOWLEDGMENT
Instruments (from left to right) as shown in Figure 27. Mr Serg Pal, MRCS DOHNS, Specialist Registrar in
(1 and 2) Male and female window calipers, male (9 mm) Otol­
aryngology, has contributed to the design and
and female (7 mm) content of this chapter. His contribution is graciously
(3) Elevator to elevate perichondrium from thyroid cartilage acknowledged.
 The Surgical Technique of Otoplasty 1235
CHAPTER

136 Arytenoid Rotation

Jayakumar Menon

ipsilateral thyroid ala along its lower border (Figs 6

INDICATIONS to 15)
Unilateral vocal cord palsy with: • Hemostasis is secured, and wound is closed in layers
• Maximum phonation duration (MPD) less than with a Redivac drain.
4 seconds
• Wide posterior phonatory gap
• Vertical level incompatibility.

SURGICAL TECHNIQUES
• This surgery is generally combined with Type I
thyroplasty
• The incision is extended laterally beyond the lateral
border of the thyroid cartilage
• Strap muscle on the side of operation is divided near
their superior attachment (Fig. 1)
• Posterior border of the thyroid cartilage is clearly
defined (Figs 2 and 3)
• Cricothyroid joint is disarticulated (Fig. 4)
• A rim of thyroid cartilage is removed posteriorly to
expose cricoarytenoid joint (Fig. 5)
• A prolene suture is taken through the muscular process
of the arytenoid and tied over a silastic bolster on the Fig. 2: Freeing the posterior border of the thyroid cartilage

Fig. 1: Dividing the strap muscle Fig. 3: Retracting the freed posterior border
of the thyroid cartilage
1236 Voice and Laryngotracheal Surgery

Fig. 4: Cricothyroid joint disarticulation Fig. 5: Removing a rim of ala

Fig. 6: Palpating the muscular process Fig. 7: A prolene suture through the arytenoid

Fig. 8: Muscular process with suture through Fig. 9: Second throw of suture
through the muscular process
 Arytenoid Rotation 1237

Fig. 10: Passing the wide bore needle Fig. 11: Threading the suture through the needle
through the thyroid ala

Fig. 12: Passing the wide bore needle again through the Fig. 13: Threading the other end of the suture
thyroid ala, at an adjacent site

Fig. 14: Arytenoid suture taken out through Fig. 15: Final anchoring of suture
a small bolster of silastic
1238 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1238
CHAPTER

137 Type I Thyroplasty

Jayakumar Menon

• The author’s choice is intramuscular injection of pethi-

INDICATIONS FOR TYPE I SURGERY dine 1 mg/kg body weight + phenergan 0.5 mg/kg body
• Unilateral vocal cord palsy with phonatory gap/ weight 1 hour before surgery
aspiration • The skin is infiltrated with a solution containing 5 mL
• Sulcus vocalis of 2% xylocaine, 5 mL of 0.5% bupivacaine, and 2 or
• Presbylarynx. 3 drops of adrenaline. It is important to infiltrate the
external perichondrium also.
OTHER PREOPERATIVE
CONSIDERATIONS POSITION
• Stroboscopy showing good mucosal waves • Patient is placed supine with minimal neck extension.
• Improvement of voice with medial compression of
thyroid ala (in young patients only).
SURGICAL TECHNIQUES
CONTRAINDICATIONS OF • Skin incision—along the lower border of thyroid carti-
THYROPLASTY lage for 3 cm on the side of paralysis and extending
across the midline for 1 cm to the opposite side (Fig. 1)
• Irradiated larynx (within 18 months). • Elevation of subplatysmal flaps (Figs 2 and 3)
• Separating the strap muscles in the midline (Fig. 4)
• Expose the thyroid ala (Figs 5 and 6)
ANESTHESIA FOR THYROPLASTY • Clearly, delineate the lower border of thyroid cartilage
• Preferably done under local anesthesia with sedation (Fig. 7)

Fig. 1: Skin incision Fig. 2: Subplatysmal flap

 Type I Thyroplasty 1239

Fig. 3: Subplatysmal flaps are raised Fig. 4: Strap muscles are separated in the midline

Fig. 5: Thyroid ala is skeletonized Fig. 6: Retractor is applied

• Mark the window (Fig. 8) be in line with the midpoint on the midline of thyroid
• Window should be roughly 12 mm × 6 mm in males cartilage (Figs 10 and 11)
and 10 mm × 5 mm in females • External perichondrium over the window is removed
• Anterior end of the window should be 5–6 mm behind (Figs 12 and 13)
the midline (Fig. 9) • Cartilage in the window is removed by using a
• Posterior end should be at least 3 mm in front of the knife/drill (Figs 14 and 15)
oblique line • Internal perichondrium is kept intact (Fig. 16)
• Superior border of the window should be parallel to • At the anterior and posterior ends, small pockets are
the lower border of the thyroid cartilage, and should created deep to the cartilage
1240 Voice and Laryngotracheal Surgery

Fig. 7: Delineating the inferior border of thyroid cartilage Fig. 8: Marking the midpoint of thyroid cartilage

Fig. 9: Upper anterior corner of the window Fig. 10: Marking the superior border of window

Fig. 11: Marking the inferior border of window Fig. 12: Incising the external perichondrium
 Type I Thyroplasty 1241

Fig. 13: Removing the external perichondrium Fig. 14: Drilling out the window

Fig. 15: Cartilage window being removed Fig. 16: Cartilage window is removed. Internal
perichondrium is kept intact

• A suitably sized silastic implant is carved (Fig. 17)

• The length of the implant should be 4 mm longer than
the window, breadth 0.5 mm less than the width of the
window. The depth of the implant varies according to
the size of phonatory gap. Anteriorly very little medi-
alization is required, when compared to the posterior
end (Fig. 18)
• The implant is introduced atraumatically (Figs 19 to 21)
• After obtaining hemostasis, wound is closed in
Fig. 17: Carving the implant layers.
1242 Voice and Laryngotracheal Surgery

Fig. 18: Carved implant Fig. 19: Posterior end of the implant being introduced

Fig. 20: Anterior end of the implant being introduced Fig. 21: Implant in position

COMPLICATIONS OF THYROPLASTY • Improperly positioned implant

• Injury to pyriform fossae
SURGERIES • Injury to internal jugular vein (IJV)
• Fracture of thyroid cartilage • Hematoma
• Extensive injury to internal perichondrium • Infection
• Improperly sized implant • Implant intrusion or extrusion.
 The Surgical Technique of Otoplasty 1243
CHAPTER

138 Type II Thyroplasty

Jayakumar Menon

• The author’s choice is intramuscular injection of pethi-

INDICATIONS FOR TYPE II SURGERY dine 1 mg/kg body weight + phenergan 0.5 mg/kg body
• Only indication is adductor spasmodic dysphonia. weight 1 hour before surgery
• The skin is infiltrated with a solution containing 5 mL
OTHER PREOPERATIVE of 2% xylocaine, 5 mL of 0.5% bupivacaine and 2 or
3 drops of adrenaline. It is important to infiltrate the
CONSIDERATIONS
external perichondrium also.
• Patient not fit for/does not want botulinum toxin
injection.
POSITION
CONTRAINDICATIONS OF • Patient is placed supine with minimal neck extension.
THYROPLASTY
• Irradiated larynx (within 18 months).
SURGICAL TECHNIQUES
• A 3 cm long incision along the lower border of thyroid
cartilage symmetrically extending on either side
ANESTHESIA FOR THYROPLASTY • Subplatysmal flaps are raised
• Preferably done under local anesthesia with sedation • Strap muscles are separated in the midline

Fig. 1: Thyroid alae are separated, taking Fig. 2: Thyroid alae are pulled apart
care not to open internal perichondrium till the satisfactory best voice
1244 Voice and Laryngotracheal Surgery

Fig. 3: Implant in between the alae Fig. 4: Four sutures are passed

Fig. 5: Implant firmly anchored with four sutures Fig. 6: Implant secured in position

• Thyroid ala is cut open in the midline, taking care

COMPLICATIONS OF THYROPLASTY
not to open the internal perichondrium (Fig. 1) SURGERIES
• Using blunt skin hooks, the alae are pulled apart till • Fracture of thyroid cartilage
satisfactory voice is obtained (Fig. 2) • Extensive injury to internal perichondrium
• The distance, at which the voice was best, was meas- • Improperly sized implant
ured and a silastic implant of the same width is kept • Improperly positioned implant
in between the alae in the midline (Fig. 3) • Injury to pyriform fossae
• The implant is kept in position by two prolene • Injury to internal jugular vein (IJV)
sutures on either side (Figs 4 to 6) • Hematoma
• Hemostasis is secured, and wound is closed in • Infection
layers. • Implant intrusion or extrusion.
 The Surgical Technique of Otoplasty 1245
CHAPTER

139 Type III Thyroplasty

Jayakumar Menon

3 drops of adrenaline. It is important to infiltrate the

INDICATIONS FOR TYPE III SURGERY external perichondrium also.
• Only indication is puberphonia, not responding to
voice therapy.
POSITION
OTHER PREOPERATIVE • Patient is placed supine with minimal neck extension.
CONSIDERATIONS
• Adequate trial of voice therapy (Minimum 6 weeks).
SURGICAL TECHNIQUE (FIGS 1 TO 15)
• A 3 cm long incision is taken along the lower border
CONTRAINDICATIONS OF of thyroid cartilage, extending symmetrically on both
THYROPLASTY sides
• Subplatysmal flaps are raised
• Irradiated larynx (within 18 months) • Thyroid cartilage is skeletonized
• A vertical cut is made on the alae on either side at a
distance of 5 mm from the midline, superior to inferior
ANESTHESIA FOR THYROPLASTY border
• Preferably done under local anesthesia with sedation • Care is taken not to damage the internal perichondrium
• The author’s choice is intramuscular injection of • The freed median segment automatically retrudes, and
pethidine 1 mg/kg body weight + phenergan 0.5 mg/kg the pitch becomes low
body weight 1 hour before surgery • A horizontal mattress suture is used to keep the new
• The skin is infiltrated with a solution containing 5 mL alignment in position
of 2% xylocaine, 5 mL of 0.5% bupivacaine and 2 or • Hemostasis is secured, and wound is closed in layers.

Fig. 1: Surface markings for incision Fig. 2: Local anesthetic infiltration

1246 Voice and Laryngotracheal Surgery

Fig. 3: Subplatysmal flap Fig. 4: Investing layer is divided in the midline

Fig. 5: Thyroid cartilage is skeletonized Fig. 6: Midline marking

Fig. 7: Paramedian cuts being marked Fig. 8: Paramedian cartilage cut on

the rim of thyroid cartilage
 Type III Thyroplasty 1247

Fig. 9: Drill being used to cut the ossified cartilage Fig. 10: After incising the cartilage

Fig. 11: Overriding the posterior segment Fig. 12: Median segment retrodisplaced

Fig. 13: Continuous horizontal mattress sutures taken Fig. 14: Suturing completed
1248 Voice and Laryngotracheal Surgery

COMPLICATIONS OF
THYROPLASTY SURGERIES
• Fracture of thyroid cartilage
• Extensive injury to internal perichondrium
• Improperly sized implant
• Improperly positioned implant
• Injury to pyriform fossae
• Injury to internal jugular vein (IJV)
• Hematoma
• Infection
Fig. 15: Closure • Implant intrusion or extrusion.
 The Surgical Technique of Otoplasty 1249
CHAPTER

140 Type IV Thyroplasty

Jayakumar Menon

3 drops of adrenaline. It is important to infiltrate the

INDICATIONS FOR TYPE IV SURGERY external perichondrium also.
• Androphonia not responding to voice therapy
• Bilateral/unilateral external laryngeal nerve palsy.
POSITION
OTHER PREOPERATIVE • Patient is placed supine with minimal neck extension.
CONSIDERATIONS
• Adequate trial of voice therapy.
SURGICAL TECHNIQUES
• A 3 cm long incision is taken along the lower border of
CONTRAINDICATIONS OF thyroid cartilage, but extended laterally on either side
for 1 cm
THYROPLASTY
• Subplatysmal flaps are raised
• Irradiated larynx (within 18 months). • Thyroid and cricoid cartilages are exposed
• A prolene suture is inserted through the space below
the cricoid cartilage (Fig. 1) 5 mm to the midline on
ANESTHESIA FOR THYROPLASTY one side and taken out through the cricothyroid space
• Preferably done under local anesthesia with sedation (Figs 2 and 3). The needle is again, passed through the
• The author’s choice is intramuscular injection of cricothyroid space and brought out through the thyroid
pethidine 1 mg/kg body weight + phenergan 0.5 mg/kg cartilage (Figs 4 to 6). A similar suture is put on the oppo-
body weight 1 hour before surgery site side. Some surgeons prefer two sutures on either
• The skin is infiltrated with a solution containing 5 mL side. Finally, all the sutures are tightened and tied over
of 2% xylocaine, 5 mL of 0.5% bupivacaine and 2 or a silastic bolster on the thyroid cartilage (Figs 7 and 8)

Fig. 1: Defining the lower border of the cricoid cartilage Fig. 2: Defining the cricothyroid space
1250 Voice and Laryngotracheal Surgery

Fig. 3: A prolene suture through the space below Fig. 4: Needle comes out through the cricothyroid space

Fig. 5: Needle goes back through the cricothyroid space Fig. 6: Needle comes out through
the middle of thyroid cartilage

Fig. 7: Suture goes through the silastic bolster Fig. 8: Suture tightened
 Type IV Thyroplasty 1251

• Hemostasis is secured, and wound is closed in layers

(Fig. 9).

COMPLICATIONS OF
THYROPLASTY SURGERIES
• Fracture of thyroid cartilage
• Extensive injury to internal perichondrium
• Improperly sized implant
• Improperly positioned implant
• Injury to pyriform fossae
• Injury to internal jugular vein (IJV)
• Hematoma
• Infection
Fig. 9: Same procedure done on opposite side • Implant intrusion or extrusion.
1252 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1252
CHAPTER
Expertise of Voice Feminization
141 Surgery to 270 Diverse
International Patients
Ornouma Sriwanishvipat, Suthee Rattanathummawat, Egoy-Salvan Lucel

INTRODUCTION vocal F0.4,5 In Yang et al.6 studies, one of the patients said,
“CTA allowed me to have a choice about the gender I am.”
Transgender (also known as transvestites or transsexuals) Voice feminization surgery is becoming increasingly
is the state of one’s “gender identity” not matching one’s sought after by transsexuals/transgender from overseas,
“assigned sex”.1 It is a recognized disorder of gender iden- who fly in specifically to receive this treatment.7 In fact,
tity in which people believed themselves to be born into 76.29% of the authors’ patients are from different countries.
the “wrong” gender body. They hate every aspect of their This study reviews the success rate of the CTA proce-
male bodies and may have a history of self-castration and dure, the authors have performed. Though it was effi-
suicide attempts.2 Their body surgery had been successful; cient to majority of the patients, it was also less efficient
yet, they were still quite distraught about their voice. The to a few.5 However, there was no significant complaint of
acceptance of this disorder has led them to medical and dissatisfaction of the result in the 9-year experience of the
surgical approaches for physical alteration.2 Wagner et al.3 surgeon.
say, “Persistence of a masculine voice contrasting with a This article presents a series of 270 international male
feminine body affects the patient’s quality of life.” to female patients who underwent CTA through a single
For this reason, they resolve to speech therapy. voice surgeon across 9 years of experience.
However, their effort is generally unsuccessful. Finally,
they resolve to voice feminization surgery.3 Kanagalingam
et al.2 affirmed that although much can be done with
METHODS
speech training to achieve perceived femininity in voice
without raising pitch, surgical pitch elevation is often Patients
necessary. They also affirmed, “Although much can be From the year 2002–2011, the total number of 270 male-
done with speech training to achieve perceived femininity female transsexual patients underwent voice feminization
in voice without raising pitch, surgical pitch elevation is surgery. All of them had undergone hormone therapy for
often necessary.” several years; most had undergone gender reassignment
Such patients wish to raise the vocal fundamental as well, and breast augmentation.
frequency (F0) to make their voices more feminine and Patients’ nationalities are Thai, Japanese, English,
therefore enhance their self-esteem and avoid social Australians, Singaporeans, Koreans, Americans, Brazilians,
embarrassment. F0 is the most evident voice quality and Malaysians, Filipinos, Swiss, Italians, Laotians, Iranians,
can be defined as the number of cyclic movements that Irish, Burmese, Saudi Arabians, Kuwaitis, Vietnamese and
vocal folds perform per second expressed in hertz. F0 Chinese; sequence is according to the number of patients
ranges from 100 Hz to 150 Hz in men and from 200 Hz to from the most to the least. The mean age of these patients
300 Hz in woman.4 at the time of surgery was 39 years (range: 25–60 years).
Cricothyroid approximation (CTA)—the feminization Patients were interviewed by the attending physi-
voice surgery—is the technique that increases vocal fold cian and had preoperative video-stroboscopic and voice
tension and increases fundamental voice frequency. This recordings done.
procedure is planned to emulate the function of the vocal The protocol included video-stroboscopy, digital
muscles, the cricothyroids. Evaluating the publications in recording of sustained vowels, a modified voice range
the recent medical literature, we can infer that CTA is still profile and a reading task of a standard passage (rainbow
the most popular and frequently used method to raise the passage).8
 Expertise of Voice Feminization Surgery to 270 Diverse International Patients 1253

Video-Stroboscopy a scalpel, the perichondrium along the inferior border of

the thyroid cartilages is detached.
The authors use Kay Elemetrics (Corp., Lincoln Park, NT, Subluxation of the upper portion of the cricoid arch,
USA), Rigid Laryngoscope code of SN 1898, and Kay View below the lower border of the thyroid cartilage, is needed.
Sonic Graphic Series G90m computer. A scalpel is used to cut into the perichondrium along the
All patients underwent video-stroboscopic exami- anterior edge of the lower border of the thyroid cartilage
nation with two microphones: (i) a throat microphone in a manner similar to thyroid chondroplasty. The peri-
coupled to the patient’s neck and (ii) an acoustic micro- chondrium reflects posteriorly, freeing the thyrocricoid
phone set at a fixed distance from the patient’s mouth to membrane from the lower border of the thyroid laminae.
record patient phonation and track amplitude (dB SPL) This allows subluxation of the cricoid, under thyroid carti-
during phonation. Endoscopy was performed using a tele- lage, to maximize approximation. The contour of the lower
scope with 70° oblique view. border of the thyroid cartilage can be shaped to reduce
The authors applied, (as necessary), a topical anes- hindrance to CTA.3,6
thetic (1% lidocaine) to the pharynx to reduce gagging. The surgeon prefers 0/0 Ethicon suture with a needle
The video-stroboscopy is the standard protocol at both ends. Each needle is inserted through the middle
consisting of observation of laryngeal function during of the inferior border of cricoid cartilage, but must exit
normal respiration, deep inhalation, exhalation, and then the superior border at its anterior edge. The mattress
sustained vowel /I/ at habitual (normal) pitch and loud- sutures are completed by going under thyroid cartilage
ness. F0 was measured on a sustained /a/ “ah” and during and coming out on the surface, below the level of the
the reading of standard text (the rainbow passage). Pitch vocal folds, approximately 5 mm apart. Figures 1 and 2
or jitter was recorded across two trials of the sustained illustrate how these suture placements cause approxima-
vowel task.8,9 Stroboscopy uses a flashing light to create tion and subluxation of laryngeal cartilages. The sutures
a slow motion view of vocal folds allowing the identifica- are tied with multiple knots while under tension. The
tion of vocal folds anatomy, and measures hertz through strap muscles are approximated and overlapped using an
microphones.4 absorbable suture. The skin is closed using a subcuticular
The characteristic pitch or Fo of the male voice ranges monofilament and steristrips.3-6,12
from about 100 Hz to 150 Hz; for the female voice, F0 Patients were under general anesthesia. A broad-spec-
ranges from 200 Hz to 300 Hz. Most patients tolerate this trum antibiotic is administered before surgery and are
procedure with minimal discomfort.3 continued orally for 7 days.5

