laryngoplasty,phonosurgery,

1. Phonosurgery
By Dr Sandeep Shrestha
2nd year resident
ENT-HNS
NMCTH

2. Introduction
• Any surgery designed primarily for the
improvement or restoration of the voice.
• The term is firstly adopted by Godfrey Arnold and
Hans von Leden in 1971.
• Phonosurgery should be considered the very last
treatment option once all conservative measures
have either failed to improve the voice or
inadequate.

3. • It emcompasses :
– Microlaryngeal surgery
– Injection laryngoplasty
– Laryngeal framework surgery
– Recurrent laryngeal nerve reinnervation
– Laryngeal pacing

4. Microlaryngeal surgery
• Prof. Rosemarie Albrecht - Germany (1954)
described the first microscopic visualization of
the Vocal Folds.
• Prof. Oskar Kleinsassar - Germany (1962)
introduced the modern state of the art method of
microlaryngosurgery.
• Dr. Geza Jako – USA (1962) designed a series of
microlaryngeal instruments.

5. • Oskar Kleinsasser described the adaptation of the
microscope to direct laryngoscopy allowing for fine
manipulation of the vocal folds.
• Examination of the larynx usually done under GA
to further establish a diagnosis, but more
importantly to surgically treat a pathology with
the aim of improving voice.
• Done using a suitable sized rigid laryngoscope.

6. • Position : flexed cervical-thoracic junction and
extended atlanto-occipital joint.

7. Advantages
• Binocular vision
• Magnification
• Better illumination
• The ability to use bimannual instrumentation
• The ability to use the carbon dioxide laser

8. • Conventional microlaryngeal surgery
• Laser mircosurgery : CO2, KTP, diode
• Laryngeal microdebrider

9. Conventional Microlaryngeal surgery
• Proper instrumentations with a wide range of
laryngoscopes and micro-instruments is required.
• Instruments need to be fine, sharp and well
maintained to allow precise removal of lesion with
less scaring and without injuring of vocal ligament.
• A selection of endoscopes with a wide proximal
end and distal illumination is desirable and
internal distension of the larynx by using largest
laryngoscope possible is recommended.
• Cheap and easily available.
• Gives similar result in expert hands in comparison
to Laser microsurgery.

14. Laser Microsurgery
• CO2 Laser is most commonly used laser in
laryngeal microsurgery.
• Best used in vascular lesions or lesions that
bleeds on removal such as papillomatosis or
granulomas, removal of cartilage and excising
large areas of tissue.

15. Laryngeal Microdebrider.
• Microdebrider has been used for various
laryngeal lesions including papillomas and there
is report that patients have less post-operative
pain and quicker return to a usable speaking
voice.

16. • General anaesthesia.
• Standard oral-tracheal intubation is prefered.
• Endotracheal tube choice should be made in
consultation with the treating anaesthetist,
though the endotracheal tube with the smallest
outer diameter that can offer safe respirations
should be utilized.

17. • If available, micro-laryngoscopy tubes (MLT)
should be requested to improve the overall
length of the tube with smaller diameters.
• If laser is used during surgery, a lasersafe
endotracheal tube should be placed, again with
the smallest possible outer diameter, and the
tracheal balloons filled with normal saline.

19. • Benign disease is usually located in the mucosal
layer or in the superficial part of the lamina
propria.
• Surgery should, therefore, be superficial, staying
out of the vocal ligament, with limited mucosal
excision only.
• There is no role for stripping of the mucosa of the
vocal fold for benign disease, and vocal fold
preservation should be the paramount concern of
phonosurgery for benign disease.

20. Vocal nodule
• These are bilateral lesions.
• They are found at the midpoint of the
membranous vocal cord and are confined to the
superficial squamous epithelium.
• Histopathological studies show thickening of the
basement membrane together with areas of
haemorrhage, fibrin deposits and hyalinization.

21. • During surgery, the centre
of the nodule is held with
atraumatic forceps and
pulled medially towards
the opposite cord.
• The mucosa is cut at its
base, by cold instruments
or laser, producing a
straight vibratory edge
and preventing secondary
notching.

22. • The opposite nodule can
then be removed in a
similar fashion, taking
care not to damage the
mucosa of the anterior
commissure.
• There is no
contraindication to
removing both nodules at
the same time using this
precision technique.

23. Vocal polyp
• These are usually unilateral, localized areas of
oedematous tissue although some may be
angiomatous and may also contain areas of
haemorrhage.
• The site of the lesion is again superficial to the
vocal ligament.

