ORL Operative Techniques in Laryngology

Clark A. Rosen, C.
Blake Simpson
Operative Techniques in Laryngology
Clark A. Rosen
C. Blake Simpson
Operative Techniques
in Laryngology
Forewords by Hans von Leden

and Robert H. Ossoff
With 390 Figures and 11 Tables
123
Clark A. Rosen, M.D. C. Blake Simpson, M.D.
University of Pittsburgh Voice Center The University of Texas Health Science Center
UPMC Mercy Hospital Department of Otolaryngology
1400 Locust Street, 2100 Bldg D 7703 Floyd Curl Drive MC-7777
Pittsburgh, PA 15219, USA San Antonio, TX 78229-390, USA
E-mail: rosenca@upmc.edu E-mail: simpsonc@uthscsa.edu
ISBN 978-3-540-25806-3 e-ISBN 978-3-540-68107-6
Library of Congress Control Number: 2008926220
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Dedication
I have had the incredible good fortune to be blessed with sup- cept to completion. I have grown as a laryngologist due to our
portive family, teachers, and friends. It is imperative that I “mind meld” of laryngologic experience and philosophy while
recognize the huge impact of some of these individuals on my writing this book together.
personal and professional development and growth. I would I am indebted to the wonderful group of teachers and col-
like to dedicate this book to my parents, Paul Jack Rosen, M.D., leagues with whom I have had the pleasure and privilege to
and Shirley Maureen Orr Rosen, who worked tirelessly to pro- work: Gayle Woodson, M.D.; Thomas Murry, Ph.D.; Robert
vide the optimal growth environment for me and instill in me Buckmire, M.D.; Lori Lombard, Ph.D.; and Jackie Gartner-
the best possible work ethic. Schmidt, Ph.D. I would like to acknowledge the importance of
Over my many years of education, I have had many won- my Fellows and OR staff, without whom many of the concepts
derful teachers. However, one has had the greatest impact, in this book would not exist: AT, TK, PK, MJB, AF, TC, SR, SO,
not only on my knowledge base, but also on my approach to NS, CP, MB, Icarus, and MLL.
learning, teaching, and academic life. I would like to thank Ja- Lastly and most importantly, I dedicate this book to Monica
mie Cohen, M.D., Ph.D., for being an outstanding role model, Anne Linde, without whose support, energy and love, none of
mentor, and friend. Eugene N. Myers, M.D. has been vital to my professional success would have been possible.
me from a professional and career development perspective, Sincerely and with deepest gratitude,
for providing me the opportunity to achieve my dreams and
goals. Without his support, this book would not have been Clark A. Rosen M.D.
possible. I would like to acknowledge the primal role of Blake Pittsburgh, Pennsylvania
Simpson, M.D., in the development of this book from con- March 2008

Dedication
This work is dedicated to my wife, Cristina, and my twin

daughters, Juliana and Audrey. I am eternally grateful for all
the love and support you have given me.
C. Blake Simpson, M.D.

San Antonio, Texas
March 2008

Foreword
In this age of communication, the care of the human voice and recommended for all common benign lesions and for local-
the vocal organ has assumed greater and greater importance. ized neoplasms of the vocal folds. The use of lasers is described
The maintenance of good vocal health and the treatment of the for stenosis of the vocal folds and circumscribed malignant
diseased larynx are essential for all members of society—from lesions.
heads of state to the receptionist with the golden voice on The chapters on vocal fold augmentation include precise
the telephone. The necessity for the restoration of pathologic information on injection techniques via microlaryngoscopy,
changes in the larynx has resulted in the application of numer- as well as peroral and percutaneous approaches. Specific chap-
ous operative techniques, which may bewilder the clinician. ters are devoted to the principles of operative care for laryn-
There is a real need for a comprehensive educational resource geal framework surgery. These procedures range medializa-
like Operative Techniques in Laryngology. tion laryngoplasty or arytenoid adduction to problems more
The two authors of this textbook, Clark A. Rosen and C. complex such as cricothyroid subluxation, laryngeal fractures,
Blake Simpson, both leading scholars and experienced sur- sulcus vocalis, and stenosis of the larynx and trachea.
geons at major medical centers, have created a superb treatise, The reader will be impressed with the clarity of the presen-
which expertly details the surgical care of different laryngeal tations, which is enhanced by the use of systematic headings,
pathologies. The introductory chapters call attention to the and by the precision and the rich color of the illustrations with-
current methods of clinical evaluation for laryngeal disorders, in each chapter. An abundance of carefully selected references
including videostroboscopy and flexible laryngoscopy, as well enables the prospective surgeon to pursue further detailed in-
as the medical treatment of patients with vocal problems. The formation from various experts as desired. It is apparent that
indicated preoperative measures are discussed in detail, and the authors and the publisher have combined their expertise to
the importance of anesthesia and airway management during present an outstanding educational and inspirational textbook
surgical procedures within the larynx are stressed. for both the clinical otorhinolaryngologist as well as the expe-
Subsequent chapters advance the reader from the funda- rienced laryngeal surgeon. I shall cherish my own copy of this
mental principals of laryngeal surgery to such major surgical exciting edition.
techniques as phonomicrosurgery, laser surgery, vocal fold
augmentation, and surgery of the laryngeal framework. In Hans von Leden, M.D., Sc.D.
successive chapters, each pathologic entity is presented in Professor Emeritus
detail, including the etiology, history, vocal quality, physical University of Southern California
examination, surgical intervention, postoperative care, and Los Angeles, California
potential complications. Specific microsurgical procedures are February 2008

Foreword
The subspecialty of laryngology has gone through a tremen- the step-by-step surgical approach to the many problems cov-
dous period of growth and maturation during the past 20 years. ered in the atlas, but also addressing the important medical
Fellowships dedicated to advanced training in laryngology, information associated with the various conditions requiring
neurolaryngology, and voice care are now available at several the surgical procedures highlighted in this book. The quality
academic health centers and private practices. Furthermore, of the illustrations are excellent, and the reader will feel very
it is now very common to find at least one fellowship-trained confident using this atlas as a primary reference for managing
laryngologist on the full-time faculty of many of our resident appropriate cases in the operating theatre.
education programs in otolaryngology–head and neck surgery This atlas represents a major contribution to our laryngol-
in the United States and Canada. The quality of resident edu- ogy literature, and it should find its way to the office of all lar-
cation, patient care, and laryngology-related research has im- yngologists, laryngology fellows, resident education program
proved because of the advances in this subspecialty promoted libraries, and many community-based otolaryngologist–head
by this growing critical mass of individuals who have complet- and neck surgeons who perform a moderated volume of laryn-
ed fellowships in laryngology and voice care after their formal geal surgery in their practices.
residency training in otolaryngology. Now, the cycle has come I am very proud of Blake and Clark for realizing the vision
full circle, with several of the earlier fellowship-trained laryn- of the growing need for an atlas of surgical techniques in lar-
gologists directing laryngology fellowship training programs yngology. I am honored to have had the opportunity to serve as
of their own. Blake’s fellowship mentor and to have had Clark spend a visit-
Drs. Blake Simpson and Clark Rosen are excellent examples ing fellow week at Vanderbilt during his fellowship year with
of this training model. Blake spent a year at Vanderbilt in fel- Dr. Woodson. I am further honored to be asked by Blake and
lowship with me and my colleagues, and Clark spent a year Clark to write this foreword to their excellent and very impor-
of fellowship training at the University of Tennessee with Dr. tant book.
Gayle Woodson. Now, both Blake and Clark direct fellowship
training programs at their respective institutions.
Operative Techniques in Laryngology fills a real void in the Robert H. Ossoff, D.M.D., M.D.
field of laryngology and voice care. Drs. Simpson and Rosen Guy M. Maness Professor and Chairman
present us with a surgical atlas dedicated to and highlighting Department of Otolaryngology
modern techniques for microlaryngeal surgery and laryngeal Vanderbilt University Medical Center
framework surgery. They have selected an outstanding group Nashville, Tennessee
of experts in the field to whose contributions include not only March 2008

Preface
The field of laryngeal surgery for voice and airway pathologic All the chapters have been designed to allow the reader
conditions has dramatically changed over the last 20 years, and to understand indications, contraindications, equipment re-
the impetus for this book was to reflect these major paradigm quired, step-by-step aspects of the procedure, perioperative
shifts, and bring together in one place essential information on care, and management of complications. In almost every chap-
the rapidly growing and changing field of laryngeal surgery. ter, one will find important insights or pearls that, until now,
The book was written to provide the laryngeal surgeon with: have only been taught verbally by mentor to student.
(1) essential background information in voice disorders, (2) We feel that this book will become essential reading for all
step-by-step surgical information for laryngeal surgery, and students of laryngology, and general otolaryngologists per-
(3) key pearls and pitfalls about indications, surgical steps, and forming laryngeal surgery.
postoperative management of laryngeal surgeries. We have written each chapter of this book; however, for se-
The book provides essential “background” information lected chapters, we have been honored to have leaders in our
of which any laryngeal surgeon must have mastery. We feel field with whom we collaborated. We would like to thank all
strongly that a true surgeon is a physician first, and must al- of these truly gifted surgeons for sharing their knowledge and
ways approach each patient in a holistic manner, and thus expertise.
understand the essential anatomy and pathology of voice dis- This surgical atlas is richly illustrated with detailed, colorful
orders, as well as the nonsurgical treatment modalities. This artwork as well as essential photographic documentation. This
supports the concept of vocal medicine, not just vocal surgery. book would not have been possible without the hard work and
Once surgery has been chosen as a treatment modality, the phenomenal talent of the medical illustration team at the Uni-
surgeon must carefully consider timing, planning, anesthe- versity of Texas Health Science Center, San Antonio. We would
sia, and airway considerations. These important issues are re- like to personally thank these gifted and insightful individuals:
viewed in Chaps. 8 and 9. David Baker, David Aten, and Chris McKee.
The book encompasses a wide range of laryngeal proce- In closing, we feel that this book brings together a wide va-
dures, and it has been organized around the broad catego- riety of new and exciting surgical procedures involving the lar-
ries of phonomicrosurgery and laryngeal framework surgery. ynx and upper airway. We would like to thank our supporting
Within phonomicrosurgery, detailed information is provided staff of Diane Keane and Veronica Aleman, as well as Springer
regarding surgery for benign and malignant vocal fold lesions, for valuable support from their staff, including Marion M.
vocal fold augmentation, and laser laryngeal surgery. The la- Philipp and Irmela Bohn.
ryngeal framework surgery sections include essential chapters
on “open” treatment for unilateral vocal fold paralysis, bilateral
vocal fold paralysis, laryngeal trauma, airway stenosis (glottic, Clark A. Rosen, M.D.
subglottic and tracheal), and vocal fold scar/sulcus vocalis. C. Blake Simpson, M.D.

Acknowledgements
The authors wish to thank the following individuals for their These individuals worked closely with the authors over a four-
important contributions to the book: year period during the writing of this book. The illustrators
went the extra mile, studying cadaveric specimens, attend-
Kristin J. Otto, M.D., Chap. 1 ing surgical procedures, and reviewing surgical photos from
Phillip Song, M.D., Chap. 2 multiple perspectives. Their mastery of laryngeal anatomy
Scott M. Green, Chap. 13 and the surgical perspectives of laryngeal surgery are without
Paolo Pontez, M.D., Chap. 23 peer. Their efforts ultimately resulted in, we believe, the high-
Robert Eller, M.D., Chap. 25 est quality laryngeal surgical illustrations to date.
J. Michael King, M.D., Chap. 34
S. Carter Wright, Jr., M.D., Chap. 39
The authors wish to express thanks to the following companies
Each one of these individuals contributed a portion of the for their financial support in the making of this book:
chapter’s contents or supplied the initial draft prior to editing.
Olympus Surgical
Medtronic ENT
The authors would like to thank the superb team of medical Kay Pentax
illustrators at the University of Texas Health Science Center, Karl Storz Endoscopy America
San Antonio:
Salary support for the medical illustrators was significantly
David Baker funded though generous donations from these corpora-
David Aten tions. Without their support, this book would not have been
Chris McKee possible.

Contents
Part A Clinical Evaluation of Laryngeal Disorders 3 Videostroboscopy and Dynamic Voice

Evaluation with Flexible Laryngoscopy . . . . . . . 17
1 Anatomy and Physiology of the Larynx . . . . . . . 3 3.1 Fundamental and Related Chapters . . . . . . . . . . . 17
1.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.1.1 Laryngeal Cartilages . . . . . . . . . . . . . . . . . . . . . . . . 3 3.3 Surgical Indications and Contraindications . . . . 17
1.1.1.1 Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3.4 Dynamic Voice Assessment with Flexible
1.1.1.2 Cricoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.1.1.3 Arytenoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3.4.1 Nasopharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.1.1.4 Accessory Cartilages: Cuneiform and 3.4.2 Base of Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Corniculate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3.4.3 Larynx (Global) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.1.1.5 Epiglottis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3.4.4 Vocal Fold (Focal) . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.1.2 Laryngeal Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 3.5 Recording of Laryngeal Examination . . . . . . . . . . 19
1.1.2.1 Cricothyroid Joint . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.1.2.2 Cricoarytenoid Joint . . . . . . . . . . . . . . . . . . . . . . . . 4 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 20
1.1.3 Laryngeal Musculature . . . . . . . . . . . . . . . . . . . . . . 4
1.1.3.1 Intrinsic Laryngeal Muscles . . . . . . . . . . . . . . . . . . 4
1.1.3.2 Extrinsic Laryngeal Muscles . . . . . . . . . . . . . . . . . 5 4 Pathological Conditions of the Vocal Fold . . . . . 21
1.1.4 Fibroelastic Tissue of the Larynx . . . . . . . . . . . . . 5 4.1 Fundamental and Related Chapters . . . . . . . . . . . 21
1.1.4.1 Quadrangular Membrane . . . . . . . . . . . . . . . . . . . 5 4.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.1.4.2 Conus Elasticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4.3 Epithelial Pathology of the Vocal Folds . . . . . . . . 21
1.1.5 Microanatomy of the Vocal Fold . . . . . . . . . . . . . . 6 4.3.1 Recurrent Respiratory Papillomatosis
1.1.6 Vasculature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 of the Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.1.7 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4.3.2 Leukoplakia of the Vocal Fold . . . . . . . . . . . . . . . . 21
1.2 Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4.3.3 Dysplasia–Carcinoma in Situ of the Vocal
1.2.1 Major Laryngeal Functions: Lower Airway Folds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Protection, Respiration, and Phonation . . . . . . . . 7 4.3.4 Carcinoma of the Vocal Fold . . . . . . . . . . . . . . . . . 22
1.2.1.1 Phonation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4.4 Benign Diseases of the Vocal Fold Lamina
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Propria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 8 4.4.1 Overview of Midmembranous Vocal Fold
Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.4.2 Approach to Midmembranous Vocal Fold
2 Principles of Clinical Evaluation for Voice Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 4.4.3 Vocal Fold Nodules . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.1 Fundamental and Related Chapters . . . . . . . . . . . 9 4.4.4 Vocal Fold Cyst (Subepithelial) . . . . . . . . . . . . . . . 23
2.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 4.4.5 Vocal Fold Cyst (Ligament) . . . . . . . . . . . . . . . . . . 24
2.3 Gathering a Patient History . . . . . . . . . . . . . . . . . . 9 4.4.6 Vocal Fold Polyp . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.4 History of Present Illness . . . . . . . . . . . . . . . . . . . . 9 4.4.7 Fibrous Mass (Subepithelial) . . . . . . . . . . . . . . . . . 24
2.5 Past Medical History . . . . . . . . . . . . . . . . . . . . . . . . 10 4.4.8 Fibrous Mass (Ligament) . . . . . . . . . . . . . . . . . . . . 24
2.6 Past Surgical History . . . . . . . . . . . . . . . . . . . . . . . . 11 4.4.9 Reactive Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.7 Social History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 4.5 Miscellaneous Disorders of the Vocal Fold . . . . . 25
2.8 Occupational History . . . . . . . . . . . . . . . . . . . . . . . 11 4.5.1 Polypoid Corditis (Reinke’s Edema) . . . . . . . . . . . 25
2.9 Listening to the Voice . . . . . . . . . . . . . . . . . . . . . . . 11 4.5.2 Vocal Fold Granuloma . . . . . . . . . . . . . . . . . . . . . . 25
2.10 Perceptual Analysis . . . . . . . . . . . . . . . . . . . . . . . . . 12 4.5.3 Rheumatologic Lesions of the Vocal Folds . . . . . 26
2.11 Quality-of-Life Questionnaires . . . . . . . . . . . . . . . 12 4.5.4 Vascular Lesions of the Vocal Folds . . . . . . . . . . . 26
2.12 Professional Speaking/Singing Voice . . . . . . . . . . 12 4.5.5 Vocal Fold Scar and Sulcus Vocalis . . . . . . . . . . . . 27
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 14 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 27
XVIII Contents
5 Glottic Insufficiency: Vocal Fold Paralysis, 6.7.2 Criteria for Endoscopic Treatment
Paresis, and Atrophy . . . . . . . . . . . . . . . . . . . . . . . 29 for Subglottic Stenosis . . . . . . . . . . . . . . . . . . . . . . . 41
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 6.7.3 Criteria for T-Tube Stenting for Subglottic
5.2 Unilateral Vocal Fold Paralysis . . . . . . . . . . . . . . . 29 Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.2.1 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 6.7.4 Criteria for External Treatment of Glottic/
5.3 Surgical Indications and Contraindications . . . . 30 Subglottic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.3.1 Vocal Quality and Swallowing . . . . . . . . . . . . . . . . 30 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.4 Unilateral Vocal Fold Paralysis: Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 42
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . 31
5.4.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5.4.2 Laryngeal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 7 Nonsurgical Treatment of Voice Disorders . . . . 43
5.5 Unilateral Vocal Fold Paralysis: Workup . . . . . . . 32 7.1 Fundamental and Related Chapters . . . . . . . . . . . 43
5.5.1 Serology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 7.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.5.2 Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 7.3 Surgical Indications and Contraindications . . . . 43
5.6 Unilateral Vocal Fold Paralysis: Treatment . . . . . 32 7.4 Vocal Fold Granuloma . . . . . . . . . . . . . . . . . . . . . . 43
5.7 Unilateral/Bilateral Vocal Fold Paresis . . . . . . . . . 33 7.5 Infectious and Inflammatory Disorders . . . . . . . . 44
5.7.1 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 7.6 Neurologic Disorders . . . . . . . . . . . . . . . . . . . . . . . 45
5.7.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 7.6.1 Spasmodic Dysphonia . . . . . . . . . . . . . . . . . . . . . . 45
5.7.3 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . 33 7.6.2 Essential Tremor . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.7.4 Diagnostic Workup . . . . . . . . . . . . . . . . . . . . . . . . 33 7.6.3 Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . 45
5.7.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 7.6.4 Muscle Tension Dysphonia . . . . . . . . . . . . . . . . . . 45
5.8 Presbylaryngis/Age-Related Changes 7.6.5 Paradoxical Vocal Fold Motion Disorder . . . . . . 46
in the Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 7.6.6 Postviral Vagal Neuropathy . . . . . . . . . . . . . . . . . . 46
5.8.1 General Considerations . . . . . . . . . . . . . . . . . . . . . 34 7.7 Allergy and Voice Disorders . . . . . . . . . . . . . . . . . 46
5.8.2 Etiology, History, and Physical Findings . . . . . . . 34 7.8 Medications and Their Effects on Voice . . . . . . . . 46
5.8.3 Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 7.9 Vocal Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 7.10 Role of the Speech–Language Pathologist
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 35 in Voice Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 48
6 Glottic and Subglottic Stenosis: Evaluation
and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . 37
6.1 Fundamental and Related Chapters . . . . . . . . . . . 37 8 Timing, Planning, and Decision Making
6.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 in Phonosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.3 Etiology of Glottic and Subglottic 8.1 Fundamental and Related Chapters . . . . . . . . . . . 49
(Laryngotracheal) Narrowing . . . . . . . . . . . . . . . . 37 8.2 Key Components to Successful Care
6.3.1 Common Clinical Conditions of Patients with Voice Disorders . . . . . . . . . . . . . . 49
and Associated Risk Factors . . . . . . . . . . . . . . . . . . 37 8.3 Surgical Indications and Contraindications . . . . 49
6.4 Glottic and Subglottic Stenosis: History . . . . . . . . 38 8.3.1 Timing of Phonomicrosurgery . . . . . . . . . . . . . . . 49
6.4.1 Symptoms/Time Course . . . . . . . . . . . . . . . . . . . . . 38 8.3.2 Preoperative Considerations for
6.4.2 Medical Comorbidities . . . . . . . . . . . . . . . . . . . . . . 38 Phonomicrosurgery . . . . . . . . . . . . . . . . . . . . . . . . 49
6.5 Glottic and Subglottic Stenosis: 8.4 Decision Making in Phonosurgery . . . . . . . . . . . . 50
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . 38 8.5 Informed Consent Regarding Phonosurgery . . . 51
6.5.1 Local Anesthesia Techniques for Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 51
6.5.2 Documentation of Examination . . . . . . . . . . . . . . 38
6.5.2.1 Flexible Laryngoscopy/Tracheoscopy
Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 9 Anesthesia and Airway Management
6.6 Additional Studies for the Evaluation for Laryngeal Surgery . . . . . . . . . . . . . . . . . . . . . . 53
of Glottic/Subglottic Stenosis . . . . . . . . . . . . . . . . . 40 9.1 Fundamental and Related Chapters . . . . . . . . . . . 53
6.6.1 Voice Evaluation 9.2 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
(VHI-10, Audio Recording) . . . . . . . . . . . . . . . . . 40 9.3 Surgical Indications and Contraindications . . . . 53
6.6.2 Air-Flow Measures . . . . . . . . . . . . . . . . . . . . . . . . . 40 9.4 Principles of Airway Management:
6.6.3 Radiographic Studies . . . . . . . . . . . . . . . . . . . . . . . 40 Subglottic and Tracheal Stenosis . . . . . . . . . . . . . . 54
6.6.4 Laboratory Testing . . . . . . . . . . . . . . . . . . . . . . . . . 40 9.5 Special Circumstances: Difficult Exposure
6.7 Glottic and Subglottic Stenosis: Surgical of the Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 9.6 Anesthesia for Laryngeal Framework
6.7.1 Corrective Surgical Procedures for Glottic/ Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Subglottic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . 41 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 58
Contents XIX
Part B Phonomicrosurgery for Benign 13.2.2 Tissue Interaction . . . . . . . . . . . . . . . . . . . . . . . . . 85

Laryngeal Pathology 13.2.3 Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 85
13.2.4 Types of Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
I Fundamentals of Phonomicrosurgery 13.3 Surgical Indications and Contraindications . . . 86
13.4 Equipment: Laser Microlaryngoscopy Setup . . 87
10 Principles of Phonomicrosurgery . . . . . . . . . . . . 63 13.5 CO2 Laser Safety Guidelines . . . . . . . . . . . . . . . . 87
10.1 Fundamental and Related Chapters . . . . . . . . . . . 63 13.5.1 General Guidelines (Fig. 13.1) . . . . . . . . . . . . . . . 87
10.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 13.5.2 CO2 Laser Settings . . . . . . . . . . . . . . . . . . . . . . . . . 88
10.3 Surgical Indications and Contraindications . . . . 63 13.5.3 Safety Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
10.4 Equipment for Phonomicrosurgery . . . . . . . . . . . 65 13.6 Surgical Principles . . . . . . . . . . . . . . . . . . . . . . . . 88
10.5 Phonomicrosurgery Procedures, 13.6.1 Smoke Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . 88
Techniques, and Methods . . . . . . . . . . . . . . . . . . . 67 13.6.2 Protecting Surrounding Tissue from Laser
10.5.1 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
10.5.2 Patient Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 13.6.3 Maintenance of a Clean Surgical Field . . . . . . . . 88
10.5.3 Laryngoscope Placement . . . . . . . . . . . . . . . . . . . . 68 13.7 Complications and Their Treatments . . . . . . . . . 89
10.5.4 Suspension Device . . . . . . . . . . . . . . . . . . . . . . . . . 70 13.7.1 Laser Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
10.5.5 External Counter-Pressure . . . . . . . . . . . . . . . . . . . 71 13.7.2 Tracheal Perforation . . . . . . . . . . . . . . . . . . . . . . . 89
10.5.6 Telescopic Evaluation of Vocal Fold Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . 89
10.5.7 Operating Microscope and Surgeon
Ergonomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
10.5.8 Microflap Approach to Submucosal 14 Principles of Vocal Fold Augmentation . . . . . . 91
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 14.1 Fundamental and Related Chapters . . . . . . . . . . 91
10.6 Postoperative Care and Complications . . . . . . . . 75 14.2 Vocal Fold Augmentation: Advantages,
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Disadvantages, and Clinical Utility . . . . . . . . . . 91
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 75 14.3 Surgical Indications and Contraindications . . . 91
14.4 Characteristics of Vocal Fold Augmentation
Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11 Perioperative Care for Phonomicrosurgery . . . . 77 14.4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11.1 Fundamental and Related Chapters . . . . . . . . . . . 77 14.4.2 Categories of Vocal Fold Augmentation
11.2 Timing of Phonomicrosurgery . . . . . . . . . . . . . . . 77 Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
11.3 Surgical Indications and Contraindications . . . . 77 14.4.3 Description of Vocal Fold Augmentation
11.4 Considerations for the Day of Materials Characteristics . . . . . . . . . . . . . . . . . . . 92
Phonomicrosurgery . . . . . . . . . . . . . . . . . . . . . . . . 78 14.5 General Principles of Vocal Fold
11.5 Postoperative Voice Rest . . . . . . . . . . . . . . . . . . . . 78 Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
11.6 Postoperative Voice Care . . . . . . . . . . . . . . . . . . . . 78 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
11.7 Intralaryngeal Steroid Injection to Soften Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . 96
Postoperative Scar in the Vocal Fold . . . . . . . . . . 78
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 79 II Phonomicrosurgical Voice Procedures
15 Vocal Fold Polyp . . . . . . . . . . . . . . . . . . . . . . . . . . 99

12 Management and Prevention 15.1 Fundamental and Related Chapters . . . . . . . . . . 99
of Complications Related 15.2 Disease Characteristics and Differential
to Phonomicrosurgery . . . . . . . . . . . . . . . . . . . . . 81 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
12.1 Fundamental and Related Chapters . . . . . . . . . . . 81 15.3 Surgical Indications and Contraindications . . . 99
12.2 Overview of Management and Prevention of 15.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . . 99
Complications Related to Phonomicrosurgery 81 15.5 Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . 100
12.3 Surgical Indications and Contraindications . . . . 81 15.6 Postoperative Care/Complications . . . . . . . . . . 103
12.4 Postoperative Dysphonia . . . . . . . . . . . . . . . . . . . . 81 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
12.5 Medical Complications Associated with Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 103
Phonomicrosurgery . . . . . . . . . . . . . . . . . . . . . . . . 82
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . . . 83 16 Vocal Fold Nodules . . . . . . . . . . . . . . . . . . . . . . . 105
16.1 Fundamental and Related Chapters . . . . . . . . . 105
16.2 Disease Characteristics and Differential
13 Principles of Laser Microlaryngoscopy . . . . . . . . 85 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
13.1 Fundamental and Related Chapters . . . . . . . . . . . 85 16.3 Surgical Indications and Contraindications . . 105
13.2 Laser Physics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 16.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 105
13.2.1 Wavelength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 16.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 106
XX Contents
16.6 Postoperative Care and Complications . . . . . . 107 21.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 130
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 21.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 130
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 107 21.6 Postoperative Care and Complications . . . . . . 133
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 134
17 Vocal Fold Cyst and Vocal Fold Fibrous
Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
17.1 Fundamental and Related Chapters . . . . . . . . . 109 22 Surgical Management of Vocal Fold
17.2 Diagnostic Characteristics and Differential Vascular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . 135
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 22.1 Fundamental and Related Chapters . . . . . . . . . 135
17.3 Surgical Indications and Contraindications . . 109 22.2 Diagnostic Characteristics and Differential
17.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 109 Diagnosis of Vocal Fold Varicosities . . . . . . . . . 135
17.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 109 22.3 Surgical Indications and Contraindications . . 136
17.6 Postoperative Care and Complications . . . . . . 111 22.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 136
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
18 Polypoid Corditis . . . . . . . . . . . . . . . . . . . . . . . . 113
18.2 Disease Characteristics . . . . . . . . . . . . . . . . . . . . 113 23 Vocal Fold Scar and Sulcus Vocalis . . . . . . . . . 141
18.3 Surgical Indications and Contraindications . . 113 23.1 Fundamental and Related Chapters . . . . . . . . . 141
18.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 114 23.2 Disease Characteristics and Differential
18.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 114 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
18.6 Postoperative Care and Complications . . . . . . 116 23.3 Surgical Indications and Contraindications . . 142
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 23.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 143
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 117 23.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 143
23.6 Postoperative Care and Complications . . . . . . 150
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
19 Vocal Fold Granuloma . . . . . . . . . . . . . . . . . . . . 119 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 150
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 24 Endoscopic Management of Teflon
19.3 Surgical Indications and Contraindications . . 119 Granuloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
19.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 119 24.1 Fundamental and Related Chapters . . . . . . . . . 151
19.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 120 24.2 Disease Characteristics and Differential
19.6 Postoperative Care and Complications . . . . . . 121 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 24.3 Surgical Indications and Contraindications . . 151
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 121 24.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 151
24.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 151
20 Vocal Fold Leukoplakia and Hyperkeratosis 123 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
20.1 Fundamental and Related Chapters . . . . . . . . . 123 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 154
20.2 Diagnostic Characteristics and Differential
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
20.3 Surgical Indications and Contraindications . . 123 25 Endoscopic Excision of Saccular Cyst . . . . . . . 155
20.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 123 25.2 Disease Characteristics and Differential
20.6 Postoperative Care and Complications . . . . . . 126 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
25.5 Surgical Procedure for Saccular Cyst . . . . . . . . 156
21 Surgical Treatment of Recurrent Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Respiratory Papillomatosis of the Larynx . . . 129 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 158
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 26 Anterior Glottic Web . . . . . . . . . . . . . . . . . . . . . 159
Contents XXI
26.2 Disease Characteristics and Differential 30.2 Disease Characteristics and Differential
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
26.3 Surgical Indications and Contraindications . . 159 30.3 Surgical Indications and Contraindications . . 191
26.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 159 30.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 191
26.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 160 30.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 192
26.6 Postoperative Care and Complications . . . . . . 164 30.6 Postoperative Care and Complications . . . . . . 192
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 164 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 193
III Laser Microlaryngeal Surgery IV Laryngeal Injection Techniques

(Airway/Neoplastic Conditions)
31 Vocal Fold Augmentation via Direct
27 Bilateral Vocal Fold Paralysis . . . . . . . . . . . . . . . 167 Microlaryngoscopy . . . . . . . . . . . . . . . . . . . . . . 197
27.1 Fundamental and Related Chapters . . . . . . . . . 167 31.1 Fundamental and Related Chapters . . . . . . . . . 197
27.2 Disease Characteristics and Differential 31.2 Disease Characteristics . . . . . . . . . . . . . . . . . . . 197
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 31.2.1 Material Selection . . . . . . . . . . . . . . . . . . . . . . . . 197
27.3 Surgical Indication and Contraindications . . . 167 31.3 Surgical Indications and Contraindications . . 198
27.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 168 31.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 198
27.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 168 31.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 198
27.6 Postoperative Care and Complications . . . . . . 171 31.5.1 Principles of Deep Vocal Fold
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 173 31.5.2 Vocal Fold Augmentation via
Microlaryngoscopy . . . . . . . . . . . . . . . . . . . . . . . 199
31.5.3 Endoscopic Vocal Fold Injection . . . . . . . . . . . . 199
28 Posterior Glottic Stenosis: Endoscopic 31.5.4 Lipoinjection of the Vocal Fold . . . . . . . . . . . . . 200
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 31.6 Postoperative Care and Complications . . . . . . 202
28.1 Fundamental and Related Chapters . . . . . . . . . 175 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
28.2 Diagnostic Characteristics and Differential Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 203
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
28.3 Surgical Indications and Contraindications . . 176
28.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 176 32 Superficial Vocal Fold Injection . . . . . . . . . . . . 205
28.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 176 32.1 Fundamental and Related Chapters . . . . . . . . . 205
28.6 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . 179 32.2 Disease Characteristics
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 and Differential Diagnosis . . . . . . . . . . . . . . . . 205
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 180 32.3 Surgical Indications and Contraindications . . 205
32.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 205
29 Subglottic/Tracheal Stenosis: Laser/ 32.6 Postoperative Care and Complications . . . . . . 206
Endoscopic Management . . . . . . . . . . . . . . . . . 181 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
29.3 Surgical Indications and Contraindications . . 181 33 Peroral Vocal Fold Augmentation
29.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 182 in the Clinic Setting . . . . . . . . . . . . . . . . . . . . . . 209
29.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 182 33.1 Fundamental and Related Chapters . . . . . . . . . 209
29.6 Postoperative Care and Complications . . . . . . 185 33.2 Disease Characteristics and Differential
29.7 T-Tube Stenting of SGS . . . . . . . . . . . . . . . . . . . 185 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
29.8 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 185 33.3 Surgical Indications and Contraindications . . 209
29.9 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 185 33.3.1 Suitability for Peroral Vocal Fold
29.10 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . 189 Augmentation in the Clinic Setting . . . . . . . . . 210
29.11 Special Considerations in T-Tube Stenting . . . 189 33.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . 210
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
30 Carcinoma of the Vocal Fold . . . . . . . . . . . . . . . 191
XXII Contents
34 Percutaneous Vocal Fold Augmentation 37.5 Long-Term Surgical Issues . . . . . . . . . . . . . . . . . 239

in the Clinic Setting . . . . . . . . . . . . . . . . . . . . . . 215 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
34.1 Fundamentals and Related Chapters . . . . . . . . 215 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 239
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
34.3 Surgical Indications and Contraindications . . 215 38 Silastic Medialization Laryngoplasty
34.3.1 Suitability for Percutaneous Vocal for Unilateral Vocal Fold Paralysis . . . . . . . . . . 241
Fold Augmentation in the Clinic Setting . . . . . 216 38.1 Fundamental and Related Chapters . . . . . . . . . 241
34.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 216 38.2 Disease Characteristics and Differential
34.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 216 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
34.6 Postoperative Care and Complications . . . . . . 219 38.3 Surgery Indications and Contraindications . . . 241
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
35 Botulinum Toxin Injection of the Larynx . . . . 221 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 251
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 39 GORE-TEX® Medialization Laryngoplasty . . . . 253
35.2.1 Botulinum Toxin Fundamentals . . . . . . . . . . . . 221 39.1 Fundamental and Related Chapters . . . . . . . . . 253
35.2.2 Spasmodic Dysphonia and Essential Tremor 221 39.2 Disease Characteristics and Differential
35.2.3 Different Botulinum Toxin Injection Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 39.3 Surgical Indications and Contraindications . . 253
35.3 Surgical Indications and Contraindications . . 222 39.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . 253
35.4 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 39.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 254
35.5 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 39.6 Postoperative Care and Complications . . . . . . 255
35.6 Postprocedure Care and Complications . . . . . . 227 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 256
40 Arytenoid Adduction . . . . . . . . . . . . . . . . . . . . . 257

Part C Laryngeal Framework Surgery 40.2 Fundamentals of Arytenoid Adduction . . . . . . 257
36 Principles of Laryngeal Framework Surgery 231 40.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 257
36.1 Fundamental and Related Chapters . . . . . . . . . 231 40.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 257
36.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 40.6 Postoperative Care and Complications . . . . . . 262
36.3 Surgical Indications and Contraindications . . 231 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
36.3.1 Medialization Laryngoplasty . . . . . . . . . . . . . . . 231 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 262
36.3.2 Arytenoid Adduction . . . . . . . . . . . . . . . . . . . . . 231
36.3.3 Cricothyroid Subluxation . . . . . . . . . . . . . . . . . . 232
36.4 Patient Selection for Laryngeal Framework 41 Cricothyroid Subluxation . . . . . . . . . . . . . . . . . 263
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 41.1 Fundamental and Related Chapters . . . . . . . . . 263
36.5 Timing of Medialization Laryngoplasty . . . . . . 232 41.2 Disease Characteristics and Differential
36.6 Technical Notes and Pertinent Anatomic Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Landmarks for Medialization Laryngoplasty 232 41.3 Surgical Indications and Contraindications . . 263
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
37 Perioperative Care for Laryngeal Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Framework Surgery . . . . . . . . . . . . . . . . . . . . . . 235
37.2 Perioperative Issues in Laryngeal 42 Translaryngeal Removal of Teflon
Framework Surgery . . . . . . . . . . . . . . . . . . . . . . . 235 Granuloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
37.4 Suboptimal Results/Surgical Errors . . . . . . . . . 236 42.2 Disease Characteristics and Differential
37.4.1 Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 237 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Contents XXIII
42.3 Surgical Indications and Contraindications . . 267 46 Glottic and Subglottic Stenosis:
42.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . 268 Cricotracheal Resection with Primary
42.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 268 Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
42.6 Postoperative Care and Complications . . . . . . 271 46.1 Fundamental and Related Chapters . . . . . . . . . 289
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 46.2 Diagnostic Characteristics for Open
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 271 Treatment of Subglottic Stenosis . . . . . . . . . . . . 289
43 Excision of Combined Laryngocele . . . . . . . . . 273 46.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 289
43.1 Fundamental and Related Chapters . . . . . . . . . 273 46.6 Postoperative Management . . . . . . . . . . . . . . . . 292
43.2 Disease Characteristics and Differential Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 293
43.2.1 Anatomy and Classification . . . . . . . . . . . . . . . . 273
43.2.2 Clinical Presentation and Differential
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 47 Tracheal Stenosis: Tracheal Resection
43.3 Surgical Indications and Contraindications . . 274 with Primary Anastomosis . . . . . . . . . . . . . . . . 295
43.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 275 47.2 Background Information and Diagnosis
43.6 Postoperative Care and Complications . . . . . . 277 of Tracheal Stenosis . . . . . . . . . . . . . . . . . . . . . . . 295
44 Repair of Laryngeal Fracture . . . . . . . . . . . . . . 279 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
44.2 Disease Characteristics . . . . . . . . . . . . . . . . . . . 279
44.4 Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . 280 48 The Gray Minithyrotomy for Vocal Fold
44.5 Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . 280 Scar/Sulcus Vocalis . . . . . . . . . . . . . . . . . . . . . . . 299
44.6 Postoperative Care and Complications . . . . . . 282 48.1 Fundamental and Related Chapters . . . . . . . . . 299
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 48.2 General Considerations . . . . . . . . . . . . . . . . . . . 299
Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 282 48.3 Surgical Indications and Contraindications . . 299
45 Glottic and Subglottic Stenosis: 48.6 Postoperative Care and Complications . . . . . . 303
Laryngotracheal Reconstruction Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
with Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Selected Bibliography . . . . . . . . . . . . . . . . . . . . . 304
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Contributing Authors
Milan Amin, M.D. Patrick J. Gullane, M.D.