Post Surgery
SURGICAL TECHNIQUE In other studies, patients were placed on voice rest for
a period of 10 days.6 On the authors’ part, they allowed
Cricothyroid Approximation
patients to start talking after a period of 7 days. All forms
The CTA surgery raises vocal pitch by stimulating crico- of verbal communication were not allowed, including
thyroid muscle contraction through the approximation whispering. Patients were advised to refrain from strenu-
of the cricoid and thyroid.10 This technique is extremely ous activities for at least 3 weeks. Patients’ voices often
popular.4 seemed quite soft, tight or effortful to use. The voices likely
The authors followed the CTA procedure of N Isshiki got worse before they got better.5
et al.10 and then Kanagalingam et al.2 The neck is prepared
and draped in a sterile manner. The surgeon mades a
1.5–2 cm transverse incision, in an existing skin crease over
the cricothyroid (so, the resulting scar will be barely visible
or easily concealed).5,11 A superior and inferior subplatys-
mal dissection is carried out extending from lower border
of the cricoids cartilage to above, the laryngeal promi-
nence. Strap muscles are separated in the midline, and the
anterior aspects of the thyroid and cricoid cartilages are
completely exposed.3,6
The level of the vocal folds at the anterior commissure
is marked at a point halfway from the thyroid notch to the Fig. 1: Cricothyroid approximation (CTA) with
lower border of the thyroid cartilages in the midline. Using 4 pairs of stitches
1254 Voice and Laryngotracheal Surgery

Fig. 2: Anterior and posterior view

In the initial postsurgery week, it was possible that undergoing CTA. They received a favorable feedback with
patient’s voice sounded lower than presurgery or vice the percentage of 90.74.
versa. Initial pain or discomfort from the procedure was In the objective evaluation, it was done via strobos-
present. Patients described symptoms, such as a sore copy comparing the results of feminized voice pitch range
throat sensation and difficulty swallowing, discomfort and of before and after surgery was completed. Majority of
pain, numbness and visible scars. the patients were within the range of feminine voice. The
Two days after the operation, patients had pre- result shows in Tables 1 to 8.
discharge checkup. Seven days after the surgery was the
first postoperative follow-up checkup; suture along neck-
line was removed. At that time, patients were allowed to
RESULT
begin speaking and were advised to use the full voice. All All 270 patients underwent CTA surgery as inpatients.
patients were advised to stay in Thailand for up to 14 days Mean postoperative hospital length of stay was 2 nights
for the second follow-up checkup. (range: 2–3 nights). After transfer from the recovery room,
the patients were stayed 48 hours and monitored closely.3
Voice Pitch Evaluation There were no immediate postoperative complications.
Evaluation was done both subjectively and objectively. Seven patients developed infection, 10 days after surgery;
This was furnished within 2 weeks to 9 years after surgery. the infection was treated with injectable antibiotic.
In subjective evaluation, all of the patients were asked Two years after surgery, one patient (0.37%) verbal-
of their own perceptions regarding overall satisfaction ized of discomfort and unpleasant sensation of the stitch
with their current voice. knot around Adam’s apple area; four pairs of stitches were
The authors have sent an e-mail to 69.25% of the removed as per request; however, her voice frequency was
patients, and 62.96% replied and confirmed they are 262 via video-laryngeal stroboscopy.
happy and satisfied; 5.55% did not reply and 0.74% replied Three years after surgery, there was a drop of voice
with dissatisfaction. pitch (138 Hz), and became hoarse with 1.11% (three
Through personal communications (face-to-face and patients) who tried to talk too much (due to the nature of
telephone calls), the authors asked of the 30.74% of their occupation), drank alcohol, and smoked, but were treated
patients with regard to overall satisfaction with their current timely; voice frequency went back to female range.
voice; 27.78% responded that they were happy and others Four patients’ (1.48%) postoperative recovery was
perceived their voices as female; 2.96% verbalized of dissat- slow after surgery. The pitch was still very high (325 Hz).
isfaction, stated that their expected voice pitch were not met. They went to speech therapy for 1–2 months after the
The authors have noticed that most of the unsatis- surgery, and were improved timely with the average voice
fied patients underwent Adam’s apple shaving, before frequency of 284 Hz after 3 months. Because of this reason,
 Expertise of Voice Feminization Surgery to 270 Diverse International Patients 1255

Table 1: Stroboscopy of voice range frequency before surgery, and 2 weeks after surgery

270 (Total number Age range (Years) Range of fundamental frequency

of participants) Before surgery (Range: 102–157) 14 days after surgery (Range: 272–325)
13 25–30 102–152 284–320
37 31–35 102–157 290–325
168 36–40 106–136 272–313
17 41–45 110–149 296–301
27 46–50 102–157 275–308
8 51–60 109–131 281–304
Mean 39 124 294

Table 2: Stroboscopy of voice range frequency before surgery and 3 months after the surgery
187 (Total number Age range (Years) Range of fundamental frequency
of participants)
Before surgery (Range: 102–157) 3 months after surgery (Range: 260–284)

9 25–30 102–152 261–284

26 31–35 102–157 274–280

124 36–40 106–136 269–283
11 41–45 110–149 264–281
13 46–50 102–157 260–281
4 51–60 109–131 261–272
Mean 38 124 275

Table 3: Stroboscopy of voice range frequency before surgery and 6 months after the surgery
109 (Total number of Age range (years) Range of fundamental frequency
participants) Before surgery (Range: 102–157) 6 months after surgery (Range: 262–284)

9 25–30 102–152 271–273

14 31–35 102–157 269–273
68 36–40 107–133 262–284
5 41–45 110–149 269–276
9 46–50 105–111 266–271
4 51–60 108–117 264–273
Mean 38 121 273
1256 Voice and Laryngotracheal Surgery

Table 4: Stroboscopy of voice range frequency before surgery and 1 year after the surgery
64 (Total number of Age range (Years) Range of fundamental frequency
participants) Before surgery (Range: 105–149) 1 year after surgery (Range: 260–275)
2 25–30 113–120 264–266
6 31–35 109–111 261–268
39 36–40 106–143 260–275
5 41–45 110–149 260–271
7 46–50 105–130 261–265
5 51–60 111–131 263–265
Mean 40 122 266

Table 5: Stroboscopy of voice range frequency before surgery and 2 years after the surgery
48 (Total number Age (Years) Range of fundamental frequency
of participants) Before surgery (Range: 102–149) 2 years after surgery (Range: 254–268)
1 27 112 264
2 31 109–111 261–268
14 38 105–114 260–266
18 39 102–110 259–263
7 42 110–149 254–261
1 43 110 260
1 45 110 261
2 53 108–117 257–261
3 55 109 260–261
Mean 37 113 267

Table 6: Stroboscopy of voice range frequency before surgery and 3 years after the surgery
29 (Total number Age (Years) Range of fundamental frequency
of participants) Before surgery (Range: 102–149) 3 years after surgery (Range: 138–260)

2 33 109–111 242–251
7 38 105–114 244–250
14 40 102–110 138–260
1 42 149 243
1 41 110 244
1 46 110 246
2 49 108–109 247–249
1 51 110 246
Mean 40 109 203
 Expertise of Voice Feminization Surgery to 270 Diverse International Patients 1257

Table 7: Stroboscopy of voice range frequency before surgery and 6 years after the surgery
21 (Total number Age (Years) Range of fundamental frequency
of participants) Before surgery (Range: 102–143) 6 years after surgery (Range: 240–251)
3 32 109–111 240–251
5 42 105–114 244–250
8 43 102–110 242–247
4 46 109–143 243–245
1 48 110 244
Mean 42 111 245

Table 8: Stroboscopy of voice range frequency before surgery and 9 years after the surgery
15 (Total number Age (Years) Range of fundamental frequency
of participants)
Before surgery (Range: 102–136) 9 years after surgery (Range: 220–250)
1 39 102 242
3 46 108–130 220–244
6 47 106–136 242–250
3 48 109–114 243–245
2 50 110–123 243
Mean 47 117 242

the postoperative voice therapy is especially impor- as measured by stroboscopy. Stroboscopy was done before
tant; without it, the functional long-term result would be the surgery and every follow-up checkup. The mean of the
threatened.10 follow-up was 14 days. This resulted in a satisfactory pitch
alteration from an average F0 of 124 Hz before operation to
Objective Evaluations an average of: 294 Hz after 2 weeks; 275 Hz after 3 months;
273 Hz after 6 months; 266 Hz after 1 year; 267 Hz after
Follow-Ups 2 years; 203 after 3 years; 245 Hz after 6 years; and 242 Hz
Tables 1 to 8 show the preoperative and postoperative after 9 years.
number of available patients on follow-up checkup.
Eight patients (2.96%) were not available at all for Subjective Evaluations
further assessment postoperatively; likewise, 14 days after Subjective evaluation was done through communications
surgery 97.03% (262 patients); 3 months after surgery done via emails, face-to-face interviews and telephone calls.
69.25% (187 patients); 6 months after surgery 40.37% Interviews and telephone calls resulted in 27.78%
(109 patients); 1 year after surgery 23.70% (64 patients); responding satisfied and 2.96% verbalizing dissatisfaction.
2 years after surgery 17.77% (48 patients); 3 years after Through e-mail, 62.96% replied and confirmed that they
surgery 10.74% (29 patients); 6 years after surgery 7.77% were happy and satisfied; 5.55% did not reply and 0.74%
(21 patients); and 9 years after surgery 5.55% (15 patients). replied with dissatisfaction.
The rates of success of the reported method of treat-
Stroboscopic Evaluation ment can be seen as very positive, compared to the related
Tables 1 to 8 show the preoperative voice characteristics literature.11 The postoperative result was a major subjec-
(minimal to maximal range of fundamental frequencies) tive satisfaction.13
1258 Voice and Laryngotracheal Surgery

Most patients expressed of increased self-confidence to any of the follow-up check-ups at all. Postoperative
and satisfaction with the result. Overall satisfaction rate medical advice and instructions were done through emails
was 90.74%. and telephone calls. Stitch removal along the neckline was
even done in their countries.
The 90.74% of the patients, expressed overall satisfac-
DISCUSSION tion with their current voice characteristics and increased
Functional changes in voice production, including pitch self-confidence with the CTA. Majority of the patients
elevation, may help male to female transsexuals/transgen- acquired the desired female voice range frequency.
ders.14 There is a linear correlation between F0 and percep- The limitation of the present study is the geographic
tion of a voice as feminine or masculine.3 Preoperatively, location between the authors’ patients and their center
the average of masculine voice fundamental frequencies, because majority of them are foreigners, with a transient
in reading and sustained “ah” and “eh”, was 124 Hz (range: stay in Thailand, thus making it difficult for them to come
102–157 Hz) as compared to a feminine voice with an aver- back for another evaluation objectively.
age of 242 Hz (range: 220–250 Hz), 9 years after surgery.
However, Wagner et al.3 say that F0, which is determined
solely by the characteristics of the larynx (length, tension,
CONCLUSION
size of the vocal cords, and to a lesser extent, subglot- Cricothyroid approximation is an effective method for
tic pressure), is not indispensable to feminine-masculine long-term alteration of voice in male-to-female trans-
distinction. A small, short, narrow vocal tract produces a sexuals. It provides a satisfactory voice, with minimal
higher resonance frequency than does a long, wide vocal rate of complications.3 Surgery improves both subjec-
tract. Other factors include intonation (with greater pitch tive and objective criteria, and makes patients more
variability in the feminine voice). F0 may be the main char- relaxed by giving them stability and effortless control of
acteristic for identifying the feminine voice, and the reso- voice. Majority of the patients expressed of satisfaction
nance produced by the vocal tract for the masculine voice. of the voice feminization surgery. A maintained feminine
The entire impression of a feminine appearance should voice range frequency and patients’ satisfaction are key
further be supported by a feminine voice, even by surgery factors of the evaluation of the result, but continuous or
if it is necessary and possible.15 Thus, CTA procedure is the long-term monitoring of every individual is essential to
most helpful to the most. Although the technique requires ensure continued vocal health.
a neck incision, with the disadvantage of leaving a scar
(usually barely visible), it has the advantage of allowing
reduction of the laryngeal prominence during the same
REFERENCES
procedure, thus giving the patients a more feminine 1. Wikipedia, the free encyclopedia (2012). Transgender
appearance. This method has evidence of good results, (Mr. Oizo). [online] Available from http://en.wikipedia.org/
with very minimal complications.3,10 wiki/Transgender. [Accessed November, 2012].
Jeffrey H. Spiegel15 mentioned in his research that 2. Kanagalingam J, Georgalas C, Wood GR, et al. Cricothyroid
several inventive surgeons have designed procedures to approximation and subluxation in 21 male-to-female trans-
achieve the goal (voice feminization and masculiniza- sexuals. Laryngoscope. 2005;115(4):611-8.
tion), and the author presented many of them in their arti- 3. Wagner I, Fugain C, Monneron-Girard L, et al. Pitch-
cle, together with a review of degree to which they were raising surgery in fourteen male-to-female transsexuals.
successful. Laryngoscope. 2003;113(7):1157-65.
Long-term monitoring of the progress of the patients 4. Chung D, Tsuji DH, Sennes LU, et al. Upper displacement
is the major impediment, the authors have encountered. of the anterior commissure: experimental study of a new
Since most of their cases involved foreigners, 14 days post- phonosurgical approach to raising vocal pitch. Ann Otol
operatively, most of them went back to their countries and Rhinol Laryngol. 2007;116(6):462-70.
had a very slim chance to have further evaluation both for 5. Thomas JP (2012) Feminization laryngoplasty. [online]
their benefit and the authors’ study. The authors evaluate Available from http://www.voicedoctor.net/Surgery/Pitch/
the patients through emails, telephone calls, and some of Feminization-Laryngoplasty. [Accessed November, 2012].
them sent video clips of their voices 3 months to 9 years 6. Yang CY, Palmer AD, Murray KD, et al. Cricothyroid
after surgery. approximation to elevate vocal pitch in male-to-female
Due to an immediate family problem (from the home transsexuals: results of surgery. Ann Otol Rhinol Laryngol.
country), the eight foreign patients were not able to comply 2002;111(6):477-85.
 Expertise of Voice Feminization Surgery to 270 Diverse International Patients 1259

7. Persona non grata (2012). Transvestites! [online] Available 12. Isshiki N, Morita H, Okamura H, et al. Thyroplasty as a
from http://cnngo.com/seoul/korean-medicaltour.com. new phonosurgical technique. Acta Otolaryngol. 1974;78
[Accessed November, 2012]. (5-6):451-7.
8. Anderson J. Endoscopic laryngeal web formation for pitch 13. Neumann K, Welzel C, Berghaus A. [Operative voice pitch
elavation. J Otolaryngol. 2007;36(1):6-12. rising in male-to-female-transsexuals. A survey of our tech-
9. Palmer D, Dietsch A, Searl J. Endoscopic and stroboscopic nique and results]. HNO. 2003;51(1):30-7.
presentation of the larynx in male-to-female transsexual 14. Rosanoski F, Eysholdt U. The phoniatric expert opinion of the
persons. J Voice. 2012;26(1):117-26. retention of a male voice in cases of male-to-female trans-
10. Sataloff RT, Spiegel JR, Carroll LM, et al. Male soprano sexuals. Division for phoniatry and Pedaulogy. Clinic of the
voice: a rare complication of thyroidectomy. Laryngoscope. Friedrich Alexander University of Erlangen Nuernberg.
1992;102(1):90-3. 15. Spiegel JH. Phonosurgery for pitch alteration: feminization
11. Lawerence AA. Voice feminization surgery: a critical over- and masculinization of the voice. Otolaryngol Clin North
view. Transsexual Women’s Resources. January 2004. Am. 2006;39(1):77-86.
1260 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1260
CHAPTER

142 Decision-Making in
Laryngotracheal Stenosis
Vicky S Khattar, Bachi T Hathiram

INTRODUCTION
The management of laryngotracheal stenosis, whether
congenital or acquired, requires a multidisciplinary
approach. Although at some stage during the patient’s
illness, he/she will present to an ear, nose and throat
(ENT) surgeon, a large majority of the cases would even-
tually require the involvement of more than one speciality.
The importance of the above statement lies in the fact that
the ENT surgeon must recognize and accordingly involve
the concerned specialist at the very outset, so that the
definitive treatment may be planned correctly with all the
necessary precautions. The laryngotracheal surgeon must
always remember that the maximum chance of success
lies in the first surgical attempt. As the dictum goes, “the
first attempt is the best attempt.”
Although authors have described the steps of various Fig. 1: Endoscopic view of the larynx, showing subglottic
surgeries for laryngotracheal stenosis in the subsequent granulations in a suspected case of Wegener’s granulomatosis
chapters, the preoperative procedure, surgical plan-
ning and decision-making have been mentioned in this
chapter. patient with a history of prolonged endotracheal intuba-
tion in the Intensive Care Unit (ICU) with an underlying
pulmonary pathology may not be fit for surgery due to the
HISTORY lung pathology, despite having an organized stenosis, or
When a patient with suspected or diagnosed laryngotra- may have an active mucosal inflammation at the site of
cheal stenosis presents to the surgeon, it is essential to stenosis, which may require some local medical treatment
take a detailed history in a chronological fashion and try initially so as to allow the cicatrix to localize, follo­wing
to recapitulate the events from the precipitating event to which he/she may be taken up for a definitive surgical
the present situation. This is important for understanding intervention.
the pathophysiology and evolution of the stenosis and to
determine the probable etiology as accurately as possible, Neonates/Children
since this would eventually determine the subsequent In the case of children and neonates, an additional history
course of events. For example, a patient with suspected or right from the time of birth, through the time of initial pres-
proved Wegener’s granulomatosis (Fig. 1) may require a entation of symptoms, to the present stage must be taken,
combination of medical and surgical procedures to treat so as to understand the nature of the stenosis, whether it is
the condition with due importance of timing and sequenc- congenital, acquired or acquired following some manipu-
ing these two modalities. On the other hand, a patient with lation in a patient with an otherwise “silent” congenital
post-traumatic stenosis, such as after a vehicular accident, anatomical variation or abnormality of the laryngotrache-
may require urgent surgical repair; and even further, a obronchial tree.
 Decision-Making in Laryngotracheal Stenosis 1261

