Phonosurgery Quick Review For Otorhinolaryngology -Books Download

Phonosurgery Quick Review for Otorhinolaryngology

2019 | 2 views | 10 Pages | 824.32 KB

Phonosurgery Phonosurgery is defined as 'any surgery designed primarily for the improvement or restoration of the voice'. Complete assessment of a patient with a voice disorder should now include video laryngoscopy, stroboscopy and other laboratory recordings including laryngeal electromyography and quantitative voice measurements.



Laser and alternative dissecting instrumentation
In many ways laser and cold instruments should be considered as synergistic tools rather than in
direct opposition
Author prefers to limit laser to vascular lesions or those that bleed on removal such as
papillomatosis or granulomas or to the removal of cartilage and when excising large areas of
tissue
Some surgeons now advocate the use of power instrumentation such as the laryngeal
microdebrider as it eliminates many of the risks of laser
Microdebrider has less postoperative pain and a quicker return to a usable speaking voice
Microdebrider for papillomas polyps Reinke s oedema and also for removing tumours at both
glottis and subglottic levels
Anaesthesia
GA is a norm
Ventilation during phonosurgery can either be via an endotracheal tube which may be laser proof or
via jet ventilation
Voice rest
48 hours of absolute voice rest following a phonosurgical procedure is essential
VOCAL NODULES Ch 167
3mm bilateral midmembranous whiplash hypothesis of shearing forces hourglass vocal folds
Histopathological studies show thickening of the basement membrane together with areas of
Haemorrhage Fibrin deposits and Hyalinization
Their aetiology is associated with phonatory strain and a stroboscope can be useful in distinguishing
between hard usually require surgery and soft usually respond to speech therapy nodules
The centre of the nodule is held with grasping forceps and pulled medially towards the opposite cord
Microscissors are then used to cut the mucosa close to its base thus preserving normal mucosa
keeping a straight vibratory edge and preventing secondary notching Remember voice therapy
utmost important or high chance of recurrence
Anterior commisure mucosa should be preserved
Postoperative voice rest for 48 hours
POLYPS
3mm These are usually unilateral localized areas of oedematous tissue although some may be
angiomatous and contain areas of haemorrhage
M F Smokers 30 to 50 yrs Phonotrauma causes
Disruption of vascular basement membrane capillary proliferation thrombosis minute haemorrhages
and fibrin exudation
Some are haemorrhagic some gelatinous and grey
Occasionally a sulcus mucosal bridge or intracordal cyst is found immediately opposite on the
other vocal fold
Polyps can shrink spontaneously or even be coughed up
Voice therapy Excision under GA
The site of the lesion is again superficial to the vocal ligament and careful examination may show a
contact response on the contralateral vocal fold
Gentle steady traction is applied by grasping forceps towards the opposite cord and the base of the
polyp cut with microscissors
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 vocal fold
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 in the membranous portion of vocal cord from anterior commisure to
vocal process
Vocal folds are chronically and irreversibly swollen
Aka Other terms for the condition include
Polypoid vocal cord polypoid degeneration or polypoid hypertrophy cordal polyposis or
polypoid corditis
Chronic oedema of vocal folds
Pseudomyxoma or pseudomyxomatous laryngitis
Smoker s larynx
Exclusively in moderate to heavy smokers Voice strain and GERD can play role
Some cases concomittent hypothyroidism seen
HISTOPATHOLOGICALLY
Epithelium shows nonspecific changes and basement membrane is thickened
In Reinke s space there are lakes of oedema extravasated erythrocytes and thickening of walls of
subepithelial vessels
This poor lymphatic drainage however is also advantageous by giving a good prognosis for small
glottic tumours
Patients most commonly seek a medical opinion between the ages of 40 and 60 years of age
SYMPTOMS
The most common symptoms are
Deepening of the pitch of the voice with women often being mistaken for a man
particularly on the telephone
Gruffness of the voice
Effortful speaking
An inability to raise the pitch of the voice
Choking episodes
Other symptoms associated with extraoesophageal reflux
Bilateral in 62 85 percent of cases
Typically the vocal folds are grey or yellowish in colour with prominent superficial vessels
In severe cases the vocal folds look like bags of fluid that flop up and down through the glottis with
respiration
The severity of the swelling is best judged on deep inspiration and is frequently underestimated if an
assessment is only made on phonation as the oedematous tissue bunches up on the superior surface
and into the ventricle
A severity grading system has been proposed by Savic
The decision to treat a patient with Reinke s
oedema depends on their symptoms the
severity of the oedema and the presence of
leukoplakia In most cases conservative
measures such as reassurance an
explanation of their condition and vocal
hygiene advice including smoking
cessation should be tried initially
Hypothyroidism upper airway infections
and allergies and extraoesophageal reflux should be treated
Patients must be aware that after surgery
friends and relatives may not recognize them by their voice
the singing voice may be permanently altered
speaking may be more effortful for up to one year or occasionally
permanently
the voice seldom returns to normal but is generally of better quality
the Reinke s oedema is likely to return within two years if the patient
continues to smoke
The principles of surgery for Reinke s oedema include
o reducing the bulk of the mucosa mass per unit length of the vocal fold
o obtaining a straight mucosal edge i e avoiding leaving small deposits of the myxoematous
material behind
o avoiding damage to and exposure of the underlying ligament thereby reducing the chances
of scarring and web formation
HIRANO s APPROACH
A cordotomy incision is made on the lateral aspect of the superior surface of the vocal fold with an
arrow headed knife or laser
Mucosa is then elevated with a blunt dissector and myxomatous contents either aspirated or removed
with cupped forceps
Care must be taken to avoid damaging the vocal ligament or traumatizing the overlying mucosa with
excessive suction
Following removal of the contents the mucosal flap is replaced and any excess epithelium trimmed
with micro scissors
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
INTRACORDAL CYSTS
These may be mucosal retention or epidermoid cysts and stroboscopy has greatly increased the ease
of diagnosis
VOCAL FOLD VARICES
These are often considered a potential source of haemorrhage but in most cases if lying in a
longitudinal orientation can be left and treated conservatively unless recurrent haemorrhage occurs
The presence of vessels lying at 90 or at a different orientation may indicate underlying disease and
require further investigation
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
GRANULOMAS
These are located on the vocal process of the arytenoid cartilage and are usually unilateral sessile
bilobed lesions
Combination of surgery to confirm histological diagnosis together with postoperative gastro
oesophageal reflux treatment injection of steroids into the base oral prostaglandins speech
therapy osteopathy for neck manipulation and even botulinum toxin injection into the lateral
cricoarytenoid muscle to decrease the force of adduction have been tried
There is also an opinion that a granuloma is a self limiting process that will burn itself out when the
arytenoid cartilage scleroses
The author s preference is a local mucosal rotational flap at the time of laser excision to cover the
exposed cartilage
PAPILLOMAS
These are due to the human papilloma virus subtypes 6 and 11 and frequently recur
CO2 laser excision is the treatment of choice with minimal trauma to surrounding tissue
Single papillomas are grasped gently as they may be friable and the laser is used to excise the base
Surgical techniques for multiple papilloma include using injection of saline epinephrine
submucosally hydrodissection and excising the mucosa en bloc
Other Rx for papilloma include retinoids interferon ribavarin Cidofovir COX2 inhibitors
Photodynamic therapy
VOCAL SULCUS


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