Chief, Division of Laryngology 7-242 Eaton Wing N
Department of Otolaryngology Toronto General
New York University School of Medicine 200 Elizabeth Street, Room 3S438
550 First Avenue, NBV 5E5 Toronto, Ontario M5G 2CH
New York, NY 10016 Canada
USA
Chapter 46: Glottic and Subglottic Stenosic: Cricotracheal
Chapter 2: Principles of Clinical Evaluation resection with primary anastamosis
for Voice Disorders
Chapter 45: Subglottis Stenosis: Laryngotracheal
Rene Gupta, MD
Reconstruction with Grafting
Department of Otolaryngology
New York University School of Medicine
Michiel J. Bové, M.D. 550 First Avenue, NBV 5E5
Searle Building New York, NY 10016
Room 12-561 USA
320 Superior
Chapter 29: Subglottis Stenosis: Laryngotracheal
Chicago, IL 60611
Reconstruction with Grafting
USA
Chapter 2: Principles of Clinical Evaluation
Michael Johns, M.D.
for Voice Disorders
Emory Health Care
Dept. of Otolaryngology
Mark Courey, M.D. 550 Peachtree Street, Suite 9-4400
UCSF Voice & Swallowing Center Atlanta, GA 30308
2330 Post Street, 5th Floor USA
San Francisco, CA 94115
Chapter 1: Anatomy and Physiology of the Larynx
USA
Chapter 28: Posterior Glottis Stenosis—Endoscopic Approach
Priya Krishna, M.D.
(Laser Division with MMC)
University of Pittsburg
Voice Center
Jonathan R. Grant, M.D. Department of Otolaryngology
Dept. of Otolaryngology and Communication Sciences 200 Lothrop Street, Suite 500
Medical College of Wisconsin Pittsburgh, PA 15213
Milwaukee, IL USA
USA
Chapter 7: Medical Treatment of Voice Disorders
Chapter 34: Percutaneous VF Augmentation
in a Clinical Setting
XXVI Invited Authors
Albert Merati, M.D. Anthony Rider, MD

University of Washington Department of Otolaryngology and Communication Sciences
Department of Otolaryngology Medical College of Wisconsin
Box 356515 Milwaukee, WI
Health Sciences Building USA
Suite BB1165
Chapter 47: Tracheal Resection with Primary Anastomosis
Seattle, WA 98195
Chapter 34: Percutaneous VF Augmentation
Robert T. Sataloff, M.D.
in a Clinical Setting
1721 Pine Street
Chapter 47: Tracheal Resection with Primary Anastomosis
Philadelphia, PA 19103
USA
Christine Novak PT
Chapter 22: Vocal Fold Varix
7-242 Eaton Wing N
Toronto General
200 Elizabeth Street, Room 3S438 Lucian Sulica, M.D.
Toronto, Ontario M5G 2CH 10 Union Square East, Suite 4J
Canada New York, NY 10003
USA
Chapter 46: Glottic and Subglottic Stenosic: Cricotracheal
resection with primary anastamosis Chapter 35: Botox Toxin Injection
Chapter 37: Peri-Operative Care for Laryngeal
Framework Surgery
Gregory Postma, M.D.
Chapter 38: Principles of Laryngeal Framework Surgery
Department of Otolaryngology
Chapter 48: Mini-Thyrotomy for Vocal Fold Scar
Medical College of Georgia
1120 15th Street
Augusta, GA 30912
USA
Chapter 39: Goretex Medialization Laryngoplasty
Part A Clinical Evaluation
of Laryngeal Disorders
Chapter 1
Anatomy and Physiology

of the Larynx 1
the anterior surface of the thyroid laminae at the oblique line.
1.1 Anatomy
The inferior pharyngeal constrictor muscles insert on the pos-
terior edge of each thyroid lamina.
1.1.1 Laryngeal Cartilages
The relationship of the internal laryngeal structures to the
surface anatomy of the thyroid cartilage is important in sur-
1.1.1.1 Thyroid
gical planning, particularly in planning the placement of the
window for thyroplasty. The level of the vocal fold lies closer to
The laryngeal skeleton consists of several cartilaginous struc- the lower border of the thyroid cartilage lamina than to the up-
tures (Fig. 1.1), the largest of which is the thyroid cartilage. The per, and not at its midpoint, as is frequently (and erroneously)
thyroid cartilage is composed of two rectangular laminae that stated. Correct placement of the window is necessary to avoid
are fused anteriorly in the midline. The incomplete fusion of medialization of the false vocal folds or ventricular mucosa.
the two laminae superiorly forms the thyroid notch. Attached
to each lamina posteriorly are the superior and inferior cor-
nua. The superior cornua articulate with the greater horns of
1.1.1.2 Cricoid
the hyoid bone, while the inferior cornua form a synovial joint
with the cricoid cartilage (the cricothyroid joint). At the junc-
tion of each superior cornu with its respective thyroid ala is a This signet ring-shaped cartilage is the only laryngeal cartilage
cartilaginous prominence, the superior tubercle. The superior to encircle completely the airway. The cricoid cartilage articu-
tubercle is of significance because it marks the point 1 cm be- lates with the thyroid cartilage’s inferior cornua on the crico-
low which the superior laryngeal artery and nerve cross over thyroid joint facets. It joins the first tracheal ring inferiorly via
the lamina from laterally to pierce the thyrohyoid membrane. membranous attachments. The face of the cricoid cartilage has
The sternothyroid and the thyrohyoid strap muscles attach to a vertical height of only about 3–4 mm, while the lamina pos-
teriorly stands about 20–30 mm high. There is a steep incline
from anterior to posterior of the superior margin of the cricoid
cartilage. This incline leaves an anterior window where the cri-
cothyroid membrane lies.
1.1.1.3 Arytenoid
The arytenoid cartilages are paired, pyramidal cartilages that

articulate with the posterior lamina of the cricoid cartilage at
the cricoarytenoid joint. Each arytenoid has both a vocal pro-
cess medially and a muscular process laterally. These processes
act as the attachment sites for the vocal ligament and the major
intrinsic muscles of vocal fold movement respectively.
1.1.1.4 Accessory Cartilages:

Cuneiform and Corniculate
The cuneiform cartilages are crico-arytenoid joint paired elas-

tic cartilages that sit on top of, and move with, the correspond-
ing arytenoid. The soft tissue of the aryepiglottic folds covers
these cartilages. The corniculates are small, paired, fibroelastic
cartilages that sit laterally to each of the arytenoids, and are
Fig. 1.1 Cartilaginous and fibroelastic structures of the larynx completely embedded within the aryepiglottic folds. These
Anatomy and Physiology of the Larynx
1 likely serve to provide additional structural support to the ary-

1.1.2 Laryngeal Joints
epiglottic folds.
1.1.2.1 Cricothyroid Joint
1.1.1.5 Epiglottis
The cricothyroid joint is a synovial joint formed from the ar-
ticulation of the inferior cornua of the thyroid cartilage with
The epiglottis is an oblong, feather-shaped fibroelastic carti- facets on the cricoid lamina. The two major actions at this
lage that is attached, at its inferior end, to the inner surface joint are anteroposterior sliding and rotation of the inferior
of the thyroid cartilage laminae just above the anterior com- thyroid cornu upon the cricoid cartilage. Cricothyroid muscle
missure. The major function of the epiglottis is to help prevent contraction pulls the thyroid ala anteriorly with respect to the
aspiration during swallowing. The epiglottis is displaced poste- cricoid cartilage and closes the anterior visor angle between
riorly by tongue base contraction and laryngeal elevation. This the thyroid and the cricoid cartilage. This motion increases the
causes the superior free edge of the epiglottis to fall over the distance between the anterior commisure and the vocal pro-
laryngeal inlet, which, in conjunction with sphincteric closure cesses and serves to lengthen and tense the vocal folds. This
of the larynx at the glottic and supraglottic level, closes off the joint can be manipulated to assist in pitch control in cases of
laryngeal vestibule. paralytic dysphonia. Cricothyroid joint subluxation, resulting
in an exaggerated decrease in the anterior cricothyroid angle,
can assist in traditional medialization procedures to provide
vocal fold tightening.
1.1.2.2 Cricoarytenoid Joint
The cricoarytenoid joint is the primary moving structure of the

intrinsic larynx (Fig. 1.2). The arytenoids articulate with the
cricoid cartilage forming multiaxial joints. The action of move-
ment at the cricoarytenoid joints changes the distance between
the vocal processes of the two arytenoids and between each vo-
cal process and the anterior commissure. The combined action
of the intrinsic laryngeal muscles on the arytenoid cartilages
Fig. 1.2 Cricoarytenoid joint action in abduction (left) and adduction alters the position and shape of the vocal folds. Each cricoary-
(right). Note the lowering of the vocal process as adduction occurs tenoid joint sits at a surprisingly steep 45° angle with the hori-
zontal plane on the cricoid cartilage and permits motion in a
sliding, rocking, and twisting fashion.
1.1.3 Laryngeal Musculature
1.1.3.1 Intrinsic Laryngeal Muscles
The intrinsic muscles of the larynx are responsible for alter-

ing the length, tension, shape, and spatial position of the vocal
folds by changing the orientation of the muscular and vocal
processes of the arytenoids with the fixed anterior commissure
(Fig. 1.3). Traditionally, the muscles are categorized into the
following scheme: three major vocal fold adductors, one ab-
ductor, and one tensor muscle.
Adductor Muscles
The Lateral Cricoarytenoid Muscle (LCA)
This paired laryngeal muscle is attached to the anterior part

of the muscular process medially and to the superior border
of the cricoid cartilage laterally. Contraction of this muscle
Fig. 1.3 Neuromuscular structures of the larynx results in movement of the muscular process anterolaterally,
Chapter 1
while simultaneously forcing the vocal process downward and noids “upright” and has a major role in vocal fold length and
medially. The result is adduction and lengthening of the vocal tension. The PCA muscle anatomy serves as a key landmark for
folds. This muscle runs lateral and in large part parallel with arytenoid adduction surgery.
the thyroarytenoid muscle.
Tensor Muscle
Thyroarytenoid Muscle (TA)
Cricothyroid Muscle
The thyroarytenoid muscle consists of two main muscle bellies,
the internus and the externus. The thyroarytenoid externus in- The cricothyroid muscle is a laryngeal tensor, composed of two
serts anteriorly at the anterior commissure (Broyles’ ligament), separate muscle bellies, located on the external surface of the
and posterolaterally on the lateral surface of the arytenoid. laryngeal cartilages. The pars recta, the more vertical compo-
During contraction of this portion of the muscle, the vocal nent, arises laterally from the superior rim of the cricoid car-
process is brought closer to the anterior commissure and the tilage and inserts on the inferior rim of the thyroid cartilage,
vocal folds are shortened and adducted. The thyroarytenoid while the pars obliqua, runs obliquely from the superior arch
internus arises from the anterior commissure and inserts onto of the cricoid to insert on the inferior cornu. Contraction of
the vocal process of the arytenoid cartilage. During contrac- the cricothyroid muscle bellies affects motion at the crico-
tion, the vocal folds are shortened and thickened. This portion thyroid joint. During contraction, the cricothyroid space is
of the thyroarytenoid is also known as the vocalis muscle. In narrowed anteriorly, while the posterior cricoid lamina and
isolation, this action serves to lower the resonant frequency of cricoarytenoid joints are forced caudally, resulting in length-
the vocal folds. In most cases, there is a significant superior ening, tightening and thinning of the vocal folds and as well as
extension of the TA muscle into the false vocal folds, often re- increasing their resonant frequency. This action also results in
ferred to as the ventricularis muscle. vocal fold adduction.
Interarytenoid Muscle (IA)

1.1.3.2 Extrinsic Laryngeal Muscles
This nonpaired muscle consists of both transverse fibers and
oblique fibers. The transverse fibers insert on the posterior face
of each arytenoid and run horizontally, while the oblique fi- The infrahyoid strap muscles (the sternothyroid, the sternohy-
bers attach to each arytenoid apex and run obliquely to attach oid, and the thyrohyoid), the mylohyoid, digastric, geniohyoid,
to the posterior face on the opposite side. Contraction of this and stylopharyngeus muscles all act in concert to provide laryn-
muscle leads to arytenoid adduction, closure of the posterior geal stabilization, and indirectly may affect vocal fold position.
glottis, and narrowing of the laryngeal inlet. Some oblique fi-
bers extend to travel along the quadrangular membrane and
are referred to as the aryepiglottic muscle
1.1.4 Fibroelastic Tissue of the Larynx
Abductor Muscle 1.1.4.1 Quadrangular Membrane
Posterior Cricoarytenoid Muscle (PCA)
The quadrangular membrane is an accessory elastic support
The posterior cricoarytenoid muscle arises from the posterior structure of the supraglottic larynx. It attaches anteriorly to the
face of the cricoid lamina. Its fibers run diagonally to insert on lateral edges of the epiglottis, and wraps around posteriorly to
the muscular process of the arytenoid. Contraction displaces attach to the arytenoids. The superior free edge of the quad-
the muscular process posteriorly and caudally, while the vo- rangular membrane is the mucosa-covered aryepiglottic fold.
cal process moves upward and laterally. The result is vocal fold As the quadrangular membrane extends inferiorly, it becomes
abduction. The posterior cricoarytenoid is the only abductor the medial wall of the piriform sinus. At its inferior extent, it is
of the vocal folds and is principally responsible for control of continuous with the vestibular ligament.
the glottic airway. The posterior cricoarytenoid muscle affects
motion at the cricoarytenoid joint in two planes by its two
separate muscle bellies. The medial portion of the posterior
1.1.4.2 Conus Elasticus
cricoarytenoid (horizontal belly) arises from the posterior cri-
coid lamina and courses obliquely in a superiolateral fashion to
insert on the medial aspect of the muscular process. The lateral The thick fibroelastic support structure of the glottis and sub-
portion (vertical belly) runs in a more vertical fashion to insert glottis originates inferiorly along the superior border of the
on the lateral side of the muscular process. Because of slightly cricoid cartilage. Is extends superiorly to attach to the anterior
different positions and orientations, contraction of each mus- commissure and vocal processes. The conus elasticus rolls me-
cle belly in isolation causes cricoarytenoid joint motion about dially within the substance of the vocal fold; its medial extent
a different oblique axis. The horizontal belly has been shown, is the vocal ligament. Anteriorly, the conus elasticus is continu-
in cadaver studies, to cause motion in a more vertical axis (true ous with the cricothyroid membrane.
vocal fold abduction), while the vertical belly keeps the aryte-
1 1.1.5 Microanatomy of the Vocal Fold
The complex microanatomy of the true vocal fold allows the

loose and pliable superficial mucosal layers to vibrate freely
over the stiffer structural underlayers (Fig. 1.4). The true vo-
cal fold can be divided into three major layers: the mucosa,
the vocal ligament, and the underlying muscle. The mucosa of
the vocal fold is highly specialized for its vibratory function;
it can also be divided into layers. The most superficial layer
is the squamous epithelium. Deep to the epithelium are three
layers of lamina propria, each of increasing rigidity. The most
superficial layer (superficial layer of the lamina propria, or
SLP) is mostly acellular and composed of extracellualar ma-
trix proteins, water, and loosely arranged fibers of collagen and
elastin. The SLP is gelatinous in nature. The potential space be-
tween the SLP and the intermediate layer of lamina propria is
Reinke’s space. The intermediate and deep layers of the lamina Fig. 1.4 Coronal section through the free edge of the vocal fold, dem-
propria (ILP and DLP) are composed mostly of elastin and col- onstrating the layered microanatomical structures that allow vibration
lagen; the deepest and most dense layer (DLP) is composed
of tightly arranged collagen fibers. The ILP and DLP together
form the vocal ligament. The gelatinous superficial layer of the
lamina propria, together with the squamous epithelium, moves
1.1.7 Innervation
freely over the underlying vocal ligament and muscle to form
the vibrations that produce sound.
The vocal fold mucosa and vocal ligament cover the vocalis Corticobulbar fibers from the cerebral cortex descend through
muscle and extend from the anterior commissure to the vocal the internal capsule and synapse on the motor neurons in the
processes of the arytenoids. The mucosa and vocal ligament nucleus ambiguus. The nucleus ambiguus is the area within the
extend posteriorly to cover the entirety of the vocal process. brainstem (medulla) from which the fibers that will contribute
The posterior third of the endoscopically visualized true vo- to the vagus nerve arise. Lower motor neurons leave the nucleus
cal fold, then, is the aphonatory (respiratory), or cartilaginous ambiguus and travel laterally, exiting the medulla between the
portion, while the anterior two thirds of the endoscopically vi- olive and the pyramid as a series of eight to ten rootlets. These
sualized vocal fold is the phonatory, or membranous portion. rootlets coalesce into a single nerve root, known as the vagus
nerve, which then exits the skull base via the jugular foramen.
The vagus nerve descends in the carotid sheath, giving off three
major branches: the pharyngeal branch, the superior laryngeal
1.1.6 Vasculature
nerve (SLN), and the recurrent laryngeal nerve (RLN). The SLN
supplies sensation to the glottic and supraglottic larynx, as well
The arterial supply to the larynx comes from the superior and as motor input to the cricothyroid muscle, which controls vo-
inferior laryngeal arteries; the venous supply mirrors the ar- cal fold lengthening and pitch. There are some recent anatomic
terial supply. The superior laryngeal artery is a branch of the studies that suggest that the superior aspect of the TA muscle
superior thyroid artery, which arises directly from the external (the ventricularis muscle in the false vocal fold) may have SLN
carotid. The superior laryngeal artery branches from the supe- innervation, which could explain the presence of false vocal
rior thyroid artery at the level of the hyoid bone. This artery fold muscular contraction in cases of RLN transection. The
then courses medially with the internal branch of the superior RLN arises from the vagus nerve in the upper chest and loops
laryngeal nerve and enters the thyrohyoid membrane 1 cm an- under the aortic arch (left) or subclavian artery (right), and
terior and superior to the superior tubercle. The cricothyroid ascends back into the neck, traveling in the tracheoesophageal
artery, one of the major branches of the superior laryngeal ar- groove. The nerve enters the larynx posteriorly, adjacent to the
tery, runs along the inferior surface of the thyroid cartilage to cricothyroid joint (Fig. 1.3). The RLN innervates the ipsilateral
supply its similarly named muscle and joint. Branches of this posterior cricoarytenoid (PCA), the interarytenoid (IA) (an
artery pierce the cricothyroid membrane and ascend on the in- unpaired muscle), and the lateral cricoarytenoid (LCA), and
ternal surface of the thyroid cartilage, making them possible terminates in the thyroarytenoid (TA). Thus, the RLN supplies
targets during the creation of a thyroplasty window. The sec- all of the intrinsic laryngeal muscles with the exception of the
ond major arterial supply to the larynx comes from the inferior cricothyroid muscle (and possibly the ventricularis muscle, as
laryngeal artery, a branch of the inferior thyroid artery. This indicated above). Ipsilateral RLN transection typically results
artery enters the larynx between fibers of the inferior constric- in vocal fold immobility (the ipsilateral CT does not contribute
tor muscle and anastomoses with branches of the superior la- to vocal fold adduction or abduction). It is important to re-
ryngeal artery. member, however, that the interarytenoid muscle is unpaired,
Chapter 1
and contralateral RLN input to the IA may lead to some adduc- interarytenoid muscle, on the other hand, has been shown to
tion of the vocal fold on the paralyzed side. have increased latency of contraction, but regular sustained to-
The RLN also supplies the glottic and subglottic mucosa nicity during prolonged sound production. The cricothyroid
and the myotatic receptors of the laryngeal musculature. seems to have the greatest measurable action with increases in
pitch and volume, while the posterior cricoarytenoid shows its
greatest degree of activation with voluntary deep inhalation
and sniff functions.
1.2 Physiology
Actual phonation is a complex and specialized process that
involves not only brainstem reflexes and the muscular actions
1.2.1 Major Laryngeal Functions:
described above, but high-level cortical control as well. Acces-
Lower Airway Protection,
sory effects such as lung capacity, chest wall compliance, pha-
Respiration, and Phonation
The most primitive of the laryngeal functions is protection of

the airway. In humans, the larynx has evolved into a highly
complex and specialized organ not only for airway protec-
tion and control of respiration, but also for sound and speech
production. Precise control of all of these mechanisms, as well
as exact anatomic structure, is required for normal laryngeal
functioning. The larynx has evolved several important reflexes
for the purpose of airway protection against external stimuli
and foreign bodies. These reflex mechanisms are relayed by the
mucosal (sensory afferent), myotatic, and articular receptors of
the larynx via both the superior and recurrent laryngeal nerves
(Fig. 1.3).
The strongest of the laryngeal reflexes is that of laryngo-
spasm—a response to mechanical stimulation. The larynx has
also evolved reflexes that produce cough, apnea, bradycardia,
and hypotension.
1.2.1.1 Phonation
The most complex and highly specialized of the laryngeal

functions is sound production. The ability to couple phona-
tion with articulation and resonance allows for human speech.
Phonation and precisely how it relates to laryngeal vibration
has undergone many evolving theories over the years. Sound
production requires that several mechanical properties be met.
There must be adequate breath support to produce sufficient
subglottic pressure. There also must be adequate control of the
laryngeal musculature to produce not only glottic closure, but
also the proper length and tension of the vocal folds. Finally,
there must be favorable pliability and vibratory capacity of the
tissues of the vocal folds. Once these conditions are met, sound
is generated from vocal fold vibration.
The detailed contribution, timing, and recruitment of each Fig. 1.5 Schematic coronal section through the vocal folds, demon-
of the above-described laryngeal muscles in the production strating mucosal wave propagation. 1 Vocal folds are completely closed
of sound have been studied. In a fine-wire electromyographic as subglottal pressure (arrow) builds up. 2 Lower lips separate due to
study of human larynges, it was found that the intrinsic laryn- rising subglottal pressure. 3 Only the upper lips are in contact. 4 A puff
geal muscles are not only highly specialized for their particular of air is released as the vocal folds separate completely. 5, 6 As airflow
vector of action, but they are also controlled for the timing of continues, the elastic recoil of the vocal folds, as well as Bernoulli’s
onset of contraction, and the degree of recruitment and fade forces, result in the lower lips of the vocal folds drawing inward. At
during phonation. The thyroarytenoid and the lateral cricoary- the same time, the mucosal wave is propagated superiolaterally. 7 Air-
tenoid muscles have been shown to exhibit burst-like activity flow is reduced, and the lower lips are completely approximated. 8 In
at the onset of phonation (as well as pre-phonatory), with a a zipper-like closure, the free edge of the vocal folds come into contact
measurable degree of fade during sustained phonation. The from inferiorly to superiorly
1 ryngeal, nasal, and oral anatomy, and subsequent mental status

Selected Bibliography
also play a role. The process begins with inhalation and subse-
quent glottal closure. An increase in subglottic pressure follows
until the pressure overcomes the glottal closure force and air 1 Bielamowicza S (2004) Perspectives on medialization laryngo-
is allowed to escape between the vocal folds. Once air passes plasty. Otolaryngol Clin N Am 37:139–160
between the vocal folds, the body-cover concept of phonation 2 Schwenzer V, Dorfl J (1997) The anatomy of the inferior laryn-
takes effect. The body-cover theory describes the wave-like geal nerve. Clin Otolaryngol Allied Sci 22:362–369
motion of the loose mucosa of the vocal folds over the stiffer, 3 Zeitels SM (2000) New procedures for paralytic dysphonia: ad-
more densely organized vocal ligament and vocalis muscle. duction arytenopexy, Gortex medialization laryngoplasty, and
This motion is known as the mucosal wave. The wave begins cricothyroid subluxation. Otolaryngol Clin N Am 33:841–854
infraglottically and is propagated upward to the free edge of 4 Ludlow C (2004) Recent advances in laryngeal sensorimotor
the vocal fold and then laterally over the superior surface (Fig. control for voice, speech, and swallowing. Curr Opinion in Oto-
1.5). Eventually, the inferior edges become reapproximated laryngol 12:160–165
due both to a drop in pressure at the open glottis, and to the 5 Hillel A (2001) The study of laryngeal muscle activity in normal
elastic recoil of the tissues themselves. The closure phase is also human subjects and in patients with laryngeal dystonia using
propagated rostrally. With the vocal folds fully approximated, multiple fine-wire electromyography. Laryngoscope 111:1–47
subglottic pressure may again build and the cycle is repeated 6 Hirano M (1977) Structure and vibratory behavior of the vo-
(Fig. 1.5). cal fold. In: Sawashima M, Cooper F (eds) Dynamic aspects of
speech production. University of Tokyo, Tokyo, Japan, pp 13–30
7 Jones-Bryant N, Woodsen GE, Kaufman K et al (1996) Human
posterior cricoarytenoid muscle compartments: anatomy and
Key Points
mechanics. Arch Otolaryngol Head Neck Surg 122:1331–1336
8 Armstrong WB, Netterville JL (1995) Anatomy of the larynx, tra-
chea, and bronchi. Otolaryngol Clin N Am 28:685
1. The relationship of the surface anatomy of the
9 Mathew OP, Abu-Osba YK, Thach BT (1982) Influence of upper
thyroid and arytenoid cartilages to the internal la-
airway pressure changes in respiratory frequency. Resp Physiol
ryngeal structures are critical to surgical planning
29:223
for laryngeal framework surgery and in-office pro-
10 Hirano M, Kakita Y (1985) Cover-body theory of vocal fold vi-
cedures (i. e., percutaneous laryngeal injections).
bration. Speech science. College-Hill Press, San Diego
2. The primary adductor muscles of the larynx con-
11 Bryant NJ et al (1996) Human posterior cricoarytenoid muscle
sist of:
compartments: anatomy and mechanics. Arch Otolaryngol
■ Lateral cricoarytenoid (LCA)
122:1331
■ Thyroarytenoid (TA)
12 Kempster GB, Larson CR, Distler MK (1988) Effects of electrical
■ Interarytenoid (IA)
stimulation of cricothyroid and thyroarytenoid muscles on voice
3. The main abductor muscle of the larynx is the
fundamental frequency. J Voice 2:221
posterior cricoarytenoid (PCA).
13 Buchthal F, Faaborg-Anderson K (1964) Electromyography of la-
4. The cricothyroid and the TA/LCA muscles control
ryngeal and respiratory muscles: correlation with respiration and
vocal fold length, tension, and vocal frequency.
phonation. Ann Otol Rhino Laryngol 73:118
5. The microanatomy of the vocal folds is complex
14 Gay T et al (1972) Electromyography of intrinsic laryngeal mus-
and consists of the following layers, from superfi-
cles during phonation. Ann Otol 81:401
cial to deep:
15 Kotby MN, Kirchner JA, Kahane JC, Basiouny SE, el-Samaa M
■ Epithelium
(1991) Histo-anatomical structure of the human laryngeal ven-
■ Superficial lamina propria
tricle. Acta Otolaryngol 111:396–402
■ Intermediate lamina propria
16 Sanud, JR, Maranillo E, Leon X et al (1999) An anatomical study
■ Deep lamina propria
of anastomoses between the laryngeal nerves. Laryngoscope
■ Vocalis muscle
109:983–87
6. Reinke’s space is a potential space between the
17 Platzer W (ed) Atlas of topographic and applied human anatomy:
superficial and intermediate layer of the lamina
head and neck, (Pernkopf Anatomy, vol 1, 3rd edn.). Urban &
propria. The intermediate and deep layers of the
Schwarzenberg, Vienna
lamina propria together are referred to as the vo-
cal ligament.
Chapter 2
Principles of Clinical Evaluation

for Voice Disorders 2
2.1 Fundamental and Related Chapters 2.4 History of Present Illness
Please see Chaps. 1, 3, 4, and 5 for further information. The exact nature of the voice patient’s chief complaint should
be reviewed with care. The term hoarseness, for instance, is of-
ten used to describe a variety of symptoms, including loss of
upper register, roughness, pitch instability, difficulty in tran-
2.2 Introduction
sition between singing registers, breathiness, and early vocal
fatigue. Each of these symptoms can have distinct implica-
Many processes resulting in dysphonia affect the vocal folds tions. A rough voice is often associated with abnormalities of
in subtle ways. Objective evidence of vocal pathology is not the free edge of the vocal fold, as seen in laryngitis or mass
always easily discernable on physical examination, even when lesions. Breathiness, on the other hand, results from any condi-
aided with sophisticated diagnostic instruments. It is, therefore, tion preventing full approximation of the vocal folds leading to
essential that the laryngologic exam be supported by a careful excessive loss of air during vocalization. Conditions that may
review of the patient’s medical and vocal history. Perhaps more cause breathiness include vocal fold paralysis/paresis, ankylo-
than any other aspect of otolaryngology, the information de- sis of the cricoarytenoid joint, arytenoid dislocation, vocal fold
rived from a careful review of the patient’s complaints provides scar, vocal fold lesions, and presbylarynx. Raspiness refers to a
an invaluable context within which to interpret the findings on disruption of the vocal harmony that usually reflects pertur-
physical exam and objective voice testing. bation of normal mucosal wave, resulting in instability of the
fundamental frequency. A strained voice is often the result of
hyperfunctional glottal closure. Although primary glottal hy-
perfunction may be the result of neurological impairment or
2.3 Gathering a Patient History
poor vocal technique, this hyperfunction may also represent
a supraglottic compensation for glottal insufficiency. Early vo-
A detailed and directed questionnaire mailed to patients before cal fatigue can similarly result from glottal incompetence sec-
their office visits can have multiple advantages. First, it enables ondary to vocal fold atrophy, vocal fold scar, vocal fold lesions,
patients to record accurately the symptoms they are experienc- or paresis. Inadequate airflow production from the lungs due
ing and to chronicle the history of their problems. It also allows to pulmonary or neuromuscular pathologies can also present
them to document comprehensively and accurately all their with vocal fatigue and/or decreased volume.
medications and dosages. Addresses and telephone numbers Determining the duration of each voice complaint will dis-
of primary care and referring physicians can also be obtained. tinguish acute processes from chronic dysfunction. An acute
This strategy not only increases the efficiency of an office con- process, such as an upper respiratory infection, for instance,
sultation, but it may also allow preliminary differential diagno- may unmask or exacerbate a separate and potentially more
sis to be formulated in certain patients. To this aim, Sataloff has consequential chronic process such as a vocal lesion or a pat-
developed a pair of questionnaires, one directed at the singer, tern of vocal misuse. In addition, upper respiratory infection
another at the professional voice user. Standardized, patient- (URI) symptoms frequently precede the onset of a viral va-
based, voice-related quality of life instruments should also be gal neuropathy. Careful attention to the duration of each of
given to the patient prior to the start of the patient evaluation a patient’s symptoms will thereby allow a complex symptom
(see Sect. 2.9, “Listening to the Voice”). picture to be segregated into its component pathologies. The
Although useful, the questionnaire cannot substitute for a exact time course of the ailment can be particularly helpful in
thoughtful and thorough face-to-face interview with the pa- the evaluation of rapid onset dysphonia. Sudden development
tient. The classic template of history of present illness, past of hoarseness (occurring over seconds or minutes) should, in
medical history, past surgical history, review of systems, medi- fact, always raise suspicion of vocal fold hemorrhage or psy-
cations, and social history provides a reliable framework for chogenic etiologies.
achieving a thorough medical and voice history.
10 Principles of Clinical Evaluation for Voice Disorders
lamina propria. An increase in acid mucopolysaccharides in

2.5 Past Medical History
the submucosal tissues of the vocal fold has been demonstrated
2 in an animal model of induced hypothyroidism. This increase
Salient points regarding the patient’s history include any con- draws fluid into Reinke’s space osmotically, resulting in edema.
dition or medications potentially affecting pulmonary status, The patient may complain of dysphonia, vocal fatigue, muf-
posture, and hydration. Chronic obstructive pulmonary dis- fling of the voice, loss of range, and globus.
ease (COPD) will adversely affect the power supply for the Some women report vocal changes associated with the nor-
patient’s voice. Various rheumatological and musculoskeletal mal menstrual cycle. Most of the adverse effects occur in the
ailments can alter posture, impairing voice quality. Any un- premenstrual phase, a phenomenon known as laryngopathia
derlying acute or chronic inflammatory conditions can signifi- premenstrualis. Slight hoarseness and muffling, vocal fatigue,
cantly affect voice. Allergic disease manifesting as persistent and loss of the highest notes in the voice characterize this vocal
postnasal drip, for instance, will lead to chronic laryngeal in- dysfunction. While relatively uncommon in women without
flammation and vocal fold trauma. Anticholinergic effects of formal vocal training, as many as a third of singers report men-
prescription, as well as over the counter medications, can affect strual related dysphonia. In addition, vocal fold varices often
mucosal hydration and lubrication, and have an adverse effect increase in size before and during menstruation and have been
on vocal fold vibration. associated with an increased incidence of submucosal vocal
It has been estimated that approximately half of patients fold hemorrhages.
presenting with laryngeal and voice disorders have laryn- A few important generalized neurological disorders are
gopharyngeal reflux (LPR) as the primary cause, or as a sig- characterized by specific patterns of dysphonia. Neurologic
nificant etiologic factor. Typical symptoms include chronic or disorders resulting in hypoadduction of the vocal folds will
intermittent dysphonia (especially in the morning), halitosis, present with a weak, breathy voice, vocal fatigue, and an inef-
globus, excessive throat mucous, frequent throat clearing, and fective cough. Such diseases include myasthenia gravis, mus-
chronic cough. A frequent complaint of patients with LPR is cular dystrophy, Parkinson’s disease, Shy-Drager syndrome,
morning hoarseness that improves as the day progresses. This postpolio syndrome, traumatic brain injury, and abductor
pattern is not seen in most other conditions causing dyspho- spasmodic dysphonia. Hyperfunctional neurologic disorders
nia. Surprisingly, most patients with LPR do not present with are associated with a staccato or strained voice. These disor-
heartburn, indigestion, or belching—the cardinal symptoms ders include adductor spasmodic dysphonia, pseudobulbar
of gastroesophageal reflux disease. Consequently, LPR is often palsy, and Huntington’s disease. Other neurologic disorders
referred to as silent reflux. The pervasive but often overlooked present with mixed ad- and abductor components, making the
nature of LPR demands that the physician evaluating the dys- dysphonia more difficult to diagnose. These disorders include
phonic patient consider this diagnosis in almost every case. multiple sclerosis, ataxic (cerebellar) dysphonia, and amyo-
The reflux symptom index (RSI) is a nine-item, patient-based trophic lateral sclerosis. Lastly, vocal tremor can be associated
outcome instrument that is useful in predicting the likelihood with Parkinson’s disease, benign essential tremor, spasmodic
of LPR (Table 2.1) It is easily administered, and highly repro- dysphonia, and palatopharyngeal myoclonus.
ducible. Some degree of reflux is present in normal individuals, Table 2.2 provides an overview of the historical elements
and an RSI of greater than 10 is considered abnormal. of particular importance when obtaining a voice history. Table
Endocrinologic changes can have profound effects on the 2.3 demonstrates symptoms suggestive of specific voice disor-
voice. Many of these changes are reflected in alterations of the ders.
Table 2.1 Reflux Symptom Index
Within the last month, how did the following problems affect you? 0 = No problem
5 = Severe problem
1. Hoarseness or a problem with your voice. 012345
2. Clearing your throat. 012345
3. Excess throat mucus or postnasal drip. 012345
4. Difficulty swallowing food, liquids or pills. 012345
5. Coughing after you ate or after lying down. 012345
6. Breathing difficulties or choking episodes. 012345
7. Troublesome or annoying cough. 012345
8. Sensations of something sticking in your throat or a lump in your throat. 012345
9. Heartburn, chest pain, indigestion, or stomach acid coming up. 012345
From: Belafsky PC, Postma G, Koufman JC (2002) Validity and reliability of the Reflux Symptom Index (RSI). J Voice 16:274–277
Chapter 2 11
creasing the efficiency of vocal fold vibration. Certain foods and

2.6 Past Surgical History
alcohol predispose to gastroesophageal reflux. The deleterious
effects of tobacco smoke on vocal fold are well documented.
A history of prior surgery is important to elicit with laryngeal Both smoke and the heat produced by burning tobacco appear
dysfunction. In addition to questions concerning otolaryngolog- to contribute. Other fumes, such as stage smoke—particularly
ic procedures, any procedure requiring general anesthesia and oil-based ones—can be of significance to vocal performance,
endotracheal intubation—even briefly—should be identified. especially stage actors.
Injuries associated with endotracheal intubation include aryte-
noid dislocation, vocal process granuloma, vocal fold paralysis/
paresis from cuff pressure on the recurrent laryngeal nerves,
2.8 Occupational History
posterior glottic stenosis, and interarytenoid adhesions.
Voice disorders affecting vocal professionals have considerably

greater impact on function than those affecting nonprofes-
2.7 Social History
sional voice users. Koufman and Isaacson describe four levels
of vocal usage based on occupation. Level I refers to the elite
The voice patient’s personal habits should be detailed. Even vocal performer such as singers and actors. Level II describes
moderate consumption of alcohol is detrimental to the voice, professional voice users such as lecturers and clergy. Level III
through dehydration and effects on judgment. Caffeine, a di- patients are nonvocal professionals such as teachers and law-
uretic, can affect the voice by thickening secretions and de- yers and level IV users are nonvocal nonprofessionals. Vocal
needs and function vary widely among these groups. Although
the description of vocal usage is useful as a general categoriza-
Table 2.2 Special topics to include within a voice history tion, evaluation and therapy must be individually tailored to a
person’s specific voice use setting and demands.
Upper respiratory infection
Endotracheal intubation
Time course
Trauma 2.9 Listening to the Voice
Voice usage/demands
Profession A critical part of the clinical evaluation is a careful subjective
Vocal abuse assessment of the patient’s voice. While taking the history, one
Tobacco, alcohol, and drug use should evaluate the quality of the patient’s speaking voice. The
Dietary habits pitch of the voice and the rate and rhythm of speech should be
Foods precipitating reflux esophagitis noted. Posture and respiratory rate are important and should
Hydration be noted during the encounter. Facial movements, especially
Allergy history around the mouth, as well as neck and shoulder movements
Environmental history should be examined for evidence of excess tension, tremors, or
Climate spasms. Consideration should be given to efficiency of breath
Heating and cooling units support during speech. Evidence of excess rate, volume, or ten-
Table 2.3 Symptoms suggestive of specific voice disorders
Symptoms Associated diagnoses

Breathiness Vocal fold paralysis (unilateral), vocal fold mass lesion
Vocal fatigue Vocal fold atrophy or paralysis, neurogenic dysphonia
Choking Vocal fold paralysis, CVA
Odynophonia Vocal fold granuloma, MTD
Paralaryngeal pain or tension Muscular tension dysphonia (primary or secondary)
Laryngospasm LPR, gastroesophageal reflux disease, nerve injury
Stridor Bilateral vocal fold paralysis, laryngeal stenosis, paradoxical vocal fold motion
Vocal tremor Parkinson’s disease, spasmodic dysphonia, benign essential tremor, myoclonus
Velopharyngeal insufficiency Myasthenia gravis, ALS, vagal paralysis
Globus LPR, neurologic disease, MTD
CVA cerebrovascular accident, MTD muscle tension dysphonia, ALS amyotrophic lateral sclerosis, LPR laryngopharyngeal reflux
sion during speech may indicate vocal abuse, which is highly Special Interest Division 3 of the American Speech-Language-
prevalent in the dysphonic population. Hearing Association as a standardized tool for assessment of
2 After careful patient observation, formal vocal testing may auditory–perceptual attributes of voice. Six salient features—
proceed by having the patient perform several different vocal overall dysphonia severity, roughness, breathiness, strain,
tasks. After hearing normal speech, the patient may be asked to pitch, and loudness—are rated by trained listeners (SLPs and
alter his or her type of vocal output, such as hum, sing, whisper, laryngologists) using a 100-mm visual analogue scale for each
or yell. Also, the patient should alter pitch, perform glissando, parameter, with the option for additional user-defined param-
and use rapid alternating speech. Such vocal tasks will help the eters.
listener gain insight into how the vocal pathology is affecting
the different aspects of the patient’s speech, and may provide
insight into the nature of the vocal dysfunction.
2.11 Quality-of-Life Questionnaires
Additionally, various words or sounds call upon the coor-
dination of different phonatory elements. Asking the patient
to recite certain phrases will assist the clinician in character- Much work has been performed to codify and measure patient
izing the disorder. For instance, the word “taxi” can be used self-perception of vocal dysfunction in the form of standard-
to elicit signs of abductor spasmodic dysphonia. The phoneme ized questionnaires and other metrics. The voice handicap
“kaa” requires good palatal lift and closure and “maa” requires index (VHI) is a quality-of-life questionnaire specific to voice
mouth closure. The /m/ and /n/ phonemes require good nasal disorders, which has excellent reliability and reproducibility.
resonance and are useful for testing hyper- and hyponasality. The VHI assessment is a subjective patient-based question-
The rainbow passage (Table 2.4), which is composed of every naire composed of 30 questions. Rosen et al. have introduced
phoneme in the English language, is used as a standardized an abridged version composed of ten questions, the VHI-10
method of recording voice in order to track clinical progress. (Table 2.6). This instrument is both easily self-administered
and scored quickly at the time of evaluation while preserving
the original VHI’s utility and validity.
Because vocal pathologies have different levels of handicap
2.10 Perceptual Analysis
to different individuals, these questionnaires are extremely
important in understanding the personal impact of these dis-
To evaluate the voice, the “trained” ear remains the most disorders on daily activities. For instance, vocal nodules that are
cerning instrument. Nonetheless, a standardized objective, devastating to a professional voice user may only be a minor
instrument to characterize voice remains an important goal inconvenience to a non-professional. The Voice-related Qual-
of voice science. To this end, Hirano proposed the GRBAS ity of Life (VRQOL) instrument has been validated and found
scale—a widely used perceptual rating instrument used by to be useful (see Bibliography). Voice-related, patient-based
speech pathologists and laryngologists for the evaluation of surveys are helpful in judging quickly and accurately the pa-
voice quality in clinical settings. This scale is a subjective per- tient’s perception of their degree of voice handicap.
ceptual evaluation of five vocal characteristics assigned a value
between 0 to 3, where 0 is normal, and 3 is extreme. The five el-
ements are grade (G), a description of the degree of hoarseness,
2.12 Professional Speaking/Singing Voice
roughness (R), the perceptual irregularity of vocal fold vibra-
tions, usually the result of a change in fundamental frequency
or amplitude of vibration. Breathiness (B), or the assessment of A comprehensive and somewhat adapted historical background
air leakage through the glottis, is the third component of the is necessary in the evaluation of the singing voice. The date of
scale. Aesthenic (A) voice denotes weakness and lack of power. the next important performance, for instance, will determine
Strain (S) reflects a perception of vocal hyperfunction. whether management of the voice problem can be conserva-
Another widely used auditory-perceptual evaluation of dys- tive—designed to assure the long-term protection of the lar-
phonia is the Consensus Auditory-Perceptual Evaluation-Voice ynx—or, rather, whether more urgent intervention is needed
(CAPE-V) (Table 2.5). This rating scale was recently created by in view of a impending important engagement. The length
Table 2.4 Rainbow passage
When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of white
light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends appar-
ently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it.
When a man looks for something beyond his reach, his friends say he is looking for the pot of gold at the end of the rainbow.
Passage reprinted from: Fairbanks G (1960) Voice and articulation handbook, p 127. Copyright 1960 by Harper Collins Publishers, Inc.
Chapter 2 13
Table 2.5 Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)
of time a singer has been performing is also important, espe- This is especially true if stage construction is underway dur-
cially if his or her performance career predates their formal ing rehearsals. A history of recent or frequent airplane travel
vocal training. Undesirable singing techniques developed by suggests an alternate source of mucosal irritation. Cabin air is
amateur singers are particularly difficult to modify. Moreover, dry, usually at 5% or less humidity. Singers must therefore take
intermittent training, or training at the hand of multiple teach- care to maintain adequate laryngeal moisture by maintaining
ers/coaches can often result in an incompatible amalgamation nasal breathing and constant hydration. Finally, exposure to
of techniques requiring significant time and expert instruc- stage smoke presents a unique problem, most prevalent among
tion to rectify. The settings in which the singer performs are stage actors. Most stage smoke preparations, especially oil-
of importance. Allergies to dust and mold can become major based ones, can result in mucosal irritation, allergy, and bron-
factors in older concert halls where curtains, backstage trap- chospasm resulting in the commonly encountered complex of
pings, and cramped dressing room quarters are rarely cleaned. hoarseness, vocal “tickle,” and vocal fatigue.
Table 2.6 Voice Handicap Index 10
My voice makes it difficult for people to hear me. 01234

2 People have difficulty understanding me in a noisy room. 01234
My voice difficulties restrict personal and social life. 01234
I feel left out of conversations because of my voice. 01234
My voice problem causes me to lose income. 01234
I feel as though I have to strain to produce voice. 01234
The clarity of my voice is unpredictable. 01234
My voice problem upsets me. 01234
My voice makes me feel handicapped. 01234
People ask, “What’s wrong with your voice?” 01234
From: Rosen CA, Lee AS, Osborne J, Zullo T, Murry T (2004) Development and validation of the voice handicap index-10 (VHI-10) Laryngo-
scope 114:1549–1556
6 Silverman EM, Zimmer CH (1978) Effect of the menstrual cycle

Key Points
on voice quality. Arch Otolaryngol Head Neck Surg 104:7–10
7 Courey MS, Postma GN (1996) Microvascular lesions of the true
vocal folds. Curr Opin Otolaryngol Head Neck Surg 4:134
■ A successful surgical outcome is dependent upon
8 Sataloff RT (1995) Vocal fold hemorrhage: diagnosis and treat-
proper clinical evaluation of the patient’s voice dis-
ment. NATS J May/June:45
order. It therefore behooves the serious practitio-
9 Smith ME, Ramig LO (1995) Neurological disorders and the
ner of laryngology to focus not only on his or her
voice. In: Rubin JS, Sataloff RT, Korovin GS et al (eds) Diagno-
surgical skills, but also on evaluative and percep-
sis and treatment of voice disorders. Igaku-Shoin, New York, pp
tual skills. This will ensure proper patient selection
203–219
and make for improved surgical outcomes.
10 Koufman JA, Isaacson G (1991) The spectrum of vocal dysfunc-
■ Careful history taking and clinical evaluation are
tion. Otolaryngol Clin North Am 24:985–988
important tools in the diagnostic evaluation of the
11 Cooper M (1973) Modern trends in voice rehabilitation. Charles
voice patient.
C. Thomas Springfield, Ill.
■ When caring for patients with voice disorders, the
12 Bassich CJ, Ludlow DL (1986) The use of perceptual methods
clinician should pay particular attention to the
by new clinicians for assessing voice quality. J Speech Hear Dis
level of voice use, the importance of the voice to
51:125
the patient, and the impact of the voice disorder
13 Dejonckere PH et al (1993) Perceptual evaluation of dysphonia:
on their quality of life.
reliability and relevance, Folia Phoniatr (Base1) 45:76
■ Clinical outcome instruments such as the Reflux
14 Kreiman J et al (1993) Perceptual evaluation of voice quality: re-
Symptom Index (RSI) and the Voice Handicap
view, tutorial, and a framework for future research, J Speech Hear
Index 10 (VHI-10) are extremely useful tools for the
Res 36:21
evaluation of vocal complaints.
15 Hirano M (1981) Clinical examination of the voice. Springer,
Berlin, Heidelberg, New York
16 Voice disorders: Consensus Auditory-Perceptual Evaluation of
Voice (CAPE-V). American Speech-Language-Hearing Associa-
tion Special Interest Division 3: Voice and Voice Disorders. 2003.
1 Sataloff RT (1997) Professional voice—the science and art of Available at: http://www.asha.org
clinical care, 2nd edn. Singular, San Diego 17 Benninger MS, Ahuja AS, Gardner G, Grywalski C (1998) As-
2 Koufman JA, Amin MR, Panetti M, Prevalence of reflux in 113 sessing outcomes for dysphonic patients. J Voice 12:540–550
consecutive patients with laryngeal and voice disorders (2000) 18 Jacobson GH, Johnson A, Grywalski C et al (1997) The Voice
Otolaryngol Head Neck Surg 123:385–8. Erratum in: Otolaryn- handicap index (VHI): development and validation. Am J Speech
gol Head Neck Surg 124:104 Lang Pathol 6:66–70
3 Koufman JA (1991) The otolaryngologic manifestations of gas- 19 Hogikyan ND, Sethuraman G (1999) Validation of an instru-
troesophageal reflux disease. Laryngoscope 101(Suppl.)53:1–78 ment to measure voice-related quality of life (V-RQOL). J Voice
4 Belafsky PC, Postma GN, Koufman JA (2002) Validity and reli- 13:557–569
ability of the reflux symptom index (RSI). J Voice 16:274–277 20 Ma EP-M, Yiu EM-L (2001) Voice activity and participation
5 Ritter FN (1973) Endocrinology. In: Paparella M, Shumrick D profile: assessing the impact of voice disorders on daily living. J
(eds) Otolaryngology. Saunders, Philadelphia, pp 727–734 Speech Lang Hear Res 44:511–524
Chapter 2 15
21 Carding PN, Horsley IA, Docherty GD (1999) Measuring the ef- 24 Jacobson BH, Johnson A, Grywalsky C et al (1997) The Voice
fectiveness of voice therapy in a group of forty-five patients with Handicap Index (VHI): development and validation. Am J
non-organic dysphonia. J Voice 13:76–113 Speech Lang Pathol 6:66–70
22 Deary IJ, Wilson JA, Carding PN et al (2003) VoiSS, a patient- 25 Rosen CA, Lee AS, Osborne J, Zullo T, Murray T (2004) Develop-
derived voice symptom scale. J Psychosometr Res 54:483–489 ment and validation of the Voice Handicap Index-10. Laryngo-
23 Hogikyan ND, Rosen CA (2002) A review of outcome measure- scope 114:1549–1556
ments for voice disorders. Otol Head Neck Surg 126:562–572
Chapter 3
Videostroboscopy
and Dynamic Voice Evaluation 3
with Flexible Laryngoscopy
Stroboscopy helps elucidate specific lesions of the vocal folds,