External Trauma procedure should be used. Of course, various procedures

In patients presenting with a history of external trauma on the same patient may require different sizes of tubes,
preceding laryngotracheal stenosis, the exact nature of the as the duration of anesthesia is also important, keeping
trauma must be determined. The larynx and trachea have in mind not only the ventilation but also the build-up of
certain ways of responding and collapsing or fracturing, expiratory carbon dioxide.
etc. after trauma and knowing the details of the incident
helps us in understanding the evolution of the stenosis. Type of Endotracheal Tube
It must be understood that many times blunt trauma can Much has already been written in literature about using
be more damaging than sharp cut-throat injuries, as their “soft” endotracheal tubes and their advantages.
effects are unpredictable, besides being present over a
large segment of the airway. Tracheostomy
Many patients with laryngotracheal stenosis are already
Prolonged Intubation on a tracheostomy tube at the time of presentation. While
It is well known that the effects of endotracheal intubation the presence of a tracheostomy tube may be life-saving for
can be far reaching, especially in the scenario when the the patient, it carries with it numerous risks. It is known
patient already has an underlying pulmonary pathology. that a tracheostomy itself can contribute to the develop-
Often, it is a combination of various factors, which may be ment of a stenotic segment in the airway. This may be due
responsible for the stenosis; this may also explain why only to a variety of factors.
some patients will eventually develop a stenotic segment,
while others may not. Certain factors, which need to be The Site of a Tracheostomy Tube
discussed at this stage, are following. When placed close to the subglottis, a tracheostomy tube
can cause perichondritis and cartilage necrosis, due to
Duration of Intubation the constant friction between the tube and the cricoid
It has been established that prolonged intubation is a cartilage.
major contributory factor for the development of acquired
laryngotracheal stenosis. It must, however, be kept in The Number of Tracheal Rings Cut
mind that there have been reports of even a single episode It is prudent to cut just one tracheal ring for a tracheo­stomy
of intubation for a short duration (even a few hours) lead- and utilize the upper and lower intercartilaginous spaces
ing to stenosis at a later stage. for the tube along with the cut ring. This prevents violation
of a large segment of the trachea, and subsequent mala-
Peri-intubational Circumstances cia at a later stage. Many surgeons advocate the use of an
There is a great difference between intubating a patient inferiorly based Bjork flap, which is then fixed to the skin
in the sterile surroundings of an operation theater and so as to allow for a relatively immobile and secure stoma
an emergency intubation carried out, say in a patient with an increased ease of changing the tube, as and when
presenting to the “Accident and Emergency Department” required.
in a semi-conscious state, or with extensive injuries, or a
convulsing patient, etc. It is thus vital to understand that Cuff
every person who is trained to perform endotracheal intu- • A well performed tracheostomy may become prob-
bations must be aware of the potential pitfalls during the lematic, if the cuff is not managed well. As a rule, the
procedure (Figs 2A to D). cuff pressure should not exceed the capillary perfusion
pressure, which is usually 20−25 mm Hg. The cuff also
Size of Tube needs to be deflated at timely intervals, so as to allow
There is a constant tussle between an experienced laryn- the tracheal mucosa to “breathe”. In any case, except
gotracheal surgeon and anesthesiologist as regards the in patients who require positive pressure ventilation or
size of the tube to be used during general anesthesia. those who are aspirating, the cuff can be kept deflated
Most anesthesiologists prefer to use an adequately large at all times or at least as far as possible.
endotracheal tube for ventilation. It would be wise to first
develop a good working rapport with the anesthesiolo- Material of Tube
gist, and then discuss the pitfalls of a large endotracheal • Just as in the case of endotracheal tubes, the material of
tube; eventually come to a consensus that the smallest the tracheostomy tube is also important. Silicone tubes
possible­endotracheal tube, which shall be able to deliver are preferred for prolonged intubation, as compared to
an adequate amount of air and gases required for the Portex®, metal tubes, etc.
1262 Voice and Laryngotracheal Surgery

B C

Figs 2A to D: (A) Axial CT scan images of a patient

who had been intubated on an emergency basis, and
developed dysphonia and mild dyspnoea after extubation.
Note the granuloma at the level of the glottis; (B) The same
is confirmed on coronal CT scan; (C) Outpatient Rigid 70
degrees Hopkins telescopic view of the patient showing the
granuloma at the level of the posterior glottis; (D) The rigid
70 degrees telescopic view of the same patient after 10 days
of conservative treatment, showing reduction in the size of
D the granuloma
 Decision-Making in Laryngotracheal Stenosis 1263

Infection very close to the stenosis, then it can be resected along

As again for endotracheal tubes, local site infections may with the stenotic segment and an end-to-end anastomo-
play havoc with the integrity of the tracheal cartilage, and sis may be performed in a single stage. In the latter case,
lead to perichondritis, cartilage necrosis and subsequent if the tracheostoma is very much away from the stenotic
stenosis, and should be avoided at all costs. segment, then the tracheostomy will not interfere with the
site of anastomosis, and the procedure can be performed
Site of Tracheostomy without additional loss of tracheal rings with the tracheos-
This entity has been separately mentioned for a reason; toma, being closed surgically later. In the interim scenario,
often the site of tracheostomy becomes the crucial decid- if the tracheostomy has been performed two or three rings
ing factor for a single-staged versus a double-staged away from the stenotic segment, then it will have to be
reconstruction procedure; it is also the deciding factor resected along with the stenotic segment, because if it is
for the number of healthy tracheal rings, which may need left in place, it would lie very close to the anastomotic site,
to be unnecessarily sacrificed. For example, in a case of and cause infection, friction (from the tube) and resteno-
subglottic stenosis (SGS), the tracheostoma should either sis or anastomotic failure; also, if it were to be resected
be placed very close to the stenosis (preferably at the with the stenotic segment, then it would cause a loss of
first tracheal ring, or more simply, just below the steno- a large length of relatively normal trachea, thus making
sis and in some cases even though the stenosis in case it the anastomoses difficult or under tension or requiring
is partial, and of course in case it is possible!), or at least extensive tracheal mobilization superiorly and inferiorly
4–5 rings away; the reason is that if the tracheostoma is (Figs 3A to D).

A B C D

Figs 3A to D: Schematic diagram showing a patient with a stenosis of the subglottis and first tracheal ring (S). The green
dot represents the site of tracheostomy. ‘L’ denotes the length of the airway that needs to be resected; (A) Thus we can
appreciate, that when the site of the preoperative tracheostomy is just distal to the site of stenosis, the length of airway that
needs to be excised during surgery is relatively less; (B) When the site of the preoperative tracheostomy is relatively far
away from the stenosis (atleast 4 to 5 tracheal rings intervening), then the length of the airway to be sacrificed is again not
too much; the drawback being that the tracheostomy would have to be closed at a second stage after the primary laryngo-
tracheal reconstructive surgery, and thus the procedure would have to be a double staged one; (C) When the preoperative
tracheostoma has been made just a few rings away from the site of stenosis, it becomes difficult to conserve the normal
tracheal rings between the stenosis and stoma. Thus eventually a large segment of the airway would have to be sacrificed
(including the normal tracheal rings!), and the anastamosis could come under tension, and require a ‘release procedure’
such a laryngeal drop, etc.. This is the worst scenario!; (D) An ideal situation, in which the preoperative tracheostomy has
been performed THROUGH the stenotic segment of the airway, thus causing no wastage of tracheal rings; in addition, the
procedure may be also planned as a single stage procedure, other conditions permitting. This would be the best scenario!
1264 Voice and Laryngotracheal Surgery

Revision Procedures GENERAL PHYSICAL EVALUATION

Everything changes when one is dealing with a revi-
sion procedure. It cannot be emphasized more that the This will confirm and corroborate with the history taken
first attempt at surgically correcting a stenosis offers the and determine the candidacy for surgery. Besides, it
best chance for a successful outcome. Once the surgical will reveal any other coexistent medical issues (whether
planes have been violated with subsequent fibrosis and syndromic or otherwise). It would also help to determine
scar tissue, and tracheal length has been lost, it becomes the cardiopulmonary reserve and neurological status of
increasingly difficult at each subsequent attempt to recon- the patient. It will also help in planning the method of
struct the laryngotracheal tree to a functional state. If the securing the airway during surgery.
patient presents after one or more failed procedures, then
it is wise to obtain the surgical records of all the proce-
dures. The idea is the same—to reconstruct the sequence
PREOPERATIVE EVALUATION
of events, which have led to the current state. This would Certain factors are to be borne in mind when evaluating a
help us to be prepared for the difficulties that can be patient of laryngotracheal stenosis:
encountered during the surgery. • Endoscopic evaluation offers the best understanding
of the airway.
Comorbidities • It may be coupled with radiological evaluation when
Often airway problems are accompanied by swallowing needed, but the primary assessment should always be
and/or aspiration issues. This is more common in post- endoscopic (Figs 5A to G).
traumatic stenosis (either accidental or iatrogenic). A • A dynamic assessment gives a better physiologi-
detailed history of the patient’s current swallowing status, cal understanding of the airway; especially it helps
the nature of the food he/she is able to ingest (including in confirming aspiration problems and malacic
the consistency) as well as any clinical signs of aspiration. segments in the airway.
Often, silent aspirators would present with a recurrent • It is prudent to assess dynamically in upright and
history of pulmonary problems, requiring medical atten- recumbent positions to rule out coexistent sleep
tion. In fact, all patients who fall in the above two catego- apnea, which may contribute to the airway issue.
ries, i.e. post-traumatic and post-surgical may be endo- • In post-traumatic and post-surgical cases, assess-
scopically evaluated for airway as well as swallowing. ment of the upper gastrointestinal tract would be
wise.
Coexistent Medical Conditions • It is important to rule out clinical and sub­clinical
In certain cases, the deciding factor for the possibility, gastroesophageal reflux, which may not only contri­
staging as well as timing of surgery is determined not only bute to the development of the stenosis but also
by local but also by general medical conditions. Special impede good healing after the surgery.
emphasis may be laid on cardiopulmonary and neuro- Various forms of endoscopic techniques are available
logical issues, which often place the patient at a high-risk for evaluating a patient with laryngotracheal stenosis.
of prolonged general anesthesia. Sometimes, despite not
being a major deterrent for general anesthesia, they may Awake Fiberoptic Endoscopic Evaluation
still not render the patient a candidate for surgery, if the This provides a dynamic assessment and is the preferred
medical condition prevents them from taking adequate method for all cooperative patients. It is best tolerated
care after surgery. Neurological problems may at times, when performed transnasally. It should be performed
predispose the patient to the risk of aspiration and in such in the sitting as well as recumbent positions, which will
patients, reconstruction or widening of the airway may further help in ruling out any coexisting sleep apnea. It will
only exacerbate the problem (Figs 4A to D). also give an idea about the dynamic nature and collapsi-
bility of the “otherwise normal” airway, such as in patients
Syndromic Association with tracheomalacic segments (Fig. 6), suprastomal
A history of syndromic abnormalities may give a clue as to collapse (Fig. 7), etc. It may also be performed through the
the etiology of the stenosis; whether the stenosis is a part tracheostoma (when present) to assess the lower airway as
of the syndrome complex or may have resulted due to a well as the segment below the site of stenosis (retrograde)
therapeutic attempt in a syndromic patient for whatever in the presence of a tight stenosis. The greatest advantage
reason. is that it may be performed as an outpatient procedure
 Decision-Making in Laryngotracheal Stenosis 1265

A B

D
Figs 4A to D: (A) Axial CT scan images of a two-year old girl who was intubated for tuberculous meningitis for a prolonged
period of time, and developed glotto-subglottic stenosis after extubation, for which she was tracheostomised; (B) clinical
photograph of the patient showing her inability to even hold the head upright; (C) the axial CT scan images of the brain
showing the hypoxemic ischemic changes with dilated ventricles, secondary to the tuberculous meningitis; (D) the barium
swallow of the patient at three years of age showing no evidence of aspiration. Now it remains to be guessed whether the
absence of aspiration is due to a good neurological control, or due to the laryngeal stenosis; in such a situation, wherein
any laryngeal widening procedure would result in the possibility of aspiration, and only add to the comorbidity of the patient,
it would be wise to either leave the child with a tracheostoma, or wait till she recovers neurological function
1266 Voice and Laryngotracheal Surgery

A B

C D

E F
Figs 5A to F
 Decision-Making in Laryngotracheal Stenosis 1267

Figs 5A to G: The difference between radiological and endoscopic

assessment. (A) The Axial CT scan of a patient at the level of
the supraglottis (see below); (B) The Axial CT scan of the same
patient (Fig. 10) showing a narrowed glottis; (C) The Axial CT
scan of the same patient showing a subglottic stenosis; (D) The
sagittal reconstruction of the CT scan of the same patient showing
the Glotto-subglottic stenosis; (E) The endoscopic view of the
same patient showing a normal supraglottis; (F) The endoscopic
view of the same patient showing the glotto-subglottic stenosis;
(G) Endoscopic view of the same patient showing the use of a
Vocal fold spreader/retractor to see the extent of the posterior
glottic stenosis/scarring
As we can see from Figures 5A to G, the information obtained
from the endoscopic evaluation far supercedes that obtained
from radiological assessment; besides, the radiological
assessment does not offer any added information as compared
G
to the endoscopic evaluation! In addition, the endoscopic
evaluation can also reveal the status of vocal fold mobility,
while the patient is being reversed from anesthesia, which
cannot be appreciated on radiology

Fig. 6: Endoscopic view showing a small scar on the anterior Fig. 7: Endoscopic view of a patient with a tracheostomy,
wall of the trachea—which however on dynamic assessment with the trachea showing a suprastomal flap—it is important
revealed a localized malacia of the trachea involving three to differentiate this from a suprastomal collapse, as the
tracheal rings former would require a resection of the malacic tracheal
rings, while the latter simply requires a surgical closure of
the tracheostoma, with the sutures in a vertical fashion to
prevent stenosis

in most and on a day care basis for the remaining. It esophagus can be evaluated for evidence of gastroesoph-
also gives vital information about the vocal fold mobility ageal reflux disease (GERD), which needs to be treated
(Figs 8 and 9), which may eventually end up in being one prior to surgery.
of the key deciding factors in making surgical decisions,
especially with reference to the assessment of aspiration. Rigid Hopkins Telescopic Evaluation
It will also help in procuring lavages for obtaining bacte- (Direct Laryngotracheoscopy)
rial cultures as certain organisms, such as Staphylococcus It is performed under general anesthesia, preferably
and Pseudomonas may cause postoperative infections and intravenous. It is an important part of the assessment, and
subsequent wound breakdown with restenosis. Even the can be performed after the awake fibreoptic evaluation.
1268 Voice and Laryngotracheal Surgery

Fig. 8: The importance of assessment of the vocal fold Fig. 9: Endoscopic view of the same patient (Fig. 5)
mobility as this changes the grade of the stenosis as per showing the vocal folds in adduction
the modified Myer-Cotton Grading system—An endoscopic
view of a patient with a subglottic stenosis, showing the vocal
folds in the abducted position

It gives an idea of the airway and all anatomical luminal

narrowings. In addition, with the help of an assistant,
even the arytenoids can be palpated for passive mobility
or fixity with a spatula and the posterior glottis assessed
with a “cord spreader or vocal fold retractor”. The actual
mobility can be assessed as the patient comes out of
anesthesia. The site of tracheostoma, the suprastomal
area and the distal airway can also be assessed. It is
important to bear in mind that even if this procedure
has been performed preoperatively, it must be repeated
again at the time of surgery, just before the beginning of
surgical procedure. This allows for any changes that may
have occurred in the interim period (especially if long),
more so if it is an evolving scar. If performed properly,
one may avoid a suspension microlaryngoscopy (which is
performed in the cases of bilateral vocal fold immobility)
Fig. 10: Endoscopic view of a patient showing a
to rule out cricoarytenoid joint fixation. The best
complete subglottic stenosis
equipment to use is an anesthesiologists’ laryngoscope,
along with a 0° Hopkins rigid telescope. The laryngoscope
suspends the larynx, and allows for the easy insertion of
the telescope through the vocal folds into the tracheal Following the above two assessments, a schematic
lumen. In cases of complete stenosis (Fig. 10), the diagram may be drawn of the airway, and the surgical
distance from the vocal folds to the site of stenosis may be planning, which may commence as following:
measured, and the scope is then advanced in a retrograde • As and when it may be relevant, an assessment of the
fashion through the tracheostoma till the distal end of the esophagus and bronchi may be performed (vide supra).
stenosis. This given an approximate length (or number • This evaluation under anesthesia may also reveal a
of tracheal rings) that may be involved in the stenosis. laryngotracheal cleft, which may be otherwise missed
In addition, the scope may then be advanced through out on any other evaluation technique, as arriving at a
the tracheostoma in an antegrade fashion and the distal diagnosis of the latter may completely alter the surgical
trachea assessed. procedure planned.
 Decision-Making in Laryngotracheal Stenosis 1269

INDICATIONS FOR SURGERY AND easy. Once the diagnosis has been confirmed, the deci-
sion to surgically manage these patients should be taken
OPERATIVE DECISIONS only after adequate time has been permitted for spon-
The decision for surgery and the extent of surgical proce- taneous recovery, which can range anywhere between
dure required can be determined by classifying the 12 months and 24 months. Since most procedures,
patients on the basis of the modified Myer-Cotton airway currently accepted today, are permanent with a definite
grading system, which is shown in Table 1. possibility of deterioration in the quality of voice after
There are certain other conditions that have not been surgery, it is mandatory to understand other factors which
mentioned in the Table 1 above and warrant a mention may eventually influence the outcome. In the case of chil-
to complete the plethora of laryngotracheal stenosis. dren, there is a school of thought that advocates waiting
They are namely bilateral vocal fold immobility, posterior till the child has attained maturity and is capable of legally
glottic stenosis, webs and circumferential stenosis in the taking his/her own decisions. This is very important, if the
airway. These are briefly discussed below. child may want to pursue a career that requires the voice
to be used in a professional manner, such as a teacher,
Bilateral Vocal Fold Immobility lawyer, etc.; however, the other school of thought believes
The diagnosis of bilateral vocal fold immobility must be that once the waiting-period of 24 months is over, and there
confirmed by evaluation under general anesthesia, espe- is no recovery, it is advisable to go ahead with the surgery
cially to differentiate it from posterior glottic stenosis as the as this reduces the risk of dependence on a tracheostomy
treatment for both differ. A large majority of these patients (especially so in children) as well as it helps to overcome
are usually with a tracheostomy and hence securing the the lifestyle issues faced by the patient and their families,
airway during evaluation under anesthesia is relatively due to the tracheostomy itself. Many patients may not have

Table 1: The modified Myer-Cotton airway grading system

Myer-Cotton grade Isolated SGS Isolated SGS + SGS + Glottis SGS + Glottis
(of luminal stenosis) Comorbidities involvement involvement +
Comorbidities
Stages
A B C D

I 0–50% Ia: Wait and watch Ib: Wait and watch Ic: Wait and watch Id: Wait and watch
policy versus radial policy versus radial policy versus radial policy versus radial
LASER incisions LASER incisions with LASER incisions with LASER incisions with
with dilatation dilatation dilatation dilatation
II 51–70% IIa: Endoscopic IIb: Endoscopic IIc: SS-LTR or IId: DS-LTR with
treatment [if a thin treatment (if a thin SS-PCTR or DS-LTR stenting (ACCG and/or
membrane like membrane like with stenting (Fig. 12) PCCG) or DS-PCTR
stenosis (Figs 8, stenosis) or a DS-LTR (ACCG or PCCG)
9 and 11)] or a with ACCG
SS-LTR with ACCG
III 71–99% IIIa: SS-PCTR or IIIb: DS-PCTR or IIIc: DS extended IIId: DS extended
DS-LTR + stenting DS-LTR + stenting PCTR + stenting or PCTR + stenting or
DS-LTR + prolonged DS-LTR + prolonged
stenting stenting
IV 100% IVa: SS-PCTR or IVb: DS-PCTR or IVc: DS Extended IVd: DS Extended
DS-LTR + stenting DS-LTR + stenting PCTR + stenting or PCTR + stenting or
DS-LTR + prolonged DS-LTR + prolonged
stenting stenting

SGS: Subglottic stenosis; LASER: Light amplification by stimulated emission of radiation; SS-LTR: Single stage laryngotracheal
reconstruction; DS-LTR: Double stage laryngotracheal reconstruction; ACCG: Anterior costal cartilage graft; PCCG: Posterior
costal cartilage graft; SS-PCTR: Single stage partial cricotracheal resection; DS-PCTR: Double stage cricotracheal resection
1270 Voice and Laryngotracheal Surgery