24. Preservation of mucosa is essential, too little resulting in
reformation of the polyp, too much resection giving a
notched, scarred cord with tethering of the layers of the VF.
Gentle, steady traction is applied by grasping forceps
towards the opposite cord and the base of the polyp is
sectioned.

25. Reinke’s oedema
• This is a bilateral diffuse condition where there is
a collection of polypoidal tissue in the superficial
layer of the lamina propria.
• Almost universally associated with cigarette
smoking.
• Patients who continue to smoke should be
considered poor surgical candidates as this
condition has a high likelihood of recurrence with
continued smoke irritation.

26. Incision is made on the lateral aspect of the
superior surface of the vocal fold with micro-scalpel
or laser.
The median vibrating edge of the vocal fold is,
therefore, preserved.

27. Mucosa is then elevated with a blunt dissector and
myxomatous contents either aspirated (suctioned) or
removed with cupped forceps.
Care must be taken to avoid damaging the vocal
ligament or traumatizing the overlying mucosa with
excessive suction.

28. Following removal of the contents, the mucosal flap is
replaced and any excess epithelium trimmed with
microscissors.
The mucosal flap can be laid on the surface and left to
heal by surface tension, suturing or tissue glue
(autologous or commercial) used to hold this in place.

30. INTRACORDAL CYSTS
• These primarily surgical lesions may be either
secondary to mucosal retention or epidermoid
cysts, and stroboscopy has greatly increased the
ease of diagnosis, though it remains an ultimately
a very challenging diagnosis at times.
• The mucous retention cyst is found in the cover
of the vocal fold and can be removed either with
cold instruments or with the laser, but again
remaining superficial to the ligament.

31. • An epidermoid submucosal cyst can be
approached via a lateral microflap where an
incision is made on the superior surface of the
vocal fold away from its medial edge.
• The flap is then elevated from lateral to
medial, the lesion excised and the flap
replaced.

32. VOCAL FOLD VARICES
• These are often considered a potential source of
haemorrhage but in most cases, if lying in a
longitudinal orientation, they can be left and
treated conservatively unless recurrent
haemorrhage occurs.
• The presence of vessels lying at 90 degrees or at a
different orientation may indicate underlying
disease, possibly neoplastic, and require further
investigation.
• Recurrent haemorrhage from these vessels can be
dealt with either by lasering the blood vessel or
needle cautery to ablate the vessels.
• Angiolytic lasers such as KTP or pulse-dye lasers
can be of particular utility with these lesions.

33. ANTERIOR WEBS
• If these are small and thin, they can be divided
either with a laser or with cold steel.
• A microweb is frequently associated with vocal
cord nodules and can be removed at the same
time.
• Thick webs have a 50% chance of recurring
following laser excision and may require insertion
of a keel, either endoscopically or via an open
procedure, to prevent recurrence.

35. Granuloma
• Inflammatory tissue arising from the
perichondrium near the arytenoid cartilage.
• Classically seen after endotracheal intubation.
• Most common causes - laryngopharyngeal reflux,
vocal misuse or hyperfunction, glottal
incompetence with severe hyperfunction.
• Patients experience globus sensation, dysphonia,
and/or odynophonia.
• Surgery should be performed if concern exists
regarding a malignancy or infection, or all
nonsurgical treatment options have been
exhausted.

36. • Curved alligator (curved in the
opposite direction of the side
that the vocal fold granuloma is
on) to grab the stalk that runs
between the vocal fold
granuloma and the arytenoid
cartilage.
• Preferably, the alligator will
grasp the stalk on its most
medial aspect.
• The vocal fold granuloma stalk
can then be gently retracted
towards the midline, and a
curved microscissors (curved in
the same direction as the
curved alligator)
• Then used to release or cut
the stalk immediately lateral
to the curved alligator, thus
allowing the removal of the
vocal fold granuloma.

37. PAPILLOMA
• These neoplastic lesions are due to the human
papilloma virus (subtypes 6 and 11) and frequently
recur.
• They are often found at areas of transition in the
upper aerodigestive tract where there is increased
air turbulence, drying and cooling of mucosa, and
at the change of ciliary to squamous epithelium.
• CO2 laser excision is the treatment of choice
• An endoscope with a smoke evacuation channel is
useful.
• Single papillomas are grasped gently as they may
be friable and the laser is used to excise the base.

38. • Surgical techniques for multiple papilloma
include using injection of saline (+/−
epinephrine) submucosally (hydrodissection)
and excising the mucosa en bloc.
• This gives a lower recurrence rate than surface
ablation.