3.1 Fundamental and Related Chapters
especially as they relate to closure pattern for exophytic lesions
and defects of the lamina propria such as seen in adynamic
Please see Chaps. 1, 2, 4, and 5 for further information. segments of the vocal fold, vocal fold scar, and sulcus vocalis.
Vocal fold closure pattern is typically described as the global
overall pattern of vocal fold closure, as seen during the major-
ity of the examination specifically at modal pitch and intensity
3.2 Introduction
of vowel prolongation. The most commonly cited and utilized
closure patterns include complete, incomplete, hourglass, an-
Visualization of the larynx and specifically the vocal folds is terior glottic gap, and excessive posterior glottic gap (Fig. 3.2).
paramount for the evaluation and care of patients with voice Mucosal wave as seen during stroboscopy refers to a rip-
disorders. There are a variety of methods used for this visualiza- pling motion traveling over the vocal fold and within the vocal
tion, ranging from indirect mirror laryngoscopy to high-speed fold mucosa. The wave is propagated from the subglottic area
photography. The most common and relevant clinical tools for and travels from underneath the vocal fold along the free edge,
modern-day voice evaluation and care include stroboscopic then over the superior surface of the vocal fold and is damp-
visualization of vocal fold vibration and dynamic voice evalu- ened in the area of the ventricle. This mucosal wave activity is
ation with flexible laryngoscopy. These two techniques when crucial for assessing the pliability and functional characteris-
used in a complimentary fashion can provide the clinician with tics of the lamina propria of the vocal folds. Areas of dimin-
detailed information on intricate vocal fold vibratory activity ished mucosal wave represent loss of pliability or viscoelastic-
and phonatory and functional use of the entire vocal tract. This ity of the vocal fold lamina propria and are an important aspect
chapter focuses on these two main clinical methods. of voice evaluation. Mucosal wave activity should be assessed
at a variety of phonatory tasks, specifically at low, medium, and
high pitch and different levels of intensity.
The duration of vocal fold closure is also an important clini-
3.3 Surgical Indications
cal assessment parameter. At modal pitch and intensity, vocal
and Contraindications
fold vibratory closure should occur approximately half of the
vibratory cycle. This can be measured in a detailed fashion us-
Stroboscopy utilizes a method of “shuttering,” or synchronized
illumination of the vocal folds during vocal fold vibration (Fig.
3.1). This provides “pseudo” slow motion visualization of vocal
fold vibration. Real-time vocal fold vibration is too rapid to
visualize with the unaided eye. The stroboscopic light source
illumination provides representative images from the entire vi-
bratory cycle. A periodic or nearly periodic vocal fold vibratory
activity is required for stroboscopy to be successful. It is impor-
tant to note that stroboscopy can be done through any type of
visualization instrument including flexible laryngoscopy and
rigid perioral laryngoscopy. Stroboscopy is strictly the light
source and not the actual equipment used for visualization of
the vocal folds. (i. e., flexible laryngoscopy or rigid telescope).
The most common vocal fold vibratory characteristics that
stroboscopy allows one to view are:
■ Vocal fold closure (pattern and duration)
■ Mucosal wave movement (propagation)
■ Symmetry of vibration
■ Amplitude of vocal fold vibration
Fig. 3.1 “Representative” set of images from stroboscopy depicting
■ Periodicity
“one” vibratory cycle
18 Videostroboscopy – Flexible Laryngoscopy
ing electroglottography but can also be estimated using frame- ments of the vocal fold with poor vibratory characteristics due
by-frame review of the recorded stroboscopic images. to scar, subtle lesions, loss of lamina propria tissue or sulcus
Vocal fold vibration symmetry during stroboscopy is judged vocalis (see Chap. 23, “Sulcus Vocalis and Vocal Fold Scar”).
by comparing the vocal folds’ vibratory activity to one another. Stroboscopy to assess vocal fold vibratory activity should
3 The vibration of one vocal fold should be a mirror image of the be done using a fairly consistent assessment protocol. First, it
contralateral fold. is essential to identify that the patient has a periodic or nearly
The degree of vocal fold amplitude (horizontal excursion periodic signal. A typical stroboscopy examination protocol
from midline) during vocal fold vibration as seen during stro- includes:
boscopy is an important assessment tool and involves both
■ Modal voice (most comfortable pitch and intensity)
the comparative as well as overall subjective assessment of
■ Low pitch (soft and loud to assess maximum pliability)
the amount of amplitude of each vocal fold during vocal fold
■ High pitch, soft intensity phonatory task
vibration (Fig. 3.3). Of course, amplitude and closure are two
stroboscopy parameters that are directly affected by the voice
intensity and pitch during the stroboscopic examination and The latter is extremely helpful for identifying subtle lesions of
these factors must be constantly monitored and taken into the vocal fold as well as assessing abnormalities associated with
consideration when assessing these parameters. For example, vocal fold pliability and vocal fold vibratory activities. The low
at high pitches both the amplitude and mucosal wave decrease pitch-loud task is helpful not only for assessing overall pliabil-
as compared to lower pitches. ity, but also for patients with the most aperiodic voice. When
Periodicity describes the regularity of vocal fold vibra- performing stroboscopy, the vocal fold vibratory activity and
tion. Periodicity is based on the regularity of successive cycles characteristics should be first compared internally (to each
of vibration. Even though symmetry and periodicity may be other), and then compared to the examiners experiential da-
thought to assess similar behavior, in fact, vocal folds can have tabase and most importantly correlated with the amount and
distinctly different amplitude and symmetrical activity and still nature of dysphonia of the patient. There should be a good cor-
be quite periodic. The converse is also true where vocal folds relation from an auditory and visual perceptual basis. If this is
can demonstrate aperiodic activity with normal and symmet- not the case, then a repeat examination or careful examination
ric amplitude (as often seen with vocal fold paresis). of other factors should be undertaken.
Stroboscopy of the vocal folds is helpful for visualization of
a variety of vocal fold lesions, which are discussed in detail in
Chap. 4, “Pathological Conditions of the Vocal Cords.” Stro-
3.4 Dynamic Voice Assessment
boscopy is also extremely important for visualization of seg-
with Flexible Laryngoscopy
Flexible laryngoscopy is an essential evaluation technique for

voice disorders-related “functional” problems such as muscle
tension dysphonia, paradoxical vocal fold motion disorder and
Fig. 3.2 Different vocal fold closure patterns Fig. 3.3 Vocal fold amplitude
Chapter 3 19
functional aphonia, neurologic voice disorders (spasmodic dys- Table 3.1 DVA tasks, findings, and correlated diagnoses: examination
phonia, essential tremor, etc.), and vocal fold paresis. Dynamic protocol—tasks
voice assessment with flexible laryngoscopy evaluates multiple
parameters associated with phonation done in a dynamic and Velum
“most natural” setting. Equipment required includes nasal Sustained /ee/
speculum, decongestant and anesthetic for the nasal cavity, /koka kola/
flexible laryngoscopy, and illumination light source(s) (contin- Base of tongue
uous halogen and preferably stroboscopy). This examination is Evaluation of symmetry and mucosa
done in a stepwise fashion, examining each section of the vocal Larynx
tract which is outlined below from an anatomic and a physi- Quiet respiration
ologic perspective (at rest and then in activation). The specific Sustained /ee/—comfortable pitch
areas of activation include vegetative functions and phonation. Sustained /ee/—low and high pitch
The subregions of the dynamic voice assessment include naso- /ee/ /ee/ /ee/ (with a breath between each “hee”)
pharynx, base of tongue, larynx (global), and the vocal folds. “We were away a year ago.”
At each one of these specific subportions of the dynamic voice “We were away a year ago.”—comfortable pitch
assessment, specific tasks are elicited from the patient to look Example of connected speech (Ask,
for different pathologies in the area and confirm or rule out a “What did you do yesterday?”)
variety of disorders (Table 3.1). Sing “Happy Birthday”
Cough
Laugh
3.4.1 Nasopharynx
1. Patient task: rest, sustained phonation (/ee/) and speech

(/koka kola/) and prolonged fricative /s/
2. Parameters of evaluation: nasal disease, masses of the naso-
3.4.4 Vocal Fold (Focal)
pharynx, tremor of the soft palate (rest and activation) and
velopharyngeal incompetence (VPI)
3. Pathology: velopharyngeal incompetence, vocal tremor, 1. Patient task: respiration, sustained phonation and alternat-
sinonasal disease, (infectious or allergic) nasopharyngeal ing speech and respiration (see Table 3.1)
neoplasms 2. Parameters of evaluation: vocal fold lesions, glottal insuf-
ficiency and tremor
3. Pathology: focal vocal fold lesions (polyp, nodules, etc.)
cancer, vocal fold atrophy, vocal field paralysis and vocal
3.4.2 Base of Tongue
fold paresis
1. Patient task: rest and tongue protrusion

2. Parameters of evaluation: tremor, fasciculations (ALS), tu-
3.5 Recording of Laryngeal Examination
mors, infections
3. Pathology: essential tremor of the vocal tract, amyotrophic
lateral sclerosis (ALS), neoplasm (benign and malignant) It is highly recommended but not absolutely necessary that
and infection the stroboscopy and/or dynamic voice evaluation be recorded.
The two most common methods of recording portions or all of
these examinations are with either still photography or video
recording. The advantages of recording all or portions of the
3.4.3 Larynx (Global)
laryngeal examinations include:
■ Longitudinal comparison
1. Patient task: quiet respiration, alternating sustained phona-
■ Preoperative planning
tion and respiration (hee-hee-hee, with a breath between each
■ Patient education
“hee”) and connected speech (“We were away a year ago.”)
■ Medical/legal uses
2. Parameters of evaluation: vocal fold mobility and synchro-
ny of mobility Paradoxical vocal fold motion, supraglottic
constriction associated with phonation, and global laryn- Further justification and use of a video recording include the
geal tremor ability to record an audio track in conjunction with the video
3. Pathology: paradoxical vocal fold motion disorder, primary examination. Both audio and video examination can be ex-
muscle tension dysphonia, secondary muscle tension dys- tremely helpful for all of the above-mentioned reasons; es-
phonia, vocal tremor, vocal fold paralysis, vocal fold paresis, pecially in a court of law. It is essential to have a baseline or
as well as pyriform/vallecular lesions, LPR preoperative audio and/or voice recording prior to and after
20 Videostroboscopy – Flexible Laryngoscopy
elective surgical procedures. This is analogous to the docu- ■ The combination of stroboscopy and dynamic
mentation procedures for cosmetic surgical procedures. Video
voice assessment with flexible laryngoscopy allows
recordings of the vibratory parameters of the vocal fold are also
the clinician to correlate the patient’s voice symp-
very helpful to refer to when surgically resecting a lesion.
toms, related physical exam abnormal findings,
3 craft an accurate diagnosis and form a successful
treatment plan.
Key Points
■ Stroboscopy and dynamic voice assessment (DVA)
with flexible laryngoscopy are essential aspects of
1 Hirano M, Bless DM (1993) Videostroboscopic examination of
a voice evaluation and care.
the larynx. Singular, San Diego
■ Strobe and DVA are complementary and should
2 Stasney CR (1996) Atlas of dynamic laryngeal pathology. Singu-
not be viewed in isolation.
lar, San Diego
■ The dynamic voice assessment and evaluation
3 Cornut G, Bouchayer M. Assessing dysphonia: the role of video-
allows for a natural in vivo evaluation of the entire
stroboscopy. Five videocassettes, 254 min
vocal tract during rest, vegetative activities, and
4 Rosen CA (2005) Stroboscopy as a research instrument: develop-
phonation (connected and sustained), and stro-
ment of a perceptual evaluation tool. Laryngoscope 115:423–428
boscopy allows the examiner insight into key vocal
5 Roehm PC, Rosen C (2004) Dynamic voice assessment using
fold vibratory activity, specifically the physiologic
flexible laryngoscopy—how I do it: a targeted problem and its
and pathophysiologic activities related to the
solution. Am J Otolaryngol 25:138–141
patient’s dysphonia.
Chapter 4
Pathological Conditions
of the Vocal Fold 4
monary involvement, and alcohol exposure increase the risk of
RRP malignant transformation. It cannot be overemphasized
that the chance of curing patients with RRP using surgical ex-
Please see Chaps. 2 and 3 for further information. cision alone is low; likewise, there is no evidence that a more
aggressive operation will increase the patient’s long-term con-
trol of his or her disease. The surgical philosophical approach
for RRP should be to: (1) maintain a patent airway without us-
4.2 Introduction
ing a tracheotomy, (2) optimize functional results with respect
to voice and swallowing, and (3) minimize chance of operative
The variety of pathologic conditions that occur within the vocal complications and sequelae such as glottic webbing and vocal
fold can be separated into categories based on their anatomical fold scar formation.
location. The chapter is divided among epithelial pathology of
the vocal folds, benign midmembranous lesions, and miscel-
laneous vocal fold pathology. A brief overview and discussion
4.3.2 Leukoplakia of the Vocal Fold
of the key points of each of these vocal fold lesions, especially
as they relate to the surgical treatment is included. It should
be stressed that with the exclusion of carcinoma and recurrent Abnormal epithelial hypertrophy or dysplasia of the vocal folds
respiratory papilloma of the vocal folds, most of the vocal fold can be manifested as redundancy of the epithelial or keratotic
lesions are benign and in general should be managed with a layers of the vocal folds resulting in hyperkeratosis, parakerato-
conservative approach that involves maximizing all nonsur- sis, and is clinically referred to as leukoplakia (Fig. 4.2). An im-
gical treatment methods first, and then only proceeding with portant differentiation of this pathology relates to the anatomic
surgical treatment if key functional issues (i. e., voice quality structure of the cells involved in the abnormal epithelium. Of-
and vocal function) are still persistent. ten these cells can become dysplastic and are thought to be a
precursor for malignancy. However, many patients who suffer
from keratosis of the vocal fold show no dysplasia of these le-
sions and are strictly burdened by the repetitive regrowth of a
4.3 Epithelial Pathology
hyperkeratotic epithelial covering at various locations of the
of the Vocal Folds
4.3.1 Recurrent Respiratory

Papillomatosis of the Larynx
Recurrent respiratory papillomatosis of the larynx is an epithe-

lial growth of the larynx most commonly seen at the level of
the vocal folds (Fig. 4.1). These growths are a direct response
to a human papilloma virus infection and tend to be recurrent
in nature. The most common human papilloma virus types in-
volved with RRP of the larynx are HPV types 6 and 11. These
recurrent benign lesions grow most significantly at epithelial
transition sites, such as where pseudostratified columnar and
stratified squamous are juxtaposed.
Any time a new epithelial transition site is created in a pa-
tient who is infected with the human papilloma virus, there is
a high risk of a new papillomatous disease growth at that site.
This is frequently demonstrated when a tracheotomy is per-
formed on a patient with recurrent respiratory papillomatosis.
Malignant transformation of these types of HPV infection are
extremely rare, and historical experience has demonstrated
that external beam radiation therapy, tobacco exposure, pul- Fig. 4.1 Recurrent respiratory papillomatosis, bilateral
22 Pathological Conditions of the Vocal Fold
vocal folds. These lesions can be singular in nature or they can

be multiple and diffuse throughout the vocal folds and aryte-
noid cartilages. Given that the risk of transformation of this
leukoplakic biologic activity into a malignancy is present (sta-
tistically < 10%), these patients require careful monitoring and
a complete surgical excision of any suspicious leukoplakic le-
4 sion. Suspected risk factors for keratosis include viral infection,
LPR, and vocal fold phonotrauma (primary or secondary to
glottal insufficiency). It is equally important to remember that
the majority of patients with keratosis of the vocal folds will
not develop a malignancy and most likely will have recurrent
lesions in the future; thus, principles of conservative excision
and patient observation with longitudinal photo documenta-
tion are essential to the care of this patient group. There is no
role for external beam radiation for these patients.
4.3.3 Dysplasia–Carcinoma in Situ

Fig. 4.2 Keratosis of the left vocal fold
of the Vocal Folds
Dysplasia or carcinoma in situ of the vocal folds represents a

demonstrable change of the normal epithelial cellular structure
and is thought to be a precursor toward development of ma-
lignancy of the vocal folds (Fig. 4.3). Specifically, dysplasia is
graded on the severity of the abnormal morphology of the epi-
thelial cells. Carcinoma in situ refers to carcinomatous trans-
formation without basal membrane penetration. Once abnor-
mal epithelial cells have breached the basement membrane of
the epithelium, the condition is then defined as a carcinoma
or microinvasive carcinoma of the vocal folds. Complete exci-
sion of dysplasia and/or carcinoma in situ of the vocal folds is
crucial to preventing more serious and significant problems of
carcinoma of the vocal folds.
4.3.4 Carcinoma of the Vocal Fold

Fig. 4.3 Dysplasia–carcinoma in situ of the right vocal fold
Carcinoma of the vocal fold represents a malignant invasion
of the epithelial cells into the vocal fold, lamina propria, and
beyond, depending on the severity of the invasion. (Fig. 4.4)
Staging of vocal fold cancer is based on the location(s) of the
disease as well as the degree of invasion and subsequent limita-
tion of vocal fold motion due to the cancer invasion. Early T1
and T2 stage cancer of the vocal folds can be successfully treat-
ed with surgical excision and/or radiation therapy. T1 vocal
cord carcinoma has a 5-year survival of 90–98% when treated
with either one of these modalities (see Chap. 30, “Carcinoma
of the Vocal Fold”).
Fig. 4.4 Carcinoma of the left vocal fold

Chapter 4 23
improve without surgery (i. e., a large, pedunculated polyp). In

4.4 Benign Diseases of the Vocal
these instances, a short period of both reduced voice use and
Fold Lamina Propria
voice therapy is implemented (2–3 weeks), followed by a re-
evaluation of the lesion(s) and patient’s vocal functional abili-
4.4.1 Overview of Midmembranous
ties (see Chap. 8, “Timing, Planning, and Decision Making for
Vocal Fold Lesions
Laryngeal Surgery”).
Midmembranous lesions of the vocal fold are abnormalities of

lamina propria of the vocal fold, with minimal or no changes of
4.4.3 Vocal Fold Nodules
the overlying epithelium. These lesions are extremely common
causes of voice disorders and often require surgical therapy.
Significant confusion and debate exists regarding the nomen- Vocal fold nodules are benign, midmembranous vocal fold le-
clature and classification of these lesions. Unfortunately, visu- sions involving most likely the most superficial aspect of the
alization alone of these lesions does not properly stratify and lamina propria as well as the basement membrane zone of the
classify these lesions, and thus a multidimensional system has vocal fold epithelium (Fig. 4.5). They are thought to be “cal-
been developed and is required to classify properly the mid- luses” of the vocal folds and are always bilateral and fairly
membranous vocal fold lesions. It is important for this clas- symmetric. Vocal fold nodules are seen almost exclusively in
sification to be exact, given that clinical outcomes and patient females in adults, and both genders in children. These lesions
prognosis, and surgical treatment with different midmem- by definition respond to a combination of voice rest and voice
branous vocal fold lesions differ significantly. This book uses therapy, when the patient is compliant and the voice therapy is
a classification system utilizing four commonly used clinical done in an appropriate fashion. Stroboscopic behavior of vocal
modalities to differentiate seven distinct benign midmembra- fold nodules typically demonstrates an hourglass closure pat-
nous vocal fold lesions. These classification methods include tern and normal or minimally reduced mucosal wave vibratory
(1) morphology (midmembranous vocal fold lesion), (2) char- activity (see Chap. 16, “Vocal Cord Nodules”).
acteristics of the mucosa wave of the lesion and surrounding
areas as seen on stroboscopy (minimal–normal versus signif-
icant impairment), (3) response of the lesion in the form of
4.4.4 Vocal Fold Cyst (Subepithelial)
resolution or reduction in size to voice rest/voice therapy, and
(4) intraoperative findings. The latter includes location of the
pathology (subepithelial or near the vocal ligament) and the A subepithelial vocal fold cyst represents an encapsulated le-
physical characteristics of the lesion, presence or absence of a sion within the superficial aspect of the lamina propria, typi-
capsule wall, physical features, and nature of the pathology. cally found in the midmembranous vocal fold (Fig. 4.6). The
stroboscopic pattern of a subepithelial vocal fold cyst is an
hourglass closure pattern, with normal to minimal disrup-
tion of the mucosal wave vibratory activity (depending on
4.4.2 Approach to Midmembranous
Vocal Fold Lesions
In most instances, patients with midmembranous vocal fold le-

sions have relatively normal epithelium overlying their patho-
logic process, and thus, the concern for cancer is extremely
low. Often these lesions respond extremely well to nonsurgical
treatment methods such as voice therapy and treatment of co-
morbid medical problems. This approach should be taken for
most patients with midmembranous vocal fold lesions caus-
ing significant dysphonia (see Chap. 7, “Medical Treatment
of Voice Disorders”). After the implementation and adequate
treatment time of these nonsurgical treatment methods, the
patient should have a repeat comprehensive voice evaluation
to determine the amount of improvement and to determine
if there are any residual functional limitations to their voice
use and demands. If these functional limitations are signifi-
cant to the patient and can be reasonably projected to improve
with surgical excision of the vocal fold lesion(s), then pho-
nomicrosurgery is indicated. The decision making on initial
treatment(s), duration and timing of surgery is complex and
does not lend to formulaic approaches. In general, patients
should be treated with nonsurgical therapy before surgery.
Exceptions include distinct lesions that are hightly unlikely to Fig. 4.5 Vocal fold nodules (bilateral)
rest or voice therapy, and the prognosis for prompt recovery of

the voice after surgical excision is less when compared with a
vocal fold polyp or subepithelial cyst. The surgical approach to
this lesion involves a microflap (see Chaps. 10 and 17).
4 4.4.6 Vocal Fold Polyp
A vocal fold polyp is a pathologic process of the lamina propria

that involves typically an exophytic or pedunculated lesion of
the midmembranous vocal fold that can be unilateral or bilat-
eral (Fig. 4.8). The stroboscopic pattern of a vocal fold polyp
shows an hourglass closure pattern with normal or minimal
reduction of the vibratory activity of the mucosa. A vocal fold
polyp does not respond to voice therapy and rest (by defini-
tion), and intraoperative exploration reveals a focal accumula-
Fig. 4.6 Cyst (subepithelial) of left vocal fold tion of a gelatinous material, often under a severely thin and
atrophic epithelium. Surgical excision of the vocal fold lesion
can be done through a microflap approach or truncation of the
vocal fold lesion (see Chap. 10, “Principles of Phonomicrosur-
gery” and 15, “Vocal Fold Polyp”).
4.4.7 Fibrous Mass (Subepithelial)
A subepithelial fibrous mass represents an accumulation of

fibrous tissue within the subepithelial aspect of the midmem-
branous vocal fold (Fig. 4.9). This material is typically amor-
phous in nature and often has thin extensions anteriorly and
posteriorly within the vocal fold, giving it a fusiform shape.
Stroboscopic pattern of fibrous mass in the subepithelium
demonstrates an hourglass closure pattern, with significant
reduction of the mucosal wave vibratory activity as seen on
stroboscopy. This pathology does not respond to nonsurgical
treatment methods, and the surgical approach for this lesion is
through a microflap. The surgical approach to these lesions is
Fig. 4.7 Cyst (ligament) of left vocal fold similar to a subepithelial vocal fold cyst, but the vocal recovery
is more delayed and overall prognosis reduced comparatively
(see Chaps. 10, “Principles of Phonomicrosurgery” and 17,
“Vocal Fold Cyst and Fibrous Mass”).
size). Subepithelial vocal fold cysts typically do not respond or
change in any appreciable fashion to voice rest or voice therapy.
Surgical excision when indicated of a vocal fold subepithelial
4.4.8 Fibrous Mass (Ligament)
cyst is done through a microflap approach to the vocal fold (see
Chaps. 10, “Principles of Phonomicrosurgery” and 17, “Vocal
Fold Cyst and Fibrous Mass”). A ligamentous fibrous mass represents fibrous tissue accumula-
tion in the midmembranous vocal fold near the vocal ligament
(Fig. 4.10). Often this tissue is amorphous and has extensions
anteriorly and posteriorly in the vocal fold. This lesion does not
4.4.5 Vocal Fold Cyst (Ligament)
respond to nonsurgical treatment methods. The stroboscopic
pattern of fibrous mass and ligament reveals hourglass closure
A vocal fold cyst found in the area near the vocal ligament is an pattern and significant reduction of the mucosal wave vibra-
encapsulated, benign pathologic process that typically involves tory activity. The surgical approach is similar to a ligamentous
significant reduction of mucosal wave vibratory wave activity vocal fold cyst, via a microflap. The speed of vocal recovery is
as seen on stroboscopy as well as an hourglass closure pattern reduced compared with a vocal fold cyst, and the overall vocal
(Fig. 4.7). It is located in the deep aspect of the lamina propria function prognosis is worse than other midmembranous vocal
and often better visualized within the vocal fold in abduction fold lesions (see Chaps. 10, “Principles of Phonomicrosurgery”
compared to adduction. This lesion does not respond to voice and 17, “Vocal Fold Cyst and Fibrous Mass”).
Chapter 4 25
4.4.9 Reactive Lesion
A reactive lesion is a submucosal, pathologic process of the vo-

cal fold in response to a contralateral vocal fold lesion (i. e.,
vocal fold cyst, vocal fold polyp, fibrous mass) (Fig. 4.11). This
lesion typically has a hourglass closure pattern seen on stro-
boscopy and has minimally reduced or normal mucosal wave
vibratory activity on stroboscopy. This lesion responds quite
favorably to voice rest and voice therapy and typically will re-
duce in size with this treatment modality. Surgical excision of
the lesion can be done if the contralateral lesion requires sur-
gery. The surgical approach is similar to a vocal fold polyp (see
Chaps. 10, “Principles of Phonomicrosurgery” and 15, “Vocal
Fold Polyp”). One may also elect not to operate on the reactive
lesion, to remove the risk of an adverse surgical outcome (scar)
at the operative site.
4.5 Miscellaneous Disorders

of the Vocal Fold
Fig. 4.8 Polyp, left vocal fold
4.5.1 Polypoid Corditis (Reinke’s Edema)
Reinke’s edema is a pathologic condition of the vocal fold that

involves an accumulation of a gelatinous type of fluid through-
out the superficial aspect of the lamina propria (Fig. 4.12).
Often these accumulations can be quite severe, and it may
become asymmetric; however, in general the process occurs
throughout the entire vocal fold and is also exclusively found
bilaterally. Reinke’s edema involves a demonstrable increase in
size of the mass and volume of the vocal fold, which typically
lowers the pitch of the voice and causes increased vocal effort
and instability. The most common etiologic factors of Reinke’s
edema involve tobacco abuse (97%), laryngopharyngeal reflux
disease, and phonotrauma. Each of these potential etiologic
factors should be addressed in a strict and thorough fashion
prior to proceeding with surgical treatment of the Reinke’s
edema (see Chaps. 10, “Principles of Phonomicrosurgery” and
Fig. 4.9 Fibrous mass (subepithelial), right vocal fold 18, “Polyp Corditis [Reinke’s Edema]”).
4.5.2 Vocal Fold Granuloma
A vocal fold granuloma is inflammatory tissue arising from

the perichondrium of the arytenoid cartilage (Fig. 4.13). This
is a response to trauma of the arytenoid perichondrium, often
found after orotracheal intubation, or excessive hyperadduction
of the arytenoid cartilage (found in some phonatory behaviors
and chronic cough). LPR is thought to contribute to further
inflammation and propagation of granulomatous formation.
Once the etiologic trauma and irritants that initiated the vocal
fold granuloma are removed, vocal fold granuloma disease will
often spontaneously resolve over a matter of several months.
Surgical excision of vocal fold granuloma should only be per-
formed if there is an acute airway obstruction, a suspicion of
malignancy or after all etiologic factors have been thoroughly
Fig. 4.10 Fibrous mass (ligament), left vocal fold addressed (see Chap. 19, “Vocal Process Granuloma”).
4.5.3 Rheumatologic Lesions

of the Vocal Folds
A variety of rheumatological disorders (e. g., rheumatoid ar-

thritis, systemic lupus) can cause an unusual inflammatory
4 process and deposition of abnormal tissue within the lamina
propria of the vocal fold. This tissue typically results in severe
reduction of the vibratory activity of the vocal folds, as seen in
stroboscopy. These lesions are often adjacent to the vocal fold
ligament or can occupy the entire width of the lamina propria.
They have been known to form several distinct lesions within
a single vocal fold, resulting in a “bamboo” appearance of the
vocal fold; thus, these lesions are often called bamboo lesions
of the vocal fold (Fig. 4.14). Microflap approach to surgical ex-
cision of these lesions is warranted when there is significant
dysphonia, and all attempts to control the rheumatological
disease have been implemented (see Chap. 10, “Principles of
Fig. 4.11 Reactive lesion of the right vocal fold (asterisk) Phonomicrosurgery”). Given the intense fibrotic nature of this
lesion(s), the surgical dissection can be difficult and tedious,
and postoperative vocal fold stiffness is common.
4.5.4 Vascular Lesions of the Vocal Folds
A variety of vascular lesions of the vocal fold can occur, most

commonly associated with repeated phonotrauma of the vocal
folds. This involves an abnormal vascular structure formation
and vessel diameter of the subepithelial blood vessels of the vo-
cal fold (Fig. 4.15). By convention, the normal subepithelial vo-
cal fold vasculature runs parallel to the longitudinal axis of the
vocal fold. Vascular abnormalities of the vocal fold typically
run perpendicular to the longitudinal axis of the vocal fold and
are significantly greater than one millimeter in diameter. They
can present and develop in a variety of different patterns, such
as vascular lakes, ectasias, and varices. The management and
Fig. 4.12 Reinke’s edema of the vocal folds, bilateral
Fig. 4.13 Arytenoid granuloma Fig. 4.14 Rheumatological lesions of the right vocal fold (asterisks)
Chapter 4 27
mation of the vocal fold epithelium onto the vocal fold liga-
ment. Sulcus vocalis presents typically as a furrow along the
free edge of the vocal fold in varying lengths and varying se-
verity with respect to the degree of loss of the lamina propria
(Fig. 4.16). Sulcus vocalis can often also have associated vocal
fold pathologic entities, such as vocal fold lesions (e. g., cysts,
fibrous mass, etc.) and mucosal bridges. The medical and sur-
gical approaches to vocal fold scar and sulcus vocalis are dis-
cussed in Chaps. 23, “Sulcus Vocalis and Vocal Fold Scar,” and
48, “Gray’s Minithyrotomy for Vocal Fold Scar/Sulcus Vocalis,”
respectively.
Key Points
■ Most pathological conditions of the vocal folds

are benign and occur within the epithelium or the
Fig. 4.15 Vascular lesions of the vocal fold
lamina propria.
■ Recurrent respiratory papillomatosis of the larynx
occurs from a viral (HPV) infection of the epithe-
lium (most commonly the epithelium of the vocal
folds). The diffuse infection of the virus and the
recurrent nature of the disease demand a conser-
vative surgical approach.
■ Premalignant changes of the epithelium and
cancer of the vocal fold require careful observa-
tion/treatment to maximize treatment success and
voice preservation.
■ Benign midmembranous vocal fold lesions typical-
ly occur from vocal misuse/overuse. These lesions
cannot be accurately diagnosed by viewing alone.
Using morphology, response to voice therapy
and surgical findings, seven distinct lesions can
be strictly defined: vocal nodules, fibrous mass
(subepithelial or ligament), cyst (subepithelial or
ligament), polyp, and reactive lesion.
■ Vocal fold scar and sulcus vocalis represent severe
derangement or loss of the vocal fold lamina pro-
pria (respectively).
Fig. 4.16 Sulcus vocalis
surgical approach to these lesions are discussed in Chap. 22, 1 Rosen CA et al (2003) Benign midmembranous vocal fold lesion
“Surgical Management of Vocal Fold Vascular Lesions”. nomenclature paradigm. AAO-HNS annual meeting, Orlando,
Fla., 23 September 2003
2 Derkay CS, Hester RP, Burke B, Carron J, Lawson L (2004)
Analysis of a staging assessment system for prediction of surgi-
4.5.5 Vocal Fold Scar and Sulcus Vocalis
cal interval in recurrent respiratory papillomatosis. Int J Pediatr
Otorhinolaryngol 68:1493–1498
Vocal fold scar and sulcus vocalis represent severe abnormali- 3 Schweinfurth JM, Powitzky E, Ossoff RH (2001) Regression of la-
ties of the lamina propria of the vocal fold. The former involves ryngeal dysplasia after serial microflap excision. Ann Otol Rhinol
replacement of the normal extracellular matrix proteins of the Laryngol 110:811–814
lamina propria with abnormal scar tissue and an altered col- 4 Thekdi, AA, Rosen CA (2003) Surgical treatment of benign
lagen matrix structure. Sulcus vocalis is a loss or absence of vocal fold lesions. Curr Opin Otolaryngol Head Neck Surg
the vocal fold lamina propria, resulting in a direct approxi- 10:492–496
5 Zeitels SM, Hillman RE, Bunting GW, Vaughn T (1997) Reinke's 7 Welham NV, Rousseau B, Ford CN, Bless DM (2003) Tracking
edema: phonatory mechanisms and management strategies. Ann outcomes after phonosurgery for sulcus vocalis: a case report. J
Otol Rhinol Laryngol 106:533–543 Voice 17:571–578
6 Hochman I, Sataloff RT, Hillman RE, Zeitels SM (1999) Ectasias 8 Rosen CA (2000) Vocal fold scar: evaluation and treatment. Oto-
and varices of the vocal fold: clearing the striking zone. Ann Otol laryngol Clin North Am 33:1081–1086
Rhinol Laryngol 108:10–16 9 Verdolini K, Rosen CA, Branski R. (2005) Classification Manual
4 of Voice Disorders. Lawrence Erlbaum Associates, Mahwah, NJ
Chapter 5
Glottic Insufficiency: Vocal Fold

Paralysis, Paresis, and Atrophy 5
current laryngeal nerve (RLN). The SLN supplies sensation to
5.1 Introduction
the glottic and supraglottic larynx, as well as motor input to
the cricothyroid muscle, which controls vocal fold lengthening
Glottic insufficiency is one of the most common contributing fac- and pitch. The RLN arises from the vagus nerve in the upper
tors in patients who present with dysphonia. It is also one of the chest and loops under the aortic arch (left) or subclavian ar-
easiest findings to overlook in the clinical evaluation (Fig. 5.1). tery (right), and ascends back into the neck, traveling in the
tracheoesophageal groove. The nerve enters the larynx poste-
Causes of glottal insufficiency include: riorly, adjacent to the cricothyroid joint. The RLN innervates
the ipsilateral posterior cricoarytenoid (PCA), the interaryte-
■ Vocal fold immobility/partial immobility from one or a
noid (IA) (an unpaired muscle), and the lateral cricoarytenoid
combination of:
(LCA), and terminates in the thyroarytenoid (TA). Thus, the
■ Vocal fold paralysis
RLN supplies all of the intrinsic laryngeal muscles with the ex-
■ Vocal fold paresis
ception of the cricothyroid muscle. Ipsilateral RLN transection
■ Cricoarytenoid joint derangements (e. g., fixation or
usually results in complete unilateral vocal fold immobility
subluxation)
(the ipsilateral CT does not contribute to vocal fold adduction
■ Vocal fold atrophy/soft tissue deficiency due to:
or abduction). It is important to remember, however, that the
■ Deinnervation (vocal fold paralysis/paresis)
interarytenoid muscle is unpaired, and contralateral RLN in-
■ Age-related changes (presbylaryngis)
put to the IA may lead to some adduction of the vocal fold on
■ Tissue loss from ablative/destructive vocal fold pro-
the paralyzed side (Fig. 5.2)
cedures
The causes of unilateral VFP are myriad, but can be broken
■ Vocal fold scar
down into categories to highlight the relevant pathophysiol-
■ Sulcus vocalis deformity
ogy. These are shown in Table 5.1.
■ Myopathic disease (rare)
Iatrogenic nerve injury likely represents the most common
cause for otolaryngologic referral. Common iatrogenic surgi-
In clear-cut clinical settings such as unilateral vocal fold paral- cal causes of UVFP include thyroidectomy/parathyroidectomy,
ysis, the diagnosis of glottic insufficiency can is made through anterior cervical disc surgery, esophagectomy, thymectomy,
flexible laryngoscopy alone. However, videostroboscopy is es- neck dissection, carotid endarterectomy, mediastinoscopy, and
sential to evaluate for glottal insufficiency when both vocal cardiothoracic surgery, including aortic surgery, coronary ar-
folds appear mobile, as is frequently the case with subtle vo-
cal fold weakness, vocal fold scar and sulcus vocalis (Chap. 3,
“Videostroboscopy and Dynamic Voice Evaluation with Flex-
ible Laryngoscopy”).
The most common causes of symptomatic glottic insuffi-
ciency and the focus of this chapter are:
1. Unilateral vocal fold paralysis (UVFP)
2. Presbylaryngis/age-related changes of the larynx
3. Vocal fold paresis (unilateral and bilateral)
5.2 Unilateral Vocal Fold Paralysis
5.2.1 Etiology
The etiology of UVFP involves dysfunction of the brainstem

nuclei, the vagus nerve, or the recurrent laryngeal nerve (RLN)
supplying the involved side of the larynx. The vagus nerve ex-
its the skull base via the jugular foramen and descends in the Fig. 5.1 Videostroboscopy image of glottic insufficiency due to a right
carotid sheath, giving off three major branches: the pharyn- vocal fold paralysis. The right vocal fold is lateralized and a visible
geal branch, the superior laryngeal nerve (SLN), and the re- glottic gap is present during phonation
30 Glottic Insufficiency
tery bypass grafting, and pulmonary lobar resection. Endotra- pes simplex infection (HSV1) of the vagus nerve or its branch-
cheal intubation, prolonged nasogastric tube placement, and es. The injury is presumed to be an inflammatory neuropathy,
even esophageal stethoscope placement have been implicated similar to the cranial neuritis observed with Bell’s palsy. Al-
as occasional causes of VFP. though this theory is widely regarded as true, little scientific
Nonlaryngeal malignancies are another common cause of data have been published to demonstrate that HSV neuritis is
unilateral VFP. The most common scenario involves bron- the causative agent in “idiopathic” UVFP. In addition, no stud-
chiogenic carcinoma of the lung associated with a left RLN ies exist that evaluate the benefit of systemic corticosteroids
paralysis. The cause in these cases is usually due to mediastinal and/or antivirals in the treatment of this condition. Idiopathic
spread of the malignancy into the aortopulmonary window. UVFP is a diagnosis of exclusion, only after a detailed history
5 These paralyses rarely resolve spontaneously, and deserve early and appropriate imaging studies fail to demonstrate a cause.
intervention. Other nonlaryngeal malignancies include thy- Medications such as the vinca alkaloids (vincristine and vin-
roid, esophageal, and skull base (i. e., paraganglioma) tumors. blastine), and cisplatinum, are known to cause neurotoxicity
The neurologic event most commonly associated with uni- of the RLN (unilateral or bilateral). Fortunately, the VFP as-
lateral VFP is stroke, usually of the brainstem. However, in sociated with the vinca alkaloids is dose related, and usually
these patients, other neurologic symptoms (such as paraple- resolves over a 4- to 6-week period after stopping or adjusting
gia) or additional cranial nerve involvement are the rule, and the dose of the medication
isolated UVFP in this setting is highly unlikely. Many of these Systemic diseases can (rarely) cause vocal fold immobility,
patients have severe dysphagia and aspiration due to ipsilateral due to either paralysis or joint fixation. Such diseases include
laryngopharyngeal sensory and motor deficits. gout, sarcoidosis, tuberculosis, rheumatoid arthritis, and hy-
Idiopathic UVFP is also seen frequently. A small number of pothyroidism (only in cases of myxedema). These systemic
case reports suggest that “idiopathic” UVFP may be due to her- diseases would be expected to have myriad symptoms in ad-
dition to unilateral vocal fold immobility, and these conditions
should not be suspected in cases of isolated VFP.
In the case of endotracheal intubation leading to unilateral
vocal fold mobility, one must be careful to rule out the possi-
bility of arytenoid dislocation or subluxation as the true cause
of an immobile vocal fold, although this scenario is probably
quite rare. Laryngeal electromyography is helpful in these situ-
ations, as indicated below. Other traumatic causes of VFP in-
clude blunt or penetrating injuries to the neck.