Fig. 11: Endoscopic view of a patient with a membranous Fig. 12: Endoscopic view of a patient with a silicone
subglottic stenosis which would be amenable to treatment laryngotracheal stent in situ
with a LASER

the necessary family support or infrastructure to maintain Posterior Glottic Stenosis

a tracheostomy safely, and in such patients, it may be advis- Isolated stenosis of the posterior glottis is usually seen as
able to attempt surgery and decannulation sooner. Thus a sequel of prolonged intubation. Many of these patients
the decision to perform surgery and decannulation should survive well without a tracheostomy and can tolerate a
be taken after due counseling of the patient, the family, and mild to moderate degree of dyspnea. Depending upon
keeping in mind, the socioeconomic status of the patient. the types of stenosis as well as the degree of airway
Once the decision has been taken to operate, there compromise, various procedures have been described in
are various modalities available to the patient; this also Table 2.
depends upon the surgical training and expertise of the
treating clinician to a great extent. At the end of the day,
whatever works best in the hands of the treating clinician
PRESURGICAL PLANNING
with sufficient backup provisions for managing any conse- Once the airway has been assessed and the type of ­stenosis
quences and complications should be decided upon. identified, the patient and the guardian/parent/rela-
tive should be counseled about the nature of the surgical
Options Available procedure, the risks involved, the chances of a successful
outcome, the postoperative care, which may be required
Open Procedures
as well as the chances that the patient may require moni-
• Laryngofissure with arytenoidectomy and lateraliza­tion. toring in the ICU for a few days after surgery, especially for
• Arytenoidopexy with the lateral approach. the single stage procedures.
• Posterior cricoid split with arytenoid separation using
cartilage graft.
PREOPERATIVE MEDICATIONS
Endoscopic Procedures Usually, proton pump inhibitors may be started a week
• CO2 light amplification by stimulated emission of prior to the surgery, and continued for at least 6 weeks
radiation (LASER) arytenoidectomy. postsurgery and even longer in patients with a diagnosed
• CO2 LASER posterior cordotomy. GERD.
• Posterior cricoid split with cartilage graft. Antibiotics are ideally administered, depending upon
• Arytenoidopexy taking a stay suture (using the the culture report available (if taken), especially, if these
Lichtenberger needle carrier). cultures grow methicillin-resistant Staphylococcus aureus
 Decision-Making in Laryngotracheal Stenosis 1271

Table 2: Depending upon the type of stenosis as well as the degree of

airway compromise, various procedures have been described
Type of Description of stenosis Treatment options available
stenosis
Type I Interarytenoid adhesion • CO2 LASER division
Type II Posterior glottic stenosis with • Initially, endoscopic LASER division of the stenosis with dilatation and
preserved active mobility of application of topical Mitomycin C may be attempted
both vocal folds – If this fails and the pathology recurs, an endoscopic posterior cricoid
split with costal cartilage interposition with stenting of the airway,
using a laryngeal stent would be advisable (in such cases, a temporary
tracheostomy will need to be performed)
• If all the above fails, an open surgical option should be attempted
(see below)
(Type III Posterior glottic stenosis with • In selected cases of Type III (with unilateral cricoarytenoid joint fixation,
and unilateral or bilateral crico­ especially, if not completely fixed) an endoscopic procedure similar to
Type IV) arytenoid joint fixation that mentioned for Type II may be performed
• In most cases of Types III and IV (bilateral cricoarytenoid joint fixation),
a laryngofissure with posterior cricoid split, costal cartilage grafting and
laryngeal stenting will have to be performed

LASER: Light amplification by stimulated emission of radiation

Fig. 13: Schematic diagram showing a laryngotracheal resection anastomosis procedure

1272 Voice and Laryngotracheal Surgery

Fig. 14: Schematic diagram showing a laryngeal expansion/widening procedure

(MRSA) or Pseudomonas aeruginosa, as these are notori- not necessarily have a negative influence on the even-
ous for causing suture line or anastomotic dehiscence and tual s­ urgical outcome of the procedure. Although it may
subsequent restenosis in many cases. be borne in mind that the airway (even if congenitally
All comorbidities should be addressed and treated, or narrowed) does grow luminally, and there would thus
at least optimized so as to allow for a successful outcome, be more tissue available for surgery to perform later;
such as cardiorespiratory problems, neurological prob- nevertheless, if the delay in surgery is going to cause
lems including aspiration, etc. a further delay in the development of speech of the
Eosinophilic esophagitis is an increasingly recognized child (due to a tracheostoma or even otherwise), then it
entity in both the pediatric as well as adult age groups, and would be wise to perform the surgery earlier.
needs to be proved if suspected with a biopsy. If present, it The subsequent chapters will describe the surgi-
needs to be treated prior to the surgery so as to allow for a cal technique of laryngotracheal reconstruction (LTR),
successful outcome. partial cricotracheal resection (PCTR) and extended
PCTR, and other surgical procedures for the manage-
ment of laryngo­tracheal stenosis.
SURGICAL TIMING However, at this stage, it warrants mention to
As mentioned earlier, the surgery should be only understand the two most important principles of
performed when there is no active mucosal pathology, Laryngotracheal stenosis surgery, namely expansion
when the scar is matured and when there are no coexis­ and resection procedures (Figs 13 and 14).
ting airway issues or obstructions. In children with
congenital stenosis, they should be of sufficient age and
body weight to be able to withstand the prolonged anes-
BIBLIOGRAPHY
thesia, and also some airway compromise which may 1. Paediatric Airway Surgery—Management of Laryngo­
occur although temporarily. There have been studies tracheal Stenosis in Infants and Children. In: Monnier P
to prove that surgery performed at an earlier age does (Ed). Berlin Heidelberg: Springer-Verlag; 2011.
 The Surgical Technique of Otoplasty 1273
CHAPTER

143 The Surgical Management of

Tracheal Stenosis
Danic Davorin, Prgomet Drago, Danic Hadzibegovic Ana

INDICATIONS FOR THE SURGERY Preferred Examination

The causes of cervical tracheal stenosis are: For tracheal stenosis preoperative evaluation is used to
Trauma: Internal—prolonged endotracheal intubation, demonstrate:
tracheotomy, surgery, irradiation, endotracheal burns a. The precise location of the stenosis in relation to the
External: Blunt or penetrating neck trauma top of the vocal cords
Specific chronic inflammatory diseases—Amyloidosis, b. The length of stenosis
Sarcoidosis, Polychondritis c. The thickness of the stenosis
Neoplasm: Bening—Papillomatosis • Rigid or flexible laryngotracheoscopy
Malignant—Primary, secondary, metastasis • Radiography
Idiopathic stenosis • Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Ultrasonography
SPECIFIC PREOPERATIVE • Nuclear imaging
EVALUATION • Pulmonary function tests
Dilatation of tracheal stenosis does not work.
The types of stenosis are based on detailed description
of the type, location and degree of airway stenosis.
ANESTHETIC CONSIDERATIONS
The type of stenosis includes as follows: • Jet ventilation for nontracheotomized patient
• Structural stenosis • Conventional ventilation system in tracheotomized
–– Stenosis due to all types of exophytic intraluminal patient
bening, malignant tumors or granulation tissue
–– Extrinsic compression
–– Narrowing due to airway distorsion, kniking, bend-
SURGICAL STEPS1-4
ing or bucking The surgical management of tracheal stenosis remains
–– Shirking or scarring a challenge for otorhinolaryngologist. No single treat-
• Functional (dynamic) stenosis ment modality can solve the problem due to the variety of
–– Triangular or tent-shaped airway, in which carti- preoperative clinical findings. According to the nature and
lage is damaged severity of the condition there are various types of treat-
–– Inward bulging of the floppy posterior membrane ment. The best chance for patient lies in a successful first
The degree of the stenosis: surgery, which implies that surgeon must be fully trained
• none in upper airway endoscopy and laryngotracheal surgery.
• < 25%
• 26% to 50% Operative Technique Tracheal Resection for
• 51% to 75% Stenosis and Reanastomosis
• 76% to 90% Surgery is definitive management for tracheal stenosis.
• 91% to 100% The classic surgical procedure is a sleeve resection of the
The location of tracheal stenosis is divided into: involve segment of the trachea and primary end-to-end
• Upper one third anastomosis. Following induction in general anesthesia,
• Middle one third the head and neck area is isolated in usual fashion, with
• Lower one third neck fully extended.
1274 Voice and Laryngotracheal Surgery

Fig. 1: CT scan of the neck showing high tracheal stenosis Fig. 2: Endoscopic view of the larynx
showing tracheal stenosis

A collar incision is usually made at the level of second thyrohyoid membrane, the thyroid cartilage, the crico-
tracheal ring or 2 cm below the inferior edge of the cricoid thyorid membrane, the cricoid cartilage and the cervical
cartilage, curving slightly up and into each sternocleido- trachea from first up to the eight rings are exposed. The
mastoid muscle, with a total length of 8 cm for thin neck, area of narrowing must be clearly exposed.
and 10 cm for heavy neck. In tracheotomized patient, a The level and length of tracheal resection is deter-
horizontal crescent-sharpe excision of the skin is made mined by radiographic assessment preoperatively as well
around the stoma. Depending on where the stenosis is, as by bronchoscopic assessment under general anesthesia
sometimes the collar incision is combined with a median (Figs 1 and 2). A maximum excision length of 3.0 to 3.5 cm
sternotomy incision. The upper and lower subplatysmal of trachea is preferred or five to seven rings of the trachea
skin flap is elevated and the strap muscles are separated can be safely resect with primary anastomosis achieved
from the midline to provide exposure from hyoid bone to in most patients via suprahyoid release. Long segment
suprasternal notch with an electrocautery. The isthmus tracheal stenosis, greater than 30% of the tracheal length,
of the thyroid gland is doubly clamped and divided. The is contraindication for tracheal resection and reanasto-
stumps of the isthmus are ligated for hemostasis. With mosis because it leads to excessive anastomotic tension
benign stenosis, the trachea is dissected anteriorly and followed by recurrent stenosis or fatal separation.
laterally without identification of recurrent laryngeal When tracheal stoma exists in the area of stenosis,
nerves by staying in close contact with the underlying the anterior tracheal wall is divided in the midline supe-
cartilaginous rings. With neoplastic stenosis, one must riorly and inferiorly from the stoma until normal lumen
determine the extension of the disease identifying one or is encountered. When there is no tracheal stoma, resec-
both recurrent laryngeal nerve. Dissection for identifica- tion of the stenosis proximally and distally is performed
tion nerves begins with the mobilization of thyroid lobe in stages to avoid resecting excessive length (Fig. 3). An
from medial to lateral until the tracheoesophageal groove endotracheal tube is than passed directly into the distal
is reached. The blood supply to the thyroid lobes and para- tracheal stump. It is important to pass a couple of tagging
thyroid glands, coming through the superior and inferior sutures through the edge of the distal stump to prevent its
thyroid arteries, respectively, is thus preserved. The para- retraction into the mediastinum before circumferential
thyroid glands located on posterior capsule of thyroid transection of the trachea (Fig. 4). Mobilization of sten-
lobes are also retracted laterally in situ. Recurrent laryn- otic part than should be carried out carefully between the
geal nerve is shown entering the larynx through the crico- membranous trachea and the cervical esophagus, particu-
thyroid membrane. The vascular supply coming laterally larly near the lower border of cricoid to prevent inadvert-
from the tracheoesophageal grooves should be always ent injury to recurrent laryngeal nerves or esophagus. It is
carefully preserved, especially in the extensive mobiliza- very important to resect all abnormal trachea and mini-
tion of the distal trachea. Circumferential dissection of mize the risk of restenosis (Fig. 5).
trachea should be limited to the area of the stenosis and The luminal diameter of the distal trachea is always
just slightly above and below the stenosis. The hyoid, the much larger than that of proximal or subglottic lumen,
 The Surgical Management of Tracheal Stenosis 1275

Fig. 3: Identification of stenotic segment Fig. 4: Surgical defect of the trachea after circumferential
incision above and below the stricture

Fig. 5: Resected tracheal segment with granulation Fig. 6: High tracheal anastomosis and two intact tracheal
and fibrous tissue rings between the anastomosis and tracheostomy

so the first normal tracheal ring used for the anastomo- anatomy, patients age, body build, height or any prior
sis must be adapted to the size of proximal tracheal or surgery performed.
subglottic lumen (Fig. 6). This difference is even more The technique of suprahyoid or infrahyoid laryngeal
pronounced in children. release is performed unless the stenotic segment is short
After resection is complete, mobilization of proxi- enough to allow reanastomosis of the trachea with mini-
mal tracheal ring or cricoid and distal tracheal stump is mal tension on the suture line.
required to achieve the closure without tension (Fig. 7). The When performing an infrahyoid larynx release one
usual question that arises is how trachea can be resected must divide sternohyoid and omohyoid muscles at the
and the anastomosis still safely accomplished. There is level of the thyrohyoid membrane. The superior cornua
no straightforward answer. It depends on the individual of the thyroid cartilage are divided and the thyrohyoid
1276 Voice and Laryngotracheal Surgery

Fig. 7: Suturing of the fifth tracheal Fig. 8: Endoscopic view of the larynx
ring to the cricoid cartilage showing subglottic stenosis

membrane is divided with sharp dissection, using care • Nontracheotomized patient stay under supervision in
to stay against the upper edge of the thyroid cartilage to the intensive care and the endotracheal tube may be
prevent damage to the superior laryngeal nerve. This removed within 24 hours of surgery.
infrahyoid release allows about 2.5 cm drop of larynx. In • Antibiotics and antireflux medications are given to all
some cases, sternohyoid muscle can be preserved. The patients for minimum of one week.
thyrohyoid muscle is cut bilaterally just above its insertion • Corticosteroids are administrated after surgery and
on the thyroid cartilage. Then, the thyrohyoid membrane is continued for the next few days, if necessary.
cut in the midline and along the upper edge of the thyroid • Oral administration of fluid can start after 48 hours.
cartilage, leading laterally to the upper cornu, which is cut • First control endoscopy is performed 7 or 10 days,
bilaterally and resulting in 1.5 to 2.0 cm drop of larynx. postoperatively.
The suprahyoid release involves dividing the muscle
attachments from superior surface of the hyoid bone. The
hyoid then is transected at the level of the lesser cornu.
NEW TECHNIQUES IN THE
The body of the hyoid, the thyroid and cricoid cartilages SURGERY
and proximal tracheal segment drop inferiorly about 3 cm.
Prior anastomosis, the endotracheal tube is removed Reconstruction of Partial Tracheal Stenosis
from distal trachea and reintroduced from oral cavity, past with Cervical Fascia
the larynx into distal trachea. First 3-0 interrupted Vicryl In 1970, Krajina Z in Croatia first described and used ster-
sutures are used for membranous trachea and 2-0 Vicryl nohyoid muscle fascia for the laryngeal reconstruction
sutures for lateral and anterior anastomosis. The sutures after vertical and frontolateral partial laryngectomy. He
are placed submucosally from the outside-in through named it, “The Zagreb method for partial laryngectomies.”
the lateral walls of the trachea, on to two rings above and Since 1980 we have been using cervical fascia in laryn-
below the level of transaction. Suction drains are placed geal reconstructions after partial vertical and horizontal
and brought out laterally through the neck than the thyroid laryngectomies and in reconstruction of posterior phar-
isthmus and strap muscles are resutured on midline and yngeal wall after resection of malignant tumors. We have
skin is closed in two layers. also used cervical fascia in stabilization of laryngeal and
tracheal cartilage after external wartime and peacetime
Postoperative Care trauma. After these positive experiences, we also used
• A heavy suture is placed from the chin to the chest to cervical fascia in tracheal reconstruction after partial
keep neck in maximum flexion for two to three weeks. resection of tracheal cartilage up to 50% of circumference
 The Surgical Management of Tracheal Stenosis 1277

Fig. 9: Plain neck radiograph with tracheal column Fig. 10: Cervical fascia between sternocleidomastoid
muscle and hyoid bone

Fig. 11: Surgical field from anterior aspect Fig. 12: Cervical fascia flap with cranial base
1278 Voice and Laryngotracheal Surgery

Fig. 13: Cervical fascia flap with lateral base Fig. 14: Endoscopic view of the proximal trachea after
cervical flap reconstruction

and 2 to 3 cms in length. External, internal trauma and limited to the area of the stenosis and just slightly above
benign tumors are the most common causes of tracheal and bellow the stenosis. The recurrent laryngeal nerve
stenosis (Figs 8 and 9). need not be exposed.
After the resection of stenosis is completed, fascial flap
Operative Technique is pulled under sternohyoid and sternothyroid muscles
The cervical fascia consists of strong fibrous tissue encom- and sutured to the resected margin of the tracheal peri-
passing only the anterior plane of the neck. It stretches chondrium with 4-0 Vicryl sutures (Fig. 14). In the case
between the omohyoid muscle and encloses the sterno- of tracheal injury after a conservative debridement
hyoid. Cranially it is tied to hyoid bone and caudally to the “i.e. a tissue sparing removal of damaged mucosa and
posterior border of the sternum and clavicular incisure cartilage, the continuity of the lacerated, but vital mucosa
(Fig. 10). Cervical fascia receives its vascular supply from is prove with 4-0 Vicryl resorptive sutures. Fractured parts
branches of the superior and inferior thyroid artery. of cartilage, which are connected to the perichondrium
After tracheotomy and tracheostomy formation, which are returned in anatomical position by 2-0 Vicryl. Only the
should be placed as low as possible, a tracheal tube with parts of the cartilage completely separated from perichon-
cuff is inserted. The U-shaped incision of the skin is made drium are removed. Major defects of the cartilage skeleton
according to Gluck-Soerensen, placing its base below are covered with the cervical fascia flap and connected
mandible. In this way the flap, which includes skin, subcu- by 4-0 Vicryl to the healthy perichondrium from inside. If
taneous fat and platisma is raised (Fig. 11). This approach necessary, the cervical fascia flap can be reinforced from
opens a wide view of the larynx and cervical trachea and outside by sternohyoid muscle. In the case of instability
allows the exploration of the vital structures on the both of tracheal ring a stent is placed endotracheally and kept
sides of the neck. there for four weeks.
Depending on the place and size of tracheal or laryn- The advantages of cervical fascia flaps are easy shap-
gotracheal stenosis1 and expected size of defect, the ing, one stage reconstruction and the length and width
base of the flap is left cranially, on hyoid bone, or later- of the flap is always adequate for reconstruction defect.
ally, on omohyoid muscle (Figs 12 and 13). The incision The thinness, elasticity and strength of the fascia make it
for lateral base fascial flap is formed on lateral margin of a perfect tissue for the reconstruction of two-dimensional
omohyoid muscle, on the side of the stenosis. The incision defects (Fig. 15). Based on our experience, cervical fascia
is continued cranially up to the level of the hyoid margin flap proved to be useful for covering denuded cartilage
and extended along the entire length of the hyoid. The surface and for additional external fixation of thyroid,
fascia is carefully prepared and detached from omohy- cricoid or tracheal cartilages in lesions that cause instabil-
oid and suprahyoid muscle. The base and delicate blood ity of the laryngotracheal framework.
supply are on the contralateral omohyoid and sternohyoid
muscles. The created flap is at least 15% to 20% lager than
the expected size of the tracheal defect. The strap muscles
COMPLICATIONS
are separated in the midline, and the entire trachea with The use of mesenchymal tissue, such as the cervical fascia
stenosis is exposed. Dissection of the trachea should be flap, represents simple technique, and it yields good
 The Surgical Management of Tracheal Stenosis 1279