40. Vocal Fold Injection
• Wilhelm Brunings – first – injection of vocal
folds – 1911
• Paraffin - direct laryngoscopic – under LA.
• In 1962 – Arnold – teflon.
• Aim : To medialize an adductor cord palsy
• Needle is inserted anterior and lateral to vocal
process approx 2mm deep at the level of
lower margin of the true folds.

41. Indication
• Vocal fold paralysis
• Vocal fold paresis
• Vocal fold atrophy
• Vocal fold scar
• Adjunctive augmentation after prior surgery

42. Ideal material
• Readily available
• Inexpensive
• Inert
• Easy to use
• Completely biocompatible

43. • General anesthesia
• Local anaesthesia
– Transcutaneous route through the cricothyroid
membranes.
– Transcutaneous route through the thyroid
cartilage.
– Transcutaneous route through the thyrohyoid
membrane.
– Transoral route.

45. General anesthesia
• Drawbacks
– Visualization problems due to the anaesthetic
tube or some other means of ventilation.
– The abnormal anatomical position of the neck.
– Difficulty in gaining access to the larynx in patients
with cervical spine problems.
– lack of patient feedback via phonation during
injection.

46. LOCAL ANAESTHESIA
• Injection laryngoplasty is also routinely
performed under local anaesthesia with the
guidance of real-time visualization, typically
through nasolaryngeal flexible laryngoscopy.

47. Transcutaneous route through the
cricothyroid membranes.
• Needle is pass directly into
the cord.
• If ossified thyroid cartilage ala
is identified then the needle
point is angled inferiorly to
tuck under the inferior edge
of the thyroid cartilage and an
audible click is usually heard
once the membrane is
penetrated.
• The needle should then
immediately be angled
superior-laterally to find a
position deep within the
adductor muscle group.

49. Transcutaneous route through the
thyroid cartilage.
• Typically the most
straight forward
approach to injection
laryngoplasty.
• Penetration should be
through the inferior half
of the thyroid cartilage
but difficulty can occur
when the cartilage is
ossified or the needle
bore is blocked with
cartilage.

51. Transcutaneous route through the
thyrohyoid membrane.
• The transthyrohyoid
method requires topical
anaesthesia of the glottis
(typically topical 4%
lidocaine) before injection.
• Following adequate
anaesthesia the needle is
placed at the thyroid notch
and angled immediately
inferiorly. Under direct
visualization, the needle tip
is seen exiting the petiole
mucosa at midline to enter
the supraglottic lumen.

52. • Following this, the needle tip can be guided
under visualization laterally into the deep
adductor muscle group where laryngoplasty can
be performed.

53. Transoral route
• Rigid curved cannula
(Abraham cannula), a
needle may be guided
transorally to achieve
direct injection into the
superior surface of the
lateral vocal fold.

56. Materials
Teflon
• Polymer of tetrafluoroethylene and is sold as a
paste consisting of 50% glycerine.
• The glycerine component is absorbed in the first
few weeks and its volume is partially replaced
initially by an acute inflammatory reaction and
later by a localized chronic inflammatory
response, which encapsulates the remaining
Teflon.

57. • Difference in the initial volume injected and the
final space-occupying lesion is unpredictable,
which may cause a good immediate result to
deteriorate with time.
• If Teflon is incorrectly placed superficially and
erosion of the overlying mucosa occurs, this can
lead to a granuloma on the surface of the vocal
fold, and a 36% incidence of granuloma
production has been reported.
• Inserted deep to thyroarytenoid muscle.

58. Fats
• Advantages
– easily harvested
– readily available
– does not give a foreign body reaction.
• Its harvesting : liposuction (which can lead to up to
30% cell destruction and an increased
hypersensitivity reaction) or through a larger
incision followed by irrigation with saline and
soaking in insulin.

59. • It is reported that 30–50% of this fat will be
absorbed within the first month and long-term
studies also suggest a decrease in volume with
time.
• As a result of its absorption, many suggest
overcorrection at the time of injection.
• The material is of high density and requires
insertion deep into the vocal fold.
• Encouraging quantitative voice results have been
reported post-injection.

60. Glycerine
• This can be used as a temporary material as it is
absorbed within the first 2–6 weeks.
• It is completely reversible and frequently
combined with laryngeal electromyography
(EMG) in cases of a temporary paralysis.
• The EMG can be used prognostically to look at
reinnervation of the vocal fold and the glycerine,
by augmenting the paralyzed fold, allows glottic
closure.
• Once again, its site should be deep within the
muscle of the vocal fold.