5.3.1 Vocal Quality and Swallowing
The primary symptom of UVFP is dysphonia. The voice can

vary from simple vocal fatigue in mild or well-compensated
cases, to almost complete aphonia in severe cases. Much of the
quality of the voice is determined by the muscular tone and
Fig. 5.2 Diagram depicting the dual innervation (from both the right position of the affected vocal fold and each patient’s unique
and left RLN) of the interarytenoid muscle laryngeal compensatory strategy. An atrophic and poorly com-
pensated vocal fold paralysis typically presents with a breathy,
weak voice due to air escape. The voice may also have a wa-
Table 5.1 Unilateral vocal fold immobility: causes tery or “gurgle-y” quality to it if secretions are retained in the
pyriform sinus, as is typical in high vagal injuries. With time,
Cause (%) some patients will eventually progress to a stronger voice, us-
Malignancy—nonlaryngeal (24.7) ing various compensatory strategies. Supraglottic hyperfunc-
Iatrogenic—surgical trauma (23.9) tional compensation is common. These patients constrict the
Idiopathic (19.6) supraglottic tract either laterally, apposing the false folds, and/
Nonsurgical trauma (11.1) or in an anterior posterior dimension, apposing the epiglottis
Intubation (7.5) to the arytenoids. This hyperfunctional muscular contraction
Neurologic (7.9) leads to a characteristic rough, pitch-locked, low-frequency
Thoracic aortic aneurysm (4.3) voice. This voice can sound quite similar to a patient with pri-
Pulmonary or mediastinal TB (1.1) mary muscular tension dysphonia, and the diagnosis of vo-
cal fold paralysis may not be suspected. “Unloading” of the
Adapted from: Benninger MS, Gillen JB, Altman JS (1998) Changing voice, as described later in this chapter, is used to help analyze
etiology of vocal fold immobility. Laryngoscope 108:1346–1349 these patients. In contrast, other patients, often females, may
Chapter 5 31
develop an unnaturally high-pitched voice that is breathy in patient to perform an “ee-sniff ” maneuver, where the patient
quality. This has been referred to as a “paralytic falsetto,” and is alternates between phonating an “e” vowel and sniffing vigor-
characterized by a mean increase in fundamental frequency 85 ously. This causes the vocal folds to alternately adduct and ab-
Hz above “natural” pitch. This condition is thought caused by duct maximally and is an excellent way to judge the degree of
compensatory contraction of the ipsilateral cricothyroid (CT) paresis/paralysis. Any purposeful and appropriate abduction of
muscle, which remains innervated in isolated RLN paralysis. the affected vocal fold suggests incomplete paralysis (paresis).
Swallowing difficulties are often encountered, specifically It is important not to falsely attribute a small amount of ad-
aspiration of liquids, along with a weak and ineffective cough. duction of the affected vocal fold as representing evidence of
Some dysphagia for solids may also be present, especially in partial innervation. RLN sectioning leads to paralysis of the
brainstem or high vagal injuries, due to the concomitant de- ipsilateral thyroarytenoid, posterior cricoarytenoid, and lateral
nervation of the pharyngeal constrictors. Risk of aspiration is cricoarytenoid, but not the interarytenoid. The interarytenoid
heightened in these instances as well, due to the loss of ipsilat- is a midline muscle, and has dual innervation from both RLNs;
eral laryngeal sensation from SLN involvement. therefore, some residual adduction may be present in complete
It is important to obtain a vocal inventory of the patient’s unilateral VFP, due to innervation from the contralateral RLN.
voice responsibilities (both work related and social). Vocal A paralyzed vocal fold can occupy a variety of positions,
professionals rely on a serviceable voice for their livelihood, including lateral (cadaveric), paramedian, and median. It was
and these patients should be questioned regarding their up- once thought that the position of the paralyzed vocal fold had
coming work schedule to help determine the urgency of early some topognostic significance (for example, that lateral vocal
surgical intervention. Most professional voice users will opt for fold position indicated complete CN X paralysis due to RLN
temporizing vocal augmentation (Chap. 14, “Principles of Vo- and SLN involvement). This theory was later disproven by both
cal Fold Augmentation”) so that they may return to work as Woodson and Koufman. The final position of the vocal fold af-
soon as possible. A validated instrument, such as the VHI-10 ter nerve injury is now thought to be due entirely to the degree
is very useful for understanding the perceived severity of the of reinnervation and synkinesis present.
patient’s vocal disability. It is important to focus on the vocal fold movement itself,
rather than the arytenoid position, in determining vocal fold
immobility. In some cases of vocal fold immobility, however,
an overhanging arytenoid obscures the observation of the un-
5.4 Unilateral Vocal Fold Paralysis:
derlying vocal fold, making it impossible to ignore its position.
Physical Examination
This overhanging, anteriorly displaced arytenoid is sometimes
mistaken for an arytenoid dislocation; however, this finding is
5.4.1 General
usually caused by complete denervation or poor reinnervation
of the PCA muscle
Examination of the neck for adenopathy and thyroid masses In some patients with UVFP, compensatory supraglot-
should be performed. Cranial nerve X neural compression and tic contractions (i. e., “plica ventricularis”) obscure vocal fold
infiltration by a neck or thyroid neoplastic process can lead to movement. In these cases, the author advocates that the pa-
VFP in advanced cases. Palatal movement when phonating /a/ tient phonate with an easy onset such as a “sigh,” or be in-
should be observed. Palatal paralysis in combination with ip- structed to “hum through the nose.” This technique, described
silateral VFP may indicate a “high” vagal lesion. In the case by Koufman as “unloading,” is useful for removing unwanted
of palatal paralysis, the palate retracts toward the uninvolved compensatory supraglottic hyperfunction that obscures vocal
“good” side (e. g., in a left vagal paralysis, the palate retracts fold visualization. This technique is invaluable in many cases
to the right). A complete cranial nerve exam should evaluate of longstanding VFP that have been misdiagnosed as primary
for other involved nerves, especially CN XI and XII due to the muscle tension dysphonia, or plica ventricularis.
close proximity these have to CN X at the skull base. Involve- Videostroboscopy is a helpful part of the workup of vocal
ment of these adjacent cranial nerves warrants a thorough ra- fold movement abnormalities, demonstrating the degree of in-
diographic evaluation of the base of the skull. complete closure present. In many cases of VFP, however, the
paralyzed vocal fold shows increased amplitude of vibration
due to the atrophic, “floppy” nature of the denervated voca-
lis muscle. In cases of mild or moderate vocal fold paresis, the
5.4.2 Laryngeal
increased amplitude seen on stroboscopy, or an asynchronous
“chasing wave” may be the only signs of vocal fold weakness.
The appropriate evaluation for VFP starts with the recognition Stroboscopy may also provide information regarding vocal
of unilateral vocal fold immobility on examination. Indirect fold height differences and the status of vocal process contact
(mirror) laryngoscopy and rigid 70 or 90° laryngoscopy are during phonation. These parameters help determine the need
helpful but do not replace flexible laryngoscopy. It is impor- for arytenoid adduction, when evaluating patients for laryn-
tant to obtain an unencumbered, extended viewing period of geal framework surgery.
the vocal folds during a variety of tasks. Flexible laryngoscopy A simple test to evaluate the degree of vocal disability and
is the only method to view vocal fold mobility in its natural glottic incompetence is measuring the patient’s maximal pho-
state (refer to Chap. 3, “Videostroboscopy and Dynamic Voice nation time (MPT). This is done by simply instructing the pa-
Evaluation with Flexible Laryngoscopy”). When evaluating tient to take a deep breath and phonate an “ee” vowel for as
for suspected UVF paralysis/paresis, a useful task is to ask the long as possible. Normal MPT for a healthy adult is approx-
imately 25 seconds. In cases of VFP, the MPT is reduced to In cases where a clear-cut temporal relation exists between
10 seconds or less, typically. Shorter MPT values indicate more surgical iatrogenic trauma and VFP, no additional radiologic
severe glottic incompetence, worse voice, and increased vocal workup is necessary. In cases where no cause can be found
fatigue. MPT values of 5 seconds or less indicate severe, un- for the VFP, imaging studies are essential. Most investigators
compensated VFP that may need arytenoid adduction in ad- agree that a CT (with contrast) or MRI encompassing the base
dition to medialization laryngoplasty. Poor pulmonary reserve of skull through the upper chest is adequate. Laryngeal elec-
from asthma or chronic obstructive pulmonary disease may tromyography (LEMG) undoubtedly has a place in the work
reduce MPT significantly, so results need to be taken in context up of unilateral vocal fold immobility; its role is still yet to be
of the patient’s pulmonary status. MPT should be expected to determined. LEMG can provide definitive diagnosis and prog-
5 improve (i. e., increase) after successful medialization surgery nostic information on the possibility for spontaneous recovery
for VFP. of VFP.
Useful information from LEMG is obtained between 1 and
6 months after the onset of VFP. Evaluation outside of these
parameters can render the information misleading (early), or
5.5 Unilateral Vocal Fold
of limited usefulness (late).
Paralysis: Workup
It should be noted that unilateral vocal fold immobility is a

5.6 Unilateral Vocal Fold
physical finding, and not a diagnosis. One must determine the
Paralysis: Treatment
cause of the immobility. In the vast majority of cases of uni-
lateral vocal fold immobility, VFP is the cause. Therefore, the
bulk of the evaluation pertains to UVFP. In a small number of The treatment of VFP can be broken into three management
cases, the etiology may be cricoarytenoid (CA) joint arthritis strategies:
(rheumatoid arthritis, gout), cricoarytenoid joint effusion/sub- 1. Observation for 9–12 months, reserving treatment for pa-
luxation/dislocation (external trauma/ traumatic endotracheal tients with continued dysphonia
intubation), or neoplastic infiltration (“occult” carcinoma in 2. Referral to speech pathology for voice strengthening or
the ventricle/paraglottic space). In general, the history will sug- swallow therapy, as indicated
gest whether CA joint derangements are the culprit, and care- 3. Early surgical intervention:
ful flexible laryngoscopy combined with CT scan will reveal a) Temporary: injection augmentation
neoplastic infiltration as the cause of vocal fold immobility. In b) Permanent: laryngeal framework surgery, injection aug-
cases where one cannot confidently exclude the CA joint in- mentation
volvement or neoplasm as the cause of unilateral vocal fold im-
mobility, laryngeal electromyography and a laryngoscopy with Obviously, these treatment strategies may overlap or may be
palpation for passive mobility of the vocal folds is warranted. employed simultaneously, but a management plan should be
developed and followed as soon as all of the important di-
agnostic information is gathered. Several factors should be
considered when determining the best course of action, and
5.5.1 Serology
treatment must be individualized for each patient. A treatment
algorithm is not advocated, as each patient’s expectations and
There is little yield from ordering screening laboratory tests vocal needs are unique.
such as chemistry panel, complete blood count, urinalysis, Classical teaching for the treatment of VFP advocates a
VDRL/FTA-ABS, thyroid function tests, autoimmune panels, watchful waiting period of 9–12 months before surgical inter-
or erythrocyte sedimentation rate. If additional elements of the vention is considered. This management strategy was devel-
history and physical exam point towards a systemic process as oped in the 1970s, when the only viable treatment option for
the cause of unilateral vocal fold immobility, directed serology VFP was injection augmentation with Teflon. As Teflon injec-
tests may be indicated. However, in general, a “shotgun” ap- tion is irreversible and sometimes associated with an unfavor-
proach to the workup of uncomplicated UVFP is unnecessary able vocal outcome, early surgical intervention was ill advised
and wasteful. during this era. LEMG and laryngeal framework techniques,
along with an arsenal of injectable substances, have made early
surgical intervention an excellent option in the treatment of
VFP.
5.5.2 Imaging Studies
In patients with clear-cut aspiration due to VFP, early sur-
gical intervention is indicated, either with injection augmen-
As screening tools, barium swallow and thyroid scans have vir- tation of the vocal fold, or medialization laryngoplasty (ML).
tually no yield in determining the etiology of VFP and are not Evidence of severe denervation injury on LEMG may also lead
advocated in the diagnostic workup. In contrast, a modified to early surgical intervention. Clinical experience has shown
barium swallow or functional endoscopic evaluation of swal- that RLN paralysis due to carcinoma (lung, esophagus, thy-
lowing to evaluate swallowing and aspiration risk is frequently roid, …) rarely recovers, and patients are counseled to consider
helpful in managing patients with dysphagia in the workup of early surgical intervention in these cases. Patients with VFP
VFP. and high-level vocal demands (salespersons, clergy, teachers,
Chapter 5 33
attorneys) often have difficulty continuing their work-related

5.7.3 Physical Examination
duties. In these cases, it may be necessary to intervene early
(prior to 9 or 12 months) to get the patient back on the job.
Temporary surgical procedures such as injection augmenta- Flexible laryngoscopy and videostroboscopy, as outlined for
tion of the vocal fold should be considered in this population. UVFP in the previous sections is essential in the examination
The medical health of the patient occasionally comes into of the patient with suspected vocal fold paresis. The “ee-sniff ”
play. Patients with significant cardiopulmonary and other maneuver should be performed, using slow-motion review to
medical comorbidities may not be candidates for a general an- evaluate for motion asymmetries in abduction and adduction
esthetic (i. e., for microlaryngoscopy with vocal fold injection of the vocal folds. Compensatory muscle tension disorders are
augmentation), yet may be perfectly suitable for ML or injec- common with vocal fold paresis; therefore, “unloading” tech-
tion augmentation performed under local anesthesia. In most niques are useful as described previously.
cases, the patient should be counseled regarding the different
■ Videostroboscopy plays a pivotal role in the evaluation
treatment options, including the advantages and disadvantages
of suspected paresis. Subtle clues include:
of the three main strategies of treatment. In this way, the pa-
■ Mild bowing of the vocal fold(s)
tient can actively participate in the decision-making process.
■ Incomplete glottic closure
When LEMG is available, it can serve as a crucial guide to the
■ Prolonged “open phase” of vibratory cycle
patient and surgeon regarding (1) treatment or observation
■ Increased vibratory amplitude in the paretic vocal
and (2) temporary versus permanent treatment.
fold (see Chap. 3, Fig 3.3)
■ “Chasing”/asynchronous mucosal wave propagation
5.7 Unilateral/Bilateral Vocal Fold Paresis
5.7.1 Etiology
5.7.4 Diagnostic Workup
As is the case with vocal fold paralysis, incomplete paralysis
or paresis can be due to iatrogenic, neoplastic, neurologic, and Is the same as for UVFP, with the following notable excep-
idiopathic causes outlined in section 5.2. Idiopathic causes are tions:
much more common with vocal fold paresis, and may repre-
■ LEMG is critical to confirming the diagnosis, and
sent a viral neuropathic process. A high index of suspicion
establishing the “sidedness” of the vocal fold paresis
for an underlying progressive neurologic disease (e. g., amyo-
(left, right, or bilateral). Findings are typically limited to
trophic lateral sclerosis, postpolio syndrome) must be main-
reduced recruitment of motor units in the RLN or SLN
tained as well.
distribution.
■ Imaging studies are not generally obtained to evaluate
the course of the vagus/RLN in cases of long-standing,
5.7.2 History stable vocal fold paresis. If vocal fold paresis progres-
sively worsens or the affected vocal fold becomes im-
mobile, then radiologic evaluation is indicated.
In contrast to patients presenting with UVFP, the presenting
■ Some consideration should be given to the possibil-
symptoms of a patient with vocal fold paresis can be very sub-
ity that the paretic vocal fold is a manifestation of a
tle. While the patient may complain of a breathy, weak voice,
progressive neurological disorder (if no clear etiology is
more subtle forms of dysphonia are often present. These symp-
identified). Neurologic consultation may be indicated.
toms include:
Possible conditions include:
■ Loss of volume/projection ■ ALS
■ Vocal fatigue ■ Postpolio syndrome
■ Loss of voice after extended use ■ Pseudobulbar palsy
■ Odynophonia
■ Loss of a portion of the vocal range (especially upper
end of the register) 5.7.5 Treatment
■ Problems with stamina/quality of the singing voice
As with UVFP, treatment options include observation, voice
Vocal fatigue is usually present in patients with vocal fold pa- therapy with a speech language pathologist, or surgical man-
resis, and is a cardinal symptom of glottic insufficiency. The agement either with injection augmentation of the vocal fold(s)
temporal course of the presenting vocal complaints can vary or laryngeal framework surgery. In general, a less aggressive
from sudden in onset, to gradually progressive, and even in approach is used in the treatment of vocal fold paresis, as com-
some cases intermittent in nature. pared to UVFP. Voice therapy is more likely to be successful,
and injection augmentation (lipoinjection, Radiesse) may be
preferred over laryngeal framework surgery. If the diagnosis of
vocal fold paresis is suspected, but cannot be confirmed, then
a “diagnostic” injection augmentation using a temporary filler cal fold muscular atrophy due to deinnervation, presbylaryngis
can be done. Improvement in the voice after injection augmen- is a more global process that involves not only loss of muscle
tation suggests that glottic insufficiency is present. Long-term bulk, but also degeneration/loss of the layers of the lamina
strategies can then be employed after the effects of the injec- propria, as well as CA joint changes. For this reason, the vo-
tion wear off. cal dysfunction related to presbylaryngis is usually addressed
incompletely when “medialization” framework surgery is used
to correct the glottal gap.
5.8 Presbylaryngis/Age-Related
Changes in the Larynx
5 5.8.3 Workup
5.8.1 General Considerations
A diagnostic workup for suspected presbylaryngis is usually
It is a common misconception to use the term vocal fold bow- not necessary in most cases of elderly patients with a find-
ing synonymously with presbylaryngis. Vocal fold bowing is ing of vocal fold bowing on laryngeal examination. However,
not a diagnosis, but a physical finding indicating an elliptical it should be noted that Parkinson’s disease (PD) often has an
or scalloped contour to the membranous vocal fold (Fig. 5.3). identical clinical presentation to that of presbylaryngis. Pa-
Bowing can be due to vocal fold atrophy, vocal fold paresis/ tients with PD, however, are more likely to have vocal tremor
paralysis, age-related changes (presbylaryngis), vocal fold soft- and monotone pitch in addition. The clinical distinction is im-
tissue loss/scarring, and sulcus vocalis. portant, as PD patients are generally poor surgical candidates
for treatment of glottic insufficiency, due to the global brady-
kinetic nature of their vocal dysfunction. Lee-Silverman voice
therapy (see Chap. 7, “Medical Treatment of Voice Disorders”)
5.8.2 Etiology, History, and Physical Findings
is the preferred primary method of treatment for dysphonia
due to PD. Injection augmentation and laryngeal framework
Presbylaryngis is the condition caused by senescent changes surgery are reserved as an adjunctive treatment in select cases.
in the larynx, which generally present in the fifth decade of
life or later. Typically, the patient complains of mild/moderate
dysphonia, lack of volume/projection, and vocal fatigue, espe-
Key Points
cially at the end of the day. Bilateral vocal fold bowing is the
typical laryngoscopic feature on physical examination. Vid-
eostroboscopic exam often reveals mild/moderate degrees of ■ Glottic insufficiency is one of the most common
glottal insufficiency/incomplete closure. However, unlike vo-
contributing factors in patients who present with
dysphonia and one of the easiest findings to over-
look in the clinical evaluation.
■ The most common causes of symptomatic glottic
insufficiency are unilateral vocal fold paralysis, uni-
lateral or bilateral vocal fold paresis, and presbylar-
yngis.
■ Treatment of “early” unilateral vocal fold paralysis
is individualized for each patient, and takes into
account the patient’s risk of aspiration, vocal de-
mands, nature of neural injury, and LEMG findings.
■ Videostroboscopy plays a pivotal role in the evalu-
ation of suspected vocal fold paresis. Subtle clues
include:
■ Mild bowing of the vocal fold(s)
■ Incomplete glottic closure
■ Prolonged “open phase” of vibratory cycle (see
Chap. 2, “Principles of Clinical Evaluation for
Voice Disorders”)
■ Increased vibratory amplitude in the paretic vo-
cal fold
■ Chasing/asynchronous mucosal wave propaga-
tion
■ Loss of vocal projection and voice fatigue with
extended use are classic symptoms of vocal fold
Fig. 5.3 Videostroboscopy image of bilateral vocal fold bowing due to
paresis and can easily be missed in the history.
presbylaryngis
Chapter 5 35
6 Glazer HS, Aronberg DJ, Lee JKT, Sagel SS (1983) Extralaryn-

■ All unexplained vocal fold paralysis should be
geal causes of vocal cord paralysis: CT evaluation. Am J Radiol
investigated with imaging studies (CT or MRI), trac-
141:527–531
ing the entire RLN from skull base to upper chest.
7 Koufman JA (1995) Evaluation of laryngeal biomechanics by
■ Parkinson’ s Disease (PD) often presents with
flexible laryngoscopy. In: Rubin JS, Sataloff RT, Korovin GS,
dysphonia and vocal fold bowing and can be
Gould WJ (eds) Diagnosis and treatment of voice disorders.
confused with presbylaryngis. The clinical distinc-
Igaku-Shoin, New York, pp 122–134
tion is important, as PD patients are generally poor
8 Koufman JA, Walker FO, Joharji GM (1995) The cricothyroid
surgical candidates, and should instead undergo
muscle does not influence vocal fold position in laryngeal pa-
voice therapy as primary treatment for their dys-
ralysis. Laryngoscope 105:368–372
phonia.
9 Koufman JA, Walker FO (1998) Laryngeal electromyography in
clinical practice indications, techniques, and interpretation. Pho-
noscope 1:57–70
10 Munin MC, Murry T, Rosen CA (2000) Laryngeal electromyog-
raphy. Otolaryngol Clin North Am 33:759–770
11 Netterville JL, Koriwchak MJ, Winkle M et al (1996) Vocal fold
1 Benninger MS, Crumley RL, Ford CN et al (1994) Evaluation paralysis following the anterior approach to the cervical spine.
and treatment of the unilateral paralyzed vocal fold. Otolaryngol Ann Otol Rhinol Laryngol 105:85–91
Head Neck Surg 111:497–508 12 Phillips TG, Green GE (1987) Left recurrent laryngeal nerve in-
2 Benninger MS, Gillen JB, Altman JS (1998) Changing etiology of jury following internal mammary artery bypass. Ann Thoracic
vocal fold immobility. Laryngoscope 108:1346–1349 Surg 3:440
3 Blitzer A, Brin MF, Sasaki CT et al (eds) (1992) Neurologic disor- 13 Shin-ichi I kKenji K, Ken I, Oshima K (2003) Hoarseness after
ders of the larynx. Thieme, Stuttgart cardiac surgery: possible contribution of low temperature to the
4 Blitzer A, Jahn AF, Keider A (1996) Semon’s law revisited: an recurrent nerve paralysis. Laryngoscope 113:1088–1089
electromyographic analysis of laryngeal synkinesis. Ann Otol 14 Terris DJ, Arnstein DP, Nguyen HH (1992) Contemporary evalu-
Rhinol Laryngol 105:764–769 ation of unilateral vocal cord paralysis. Otolaryngol Head Neck
5 Flowers RH, Kernodle DS (1990) Vagal mononeuritis caused by Surg 107:84–90
herpes simplex virus: association with unilateral vocal cord pa- 15 Woodson GE (1993) Configuration of the glottis in laryngeal pa-
ralysis. Am J Med 1990; 88:686–688 ralysis. I: Clinical study. Laryngoscope 103:1227–1234
Chapter 6
Glottic and Subglottic Stenosis:

Evaluation and Surgical Planning 6
Please see Chaps. 9, 13, 26, 28, 29, 45, 46, and 47 for further
information.
6.2 Introduction
Evaluation of airway stenosis must be performed in a system-

atic and thorough manner to ensure accurate diagnosis and
treatment planning. In the case of a patient with stridor and
acute airway distress, the medical evaluation may be limited
initially. However, once a secure airway is obtained, a more de-
tailed evaluation (as outlined in this chapter) can be obtained.
Fig. 6.1 Subglottic stenosis
6.3 Etiology of Glottic and Subglottic

(Laryngotracheal) Narrowing
after 10 days of endotracheal intubation. Additional medical
factors may increase the risk of stenosis, including hypoxia,
■ Prolonged endotracheal intubation
diabetes, LPR, vascular disease, localized infection, and other
■ Complications related to tracheostomy tube placement
conditions. Tracheostomy tube placement (especially percuta-
■ External laryngeal trauma
neous dilational techniques) may narrow the airway through
■ Thermal inhalation (burn) and caustic ingestion
displacement of tracheal cartilage into the airway. Necrosis of
■ Autoimmune disease
tracheal cartilaginous flaps (e. g., the Björk flap) may also lead
■ Wegener’s granulomatosis
to delayed contracture and collapse of the supporting tracheal
■ Relapsing polychondritis
framework (see Chap. 29, Fig. 29.3). The other etiologies listed
■ Amyloidosis
are much less common, but must be considered in non-trau-
■ Laryngopharyngeal reflux disease
matic airway stenosis, as described below.
■ Malignancy
■ External tracheal compression (mediastinal tumor)
■ Intratracheal tumor (carcinoid, metastatic tumor)
■ Primary tumor of airway (e. g., chondrosarcoma of 6.3.1 Common Clinical Conditions
cricoid) and Associated Risk Factors
■ Idiopathic
■ History of prolonged mechanical ventilation

The vast majority of patients with glottic and subglottic air-
■ Posterior glottic stenosis
way narrowing (Fig. 6.1) are due to prolonged (at least 48–72
■ Subglottic/tracheal stenosis
h or more) endotracheal intubation and complications related
■ History of prior tracheostomy
to tracheostomy tube placement. The endotracheal tube itself
■ Tracheal collapse, typically second or third ring
can lead to posterior glottic stenosis (PGS) from interaryte-
■ Suprastomal granulation tissue
noid ulceration, pressure necrosis, and cicatricial formation in
■ History of radiation to neck
the posterior glottic space. The balloon and/or distal tip of the
■ Laryngeal edema
endotracheal tube (ETT) can likewise lead to subglottic and
■ Glottic stenosis/fibrosis, especially in advanced
proximal tracheal stenosis from pressure-related effects dur-
T3/T4 squamous cell carcinoma (SCCa)
ing prolonged intubation. The risk of PGS increases markedly
38 Glottic and Subglottic Stenosis
■ Nontraumatic subglottic narrowing (CRAWLS) ■ Diabetes mellitus

■ Chondrosarcoma ■ History of radiation therapy of the larynx
■ Relapsing polychondritis ■ Severe aspiration/PEG tube dependence
■ Amyloidosis ■ Morbid obesity with severe obstructive sleep apnea
■ Wegener’s granulomatosis (OSA)
■ Laryngopharyngeal reflux disease ■ Autoimmune disease, especially if steroid dependent
■ Sarcoidosis
6.4 Glottic and Subglottic 6.5 Glottic and Subglottic Stenosis:

Stenosis: History Physical Examination
6
6.4.1 Symptoms/Time Course 6.5.1 Local Anesthesia Techniques
for Examination
The patient with glottic or subglottic/tracheal stenosis typically
presents with shortness of breath. They may have been previ- Careful flexible laryngoscopic exam of the larynx and trachea
ously misdiagnosed with asthma or “reactive airway disease,” in the clinic setting is the most important step in the evaluation
and in many cases, they are using bronchodilators or inhaled of suspected glottic/subglottic stenosis. This can be achieved
steroids for their presumed condition. It is important to inquire only if the patient’s upper airway is properly anesthetized.
specifically what level of activity the patient can tolerate before These methods of anesthesia include:
breathing difficulties are encountered (e. g., climbing up a flight
■ Topical lidocaine (4%) drip delivered through the side
of stairs, ambulating across the room, or simply at rest); this
channel of the endoscope or an Abraham cannula
provides insight into the severity of the obstruction. In addi-
■ Nebulized lidocaine
tion, one should specifically inquire whether the patient’s dys-
■ Cricothyroid (or transtracheal) puncture, with instilla-
pnea is accompanied by an audible noise during inspiration.
tion of 4% lidocaine
Given the strong association between prolonged endotra-
cheal intubation and the development of airway stenosis, one
should inquire about previous intubations in the past medical To begin the exam, the nose is anesthetized in the standard
history especially if they extend beyond 2–3 days. Although fashion for nasolaryngoscopy (lidocaine and Neosynephrine
the risk of airway stenosis increases markedly after 10 days of sprays). After this, the flexible endoscope is passed transna-
intubation, it can occur occasionally with shorter exposures. sally, and positioned over the laryngeal inlet. When properly
In addition, caustic ingestions, thermal inhalational injuries positioned, approximately 2–3 ml of lidocaine 4% is delivered
(smoke inhalation/burns), and laryngeal trauma are also im- through a side channel of the scope while the patient is phonat-
portant risk factors for the development of upper airway steno- ing /ē/. This may have to be repeated until the patient demon-
sis. In many patients with airway stenosis, there is a history of strates little or no response to the presence of the lidocaine in
tracheostomy placement and decannulation 2–3 months prior the laryngeal inlet. The endoscope is then advanced through
to the development of airway obstruction. In some patients, the the glottis, and additional topical lidocaine is applied as needed
latency to onset of airway symptoms is due to gradual matura- only. An alternative is the use of an Abraham cannula, which
tion of scar formation in the glottis/subglottis. However, the can deliver lidocaine through a peroral technique (Fig. 6.2). The
tracheostomy can be the direct cause of the airway obstruction maximum recommended adult dose of lidocaine is typically
due to tracheal granulation tissue proliferation or cartilage re- 300–400 mg (7–10 ml of lidocaine 4% in a 70-kg patient).
sorption/collapse after decannulation. In patients with a tracheotomy or a permanent tracheal sto-
ma, the tracheostomy tube is removed and 2–5 ml of 4% lido-
caine is dripped into the stoma. The patient’s stoma should be
briefly occluded manually on anesthetic instillation so that the
6.4.2 Medical Comorbidities
cough will distribute the anesthetic throughout the subglottis
and trachea. With proper anesthesia, the entire laryngotrache-
Medical comorbidities should be noted which can have a pro- al airway can be examined with a standard flexible endoscope
found effect on determining if the patient is a surgical can- in the clinic setting.
didate for treatment of their airway stenosis. The following
conditions are not absolute contraindications to surgical treat-
ment; however, they may reduce the chances of success and/or
6.5.2 Documentation of Examination
decannulation:
■ Severe restrictive or obstructive pulmonary disease
It is helpful to capture the flexible endoscopic airway evalua-
(especially if oxygen dependant)
tion on videotape (or digital storage device) so that a more de-
■ Severe kyphoscoliosis
tailed review of the airway anatomy can be carried out after the
Chapter 6 39
Fig. 6.2 Abraham cannula for peroral delivery of topical lidocaine to Fig. 6.3 Normal laryngeal exam during maximal abduction (sniffing).
the laryngotracheal region Note the general shape of an equilateral triangle within the boundaries
of the glottal aperture
examination. This is especially true those patients where only

a brief examination can be performed (due to poor respiratory
status or inability to tolerate the procedure). In these cases, the
video can be reviewed in slow motion or freeze frame to insure
accuracy of the examination.
6.5.2.1 Flexible Laryngoscopy/

Tracheoscopy Protocol
The following information should be obtained during the flex-

ible laryngoscopic airway examination:
1. Vocal fold mobility testing
Having the patient alternate between phonating /ee/ and
sniffing will test for vocal fold adduction and abduction. In
general, during sniffing, maximal abduction occurs, and the
glottic aperture has the general configuration of an equilat-
eral triangle. Reduced abduction and narrowed glottic inlet
can be due to posterior glottic stenosis and/or bilateral vocal
fold paralysis/paresis (Figs. 6.3, 6.4). Patients with paradox- Fig. 6.4 Laryngeal examination in a patient with posterior glottic ste-
ical vocal fold mobility disorder may be confused with these nosis during maximal abduction. Note the limited space in the pos-
conditions; however, these patients will generally have full vo- terior glottis due to interarytenoid scarring, which results in a glottic
cal fold abduction immediately after cough or other involun- aperture of a more narrowed isosceles triangle
tary glottic closure task (see Chap. 3, “Videostroboscopy and
Dynamic Voice Evaluation with Flexible Laryngoscopy”).
2. Examination of the posterior glottic space for scar diameter in mm. The presence of tracheomalacia/cartilage
The flexible scope should be advanced into the interaryte- collapse or suspected external compression of the airway
noid space at the level of the vocal folds to evaluate for the should be also noted.
presence of scar within the posterior glottis. 5. Retrograde flexible examination of the subglottic airway
3. Scope advancement past the vocal folds, into the subglottis through the tracheal stoma (if present)
and trachea, including the main-stem bronchi This perspective gives an unparalleled view of vocal fold
4. Documentation of airway measurements mobility and posterior glottic configuration from below.
If a stenosis is identified the approximate location should The posterior glottic space can be clearly examined for scar
be noted (distance in mm distal to the vocal folds), then formation.
the length of the stenotic segment, and the estimated airway
Fig. 6.5 Normal flow-volume loop Fig. 6.6 Flow-volume loop of patient with
subglottic stenosis, demonstrating “flatten-
ing” of the inspiratory limb. This is com-
monly referred to as a “fixed extrathoracic
obstructive pattern”
6.6 Additional Studies for the Evaluation 6.6.3 Radiographic Studies

of Glottic/Subglottic Stenosis
A fine-cut (1 mm) CT scan of the airway (neck and chest) with
6.6.1 Voice Evaluation
contrast is helpful in the evaluation of suspected airway ob-
(VHI-10, Audio Recording)
struction. This is especially true in cases of suspected external
compression or cartilage collapse (Fig. 6.7). Both of these con-
Patients with glottic and subglottic stenosis often have varying ditions are contraindications for an endoscopic laser approach.
degrees of dysphonia preoperatively and may develop worsen- It is important to remember that radiographic studies of the air-
ing of their voice after surgery. For this reason, preoperative way only provide a static view of the airway. Dynamic collapse
documentation of the voice is essential. of the airway (e. g., tracheomalacia) can only be ruled out with
a flexible endoscopic examination of the entire upper airway.
6.6.2 Air-Flow Measures

6.6.4 Laboratory Testing
Pulmonary function testing with a flow-volume loop can help
establish the presence of upper airway obstruction. A test that In a small handful of patients, there is no obvious traumatic/
is consistent with “extrathoracic airway obstruction” is typi- iatrogenic cause of the patient’s subglottic/tracheal narrowing.
cally seen in patients with glottic or subglottic/tracheal airway In these cases, one must have a high degree of suspicion for
narrowing (Figs. 6.5, 6.6). an underlying inflammatory/autoimmune, or neoplastic cause.
Chapter 6 41
6.7.1 Corrective Surgical Procedures

for Glottic/Subglottic Stenosis
These procedures are listed in order from least invasive to most

invasive approach.
■ Endoscopic (microlaryngoscopy, laser excision, rigid
dilation)
■ Endoscopic with indwelling stent placement
■ T-tube stent with external limb (long term)
■ Intraluminal stent (short term, palliative)
Dumon, Wall, Ultraflex, etc.
■ External procedures
■ Laryngotracheoplasty with cartilage grafting (airway
expansion)
■ Cricotracheal resection with primary anastomosis
Fig. 6.7 Computerized tomography of the trachea (axial), demon-
strating collapse of the cartilaginous tracheal walls, resulting in air-
way narrowing. There is no evidence of intraluminal scar or soft tissue In general, the least invasive procedures are attempted first
obstruction (unless contraindicated), saving external procedures for those
cases that fail to respond to an endoscopic approach. Airway
stenting is a “middle ground” between endoscopic and exter-
The mnemonic for this condition (nontraumatic subglottic nal procedures; however, it is not widely practiced and requires
narrowing) is CRAWLS (see above). experience to achieve consistent results. T-tube stenting is gen-
In these cases, the following protocol may be used: erally more successful for long-term stenosis treatment than
are intraluminal stents, which have a tendency to migrate and
■ c-ANCA, auto-immune profile, angiotensin-converting
incite granulation tissue formation. In general, intraluminal
enzyme (ACE) level serum testing
stents are not appropriate for long-term treatment of stenosis.
■ Biopsies of the involved tissue (histopathology and
These stents are better suited for palliative airway obstruction
culture)
from metastatic tumor infiltration of the airway, and patients
■ Selective pH probe testing for LPR
with terminal disease. External procedures are indicated when
endoscopic treatments are contraindicated or are unsuccessful.
In general, the morbidity and mortality of these procedures are
significantly higher than for endoscopic treatments. Patients
6.7 Glottic and Subglottic
with significant comorbidities and advanced age may not be
Stenosis: Surgical Planning
candidates for external stenosis treatment. Tracheostomy, al-
though not a “corrective” procedure for airway stenosis, may
In most cases, the initial microlaryngoscopy/ be the appropriate treatment for extensive stenosis in patients
tracheobronchoscopy is planned as a therapeutic surgery. In with poor medical health, or when all treatments fail.
certain instances, however, it may be appropriate to perform
an airway endoscopy in the operating room strictly for diag-
nostic purposes. Examples include:
6.7.2 Criteria for Endoscopic Treatment
■ Incomplete office/radiographic evaluation of the air- for Subglottic Stenosis
way—in this case, additional information (via operative
endoscopy) needs to be obtained before a definitive
Criteria include:
treatment plan can be implemented
■ Suspicion of malignancy, or systemic disease—these ■ No external compression, tracheomalacia, or significant
cases should be evaluated with biopsy in the operating cartilage collapse
room. Definitive treatment may need to be delayed until ■ Length of stenosis no more than 2–3 cm
histologic and/or microbiologic diagnosis is obtained, ■ Identifiable airway lumen
or the systemic disease is treated medically. ■ If present, tracheostomy entry point not involving/adja-
■ Evaluation and mapping of stenosis as an aid to plan- cent to the stenotic site
ning an external procedure—in this instance the patient
is known to have a stenosis that is not amendable to
endoscopic treatment; however, anatomic mapping of
the stenosis and tracheostomy location are obtained to
aid in selection of the appropriate external surgical ap- Repetitive mechanical trauma from the tracheostomy tube post-
proach. (See Chap. 29, “Subglottic Stenosis,” for details operatively has an adverse effect on healing of airway stenosis.
in mapping the extent of the stenosis.) Thus, if a tracheostomy tube is present, the stenotic region ideally
should not extend down to the entry point of the tracheotomy.
6.7.3 Criteria for T-Tube Stenting ■ Nontraumatic subglottic narrowing should be

for Subglottic Stenosis investigated thoroughly to rule out associated
inflammatory and neoplastic conditions, such as
Wegener’s granulomatosis and laryngopharyngeal
■ Tracheotomized patients with subglottic/tracheal nar- reflux disease.
rowing (from any cause) who have failed serial CO2 ■ Physical examination of a patient with suspected
radial incisions/dilation treatment laryngotracheal stenosis should include a flex-
■ Proximal subglottic/infraglottic region free of stenosis ible laryngoscopy and tracheoscopy (down to the
■ 5- to 8-mm length of “normal” airway below vocal carina) in the clinic setting, using topical lidocaine
folds for endolaryngeal/tracheal anesthesia.
■ Accommodates proximal limb of T-tube, without ■ Radiographic airway studies are essential if exter-
6 impingement on vocal fold nal compression is suspected, but do not replace a
laryngoscopic airway evaluation.
■ Corrective surgical procedures for laryngotracheal
6.7.4 Criteria for External Treatment stenosis include endoscopic management (mi-
of Glottic/Subglottic Stenosis crolaryngoscopy with laser radial incisions with
dilation), indwelling stent placement, and external
treatments (cartilage expansion grafts vs. segmen-
Criteria include:
tal resection and primary anastomosis).
■ Failure of endoscopic and/or T-tube stent treatments ■ In patients with laryngotracheal stenosis, the
■ Extensive stenosis (no identifiable lumen, length greater least invasive surgical procedures are attempted
than 3 cm) first (unless contraindicated), reserving external
■ Tracheomalacia, cartilage collapse procedures for those cases that fail to respond to
an endoscopic approach.
■ Medical comorbidities (diabetes mellitus, restric-
It should be noted that the above recommendations are not ab-
tive or obstructive pulmonary disease, and ob-
solute criteria for selecting external treatment approaches; they
structive sleep apnea) may have a significant nega-
simply represent general guidelines. Certainly patients with
tive impact on the surgical outcome and should
lesser degrees of stenosis have failed endoscopic management,
be carefully considered prior to undertaking these
while conversely, those with more extensive stenosis have oc-
treatments.
casionally responded favorably to endoscopic treatment. The
surgeon should use his/her judgment in determining suitabil-
ity for endoscopic approach.
1 Benjamin B (1993) Prolonged intubation injuries of the larynx:

Key Points
endoscopic diagnosis, classification, and treatment. Ann Otol
Rhinol Laryngol 160(Suppl):1–15
2 Amin MR, Simpson CB (2004) Office evaluation of the tracheo-
■ Laryngotracheal airway obstruction is gener-
bronchial tree. Ear Nose Throat J 83(Suppl.):10–12
ally caused by trauma to the upper airway from
3 Shapshay SM, Beamis JF, Hybels RL et al (1987) Endoscopic
prolonged endotracheal intubation, which leads
treatment for subglottic and tracheal stenosis by radial laser inci-
to pressure necrosis, granulation tissue, localized
sion and dilation. Ann Otol Rhinol Laryngol 96:661–664
infection, and cicatrix formation. The risk of airway
4 McCaffrey TV (1991) Management of subglottic stenosis in the
stenosis increases markedly after 10 days of intu-
adult. Ann Otol Rhinol Laryngol 100:90–94
bation.
5 Gardner GM, Courey MS, Ossoff RH (1995) Operative evaluation
■ Tracheostomy can lead to delayed tracheal ste-
of airway obstruction. Otolaryngol Clin North Am 28:737–750
nosis (typically 1–3 months after decannulation)
6 Lano CF Jr, Duncavage JA, Reinisch L, Ossoff RH, Courey MS,
and is typically due to collapse/contraction of the
Netterville JL (1998) Laryngotracheal reconstruction in the adult:
cartilaginous support.
a ten-year experience. Ann Otol Rhinol Laryngol 107:92–97
Chapter 7
Nonsurgical Treatment
of Voice Disorders 7
studies have shown that twice-a-day therapy appears to result
in the highest symptom resolution. Most clinicians and studies
support duration of treatment of at least 4–6 months. It takes
Please see Chaps. 2, 4, 5 and 8 for further information. several months for affects to be noted by the patient, so pa-
tients typically need encouragement to remain compliant with
their medication.
Several controversies in the treatment of LPR include the
7.2 Introduction
strength of association between cough and LPR and duration
of treatment. An additional point of contention is the use of
Many voice problems do not require surgery if properly iden- histamine type 2 (H2RA) receptor antagonists in combination
tified and treated. Though phonosurgical management of with PPIs. A few studies have confirmed that the H2RAs do
certain vocal pathologies is critical, many voice disorders are not add any additional efficacy to treatment; however, many
treated effectively by non-surgical means. This chapter gives a clinicians have noted significant improvement in LPR control
brief overview of several categories of voice disorders that are with H2RAs, especially when given at night for the treatment
primarily treated without surgery. of nocturnal acid breakthrough.
7.3 Surgical Indications 7.4 Vocal Fold Granuloma

Vocal fold granulomas (specifically nonintubation related) are
Four to 10% of otolaryngologic visits are related to gastro- notoriously recalcitrant to surgical therapy when underlying
esophageal reflux disease-related laryngeal complaints. Up to causative factors (such as LPR) are not controlled. Most vocal
50% of voice disorder patients may have coexisting laryngo- fold granulomas are located in the posterior third of the vocal
pharyngeal reflux (LPR). LPR manifests in many ways: sore fold either unilaterally or bilaterally. When granulomas occur
throat, globus, hoarseness, throat clearing, dysphagia, chronic postsurgically, they can occur anywhere an operative site exists.
cough, and postnasal drip. The diagnosis of LPR is based on LPR plays an important role in the development of granulomas
patient history and laryngeal signs noted during laryngos- as do phonotrauma and trauma secondary to endotracheal in-
copy. These include edema and erythema of the larynx, pseu- tubation. Intubation granulomas are more common in wom-
dosulcus (infraglottic edema), Reinke’s edema, interarytenoid en, presumably because their smaller larynx is more prone to
mucosal changes, contact ulcers, granulomas, and posterior trauma from the endotracheal tube. One study found that of
pharyngeal mucosal cobblestoning. It has been associated as patients with LPR, up to 75% responded to clinical treatment
well with paradoxical vocal fold motion disorder and asthma. with PPIs; however, 21% demonstrated recurrence. The other
It has also been linked to the development of leukoplakia and treatment options for granulomas are voice therapy and botu-
potentially, laryngeal cancer. Studies have alluded to the fre- linum toxin type A injection to the thyroarytenoid muscle. The
quent association of LPR and/or gastroesophageal reflux dis- latter causes a temporary paresis of the vocal fold to reduce ex-
ease (GERD) with subglottic stenosis in adults and children. It tensive interarytenoid contact. Vocal fold granulomas also of-
is critical to treat LPR after any type of airway reconstruction. ten occur (and recur) due to an underlying glottal insufficiency
Symptoms can be quantified by means of the Reflux Symptom that may not be recognized by the treating physician. Excessive
Index and findings by the Reflux Finding Score. It is felt that vocal fold closure pressure is applied to the arytenoids in an
both the acid and pepsin contribute to the inflammation as- attempt to compensate for the glottal insufficiency, resulting in
sociated with LPR and/or GERD. vocal fold granuloma formation or recurrence. Treatment for
The gold standard in diagnosis remains the 24-h double- vocal fold granuloma due to glottal insufficiency involves vocal
probe (esophageal and pharyngeal) pH study. With this study, fold augmentation and/or medialization (see Chaps. 31, ”Vo-
a reflux event is defined as a 5 second drop in the intraluminal cal Fold Augmentation via Direct Laryngoscopy”; 38, “Silastic
pH below 4.0. The standard of care for the treatment of LPR Medialization Laryngoplasty for Unilateral Vocal Fold Paraly-
is the proton pump inhibitor (PPI), which works to irrevers- sis”; and 39, “GORE-TEX® Medialization Laryngoplasty”).
ibly inhibit the proton pumps of the gastric parietal cell. Recent
44 Nonsurgical Treatment of Voice Disorders
coarytenoid arthritis and rheumatoid lesions of the vocal fold.