Fig. 15: One week postoperative view Fig. 16: Peripheral necrosis of the cervical fascia flap
of the larynx and trachea

functional results. The fascia proved to be good-quality endoscopy before addressing the challenging surgery of
biological material for reconstruction since it is resistant tracheal stenosis. Surgeon must carefully respect the indi-
for local infection and saliva and does not require a major cation for management of each type of stenosis and use
blood supply. The necrosis of fascia was very rare and optimal operative technique. Below are some of the most
when it occurred was peripheral or circumscribed and not common treatment options for tracheal stenosis.
diffuse or central (Fig. 16). Similarly, abundant formation • Tracheal resection and reconstruction (minimally
of granulation tissue was not common in our patients, in invasive open technique)
contrast to the findings of other authors. The time needed • Tracheal LASER surgery (less is more)
for fascial epithelization varied depending on the flap • Tracheal dilatation
size, local complications and patient’s general condi- • Tracheal airway stent
tion. Beside epithelization of the flap, tissue shortening And rare surgical options include:
occurred and in some cases measured up to 15% of the • Rib-cartilage tracheoplasty
flap size. Shortening was more significant in lager flaps. • Pericardial patch tracheoplasty
• Tracheal autograft
• Slide tracheoplasty
SPECIAL INSTRUMENTS USED FOR • Microdebrider
THE SURGERY • Robotic surgical technique.
We use standard surgical instruments.
REFERENCES
OTHER TREATMENT OPTIONS 1. Danic D, Prgomet D, Rubin O, et al. Laryngotracheal steno-
AVAILABLE FOR THE SAME sis-etiology and therapeutic options. Acta Med Croatia.
2006; 60(4):319-23.
CONDITION 2. Danic D, Prgomet D, Sekelj A, et al. External laryngotracheal
trauma. Eur Arch Otolaryngol. 2006; 263(3):228-32.
Each case present a different surgical problem and it 3. Danic D, Milicic D, Prgomet D, et al. Acute laryngotracheal
is difficult to follow a set routine on each one. There are trauma: a comparison between peace time and war injuries.
many other methods in which the surgeon should be J Laryngol Otol. 1996; 110:435-9.
versed in order to cope with any situation and some degree 4. Danic D, Milicic D, Prgomet D, et al. Reconstruction of
of ad-libbing is required in each case. Train yourself laryngotracheal injuries with the median layer of deep
adequately in laryngotracheal surgery and upper airway cervical fascia. J R Army Med Corps 1995; 141(1):16-19.
1280 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1280
CHAPTER

144 The Surgical Management of

Tracheal Stenosis
Mariano M Boglione

INDICATIONS FOR THE SURGERY than 50% of the trachea) while slide tracheoplasty is most
effective for the long-segment ones.
Patients with tracheal stenosis present with variable
symptomatology depending on the age of the patient, the SPECIFIC PREOPERATIVE
­severity of the stenosis and the presence or absence of EVALUATION
associated malformations.
Surgical management of this pathology represents Algorithms for preoperative evaluation and treatment
a complex technical challenge due to the fact that exists options decision making are shown in Figures 1 and 2.
diverse lengths of stenosis, at different levels of the trachea
and that can be associated with other pathologies or
malformations that may require concomitant correction.
ANESTHETIC CONSIDERATIONS
Tracheal reconstruction is needed in cases of acquired Adequate airway patency must be provided to allow venti-
stenosis (secondary to long-term intubation, tracheo­ lation of the lungs either before and during the surgical
stomy, trauma or tumors) that do not respond to conserv- procedure.
ative treatment with periodic dilatations and also in cases The main difficulty at the time of operation for tracheal
of congenital stenosis that characteristically presents with resection is need for simultaneous control of the airway,
a variable number of complete rings that result in a fixed to maintain adequate gas exchange, and for satisfac-
tracheal narrowing resistant to dilatation. tory surgical exposure. Distal ventilation during tracheal
There is a consensus about segmental resection and resection and reconstruction has always been a major
anastomosis being best for short segment stenosis (less challenge.
The method we use consists of ventilation of the distal
airway by a sterile tube passed by the anesthesiologist
across the operative field.

Fig. 1: Algorithm for preoperative evaluation Fig. 2: Algorithm for the treatment
 The Surgical Management of Tracheal Stenosis 1281

Fig. 3: Endotracheal tube Fig. 4: Endotracheal tube across the operative field entering
across operative field distal trachea. Note that posterior wall is already sutured

Complete control of ventilation and oxygenation must

be maintained continuously.
Depends on the clinical status of the patient, he/she is
extubated in the operating room or later on in the inten-
sive care unit.
When a thoracotomy is performed, is useful to place an
epidural catheter before the operation to provide posop-
erative analgesia.

SURGICAL STEPS
Surgical techniques varies from tracheal resection and
end-to-end anastomosis, to tracheal enlargement using
tracheoplasty “augmentation” techniques, such as peri-
cardial or cartilage grafting or slide tracheoplasty.
Techniques for treating concomitant tracheoesopha-
Fig. 5: When posterior wall suture is finished, the cross- geal fistula and for carinal resection and reconstruction
field tube is withdrawn and the transoral endotracheal tube are also described.
is advanced from above across the anastomosis to the distal
trachea Resection and Reconstruction
Almost all supracarinal lesions of the trachea may be
The patient is initially intubated transorally with and corrected through a collar incision or a collar incision
endotracheal tube that can be advanced into the distal with an upper sternotomy extension reaching the angle of
trachea if it is desired. Once the area of the trachea to be Louis. The collar incision is placed low in the neck.
resected has been sectioned, distal trachea is intubated Tracheal stomas are handled in different ways. If it lies
with a sterile, flexible tube whose connecting system is close to the stenotic lesion, it is excised in continuity. If
passed to the anesthesiologist (Fig. 3). The tube can be the stoma is far away the stenotic lesion, we prefer to close
safely removed intermittently for brief periods of time it separately in order not to lose healthy trachea. In any
to place the sutures precisely (Fig. 4). When the anasto- case, the cutaneous stoma is always included in the collar
mosis is ready to be approximated, the crossfield tube is incision. We always close the tracheal stoma at the same
withdrawn and the original transoral endotracheal tube procedure of tracheal resection and reconstruction.
advanced from above across the anastomosis to the distal Pretracheal muscles are incised longitudinally in the
trachea (Fig. 5). Previously placed stay and anastomotic midline and retracted. Dissection is done immediately
sutures are then tied. on the anterior tracheal wall in meticulous and precise
1282 Voice and Laryngotracheal Surgery

fashion. The innominate artery and other vessels are not hemostats. After all sutures are placed, they are tied begin-
dissected out of their investing tissues to avoid later adhe- ning posteriorly and working anteriorly (Fig. 8). The anas-
sion formation and eventual fistulas to the tracheal anas- tomosis is then covered with surrounding fat tissue or a
tomosis. The recurrent laryngeal nerves are not exposed or strap muscle to prevent fistula formation.
visualized at all in these procedures. Surrounding inflam-
mation and scar make it unsafe to expose them. Concomitant Tracheoesophageal Fistula
Electrocautery is avoided. For hemostatic purposes, Although associated tracheoesophageal fistula (TEF) may
small gauzes imbibed in a solution of adrenaline are used. be of congenital origin, it is generally secondary to trau-
Once the stenotic area is recognized, circumferential matic lesions due to foreign bodies, cuffed endotracheal
dissection is done only immediately above and below the tubes or stent placement.
lesion. No more than one tracheal ring of normal trachea Surgical approach is similar to the one described
that is going to be left in place is ever circumferentially above.
dissected. Otherwise, the blood supply that enters later- Once the stenotic area of the trachea is reached, its
ally can easily be damaged and later necrosis and reste- anterior wall is opened to define TEF position (Fig. 9).
nosis may occur. When dissection of the trachea below Dissection must be carried out below and above the
the lesion is completed, the airway is transected and borders of the common TEF wall until healthy trachea and
intubation performed across the surgical field. Lateral esophagus are identified in order to separate from each
traction sutures (stay suture) of polydioxanone, includ- other. The esophagus is closed either longitudinally or
ing both ends of the trachea are placed in the midpoint of transversely using continuous polydioxanone or polyga-
the tracheal wall at either side. The specimen is elevated lactine suture. Transverse closure puts more tension on
and pulled upward, separating it from the esophagus the esophageal suture. Conversely, longitudinal closure
and lateral tissues. This traction helps to protect both the removes tension from the suture. Moreover, the ­flexibility
esophagus and the recurrent laryngeal nerves. A small of the posterior esophageal wall makes some degree
margin of membranous wall must be obtained. Then, the of narrowing without functional consequences. Then,
stenotic area is resected and tentative approximation is tracheal stenosis is managed as explained before.
demonstrated by pulling proximal and distal tracheal ends Recurrence of TEF can be prevented by the avoid-
together. ance of contact between esophageal and tracheal sutures
Anastomosis is performed using a running polydiox- lines. We consider interposition of a strap muscle, which
anone suture in the posterior membranous wall that is provides the best material because it is of good substance,
left loose until its completion (Fig. 6). After this, running easy to mobilize, and will not cause protrusion into the
suture is tightened while both lateral traction sutures are tracheal lumen. So, it is important to preserve the ster-
pulled and tied. Ends of the running suture are tied with nohyoid muscle during the approach. Detachment of
the lateral traction sutures (Fig. 7). Anterior cartilaginous its superior origin and careful protection from crush-
tracheal wall anastomosis is done using X-fashioned poly- ing and contamination preserves adequate material for
dioxanone stitches that remain untied and marked with reinforcement.

Fig. 6: Running suture in the posterior membranous wall Fig. 7: Posterior wall suture
 The Surgical Management of Tracheal Stenosis 1283

Fig. 8: Anterior wall suture Fig. 9: Tracheoesophageal fistula. When trachea is tran­
sected, the nasogastric tube is seen into the esophagus

Fig. 10: Anterior cartilage grafting. Lungs are ventilated Fig. 11: Cartilage graft is sutured to the tracheal incision
through a crossfield endotracheal tube using interrupted 4/0 or 5/0 monofilament absorbable sutures
(polidioxanone, PDS®)

Tracheal Augmentation defect. Cartilage harvested from the upper portion of the
sternum can also be used.
Autologous Costal Cartilage Graft Procedure The cartilage graft is sutured to the tracheal incision,
The anterior wall of the trachea is reached through either using interrupted 4/0 or 5/0 monofilament absorbable
a cervical incision or a median sternotomy. Sometimes sutures (polidioxanone, PDS®) (Figs 10 and 11).
transpericardial approach is needed to have sufficient An endotracheal stent tube is left in place with the tip
surgical access to the stenotic area. If this occurs, supe- beyond the reconstruction for approximately 10 days.
rior vena cava and ascending aorta are dissected free, The mesenchymal surface of the cartilage becomes
repaired with hemostats and separated from each other. epithelialized in time.
This maneuver gives a wide exposure of the distal trachea,
including the carina. The right pulmonary artery should be Autologous Pericardial Patch Grafting
retracted inferiorly if exposure of both bronchi is required. Procedure
The entire stenotic segment is longitudinally incised Pericardial patch augmentation tracheoplasty requires
and opened. A cartilage graft harvested from the fifth or extracorporeal circulation, complete sternotomy and wide
seventh rib is trimmed into an ellipse to match the tracheal exposure of the tracheal via a transpericardial approach.
1284 Voice and Laryngotracheal Surgery

The stenotic area of the trachea is incised vertically and placed approximately 3 milimeters apart through the full
opened, the pericardial patch is sutured into place using thickness of the trachea so that the future knots will be
interrupted 4/0 or 5/0 monofilament nonabsorbable tied external to the tracheal wall. Suturing is begun proxi-
sutures (Prolene®). mally and carried in parallel succession distally, the final
The patch is suspended to the innominate artery and suture being placed at the distal end of the anterior wall of
the artery is suspended to the sternum. Endotracheal intu- the upper segment of the trachea. All sutures are carefully
bation for stenting purposes and mechanical ventilation held with a hemostat and clipped to the ipsilateral drapes.
are necessary for approximately 1 week postoperatively. After placement of all sutures, the endotracheal tube
The pericardial patch is replaced by mature scar tissue from above is advanced into either the distal trachea or
in the graft site and is completely reepithelialized with mainstem bronchi to continue ventilation. With the help
pseudostratified ciliated columnar epithelium. of the previously placed traction sutures, the ends of both
segments are approximated by sliding one over the other.
Slide Tracheoplasty Technique The anastomotic sutures are tied commencing proxi-
Anteroinferior cervical collar incision alone or with addi- mally and posteriorly, working down sequentially on both
tional partial upper median sternotomy to a level just sides until the anastomosis is completed anteriorly and
below the sternal angle or complete median sternotomy inferiorly.
with or without transpericardial approach can be used. The reconstructed stenotic segment is shortened by
The upper and lower ends of the stenotic tracheal one half its length (Figs 12C and D). The circumference of
segment are intraoperatively identified. Tracheal dissec- the stenotic trachea is doubled and its cross-sectional area
tion is performed circumferentially only around the is quadruped. This area increase is actually slightly less
midpoint of the stenotic segment to prepare for subse- due to the bilobate shape of the reconstructed lumen that
quent transection at this level (Fig. 12A). Lateral dissection tends to look like a figure of “8” during bronchoscopy.
is avoided to keep the vascular supply intact. The integrity of the tracheal anastomosis is tested by
Following transection, the distal trachea is intubated covering the trachea with saline solution while applying
with an appropriate sized endotracheal tube connected pressure of 30 cm of water to the airway.
via sterile tubing across the operative field to the ventila-
tor. If the stenosis extends to the carina, either left or right Comments
mainstem bronchi can be selectively intubated. The proxi- A major problem with augmentation tracheoplasty using
mal endotracheal tube is pulled back into the subglottic cartilage or pericardium is a similar tendency toward
larynx. recurrent granulation tissue formation at graft sites. Thus
Vertical divisions of the proximal and distal tracheal necessitating multiple bronchoscopies for debridement.
segments are performed next (Fig. 12B). The proximal Moreover, all patch techniques require prolonged stenting
segment is incised posteriorly along the entire length of with intubation during early healing.
the stenosis below the cricoid. It is essential that the full Advocates of cartilage graft tracheoplasty note that
length of the stenosis be incised. Only limited dissection cartilage, compared with pericardium, has greater inher-
of the distal tracheal segment is necessary because of the ent support, which may be of particular benefit in distal
anterior location of the vertical incision that is carried out stenosis involving the carina or mainstem bronchi, where
along the anterior wall of the stenosis down to the carina. stenting is more troublesome. Proponents of cartilage
For the upper segment, the posterior incision of the upper augmentation tracheoplasty also note the ease of costal
segment requires a greater degree of peritracheal dissec- cartilage harvesting and argue that the pericardium is
tion, which is minimized as much as possible. outside the operative field, if cervical dissection of the
The right-angled corners created by these meeting trachea without sternotomy provides adequate surgical
points of the horizontal and vertical tracheal incisions are access to the stenotic area.
trimmed (spatulated) to make gently curving corners. Advantages of slide tracheoplasty over other tech-
A stay 3/0 or 4/0 polyglactin (Vicryl®) or polydioxanone niques are several fold. Preservation of native tracheal
(PDS®) suture is placed through the tracheal wall close to tissue, allowing the reconstructed trachea to be immedi-
the distal tip of the upper segment for proximal traction. ately stable and lined with normal epithelium and negat-
Similar distal traction sutures are placed bilaterally either ing the need for autologous augmentation cartilage or
at the tracheobronchial junctions or within the anterior pericardium. There is less extensive surgical dissection,
walls of the proximal right and left mainstem bronchi. decreased likelihood of subsequent mediastinal compli-
Tracheal anastomosis is performed with interrupted cations and avoidance of the need for cardiopulmo-
4/0 or 5/0 absorbable polydioxanone (PDS®) sutures nary bypass in the absence of coexistent cardiovascular
 The Surgical Management of Tracheal Stenosis 1285

A B C D
Figs 12A to D: (A) Tracheal dissection is performed circumferentially around the midpoint of the stenotic segment.
(B) Vertical divisions of the proximal and distal tracheal segments; (C and D) Tracheal anastomosis is performed and the
reconstructed stenotic segment is shortened by one half of its length

anomalies. Prolonged endotracheal intubation for venti- supply but, most importantly, separates these suture lines
lation and stenting purposes is not necessary due to the from nearby vascular structures and suture lines. Pleural
fact that tracheal complete “O” rings provide adequate flaps, pericardial fat pads, pedicled intercostals muscle
support to the tracheal wall. The avoidance of both an flaps and even omentum can be used.
endotracheal tube stent and a mesenchymal tissue
graft results in lesser granulation tissue formation and Carinal Resection
a markedly reduced need for therapeutic postoperative
Approach
bronchoscopies.
Access to the carina is best achieved through a right poste-
Carinal Reconstruction rolateral thoracotomy through the fourth or fifth intercos-
tal space (Figs 13 and 14). This approach is useful to gain
Concepts (Principles)
access to either mainstem bronchus.
Blood supply to the trachea is predominantly segmental A left thoracotomy allows only limited resection of
and every effort should be made to avoid interruption. the carina and requires mobilization of the aorta to gain
Lateral dissection proximal and distal to the proposed access to the carina. Tapes can then be passed around the
lines of transaction should be limited to 1 to 2 rings. Sharp, distal trachea and right mainstem bronchus to facilitate
single, clean transaction lines are imperative. exposure.
Size discrepancy usually exists between the proximal Median sternotomy is adequate for limited carinal
and distal ends of the airway. Tailoring of either end by resection; this is performed transpericardially between
narrowing the proximal one or creating a “V” in the distal the superior vena cava and ascending aorta laterally and
one is unnecessary. innominate vein and the pulmonary artery superiorly and
It is convenient to cover all airway anastomoses by inferiorly. These structures need to be fully mobilized to
local vascularized tissues. This may add to the blood give adequate exposure.
1286 Voice and Laryngotracheal Surgery

Fig. 13: Right posterolateral thoracotomy. Trachea and Fig. 14: Carina is resected. RMB: Right mainstem
both mainstem bronchi are dissected and tapes are passed bronchus. LMB: Left mainstem bronchus
around them

Fig. 15: Resection with restitution of the neocarina by Fig. 16: Anastomosis of the right main bronchus in an end-
approximation of the medial walls of the left and right bronchi to-end fashion to the distal trachea and the left main bronchus
to one another in an end-to-end fashion to the intermedius bronchus

In cases of extensive involvement of the carina, Carinal reconstruction for stenosis involving the lower
distal trachea and right mainstem bronchus, a bilateral, trachea, carina and proximal main bronchi to a greater
submammary, transternal (clamshell) thoracotomy is extent, may be accomplished by the anastomosis of the
useful to gain adequate exposure. right main bronchus in an end-to-end fashion to the distal
trachea and the left main bronchus in an end-to-side fash-
NEW TECHNIQUES IN THE ion to the intermedius bronchus (Barclay) (Fig. 16). This
SURGERY reconstruction is possible only, if the right main bronchus
is left sufficiently long.
Resection with restitution of the neocarina can be A variant of this technique consists in performing a
achieved in small lesions by approximation of the reconstruction in which the trachea is anastomosed to the
medial walls of the right and left main bronchi to right main bronchus in an end-to-end manner and the left
one another, to fashion a new carina with the trachea main bronchus to the trachea above the first anastomosis
(Mathey) (Fig. 15). in an end-to-side manner (Grillo) (Fig. 17).
 The Surgical Management of Tracheal Stenosis 1287

Another option is to perform an end-to-end anasto- easily anastomosed to the lateral tracheal wall above the
mosis between the left main bronchus and lower trachea first anastomosis regardless of its residual length (Fig. 21).
(Fig. 18) and depending on the length of the remain- When performing an end-to-side anastomosis it is
ing right main bronchus, an end-to-side anastomosis important to create the ovoid opening entirely in carti-
between right and left main bronchi (short right main laginous wall, avoiding the membranous portion (Fig. 22).
bronchus) (Fig. 19) or between the right main bronchus This provides additional rigidity at the level of the anas-
and lower trachea above the first anastomosis (long tomosis. It is also important to locate the opening at least
right main bronchus) (“Inverted” technique of Barclay 1 cm away from the end-to-end anastomosis, in order to
described by Eschapasse) (Fig. 20). We prefer the later one avoid devascularization and necrosis of the intervening
because we believe that the right main bronchus can be cartilaginous isthmus.