61. Collagen
• This protein is a natural constituent of the lamina
propria of the vocal fold.
• Skin testing pre-operatively is recommended before
the collagen is injected superficially into the vocal
ligament.
• It is a challenging procedure with blanching of the
vocal fold mucosa if too superficial.

62. Silicon
• Bioplastique is a silicone gel consisting of
vulcanized polydimethylsialoxane particles
ranging from 150 to 600 microns suspended in
hydrogel.
• After an initial acute inflammatory reaction, the
material develops a fibrous capsule
• Site : deep within the body of the vocal fold

63. Calcium hydroxyapatite
• Radiesse voice implant is a solution of calcium
hydroxyapatite carried in an aqueous gel allowing
for injection through small gauge needles (25G or
27G).
• It has found widespread usage since the
commercial supply of bovine collagen has been
limited.
• The most critical aspect of this material is a deep
injection as superficial implantation will lead to
long-term hoarseness.

64. Thyroplasty
• Payr (1915) reported the first medialization
procedure by anteriorly based cartilage flap.
• Meurman (1952) implanted free rib grafts
beneath the inner thyroid perichondrium.
• Opheim (1955) placed thyroid cartilage medial to
the inner perichondrium.
• Montgomery (1966) repositioned the arytenoid
and fixed it to the cricoid cartilage with a pin.

65. • Kaufman (1986) derived a formula for calculating
the appropriate size of the window.
• Isshiki in 1974 first described the 4 types of
thyroplasty.
• 1990’s: Medialization Thyroplasty was a well-
accepted commonly-performed operation.

67. • Isshiki’s functional classification of thyroplasty
– Type I – Medialization
– Type II – Lateralization
IIa – lateral approach
IIb – medial approach
- Type III – Relaxation (shortening )
- Type IV – Tensioning (Lengthening)
IVa – Cricoid approximation
IVb – Tensioning by lateral approach

68. TYPE I THYROPLASTY
• Thyroplasty type 1 essentially involves
medialization of the vocal cord by its inward
displacement with an implant placed through a
window in the thyroid cartilage.
Indications:
• Unilateral vocal fold paralysis(m/c)
• Vocal fold atrophy
• Sulcus vocalis

69. • Surgery done under local anaesthesia with
patient AWAKE -patient need to phonate.
• 1% lignocaine with Epinephrine 1:100,000.
• Positioning: Shoulder roll with neck extended

70. • In paralyzed or atrophic vocal fold, the medial bulge
from the thyroarytenoid muscle contraction is
inadequate.
• The thyroplasty implant medializes the
midmembranous vocal fold to mimic the activity of
the TA muscle.
• Goals: To improve voice quality and prevent
aspiration.

71. Mannual compression test

72. • Anterior aspect of
window: 5-8 mm in
female and 8 to 10 mm in
male posterior to ventral
midline
• Superior aspect : at the
level of the point half the
distance between the
anterior-inferior border of
the thyroid cartilage and
the thyroid notch.
• 5X12 mm: Male,
4X10mm: Female

74. TYPE I THYROPLASTY: IMPLANT
• Pre-formed
Montgomery,
Titanium
Calcium Hydroxylapatite
• Hand carved
silicone.
layered Gore-Tex.

78. Arytenoid adduction
• Portion of posterior thyroid
cartilage margin cut to
expose muscular process of
arytenoid.
• Two 4-0 Prolene sutures
passed through muscular
process & through thyroid
cartilage sutures pulled
parallel to lateral
cricoarytenoid.
• After optimal medialization
of vocal fold, sutures tied on
external aspect of thyroid
lamina.

80. Cricothyroid subluxation
• Principle – to lengthen VF by increasing distance
from CA joint to anterior commissure by
subluxating CT joint on the side of U/L VF
paralysis.
• It is an adjunct procedure to ML.
• Done by a scissors or cottle elevator.
• Care should be taken to ensure inferior cornu is
completely free from soft tissue attachments.

81. • A 2-0 prolene suture is
passed around neck of
inferior cornu with a
clamp.
• Suture positioned as
superior as possible on
the neck of inferior
cornu.
• Needle passed in a
submucosal plane under
the anterior aspect of
the cricoid ring.

82. • Free end of the suture tied
at inferior cornu is then tied
to end of the suture passed
underneath the anterior
cricoid cartilage.
• Voice and VF length should
be evaluated as tension
applied to the knot.
• Anterior subluxation results
in VF lengthening and
expanded pitch range.
• Once an optimum tension is
found, suture secured with
several surgical knots.