7.5 Infectious and Inflammatory
Systemic treatment of RA is favored to treat rheumatoid nod-
Disorders
ules; if they persist and cause a functional voice problem, then
surgery is indicated. Vocal fold hypomobility associated with
Fungal laryngitis is increasingly recognized as a cause of lar- cricoarytenoid (CA) arthritis has resolved in some reports with
yngitis. The widespread use of steroid based inhalers for the systemic treatment and possibly steroid injection into or near
treatment of obstructive pulmonary disease has been a ma- the CA joint. Systemic lupus erythematosus (SLE) infrequently
jor contributor to the increase in fungal laryngitis incidence. manifests itself in the larynx but can be associated with laryn-
Fungal laryngitis may be mistaken for leukoplakia. Clinical geal edema in up to 28% of patients and vocal cord paralysis in
appearance of whitish plaques surrounded by erythematous 11% of patients with SLE.
mucosa is characteristic. Predisposing factors apart from Wegener’s granulomatosis (WG) is a rare disease that in-
inhaler use include radiotherapy, prolonged antibiotic use, volves principally three anatomical areas: the head and neck,
smoking, and immunosuppression. Dysphonia may occur in lower respiratory tract, and the renal system. The cause of
7 5–50% of patients using inhaled steroids. There appears to be WG is unknown, but the disease is pathologically described
a dose-dependent dysphonia in 34% of patients treated with by three findings: necrosis, granulomatous inflammation, and
beclomethasone dipropionate or budesonide when adminis- vasculitis. Signs associated with laryngeal involvement include
tered via pressured metered dose inhalers. The most common wheezing or stridor, dyspnea, and dysphonia. Diagnosis is
organism implicated is Candida, but the presence of Aspergil- based on a blood test for the identification of antinuclear cyto-
lus, Blastomyces, Histoplasma, and Coccidioides has also been plasmic antibody (ANCA) and specifically c-ANCA, which is
documented in cases of fungal laryngitis. Diagnosis is based found in 90% or more of patients with active WG. Subglottic
on demonstration of fungal spores, hyphae, and/or pseudohy- stenosis is a major concern; the vocal folds proper are usually
phae within upper epithelial layers of the laryngeal mucosa by not involved. Systemic treatment incorporates use of cortico-
culture or biopsy, both of which are done via laryngoscopy or steroids and other immunosuppressive drugs, especially cy-
office endoscopy. However, often the disease is treated clini- clophosphamide. If the stenosis is critical however, patients
cally based on the characteristic findings. Inhalers used with go on to either endoscopic or open surgical treatment, with
a spacer decrease laryngeal deposition of the medication and or without tracheostomy depending on severity of the disease
can help with reduction or complete elimination of the offend- (see Chaps. 6, “Glottic and Subglottic Stenosis: Evaluation of
ing agent. Upper Airway Disorders”; 29, “Subglottic Stenosis”; 45, “Glot-
Treatment of fungal laryngitis rests on removal of the of- tic and Subglottic Stenosis: Laryngotracheal Reconstruction
fending steroid when possible and antifungal medication. If with Grafting”; and 46, “Glottic and Subglottic Stenosis: Cri-
the organism persists, then treatment with an oral conazole cotracheal Resection with Primary Anastomosis”). The disease
agent for 3–4 weeks is commenced. Current standard of care, state should be under good medical control before performing
however, is use of an oral conazole medication as initial treat- surgical procedures for airway stenosis.
ment especially in the immunocompromised patient. Laryngeal amyloidosis is a rare and benign idiopathic dis-
Chemical laryngitis—specifically steroid inhaler laryngi- ease, which presents as a primary disease or secondary with
tis—is another common cause of dysphonia in the inhaler- other disease processes. It comprises 0.2–1.2% of all benign
using patient. Hoarseness is the most frequent local side ef- tumors. The disease is indolent and when found in the larynx,
fect of steroid inhalers. Several factors may contribute to this can cause slowly progressive dysphonia and dyspnea; airway
chemical irritation: the steroid “its preparation, the drug car- symptoms in general appear to predominate. When present in
rier” the type of inhaler device, mechanical irritation due to a secondary form, it can be associated with multiple myeloma,
cough, inflammation of the upper airways and surrounding ir- medullary thyroid carcinoma, and small cell carcinoma. Amy-
ritating triggers such as smoke. One study noted the following loid deposits or lesions are described typically as “firm, nonul-
mucosal changes in patients with inhaler-related dysphonia: cerating, orange-yellow, to gray epithelial nodules.” Definitive
vascular lesions such as dilated blood vessels, capillary ectasias diagnosis is based on histopathologic presence of amyloid fi-
and varices, and “areas of thickening, irregularity, and leuko- brils in a twisted β-pleated sheet patter with affinity for Congo
plakia.” These changes appear to improve after cessation of the red dye. The underlying condition in the secondary form re-
steroid inhaler. In addition, some have attributed dysphonia quires treatment; however, systemic treatment frequently may
secondary to steroid inhaler use to steroid myopathy, as both not eliminate the amyloid deposits. When the airway or voice
vocal folds appear atrophic and glottal closure is incomplete. is compromised, surgical intervention is warranted. Serial laser
Actual muscle bulk change due to steroid inhalers is contro- laryngoscopy is often effective at controlling symptoms. More
versial and not supported by scientific evidence. Some findings advanced disease may require laryngofissure with partial or
can overlap with those of LPR; therefore, LPR should be opti- total laryngectomy. Primary (localized) and secondary (sys-
mally controlled in conjunction with reduction or discontinu- temic) amyloidosis are distinguished based on physical exam
ation, when possible, of the inhaler. (for tender bones, heart failure, hepatosplenomegaly, lymph-
Autoimmune disorders are relatively rare but several of adenopathy), blood/serum and urine testing, chest and bone
these have effects on the vocal folds and subglottis. Rheuma- radiography, abdominal subcutaneous fat aspiration, CT exam
toid arthritis (RA) affects 2–3% of the adult population, and of suspicious parts of the body, and rectal biopsy.
25–53% of patients have involvement of the larynx. The main
two manifestations of RA at the level of the vocal folds are cri-
Chapter 7 45
of the voice is seen in 12–30% of patients with essential trem-

7.6 Neurologic Disorders
or, and a head tremor in 50%. Essential tremor of the voice is
marked by a regular 4- to 12-kHz frequency oscillation of the
7.6.1 Spasmodic Dysphonia
affected muscles. Several drugs have also been associated with
tremor production, and Parkinson’s disease is also considered
Spasmodic dysphonia (SD) is a focal dystonia characterized by in the differential diagnosis.
vocal task specific action or intention induced spasms. Dysto- Pharmacotherapy, specifically with primidone and pro-
nias in general are disorders of central motor processing, and pranolol, is employed as first-line treatment but is more effec-
SD can be found in conjunction with other disorders, such tive for limb-based tremor than voice. Recently, some work has
as Meige’s syndrome, although typically it is isolated to the emerged concerning botulinum toxin A injections for treat-
larynx. There are three classic types of SD. Adductor SD (1) ment of voice tremor. The difficulty with local treatment, how-
comprises 80% of patients with the disorder. Abductor SD (2) ever, is that multiple muscles are involved in voice tremor (both
and patients with both adductor and abductor activity, mixed intrinsic and extrinsic laryngeal musculature), so the benefit of
SD (3), comprise the rest of disease population. Adductor SD simple thyroarytenoid–lateral cricoarytenoid muscle complex
is marked by a “strained-strangled” speech pattern caused by injection is not nearly comparable to benefit of botulinum toxin
premature and excessive glottal closure, whereas abductor SD A seen in SD treatment. Medically refractory cases are treated
is marked by breathy speech breaks and an overall hypophonia with thalamotomy or deep brain stimulation (DBS); bilateral
due to inappropriate glottal opening during speech. SD typi- thalamotomy is associated with significant vocal side effects
cally presents in a female patient in her mid-30s, and if it has such as hypophonia and significant data for DBS in treatment
been present for some time, many patients develop compen- of voice tremor is pending.
satory changes, which may mask the true diagnosis. Patients
may not demonstrate speech breaks during singing or laugh-
ing tasks, and patients find worsening of symptoms when un-
7.6.3 Parkinson’s Disease
der psychological stress. Diagnosis rests primarily on audi-
tory-perceptual evaluation of connected speech supplemented
by flexible nasopharyngolaryngeal examination. Diagnosis can Parkinson’s disease (PD) affects nearly 1 million persons in
be difficult, as patients may have associated essential tremor the United States, and in severe forms, leads to considerable
or actually have muscle-tension dysphonia; both disorders can disability. The disease is caused by neurodegeneration within
cause voice breaks. the nigrostriatal tracts of the basal ganglia, a neural center for
Few if any medications have been successful in ameliorating motor control, which leads to decreased dopamine release.
symptoms of SD. Some patients find that alcohol or benzodi- The hallmark clinical findings are bradykinesia, tremor, pos-
azepines are helpful to reduce the stress that may be the trigger tural instability, and muscle rigidity. Phonatory effects include
for SD. The standard of care in the treatment of SD is injection hypophonia, breathy dysphonia, and vocal tremor. The voice
of the affected muscle(s) with botulinum toxin (BTX), which takes a monotonic quality. Many patients experience dyspha-
causes a temporary chemical denervation of the thyroaryte- gia and dysarthria. One study reported that 87% of PD patients
noid–lateral cricoarytenoid muscle complex in adductor SD demonstrated vocal fold bowing. The treatment of the voice
and the posterior cricoarytenoid muscle in abductor SD (see component of PD involves a specialized voice therapy pro-
Chap. 35, “Botulinum Toxin Injection”). Prior to this, recur- gram, Lee Silverman Voice Treatment (LSVT), with or without
rent laryngeal nerve section was performed; however, recur- vocal fold augmentation to improve glottic configuration and
rence of symptoms was typical (despite complete nerve sec- closure. Typically, LSVT is sufficient alone and vocal fold aug-
tion) and the overall voice quality worsened. Voice therapy can mentation is not required. Treatment of PD is pharmacologic
be used as adjunctive therapy to treat compensatory behaviors using dopamine agonists and medically refractory cases may
or assist in differentiating SD from muscle-tension dysphonia. undergo DBS or pallidotomy. No data are available currently
Some newer surgical techniques have been developed but no regarding the effect of DBS on the voice in PD.
long term data is available and thus are presently experimental
and not validated.
7.6.4 Muscle Tension Dysphonia
7.6.2 Essential Tremor

Muscletension dysphonia (MTD) is a term used to describe
voice disorders that are related to excessive and poorly regu-
Essential tremor is the most common movement disorder, af- lated laryngeal muscle activity during speech. Many synonyms
fecting 0.4–5.6% of those over age 40. However, the disease are used in clinical practice and these include hyperfunctional
also appears to have a bimodal age distribution, with 4.6–5.3% dysphonia, muscle misuse, and tension-fatigue syndrome to
of cases occurring in the first two decades of life. There appears name a few. The “muscletension” descriptor has been applied
to be a familial association in 17–100% of individuals transmit- to muscle contraction patterns seen on flexible laryngoscopy of
ted in an autosomal-dominant inheritance pattern with vari- the endolarynx; these are classified from types I–IV, with type I
able penetrance. Three areas of the body may be involved to being very mild constriction with an excessive posterior glottic
varying degrees: head, hands, and vocal tract. Essential tremor chink, to type IV, a concentric closure pattern of the supraglot-
tis. Some of these patterns are seen in other disorders as well Occasionally, psychiatric treatment may also be required.
such as adductor SD or even in normal voices and these are not Some have attempted use of heliox (80% helium, 20% oxygen)
pathognomonic. to decrease work of breathing, but results have been mixed.
MTD can present as a primary problem often associated
with post-URI onset, inappropriate pitch use, reflux, or signifi-
cant voice demands. It can also present in a secondary form as
7.6.6 Postviral Vagal Neuropathy
excessive compensation for glottal insufficiency. Circumlaryn-
geal massage has been used in conjunction with voice therapy
to assist in reducing laryngeal height, as these patients fre- Postviral vagal neuropathy (PVVN) is marked by chronic
quently hold their larynges in an abnormally elevated position cough, with or without laryngospasm or PVFMD. The cough
secondary to increased muscular tension. In the most severe or is thought to be a result of altered laryngeal sensitivity such
refractory patients, topical anesthetization of the endolarynx as in post viral neuralgias of other cranial nerves. The trig-
has assisted in decreasing laryngeal tension because of altered ger may be an irritant or even palpation of the larynx. La-
7 sensation and proprioception. ryngeal electromyography (EMG) is used to confirm subtle
Functional dysphonia or aphonia is a separate term that neuropathic findings of paresis. These patients are frequently
should be used for psychogenic dysphonia or conversion dis- treated for allergies, LPR, and PVFMD and may be refractory
order. Those with conversion disorder have experienced sig- to treatment. When faced with this situation, treatment with
nificant psychological trauma from an event that causes the the anticonvulsive agent gabapentin should be considered,
aphonia; as such, these patients require intense psychiatric which decreases neural sensitivity. Treatment success ranges
treatment in addition to voice therapy. “Malingering” or “facti- from 37.5 to 80%, depending on level of motor involvement
tious dysphonia” would be included under this term. of the neuropathy. A starting dose of 100 mg three times a day
is recommended, increasing to 300 mg three times a day for
symptom control.
7.6.5 Paradoxical Vocal Fold Motion Disorder
7.7 Allergy and Voice Disorders

Paradoxical vocal fold motion disorder (PVFMD) is a disorder
marked by desynchronized or paradoxical adduction of the
vocal folds during inspiration and/or expiration. As a result, Allergic diseases can manifest in the larynx in several ways.
the patient exhibits inspiratory stridor and/or experiences a The classic description is that of laryngeal angioedema, an
sensation of airway restriction. This is often confused with the acute life-threatening process initiated by exposure to a spe-
wheezing of asthma that, in contrast, occurs in the expiratory cific allergen. This process is associated with immunoglobulin
phase. Symptoms also include choking, aphonia or dysphonia, IgE-mediated anaphylaxis, but it is also seen in a non-IgE-me-
and chronic cough. diated anaphylactoid response. Treatment of this disorder in-
Many terms have been used in the past to describe this con- volves immediate airway control and injection of epinephrine
dition, including vocal cord dysfunction, factitious asthma, psy- with use of steroids and H2 blockers after the initial episode.
chogenic asthma, irritable larynx syndrome, and episodic parox- Food allergy may lead to milder swelling of the vocal tract with
ysmal laryngospasm. The differential diagnosis is bilateral vocal dysphonia and may actually stimulate or worsen LPR. Avoid-
cord paralysis, hereditary abductor paralysis, posterior glottic ance of the triggering allergen and antihistamines are the rec-
stenosis, or cricoarytenoid joint fixation. PVFMD has many ommended treatment.
causes and has been classified into five organic and two non- Many patients also suffer from chronic postnasal drip sec-
organic categories, based on etiology. These include brainstem ondary to allergic rhinitis. These patients tend to frequently
compression, severe cortical or upper motor neuron injury, nu- clear their throats, which leads to maladaptive laryngeal mus-
clear or lower motor neuron injury, movement disorder, gastro- cle usage and can lead to the development of vocal fold lesions.
esophageal reflux, factitious or malingering PVFMD, and con- Exposure and allergy to aerosolized irritants can also lead to
version disorder PVFMD. When associated with a conversion muscle-tension dysphonia. Mold and volatile organic com-
disorder, it is seen in primarily high-achieving, perfectionistic pounds (VOC) are the usual suspects. VOCs include alcohols,
adolescents who are usually athletes, as well as in young female aldehydes, and ketones. Again, avoidance and/or removal of
professionals. Patients complain of exercise-induced episodes the source of the irritant are the mainstay of treatment. Im-
of airway restriction, irritant-exposure triggers, or symptoms munotherapy is an important consideration for treatment of
after a meal. Flow-volume loops have been used to assist in allergy in the professional voice user, as it avoids drying effects
diagnosis; however, both false positives and false negatives are of antihistamines in the endolarynx.
generated, and there is no consistent pattern.
The gold standard in diagnosis is demonstration of PVFMD
during flexible laryngoscopy, which may be seen at rest of after
7.8 Medications and Their
administration of a trigger (exercise, perfumes, etc). Treatment
Effects on Voice
consists of elimination or avoidance of triggers, including re-
flux and allergy treatment, and respiratory retraining therapy
administered by the speech pathologist. Any coexisting asth- Both allergy and post-URI patients can experience dysphonia
ma/reactive airway disease must also be aggressively treated. related to persistent postnasal drip. Patients also experience
Chapter 7 47
cough due to direct irritation from mucus or because of al- primrose, garlic in high doses, vitamin E in high doses, gingko
tered sensitivity of the endolarynx. Severe coughing can result biloba, ginger, feverfew, and red root. Some may have cross-
in phonotrauma, leading to vocal fold hemorrhage and vocal reactivity to ragweed: goldenseal, chamomile after long-term
fold lesion formation. As a result, many over the counter prep- use, echinacea, St. John’s wort, yarrow, dong quai. Some herbal
arations are used for their antitussive and mucolytic proper- medications also may have hormonal effects, e. g., dong quai
ties. Guaifenesin is the most widely used mucolytic and works may increase effects of ovarian and testicular hormones. Yam
best when the patient is well hydrated. Codeine and dextro- has progesterone-like properties, and licorice root also has
methorphan are added to many cold medicine preparations. progesteronic in addition to estrogenic effects and can change
Tramadol, which is a weak opiate, may have enhanced antitus- vocal pitch. Primrose is a natural estrogen promoter, and mela-
sive properties, without the significant opioid side effects asso- tonin acts as a contraceptive in high doses.
ciated with codeine. Antihistamines again should be used with
caution in the professional voice user with allergy, as the dry-
ing effects on the vocal folds can be detrimental. Leukotriene
7.9 Vocal Hygiene
inhibitors, such as montelukast, and nasal corticosteroids can
be used in allergic patients, with less drying.
Despite widespread clinical use of oral corticosteroids for A discussion of medical treatment of voice disorders would
acute dysphonia in the professional voice user, there is mini- not be complete without discussing the importance of vocal
mal scientific literature concerning this subject. The corticoste- hygiene. Elements of vocal hygiene include understanding
roid mechanism of action is to prevent capillary dilation and that medical problems affect the voice, understanding effects
decrease capillary permeability, which consequently decreases of smoking, alcohol, drugs, hydration and nutrition, vocal
edema. Typically, oral steroids are used in short bursts, with a stress and vocal exercise, and general vocal hygiene. Vocal hy-
tapering dosage to avoid adrenocortical insufficiency and min- giene involves knowledge, avoidance, or reduction of irritants
imize long-term side effects. Intramuscular use is also reported such as gastric juices or tobacco smoke, dehydration and con-
for the acute situation. A few studies have shown improvement trol of postnasal drip of any cause. The patient should be made
in objective acoustic measures with use of steroids. However, keenly aware of the danger of “singing sick,” as vocal injuries
if used for a more extended period, corticosteroids can lead to are more likely to occur in the sick singer than in a healthy
fluid imbalance, systemic muscle weakness and atrophy, gas- one. The sick singer should take adequate vocal rest, fluids,
trointestinal and neurologic problems, glaucoma, and electro- and medical care as needed. Vocal fold hemorrhage and vocal
lyte and metabolic disorders, and can lead to fungal infection. fold lesions are the most significant concerns, and changing
Corticosteroids have been linked to peptic ulcer development; bad habits early in younger performers is critical to long-term
therefore, any patient on long-term oral corticosteroids should vocal health.
be placed on at least an H2 blocker, preferably a PPI.
Many medications have virilizing properties and should be
used with great caution in the professional voice user, or any
7.10 Role of the Speech–Language
patient for that matter. These medications, such as Danazol,
Pathologist in Voice Therapy
have been used for treatment of fibrocystic breast disease and
endometriosis. Testosterone injections have been administered
to women complaining of loss of libido or energy and have The speech–language pathologist is instrumental in teaching
been reported in female athletes for enhanced performance. the voice disorder patient about laryngeal anatomy and vocal
Nonphonatory side effects include acne, hirsutism, weight biomechanics, which are central to the voice therapy process
gain, and hairline recession. Voice effects including lowering of for many disorders. The speech–language pathologist with
fundamental frequency, vocal instability with pitch breaks, loss special training in voice disorders is an essential member of
of high frequency vocal range, and generalized dysphonia. For the diagnostic and therapeutic team required for high-quality
Danazol, the incidence may be as high as 10% in patients on voice care. The speech–language pathologist specializes in as-
the medication. Histologically, water retention in the muscle sessing and treating behavioral issues of the speaking and sing-
and fiber hypertrophy are seen. Although some reports have ing voice. Many patients with dysphonia struggle from a variety
stated that effects are temporary and cease with discontinua- of poor behaviors and/or speaking techniques or inappropriate
tion of the medication, there is potential for permanent voice use of the voice and these problems are all easily treated with
change as can be seen in histological studies. This can be par- the intervention of the speech–language pathologist, using the
ticularly damaging to the voice professional, so great caution overall global term of voice therapy. A detailed description of
must be used when considering prescribing these medications. voice therapy treatment methods for a variety of dysphonias
During the premenstrual period of the menstrual cycle, many is outside the focus of this book, but it is essential component
women exhibit pitch lowering secondary to presumed venous of the treatment of a wide variety of voice disorders is a non-
dilatation and edema of the vocal folds. Low-dose oral mono- surgical approach to voice rehabilitation with voice therapy.
phasic contraceptives have been shown to reduce this pitch Thus, the speech–language pathologist plays a crucial role in
variability and exhibit less androgenic side effects. all phases of modern voice care (diagnostic, therapeutic, and
One group of medications that should not be overlooked is rehabilitative).
herbal remedies. Many have anticoagulant properties and can
predispose a person to vocal fold hemorrhage. These include
dong quai (which actually contains coumadin), willow bark,
14 Devaney K, Ferlito A, Devaney SL, Hunter BC, Rinaldo A (1998)

Key Points
Clinicopathological consultation: Wegener’s granulomatosis of
the head and neck. Ann Otol Rhinol Laryngol 107:439–445
15 Herridge MS, Pearson FG, Downey GP (1996) Subglottic steno-
■ Up to 50% of voice disorder patients may have
sis complicating Wegener’s granulomatosis: surgical repair as a
coexisting LPR.
viable treatment option. J Thorac Cardiovasc Surg 111:961–966
■ Twice-a-day therapy with a proton pump inhibitor
16 Stappaerts I, Van Laer C, Deschepper K, Van de Heyning P, Ver-
results in the highest symptom resolution.
meire P (2000) Endoscopic management of severe subglottic ste-
■ Muscletension patterns I–IV seen in MTD are not
nosis in Wegener’s granulomatosis. Clin Rheumatol 19:315–317
pathognomonic for this disorder and can be seen
17 Bartels H, Dikkers FG, Lokhorst HM, Van der Wal JE, Hazenberg
in other voice disorders such as spasmodic dys-
BPC (2004) Laryngeal amyloidosis: localized versus systemic dis-
phonia, and even some normal voices.
ease and update on diagnosis and therapy. Ann Otol Rhinol Lar-
■ PVFMD is treated best with multimodality treat-
yngol 113:741–748
ment that includes respiratory retraining (voice
7 therapy) and proton pump inhibitors, as LPR is a
18 Akst LM, Thompson LDR (2003) Larynx amyloidosis. Ear Nose
Throat J 82(11):844–845
common trigger for PVFMD episodes.
19 Sulica L (2004) Contemporary management of spasmodic dys-
phonia. Curr Opin Otolaryngol Head Neck Surg 12:543–548
20 Warrick P, Dromey C, Irish JC, Durkin L, Pakiam A, Lang A (2000)
Botulinum toxin for essential tremor of the voice with multiple
anatomical sites of tremor: a crossover design study of unilateral
versus bilateral injection. Laryngoscope 110:1366–1374.
1 Park W, Hicks DM, Khandwala F et al (2005) Laryngopharyn- 21 Sullivan KL, Hauser RA, Zesiewicz TA (2003) Essential tremor:
geal reflux: prospective cohort study evaluating optimal dose of epidemiology, diagnosis, and treatment. Neurologist 10:250–258
proton-pump inhibitor therapy and pretherapy predictors of re- 22 Zesiewicz TA, Elble R, Louis ED et al (2005) Practice parameter:
sponse. Laryngoscope 115:1230–1238 therapies for essential tremor. Neurology 53:2008–2020
2 Belafsky PC, Postma GN, Koufman JA (2001) Laryngopharyn- 23 Blumin JH, Picolinksy DE, Atkins JP (2004) Laryngeal find-
geal reflux symptoms improve before changes in physical findings in advanced Parkinson’s disease. Ann Otol Rhinol Laryngol
ings. Laryngoscope 111:979–981 113:253–258
3 Vaezi MF (2003) Gastroesophageal reflux disease and the larynx. 24 Roy N (2003) Functional dysphonia. Curr Opin Otolaryngol
J Clin Gastroenterol 36:198–203 Head Neck Surg 11:144–148
4 de Lima Pontes PA, De Biase NG, Gadelha ME (1999) Clinical 25 Altman KW, Simpson CB, Amina MR, Abaza M, Balkissoon R,
evolution of laryngeal granulomas: treatment and prognosis. La- Casiano RR (2002) Cough and paradoxical vocal fold motion.
ryngoscope 109(Pt. 1):289–294 Otolaryngol Head Neck Surg 127:501–511
5 Walner DL, Stern Y, Gerber ME, Rudolph C, Baldwin CY, Cot- 26 Maschka D, Bauman NM, McCray PB et al (1997) A classifica-
ton RT (1998) Gastroesophageal reflux in patients with subglottic tion scheme for paradoxical vocal cord motion. Laryngoscope
stenosis. Arch Otolaryngol Head Neck Surg 124:551–555 107:1429–1435
6 Jaspersen D, Kulig M, Labenz J et al (2003) Prevalence of extra- 27 Morrison M, Rammage L, Emami AJ (1999) The irritable larynx
oesphageal manifestations in gastro-oesophageal reflux disease: syndrome. J Voice 13:447–455
an analysis based on the Pro-GERD study. Aliment Pharmacol 28 Lee B, Woo P (2005) Chronic cough as a sign of laryngeal sensory
Ther 17:1515–1520 neuropathy: diagnosis and treatment. Ann Otol Rhinol Laryngol
7 Mehanna HM, Kuo T, Chaplin J, Taylor G, Morton RP (2004) 114:253–257
Fungal laryngitis in immunocompetent patients. J Laryngol Otol 29 Amin MR, Koufman JA (2001) Vagal neuropathy after up-
118:379–381 per respiratory infection: a viral etiology? Am J Otolaryngol
8 Roland NJ, Bhalla RK, Earis J (2004) The local side effects of in- 22:251–256
haled corticosteroids: current understanding and review of the 30 Chadwick SJ (2003) Allergy and the contemporary laryngologist.
literature. Chest 126:213–219 Otolaryngol Clin N Am 36:957–988
9 Sulica L (2005) Laryngeal thrush. Ann Otol Rhinol Laryngol 31 Watts CR, Early SE (2002) Corticosteroids: effects on voice. Curr
114:369–375 Opin Otolaryngol Head Neck Surg 10:168–172
10 Mirza N, Schwartz SK, Antin-Ozerkis DA (2004) Laryngeal find- 32 Baker J (1999) A report on alterations to the speaking and sing-
ings in users of combination corticosteroid and bronchodilator ing voices of four women following hormonal therapy with viril-
therapy. Laryngoscope 114:1566–1569 izing agents. J Voice 13:496–507
11 DelGaudio JM (2002) Steroid inhaler laryngitis: dysphonia 33 Amir O, Biron-Shental T, Muchnik C, Kishon-Rabin L (2003) Do
caused by inhaled fluticasone therapy. Arch Otolaryngol Head oral contraceptives improve vocal quality? Limited trail on low-
Neck Surg 128:677–681 dose formulations. Obstet Gynecol 101:773–777
12 Woo P, Mendelsohn J, Humphrey D (1995) Rheumatoid nodules 34 Columbia University at New York Presbyterian Hospital, College
of the larynx. Ear Nose Throat J 113:147–150 of Physicians and Surgeons, Voice and Swallowing Center (2005)
13 Nanke Y, Kotake S, Yonemoto K, Hara M, Hasegawa M, Kamatani Herbal medications. http://www.voiceandswallowing.com/Voi-
N (2001) Cricoarytenoid arthritis with rheumatoid arthritis and cetreat_herb.htm
systemic lupus erythematosus. J Rheumatol 28:624–626 35 Murry T, Rosen CA (2000) Vocal education for the professional
voice user and singer. Otolaryngol Clin N Am 33:967–981
Chapter 8
Timing, Planning, and Decision

Making in Phonosurgery 8
should be made not to return for the remaining semester. For
example, phonomicrosurgery to remove any type of benign le-
sion of the lamina propria from a schoolteacher during winter
Please see Chaps. 4, 5, and 7 for further information. break—with expectations of resuming when school resumes at
the start of the new year—is a plan fraught with danger and
should be avoided. Phonomicrosurgery on teachers should
only be done at the start of summer (June) or the teacher will
8.2 Key Components to Successful Care
need to be off work for half the school year.
of Patients with Voice Disorders
This chapter addresses specific issues related to phonomicro-

8.3.2 Preoperative Considerations
surgery for benign lesions of the vocal fold, phonosurgery for
for Phonomicrosurgery
disorders of glottal incompetence, surgeries for airway enlarge-
ment, and tumor excision of the larynx. For many of the situ-
ations in voice care, the surgical procedures are elective, and Any conditions that will create temporary vocal fold edema
thus the surgeon and patient have the ability to participate in prior to phonomicrosurgery should be avoided or treated
maximum nonsurgical treatment modalities for the rehabilita- prior to proceeding. Thus, heavy vocal demands such as sing-
tion of the patient’s voice problem, psychological preparation ing, screaming, yelling, or lecturing should be avoided ap-
for surgery, and an appropriate and thorough informed con- proximately 1–2 weeks before phonomicrosurgery. Similarly,
sent process. comorbid medical conditions such laryngopharyngeal reflux
disease and sinonasal allergic disease, and upper respiratory
infection should be treated and may be reason to reschedule
the surgery. In some instances, a short dose of oral steroids can
be used to alleviate the temporary vocal fold edema associated
with these conditions prior to phonomicrosurgery. The reason
for avoiding temporary vocal fold edema immediately prior to
8.3.1 Timing of Phonomicrosurgery
phonomicrosurgery is to minimize the removal of vocal fold
tissue (epithelium and/or lamina propria) that appears per-
The majority of patients require a significant amount of time to manently pathological but, in fact, may represent temporary
recover after phonomicrosurgery. Thus, it is important that the edema. If this occurs, excessive excision may result. Further-
surgeon and patient discuss the need for an adequate amount more, most likely epithelium/lamina propria wound healing is
of time for voice recovery after these procedures. Often a short compromised in the face of an acute inflammatory condition
period of complete voice rest immediately after phonomi- resulting in suboptimal postoperative voice rehabilitation.
crosurgery is indicated. This can range from 2 to 14 days and The psychological impact of phonosurgery on patients
typically averages 7 days. The time of voice limitation before should be greatly appreciated. This is an area that is frequently
allowing the phonomicrosurgery patient to use full speaking overlooked by surgeons, especially by doctors who do not ap-
voice activities ranges from 7 to 30 days. Similarly, the vocal preciate the unique relationship that professional voice users
recovery time before full singing is allowed is individualized to and heavy voice users have with respect to their psyche and
the patient situation, but typically ranges from 30 to 90 days. their voice. It is important to realize that these individuals (to
Thus, the patient must cancel pending voice demands when a large degree) identify themselves by their voice, and thus the
scheduling phonomicrosurgery or delay the surgery date until consideration and realization of the need for surgery induces a
there is a more appropriate time after the surgery to accommo- significant amount of anxiety and concern. This must be iden-
date reduced voice demands. This is especially important for tified by the voice care team preoperatively, and discussed and
vocal performers, given that they have many demands on them dealt with in a positive, successful fashion. This will ensure
from management and staff. Financial demands also pressure maximum postoperative voice quality, patient compliance, and
the vocalist to perform sooner than is medically appropriate. minimal negative outcomes and activities during this stressful
Similarly, schoolteachers have such significant vocal demands time. Preoperative voice therapy can often play a major role in
that any decision to proceed with phonomicrosurgery during addressing these issues. Furthermore, it is essential that the pa-
the school year should be taken with great caution, or plans tient not feel pressured or rushed to decide on proceeding with
50 Timing of Phonosurgery
phonomicrosurgery. The amount of time it takes any patient of their functional abilities and limitations should follow (see
to decide to proceed with phonosurgery is highly variable, and below.)
the decision-making process must be individualized. The decision to proceed with elective phonosurgery should
Patience should be exercised by the voice care team wait- be a joint decision between the patient and the surgeon. The
ing for the patient to become comfortable with the decision to optimal role of the patient should be as the primary decision
have phonosurgery. This will significantly improve the patient’s maker and the surgeon should serve as the educator in this pro-
coping ability during this stressful process. cess. After all nonsurgical rehabilitation methods have been
employed, a formal reevaluation by the voice care team should
be performed to decide if elective phonosurgery is indicated.
An important component to this decision-making process is
8.4 Decision Making in Phonosurgery
to encourage the patient to resume his/her voice activities af-
ter nonsurgical rehabilitation has been completed. When the
In most situations, phonosurgery is an elective procedure, and patient resumes vocal activity, they should be asked to an-
thus, the patient and surgeon are afforded an amount of time swer the simple (but essential) question: “Can you do what
for nonsurgical treatment of the voice condition, and then are you need to with your voice?” or “Do you still have significant
8 able to make a joint decision to proceed with surgery. On the functional limitations (e. g., reduced range, reduced clarity, vo-
other hand, surgery should not be delayed if the following are cal fatigue)?” This assessment of functional ability is crucial in
present: prompting the patient to decide if he/she should proceed with
phonosurgery. It is essential that the surgeon not pressure or
■ Dysphagia associated with aspiration
rush the patient’s decision. The surgeon’s most important role
■ Impending airway embarrassment
is to educate the patient on his/her specific voice condition and
■ Risk for malignancy
on the risks and benefits of the surgical procedure (see Sect. 8.5,
“Informed Consent Regarding Phonosurgery,” below), as well
The majority of voice-related procedures in the category of as to discuss reasonable expectations of elective phonosurgery.
phonomicrosurgery, laryngeal framework surgery, and vocal With this information, the patient should be well equipped to
fold injection for benign lesions of the vocal fold/glottal in- be the primary decision maker for elective phonosurgery.
competence are in fact non–life threatening. Thus, the decision It is essential for patients undergoing phonomicrosurgery
making and preparation prior to surgery should be undertaken to have had a recent voice evaluation. Specifically, a laryngo
on a reasonable timetable that should be predominantly pa- videostroboscopy should be performed in the period shortly
tient driven. before surgery (1–3 weeks). This allows the surgeon to review
Generally for most elective phonosurgeries, the patient and see the most recent status of the vocal fold pathology, and
should be offered and undergo nonsurgical rehabilitative mea- this can often factor into important intraoperative decision
sures prior to proceeding with surgery. Of course, this dictum making. It is recommended that the surgeon review the recent
must be utilized within reason, given that there are instances stroboscopy examination either the day of the surgery or pref-
when the patient’s medical condition (large exophytic vocal erably immediately prior to (or during) the patient’s phonomi-
fold polyp or lateralized vocal fold paralysis) dictate that non- crosurgical procedure.
surgical treatment methods do not have a reasonable chance Intraoperative decision making can be quite challenging
for significant improvement. Thus, it is unreasonable and poor for the phonosurgeon, and there are various guidelines for the
use of resources to force all patients to undergo multiple non- types of laryngeal surgery being undertaken. For patients with
surgical rehabilitative measures (voice therapy, singing thera- cancer, intraoperative decision making is dictated by the loca-
py, allergy therapy, medical therapy) if they have no reasonable tion and nature of the cancer. However, if the surgeon is not
expectation to make a significant improvement in the patient’s comfortable with margins on frozen sections, then it is often
voice limitations and/or symptoms. If there is any possibility wise to obtain conservative margins and delay the surgical pro-
of the nonsurgical treatment options making a substantive dif- cedure until permanent pathology is available. Then, if there is
ference, then it is worthwhile having the patient undergo these a positive margin, a return to the operating room can be un-
treatments. However, close observation of the patient needs dertaken. This approach avoids excessive resection of nonma-
to be maintained to assess the patient’s response after a short lignant tissue.
time period. Specifically, this is the case with respect to voice For patients undergoing phonomicrosurgery for benign le-
therapy. Often patients with benign vocal fold lesions or with sions of the lamina propria, the intraoperative decision making
conditions of glottal incompetence will be treated with one or process should be approached in a very conservative fashion.
two sessions of voice therapy and then reassessed for progress Difficult decisions regarding how much to resection of epithe-
and potential for significant improvement. With a compliant lium and/or lamina propria should be done on the conserva-
patient and a skilled speech–language pathologist, the decision tive side; accepting the possibility a small number of patients
to proceed with phonomicrosurgery can be confidently made may require repeat phonomicrosurgery for persistent or recur-
pending the outcome and progress after one or two sessions rent disease. These repeat phonomicrosurgery procedures are
of voice therapy. Often after the initiation of voice therapy, the a small price to pay for minimizing the risk of overaggressive
patient begins to notice substantive improvement, and thus resection of epithelium and/or lamina propria, resulting in
all surgery should be delayed until voice therapy and possi- severe (and potentially irreversible) postoperative dysphonia
bly singing voice therapy is completed. A formal reevaluation from vocal fold scar.
Chapter 8 51
Intraoperative decision making regarding laryngeal frame- ter this type of surgery that persist involving loud speech and/
work procedures should follow this guideline: The best chance or singing. These limitations exist because of the persistent
for a good outcome is with the first surgical procedure. Thus, underlying pathologic condition such as vocal fold paralysis,
all attempts, regardless of the chosen method, should work to vocal fold scar, and vocal fold paresis. Informed consent for
achieve the best possible voice quality from the first surgical surgical removal of laryngeal cancer should include reduction
procedure. The reversibility and adjustability of revision laryn- of vocal and swallowing function as well as the risk for addi-
geal framework procedures may be limited. tional surgery depending on permanent pathology results after
Intraoperative decision making for airway cases, especially surgery.
for glottic enlargement procedures (transverse cordotomy, me- Informed consent for airway procedures must involve dis-
dial arytenoidectomy, total arytenoidectomy) should be done cussion that as the surgical procedure obtains an increased
in a conservative fashion. All patients should be counseled airway for the patient, the greater the likelihood of diminu-
that the greater the laryngeal airway that is created, the greater tion of the patient’s vocal function. The goal of the surgery is
is the risk for decreased vocal function. Thus, a conservative to obtain an adequate airway while at the same time minimiz-
(and, if needed, staged approach) to surgery for the enlarge- ing the negative impact on the voice. Due to this voice–air-
ment of laryngeal airway should be the guiding principle for way equation and the need for conservative removal of glottic
intraoperative decision making in this area. narrowing, the patient should be informed of the likelihood
of the need for repeat surgery. Patients with airway problems
preoperatively that do not have a tracheotomy should also be
consented for a possible tracheotomy depending on a variety
8.5 Informed Consent Regarding
of intraoperative situations.
Phonosurgery
The most important aspect of informed consent is education of

Key Points
the patient regarding the salient details of the surgical proce-
dure, providing reasonable expectations, and discussing risks
and benefits of the procedure. Documentation of the most im- ■ Most phonosurgical procedures are elective, and
portant aspects of this process is also strongly advised. With
thus, the decision to proceed with surgery should
phonomicrosurgery procedures for benign vocal fold lesions,
be patient driven. The surgeon serves as educator,
the informed consent process should involve the patient’s indi-
so that realistic goals of postoperative voice qual-
vidual pathology, specifically identified from stroboscopy and/
ity and function are clearly understood.
or from prior operative findings. The factors that play an im- ■ The key principle of decision making with respect
portant role in defining reasonable expectations of successful
to phonomicrosurgery is the use of nonsurgical
phonomicrosurgery include the patient’s vocal abilities and/or
rehabilitative treatment options (when appropri-
voice training and his/her postoperative vocal demands and
ate) prior to proceeding with surgery.
expectations. A combination of all these factors should be syn- ■ With respect to microsurgery for benign lesions
thesized and presented to the patient so he/she is offered the
of the lamina propria, the most important ques-
appropriate level of expectation. In general, appropriately per-
tion that must be answered before deciding for or
formed phonomicrosurgery for benign lesions of the lamina
against proceeding with phonomicrosurgery is:
propria in a compliant patient should have a success rate of
“Can the patient do what they need to do with his/
> 95%. Success is defined as an improvement in voice quality
her voice after undergoing maximum of nonsurgi-
and function. It is important for the surgeon to make the distinc-
cal rehabilitation?”
tion between voice improvement and restoration to the patient’s ■ Informed consent process for phonomicrosurgery
premorbid vocal capabilities. The success rate to achieve the lat-
should be individualized due to the specific patho-
ter goal is going to be lower and will be directly related to the
logic condition present and the surgical approach
pathology of the vocal folds, ability/training of the patient, and
recommended.
vocal demands. It is important to inform the patient that there
is a risk of postoperative scarring and permanent postoperative
dysphonia that could even worsen his/her condition compared
to preoperative status. This risk is quite small (1–2%), and
similarly, there is a risk that significant improvement in vo-
cal function will not be obtained despite the surgeon’s and the
patient’s best efforts (1–2% incidence of “no improvement”). 1 Bouchayer M, Cornut G (1992) Microsurgical treatment of be-
Appropriate informed consent for phonosurgeries involving nign vocal fold lesions: indications, technique, results. Folia Pho-
patients with glottal incompetence should involve the specific niatr 44:155–184
expectations, voice improvements, and persistent limitations 2 Courey MS, Gardner GM, Stone RE, Ossoff RH (1995) Endo-
after surgery. Typically, these types of surgical procedures have scopic vocal fold microflap: a three-year experience. Ann Otol
a very high degree of success with respect to increasing vol- Rhino Laryngol 104(Pt. 1):267–273
ume, clarity, and endurance with normal speaking-voice use
and normal speaking demands. There are often limitations af-
52 Timing of Phonosurgery
3 Dejonckere PH (2000) Committee on Phoniatrics of the Europe- 6 Netterville JL, Stone RE, Luken ES, Civantos FJ (1993) Silastic
an Laryngological Society. Assessing efficacy of voice treatments: medialization and arytenoid adduction: the Vanderbilt experi-
a guideline. Rev Laryngol Otol Rhinol 121:307–310 ence. A review of 116 phonosurgical procedures. Ann Otol Rhi-
4 Ford CN (1999) Advances and refinements in phonosurgery. La- no Laryngol 102:413–424
ryngoscope 109:1891–1900 7 Sataloff RT (2005) Professional voice: the science and art of clini-
5 Ford CN (2004) G. Paul Moore lecture: lessons in phonosurgery. cal care, 3rd edn. Plural, San Diego
J Voice 18:534–544 8 Zeitels SM, Hillman RE, Desloge R, Mauri M, Doyle PB (2002)
Phonomicrosurgery in singers and performing artists: treatment
outcomes, management theories, and future directions. Ann Otol
Rhino Laryngol 190(Suppl.):21–40
8
Chapter 9
Anesthesia and Airway Management

for Laryngeal Surgery 9
Please see Chaps. 13, 27, 28, 29, 39, 40, 45, 46, and 47 for fur-
ther information.
9.2 Equipment
Airway management requires the following:

1. Ventilating laryngoscope
a) Ossoff-Pilling
b) Pilling subglottiscope
2. Jet ventilator device (preferably high frequency)
3. Jet ventilation conduit
a) Hunsaker Mon-Jet jet ventilation tube (Medtronic- Fig. 9.1 Standard 5.0 endotracheal tube below (ETT) and 5.0 MLT
Xomed, Jacksonville, Fla.), or above (note longer length of MLT)
b) Jet Venturi needle
4. Laser-safe ETT
a) MLT 5.0/5.5 or smaller the neck flexed (along the cervicothoracic vertebrae) for op-
5. Tracheostomy tube/surgical tray timal laryngoscopic exposure (see Chap. 10, “Principles of
6. Rigid bronchoscopes Phonomicrosurgery”).
7. 4% lidocaine (LTA) 3. Microlaryngoscopic surgery generally employs one of the
following methods for maintaining the airway:
a) Oral intubation using a small diameter endotracheal tube
of adequate length: 5.0 or 5.5 MLT (microlaryngoscopy
tube) (Fig. 9.1). MLT (microlaryngoscopy) endotracheal
tube is a small-diameter ETT with an extended length.
Most “regular” ETT (size 5.0 and smaller) are not long
Sharing the airway with our anesthesia colleagues is one of enough to adequately span the distance between the oral
the most important (and often neglected) aspects of success- commissure and the subglottic/tracheal airway.
ful laryngeal surgery. Lack of collaboration and preoperative b) Jet Venturi ventilation using one of the following meth-
planning with the anesthesiology team can turn an otherwise- ods:
simple microlaryngoscopy case into a chaotic, life-threatening i. Subglottic Mon-Jet/Hunsaker jet ventilation tube
airway crisis. (Fig. 9.2)
The following general principles should always be observed: ii. Supraglottic jet Venturi needle (via port within la-
1. A preoperative management plan for securing the patient’s ryngoscope or attached to laryngoscope) (Fig. 9.3)
airway must be discussed with the anesthesiologist prior to 4. In general, lesions located on the anterior two thirds of
proceeding with surgery. An ideal plan (plan A), as well as the larynx (membranous vocal folds) can be adequately
one or two alternate strategies (plans B and C) should be exposed/treated with a 5.5 or smaller ETT. Lesions of the
established so that the airway management is automatic and posterior third of the larynx (vocal processes and posterior
algorithmic, as opposed to chaotic/reactive. Prior to bring- commissure/arytenoids region) require one of the following
ing the patient into the operating room, both the surgeon approaches:
and anesthesiologist should have the proper equipment in a) Jet ventilation
the room, open, and “ready to go” if alternative plans be- b) Apneic technique
come necessary. c) ETT placement anteriorly, resting on top of the laryngo-
2. The patient should be placed in the “sniffing positioning,” scope
with the head extended (at the atlanto-occipital joint), and
54 Airway Management for Larygeal Surgery
9 Fig. 9.2 Subglottic jet ventilation tube (Medtronic-Xomed) Fig. 9.3 Jet Venturi needle and jet ventilation tubing/pressure gauge
precision of fine surgical maneuvers. In addition, jet venti-

lation (containing 100% oxygen) must be suspended during
firing of the laser.
8. Subglottic jet ventilation is more efficient when used for
glottic laser surgery; the vocal folds are not as affected by
ventilatory forces. Jet ventilation can proceed even while
the laser is being fired. Another important advantage of
the Hunsaker subglottic jet ventilation tube is the built-in
CO2-monitoring port. This allows the anesthesia team to
monitor end-tidal CO2 to ensure adequate exhalation time
during jet ventilation. The potential drawback of subglot-
tic jet ventilation is the increased risk of air trapping from
the “ball-valve” phenomenon. Often, subglottic jet ventila-
tion is performed distal to the airway obstruction, and if
egress (escape) of air is prevented by the obstructed region,
then air trapping results. Complications of this include
Fig. 9.4 Laser protected ETT (Medtronic-Xomed) pneumothorax (possibly bilateral), pneumomediastinum,
and emergent ventilatory compromise. Increased vigilance
must be practiced when this ventilation technique is em-
ployed.
5. In all cases where a surgical laser is employed, an appro-

priate laser-protected tube must be in place (Fig. 9.4). The
9.4 Principles of Airway Management:
only exception to this rule is when jet ventilation or apneic
Subglottic and Tracheal Stenosis
technique is used (both are also safe for the laser).
6. In instances where the patient has an indwelling tracheos-
tomy tube: 1. Subglottic/tracheal stenosis presents a unique anesthetic
a) 5.5–6.0 reinforced ETT placed through the stoma into challenge. Ideally, the airway is not instrumented by the
the trachea, laser protected when appropriate anesthesiology team; endotracheal intubation can result in
b) Apneic technique may be employed if airway surgery is traumatic injury to the subglottic mucosa and may precipi-
carried out distal to the tracheal stoma site, using rein- tate an emergency in a patient with a marginal (but other-
sertion of stomal ETT intermittently to restore oxygen- wise stable) airway.
ation between treatment cycles. 2. Subglottic/tracheal stenosis in a stable airway should gener-
7. Jet ventilation is safest when used proximally (supraglottic, ally proceed as follows:
as opposed to subglottic) However, passive movement of a) Mask induction is performed using inhalational agents
the vocal folds due to ventilatory air movement limits the (sevoflurane):
Chapter 9 55
i. Paralytics are not used (especially succinylcholine).

ii. Induction should be gradual (no “rapid sequence”).
iii. Muscle relaxation must be present (via sevoflurane
or propofol).
iv. The surgical bed is rotated to the surgeon.
v. Suspension laryngoscopy/subglottoscopy is ob-
tained, with placement of the tip of the scope just
proximal to the stenotic region.
vi. Jet ventilation is employed through the laryngo-
scope or with a ventilating tube (Hunsaker Mon–Jet
catheter).
vii. If oxygenation cannot be maintained by jet venti-
lation, or if CO2 retention is excessive, then venti-
lation through a rigid bronchoscope (as employed
during rigid dilation of the stenotic region) can be
used intermittently.
viii. After surgical treatment of the stenotic region, the
patient’s airway is returned to the care of anesthe-
sia, and the patient is mask ventilated until reversed,
and breathing spontaneously without assistance.
ix. Reintubation at the end of the case should be avoided
due to the risk of unnecessary mucosal trauma and/
or reactive airway edema.
3. Subglottic/tracheal stenosis in an unstable, emergent airway Fig. 9.5 Illustration of ideal tracheostomy entry point for cartilagi-
case should observe the following general guidelines: nous collapse of the airway (indicated by arrow A) The length of tra-
a) The surgical approach to the treatment of emergent/ cheal resection is reduced (segment A), compared with the amount
urgent SGS should be individualized for each patient. that would need to be resected (segment B1) if the tracheostomy were
Tracheostomy is the most conservative and safe option placed more distally (arrow B)
(exceptions noted below), especially in a patient with
a “difficult surgical airway” due to coexisting anatomic
conditions (retrognathia, trismus, base-of-tongue hy-
pertrophy, limited neck flexion). However, if expert
anesthesia and intensive care monitoring are available, iii. The tracheotomy entry point should be through the
then endoscopic treatments are generally preferable, and collapsed segment.
tracheostomy can be avoided. iv. This step minimizes the length of trachea that must
b) The location and nature of the stenosis is critical in de- be excised when a tracheal resection/cricotracheal
termining the method of securing and maintaining the resection is performed at a later date (Fig. 9.5) (see
airway during surgical treatment: Chap. 47, “Tracheal Stenosis: Tracheal Resection
c) “High” SGS (confined to infraglottis/cricoid) can be with Primary Anastomosis”)
treated as described in no. 2 above (jet ventilation with- e) Intrathoracic tracheal stenosis. In these cases, trache-
out endotracheal intubation); however, tracheostomy ostomy is not a viable option, because it is unlikely to
under local is also a reasonable choice. The tracheos- bypass (enter below) the stenotic segment. The airway
tomy should be placed at least 1 cm inferior to the ste- should be exposed by the surgeon using an laryngoscope
notic region, and not through the stenotic segment. This as described in no. 2 above. Oxygenation is achieved via
will facilitate endoscopic treatment at a later date, as the jet ventilation, or by passing a ventilating bronchoscope
tracheotomy tube will not interfere with healing of the past the stenotic region. Rigid dilation/laser treatment
stenotic site after subsequent laser/dilation procedures. can then proceed as indicated. Another viable alterna-
d) Subglottic/cervical tracheal narrowing due to cartilagi- tive is placement of indwelling stent at the stenotic site.
nous collapse. This condition cannot always be anticipat-
ed preoperatively, but once recognized should be treated
in the following manner:
9.5 Special Circumstances: Difficult
i. Endoscopic laser treatment is avoided, as it is ineffec-
Exposure of the Larynx
tive.
ii. The airway is obtained by performing a tracheos-
tomy under local (alternate method: rigid bronchos- 1. In some patients, unfavorable anatomy and difficult laryn-
copy to secure the airway, followed by tracheostomy geal exposure may render all of the previously mentioned
placement) principles moot. If the larynx cannot be exposed through
the oral route using rigid laryngoscopy/bronchoscopy, then
alternative means of securing the airway must be employed.

The following conditions may predict a “difficult exposure”
perorally (Fig. 9.6):
a) Retrognathia
b) Lingual hypertrophy/Poor palatal visualization
c) Trismus/reduced interincisor opening
d) Short, thick neck
e) Limited neck extension
2. Alternative methods of obtaining an airway in a “difficult
exposure” case:
a) Tracheostomy under local
b) Awake, flexible laryngoscopy with nasotracheal intuba-
tion
c) Laryngoscopy and intubation using specialized “ante-
Fig. 9.6 Illustration of anatomic features in a patient with “difficult rior” laryngoscope
airway exposure” i. Ossoff–Pilling laryngoscope
d) Laryngoscopy and intubation without visualization of
9 vocal folds
i. Sliding Jackson laryngoscope plus curved ETT with
stylet
e) Laryngeal mask anesthesia (LMA)
3. Specialized techniques:
a) Intubation using Ossoff-Pilling laryngoscope
In patients in whom difficulty with rigid transoral airway
exposure is anticipated/encountered, the Ossoff–Pilling
(OP) laryngoscope is extremely valuable. In close to 99%
of surgical patients, the OP laryngoscope allows success-
ful transoral exposure of the glottis.
i. The patient is pre-oxygenated, and mask induction
is utilized. Paralytics are avoided, and spontaneous
ventilation (or assisted mask ventilation) is main-
tained. When the patient achieves the desired level
of anesthesia, the surgical table is turned 90°, facing
the surgeon.
ii. The OP laryngoscope is passed perorally and ad-
vanced to the level of the vocal folds (or ideally,
Fig. 9.7 Intubation through an Ossoff–Pilling laryngoscope. A 5.0 ETT slightly distal, into the infraglottis). A suspension
or smaller should be used device (Lewy) can also be used to achieve additional
Fig. 9.8 Removal of connector from ETT to facilitate passage of the Fig. 9.9 Laryngeal cup forceps are used to grasp the ETT
tube through the laryngoscope
Chapter 9 57
anterior rotation of the laryngoscope in particularly v. The cup forceps is released, and the OP scope is
difficult cases, but is not often necessary. pulled back until the entire ETT and trailing cuff-
iii. A 5.0 MLT (or smaller) is placed directly through inflation tubing are passed through its lumen (Fig.
the laryngoscope to secure the airway. The balloon 9.11). Larger cuff-inflation ports (especially the liq-
can be inflated, position confirmed, and ventilation/ uid-filled variety used in laser-protected ETTs), may
oxygenation established until the patient is stabi- get caught within the narrow distal lumen of the OP
lized (Fig. 9.7). scope. The cup forceps can be used to push this de-
iv. The laryngoscope can then be removed over the vice through the scope, however.
tube (with a pseudo-Seldinger technique), leaving b) Sliding Jackson laryngoscope
the ETT in place: In patients in whom it is impossible to visualize the vo-
i. The plastic connector is removed from the proxi- cal folds with the above (OP laryngoscopic) technique, a
mal end of the ETT (Fig. 9.8). Sliding Jackson (SJ) laryngoscope can be used for peroral
ii. A medium–large laryngeal cup forceps is used to intubation in select cases. While the SJ scope does not
grasp the proximal ETT (Fig. 9.9). provide superior visualization of the glottis in difficult,
iii. The surgeon backs the OP scope out of the oral “anterior” patients, it can be used as a “familiar” intuba-
cavity while holding the ETT stationary to prevent tion laryngoscope (analogous to the Miller blade used
extubation. by anesthesiologists). In cases where the glottis cannot
iv. When the intraoral portion of the tube can be vi- be visualized with the OP laryngoscope, the SJ is used
sualized, it is secured by an assistant (Fig. 9.10). to displace the base of tongue and provide a pathway for
placement of an ETT “blindly.” A stylet must be used,
with an exaggerated curve at the distal end of the ETT.
This curve allows the tip of the ETT to extend further
anteriorly, beyond the exposure provided by the laryn-
goscope, and into the glottic inlet. The ETT is advanced
into the oral cavity lateral to the laryngoscope (entering
at the oral commissure) and is guided toward the mid-
line of the airway (from right to left) (Fig. 9.12). It should
Fig. 9.10 As the laryngoscope is removed, the intraoral portion of the

ETT is manually secured
Fig. 9.11 The cup forceps are released as the entire laryngoscope is Fig. 9.12 Intubation using a Sliding Jackson laryngoscope. Note the
removed acute bend at the distal end of the tube
be emphasized that this type of “blind” intubation is not ■ In general, lesions located on the anterior two
a preferred method of securing the airway. Instead, is
thirds of the larynx (membranous vocal folds)
a “court of last resort” for peroral intubation when all
can be adequately exposed/treated with a 5.5 or
other options have failed. Also, it should be noted that
smaller ETT. Lesions of the posterior third of the
substantial experience with intubation/difficult laryngeal
larynx (vocal processes and posterior commissure/
exposure is required before attempting this technique.
arytenoid region) require jet ventilation, displace-
ment of the ETT anteriorly, or apneic technique.
■ Mask induction with inhalational agents, followed
9.6 Anesthesia by jet ventilation is the preferred method of airway
for Laryngeal Framework Surgery management for endoscopic treatment of sub-
glottic/tracheal stenosis. Endotracheal intubation
should be avoided in these cases.
Monitored anesthesia care for patients undergoing framework ■ Jet ventilation is safest when used proximal to the
surgery is often suboptimal due to a lack of communication be-
stenotic region; ventilation distal to the stenosis
tween the surgeon and the anesthesiologist. To most anesthesi-
carries an increased risk of air trapping and pneu-
ologists, “monitored anesthesia care” for a patient undergoing
mothorax.
a local procedure involves sedation via a propofol (Diprivan) ■ If tracheostomy is performed in a patient with
9 drip. Propofol is felt to be superior to midazolam (Versed),
subglottic/tracheal stenosis due to intraluminal
due to its ease of rapid titration, faster wake-up times, and bet-
scar formation, then the airway should be entered
ter quality of sedation. However, propofol is poorly suited for
at least 1 cm inferior to the area of the stenosis.
framework surgery performed under local anesthesia for the
Tracheostomy entry through the area of narrowing
following reasons:
is ideal (though not essential) if cartilaginous col-
■ There is tendency for an “all-or-none” phenomenon; lapse is present, however.
the patients is either deeply sedated (often snoring), or ■ The following conditions may predict a “difficult
completely awake/alert and uncomfortable. exposure” perorally:
■ Due to the rapid nature of “emergence” from the se- ■ Retrognathia
dated state, the patient often becomes disinhibited/com- ■ Lingual hypertrophy/poor palatal visualization
bative when “awakened” and asked to phonate. This is ■ Trismus/reduced interincisor opening
likely exacerbated by the presence of a noxious stimulus ■ Short, thick neck
(indwelling flexible transnasal laryngoscope). ■ Limited neck flexion
■ Alternative methods of obtaining an airway in a
“difficult exposure” case include:
Midazolam (Versed) is much better suited for sedation in ■ Tracheostomy under local
framework surgery patients, and results in a more relaxed, ■ Awake, fiberoptic nasotracheal intubation
aware, and cooperative patient. ■ Laryngoscopy and intubation using a special-
In terms of local anesthesia, 1% lidocaine with epinephrine
ized “anterior” laryngoscope
is infiltrated into the subcutaneous and deep tissues from the ■ Ossoff–Pilling laryngoscope
hyoid to the upper cricoid cartilage on the side of the proposed ■ Laryngoscopy and intubation without visualiza-
surgery, as well as 1 cm past the midline. The anesthetic solu-
tion of vocal folds
tion should be infiltrated down to the depth of the thyroid car- ■ Sliding Jackson laryngoscope plus curved
tilage. In general, 15–20 ml of solution is required. Additional
ETT with stylet
supplemental injections are usually required during the surgi- ■ LMA
cal dissection, as needed. One must be careful to avoid injec- ■ Topical 4% lidocaine (laryngotracheal anesthesia,
tion into the paraglottic space and/or thyroarytenoid muscle,
commonly referred to as “LTA”) should be applied
which could result in an inadvertent “injection augmentation.”
to the laryngotracheal region prior to instrumen-
In most cases, successful medialization and layered closure of
tation of the larynx. In addition, at the end of the
the skin can be achieved without the need for further anesthe-
surgical case, another application may be repeated
sia at the incisional site.
(if greater than 45–60 min after the initial lidocaine
treatment). Lidocaine reduces the incidence of
laryngospasm.
Key Points
■ A preoperative management plan for securing
the patient’s airway must be discussed with the
1 Hunsaker DH (1994) Anesthesia for microlaryngeal surgery: the
anesthesiologist prior to proceeding with surgery.
case for subglottic jet ventilation. Laryngoscope 104(Suppl.):1–30
All necessary equipment should be opened and
readily available in the operating room before
proceeding.
Chapter 9 59
2 Sofferman RA, Johnson DL, Spencer RF (1997) Lost airway dur- 3 Hochman II. Zeitels SM. Heaton JT (1999) Analysis of the forces
ing anesthesia induction: alternatives for management. Laryngo- and position required for direct laryngoscopic exposure of the
scope 107:1476–1481 anterior vocal folds. Ann Otol Rhinol Laryngol 108:715–724
Part B Phonomicrosurgery
for Benign Laryngeal
Pathology
I Fundamentals
of Phonomicrosurgery
Chapter 10
Principles of Phonomicrosurgery
10
Important preoperative measures before phonomicrosur-
gery include:
■ Avoiding aspirin, nonsteroidal anti-inflammatory medi-
Please see Chaps. 1, 4, 8, 11, 12, 15, 16, 17, 18, 22, and 23 for
cations or other anticoagulation medications
further information.
■ Avoiding significant vocal abuse and misuse immedi-
ately before surgery
■ Avoiding operating during the premenstrual period of
10.2 Introduction a woman’s menstrual cycle, due to the slight edema oc-
curring at this time as well as some increased fragility of
the microvasculature of the vocal fold
Phonomicrosurgery encompasses a variety of operations that
has the primary goal of improving voice quality. These are elec-
tive operations that involve precision microsurgical removal of Preoperative voice therapy (one to two sessions) is extremely
benign vocal fold pathology—most often from the subepithelial important in preparation for phonomicrosurgery for a variety
space of the vocal fold. The surgical procedures and principals of reasons:
are based on vocal fold physiology, specifically Hirano’s cover-
■ Psychological preparation for surgery
body theory of vocal fold vibration (see Chap. 1, “Anatomy and
■ Education regarding postoperative voice rest and voice
Physiology of the Larynx”). Given the importance of the inter-
use
action between the epithelium–superficial layer of the lamina
■ Modification and improvement of improper speaking
propria (cover) and the underlying deep layer of the lamina
techniques and habits
propria and muscle (body), phonomicrosurgery was born and
■ Laying the foundation for postoperative voice therapy,
has evolved to advocate the minimal disruption to the normal
both psychologically as well as from a behavioral per-
microarchitecture of the vocal fold while removing dysphonia-
spective
inducing pathology. The overarching goal is to limit dissection
to the most superficial plane possible and maximize epithelial
and lamina propria preservation. The latter tenet is important Preoperative voice therapy stresses to the patient the impor-
to facilitate primary wound healing versus secondary wound tance of changing inappropriate vocal techniques and imple-
healing. This is theorized to allow maximal functional recovery menting healthy voice behaviors in the postoperative period.
(vocal fold mucosal vibration) after surgery. Prior to phonomicrosurgery, the patient must realize he/she
will be on voice rest and reduced voice use for a variable pe-
riod (from 3 to 30 days). This is to ensure that the patient has
adjusted his/her voice use to be compliant with the surgeon’s
voice rest and reduced voice use limitations.
Preoperative consent for phonomicrosurgery should involve
the risks of general anesthesia, temporal mandibular joint in-
Phonomicrosurgery is an elective surgery, and thus, pressure jury, dental injury, and injury to the lingual nerve. The latter
should not be placed on the patient to proceed with surgery. has been shown to be temporary in nature and lasts on average
The risks and benefits of the surgery should be detailed to the 2 weeks, with a maximum duration of 1 month. A discussion
patient and most importantly, a realistic and thorough evalu- regarding postoperative voice quality after phonomicrosurgery
ation of the patient’s functional voice limitations and abilities should be taken seriously and done by the surgeon. Discussion
(speech and singing) should be reviewed. Often this review should involve the small but real risk of either no improvement
process should be done over several weeks and involve the pa- of the voice quality (~1–2% incidence) or a reduction in vocal
tient, physician, family members, a speech–language patholo- function or voice quality (~1–2% incidence).
gist and possibly a singing voice specialist. When all nonsurgi- The surgeon should review the patient’s most recent stro-
cal treatment modalities have been exhausted and significant boscopy (last exam should be within previous 15–20 days)
vocal functional limitations exist, the setting is appropriate for prior to phonomicrosurgery. Preferably, this review is done the
proceeding with phonomicrosurgery (see Chap. 8, “Timing, day of surgery or 1–2 days before the surgery. The optimal situ-
Planning, and Decision Making in Phonosurgery”). ation for this preoperative stroboscopy review is to have the
stroboscopy examination available for review in the operat-
64 Principles of Phonomicrosurgery
ing room immediately before as well as during the procedure.

This allows the surgeon to correlate stroboscopic findings with
surgical findings and make important decisions on location of
pathology, location of placement of incisions, and the degree
Table 10.1 Standard microlaryngeal instrumentation
High-quality operating microscope with 400-mm lens

Large-bore laryngoscope (largest diameter possible)
Examples include:
• Universal modular glottalscope (Endocraft)
• Sataloff laryngoscope (Medtronic ENT)
• Lindholm (Karl Storz)
• Operating laryngoscope for anterior commissure (model #8458.011, Richard Wolf )
Specialized laryngoscopes for unique situations
• Ossoff–Pilling for difficult exposure (Pilling)
• Posterior-commissure laryngoscope (Pilling)
Suspension system
• Boston University suspension (Pilling or Endocraft) (Figs. 10.16, 10.20)
10 • Fulcrum suspension: Lewy suspension and table-mounted Mayo stand (Pilling) (Fig. 10.17)
Operating chair with arm supports (Fig. 10.22)
Instrumentation (Karl-Storz, Medtronic ENT, Instrumentarium)
• Specialized blunt microelevators (Fig. 10.1)
• Microcup forceps (1–2 mm in diameter) (Fig. 10.2)
• Up-angled, right and left micro-ovoid cup forceps (Fig. 10.3)
• Microscissors (Fig. 10.4)
• Curved (left and right)
• Up angled
• Curved alligator forceps (left and right) (Fig. 10.5)
• Straight alligator forceps
• Microlaryngeal suctions (3, 5, and 7 French)
• Triangular (Bouchayer) forceps (left and right) (Fig. 10.6)
• Microlaryngeal knife (sickle or spear)
Miscellaneous equipment
• Cotton surgical pledgets (0.5 × 2 cm)
• 1:10,000 epinephrine
• Velcro strap or cloth/silk tape
• Mouth guard (maxillary, ± mandibular)
• Acrylic—custom made by dentist
• Molded “athletic” tooth protector
• Plastic “anesthesiologist” tooth guard, reinforced with layers of cloth tape (Fig. 10.18)
• Foam from operating room headrest or “doughnut” (edentulous patients only) (Fig. 10.9)
Optical telescope
• Diameter: 4–5 mm, length: 20 cm or more
• 0, 30, and 70°
Microdebrider—skimmer blade (Medtronic ENT)
Subepithelial infusion needle (25 or 27 g)
• Zeitels needle (Endocraft)
• Orotracheal injector (Medtronic ENT)
Small-diameter, extended-length endotracheal tube (5.0 or 5.5) designed
for microlaryngoscopy (Mallinckrodt)
Tracheal jet ventilation tube (Hunsaker jet ventilation tube; Medtronic ENT)
The listed equipment/vendors are those the authors have utilized. This is by no means a complete list of all the vendors who
make these products: Endocraft (Providence, R.I.), Karl Storz (Culver City, Calif.), Instrumentarium (Montreal, Quebec,
Canada), Mallinckodt (Hazelwood, Mo.), Medtronic ENT (Jacksonville, Fla.), Pilling (Research Triangle, N.C.), Richard Wolf
(Vernon Hills, Ill.)
Chapter 10 65
of dissection and excision using the preoperative stroboscopy

■ Microcup forceps (Fig. 10.2)
and the operative findings as guides.
■ Several small special cup forceps have been devel-
oped over the last 5–10 years to facilitate several
specific situations that are encountered in phonomi-
10.4 Equipment for Phonomicrosurgery crosurgery. These forceps have a sharp cutting edge
but a very limited cutting surface, only the most
distal 180º of the forceps cut. The most useful micro
Specialized laryngoscopes are required for phonomicrosurgery.
cup forceps is angled-up and has a 1-mm diameter.
The larger the laryngoscope, the better for phonomicrosurgery,
■ Micro-ovoid cup forceps (Fig. 10.3)
given that this results in significantly improved exposure and
■ Ovoid-shaped microcup forceps are also essential
access to the surgical site(s). Multiple large and specialized
for removing small pieces of pathologic mucosa and
laryngoscopes exist and a wide variety of laryngoscopes are
papilloma (see Chaps. 15, “Vocal Fold Polyp” and
necessary to manage all different types of phonomicrosurgi-
21, “Recurrent Respiratory Papillomatosis of the
cal lesions and procedures. Specialized laryngoscopes for in-
Larynx”). This instrument comes in two sizes and is
dividualized laryngoscopy needs are important, e. g., posterior
valuable for precision removal of small amounts of
commissure laryngoscope for difficult posterior glottic expo-
tissue.
sure, and the Ossoff-Pilling laryngoscope for microlaryngeal
surgery on patients with restricted upper aerodigestive tract
anatomy (Table 10.1).
The core set of instruments utilized for phonomicrosurgery
includes specialized blunt microelevators, cup forceps, scis-
sors, curved alligators, and small suctions (3, 5, and 7 French).
These elevators are often used to palpate submucosal pathology
at the start of surgery. In addition, a specialized set of instru-
ments has been developed for microflap retraction. These are
called triangular forceps or Bouchayer forceps. Most of the in-
struments described below are available from several manufac-
turers of phonomicrosurgery equipment, including Medtronic
ENT (Jacksonville, Fla.), Karl Storz (Culver City, Calif.) and
Instrumentarium (Montreal, Quebec, Canada).
Key microlaryngoscopy instruments utilized for phonomi-
crosurgery involve:
■ Specialized blunt microelevators (Fig. 10.1)
■ The microelevators should be blunt and have several
different angles and sized to allow the surgeon to
work in various angles in different positions within
Fig. 10.2 Microcup forceps (1 mm) cutting surface limited to distal
the vocal fold, specifically, dissecting the vocal fold
180°
lesion off the overlying microflap.
Fig. 10.1 Angled elevators for phonomicrosurgery Fig. 10.3 Micro-ovoid cup forceps
■ Microscissors (Fig. 10.4) ■ Sickle knife (or spear-shaped knife)

■ The most commonly used microscissors are right ■ These knives tend to become dull very quickly, and
and left curved as well as “straight up,” or angled thus it is recommended that this knife be replaced
scissors. These scissors should be maintained at all with every case or at least on a very frequent basis. A
times to appropriate surgical precision and sharp- dull knife can result in tearing of the mucosa and can
ness, given that they are the primary cutting tool for significantly limit the efficacy of phonomicrosurgery
phonomicrosurgery. ■ Microdebrider
■ Curved alligators (Fig. 10.5) ■ The microdebrider is a powered instrument that pro-
■ Epinephrine (1:10,000) and cotton pledget (0.5 × 2 cm) vides simultaneous suction and cutting activity used
■ Microlaryngeal suctions (3, 5, and 7 French) for rapid removal of exophytic lesions in the larynx
■ Triangular forceps or Bouchayer forceps (for microflap such as recurrent respiratory papillomatosis (RRP)
retraction) (Fig. 10.6) (see Chap. 21, “Recurrent Respiratory Papillomatosis
■ These instruments are designed to retract the micro- of the Larynx”). There are two different types of cut-
flap to allow vocal fold visualization and dissection ting blades:
while minimizing trauma to the microflap. They are ■ Conservative (i. e., “skimmer blade”)
made in a variety of sizes and designs for different ■ Aggressive
situations. ■ The conservative blade is the most commonly
used for laryngeal surgery. The advantages of
the microdebrider are expedient removal of a
10 significant amount of laryngeal pathology; less
pain after surgery (compared with the CO2 laser);
less expensive than the laser; and potentially even
safer, given the risks of laser laryngeal surgery.
The disadvantages of microdebrider for laryngeal
surgery include the powered instrument shaft
is relatively large, and sometimes visualization
can be limited, and the risk that the powered
instrument may be too strong and injure delicate
subepithelial tissues of the vocal fold or other
endolaryngeal structures.
Suspension of the laryngoscope is a fundamental aspect of

phonomicrosurgery. Two basic designs for placing the laryn-
goscope into a fixed and stable position exist. These are cat-
egorized as a gallows suspension device, and a rotation, or
fulcrum device. The gallows suspension laryngoscope is favor-
able, given that there is more appropriate upward vector of the
Fig. 10.4 Microscissors, curved and angled up laryngoscope, which can provide optimal exposure of the en-
Fig. 10.5 Curved alligators for phonomicrosurgery Fig. 10.6 Triangular (Bouchayer) forceps
Chapter 10 67
dolarynx with minimal risk of dental injury, especially to the

10.5 Phonomicrosurgery Procedures,
maxillary teeth. This device is not the most common due to
Techniques, and Methods
traditional and historical use of rotation-fulcrum devices (i. e.,
Lewy suspension).
10.5.1 Anesthesia
Long Hopkins rod telescopes with various visualization an-
gulations are an essential component to phonomicrosurgery.
Rarely is the surgery performed utilizing these telescopes, but A working relationship based on mutual respect, communi-
these telescopes are used to provide the surgeon a “three-di- cation, and teamwork with your anesthesia colleague(s) is es-
mensional visualization” of the vocal folds and their related sential for successful phonomicrosurgery (see Chap. 9, “An-
pathology. The 30 and 70° telescopes, which are approximately esthesia and Airway Management for Laryngeal Surgery”).
4–5 mm in diameter and 30 cm long, should be utilized im- Phonomicrosurgery involves general anesthesia, and complete
mediately prior to phonomicrosurgical incision and are often muscle relaxation should be implemented after the induction
used during phonomicrosurgery as well as at the end of the of general one and continuously monitored throughout the
surgery to ensure that all appropriate pathology has been re- surgery. Preoperatively, one should administer i.v. steroids and
moved. These angled telescopes are readily available in most Robinol™ (unless contraindicated). Placement of the endotra-
operating rooms, given they are used regularly for cystoscopy. cheal tube is extremely important, given that a misplaced or
Telescopes used for sinus surgery are too short to be effectively traumatic placement of the endotracheal tube can cause injury
used for laryngeal imaging. to the vocal folds and may result in cancellation of surgery and/
The microscope used for phonomicrosurgery should be of or injury to the vocal folds. The placement of the endotracheal
the highest quality and provide the surgeon with a stable visu- tube should be under complete controlled conditions, and no
alization method of the endolarynx. There should be signifi- stylet should be used for the placement of the endotracheal
cant adjustment as well as control over many different articu- tube. Furthermore, the otolaryngologist should be present
lated angles of the microscope. This microscope should be the during the intubation to monitor the situation and be available
same microscope that is used for precision otologic procedures to assist with intubation when the situation is required. Simi-
such as stapes surgery and other middle ear operations. The larly, controlled extubation at the end of phonomicrosurgery is
microscope that is routinely used for the placement of pres- another important aspect of the necessary teamwork between
sure equalizing tubes is typically not appropriate for phono- the anesthesia team and the phonomicrosurgeon. Extuba-
microsurgery. Furthermore, the microscope should have the tion should be done in a controlled fashion, and all measures
capability of being compatible with the CO2 laser microma- should be used to reduce the likelihood of the patient coughing
nipulator attachment. Typical length of the lens used on the after extubation.
surgical microscope for phonomicrosurgery is 400 mm. This The ventilation options for phonomicrosurgery are endo-
allows adequate space between the proximal end of the laryn- tracheal intubation, jet ventilation, or apneic methods. The
goscope and the microscope for hand instruments to be used large majority of phonomicrosurgery is best performed using
for phonomicrosurgery. endotracheal intubation with a small (5.0 or 5.5), specialized
Another important feature of the surgical microscope is ar- endotracheal tube. This provides a still operating field and
ticulated eyepieces; this allows for optimal surgeon ergonom- complete control of the airway. Sometimes the endotracheal
ics, which is important for lengthy phonomicrosurgery cases tube can be in the way for the surgical procedure and may need
as well as for the long-term health of the phonomicrosurgeon. to be repositioned or removed in its entirety. Jet ventilation for
Lasers have a limited role in phonomicrosurgery surgical phonomicrosurgery should be done only on an as-needed ba-
procedures (see Chap. 13, “Principles of Laser Microlaryngos- sis and is best done when the jet ventilation is delivered from a
copy”). The most commonly used laser is the CO2 laser, which small jet ventilation catheter placed in the mid-tracheal region.
can be used for cautery of vascular ectatic lesions. The CO2 la- (see Chap. 9, Fig. 9.1; Hunsaker tube, Medtronic ENT) Tra-
ser with the micromanipulator has also been used for making cheal jet ventilation is preferred compared with supraglottic jet
vocal fold incisions or removing free-edge lesions. However, ventilation, given that the former provides the surgeon with
there are no distinct advantages of the use of this laser in this less vibration and desiccation of the vocal fold tissues while
setting, and the risks of thermal injury and costs of the instru- phonomicrosurgery is being performed, and allows end-tidal
ment outweigh any potential benefits. The majority of phono- CO2 monitoring.
microsurgery can and should be done with “cold-steel” instru- Appropriate and successful phonomicrosurgery can rarely
mentation. Recently, the pulsed-dye (PDL) and pulsed-KTP be performed using an apneic technique for anesthesia, giv-
lasers have been advocated for phonomicrosurgery. However, en that the time between ventilations is too short for most
benefits over cold-steel surgery have not yet been demonstrat- phonosurgical procedures. An exception to this may be for
ed, but they may be complementary when dealing with vascu- bronchoscopy (flexible or rigid) and diagnostic laryngoscopy
lar lesions associated with other vocal fold lesions (cyst, polyp, prior to the placement of an endotracheal tube.
etc.). The CO2 laser does offer an “instrument-free” approach
to surgery of the vocal folds, and in a very small, crowded sur-
gical space, this can be an advantage. However, for most pho-
nomicrosurgical situations this is not a major problem, and
thus the CO2 laser is rarely indicated for this reason alone.
pillow under the head to flex the neck on the body (Fig. 10.8).
10.5.2 Patient Position
Dental and alveolar ridge protection prior to insertion of the
laryngoscope is important. For patients who are edentulous on
Patients undergoing phonomicrosurgery are placed in a supine the maxillary teeth, the best way to protect the mucosa and the
position on the operating room table. The optimal head and underlying alveolar ridge from laryngoscope placement and
neck position for exposure of the endolarynx with the laryn- suspension injury is to place a small, high-density foam pad
goscope is neck flexion on the body and the head extension on between the laryngoscope and the alveolar ridge. This foam
the neck. A shoulder roll typically places the patient in a sub- padding is present in most operating rooms in the form of a
optimal position for optimal laryngoscope placement (neck headrest or pillow material (Fig. 10.9).
extension), and thus should not be used. The neck flexion can
be achieved by using an articulated head of the operating table,
and the head extension on the neck is done by the surgeon dur-
10.5.3 Laryngoscope Placement
ing laryngoscopy and secured with the suspension device (Fig.
10.7). Another method of obtaining neck flexion is to use a
Laryngoscope placement is crucial to the success of phonomi-
crosurgery and can be quite daunting to the novice phonomi-
crosurgeon. An adequate amount of time and patience should
be allocated for this important step. Insuring a proper head
and neck position during laryngoscopy placement is a key step,
10 as described above. The overall goal is to place the largest di-
ameter laryngoscope into the endolarynx. A frequent impedi-
ment to this goal is the folding inward of the epiglottis (Fig.
10.10). When this occurs, the potential space to place the distal
aspect of the laryngoscope into the endolarynx is significantly
reduced, and the epiglottis is traumatized (Fig. 10.11). With
the use of a large-diameter laryngoscope, the positioning of the
laryngoscope can be quite difficult. Instead of aborting the use
of the large-diameter laryngoscope, patience and persistence
should be judiciously applied.
As the laryngoscope is placed into the oral cavity, the lips
and tongue should be retracted with the nondominant hand.
The laryngoscope is then slid along the ventral surface of the
Fig. 10.7 Optimal patient position for suspension laryngoscopy (note tongue and advanced down toward the base of the tongue and
neck flexion and head extension) posterior pharyngeal wall. At this juncture, there are a variety
of techniques to place the laryngoscope under the epiglottis
without folding or traumatizing the epiglottis. First, if there
is adequate space, then the laryngoscope can be passed under
Fig. 10.8 Alternative method of positioning patient without the use of Fig. 10.9 High-density foam for protecting the alveolar ridge in an
an articulated head of bed (note neck flexion due to pillow underneath edentulous patient during suspension laryngoscopy
the head)
Chapter 10 69
Fig. 10.10 Laryngoscope advancement causing “folding” of epiglottis Fig. 10.11 “Folded” epiglottis above laryngoscope limits space for the
placement of a large-diameter laryngoscope
direct vision underneath the epiglottis and advanced into the dolaryngeal space, thus allowing the endotracheal tube to slip
endolarynx. This direct approach may result in the folding of around the side of the laryngoscope and be positioned in the
the epiglottis when attempted with a large-diameter laryngo- posterior glottis.
scope (Fig. 10.11). At this stage, it best to use one of the other The third method to place a large-diameter laryngoscope
laryngoscope placement techniques instead of resorting to the into the endolarynx without damage or malposition of the
use of a smaller laryngoscope. epiglottis is to place the nondominant-hand index finger into
The second option for laryngoscope placement is to place the oral cavity and oropharynx toward the endotracheal tube
the laryngoscope between the posterior pharyngeal wall and and pick the endotracheal tube up off the posterior pharyn-
the endotracheal tube and continue to advance the laryngo- geal wall. With the endotracheal tube secured underneath
scope along the posterior pharyngeal wall (underneath the en- the index fingertip, the laryngoscope can then be advanced
dotracheal tube). Once the laryngoscope is at the approximate along the posterior pharyngeal wall and drawn up into the en-
level of the endolarynx, it can be drawn anteriorly into the endolarynx (Fig. 10.12). Using this technique, the endotracheal
Fig. 10.12 Placement of laryngoscope into endolarynx below non- Fig. 10.13 Anterior deflection of endotracheal tube with the nondom-
folded epiglottis while the endotracheal tube is positioned anteriorly inant hand to allow placement of laryngoscope into endolarynx
with a finger from the nondominant hand (note initially the laryngo-
scope will be posterior to the endotracheal tube)
10 Fig. 10.14 Laryngoscope positioned above the epiglottis, which is Fig. 10.15 Cup forceps placed outside the laryngoscope to control the
resting directly on the endotracheal tube position of the epiglottis, allowing placement of the laryngoscope into
the endolarynx without “folding” of the epiglottis
tube may be initially positioned anterior to the laryngoscope. suture is removed from the epiglottis. (Alternatively, the suture
When the laryngoscope is successfully placed in the endolar- can be removed at the end of the case.)
ynx but the endotracheal tube is anterior to the laryngoscope, The optimal position of the laryngoscope within the endol-
the endotracheal tube can be drawn gently and carefully down arynx is determined by the vocal fold pathology and pending
into the more appropriate posterior glottic position, without surgical procedure. However, in general, the laryngoscope
too much difficulty, using upward pressure of the suspend- should be positioned immediately above (superior to) the vo-
ed laryngoscope or the nondominant hand’s index finger cal fold pathology, specifically resulting in retraction of the
(Fig. 10.13). false vocal fold tissues. Care should be taken to avoid contact-
The fourth technique for the placement of a large-diameter ing the superior surface of the vocal fold given that this will
laryngoscope in a patient with difficult epiglottis anatomy (i. e., significantly alter the anatomic orientation and nature of the
large, floppy) starts with positioning the laryngoscope imme- vocal fold and often distort the vocal fold pathology.
diately above the tip of the epiglottis (Fig. 10.14). With this
visualization, a large up-cup forceps is passed outside the la-
ryngoscope, down toward the proximal tip of the laryngoscope
10.5.4 Suspension Device
and used to grab the tip of the epiglottis firmly. With firm con-
trol of the epiglottis, the cup forceps can be used to pull or
direct the epiglottis in an anterior direction (Fig. 10.15). With The gallows suspension device (Fig. 10.16), if used, should be
the epiglottis being held anteriorly, the laryngoscope is then positioned to provide upward and slightly forward (caudal)
advanced into the endolarynx on top of the endotracheal tube. suspension of the laryngoscope in the endolarynx. This spe-
Once the laryngoscope is successfully placed in the endolar- cial angulation of the laryngoscope will provide optimal laryn-
ynx, the forceps are opened and the epiglottis is released. goscopic visualization and minimal adjacent tissue injury or
The fifth option for laryngoscope placement involves place- damage. For a rotation or fulcrum laryngoscope device holder
ment of temporary suture through the epiglottis. A large-di- (such as a table-mounted Mayo stand; Fig. 10.17), it is of the
ameter laryngoscope is positioned by hand or suspension utmost importance to remember to provide special care and
above the epiglottis. Working through the microscope, a 4.0 attention to the maxillary teeth as the laryngoscope holder is
silk suture is placed through the tip of the epiglottis, and the put into place. This is especially important given that as the
two ends of the suture are brought out through the laryngo- fulcrum holder is adjusted, each amount of upward rotation at
scope. The laryngoscope is completely removed from the body the distal tip of the laryngoscope results in an equal amount of
and then replaced above the epiglottis, with the suture through downward pressure at the proximal aspect of the laryngoscope
the epiglottis being kept outside the laryngoscope. Tension can on the maxillary alveolar ridge. A tooth protector can be fash-
be applied to the epiglottis suture to control and stabilize the ioned by using a standard thin plastic tooth guard commonly
epiglottis as the laryngoscope is passed underneath it into po- found in anesthesiology carts, and reinforcing it with multiple
sition. Once good position of the laryngoscope is achieved, the layers of cloth tape (Fig. 10.18).
Chapter 10 71
Fig. 10.16 Gallows-type suspension device Fig. 10.17 Fulcrum type suspension device (Lewy apparatus suspend-
ed from a table-mounted Mayo)
Fig. 10.18 Tooth protector fashioned from a plastic tooth guard and
layers of cloth tape
Fig. 10.19 Velcro strap applied to anterior neck region (near the cri-
coid) to optimize vocal fold visualization during suspension laryngos-
copy
10.5.5 External Counter-Pressure
A Velcro strap or silk tape can be applied to the external neck patient were to move unexpectedly as the anesthesia wears off.
(in the area of the cricoid or trachea) in a downward and slight- If this occurs, the first duty of the surgeon is to release the ex-
ly cephalad vector to improve the endolaryngeal exposure on ternal counter pressure and secondly take the patient out of
an as needed basis (Fig. 10.19). The surgeon should look down suspension laryngoscopy.
the laryngoscope while applying external counter-pressure to
judge the location and amount of external counter-pressure
required. A small amount of gauze or a foam pad can be posi-
10.5.6 Telescopic Evaluation
tioned between the tape or strap and the neck skin to prevent
of Vocal Fold Pathology
any injury to the overlying skin of the larynx (Fig. 10.20). It
is extremely important that the surgeon remember this type
of external counter pressure, which is often essential to opti- Using the 0, 30, 70° (and as needed, 120°) telescope for visual-
mal exposure of the endolarynx, puts the patient at risk if the ization in a “three-dimensional” fashion of the endolarynx is of
Fig. 10.20 Patient positioned for phonomicrosurgery. Note neck flex- Fig. 10.22 Proper support of surgeon’s arms for phonomicrosurgery
ion, head extension, and angle of Velcro strap positioning the larynx
10 into an optimal viewing path of the laryngoscope
attention should be drawn to the position of the laryngoscope