Fig. 17: Trachea is anastomosed to the right main bronchus Fig. 18: Trachea is anastomosed in an end-to-end fashion to
in an end-to-end manner and the left main bronchus to the the left mainstem bronchus. Right mainstem bronchus (RMB)
trachea above the first anastomosis in an end-to-side manner is ready to be anastomosed

Fig. 19: End-to-side anastomosis Fig. 20: “Inverted” technique of

between right and left main bronchi Barclay described by Eschapasse
1288 Voice and Laryngotracheal Surgery

Fig. 21: Right mainstem bronchus anastomosis to the

lateral wall of the trachea is completed

COMPLICATIONS
Many complications may occur following tracheal
surgery. These complications can be divided according to Fig. 22: Creating the ovoid opening entirely in cartilaginous
their frequency, severity or time of appearance after the wall to avoid the membranous portion while performing an
procedure. end-to-side anastomosis
Most frequent complications are stenosis and granula-
tion tissue formation. Necrosis of the anastomosis is a challenging compli-
Most severe (hazardous) complications are necrosis or cation that often requires a major surgical procedure.
separation (dehiscence) of the anastomosis and broncho- Sometimes, small dehiscence of the anastomosis can be
vascular or tracheovascular fistulae (both are extremely conservatively managed.
infrequent). Vocal cord paralysis and swallowing (deglutitional)
Early complications are those that occur within the dysfunction often recover spontaneously. If the recurrent
first 10 to 15 postoperative days and may have almost no laryngeal nerve is seriously damaged or sectioned, vocal
importance as mucosal slough, subcutaneous emphy- cord paralysis becomes permanent. Injury of both recur-
sema or minimal granulation tissue or may be severe and rent nerves may need a tracheostomy to solve the problem.
sometimes fatal as dehiscence of the anastomosis. Other
early complications are vocal cord paralysis and degluti- Tracheal Release (Mobilization)
tional disorders with airway aspiration. The simplest maneuver to avoid excessive anastomotic
Late complications are stenosis, excessive granulation tension is flexion of the neck. Mobilization of the ante-
tissue, recurrent episodes of obstructive pneumonia (less rior pretracheal plane, avoiding injury to the lateral blood
severe) and fistulae between the airway and a major vessel supply to the trachea, increases the mobility of the airway.
(almost always fatal). Dissection of both mainstem bronchi in a similar fashion,
Granulation tissue formation is easily solved by recur- avoiding its lateral blood supply, will slightly increase the
rent bronchoscopies. mobility of the distal airway as well. Division of the infe-
Stenosis may be treated by prolonged airway stenting rior pulmonary ligament, and freeing pulmonary vessels
or repeated dilations. Sometimes a redo operative inter- from the pericardium (mobilization of the hilum) are
vention to address the area of concern is necessary (rere- important. A U-shaped incision in the pericardium infe-
section, anterior wall grafting). rior to the inferior pulmonary vein will allow the hilar
 The Surgical Management of Tracheal Stenosis 1289

structures and bronchus to advance. Additional length OTHER TREATMENT OPTIONS

may be obtained by completely incising the pericardium AVAILABLE FOR THE SAME
around the hilar vessels. It is best to preserve a posteriorly
based pedicle of tissue that includes bronchial vessels and CONDITION
lymphatics whenever complete incision of the pericar- Other strategies to solve tracheal stenosis were reported:
dium is performed. cryopreserved tracheal and aortic homografts, autologous
Laryngeal release can adjunct to tracheal resection tracheal grafts, periodical dilatations with expandable
for stenosis. Dividing hyoid muscles was suggested to balloons and LASER use.
help close the gap produced by resection of a subglottic
laryngeal stenosis. Division of the thyrohyoid muscles, Final Consideration
superior cornua of the thyroid cartilage and the thyrohy- The “silver bullet” concept: First operation is probable
oid membrane, with care to preserve superior laryngeal the unique opportunity, the patients have to get his/her
nerves, allow the larynx to drop about 2 to 3 cm. An alter- airway problem appropriately solved.
native method, known as suprahyoid release, consists in It is important to get in mind that it is not always possi-
dividing muscle attachments to the superior surface of the ble to correct failure once it has occurred; thus supporting
hyoid bone, the stylohyoid muscles and the hyoid bone the need for having the first operation performed by an
anterior to the digastrics slings. experienced tracheal surgeon.
1290 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1290
CHAPTER

Tracheal Resection and

145 Anastomosis
Bachi T Hathiram, Vicky S Khattar
(Our special gratitude towards Prof Philippe Monnier, who has been our inspiration and guide for our interest and
knowledge of laryngotracheal stenosis surgery. A special mention of Prof Sultan Pradhan for being a constant source of
encouragement).

“The tracheal tailor quickly runs out of cloth”

—Grillo HC, 2004.1

INTRODUCTION Regardless of the etiology, tracheal stenosis should

only be operated upon after certain criteria are met
There are three main techniques to tackle tracheal stenosis. with. Firstly, the scar should be a mature scar and not an
These include: (1) endoscopic dilatation [with or w ­ ithout ­evol­ving one. For example, patients who have acute post-
light amplification by stimulated emission of radiation intubation injuries, and can be managed by conservative
(LASER)], (2) tracheoplasty [using an anterior costal carti- endoscopic means, it should be done accordingly. Only
lage graft (ACCG)] and (3) tracheal resection and anasto- if after repeated endoscopic evaluations, the progress
mosis. Each technique has its own merits and limitations. comes to a halt, or the scar becomes thick/fibrotic/firm
Although endoscopic dilatation seems to be the most and organized does the patient fall into the candidacy of a
“conservative” of the three techniques, it is usually indi- resection anastomosis procedure.
cated for thin web-like/membranous stenosis,2 which
is limited to a very short segment of the trachea, is not PREOPERATIVE EVALUATION AND
occluding the entire tracheal lumen (so that there may be ANESTHETIC CONSIDERATIONS
some residual mucosa), and it should be within the tracheal
cartilaginous ring, not encroaching on the membranous These are the same as for any patient with laryngo­
trachea. The latter point is important, as any ­ stenosis tracheal stenosis, and have been covered in the previous
(however, thin) if not surrounded by a ­cartilaginous frame- ­chapters. As for most cases, a nasotracheal intubation
work, would not withstand dilatation and rapidly restenose. would eventually perform the role of the scaffold on which
Tracheoplasty using an ACCG is more of a salvage the a­ nastomosis would rest (but it must be remembered
option, and it should be reserved for such cases where that the nasotracheal tube will not in any way help in the
tracheal resection anastomosis has failed,3 or there are strength of the stenosis). The nasotracheal tube merely
insufficient tracheal rings in the neck for a re-resection stents the airway in the intraoperative and postoperative
and anastomosis. As far as possible, it would not serve as period till the anastomosis has gained sufficient strength,
an ideal first choice. It may, however, be employed as an which is usually for about a week after surgery.3
ideal solution for a post-tracheostomy anterior tracheal
dehiscence/malacic segment/scar, which only requires
cartilaginous reinforcement anteriorly.
STEPS OF SURGERY
Tracheal resection and anastomosis is a relatively The intraoperative images from Figure 1 to 25 describe the
radical, but technically simple surgery, which has optimal steps of surgery.
results in most cases, provided the basic aspects of the • Infiltration is performed with saline-adrenaline (Fig. 1).
tracheal anatomy and principles of resection and anasto- • Skin incision (Fig. 2).
mosis are kept in mind. • Subplatysmal flaps are elevated (Fig. 3).
• The subplatysmal flaps are elevated superiorly, till the
hyoid bone (Fig. 4).
INDICATIONS FOR SURGERY • The midline raphe is cauterized and divided to ­separate
It is indicated for any tracheal stenosis, which would not be the strap muscles in the midline (Fig. 5).
ideal for endoscopic management (vide supra), or steno- • The airway is skeletonized (Fig. 6).
sis extending to the posterior membranous trachea, or any • The malacic segment of the trachea is identified and
complete stenosis (since endoscopic procedures fare well, tagged with a suture for traction. This helps in dissec­
if there is atleast some normal residual mucosa available). ting around the distal trachea (Fig. 7).
 Tracheal Resection and Anastomosis 1291

Fig. 1: Infiltration is performed with saline-adrenaline Fig. 2: Skin incision

Fig. 3: Subplatysmal flaps are elevated Fig. 4: The subplatysmal flaps are elevated
superiorly, till the hyoid bone

• The trachea is entered just below the level of the Ventilation is now shifted from the nasotracheal Portex
­stenotic segment (Fig. 8). endotracheal tube to the flexometallic tube inserted
• The trachea is then entered just above the stenotic through the distal tracheal stump (Fig. 11).
segment (Fig. 9). • A suture is passed through the tube just distal to (but,
• The stenotic segment is slit open to evaluate the lumen not through) the Murphy’s eye of the Portex nasotra-
(Fig. 10). cheal tube. This is important since, if the suture is
• An armored (flexometallic) tube is inserted to venti- passed through the Murphy’s eye, the part of the tube
late the patient through the distal tracheal stump. The distal to the Murphy’s eye may get stuck in the laryn-
initial Portex endotracheal tube is withdrawn into the geal ventricle while withdrawing it into the surgical
surgical field, till the Murphy’s eye of the tube is visible. field (Fig. 12).
1292 Voice and Laryngotracheal Surgery

Fig. 5: The midline raphe is cauterized and divided to Fig. 6: The airway is skeletonized
separate the strap muscles in the midline

Fig. 7: The malacic segment of the trachea is identified and Fig. 8: The trachea is entered, just below
tagged with a suture for traction. This helps in dissecting the level of the stenotic segment
around the distal trachea

• The Portex nasotracheal tube is now withdrawn proxi- • The stenotic segment is now removed. It is important
mally into the larynx, keeping only the suture visible. to be careful, during the dissection of the membra-
This serves as a guide for the tube, which may then be nous tracheal segment so as to prevent any damage to
withdrawn into the surgical field as and when required the underlying esophagus posteriorly. Also, in order
(Fig. 13). to mobilize the proximal tracheal stump, a laryngeal
• The stenotic segment is now dissected, till normal and release procedure may be performed; while for the
healthy tracheal rings are available on both ends for distal tracheal stump, anterolateral dissection of the
anastomosis (Fig. 14). intrathoracic trachea may be done. In either case,
 Tracheal Resection and Anastomosis 1293

Fig. 9: The trachea is then entered, Fig. 10: The stenotic segment is
just above the stenotic segment slit open to evaluate the lumen

Fig. 11: An armored (flexometallic) tube is inserted to venti- Fig. 12: A suture is passed through the tube, just distal
late the patient through the distal tracheal stump. The initial to (but, not through) the Murphy’s eye of the Portex
Portex endotracheal tube is withdrawn into the surgical field, nasotracheal tube. This is important since, if the suture is
till the Murphy’s eye of the tube is visible. Ventilation is now passed through the Murphy’s eye, the part of the tube distal
shifted from the nasotracheal Portex endotracheal tube to the to the Murphy’s eye, may get stuck in the laryngeal ventricle
flexometallic tube inserted through the distal tracheal stump while withdrawing it into the surgical field

excessive circumferential dissection of the trachea • The posterior mucosal sutures are then taken (Fig. 17).
should be avoided as far as possible and, if neces- • The flexometallic tube needs to be intermittently
sary, should be restricted to as minimum as possible removed in order to take and knot the posterior
(Fig. 15). mucosal sutures. The anesthesiologist at this time
• The posterolateral anchoring sutures are taken just needs to maintain the patient on an apneic technique
short of the edge of the tracheal rings. These sutures and intermittently ventilate the patient by inserting
are vital to bring the two tracheal ends together, prior the tube, depending upon the oxygen saturation of the
to tying off the posterior mucosal sutures (Fig. 16). patient (Fig. 18).
1294 Voice and Laryngotracheal Surgery

Fig. 13: The Portex nasotracheal tube is now withdrawn Fig. 14: The stenotic segment is now dissected, till normal
proximally into the larynx, keeping only the suture visible. and healthy tracheal rings are available on both ends for
This serves as a guide for the tube, which may then be anastomosis
withdrawn into the surgical field as and when required

Fig. 15: The stenotic segment is now removed. It is important Fig. 16: The posterolateral anchoring sutures are taken, just
to be careful, during the dissection of the membranous short of the edge of the tracheal rings. These sutures are
tracheal segment so as to prevent any damage to the vital to bring the two tracheal ends together, prior to tying
underlying esophagus posteriorly. Also, in order to mobilize off the posterior mucosal sutures
the proximal tracheal stump, a laryngeal release procedure
may be performed, while for the distal tracheal stump,
anterolateral dissection of the intrathoracic trachea may be
done. In either case, excessive circumferential dissection of
the trachea should be avoided as far as possible and, if
necessary, should be restricted to as minimum as possible
 Tracheal Resection and Anastomosis 1295

Fig. 17: The posterior mucosal sutures are then taken Fig. 18: The flexometallic tube needs to be intermittently
removed in order to take and knot the posterior mucosal
sutures. The anesthesiologist at this time needs to maintain
the patient on an apnoeic technique and intermittently
• The flexometallic tube is reinserted, after the posterior ventilate the patient by inserting the tube, depending upon
mucosal sutures are taken (Fig. 19). the oxygen saturation of the patient
• Once again, the anesthesiologist needs to switch
the ventilation from the flexometallic tube, back to
the nasotracheal Portex tube, which can be easily
­withdrawn into the surgical field with the anchoring
suture (Fig. 20).
• The tube needs to be held down so as to allow the ante-
rior sutures to be taken and secured. As far as possible,
it is advisable to take the sutures submucosally so as to
prevent the devascularization of the tracheal mucosa,
from where the vascular supply proceeds to the carti-
lages. Also, the lateral supplying vessels should be
cauterized with a bipolar cautery, and that too, as close
to the tracheal cartilage as possible, so as to prevent
them from retracting into the peritracheal soft tissues
in which lie the recurrent laryngeal nerves (RLNs),
which are more prone to thermal damage (Fig. 21).
• All the circumferential sutures have been taken
between the two tracheal stumps (Fig. 22).
• The sutures are now knotted starting laterally, and
alternately, working toward the anterior midline from
Fig. 19: The flexometallic tube is reinserted,
either side (Fig. 23). after the posterior mucosal sutures are taken
• This is the appearance of the final anastomosis. Often,
it may be advisable to take the sutures alternately on
the first and second tracheal rings of the distal and
proximal tracheal stumps, so as to decrease the tension • The anastomotic site is finally reinforced by covering it
in any single horizontal plane and distribute it evenly with the vascularized thyroid gland. The closure is then
(Fig. 24). performed in the layers over a suction drain (Fig. 25).
1296 Voice and Laryngotracheal Surgery

Fig. 20: Once again, the anesthesiologist needs to switch Fig. 21: The tube needs to be held down so as to allow the
the ventilation from the flexometallic tube, back to the anterior sutures to be taken and secured. As far as possible,
nasotracheal Portex tube, which can be easily withdrawn it is advisable to take the sutures submucosally so as to
into the surgical field with the anchoring suture prevent the devascularization of the tracheal mucosa, from
where the vascular supply proceeds to the cartilages. Also,
the lateral supplying vessels should be cauterized with a
bipolar cautery, and that too, as close to the tracheal cartilage
as possible so as to prevent them from retracting into the
peritracheal soft tissues in which lie the recurrent laryngeal
nerves (RLNs), which are more prone to thermal damage

Fig. 22: All the circumferential sutures have Fig. 23: The sutures are now knotted starting laterally, and
been taken between the two tracheal stumps alternately, working toward the anterior midline from either
side
 Tracheal Resection and Anastomosis 1297

Fig. 24: This is the appearance of the final anastomosis. Fig. 25: The anastomotic site is finally reinforced by covering
Often, it may be advisable to take the sutures alternately on it with the vascularized thyroid gland. The closure is then
the first and second tracheal rings of the distal and proximal performed in the layers over a suction drain
tracheal stumps so as to decrease the tension in any single
horizontal plane and distribute it evenly

COMPLICATIONS AND THEIR ACKNOWLEDGMENTS

PREVENTION The authors are thankful to the Dean, TN Medical College
The complications, their prevention and manage- and BYL Nair Charitable Hospital for granting permis-
ment are more or less the same for any airway surgery sion to publish this Chapter. Demonstrated cases have
and hold true for tracheal resection anastomosis as been operated during numerous laryngotracheal surgery
well. workshops by the authors along with Prof Philippe
Besides these, the two main problems that may arise Monnier.
are: (1) damage to the RLNs and (2) devascularization of
the tracheal cartilages, ­causing anastomotic dehiscence. REFERENCES
For the former, it is known that the RLNs lie in the 1. Grillo HC. Preoperative consideration. In: Grillo HC (Ed).
peritracheal soft tissues, and are very prone to thermal Surgery of the Trachea and Bronchi. Hamilton/London: BC
damage. Hence only bipolar cautery should be used in this Decker Inc; 2004. p. 445.
area. Also, dissecting as close to the tracheal cartilages as 2. Shapshay SM, Beamis JF Jr, Hybels RL, et al. Endoscopic
possible ensures that the nerves are away from the field of treatment of subglottic and tracheal stenosis by radial
dissection and there is reduced risk of damaging them. laser incision and dilatation. Ann Otol Rhinol Laryngol.
1987;96:661-4.
For the latter problem of devascularization, the tech-
3. Philippe M. Tracheal resection and anastomosis. In:
nical aspects to prevent this have already been discussed Philippe M (Ed). Pediatric Airway Surgery, 1st edition.
previously. Berlin, Heidelberg: Springer-Verlag; 2011. pp. 337-47.
1298 Voice and Laryngotracheal Surgery The Surgical Technique of Otoplasty 1298
CHAPTER

146 Laryngotracheal Reconstruction

Vicky S Khattar, Bachi T Hathiram
(We express our special gratitude toward Prof Philippe Monnier, who has been our inspiration and guide for our interest
and knowledge of laryngotracheal stenosis surgery and specially mention Prof Sultan Pradhan for being a constant source
of encouragement)

INTRODUCTION SPECIFIC PREOPERATIVE EVALUATION

This is a surgical procedure performed to expand the This remains the same for all types of laryngotracheal
laryngotracheal framework using cartilage grafts, to stenosis, and has been mentioned in detail in the Chapter
maintain the expansion. It has developed over years on “Decision Making in Laryngotracheal Stenosis”.
to its present state, as a modification of the erstwhile
laryngotracheoplasty technique, which was in vogue
during the earlier part of last century. The latter
ANESTHETIC CONSIDERATIONS
comprised of incising the cricoid cartilage anteriorly
Port for Ventilation
and posteriorly, excising the cicatricial segment, and
stenting with the help of a mold to maintain the expanded Usually in patients who have been tracheotomized previ-
airway. ously, administering anesthesia is relatively simple.
Laryngotracheal reconstruction (LTR) is indeed a Sometimes, however, the change over may be required
modification of the above procedure, in which the cica- from the tracheostomy tube, to a nasotracheal tube, such
tricial stenotic segment was excised, so as to preserve as during the final anastomoses. This is of significance in
the residual mucosa. In addition, the incised cartilage patients undergoing “single-stage” procedures, and are
at the stenotic site was maintained in position with the expected to be decannulated at the end of the surgery.
help of cartilage grafts, which reinforced the frame-
work, and prevented restenosis. This was in keeping Intermittent Apnea
with the principles of laryngotracheal surgery as advo- Often during the anastomoses of the posterior airway
cated by Rethi,1 in which the airway is augmented with- mucosa, and during the posterior cricoid split and carti-
out removal of scar tissue so as to preserve the mucosal lage-grafting step, the patient may have to be maintained
lining of the inner surface of the mature stenotic on apnea intermittently. This requires the expertize of an
segment. experienced anesthesiologist, especially when dealing
with children, who are known to desaturate rapidly and
exponentially as compared to adults.
INDICATIONS FOR THE SURGERY Also, during the preoperative assessment of the patient
Although numerous surgeons have advocated the use of under anesthesia, it is imperative for the surgeon to assess
LTR as a procedure for a variety of indications, it has been an unstented airway; also, often one requires the assess-
universally shown that the procedure yields good results ment during the “wake-up” phase of anesthesia, so as to
in patients with Grade I and Grade II subglottic stenosis, assess vocal fold mobility, malacic segments, etc., and this
and some cases of early Grade III stenosis. In the other requires an excellent coordination between the anesthesi-
cases of severe Grade III stenosis, and all cases of Grade IV ologist and surgeon.
stenosis, the choice of surgery would be partial cricotra-
cheal resection. Postoperative Period
The staging of the procedure to be a single- or a Finally during the postoperative period, all patients who
double-staged procedure depends upon a variety of have undergone an airway surgery should be observed
factors, such as the site of tracheostoma, the accompa- in the intensive care unit for at least 24–48 hours, espe-
nying comorbidities such as pulmonary, cardiac and cially those that have undergone single-stage procedures,
neurological, and also the involvement of the glottis in the and have been decannulated at the end of the surgical
stenosis. procedure.
 Laryngotracheal Reconstruction 1299

SURGICAL STEPS In case, either only an anterior or only a posterior carti-

lage graft is required, then the thyroid lamina need not
Exposure be incised all the way in the midline, and incising till just
below the anterior commissure would suffice. However,
A collar incision is made, and an ellipse of skin around whenever both anterior and posterior grafts are required,
the previous tracheostomy may be included in the same. then a complete laryngofissure is warranted.2
The subplatysmal flaps are elevated superiorly up to the Also, while performing a single-stage procedure,
hyoid bone, and inferiorly up to the manubrium of the performing a complete laryngofissure would destabilize
sternum. The strap muscles are separated in the midline, the airway to a great extent, and should be avoided.
and retracted laterally. The thyroid gland is divided in the Once the airway has been entered, skin hooks/retrac-
midline at the level of the isthmus, and the two lobes are tor hooks may be used to splay apart the two thyroid lami-
retracted laterally, carefully preserving their blood supply; nae, and display the laryngeal interior (Figs 2 and 3).
this would later be used to cover the site of anastomosis,
and provide vascularity to it. The cricothyroid muscles
are carefully dissected away from the midline. The entire
stenotic segment of the airway is exposed, as well as the
normal airway proximal and distal to it.