83. Type 2 (Lateralisation) thyroplasty
• Release the tight closure of the glottis.
• Indication: adductor Spasmodic dysphonia.
• Lateralization thyroplasty is intended to prevent this
tight closure of the glottis at the terminal stage of
phonation by lateralizing the position of the vocal
cord.

84. • A vertical incision in the
thyroid cartilage and
lateralizing the
posterior segment over
the anterior one.

88. Suture Method
• Arytenoidopexy:
Displacing the vocal fold
and arytenoid without
surgical removal of any
tissue.
• Suture passed around
the vocal process of the
arytenoid and secured
laterally.
• Relatively high failure
rate.

89. Resection Method
• Arytenoidectomy- Removal of some or all of the
arytenoid cartilage.
• Endoscopically by Microsurgical technique
(Thornell procedure)
• With Laser surgery (Jako’s procedure)
• With Thyrotomy approach (Scheer’s approach)
• By lateral neck approach (Woodman’s) – Most
popular approach.

90. Woodman procedure –
• Exposure of the
arytenoid cartilage
posteriorly with removal
of the majority of the
cartilage, sparing the vocal
process.
• Suture is then placed into
the remnant of vocal
process and fixed to the
lateral thyroid ala.

91. Type 3 (shortening) Thyroplasty
• Aimed at lowering the vocal pitch.
• The VF is relaxed by A-P shortening of the
thyroid ala.
• Indications
– Males with high pitch voice, resistant to voice
therapy.
– Stiff VF with high pitched breathy voice.
– Spastic dysphonia

92. • Lateral approach:
Thyroid ala is incised at
about junction of
anterior and middle one
third
• 2-5 mm cartilage strip is
excised.

93. • Medial approach(Anterior
commissure retrusion):
Retrusion of the middle
portion of the thyroid
cartilage and leads to
reduction in the length of
vocal folds results in
normal adult voice.
• Vertical incision was
made either side of the
midline of the thyroid
cartilage.

94. • Middle portion of the
cartilage pushed
posteriorly
•
• Free edges of the
thyroid cartilage
reapproximated with 2-
0 vicryl

95. Type 4 (lengthening) Thyroplasty
• Increases the vocal pitch.
• It increases the distance between the vocal fold
attachments and thus raise the tension of vocal
fold.
• Indications:
– Abnormally lax or bowed vocal folds (as in
presbyphonia)
– Androphonias & Male to female transexualism

96. Cricothyroid Approximation :
• Increases vocal pitch by simulating the
contraction of cricothyroid muscle with sutures.
• The cricoid and thyroid cartilage is approximated
as closely as possible.

97. • 4 non absorbable
monophilic sutures are
placed to draw the
cricoid and thyroid
cartilages together.

98. • Lateral Approach (Type IV
b)
• Vertical incision is taken
at the junction of anterior
and middle one-third of
ala and silastic implant is
fixed between cartilage
edges by two mattress
sutures.
• If pitch elevation is
insufficient, the same
procedure may also be
performed on the
contralateral side.

99. Recurrent laryngeal nerve
reinnervation
• In 1909 , Horsely reported first successful vocal
cord reinnervation.
• He performed neurorraphy of RLN and obtained
nearly complete recovery of laryngeal function.
• Two most common reinnervation techniques are:
• 1. Neuromuscular pedicle
• 2. Ansa Cervicalis-RLN anastomosis

100. Neuromuscular pedicle
• The techique attempts to transfer a nerve with a
portion of its motor units intact to denervated
muscle.
• Small blocks of muscle at distal end of donor nerve
are included.
• Successful results depend on
– ability of transplanted axons to reach receptive sites on
recipient muscle
– ability of muscle fibres to accept foreign nerves.
• Principle: Muscle reinnervation occurs from sprouts
generated from intact motor neurons of partially
denervated transferred nerve to the end plate sites
of denervated muscle fibre.

101. • Horizontal skin incision at level of lower border of
thyroid cartilage.
• Branch of ansa cervicalis identified by
a) finding the main trunk as it crosses IJV and
tracing proximally and distally till appropriate
branch recognized.
b) Mobilizing the medial border of omohyoid near
its attachment to the hyoid bone carrying
dissection in medial to lateral direction.
• If nerve injured branch to sternothyroid is also
acceptable.

103. Ansa Cervicalis - RLN anastomosis
• Indicated for U/L VC palsy

104. Laryngeal pacing
• This technique still being evaluated in clinical
trials.
• Involves inserting an electrode into each
posterior cricoarytenoid muscle which then
causes automatic abduction and adduction
movement of the vocal cords.
• Electrode is connected to an external placing
device that is surgically fixed under the skin on
the chest wall.

105. Thank you