Laryngofissure
The thyroid laminae should be separated in the exact
midline with the utmost care. The preoperative endo-
scopic evaluation will enable us to decide where to begin
the division. In patients with normal and mobile vocal
folds, the laryngofissure may be started at the lower end,
and the anterior commissure visualized and confirmed
from below prior to dividing it. If the vocal folds are fused,
then one may enter the larynx from above (at the level of
the epiglottis), and work one’s way downward, keeping
strictly to the midline (Fig. 1).
Fig. 2: Schematic diagram of the axial view of the larynx
and its interior

Fig. 1: Schematic diagram of the larynx showing the frame­

work. “S” denotes the superior approach for a laryngofissure,
whilst “I” denotes the inferior approach. If “X” is the total
height of the thyroid laminae, then “X/2” is half its height, Fig. 3: A well-performed anterior laryngofissure should splay
which is the approximate distance at which the vocal folds apart the two thyroid laminae such that the vocal folds should
would be attached at the anterior commissure be divided exactly at the anterior commissure
1300 Voice and Laryngotracheal Surgery

Division of the Posterior Cricoid Lamina

The following steps have been performed on a fresh
(unembalmed) cadaver. After performing an anterior
laryngofissure, the subsequent steps have been depicted
below (Figs 4 to 21).

Fig. 4: The posterior laryngeal mucosa is incised Fig. 5: The incision is completed beyond the lower level of
the cricoid lamina (which can be palpated) for a few mm
onto the posterior tracheal wall. This lower extension of the
incision is essential to allow for adequate distraction while
placement of the cartilage grafts. This incision should be
perpendicular to the cricoid lamina. Great care must be taken
to avoid damage to the postcricoid hypopharyngeal mucosa

Fig. 6: Subsequently, the cricoid lamina is incised in the Fig. 7: The degree of widening that can be obtained with
midline. Note that the postcricoid mucosa has been preserved the help of a straight hemostat, which is used to splay the
two parts of the lamina apart
 Laryngotracheal Reconstruction 1301

Fig. 8: The interarytenoid mucosa and muscle is now divided Fig. 9: Note the additional splay obtained after incising
in the midline. Care must be taken to avoid entering the the interarytenoid muscle
pharynx

Fig. 10: This can be better appreciated with the

help of a hemostat
1302 Voice and Laryngotracheal Surgery

Cricoarytenoid Joint Ankylosis

See Figures 11 to 13.

Fig. 11: In case the cricoarytenoid joint is fixed, it may be Fig. 12: The bands are released in all directions
opened to release the fibrotic bands

Fig. 13: The articular facets are now visible

 Laryngotracheal Reconstruction 1303

Sizing of the Cartilage Graft

See Figures 14 to 16.

Fig. 14: The length of the cartilage graft to be interpositioned Fig. 15: The width of the cartilage graft is
in between the two parts of the cut cricoid cartilage is now being measured
measured

Fig. 16: Placement of the first stitch. The stitches are

placed first through the cricoid, and then through the graft
subsequently
1304 Voice and Laryngotracheal Surgery

Epiglottopexy
See Figures 17 to 20.

Fig. 17: The stitch to approximate the anterior commissure Fig. 18: The petiole of the epiglottis should be sutured
after the graft has been placed posteriorly, and is now being anteriorly, to prevent it from prolapsing into the airway
taken. This is a very vital stitch, and the anterior commissure postoperatively
should be approximated with the utmost precision, to
prevent postoperative web formation/blunting of the anterior
commissure

Fig. 19: The stitch for the epiglottopexy should be Fig. 20: Upon approximating the suture, the anterior
taken through the thyroid lamina fixation of the petiole of the epiglottis is now apparent
 Laryngotracheal Reconstruction 1305

Closure COMPLICATIONS AND

After placement of the posterior cartilage graft (and an
anterior cartilage graft, when required), the expanded
PRECAUTIONS TO PREVENT THEM
airway needs to be held open with the help of an endola- The patient should always be kept in an intensive care
ryngeal stent (Fig. 21). This stent will have to be fixed to setting for at least 48 hours after surgery, especially in
the thyroid cartilage anteriorly, and removed endoscopi- single-stage procedures. Oxygen and carbon dioxide satu-
cally by cutting the knots after 3–6 months, as and when rations should be monitored to detect any sudden airway
required. edema, collapse, etc.
After suturing the thyroid laminae, the thyroid gland Postoperative chest radiograph should be done to rule
is mobilized superiorly, and sutured to cover the anterior out a pneumothorax, and more so when a costal cartilage
graft (when placed). The strap muscles are then closed graft has been harvested.
over a suction-type drain, and then platysma and skin are The neck should be inspected daily for subcutane-
closed in layers. It is important to prevent the drain from ous emphysema, hematoma, serous collections, etc.
coming in contact with the thyroid cartilage. The drain It is prudent to leave the suction-type drain in situ for
should be directed inferiorly. at least 10–14 days. In case of an anastomotic dehis-
cence, which usually manifests after the first 5–7 days
NEWER TECHNIQUE/ of surgery, one will notice that the suction-type drain
will begin to get filled with air (which would normally
MODIFICATION IN THE SURGERY be seen in cases when the drain has been accidentally
There has never been a true consensus for the optimal expelled after any surgery). This is a very reliable sign
surgical procedure for subglottic stenosis, and reports that the anastomoses are giving way and need to be
across the world range from LASER-assisted procedures, surgically addressed.
to endolaryngeal procedures to more radical procedures • In single-staged procedures, a nasotracheal tube is
such as partial cricotracheal resection procedures, etc. sometimes kept to stent the airway for 48–72 hours,
Also, newer types of endolaryngeal stents are now availa- and sometimes even longer. This becomes difficult
ble, made of materials such as silicone (of varying consist- to manage sometimes, especially in children, who
encies), teflon, expandable stents, etc. may then require sedation, lest they struggle with the
tube causing a potential give-way of the anastomotic
sutures.
• Other complications include graft migration, endo-
luminal expulsion of graft (when the airway is not
stented), graft infection and subsequent necrosis,
wound infections and hematomas.
• Restenosis is even after years of experience, still consid-
ered more of a consequence, rather than a complica-
tion of surgery, as often despite the best efforts, it has
been seen in a large percentage of patients.

SPECIAL INSTRUMENTS USED FOR

THE SURGERY
The self-retaining retractor is a valuable tool for such
surgeries. It not only reduces the number of assistants
required, but also keeps unnecessary hands out of the
operating field. Due to the elastic hooks accompanying
the retractor, they may be serially advanced as the plane of
Fig. 21: This would be the site for the anterior cartilage graft. dissection deepens, without the added need to use more
The graft should always be placed with the perichondrial side hooks. It also aids in the surgical demonstration and docu-
facing the lumen mentation for teaching purposes.
1306 Voice and Laryngotracheal Surgery

ACKNOWLEDGMENTS REFERENCES
The authors are thankful to the Dean, TN Medical College 1. Rethi A. An operation for cicatricial stenosis of the larynx.
and BYL Nair Charitable Hospital for granting permission J Laryngol Otol. 1956;70:283-93.
to publish this Chapter. Demonstrated cases have been 2. Monnier P (Ed). Laryngotracheoplasty and laryngotra-
operated during numerous laryngotracheal surgery work- cheal reconstruction. Pediatric Airway Surgery. Heidelberg,
shops by the authors along with Prof Philippe Monnier. Berlin: Springer-Verlag; 2011. pp. 257-78.
 The Surgical Otoplasty 1307
Technique of Resection
Partial Cricotracheal
CHAPTER

147 Partial Cricotracheal Resection

Bachi T Hathiram, Vicky S Khattar
(Our special gratitude towards Prof Philippe Monnier, who has been our inspiration and guide for our interest and knowledge of
laryngotracheal stenosis surgery. A special mention of Prof Sultan Pradhan for being a constant source of encouragement)

surgeries. In patients with additional glottic involvement,

INTRODUCTION an EPCTR is indicated. There has been a constant debate
Partial cricotracheal resection (PCTR) is a standard between the indications for LTR versus PCTR in sub­glottic
accepted technique for subglottic stenosis. It is techni- stenosis, and this has been dealt within the Chapter on
cally more challenging than a laryngotracheal reconstruc- “Laryngotracheal Reconstruction.”
tion (LTR), and also carries with it the additional risk of
damaging both the recurrent laryngeal nerves (RLNs) as
well as anastomotic dehiscence. However, if performed
SPECIFIC PREOPERATIVE
for the correct indications, and in experienced hands, not EVALUATION
only does it yield excellent results, but also forms a salvage This has been explained in the Chapter on “Decision
procedure for failed LTR surgeries. Making in Laryngotracheal Stenosis.”
In patients who have combined glotto-subglottic
stenosis, PCTR needs to be combined with another open
airway procedure, and is then referred to as an extended
ANESTHETIC CONSIDERATIONS
partial cricotracheal resection (EPCTR). This entails a Whenever the PCTR has to be double-staged, ventilation
PCTR combined with a posterior cricoid split with the can be easily carried out through the tracheostoma, which
interpositioning of a costal cartilage graft, followed by remains at the end of the procedure.
stenting of the airway for about 6 weeks. Although a PCTR Whenever the procedure is single-staged, i.e. the
can be performed as a single-staged procedure when tracheostoma has to be resected along with the stenotic
conditions are favorable, and EPCTR is usually a double- segment, or if the patient does not have a preoperative
staged procedure, with a tracheostomy in situ at the end of tracheostoma, then ventilation during anesthesia
the primary surgery. This may be retained till the stented can prove to be challenging. In this case, either the
airway has mucosalized and healed, following which the patient may be induced with inhalational induction
tracheostomy is surgically closed. techniques, and maintained on intravenous anesthesia
A further advancement of the EPCTR has been the with bag mask ventilation, following which the stenosis
development of the EPCTR with intussusception of the is gently dilated transorally, with the subsequent
thyrotracheal anastomosis. This technique attempts to passage of a nasotracheal tube—this may be the ideal
further decrease the risk of anastomotic dehiscence, technique for patients who do not have a preoperative
and simultaneously preserve the function of the lateral tracheostomy. The other option for patients who have
cricoarytenoid muscles. In this, most of the cricoid arch been tracheostomized preoperatively would be to begin
is preserved (unlike as in PCTR), and is cored out with a the anesthesia via the tracheostomy tube, and pass an
diamond burr till it becomes more pliable. Then thyrotra- endotracheal tube transnasally just before the anastomosis
cheal anastomosis is performed within this cricoid, which has begun, and perform the final anastomosis over the
now reinforces the anastomosis.1 tube which may then be kept for a few days after surgery to
stent the airway as well as stabilize the anastomotic site in
the postoperative period.
INDICATIONS FOR THE SURGERY This requires an excellent coordination between the
Partial cricotracheal resection is indicated in patients anesthesiologist and the surgeon, similar to that as in
with severe Grade III and all Grade IV subglottic stenosis. performing a laryngectomy in a non-tracheostomized
In addition, it forms a salvage procedure for failed LTR patient.
1308 Voice and Laryngotracheal Surgery

and prepared for a costal cartilage graft, as well as to keep

STEPS OF SURGERY
the provision for the insertion of a thoracostomy/intercos-
The patient position, the skin incision, and subsequent expo- tal drainage tube should the pleura be damaged at any time
sure of the airway is similar as is described for LTR, and in during the harvesting of the costal cartilage.
fact it remains the same for all “open” airway surgeries. The The following steps have been performed on a cadaver
additional preparation required is to keep the chest scrubbed for a simple PCTR procedure (Figs 1 to 27).

Fig. 1: The landmarks are marked externally Fig. 2: The skin incision has been taken. It must be
for the larynx and trachea remembered that in case of the presence of a preoperative
tracheostomy, the skin incision should be elliptical, to include
the cuff of skin around the tracheostoma site

Fig. 3: The subplatysmal flaps are then elevated Fig. 4: The larynx is exposed
 Partial Cricotracheal Resection 1309

Fig. 5: The cricothyroid muscles are dissected away and Fig. 6: The trachea is exposed laterally, stopping short of
carefully preserved. It must be noted that at this level, the the posterolateral portion of the tracheal rings
recurrent laryngeal nerves (RLNs) would lie lateral to these
muscles, and reflecting the muscles away from the surgical
field ensures their protection at this level

Fig. 7: The airway is exposed. Note that both the cricothyroid Fig. 8: The airway is entered just below
muscles have been reflected away but preserved the cricoid cartilage
1310 Voice and Laryngotracheal Surgery

Fig. 9: The posterior mucosal incision is now being taken, Fig. 10: Dissection is now carried out in the party wall
with the attempt to preserve maximum normal mucosa. The between the trachea and esophagus to mobilize the distal
incision may be curved upward onto the anterior face of the tracheal stump
cricoid lamina. This mucosal flap is then dissected down, and
used later to cover the anastomosis

Fig. 11: The blood vessels supplying the trachea from Fig. 12: The lower stump of the trachea is
laterally are now clearly seen. In order to preserve the vitality freed and mobilized
of the trachea, and ensure a well-nourished anastomosis, it
is important to preserve these vessels
 Partial Cricotracheal Resection 1311

Fig. 13: At this stage, the adequacy of mobilization of the Fig. 14: The cricothyroid membrane is now incised
tracheal stump for achieving tension-free anastomosis is to enter the airway from above the cricoid
checked

Fig. 15: The cricoid arch is now excised, Fig. 16: The final cut before the cricoid
preserving its posterior lamina arch is excised

Fig. 17: The cricoid as seen after removal of the arch

1312 Voice and Laryngotracheal Surgery

Fig. 18: Removal of all scar tissue over the anterior face of Fig. 19: The first posterolateral stitch is now being taken.
the cricoid lamina. It is often necessary to thin out the anterior This is one of the most vital sutures and needs to be
face of the cricoid lamina with a diamond burr using a drill, so accurately placed on both sides
as to allow for more expansion of the subglottic airway lumen.
One must, however, never drill out the lamina completely

Fig. 20: The posterolateral suture has been placed between Fig. 21: Both the posterolateral sutures are
the cricoid lamina remnant and the tracheal ring. It is not now in place
knotted at this stage, but clamped and maintained in position
 Partial Cricotracheal Resection 1313

Fig. 22: The posterior mucosal sutures are now being taken. Fig. 23: Now the posterolateral sutures are secured and
It is important to note that all sutures at this stage are left knotted. This reduces the amount of traction on the posterior
loose, and the final knotting is performed later in a specific mucosal sutures, which can now be knotted without any
manner tension on the suture line and without the risk of tearing the
posterior tracheal mucosa, which is the most delicate part
of the anastomosis

Fig. 24: The anterior and lateral thyrotracheal Fig. 25: Once all the sutures are placed,
sutures are then placed in position knotting is performed
1314 Voice and Laryngotracheal Surgery

Fig. 26: Once again, the authors begin by knotting Fig. 27: The anastomosis is completed. Note that all the
laterally, and work their way anteriorly toward the midline sutures are placed on different levels on the trachea, so as
to distribute the traction in the craniocaudal axis, and prevent
dehiscence of the anastomosis. Occasionally, depending
upon the amount of tracheal resection, reinforcement sutures
may be taken between the thyroid cartilage and the second
tracheal ring from the edge of the anastomosis

COMPLICATIONS AND THEIR the patient to be in the intensive care unit (ICU) till
PREVENTION extubation has been performed.

The complications and their prevention are the same

as for the LTR and are described in the Chapter on
ACKNOWLEDGMENTS
“Laryngotracheal Reconstruction.” However, since The authors are thankful to the Dean, TN Medical College
PCTR requires resection of a segment of the airway, the and BYL Nair Charitable Hospital for granting permission
traction at the anastomotic site is more than that for to publish this Chapter. Demonstrated cases have been
LTR. Hence, the patients are usually requested to main- operated during numerous laryngotracheal surgery work-
tain their neck in flexion for a few days and avoid violent shops by the authros along with Prof Philippe Monnier.
coughing or straining. The other precautions as regards
the drain are the same as for LTR. Also, in single-staged
procedures, it may be necessary to stent the airway for REFERENCE
a few days (usually up to a week), and this may be done 1. Monnier P (Ed). Laryngotracheoplasty and laryngotra-
with a nasotracheal tube which has already been passed cheal reconstruction. Pediatric Airway Surgery. Heidelberg,
pre/intraoperatively. This would automatically require Berlin: Springer-Verlag; 2011.
 The Surgical
Extended Otoplasty 1315
Technique of Resection
Partial Cricotracheal 1315
CHAPTER

148 Extended Partial Cricotracheal

Resection
Vicky S Khattar, Bachi T Hathiram
(Our special gratitude towards Prof Philippe Monnier for being our inspiration and guide for our interest and knowledge of
laryngotracheal stenosis surgery and a special mention of Prof Sultan Pradhan for being a constant source of encouragement)

INTRODUCTION STEPS OF SURGERY

The rationale and indications for an extended partial The intraoperative steps of surgery are demonstrated in
cricotracheal resection (EPCTR) have already been the images seen in Figures 1 to 40.
outlined in the previous chapter on partial cricotracheal The salient features of the EPCTR are depicted
resection (PCTR). diagramma­tically below:

Fig. 1: The incision is marked in an elliptical fashion to Fig. 2: Subplatysmal flaps are elevated and the
include the previous tracheostomy site self-retaining retractor applied

Fig. 3: The midline raphe is cauterized prior to incising it.

A liberal use of the bipolar cautery helps in minimizing the
blood loss
1316 Voice and Laryngotracheal Surgery

Fig. 4: The airway is then exposed Fig. 5: A laryngofissure is performed and the thyroid alae
are retracted away from each other gently using skin hooks

Fig. 6: The two thyroid alae are divided accurately in the Fig. 7: The laryngofissure is extended
midline using a sharp blade. This incision should be precise below the thyroid cartilage

Fig. 8: The first tracheal ring is then incised in the midline

to check the extent of the stenosis. It is always better to
enter through the stenosis and then gradually work along
the airway. This prevents any inadvertent entry through and
“wastage” of normal tracheal cartilage rings
 Extended Partial Cricotracheal Resection 1317

Fig. 9: One can now appreciate a small lumen of the lower Fig. 10: The stenotic segment of the cricoid arch and
tracheal ring. Compared with the size of the rest of the lower upper trachea is now excised
trachea, it is very inadequate

Fig. 11: A sharp blade is used to separate the left true Fig. 12: The posterior cricoid split is performed. One must
vocal fold from the left false vocal fold so as to “open” up be very careful not to incise the postcricoid mucosa while
the ventricle doing so. This becomes tricky, especially in the presence of
scar tissue
1318 Voice and Laryngotracheal Surgery

Fig. 13: The two parts of the cricoid lamina are being Fig. 14: Another ring of trachea is excised from the distal
distracted to assess the degree of widening possible. Note stump to obtain a wider lumen with healthy and viable
the forceps which is in the interarytenoid space tracheal rings

Fig. 15: Instead of cutting off the entire ring, a small stump Fig. 16: The left greater cornu of the thyroid cartilage is now
of the anterior part of the tracheal ring is retained in continuity cut as part of the infrahyoid laryngeal release procedure. As
with rest of the trachea. This will eventually be wedged into one can notice, both the ends of the cut airway are gradually
the lower end of the laryngofissure between the two thyroid mobilized toward each other in a step-by-step manner so as
alae, so as to widen the lumen below the vocal folds. to approximate the two ends in a tension-free anastomosis
 Extended Partial Cricotracheal Resection 1319

Fig. 17: On giving downward traction with a skin hook, one Fig. 18: After taking an inframammary incision, the skin
can now appreciate the exact extent of laryngeal “drop” and subcutaneous tissues are incised
obtained. At this stage, both the ends of the airway have
been mobilized and prepared. Now a saline-soaked mop is
placed over the entire exposed area, and the costal cartilage
graft is harvested

Fig. 19: The costal cartilage is exposed at its upper end Fig. 20: The costal cartilage is first incised medially
1320 Voice and Laryngotracheal Surgery

Fig. 21: Careful dissection is now carried out on the medial/ Fig. 22: After excising the costal cartilage, the wound is
deeper surface of the costal cartilage. The underlying pleura filled with saline and anesthesiologist is requested to perform
is most vulnerable at this site an anesthesiologists’ Valsalva maneuver. This will test the
integrity of the pleura and any tear of the latter will manifest
as bubbles of air escaping from this site

Fig. 23: The cartilage is then carved, meticulously Fig. 24: Once the size is marked, flanges are cut out, which
measuring it to ensure a snug fit will prevent the cartilage from extruding into the lumen of
the airway

Fig. 25: Before the cartilage is placed in its new bed,

anchoring sutures are taken on both sides, and the needles
are kept with the sutures
 Extended Partial Cricotracheal Resection 1321

Fig. 26: The cartilage is then lowered into its bed between Fig. 27: The cartilage is secured into position
the two cut ends of the cricoid lamina. Note the four separate
sutures with their needles, which are kept slightly taut, to
prevent the sutures from getting caught below the cartilage

Fig. 28: The posterolateral anchoring sutures for the Fig. 29: The laryngeal silicone stent is now placed in a
anastomosis are then finally taken (see Chapter PCTR) position before the anterior anastomosis begun
1322 Voice and Laryngotracheal Surgery

Fig. 30: A prolene suture is taken through the stent at the Fig. 31: The stent is usually coated with an ointment
level of the anterior commissure. This suture serves two mixture of a steroid and an antibiotic
purposes: (1) It helps in securing the stent and prevents
its movement or migration and (2) It reconstructs the sharp
anterior commissure, and holding it such that the anterior
commissure heals and mucosalizes in the same manner as
before

Fig. 32: Tension-free closure of the laryngofissure and Fig. 33: The wedge of tracheal cartilage had been preserved,
cricotracheal anastomosis is achieved is introduced into the lower end of the laryngofissure and
sutured there. This helps in keeping the lumen below the
vocal folds wide
 Extended Partial Cricotracheal Resection 1323

Fig. 34: Excessive skin cuff around the site of the Fig. 35: The thyroid gland, which was divided in the midline,
previous tracheostoma excised is now mobilized upward and sutured over the anastomosis
anteriorly so as to aid in the vascularity of the anastomosis

Fig. 36: The final appearance of the anastomosis before Fig. 37: Schematic diagram depicting the airway. The area
the strap muscles and skin are closed over a suction drain. shaded in blue represents the area of stenosis. The inferior
The laryngeal stent will be removed endoscopically after horizontal line in red labeled “T1” is the tracheal incision.
3–6 months. This allows for adequate time for stabilization The vertical red line labeled “ILF” is the partial inferior
of the anastomosis as well as mucosalization of the newly laryngofissure
reconstructed airway. It is important to understand that
tracheostomy has been maintained, and will be surgically
closed after a period of 3–6 months when the airway is strong
and has healed completely
1324 Voice and Laryngotracheal Surgery

Fig. 38: Infrahyoid laryngeal release (IHLR). The vertical Fig. 39: The blue colored posterior costal cartilage graft
black arrows above IHLR represent the “drop” obtained. (PCCG), which will fit in the gap between the split cricoid
Posterior cricoid split (PCS). The black arrows adjacent to laminae. The dotted blue lines represent the flanges of the
PCS represent the splay of the two divided parts of the PCCG, which will prevent it from prolapsing endoluminally
posterior cricoid lamina. Skin hooks (SH) pulling apart the
two partially divided thyroid laminae. Tracheal wedge (TW)
fashioned from the lower tracheal ring, which will fit into the
gap between the thyroid laminae that have been separated
inferiorly by the partial inferior laryngofissure

ACKNOWLEDGMENTS
Fig. 40: The final appearance after the expanded partial
The authors are thankful to the Dean, TN Medical College cricotracheal resection (EPCTR). Fixation sutures (FS) are
and BYL Nair Charitable Hospital for granting permission purple colored. Note that they are all at different levels to
to publish this chapter. Demonstrated cases have been prevent excessive traction on any single horizontal plane. Also,
operated during numerous laryngotracheal surgery work- note how the tracheal wedge (TW) fits into the partial inferior
shops by the authors along with Prof Philippe Monnier. laryngofissure (ILF) snugly, expanding the “neosubglottis”
 The Surgical Technique of Otoplasty i

Index
Page numbers followed by f refer to figure and t refer to table

A B Cidofovir 1179
Cold instrument excision 1158
Abnormal hyperplasia 1125 Balloon catheters 1170 Collagen injection 1157
Acquired subglottic stenosis 1204 Bilateral vocal Complete subglottic stenosis 1268f
Acute bilateral vocal fold paralysis 1199 cord 1126f Complications of thyroplasty surgeries
Acycloguanosine 1178 paralysis 1204 1242, 1244, 1248, 1251
Acyclovir 1178 fold Computed tomography 1273
Adductor spasmodic dysphonia 1216, immobility 1269 Concomitant tracheoesophageal fistula
1217 injections 1214t 1282
Adequate trial of voice therapy 1245, 1249 paresis 1226
Congenital subglottic stenosis 1204
Airway obstruction 1234 Blood pressure 1165
Contraindications of thyroplasty 1238,
Anesthesia for thyroplasty 1238, 1243, Botulinum toxin for laryngeal dystonias
1243, 1245, 1249
1245, 1249 1212
Craniofacial malformations 1204
Anterior Bouchayer
Cricoarytenoid joint 1302f
atraumatic forceps 1195f
cartilage grafting 1283f ankylosis 1302
forceps 1113f-1115f, 1187f
commissure lesions 1115 Cricoid split 1207
Bradycardia 1170
costal cartilage graft 1269 Cricothyroid
Branch of ANSA cervicalis nerve 1218f
cricoid split 1207 approximation 1252, 1253, 1253f
Bronchoscopy 1165
face of cricoid lamina 1312f tray 1166f joint disarticulation 1236f
glottic web management 1160 Bronchospasm 1170 membrane 1213f, 1311f
part of tracheal ring 1318f Broyle’s ligament 1212 muscles 1309f
wall suture 1283f
Anterolateral dissection of intrathoracic
trachea 1294f C D
Appearance of larynx 1183f Cancer of larynx and hypopharynx 1135 Dihematoporphyrin ether 1178
Armored tube 1293f Carbon dioxide laser 1128f, 1177 Direct laryngotracheoscopy 1267
Arrangement of intrinsic laryngeal Carcinoma in situ 1125, 1131 Disphonia severity index 1155, 1208
muscles 1218f bilateral vocal cord 1138f Distal thyroarytenoid nerve 1218f
Arrhythmias 1170 Carinal Division of posterior cricoid lamina 1300
Arterial blood gas 1179 reconstruction 1285 Double stage laryngotracheal
Articular facets 1302f resection 1285 reconstruction 1269
Aryepiglottoplasty 1184, 1184f Cartilage necrosis 1191 Duration of intubation 1261
Arytenoid rotation 1235 Carving implant 1241f
Arytenoidectomy 1197f
Aspiration 1141
Central nervous system disorders 1204
E
Cervical fascia 1277f
Atypical hyperplasia 1125 flap 1277f, 1278, 1278f Electrocardiogram chest leads 1166
Autologous Chemical pneumonitis 1170 Endotracheal tube 1137, 1281f, 1283f
costal cartilage graft procedure 1283 Chronic Entering main bronchi 1168
pericardial patch grafting procedure aspiration 1204 Erythroplakia 1125, 1128, 1304
1283 laryngitis 1125 Esophageal lumen 1169f
 I-ii Atlas of Operative Otorhinolaryngology and Head & Neck Surgery (Vol. 4)

Expanded partial cricotracheal resection Improperly Laser arytenoidectomy 1195

1324f positioned implant 1244, 1248, 1251 Lateral cricoarytenoid 1217
External sized implant 1242, 1244, 1248, 1251 Laterofixation of vocal fold 1199
perichondrium 1241f Incising external perichondrium 1240f Left
trauma 1261 Indications for mainstem bronchus 1286f
bronchoscopy 1165 vocal cord keratosis 1126f
injection laryngoplasty 1147 Leukoplakia 1118, 1125
F surgery and operative decisions 1269 of vocal folds 1118
Fascia implant 1158 Infection 1244, 1248, 1251 over left vocal fold 1118f
Fat injection 1157 Inferior border of thyroid cartilage 1240f Level of vocal fold 1227
Fibroblast growth 1152 Infrahyoid Light amplification by stimulated
Final anchoring of suture 1237f epiglottis 1143f emission of radiation 1116, 1117f,
Flexible laryngotracheoscopy 1273 laryngeal release 1324f 1269, 1271, 1290
Flexometallic tube 1293f, 1295f Injection Litchenberger’s needle 1188, 1189f
Foreign body removal 1170f laryngoplasty 1147, 1151, 1157 Ljubljana classification 1127
Fracture of thyroid cartilage 1242, 1244, techniques 1149 Lower
1248, 1251 through border of cricoid cartilage 1249f
cricoid cartilage 1215 margin of thyroid lamina 1228f
cricothyroid membrane 1213
G thyrohyoid space 1214
Gastroesophageal reflux disease 1267 Intensive care unit 1260
M
Glottic Interarytenoid muscle 1217f, 1301f Magnetic resonance imaging 1273
carcinoma in situ 1138 Intermittent apnea 1298 Maturation sutures 1205f
papillomatosis 1174f Internal jugular vein 1242, 1244, 1248, Maximum
Granuloma formation 1141 1251 phonation duration 1235
Intracordal cyst 1114f phonatory time 1220
Intraoperative monitoring 1166
H Introduction of bronchoscope 1166
McIntosh laryngoscopy 1167f
Medialization
Hematoma 1242, 1244, 1248, 1251 Irradiated larynx 1238 laryngoplasty 1220, 1226
Hemorrhage 1170 thyroplasty 1155, 1156
Hemorrhagic cyst 1112f
K Membranous subglottic stenosis 1270f
Hemostasis 1116 Methicillin-resistant Staphylococcus
High tracheal stenosis 1274f Keratosis 1125 aureus 1270
Hopkin’s laryngoscope 1186 Methyl ester derivative 1131
Human papillomavirus 1127, 1175, 1176 L Microdebrider 1177, 1279
Hyaluronic acid 1150 Microlaryngeal techniques 1178
injection 1157 Lamina propria 1116 Microlaryngoscopy 1120, 1126f
Hyoid bone 1277f Large lymphangiomas 1204 Middle of thyroid cartilage 1250f
Laryngeal Midline horizontal neck incision 1217f
Hypertrophy of surface epithelium 1118f
electromyography 1199, 1220
Hypopharyngeal cancers 1141 Midpoint of
intraepithelial neoplasia 1125
thyroarytenoid muscle 1217
photodynamic therapy 1131, 1132
thyroid cartilage 1160f
I silicone stent 1321f
vocal fold 1158f
squamous cell carcinoma 1130
Identification of intralaryngeal recurrent stenosis 1141 Minimally invasive open technique 1279
laryngeal nerve branches 1216 thyroid cartilage 1217f Mitomycin C 1188f, 1194f
Implant Laryngofissure cordectomy 1208 Modality of surgical treatment 1127
design 1229 Laryngotracheal Moderate dysplasia 1125
extrusion 1234 reconstruction 1272, 1298 Modified Myer-Cotton
intrusion or extrusion 1242, 1244, resection anastomosis procedure airway grading system 1269, 1269t
1248, 1251 1271f grading system 1268f
placement 1232 stenosis 1260 M-tetra-hydroxyphenyl-chlorine 1178
 Index I-iii

Murphy’s eye 1291, 1293f Posterior Silicone laryngotracheal stent in situ

Mycobacterium bovis 1179 border of thyroid cartilage 1235f 1270f
costal cartilage graft 1324f Simple hyperplasia 1125
cricoarytenoid muscle 1214, 1215f, Single stage laryngotracheal
N 1217 reconstruction 1269
Nasogastric tube 1283f cricoid split 1324f Site of tracheostomy tube 1261
Neuroendocrine tumors 1141 glottic stenosis 1186, 1186f, 1270 Sizing of cartilage graft 1303
laryngeal mucosa 1300f Skin incision 1238f, 1291f
Neurological disorders 1204
membranous wall 1282f Slicing technique 1158
Neuromuscular disorders 1204
wall suture 1282f Slide tracheoplasty technique 1284
New techniques in surgery 1123, 1161,
Posterolateral portion of tracheal rings Spasmodic dysphonia 1212, 1214t, 1216
1174, 1207, 1276, 1286
1309f Split cricoid laminae 1324f
Number of tracheal rings cut 1261 Stenotic segment 1285f, 1293f, 1294f
Postradiation recurrent carcinoma of
posterior wall of hypopharynx 1144f of cricoid arch 1317f
O Potassium titanyl phosphate 1123, 1176 Sternocleidomastoid muscle 1277f
Presbylarynx 1238 Stroboscopy of voice range frequency
Open 1255t-1256t
Preservation of lamina propria 1114
internal perichondrium 1243f Subepithelial infiltration 1110, 1121, 1121f
Principles of
partial laryngectomy 1140f Subglottic stenosis 1263, 1267f, 1269
phonomicrosurgery 1109
Operation theater setup 1137 photodynamic therapy 1130 Subplatysmal flap 1238f, 1239f, 1246f,
Operative technique tracheal resection for Prolene suture 1188 1291f, 1315f
stenosis and reanastomosis 1273 Prolonged intubation 1261 Sulcus vocalis 1238
Overriding posterior segment 1247f Superficial lamina propria 1119, 1171
Pseudomonas aeruginosa 1272
Superior surface of vocal fold 1182f
Pulmonary function tests 1273
Supraglottic neuroendocrine tumor 1143f
P Pulse dyed laser 1123
Surgery of trachea and bronchi 1297
Pyriform fossae 1244, 1248, 1251
Palpating muscular process 1236f Surgical
Paralytic vocal fold 1147 emphysema 1141, 1206
Partial R management of
cricotracheal resection 1272, 1307 laryngeal papillomatosis using
Reconstruction of partial tracheal stenosis microdebrider 1176
inferior laryngofissure 1324f
with cervical fascia 1276 sulcus vocalis 1154
Parts of posterior cricoid lamina 1324f
Recurrent tracheal stenosis 1273, 1280
Pediatric tracheostomy 1204, 1204f
laryngeal nerve 1217f, 1218, 1218f, Suspension microlaryngoscopy 1149
Pericardial patch tracheoplasty 1279
1296, 1309f Suspicion of foreign body in airway 1165
Perichondritis 1141, 1191
precancerous lesions 1128 Synechiae formation 1141
Peri-intubational circumstances 1261
Peripheral necrosis of cervical fascia flap respiratory papillomatosis 1176
1279f Resection and reconstruction 1281
Respiratory distress syndrome 1204
T
Photodynamic therapy 1130, 1133t, 1175,
1178 Ribavirin 1178 Techniques for abductor spasmodic
for laryngeal cancers 1130 Rib-cartilage tracheoplasty 1279 dysphonia 1213, 1214
Photosensitizers under evaluation for Right mainstem bronchus 1286f, 1287 Thyroarytenoid muscle 1212, 1213f, 1214f
head and neck cancer 1130 Rigid Hopkins telescopic evaluation 1267 Thyroid
Pneumomediastinum 1170, 1206 Robotic surgical technique 1279 alae 1243f
Pneumothorax 1170, 1206 cartilage 1229f
Port for ventilation 1298 gland 1323f
Portex nasotracheal tube 1291, 1293f,
S incisura 1228f
1294f Saline adrenaline 1291f Thyroplasty 1220
Positive pressure ventilation 1165 Severe Total
Post-aryepiglottoplasty appearance of dysplasia 1125 height of thyroid laminae 1299f
larynx 1185f tracheomalacia 1204 intravenous anesthesia 1177
Postcricoid Silastic Tracheal
carcinoma 1145f implant 1231f airway stent 1279
hypopharyngeal mucosa 1300f medialization laryngoplasty 1226 augmentation 1283
 I-iv Atlas of Operative Otorhinolaryngology and Head & Neck Surgery (Vol. 4)

autograft 1279 U lesion 1226

dilatation 1279 paralysis 1199
incision 1205f Unilateral vocal
retractor 1182f
laser surgery 1279 cord palsy with phonatory gap 1238
fold paralysis 1147, 1226 process of arytenoid 1223f
lumen 1169f
stenosis 1274f Upper Vocalis muscle 1212
Tracheoesophageal fistula 1282, 1283f airway obstruction 1204 Voice
Tracheostomy 1261 margin of thyroid lamina 1228f handicap index 1154, 1208, 1220
Transoral microlaryngoscopic laser pitch evaluation 1254
resection 1135
surgery 1135
V
Treatment of laryngeal papillomatosis Valsalva maneuver 1320f W
1171 Verrucous carcinoma 1140f
Tumor illumination 1131 Video-stroboscopy 1253 Wastage of normal tracheal cartilage rings
Type of Vocal 1316f
endotracheal tube 1261 fold Wegener’s granulomatosis 1260f
stenosis 1271 atrophy 1226 Wide posterior phonatory gap 1235
Typical appearance of laryngomalacia fold augmentation techniques
Wound infection 1205
1184f 1157