in relation to the microscope and the surgeon. Optimal hand
control of instrumentation during phonomicrosurgery oc-
curs when the forearms can be supported with a stable device,
such as an operating room chair with arm supports. The wrists
are the best location for precise control, and thus some type
of surgical support should be identified (an ophthalmologist’s
or plastic surgeon’s operating room chair with arm supports,
or a Mayo stand) that will allow the most steady and stable
hand and wrist motions, but supporting the arms at the level
of the forearms (Fig. 10.22). Patient positioning should allow
the surgeon’s upper arms to be held in a vertical position, with
elbows and hands as low as possible to the surgeon’s lap. An al-
ternative to these custom surgical chairs is to use a Mayo stand
with pillows/foam padding. The Mayo stand is placed between
the surgeon and the head of bed (Fig. 10.23).
Paying attention to the surgeon’s neck, head, and back po-
Fig. 10.21 Visualization of vocal fold pathology during suspension sition during the surgical procedure is important for his/her
laryngoscopy with angled telescopes longstanding neck and back health. Often, to facilitate optimal
phonomicrosurgery ergonomics, the operating room table
should be placed in a reverse Trendelenburg position. This
great value. This is done after the laryngoscope is suspended. brings the laryngoscope lower—into the surgeon’s lap—and
This allows for unique visualization of the vocal fold pathol- the eye pieces of the surgical microscope should be utilized to
ogy, photodocumentation, and surgical planning (Fig. 10.21). allow the surgeon to sit with his/her back completely straight
Specifically, decisions are often made about the optimal loca- and upright (Fig. 10.22).
tion for an incision when evaluating the vocal fold pathology, Binocular vision at high-power magnification must be
specifically with the 30 and 70° angled telescopes. In addition, achieved during all aspects of the procedure. This will require
these telescopes provide great visualization of the ventricles, minor but important adjustments of the position of the mi-
subglottis, anterior and posterior commissure. croscope and laryngoscope to ensure that the viewing access
of the microscope is perfectly coaxial with the longitudinal as-
pect of the laryngoscope, thus allowing binocular vision. This
is a very important component to phonomicrosurgery, and it
10.5.7 Operating Microscope
should not be overlooked. The novice phonomicrosurgeon will
and Surgeon Ergonomics
initially struggle with this task, but patience and practice will
allow success. The majority of phonomicrosurgical procedures
After suspension of the laryngoscope and telescopic exami- should be done using the microscope’s highest magnification
nation, the surgical microscope is brought in to position, and setting.
Chapter 10 73
Fig. 10.23 Alternative method for support of the surgeon’s arms, us-
ing a padded Mayo stand
Fig. 10.24 Microflap incision placed lateral to the lesion with epithe-
10.5.8 Microflap Approach
lium tented up by the sickle knife
to Submucosal Pathology
The microflap approach to submucosal pathology is a key as- incision and a small curved elevator can be used to begin the
pect to most phonomicrosurgery operations. The core prin- elevation of the microflap in the plane between the vocal fold
ciples of the microflap approach to submucosal pathology in- pathology and the overlying epithelium (i. e. medial to the le-
clude: sion). This plane is the single most difficult step of phonomi-
crosurgery, and it should be performed with great patience
■ Making an incision through the epithelium at the clos-
and caution. It is often easiest to initiate and develop this plane
est possible location to the submucosal pathology
anteriorly and posteriorly to the vocal fold lesion. Often, vari-
■ Disrupting the minimum of surrounding tissue to the
ous angulated or curved elevators will be required to perform
vocal fold pathology
this aspect of the procedure, given that at the very start of the
■ Staying in as a superficial plane as possible
development of the microflap, the surgeon is initially working
■ Preservation of overlying normal mucosa (epithelium
on the upper lip of the free edge of the vocal fold medially.
plus superficial lamina propria)
Then as the microflap is carefully elevated and dissected from
the submucosal pathology, the surgeon is working in the exact
There are multiple descriptions of various forms of microflaps, opposite direction on the inferior lip of the vocal fold laterally,
specifically lateral microflap, medial microflap, and mini-mi- and thus, different curved elevators are often required to work
croflap. Over the years, many of these microflap approaches in different directions, especially to ensure minimizing the risk
have merged into a single, philosophical microflap approach to of microflap penetration or injury.
submucosal pathology, which is described below. Once a plane is developed anterior and posterior to the
The incision for the microflap should be directly overlying, lesion, then careful submucosal dissection with a small, fine
or immediately lateral to the vocal fold pathology. This results blunt elevator (curved or angled) is performed to complete
in minimal disruption of normal adjacent vocal fold mucosa. the elevation and creation of the microflap (Fig. 10.25). There
After the vocal fold pathology is palpated and an incision is may be instances where small, microcurved scissors need to be
planned, an incision is then made with a sharp sickle knife. It is used to release fibrous bands off the overlying microflap in ad-
important to note that the tip of the sickle knife should be used herent areas of the submucosal pathology or in a similar man-
to penetrate the epithelium, and then the tip of the sickle knife ner when the submucosal pathology is adherent to the deeper
can be drawn slightly superiorly, tenting up the epithelium as aspects of the vocal fold in the area of the vocal ligament (see
the incision is made in an anterior or posterior direction (Fig. Chap. 17, “Vocal Cord Cyst and Fibrous Mass”)
10.24). This prevents the sickle knife accidentally causing any Hemostasis is extremely important, and if bleeding is caus-
type of injury to the submucosal pathology or deep vocal fold ing an obstruction of visualization, then the surgery should
tissues. be temporarily stopped and the application of epinephrine
After the incision has been made, the vocal fold pathology (1:10,000)-soaked, small cotton pledgets should be utilized to
may be able to be palpated and directly visualized through the quickly and successfully provide surgical hemostasis without
cosal pathology. The majority of benign vocal fold submuco-

sal pathology is located in the immediate subepithelial plane
and is often, to a varying degree, adherent to the overlying
epithelium. This is the case in approximately 80–90% of cases;
however, there will be situations where the pathology is not
adherent to the overlying microflap and instead located deeper
within the vocal fold (in the area of the vocal fold ligament)
(Fig. 10.26). This is true for ligamentous vocal fold cyst and fi-
brous mass (see Chap. 4, “Pathological Conditions of the Vocal
Fold”). When these pathologies are encountered, the surgeon
will notice that the microflap elevation is quite easy; however,
the deeper aspect of the dissection, creating a plane between
the vocal fold pathology and the vocal ligament is quite dif-
ficult. In this situation, great care should be taken to use either
a blunt dissection technique or microscissors to release the ad-
herent bands between the vocal fold ligament and the pathol-
ogy, always erring on the side of the pathology (in a superficial
fashion).
After the superficial and deep planes around the submu-
10 cosal pathology have been elevated, there may be some addi-
tional connections to the vocal fold pathology within the vocal
fold anteriorly and posteriorly. These bands can be released
with blunt dissection or microcurved scissors. This allows the
Fig. 10.25 Elevation of microflap off vocal fold lesion beneath submucosal pathology to be removed and sent for pathologic
examination. The microflap is then redraped with either the
triangular forceps or a curved elevator (Fig. 10.27). It is often
helpful to place an epinephrine (1:10,000)-soaked Cottonoid
much difficulty. Suctioning blood and secretions from this area over the operative site for 1–2 min to reduce edema before
should be done with a 3-French suction, usually without cov- making further surgical decisions. After the microflap has been
ering the thumb port. redraped, palpation of the vocal fold should be performed to
Great care should be taken not to tear or fenestrate the mi- determine if there is any residual submucosal pathology that
croflap as it is tediously and carefully elevated off the submu- can be palpated and removed.
Fig. 10.26 Elevated microflap reveals that the pathology (fibrous Fig. 10.27 Redraped microflap after removal of vocal fold lesion. Note
mass) is on the vocal ligament and not in the subepithelial space copatation of the mucosa at the incision site and smooth free edge of
the vocal fold
Chapter 10 75
The free edge of the vocal fold should be straight after the sensation occur in approximately 10–20% of patients after pho-
pathology is removed; if not, further investigation into either nomicrosurgery. These symptoms are usually transitory, and
the under surface of the microflap or the deeper aspect of the thus the patient should be informed that these postoperative
vocal fold should be performed. If there is any residual patho- changes resolve on their own within the first month after sur-
logic tissue such as fibrous material or scar, then this tissue gery. Additional complications related to phonomicrosurgery
should be removed in a conservative and reasonable fashion. are discussed in Chaps. 11, “Perioperative Care for Phonomi-
This material can be removed with a microelevator or micro- crosurgery” and 12, “Management and Prevention of Compli-
cup forceps. Extreme care is required at this juncture of the cations Related to Phonomicrosurgery.”
surgery because overly-aggressive removal of this material can
result in significant scar formation as well as a permanent de-
formity of the free edge of the vocal fold. At the completion of
Key Points
the vocal fold lesion(s) excision, the free edge of each vocal fold
should be completely straight without exophytic mucosal tags
and without a soft tissue defect at the free edge of the surgical ■ Phonomicrosurgery is elective, precise surgery
site.
aimed to improve vocal function based on prin-
ciples of vocal fold physiology.
■ Phonomicrosurgery utilizes small, delicate surgical
10.6 Postoperative Care instrumentation and is performed with maximum
and Complications control via high-powered microlaryngoscopy for
optimal results.
■ Conservative removal of submucosal pathology
Almost all phonomicrosurgical procedures are followed by
with preservation of overlying normal epithelium
some period of voice rest. This period can range from as short
and superficial lamina propria allows healing by
as 2 days and extend to possibly 14 days, depending on the spe-
primary intention and optimal voice quality after
cific nature of the surgery, compliance of the patient, the sur-
phonomicrosurgery.
geon’s philosophy, and experience. In addition to voice rest, the ■ Microflap approach to submucosal pathology of
patient should be encouraged to stay well hydrated, continue
the vocal fold is an essential component of most
treatment for laryngopharyngeal reflux disease with a proton
phonomicrosurgical procedures and is a challeng-
pump inhibitor, and maintain GERD behavior modification. At
ing surgical task that requires patience, appropri-
the end of the prescribed strict voice rest period, stroboscopy
ate instrumentation, surgical skill, and experience.
should be performed to evaluate the recovery and healing pro-
cess of the vocal fold. If there is adequate epithelial coverage,
then the patient can be transitioned to “light voice use,” which
is usually defined as speaking using a breathy, “airy” type of
voice (not a whisper) for 5–10 min per hour. Light voice use is
often used for an additional 7–10 days after the period of strict
voice rest. There is rarely an indication for antibiotics associ- 1 Andrea M, Dias O (1995) Rigid and contact endoscopy in mi-
ated with phonomicrosurgery or long-term steroid use. Some crolaryngeal surgery: technique and atlas of clinical cases. Lip-
surgeons may use immediate intravenous, intramuscular, or pincott Williams & Wilkins, Philadelphia
intralesional steroids perioperatively to minimize postopera- 2 Bastian RW (1996) Vocal fold microsurgery in singers. J Voice
tive edema. 10:389–404
It is advisable to involve a speech–language pathologist to 3 Bouchayer M, Cornut G (1992) Microsurgical treatment of be-
assist the patient in transitioning from strict voice rest to light nign vocal fold lesions: indications, technique, results. Folia Pho-
voice use to ensure that the patient is using the optimal postop- niatr 44:155–184
erative voice technique to facilitate healing and prevent injury 4 Courey MS, Garrett CG, Ossoff RH (1997) Medial microflap for
in this important time. excision of benign vocal fold lesions. Laryngoscope 107:340–344
Complications from phonomicrosurgery include failure of 5 Courey MS, Stone RE, Gardner GM, Ossoff RH (1995) Endo-
the microflap to appropriately redrape and adhere to the vocal scopic vocal fold microflap: a three year experience. Ann Otol
fold. When this occurs, epithelial ingrowth underneath the mi- Rhinol Laryngol 104:267–273
croflap occurs, and surgical excision of the microflap is man- 6 Ford CN (1999) Advances and refinements in phonosurgery. La-
dated. This is a rare complication. Excessive edema and even ryngoscope 109:1891–1900
necrosis can occur to a microflap; this typically occurs when 7 Hirano M (1977) Structure and vibratory behavior of the vo-
the microflap is overly traumatized or injured during the surgical fold. In: Sawashima M, Cooper F (eds) Dynamic aspects of
cal procedure. Often, when this occurs, the vocal fold will heal speech production. University of Tokyo, pp 13–30
adequately on its own with appropriate time and care. Dental 8 Rosen CA, Andrade Filho PA, Scheffel L, Buckmire RA (2005)
injuries after phonomicrosurgery should be repaired to the Oropharyngeal complications of suspension laryngoscopy: a
patient’s satisfaction in a prompt fashion to minimize negative prospective study. Laryngoscope 115:1681–1684
feelings of the patient toward the surgeon. Lingual nerve inju-
ries such as numbness of the tongue and/or a change in taste
9 Sataloff RT, Spiegel JR, Heuer RJ, Barody MM, Emerich KA, 12 Zeitels SM, Vaughan CW (1994) External counter-pressure and
Hawkshaw MJ, Rosen DC (1995) Laryngeal mini-microflap: a internal distension for optimal exposure of the anterior glottal
new technique and reassessment of the microflap saga. J Voice commissure. Ann Otol Rhinol Laryngol 103:669–675
9:198–204 13 Zeitels SM, Hillman RE, Desloge R, Mauri M, Doyle PB (2002)
10 Shapshay SM, Healy GB (1990) New microlaryngeal instruments Phonomicrosurgery in singers and performing artists: treatment
for phonatory surgery and pediatric applications. Ann Otol Rhi- outcomes, management theories, and future directions. Ann Otol
nol Laryngol 98:821–823 Rhinol Laryngol 190(Suppl.):21–40
11 Thekdi AA, Rosen CA (2003) Surgical treatment of benign
vocal fold lesions. Curr Opin Otolaryngol Head Neck Surg
10:492–496
10
Chapter 11
Perioperative Care
for Phonomicrosurgery 11
anticoagulation medication such as nonsteroidal anti-inflam-
matories, aspirin, Coumadin, and Plavix, and other medica-
tions that may affect coagulation (over-the-counter medica-
Please see Chaps. 8, 10, and 12 for further information. tions, herbal supplements etc.). These medications should be
stopped 7–10 days prior to surgery.
It is also wise to avoid scheduling phonomicrosurgery dur-
ing a woman’s premenstrual period (approximately 5 days
11.2 Timing of Phonomicrosurgery
before the onset of menses). This is especially important for
singers and for patients with very small vocal fold lesions.
Phonomicrosurgery involves the surgical manipulation of the The reason for avoiding the premenstrual time period when
delicate epithelial and sub-epithelial tissues of the vocal fold engaging in phonomicrosurgery is to avoid vocal fold edema
(Fig. 11.1). Thus a variety of steps should be implemented to and vascular fragility thought to be associated with premen-
minimize edema and bleeding at the surgery sites(s) to maxi- struation affect the surgical decision making and the surgical
mize the surgeon’s precision and the voice outcome post-op- outcome. Lastly, the patient and surgeon should have a clear
eratively. There are a variety of important aspects with regard understanding of the voice demands for the next 2–3 months
to the timing and scheduling of phonomicrosurgery. First and after phonomicrosurgery. This is extremely important for sing-
foremost, the patient and the physician must be comfortable ers, schoolteachers, and individuals involved in sales and busi-
with the decision to proceed with surgery, having had a de- ness (see Chap. 8).
tailed discussion regarding the nature of the surgical procedure,
perioperative treatment plan, and should have established rea-
sonable expectations for the timing of recovery and voice out-
comes (see Chap. 8, “Timing, Planning, and Decision Making
in Phonosurgery”). It is important for the patient to stop all
It is important for the patient prior to phonomicrosurgery to

minimize his/her voice demands for approximately 7 days be-
fore the scheduled surgery (see Chap. 8, “Timing, Planning,
and Decision Making in Phonosurgery”). Voice therapy prior
to phonomicrosurgery is important for a variety of factors, in-
cluding:
■ Pre- and postoperative voice use plans
■ Voice rest, and education regarding use of the silent
cough
■ Laying a foundation for healthy voice use technique
after surgery
■ Discussing alternative communication options during
the complete-voice rest phase
If the patient has not had any voice therapy prior to surgery,
then one to two sessions of voice therapy is optimal. It is also
advisable prior to phonomicrosurgery to begin the patient on
medical therapy for LPR treatment prophylactically. Even if the
patient does not have any active symptoms of LPR, given the
risk of reflux and its possible negative effects on wound heal-
ing of the vocal folds, GERD behavior modification and proton
Fig. 11.1 Microscopic dissection of the epithelial flap using a 30° flap pump inhibitor therapy is typically started prior to phonomi-
elevator crosurgery and extended for 1–2 months after surgery.
78 Perioperative Care for Phonomicrosurgery
usually used for approximately 7–10 days. Light voice use often
11.4 Considerations for the Day
allows the patient to use a soft, conversational, breathy voice
of Phonomicrosurgery
(this is not whispering) for approximately 5–10 min per hour.
Patients should be reminded that this voice use limitation is
Psychological reassurance of the patient on the day of surgery not cumulative and should not be violated for any reason.
is extremely important. This involves seeing the patient outside
the operating room before surgery, discussing any last-minute
questions, and reviewing the surgical plans as well as the post-
11.6 Postoperative Voice Care
operative voice rest and recovery issues. Intravenous steroids
should be used (10–20 mg Decadron) prior to the induction of
general anesthesia for phonomicrosurgery. There is no indica- At the completion of strict voice rest, it is optimal for the pa-
tion for antibiotics or prolonged steroid use with most phono- tient to work with a speech–language pathologist for a short
microsurgery cases. period as they reinitiate voice production. During this session,
the speech–language pathologist emphasizes proper breath
support, airflow, resonant voice production, and minimizes
the risk of whispering or falsetto voice use. Often, there are
11.5 Postoperative Voice Rest
also psychological aspects associated with the patient transi-
tioning from total voice rest to voice use and thus, the speech–
After phonomicrosurgery, a period of total voice rest is in- language pathologist can be helpful working with the patient
dicated in most situations. The duration of this voice rest is on these issues.
controversial and should be based on the nature of the pathol- Stroboscopy is an important monitoring tool after phono-
11 ogy treated during surgery, compliance of the patient, and microsurgery and should be used to guide and assist in the
the degree of dissection performed at the time of the surgical graduation of the patient from total voice rest to light voice
procedure. It should be emphasized to the patient and family use to full voice use. Voice therapy after phonomicrosurgery
members that total voice rest involves no sound production is extremely important aspect of vocal recovery for almost all
whatsoever. Total voice rest includes no: patients undergoing phonomicrosurgery. The optimal time
for initiation of voice therapy after phonomicrosurgery is ap-
■ Speaking
proximately 7–14 days after surgery. Singing voice therapy is
■ Singing
also an important adjunctive treatment to the vocal rehabili-
■ Whispering
tation of singers and nonsingers alike. Appropriate timing for
■ Humming
initiation of singing voice therapy after phonomicrosurgery is
■ Clicking
highly variable, but typically, can be initiated approximately
■ Throat clearing
3–4 weeks after surgery.
Alternative methods of communication should have been re-

viewed preoperatively and should be reviewed immediately
11.7 Intralaryngeal Steroid Injection
postoperatively. They include the following:
to Soften Postoperative
■ E-mail Scar in the Vocal Fold
■ Pen-and-paper notes
■ A wipe-off board
A variety of factors known and unknown can contribute to sig-
■ Bell
nificant postoperative stiffness and scarring of the vocal fold
■ Whistle
after phonomicrosurgery. When significant vocal fold stiffness
■ Text messaging
after phonomicrosurgery is identified, often superficial steroid
injections to the vocal folds are helpful to reduce permanent
Silent cough is a helpful way to deal with the mucous sensation scar tissue formation and enhance wound healing of the vocal
that sometimes occurs after phonomicrosurgery, minimizing folds, resulting in better pliability, vocal fold closure and voice
trauma to the recently operated vocal folds. Silent cough in- quality. Most frequently, this treatment is done on a monthly
volves the patient taking a large inhalation and performing a basis for 3 months, starting approximately 2–4 weeks after
rapid, forced exhalation, without any sound production dur- phonomicrosurgery. The steroid injection can often be done
ing the exhalation. Immediately after the exhalation, the pain the office under local anesthesia (see Chap. 33, “Peroral Vo-
tient should tuck his/her chin and perform a hard swallow. cal Fold Augmentation in the Clinic Setting”), using Decadron
This in combination with frequent sips of water should address 10 mg/ml. Kenalog should be avoided due to the risk of particle
any issues patients have associated with mucous sensation and deposits within the vocal fold.
mucous build up in the throat while avoiding the use of pho-
notraumatic throat clearing activity. The typical duration for
voice rest after phonomicrosurgery procedures ranges from 2
to 10 days. After the period of complete voice rest, light voice is
Chapter 11 79
Key Points Selected Bibliography
1 Behrman A, Sulica L (2003) Voice rest after microlaryngoscopy:

■ The importance of involving the patient in the
current opinion and practice. Laryngoscope 113:2182–2186
decision making for phonomicrosurgery cannot be
2 Cho SH, Kim HT, Lee IJ, Kim MS, Park HJ (2000) Influence of
overemphasized.
phonation on basement membrane zone recovery after pho-
■ It is important that the patient understand the
nomicrosurgery: a canine model. Ann Otol Rhinol Laryngol
importance of clearing their future voice demands
109:658–666
for the 2–3 months after phonomicrosurgery to
3 Tateya I, Omori K, Hirano S, Kaneko K, Ito J (2004) Steroid in-
maximize the chances of successful recovery after
jection to vocal nodules using fiberoptic laryngeal surgery under
surgery.
topical anesthesia. Euro Arch Otorhinolaryngol 261:489–4923
■ A short period of strict postoperative voice rest is
4 Mortensen M, Woo P (2006) Office steroid injections of the lar-
typically indicated and helpful, and then gradu-
ynx. Laryngoscope 116:1735–1739
ated voice use can be implemented under the care
of the speech–language pathologist to maximize
vocal recovery.
■ Use of the speech–language pathologist for the
preoperative and postoperative care of patients
undergoing phonomicrosurgery is an important
aspect of successful phonomicrosurgery and the
patient’s optimal vocal recovery.
Chapter 12
Management and Prevention

of Complications Related 12
to Phonomicrosurgery
All of these complications are associated with the position-

ing and placement of the laryngoscope. Most likely, these
complications are related to the size of the laryngoscope and
Please see Chaps. 8, 10, and 11 for further information. the duration of suspension of the laryngoscope. People have
hypothesized that intermittently taking the laryngoscope off
suspension to allow blood flow to the lingual area and remove
pressure off the adjacent nerves may prevent or minimize these
12.2 Overview of Management
types of complications. However, this has not been proven sci-
and Prevention of Complications
entifically. Given that much of the success of phonomicrosur-
Related to Phonomicrosurgery
gery is based on precision of surgery—which is directly related
to the adequacy of the exposure of the vocal folds with a large
There are a host of complications related to phonomicrosur- bore laryngoscope—many of these complications are difficult
gery that range from mild to serious and involve multiple fac- to avoid completely. In fact, some laryngologists believe that
tors, some of which are known (i. e., poor postoperative com- these are not complications, but expected aspects of phono-
pliance with voice rest) and others unknown (i. e., unknown microsurgery, comparable to abdominal pain after an appen-
wound-healing phenotype). dectomy.
The sections below discuss the nature of the complications, Optimal management strategy for these complications in-
remedies for the complications, the natural clinical course, and cludes pre- and perioperative communication with the patient
prevention of these complications. Several overriding prin- regarding the possibility of these problems occurring and their
ciples associated with the management and care of patients subsequent management. A great majority of the time, lingual
experiencing complications should be kept in mind as indi- anesthesia, dysgeusia, and throat pain will be temporary in
vidual complications are discussed. Most importantly, the lines nature. Thus, the patient needs to be reassured that the symp-
of communication between the patient and the voice care team toms that he/she experiences after phonomicrosurgery resolve
are extremely important. Multiple studies have shown that pa- with time. Dental injuries should be cared for by a dentist in
tient satisfaction after medical care is related in large part to a prompt fashion to shorten and minimize the patient’s aggra-
the patient’s perception of the health care provider’s interest vation and frustration. Dental injuries can also be minimized
in their care, which in turn is directly related to the provider’s by taking great care of the dentition during placement of the
ability to communicate with the patient. Thus, the most es- laryngoscope and use of tooth guards over the mandibular and
sential aspect of managing complications associated with pho- maxillary teeth. It is extremely rare for suspension microlar-
nomicrosurgery is to establish and maintain excellent lines of yngoscopy to induce temporomandibular joint disease; how-
communication between the patient and the voice care team ever, it is common that suspension microlaryngoscopy will
members. aggravate preexisting temporomandibular joint pathology. For
this reason, if the patient has temporomandibular joint dis-
ease, prior to phonomicrosurgery, it is wise to advise that most
likely, the phonomicrosurgery procedure will exacerbate his/
her disorder, and that they may require medical or oromaxil-
lofacial intervention postoperative to assist their recovery from
this condition.
A variety of minor to major complications associated with
phonomicrosurgery can occur in the oropharyngeal region.
These include:
12.4 Postoperative Dysphonia
■ Dental injuries
■ Temporomandibular joint disorder aggravation
There are varieties of aspects related to postoperative healing
■ Lingual anesthesia
that can result in postoperative dysphonia after phonomicro-
■ Dysgeusia
surgery. These include vocal fold scar, dependent edema of the
■ Throat pain
vocal fold, granulation tissue at the operative site, failure of the
82 Prevention of Phonomicrosurgery Complications
microflap to adhere, and recurrence of the vocal fold patholo- pathology after phonomicrosurgery. This can be associated
gy. Another related complication contributing to postoperative with uncontrolled LPR, voice abuse, and/or incomplete exci-
dysphonia is a patient with unreasonable expectations of voice sion of the vocal fold pathology. Prevention of the latter can
quality and function after phonomicrosurgery. When this oc- be done by carefully examining the vocal fold at the time of
curs, patients complain of a persistent postoperative dysphonia microflap excision to ensure that all aspects of the vocal fold
or even an exacerbation of their dysphonia after phonomicro- pathology have been completely removed. This can also be
surgery, even though this may not in fact be the case. Unrea- achieved by a performing careful vocal fold palpation with the
sonable expectations after phonomicrosurgery stem from poor back of a curved instrument, and feeling for persistent vocal
communication between the voice care team and the patient, fold pathology within the microflap or deep to the microflap.
especially regarding the typical postoperative clinical course in In addition, it is important for the surgeon to perform careful
rehabilitation, plan, and the ultimate outcome of their phono- visual inspection of the operative site for persistent pathology.
microsurgical procedure, especially accounting for unsuspect-
ed vocal fold pathology found during phonomicrosurgery. The
most important prevention method for minimizing the risk of
12.5 Medical Complications Associated
patients developing unreasonable expectations associated with
with Phonomicrosurgery
phonomicrosurgery is to establish an excellent line of commu-
nication between the patient and the voice care team mem-
bers. This can be enhanced by using a special consent form Fortunately, significant medical complications after phonomi-
for phonomicrosurgery, which details in plain language the crosurgery are extremely rare. They include airway compro-
risk of exacerbating their dysphonia or failure to improve their mise, bleeding from the operative site, and infection. Overly
dysphonia due to a variety of factors. It is also important to aggressive vocal fold injection, especially in the case of poor
maximize the lines of communication between the patient and vocal fold abduction (unilateral with a contralateral vocal fold
the voice care team members by including family members, paralysis or bilateral) can result in airway compromise. This is
12 singing teachers and speech–language pathologists involved most commonly treated with systemic steroids and careful ob-
in the decision making process to proceed with phonomicro- servation. Bleeding from the vocal folds after phonomicrosur-
surgery and to avoid pressuring the patient into consenting to gery is extremely rare and most notably occurs after removal of
phonomicrosurgery (see Chap. 10, “Principles of Phonomicro- recurrent respiratory papillomatosis. In fact, when there is sig-
surgery”). nificant bleeding after phonomicrosurgery for recurrent respi-
Prevention of vocal fold scar formation after phonomicro- ratory papillomatosis, it usually indicates incomplete removal
surgery can be optimized by adhering to conservative tissue of the recurrent respiratory papillomatosis disease. Infection
handling techniques during phonomicrosurgery, ensuring that rarely occurs after phonomicrosurgery, and in fact, for this rea-
the patient is compliant with regard to voice rest and light voice son antibiotics are rarely indicated for this surgery.
use after surgery, and finally, considering the use of postopera-
tive, intra-vocal fold steroid injections to minimize permanent
vocal fold scar after phonomicrosurgery (see Chap. 11, “Peri-
Key Points
operative Care for Phonomicrosurgery”).
Physical complications after phonomicrosurgery of depen-
dent edema of the vocal fold, granulation tissue at the operative ■ The lines of communication and relationship be-
site, and failure of the microflap to adhere are typically related
tween the surgeon and the patient are absolutely
to uncontrolled LPR, poor compliance with postoperative
essential for the management and prevention of
voice rest, and a foreign-body implantation associated with the
complications related to phonomicrosurgery. The
surgical procedure. Difficulties with dependent edema of mi-
surgeon should be completely forthright and hon-
croflap can be solved with time, minimizing vocal abuse and
est when discussing with the patient potential and
treating concurrent LPR. Reducing the risk of granulation tis-
real complications of phonomicrosurgery and their
sue at the operative site can be accomplished by reducing post-
subsequent management.
operative vocal abuse, treating LPR perioperatively and ensur- ■ It is imperative for the surgeon to establish reason-
ing that there is no char from the laser or extraneous foreign
able expectations regarding voice quality and
bodies (e. g., metal flakes from instrumentation) implanted at
timeline of recovery with the patient to optimize
the operative site during phonomicrosurgery. Difficulties with
vocal recovery and achieve patient satisfaction
the microflap adhering are rare, but when they occur, it is most
from a voice quality perspective.
likely from varieties of issues. These include poor compliance ■ Many significant complications associated with
with voice rest, overly traumatic handling of the microflap, and
phonomicrosurgery can be prevented by strictly
fenestration of the microflap inferiorly, which results in non-
adhering to principles of conservative tissue han-
adherent epithelial coverage at the operative site, leaving the
dling and excision.
microflap nonadherent to the underlying vocal fold. Great care
of the soft tissues of the microflap is essential for preventing
these complications.
The last aspect of poor voice results associated with pho-
nomicrosurgery involves the formation of recurrent vocal fold
Chapter 12 83
1 Anderson TD, Sataloff RT (2004) Complications of collagen in- 3 Rosen CA, Villagomez VJ (2001) A unique complication of mi-
jection of the vocal fold: report of several unusual cases and re- croflap surgery of the vocal fold. Ear Nose Throat J 80:623–624
view of the literature. J Voice 18:392–397 4 Woo P, Casper J, Colton R, Brewer D. Diagnosis and treatment
2 Rosen CA, Andrade Filho PA, Scheffel L, Buckmire RA (2005) of persistent dysphonia after laryngeal surgery: a retrospective
Oropharyngeal complications of suspension laryngoscopy: a analysis of 62 patients. Laryngoscope 104:1084–1091
prospective study. Laryngoscope 115:1681–1684
Chapter 13
Principles
of Laser Microlaryngoscopy 13
13.1 Fundamental and Related Chapters 13.2.2 Tissue Interaction
Please see Chaps. 6, 10, 21, 22, 24–30 for further information. While appropriate wavelength determination is critical for spe-
cific tissue targeting, the time in which the energy is delivered
is also of consequence. Under prolonged exposure times, pho-
tothermal effects cause collateral coagulation necrosis, as heat
13.2 Laser Physics
transfers uniformly to surrounding tissues. However, if the
pulse width is too short, the absorbing tissue may heat rapidly.
The modern challenge of using medical lasers is the surgeon’s Extreme temperature differences between target tissue and
ability to deliver the right amount of energy at the right wave- collateral structures have been shown to cause vaporization
length to the right tissue while minimizing damage to collat- and shock wave damage, commonly referred to as a photome-
eral tissue. This process by which laser energy is restricted to chanical effect. Consequently, nonspecific thermal damage oc-
a particular site is a result of the selective absorption of the curs when the pulse width exceeds the thermal relaxation time
chromophores at that site and was first described by Anderson for the tissue. Thus, the larger the specific target, the larger the
et al. as “selective photothermolysis.” The following section will thermal relaxation coefficient. Generally, subcellular organ-
consider the major concerns confronting surgeons when using elles achieve photolysis within a nanosecond domain, cellular
lasers in a clinical setting. disruption occurs on a microsecond scale, and hemostasis is
achieved within millisecond exposure times. In actual practice,
all of these interactions occur concomitantly, but by selecting
the proper wavelength, intensity, and pulse duration, the sur-
13.2.1 Wavelength
geon can maximize the desired effects.
Unlike the energy emitted from ambient light sources, laser

light is monochromatic and usually of a single wavelength,
13.2.3 Delivery Systems
with all photons collimating into a single, thin beam of ho-
mogeneous energy. The challenge of laser surgery is finding a
wavelength in which energy is absorbed by target tissue and While recent advancements in the field have provided more
scattered or transmitted by surrounding structures. When la- options for delivery systems, laser type is still the major deter-
ser light is delivered to the chromophores within the target, minant. Traditionally, the CO2 laser has been of the most use
energy is absorbed within that tissue. Some common chromo- for laryngologists. Traditionally, an articulating arm is required
phores targeted by surgical lasers are hemoglobin, melanin, for the delivery of CO2 laser energy to the treatment site. This
water-containing soft tissue, and covalent bonds found in ma- delivery system requires a hollow tube with several joints or ar-
jor structural proteins. Depending on the chosen wavelength, ticulations that allow some maneuverability. At each articula-
either coagulation, vaporization, or a combination both will tion, a set of mirrors are positioned to reflect the beam around
take place. Tissues heated to 80–100°C will suffer plasma dena- the corner. Great care must be taken when using such a system,
turation, resulting in vessel closure and hemostasis. Tempera- as jarring or vibrations may cause misalignment within the in-
tures above 100°C will cause vaporization through rapid volu- ternal mirror system. Laryngologists have also benefited from
metric expansion of intracellular water stores, a technique that the addition of several attachments used at the end of articulat-
is useful for separating or ablating tissues. A laser’s wavelength ing arms. Micromanipulators are used to couple laser opera-
also correlates with the depth at which the energy is delivered. tion and microscopy. A greater amount of precision and beam
Therefore, greater depths of tissue disruption are achieved at control can be managed by hand-manipulated devices.
longer wavelengths until reaching the wavelength specific for The micromanipulators can control laser spot size. This is
the absorption of water, near 2,000 nm. an essential variable from an ultimate tissue interaction per-
spective. Spot size, power, energy setting, and duration have a
major role in the effect of the laser on the tissue. The smaller the
spot size, the greater the energy delivered per unit area. Thus,
when working with the typical very small spot sizes found with
the CO2 laser micromanipulators, the power settings should be
kept quite low.
86 Principles of Laser Microlaryngoscopy
Many of the other lasers used in the field are delivered via mal diffusion. Sapphire probes create a cutting and vaporiza-
fiberoptic cables. With the advent of this technology, laryn- tion effect similar to that of CO2 lasers.
gologists are able to use endoscopes, such as the flexible la- The potassium–titanyl–phosphate (KTP) laser uses a 1,064-
ryngoscope with a working channel to gain access. As with the nm YAG laser filtered through a KTP crystal that effectively
articulating arm, fiberoptics is used in a noncontact manner. halves its wavelength to 532 nm, producing a brilliant green
Normally a 1- to 2-mm distance from target tissue is optimal, as light, well within the visible spectrum. The KTP laser is the
spot size rapidly increases with distance from tissue, causing a newest addition to the laryngologist armament. Its 532-nm
great reduction in laser energy delivered and lack of precision. wavelength corresponds to a greater specific absorption for
oxyhemoglobin. Recent studies have shown great promise in
the surgical use of this solid-state laser, including shorter pulse
width and less nonspecific tissue damage. The KTP laser also
13.2.4 Types of Laser
can deliver energy through a small diameter fiber optic, result-
ing in less mechanical damage to endoscopic channels.
Although a myriad of lasers are employed in the treatment of It is important to recognize that a laser is nothing more than
head and neck pathology, there are only a few types in the field a tool in the surgeon’s armamentarium, much like forceps, mi-
of laryngology. croscissors, or bipolar cautery. It is a common misconception
Traditionally the CO2 laser is the workhorse of laryngologic that microspot CO2 lasers allow increased precision over cold
lasers. Its specific wavelength of 10,600 nm is absorbed by wa- techniques. In fact, microlaryngeal cold instrumentation are
ter found in soft tissues and is independent of tissue color. CO2 superior to microspot laser technology in terms of precision,
lasers emit continuous or pulsed waves, which can be focused while avoiding collateral heat damage that can be associated
into a thin beam and used to cut like a scalpel or defocused to with laser use.
vaporize, ablate, or shave tissue. The CO2 laser’s ability to de-
liver energy endoscopically, utilize no-touch technology, and
provide a marked reduction in postoperative swelling, contrib-
uting to its widely accepted clinical use.
13 Pulse dye lasers (PDL) emit radiation at a 585-nm wave-
length, which corresponds with the oxyhemoglobin absorption
band. This wavelength penetrates the mucosa well, minimizes Ideal indications for CO2 laser are:
absorption by melanin in the overlying mucosa, and offers ex-
■ Glottic/posterior glottic stenosis
cellent selective absorption by microvasculature. A lasing me-
dium of rhodamine dye is excited by flash lamps and is deliv-
■ Bilateral vocal fold paralysis (arytenoidectomy, trans-
ered with a pulse width just under the thermal relaxation time
verse cordotomy, …)
of small vessels. While pulse dye lasers have been employed
■ Teflon granuloma of the larynx
in many areas of laryngology, relative small pulse width and
■ Squamous cell carcinoma of the glottis (T1–select T2)
the cost of replacement dye medium have detracted from the
benefits of such technology.
YAG lasers use a yttrium–aluminum–garnet crystal rod that Additional indications for CO2 laser include:
is manufactured with specific rare earth elements dispersed
■ Papillomatosis (especially with extensive disease)
within the crystal rod. The difference in the chemical proper-
■ Vocal fold varix (select cases)
ties of each element gives the laser a specific wavelength and
■ Saccular cyst of the larynx
thus a different surgical application. All YAG lasers may be
continuous, pulsed, or Q-switched. Q switching, much like a
capacitor in a circuit, is the ability to pulse the laser, while at Relative contraindications for CO2 laser are:
the same time increasing peak energy power, shortening pulse
■ Most benign lesions of the vocal folds:
width, and improving the consistency of the lasers output
■ Nodules
throughout the pulse. Normally, continuous and pulsed modes
■ Vascular lesions
are delivered via fiber optic cables, while articulating arms use
■ Cysts
Q switching.
■ Polypoid corditis
The holmium:YAG (Ho:YAG) laser uses an active medium of
YAG crystal with holmium dispersion. Its beam falls near the
infrared region of the electromagnetic spectrum at 2,100 nm. Indications for Nd:YAG laser comprise:
Its principle use is to ablate bone and cartilage, and has found
■ Large hemangioma of the larynx
specific laryngologic application in laser incisions and dilation
■ Glottic/subglottic stenosis
for the treatment of subglottic stenosis.
(CO2 laser generally preferred)
The neodymium-coupled YAG (Nd:YAG) laser is one of the
most clinically diverse lasers in current use. A near infrared
light is emitted at 1,064 or 1,320 nm. Nd:YAG lasers may be Indications for pulse dye laser/pulsed-KTP laser are:
delivered fiber optically to coagulate tissue or through sapphire
■ Papillomatosis
probes, allowing for low-powered delivery with minimal ther-
Chapter 13 87
■ Leukoplakia Dilation equipment:

■ Granuloma • Ventilating bronchoscopes: 5, 6, 7, and
■ Vascular lesions 8 French (if no trach present)
■ Polypoid corditis
• Laryngeal rigid dilators: 20–50 French (if trach present)
• Pneumatic balloon dilator
Jet ventilation machine
13.4 Equipment: Laser Laser safety materials
Microlaryngoscopy Setup • Moistened eye pads
• Moistened towels/surgical drapes
High-quality operating microscope with 400-mm lens • Laser-safe endotracheal tube (if applicable)
Large-bore laryngoscope (largest diameter possible if oper- • Eye protection for operating room personnel
ating on vocal folds/supraglottis) (see Chap. 10, Table 10.1)
Suspension laryngoscope with suction channel and jet
ventilation port if operating on subglottis/trachea
13.5 CO 2 Laser Safety Guidelines
• Ossoff–Pilling effective for subglot-
tis/upper trachea (proximal)
13.5.1 General Guidelines (Fig. 13.1)
• Subglottiscope for upper/mid-trachea (distal)
Suspension system
In the vast majority of laryngeal laser surgery, relatively low-
• Gallows suspension power settings are employed to minimize collateral heat dam-
• Fulcrum suspension (e. g., Lewy appara- age. For the purposes of this chapter, all laser settings described
tus and table-mounted Mayo) are used in the context of a micromanipulator with a 250-μm
spot size. Laser settings are generally set below 10 W, using an
Operating chair with arm supports
intermittent or superpulse mode. Continuous firing mode is
• Alternative: Mayo stand with pillow/foam rarely employed and can sharply increase the chances of im-
Instrumentation (available from Karl-Storz mediate (laser fire) or late complications (glottic web/stenosis),
(Culver City, CA), Medtronic ENT [Jacksonville, Fla.], due to the substantial power delivery in this mode. Intermit-
Instrumentarium [Montreal, Quebec, Canada]) tent delivery or pulsed delivery (e. g., superpulse) allows some
• Injection device for hydrodissection (Orotra- thermal relaxation time in between laser delivery, thus mini-
cheal injection device, Medtronic ENT) mizing collateral heat damage.
• Small (0.5 × 2 cm) cotton pledgets
• 1:10,000 epinephrine
• Velcro strap or cloth/silk tape
• Microcup forceps (see Chap. 10, Fig. 10.2)
• Micro-ovoid cup forceps (see Chap. 10, Fig. 10.3)
• Microscissors
– Curved, left and right
– Up angled
• Curved alligator forceps
• Straight alligator forceps
• Microlaryngeal suctions
• Triangular (Bouchayer) forceps
• Hopkins Telescopes
– Diameter 4–5mm, length 30cm or more
– 0, 30, and 70°
CO2 laser
Fig. 13.1 Intraoperative photograph illustrating the key laser safety
Micromanipulator with 250-μm spot size
concepts, including wrapping the patient’s head and upper body with
(coupling device between microscope and laser)
moistened towels, the use of a laser-safe endotracheal tube, low-O2
Jet Venturi needle or Hunsaker Mon-Jet tube settings, and eye protection for operating room personnel
88 Principles of Laser Microlaryngoscopy
13.5.2 CO2 Laser Settings 13.6.2 Protecting Surrounding Tissue

from Laser Damage
(For most applications in the larynx, the following range of la-
ser settings can be employed): Platform suction can be used, as indicated above, or a moist-
ened Cottonoid can be placed over the area to be protected.
■ 4–8 W, intermittent mode (0.1 s “on” and 0.5 s “off ”)
■ Best for precision work at the vocal fold level
■ Least collateral damage
■ 4–8 W, superpulse mode 13.6.3 Maintenance of a Clean Surgical Field
■ Increased tissue ablation
■ Use sparingly near vocal folds to minimize collateral
The CO2 laser causes the accumulation of carbonaceous debris
damage
(Fig. 13.3), or char at the surgical site. This desiccated debris
■ 4–6 W, continuous
is resistant to laser penetration due to the low water content.
■ Maximum laser ablation: useful for cartilage ablation
Therefore, it must be removed periodically by wiping the tis-
(arytenoidectomy)
13.5.3 Safety Protocol
The key to laser safety in the operating room (OR) is consistent

and methodical adherence to an established protocol. A simple
yet effective protocol is to fully address three areas of safety
prior to proceeding (Fig. 13.1). The surgeon must answer affir-
matively to the following questions before firing the laser:
13 1. Is the patient’s body protected?
a) Moistened eye pads
b) Soaked surgical towels around the face and upper chest
2. Is the endotracheal tube/airway protected?
a) Laser-protected tube must be used
b) Saline filled ETT balloon
c) Moist Cottonoid covering/protecting the balloon
d) O2 concentration of 30–35% or less
If jet ventilation is used, then suspend ventilation during fir-
ing of the laser. Fig. 13.2 Platform suction device
3. Are the OR personnel protected?
a) Eyeglasses or plastic goggles with side protectors for all
personnel
b) Laser warning signs on all OR doors
13.6 Surgical Principles
13.6.1 Smoke Evacuation
Laser vaporization results in significant smoke accumulation

at the operative site, and must be rapidly removed to main-
tain visualization. Suction tubing should be connected to a side
channel of the laryngoscope to maintain continuous smoke
evacuation. It should be noted, however, that supplemental
smoke evacuation may be necessary. Platform suction (Fig.
13.2) is often employed, which provides not only smoke evacu-
ations, but also protects the distal tissues from inadvertent la-
ser damage.
Fig. 13.3 Carbonaceous debris from laser ablated tissue, right vocal
fold. This must be removed for efficient treatment of tissue with the
CO2 laser
Chapter 13 89
sues with a saline-soaked Cottonoid, or suction removal. Also, ■ Papillomatosis (especially with extensive dis-
active bleeding at the surgical site usually prevents laser va-
ease)
poration. Hemostasis must be achieved before proceeding (by ■ Vocal fold varix (select cases)
either defocusing the laser beam, or applying epinephrine- ■ Saccular cyst of the larynx
soaked Cottonoids for 1–3 min to the area of bleeding). ■ The CO2 laser is generally not a good choice for the
removal of benign lesions of the vocal fold, such
as polyps, or cysts, or nodules, due to decreased
13.7 Complications and Their Treatments precision, and unintended collateral heat damage,
which can result in scarring and dysphonia.
13.7.1 Laser Fire ■ CO2 laser settings generally employ low-wattage
settings (4–8 W) in an intermittent or superpulse
mode to minimize collateral damage to the tissues.
A laser fire is the most feared complication in laryngology, al-
The continuous-beam setting should be used
though it is quite rare today. This is likely due to better educa-
sparingly, and is most appropriate for cartilage
tion and awareness of laser safety issues, as well as improved
ablation.
laser-safe endotracheal tube design. In the unlikely event of a ■ A laser safety protocol should be employed in all
laser fire with an indwelling endotracheal tube, the following
cases where the CO2 laser is used. The key con-
steps should be followed:
cepts are protection of the patient (moist towels),
■ Immediate removal of ETT protection of the endotracheal tube (laser safe,
■ Turn off anesthetic gas/oxygen delivery with O2 concentration of 35% or less), and protec-
■ Mask patient with 100% O2 tion of operating room personnel (safety glasses).
■ Intubate with small 4.0–5.0 ETT
■ Evaluate trachea with rigid bronchoscopy with carbon
debris removal Selected Bibliography
■ Flexible bronchoscopy to evaluate more distal tracheo-
bronchial tree
1 Anderson R, Parrish J (1983) Selective photothermolysis: precise
■ Manage airway after extent of injury is established (op-
microsurgery by selective absorption of pulsed radiation. Science
tions to be considered):
220:524–527
■ Extubate, observe in monitored setting
2 Absten GT, Joffe SN (1985) Lasers in medicine. Chapman and
■ Remain intubated, treat with corticosteroids/antibi-
Hall, London
otics
3 Buckmire R et al (2006) Lasers in laryngology. In: Merati AL,
■ Tracheostomy
Bielamowicz SA (eds) Textbook of laryngology. Plural, San Di-
ego, pp 190–199
4 Ossoff RH (1989) Laser safety in otolaryngology—head and neck
13.7.2 Tracheal Perforation
surgery: anesthetic and educational considerations for laryngeal
surgery. Laryngoscope 99(Suppl.):1–26
This can lead to tracking of air into the neck and down into the 5 Schramm VL, Mattox ED, Stool SE (1981) Acute management of la-
mediastinum. Further dissection can lead to pneumothorax. Ei- ser-ignited intratracheal explosion. Laryngoscope 91:1417–1426
ther condition should be evaluated with a chest x-ray and consul- 6 Zeitels S, Anderson R et al (2006) Office-based 532-nm pulsed-
tation with cardiothoracic surgery/pulmonology specialists. KTP laser treatment of glottal papillomatosis and dysplasia. Ann
Otol Rhinol Laryngol 115:679–685
Key Points
■ The key components that determine a laser’s

interaction with tissue are wavelength, intensity,
spotsize and pulse duration.
■ The CO2 laser is the workhorse laser for laryngotra-
cheal work, and the ideal indications include:
■ Glottic/posterior glottic stenosis
■ Bilateral vocal fold paralysis (arytenoidectomy,
transverse cordotomy)
■ Teflon granuloma of the larynx
■ Squamous cell carcinoma of the glottis (T1–se-
lect T2)
Chapter 14
Principles of Vocal Fold Augmentation

14
sponds to the surgery, then permanent correction can be
done.
2. Permanent correction of mild-to-moderate glottic insuffi
Please see Chaps. 5, 31, 33, and 34 for further information. ciency
a) Vocal fold atrophy (as seen in presbyphonia)
b) Vocal fold paralysis
c) Vocal fold paresis
14.2 Vocal Fold Augmentation:
d) Adjunctive augmentation of the vocal fold(s) after prior
Advantages, Disadvantages,
laryngeal framework surgery (“touch up”)
and Clinical Utility
Patients with minor degrees of glottic insufficiency (<1-
mm glottic gap on phonation) are usually better suited for
There are primarily two treatment modalities that are used for vocal fold augmentation rather than framework surgery.
the surgical treatment of glottic insufficiency: Conversely, severe degrees of glottic incompetence appear
1. Vocal fold augmentation (see Chaps. 31, “Vocal Fold Aug- to be more difficult to correct with vocal fold augmenta-
mentation via Direct Laryngoscopy”; 33, “Peroral Vocal tion. A glottic gap of 3 mm or greater (during phonation)
Fold Augmentation in the Clinical Setting”; and 34, “Percu- is generally better suited for a laryngeal framework surgical
taneous Vocal Fold Augmentation in the Clinic Setting”) approach.
2. Laryngeal framework surgery (medialization laryngoplasty 3. Glottic insufficiency due to loss of soft tissue in the vocal fold
[ML], arytenoid adduction [AA]) (see Chaps. 38, “Silastic Examples of this clinical situation include sulcus vocalis,
Medialization Laryngoplasty for Unilateral Vocal Fold Pa- and scarring of the vocal fold after partial laser cordect
ralysis”; 39, “GORE-TEX® Medialization Laryngoplasty”; omy.
40, “Arytenoid Adduction”; and 41, “Cricothyroid Sublux-
ation”)
There is a lack of consensus among laryngologists regarding
the role of these two surgical approaches in the treatment of
glottal closure problems. The scarcity of comparative studies
for these two treatments has resulted in a lack of evidence to
■ Vocal fold augmentation is not as effective at closing
clearly support one over the other. Furthermore, not all forms
large (3 mm or greater) glottal gaps compared with
of glottic insufficiency are the same, thus while some patients
framework techniques. This especially true in the case
may be well served with either approach (i. e., mild–moderate
of a large posterior glottal gap in some patients with
gap with mobile vocal folds), other patients are clearly better
unilateral vocal fold paralysis (UVFP); these cases are
served with a specific approach (i. e., ML with AA for a lateral-
best suited for ML and AA.
ized, shortened immobile vocal fold). The choice of procedure
■ Vocal fold augmentation can be less precise than laryn-
is often a reflection of the surgeon’s own preference.
geal framework surgery. Most vocal fold augmentation
However, in general, vocal fold augmentation is used in the
procedures require some degree over-injection to allow
following settings:
for reabsorption, rendering fine adjustments to vocal
1. Temporary correction in cases of unilateral vocal fold paraly-
fold position somewhat difficult. However, a similar
sis/paresis, when the prognosis for recovery is uncertain
problem is encountered in ML when factoring in peri-
Vocal fold augmentation results in immediate improve-
operative vocal fold edema during the implant place-
ment of voice and/or swallowing, while allowing a period
ment. The overcorrection of injection issue is especially
for recovery of vocal fold function. After a period of weeks
true with lipoinjection. The vocal outcome is rendered
to months, the injected substance is typically resorbed (see
even more uncertain in those patients who require a
Table 14.1).
general anesthetic for injection, and whose voice result
Also, temporary vocal fold augmentation can be done in
cannot be immediately assessed.
cases in which it is not clear that the glottal insufficiency is
the main communication deficit and thus, the temporary
augmentation is done on a “trial” basis. If the patient re-
92 Principles of Vocal Fold Augmentation
■ Vocal fold augmentation is a more minimally invasive ■ Calcium Hydroxylapatite (Radiesse™)

approach compared to laryngeal framework surgery. ■ Teflon
Most laryngeal framework surgery requires a trip to the
operating room, i.v. sedation, and the risk of reactive
airway edema postoperatively. In addition, the patient 14.4.3 Description of Vocal Fold
is usually required to lie supine for an extended period Augmentation Materials
of time during the surgical procedure. Due to these Characteristics
limitations, many patients with acute/subacute UVFP
may not be good candidates for laryngeal framework
General characteristics of the current materials available for
surgery. Often, the patient with an iatrogenic UVFP is
vocal fold augmentation are listed in Tables 14.1 and 14.2.
unwilling to return to the operating room for another
1. Bovine gelatin
surgery, yet may be perfectly willing to undergo a vocal
Gelfoam and Surgifoam come as a gelatin powder that is
fold augmentation in a clinic-based setting (see Chaps.
derived from a bovine source. A moderate amount of prep-
33, “Peroral Vocal Fold Augmentation in the Clinic Set-
aration is required prior to injection, as the powder must
ting” and 34, “Percutaneous Vocal Fold Augmentation
be mixed with saline to form a paste. This material is quite
in the Clinic Setting”)
viscous and thus requires a large bore injection needle (18
or 19 g) and pressurized injection device (e. g., Bruning
syringe). Gelfoam has been widely used in the larynx for
over 25 years with good success. The disadvantage of these
14.4 Characteristics of Vocal Fold
products is the short duration of activity (4–6 weeks) and
Augmentation Materials
the inability to inject the substance through a fine-gauge
needle.
14.4.1 Overview
2. Collagen-based products
Collagen-based products have been used for vocal fold aug-
The ideal vocal fold injection material would be readily avail- mentation for over 20 years. The product with the longest
able, inexpensive, inert, easy to use, and completely biocom- track record is the bovine-derived cross-linked form of col-
14 patible. The search for such a material has been ongoing for lagen, Zyplast. Although no serious adverse reactions have
almost 100 years, and significant advances in vocal fold aug- been linked to bovine collagen use in the larynx, there is a
mentation material availability and design have occurred in potential for an allergic response in up to 2% of the popu-
the last 10 years. The original injection material was paraffin, lation. For this reason, skin testing is recommended prior
which resulted in a significant foreign body response and rejec- to the use of Zyplast, which can delay treatment for 2–4
tion. Similar responses have occurred with Silicone injections weeks. Zyplast has been found to last as long as 4–6 month.
as well as most recently with Teflon™ vocal fold injections. An Newer collagen-based products include Cymetra (micron-
additional requirement of all future vocal fold injection mate- ized cadaveric dermal tissue) and Cosmoplast/Cosmoderm
rials will be a matching of the biomechanical properties of the (laboratory-engineered human collagen). Neither product
material with the biomechanical properties of either the super- carries the risk of allergic response, although Cymetra has
ficial aspect of the vocal fold (superficial layer of the lamina the potential for infectious transmission due to the use of
propria) or the deep aspect of the vocal fold (vocalis, thyroary- cadaveric tissue as the source. Cymetra has been used ex-
tenoid and lateral cricoarytenoid muscle). tensively for vocal fold augmentation, and although it has
been reported to last up to 9 months or more, the authors
believe 2–3 months is more accurate. Cosmoplast/Cosmo-
derm are relatively new substances that have not been used
14.4.2 Categories of Vocal Fold
in the larynx, but have potential advantages over the other
Augmentation Materials
collagen-based substances due to the low likelihood of al-
lergic response or infectious risks.
In general, augmentation substances can be divided into tem- 3. Hyaluronic acid gels (Hyalan gels) (Restylane, Hyalaform—
porary and long-lasting (sometimes permanent) materials. Allegan-Inamed, Irvine, CA)
Temporary injection substances include: Hyaluronic acid is a naturally occurring glycosaminoglycan
that is abundant in human tissue extracellular matrix. Inject-
■ Bovine gelatin (Gelfoam™, Surgifoam™)
able preparations of this substance are composed of cross-
■ Collagen-based products
linked chains of hyaluronic acid that take on a viscous, wa-
(Zyplast™, Cosmoplast™/Cosmoderm™, Cymetra™)
ter-insoluble form. These substances have been widely used
■ Carboxymethylcellulose (Radiesse Voice Gel™)
as injectable fillers in rhytid treatment for over 10 years in
■ Hyaluronic acid gel (Restylane™, Hyalaform™)
Europe. Although these substances have been rarely used
for vocal fold augmentation in the United States, clinical
Long-lasting injection substances include: reports in the European literature support their safety and
efficacy in the temporary treatment of glottal insufficiency.
■ Autologous fat
These substances are polysaccharide-based, and thus the
Chapter 14 93
chance of immunogenicity is eliminated. Rare instances of 5. Polytetrafluoroethylene (Teflon)

hypersensitivity (0.6%) are reported, and are related to low Teflon vocal fold injection has been performed for over 40
levels of protein impurities in the manufacture of the prod- years and was initially touted as an excellent vocal fold aug-
uct. The hyalan gels include Hyalaform (manufactured from mentation material. However, long term follow up of Teflon
rooster combs), and Restylane (manufactured by bacterial vocal fold augmentations revealed a significant complica-
fermentation). The duration of effect for these substances is tion of a foreign-body granulomatous response occurring
comparable to the collagen-based products, generally 4–6 up to 5–10 years after injection. The foreign-body response
months, although some reports suggests slightly longer ef- is quite intense and often requires surgical removal of the
fect of up to 9 months (see Table 14.1). Teflon, resulting in significant destruction of the surround-
4. Radiesse Voice Gel (carboxymethylcellulose) ing vocal fold (see Chaps. 24, “Endoscopic Treatment of Tef-
Radiesse Voice Gel (Bioform Medical, San Mateo, Calif.) lon Granuloma” and 42, “Translaryngeal Removal of Teflon
is currently the only temporary injectable substance that is Granuloma”). This removal results in vocal fold tissue loss,
U.S. Food and Drug (FDA) approved for vocal fold augmen- leaving a severe deficit and morbidity at the vocal fold aug-
tation. The principle material in this substance is carboxy- mentation site(s). Because of this significant complication
methylcellulose, which is the carrier substance in Radiesse, of Teflon vocal fold augmentation, this substance presently
a long-acting injectable. There is an extremely low risk of has very limited utility.
allergic response to this substance. Radiesse Voice Gel typi- 6. Autologous fat
cally lasts 2–3 months, depending on the volume injected. Autologous fat vocal fold augmentation (a.k.a. vocal fold li-
The voice quality and vocal fold vibration after vocal fold poinjection) has been widely used for the last 10–15 years,
augmentation are good. with varying levels of reported success. Vocal fold lipoinjec-
Table 14.1 Temporary injectable substances
Material Length of effect Advantages Disadvantages Needle gauge

Gelfoam 4–6 weeks Long track record Short duration 18
Radiesse Voice Gel 2–3 months FDA approved Not as long lasting as colla- 27
No allergy testing gen/hyaluronic acid gels (?)
Bovine collagen (Zyplast) 3–4 months 20-year track record Allergy test required 27
2- to 4-week delay
Human-derived collagen 3–4 months No allergy testing New product/limited experience 27

(Cosmoplast/Cosmoderm)
Micronized AlloDerm (Cymetra) 2–3 months No allergy testing More preparation time 18–23
Unpredictable duration recommended
Hyaluronic acid gels 4–6 months (?) No allergy testing Limited experience 27
(Restylane, Hylaform)
Table 14.2 Long-term/permanent injectable substances
Material Length of effect Advantages Disadvantages Needle

gauge
Ca Hydroxylapatite 2–5 + years (?) FDA-approved New product 25
(Radiesse) Long lasting No long-term track record
Teflon Permanent Long lasting Irreversible 18 or 19

May cause vocal fold stiffness
Risk of granuloma
Autologous fat Several years– Patient’s own tissue used Time, morbidity from fat harvest 18 or 19
permanent (?) “Forgiving” (defect over-cor- Performed in OR
rection rarely occurs) Unpredictable duration
tion obviously has the advantages of using a material that is 3. Vocal fold augmentation is generally directed at the poste-
autologous and usually readily available. Sustained results rior and mid-membranous vocal fold in the treatment of
in the correction of glottic insufficiency (>1 year) have been glottic insufficiency. Ideal injection locations are identified
demonstrated in patients treated with lipoinjection for glot- at a point where a transverse line from the tip of the vocal
tic insufficiency. In addition, radiographic presence of fat process laterally intersects the superior arcuate line. A sec-
up to 2 years after lipoinjection has been demonstrated in ond injection site is sometimes needed at the mid-membra-
a number of patients. However, the variable survival in the nous vocal fold along the superior arcuate line. (Fig. 14.1).
immediate postoperative period (2 months) is disconcerting
to many surgeons, resulting in a lack of consensus regard-
ing whether autologous fat is a good long-term or “perma-
nent” correction option for glottic insufficiency. The success
of lipoinjection appears to be operator dependent and the
reasons for this have not been clearly identified; however, it
is likely due to improper harvesting and preparation of the
material as well as incorrect injection techniques.
7. Calcium hydroxylapatite (Radiesse)
Calcium hydroxylapatite (CaHA) microspheres represent a
new vocal fold injection material that has been extensively
tested in laboratory animals and used clinically as an aug-
mentation material in other parts of the body (nonlaryn-
geal). The clinical efficacy and long-term results are still
pending in the larynx, although long-term augmentation
has been demonstrated in other organ systems. This mate-
rial is composed of microspheres of CaHA (25–45 μm in di-
ameter) suspended in a temporary gel carrier (water, glycer-
in, carboxymethylcellulose), which allows for easy injection
through a needle as small as 25 g. Efficacy up to 12 months
14 has been demonstrated in a multi-institutional clinical trial
at the time. Currently, it is the only FDA-approved poten-
tially long-lasting glottic injectable. In contrast to Teflon,
Radiesse is a naturally occurring substance in the human
body; therefore, the risk of chronic granulomatous forma-
tion is theoretically small. Long-term animal studies and a Fig. 14.1 Illustration showing the correct injection site(s) for vocal
short-term human study have demonstrated excellent host fold augmentation
acceptance of the CaHA material in the larynx.
14.5 General Principles of Vocal

Fold Augmentation
1. Local anesthesia is generally preferred in most cases, so that

the patient’s voice can be monitored during the procedure.
A notable exception to the rule is vocal fold lipoinjection,
which is performed under general anesthesia to facilitate fat
harvesting and preparation.
2. Injection techniques include:
a) Peroral
i. Curved injection device in the clinic setting (Chap.
33, “Peroral Vocal Fold Augmentation in the Clinic
Setting”)
ii. Straight injection device via direct laryngoscopy in
the operating room (Chap. 31, “Vocal Fold Augmen-
tation via Direct Laryngoscopy”)
b) Percutaneous (Chap. 34, “Percutaneous Vocal Fold Aug-
mentation in the Clinic Setting”)
i. Translaryngeal (through thyroid cartilage) Fig. 14.2 Coronal section of the larynx, illustrating the correct depth
ii. Cricothyroid membrane puncture of needle placement for injection, slightly inferior to the free edge of
iii. Thyrohyoid membrane puncture the vocal fold
Chapter 14 95
Fig. 14.3 The appropriate amount of overcorrection used for most Fig. 14.4 The appropriate amount of overcorrection used for vocal
injectables (15–30%, or an additional 0.1–0.2 ml of material), as de- fold lipoinjection, as demonstrated in this left vocal fold
picted in this right vocal fold augmentation
The depth of injection is generally 3–5 mm, slightly inferior ■ Vocal fold augmentation is appropriate in a variety
or at the level of the inferior lip of the free edge of the vocal
of clinical settings, but is commonly used in the
fold (Fig. 14.2).
following situations:
4. Injection into the superficial layer of the lamina propria ■ Temporary correction for unilateral vocal fold
(Reinke’s space) should be avoided, as this will result in loss
paralysis
of mucosal pliability and poor vocal quality ■ Trial correction for glottal insufficiency (as a
5. Overinjection in recommended, to compensate for resorp-
diagnostic measure)
tion of the water-based component present in commercially ■ Permanent correction of vocal fold atrophy (as
manufactured injectables. In general, a 15–30% overcor-
seen in presbyphonia), vocal fold paresis (unilat-
rection is recommended (exception noted below), which
eral and bilateral), unilateral vocal fold paralysis
translates to an additional 0.1–0.2 ml of substance for uni- ■ Adjunctive vocal fold augmentation after laryn-
lateral procedures. The overcorrection usually results in a
geal framework surgery (“touch up”)
slightly rounded, convex contour to the injected vocal fold ■ Glottic insufficiency due to vocal fold scarring/
(Fig. 14.3). The exception to this rule is autologous fat injec-
soft tissue loss
tion. Aggressive overcorrection (100%) is recommended in ■ A variety of injectable substances are available for
these cases to account for the substantial resorption of fat
vocal fold augmentation, and can be categorized
that generally occurs within the first 6–8 weeks after lipoin-
into temporary (2–6 months) and long-acting/per-
jection (Fig. 14.4).
manent (2 years or more).
■ Temporary injection substances include:
■ Bovine gelatin (Gelfoam, Surgifoam)
Key Points ■ Collagen-based products (Zyplast, Cosmo-
plast/Cosmoderm, Cymetra)
■ Carboxymethylcellulose (Radiesse Voice Gel)
■ Vocal fold augmentation is a commonly used sur- ■ Hyaluronic acid gel (Restylane, Hyalaform)
gical treatment for glottic insufficiency. ■ Long-lasting injection substances include:
■ Key differences between vocal fold augmentation ■ Autologous fat
and laryngeal framework surgery: ■ Calcium hydroxylapatite (Radiesse)
■ Vocal fold augmentation is less effective at ■ Teflon
closing large (3 mm or greater) glottal gaps, ■ Local anesthesia is generally preferred with vocal
especially in the posterior membranous region fold augmentation (peroral or percutaneous ap-
of the vocal folds proach), so that the patient’s voice can be used as
■ Vocal fold augmentation may be less precise a constant source of feedback during the proce-
than framework surgery dure (Chaps. 33 and 34).
■ Vocal fold augmentation is however, a more ■ Augmentation is directed at the posterior and mid-
minimally invasive approach, and can be carried membranous vocal fold, along the lateral vocal fold
out in a clinic-based setting. (superior arcuate line), and at a depth of 3–5 mm.
4 Hertegar S, Hallen L, Laurent C et al (2004) Cross-linked hyal-

■ Injection into the superficial lamina propria
uronan versus collagen for injection treatment of glottal insuf-
(Reinke’s space) is to be avoided.
ficiency: 2-year follow-up. Acta Otolaryngol 124:1208–1214
■ Overinjection (15–30%) is recommended to com-
5 Remacle M, Marbaix E, Bertrand B, Hamoir M, van den Eeck-
pensate for resorption of the water-based compo-
haut J (1990) Correction of glottic insufficiency by collagen injec-
nent present in most injectable substances. The
tion. Ann Otol Rhinol Laryngol 99:438–444
exception to this rule is autologous lipoinjection,
6 Rosen CA (2000) Phonosurgical vocal fold augmentation: proce-
which requires substantial overcorrection.
dures and materials. Otol Clinics North Am 33:1087–1096
7 Rosen C, Gartner-Schmidt J, Casiano R et al (2007) Vocal fold
augmentation with calcium hydroxylapatite (CaHA). Otolaryn-
gol Head Neck Surg 136:198–204
8 Schramm VL, May M, Lavorato AS (1978) Gelfoam paste injec-
1 Brandenburg JH (1992) Vocal cord augmentation with autogen tion for vocal cord paralysis: temporary rehabilitation of glottic
ous fat. Laryngoscope 102:495–500 incompetence. Laryngoscope 88:1268–1273
2 Ford CN, Martin DW, Warner TF (1984) Injectable collagen in 9 Simpson CB, Amin MR (2004) Office-based procedures for the
laryngeal rehabilitation. Laryngoscope 94:513–518 voice. Ear Nose Throat J 83(Suppl.):6–9
3 Ford CN, Bless DM (1986) Clinical experience with injectable 10 Watterson T, McFarlane SC, Menicucci AL (1990) Vibratory
collagen for vocal fold augmentation. Laryngoscope 96:863–869 characteristics of Teflon-injected and noninjected paralyzed vo-
cal folds. J Speech Hear Disord 55:61–66
14
Pathology
II Phonomicrosurgical
Voice Procedures
Chapter 15
Vocal Fold Polyp

15
increased vascularity around the lesion, often noted as a varix
feeding the lesion (see Chap. 22, “Vocal Fold Varix”). Typically,
a vocal fold polyp is associated with misuse or heavy use of the
Please see Chaps. 4, 8, 10, 11, and 12 for further information. voice, such as in a variety of phonotraumatic behaviors. These
behaviors can result in a vocal fold polyp in a gradual/progres-
sive fashion or in a sudden fashion often associated with an
acute vocal fold hemorrhage.
15.2 Disease Characteristics
Differential diagnosis associated with vocal fold polyp in-
and Differential Diagnosis
cludes:
■ Reinke’s edema
A vocal fold polyp can have a variety of different features and
■ Vocal fold cyst
presentation characteristics, and typical features involve an
■ Pseudocyst
exophytic lesion with quite-thin mucosa (Fig. 15.1). The lesion
■ Vocal fold fibrous mass
is typically unilateral but can be bilateral. Often, there will be a
■ Localized edema of the vocal fold (temporary)
hemorrhagic nature to the polyp, giving it a maroon or blood-
■ Vocal nodules
colored appearance. If the vocal fold polyp is not hemorrhagic,
then it will be clear and may even have a translucent nature to
it. The stroboscopic features of a vocal fold polyp include mini-
mal dampening of the overall mucosal wave and an hourglass
closure pattern.
Physically, at the time of surgery, a disorganized gelatinous
material is found within the subepithelial space in patients with
a vocal fold polyp. The vocal fold polyp can be associated with Indications for surgery for vocal fold polyp include:
■ A combination of dysphonia and lack of significant
response to nonsurgical treatment methods (voice
therapy, medical management)
■ A vocal fold polyp that is associated with a significant
vocal fold varix that is at risk for vocal fold hemorrhage
Contraindications for surgery comprise:

■ Patients medically unable to tolerate general anesthesia
■ Inability to obtain proper visualization of vocal folds
during microlaryngoscopy
■ A patient without vocal functional limitations
15.4 Surgical Equipment
1. Standard phonomicrosurgical equipment (see Chap. 10,

Table 10.1)
2. Bipolar or laser equipment for the treatment of associated
vocal fold varix as needed (see Chaps. 13, “Principles of La-
ser Microlaryngoscopy” and 22, “Surgical Management of
Vocal Fold Vascular Lesions”)
Fig. 15.1 Vocal fold polyp
100 Vocal Fold Polyp
on which approach to select is based on the amount of healthy

15.5 Surgical Procedures
mucosa associated with the polyp.
1. Microflap approach for vocal fold polyp removal
Vocal fold polyp is best surgically removed via a phonomicro- a) Exposure of lesion, preferably the entire membranous
surgical approach (see Chap. 10, “Principles of Phonomicro- vocal fold
surgery”). There are two main methodological approaches to i. Application of topical epinephrine (1:10,000) to the
the surgical removal of a vocal fold polyp. First, using a micro- vocal fold lesion via a Cottonoid
flap approach and second, a truncation approach. The decision ii. Subepithelial infusion for vocal fold polyp is contra-
15
Fig. 15.2 Cordotomy at junction of polyp and vocal fold Fig. 15.3 Microflap elevation
Fig. 15.4 Removal of polyp contents Fig. 15.5 Dissection of polypoid material medially, preserving infra-
glottic mucosa
Chapter 15 101
indicated, given that this could blur the demarcation 2. Truncation of the vocal fold polyp
of the junction between the vocal fold polyp and the a) Application of topical epinephrine to the vocal fold le-
normal vocal fold tissue. sion
iii. Epithelial cordotomy is planned and made through b) Subepithelial infusion for vocal fold polyp is contraindi-
the epithelium at the junction of the lateral aspect cated, given that this could blur the demarcation of the
of the vocal fold polyp and the normal vocal fold junction between the vocal fold polyp and the normal
mucosa, along the superior surface of the vocal fold vocal fold tissue.
(Fig. 15.2). c) Grasp the vocal fold polyp with small triangular forceps
iv. The microflap elevation is performed medial to the in a medial direction (Fig. 15.9).
incision to expose the subepithelial pathologic con- The nature and approach to grasping the vocal fold polyp
tents of the vocal fold polyp (Fig. 15.3). is extremely important and is a key determinant of the
v. Vocal fold polyp material is removed via either mi- success of the procedure. The vocal fold lesion should be
crosuction or direct removal of the abnormal mate- grasped in a location and manner that is perpendicular
rial with small microcup forceps (1 mm) (Fig. 15.4). to the longitudinal axis of the vocal fold. With the non-
Alternatively, the lesion can be dissected medially dissecting hand, careful control and gentle application of
with a 30° flap elevator, preserving additional infe- tension should be applied to the vocal fold polyp.
rior microflap mucosa (Fig. 15.5). d) Microscissors that are either slightly curved (away from
vi. Redrape the microflap back over the vocal fold and the vocal fold) or straight up-cutting scissors are then
evaluate the nature and status of the microflap mu- used to incise the vocal fold polyp at the junction of the
cosa (Fig. 15.6). polyp and the vocal fold (Fig. 15.9).
vii. Trim abnormal mucosa that appears to have adher- e) After removal of the majority or the entire vocal fold
ent polyp material, or is extremely thin and atrophic, polyp, careful examination and palpation should be per-
or is excessive and will not serve as normal mucosa formed to see if there is any residual abnormal mucosa at
during the postoperative healing (Fig. 15.7). the vocal fold polyp site that should be removed. To help
viii. Redrape the remaining microflap mucosa. Once the with this assessment, an epinephrine-soaked Cottonoid
flap is redraped, use a blunt instrument (curved ele- can be placed on the operative site for several minutes. If
vator) to palpate the operative site to ensure there is there is residual abnormal mucosa, then a 1-mm micro-
no remaining pathology under the flap (Fig. 15.8). cup forceps can be used to remove this tissue. An alter-
ix. Treat the associated vascular lesion if needed (see native removal technique involves grasping of the “dog-
Chap. 22, “Surgical Management of Vocal Fold Vas- eared” mucosa with a microcup forceps or small triangle
cular Lesions”). forceps and excising the material with a microcurved
x. 4% Lidocaine is sprayed onto the larynx (commonly scissors (Fig. 15.10).
referred to as a LTA [laryngotracheal anesthesia])
Fig. 15.6 Redrape and evaluate viability of microflap mucosa Fig. 15.7 Trim abnormal microflap mucosa
102 Vocal Fold Polyp
Fig. 15.8 Redrape microflap and palpate with curved probe Fig. 15.9 Traction applied to polyp and truncation of polyp. Dashed
line indicates proposed line of excision
15
Fig. 15.10 Microscissors removal of residual mucosa

Fig. 15.11 Removal of residual mucosa with outside curve of curved
microscissors.
Chapter 15 103
15.6 Postoperative Care/Complications
Voice rest is typically used after surgical excision of a vocal fold

polyp. This voice rest period can range from 2 to 7 days. It is
wise to treat patients for perioperative laryngopharyngeal re-
flux, consisting of proton pump inhibitor and behavior modi-
fication.
Complication of surgical excision of vocal fold polyp can be:
■ Excessive vocal fold scar formation
■ Granulation tissue at the operative site
■ Vocal fold hemorrhage in the region of the surgery
Key Points
■ Precision microsurgical removal of a vocal fold

Fig. 15.12 Straight edge of left vocal fold immediately after excision
polyp is paramount.
of vocal fold polyp
■ Great care should be taken to avoid a “cookie-
bite” defect into the substance or main compo-
nent of the vocal fold after surgical removal of a
vocal fold polyp.
f) If there are some residual tags or dog-eared mucosa, then ■ Most of the mucosa of the vocal fold polyp is
this tissue should be removed.
usually not suitable for preservation due to its
If this tissue is too small to be grasped, then it can be
thin, atrophic nature.
removed by opening the blades of the microcurved scis- ■ However, some residual surrounding mucosa
sors (curved away from the surgical vocal fold), sliding
of the vocal fold polyp can be preserved and
the scissors down over the tissue in a way that the blades
redraped to allow optimal vocal fold healing
straddle the tissue to be removed. With gentle, lateral
after surgery.
pressure at the same time that the blades are closed, this
tissue will be successfully removed (Fig. 15.11).
g) After removal of the vocal fold pathology, careful exami-
nation visually as well as on palpation (using the outside
curve of curved elevator or curved alligators) should be
performed on the operative site(s). 1 Courey MS, Garrett CG, Ossoff RH (1997) Medial microflap for
There may be some additional fibrous or gelatinous ma- excision of benign vocal fold lesions. Laryngoscopy 107:340–344
terial that should be carefully removed to prevent a rapid 2 Hochman II, Zeitels SM (2000) Phonomicrosurgical manage-
recurrence of the vocal fold pathology. This material can ment of vocal fold polyps: the sub-epithelial microflap resection
be removed with a microelevator or microcup forceps. technique. J Voice 14:112–118
Extreme care is required at this juncture of the surgery, 3 Johns MM (2003) Update on the etiology, diagnosis, and treat-
because overly aggressive removal of this material can ment of vocal fold nodules, polyps and cysts. Curr Opin Otolar-
result in significant scar formation as well as a perma- yngol Head Neck Surg 11:456–461
nent deformity of the free edge of the vocal fold. At the
completion of the surgery, the free edge of each vocal
fold should be completely straight, without exophytic
mucosal tags and without a divot or concavity of the free
edge at the surgical site (Fig. 15.12).
h) Application of 4% plain lidocaine onto the endolarynx
Chapter 16
Vocal Fold Nodules

16
when present. Surgery for vocal fold nodules without a thor-
ough and properly implemented nonsurgical therapy course
is not appropriate. A relative contraindication to surgery for
Please see Chaps. 3, 4, 8, 10, 11, and 12 for further informa- vocal fold nodules is a patient that has not been compliant
tion. with voice therapy nor changed the habitual phonotraumatic
behavior that most likely led the formation of the lesions.

and Differential Diagnosis 16.4 Surgical Equipment
Vocal fold nodules are characterized as bilateral vocal fold le- 1. Phonomicrosurgery instruments (see Chap. 10, Table 10.1)
sions that are fairly symmetric (Fig. 16.1). On stroboscopy, 2. CO2 laser optional (see Chaps. 10, “Principles of Phono-
the mucosal wave is normal or near normal. The stroboscopic microsurgery” and 13, “Principles of Laser Microlaryngo
closure pattern is an hourglass configuration. Typically, these scopy”)
patients have a history of vocal abuse or misuse (phonotrau-
ma). These tend to occur in children and adult females (18–40 Cold-steel excision is the preferred method for vocal fold nod-
years of age). The differential diagnosis of vocal fold nodules ules removal; however, in rare instances, and with great experi-
includes: ence and the optimal laser technical abilities, the CO2 laser can
be used to remove vocal fold nodules as well.
■ Vocal fold polyp (bilateral or with a contralateral reac-
tive lesion)
■ Fibrous mass (bilateral or with a contralateral reactive
lesion)
■ Cyst (bilateral or with a contralateral reactive lesion)
■ Pseudocyst (bilateral or with a contralateral reactive
lesion)
Vocal fold nodules are typically treated with nonsurgical meth-

ods including voice therapy, voice rest, and treatment of co-
morbid medical conditions. It is extremely rare that true vocal
fold nodules do not respond favorably to these nonsurgical
modalities. Most often, when bilateral vocal fold lesions are
still present after the nonsurgical treatment modalities, these
lesions are in fact not vocal fold nodules, but other benign vo-
cal fold lesions (see above list).

Surgery for vocal fold nodules is reserved for persistent and

significant dysphonia (with functional limitations) after all
nonsurgical treatment options are exhausted. Nonsurgical
treatment options include high-quality voice therapy with
good compliance by the patient—also, treatment of comorbid
medical conditions such as reflux disease and allergic disease Fig. 16.1 Vocal nodules
106 Vocal Fold Nodules
scissors do not extend deep into the vocal fold nor past the
16.5 Surgical Procedure
anterior border of the vocal fold lesion (Fig. 16.3). Without
special attention to this area, excessive anterior vocal fold
1. Complete exposure of the membranous vocal folds with mucosa can be removed with the vocal fold lesion excision.
suspension laryngoscopy (see Chap. 10, “Principles of Pho- It is best to watch carefully the path of the tips of the scissors
nomicrosurgery”). to ensure that they are aimed purposely to finish the cut just
2. The vocal fold lesions should be palpated gently under high- anterior to the lesion and come through the free edge of the
power magnification. vocal fold anterior to the lesion.
During this, the vocal fold lesions should be assessed for their 5. If there are any residual mucosal irregularities at the exci-
degree of submucosal pathology and examinined for associ- sion site, then these should be removed in a careful, conser-
ated pathologic lesions such as vascular lesions, evidence of vative fashion by either removal of the irregular abnormal
scar, sulcus vocalis, and other vocal fold pathologies. Spe- mucosa with microcup forceps or by microsurgical scissors
cial attention should be given to the anterior commissure excision (Fig. 16.4).
to evaluate if there is a presence of an anterior commissure The former is best done with the microcup forceps being
microweb. Past reports have noted an increased incidence used to grab the intended mucosa for removal and allowing
of anterior commissure microwebs with recalcitrant vocal the sharp edge of the forceps to come through the mucosa
fold nodules that require surgical excision. If a microweb without any forceful stripping of the mucosal tag.
is present, then asymmetric release of the microweb can be 6. After removal of the benign vocal fold lesions, careful ex-
done with scissors or a sickle knife. Mitomycin C can be ap- amination visually as well as on palpation (using the outside
plied to the operative site. curve of curved elevator or curved alligators) should be per-
3. The surgical removal of vocal fold nodules starts with a very formed at the operative site(s).
careful grasping of one of the lesions with a small triangular There may be some additional fibrous or gelatinous mate-
or curved alligator instrument. The approach to the grasp- rial at this location, which should be carefully removed to
ing of the lesion should be as close to perpendicular to the prevent a rapid recurrence of the vocal fold pathology.
longitudinal axis of the vocal fold as possible and as super- 7. This material can be removed with a microelevator or mi-
ficially as possible. After the lesion is grasped, the lesion is crocup forceps. Extreme care is required at this juncture of
drawn to the midline gently and very careful observation the surgery, because too-aggressive removal of this material
of the demarcation between vocal fold pathology and the can result in significant scar formation as well as a perma-
normal vocal fold free edge should be identified. nent deformity of the free edge of the vocal fold.
4. Microscissors, either straight-up or curved (aimed in a di- 8. At the completion of the vocal fold lesion(s) excision the
rection away from the vocal fold) should be used for a sub- free edge of each vocal fold should be completely straight
16 mucosal excision of the vocal fold lesion (Fig. 16.2). without exophytic mucosal tags and without a divot or con-
As the excision is performed from posterior to anterior, cavity of the free edge of the surgical sites (see Chap. 15, Fig.
care should be taken to ensure that the tips of the vocal fold 15.12).
Fig. 16.2 Submucosal excision of vocal fold lesion (start) Fig. 16.3 Submucosal excision of vocal fold lesion (finish)
Chapter 16 107
Key Points
■ Vocal fold nodules are bilateral, fairly symmetric,

midmembranous vocal fold lesions that have nor-
mal stroboscopic or minimal impairment findings
that result in an hourglass closure pattern.
■ Most patients with vocal fold nodules improve
with nonsurgical treatment methods, however
there may be some rare cases of recalcitrant vocal
fold nodules that require surgical excision.
■ Surgical excision of vocal fold nodules should be
extremely conservative, precise and performed in
a subepithelial fashion.
■ The initial retraction or grasping of the vocal fold
lesion is very important. This step in large part
determines the success of the procedure.
Fig. 16.4 Removal abnormal mucosa from operative site 1 Akif Kilic M, Okur E, Yildirim I, Guzelsoy S (2004) The preva-
lence of vocal fold nodules in school age children. Int J Pediatr
2 Benjamin B, Croxson G (1987) Vocal nodules in children. Ann
16.6 Postoperative Care
3 Benninger MS, Jacobson B (1995) Vocal nodules, microwebs and
and Complications
surgery. J Voice 9:326–331
4 Courey MS, Shohet JA, Scott MA, Ossoff RH (1996) Immuno-
Voice rest is used for a variable length of time, depending not histochemical characterization of benign laryngeal lesions. Ann
only on the size and nature of the lesion, but also on compli- Otol Rhinol Laryngol 105:525–531
ance issues of the patient. In general, compared with other 5 Ford CN, Bless DM, Campos G, Leddy M (1994) Anterior
phonomicrosurgical procedures, a shortened amount of voice commissure microwebs associated with vocal nodules: de-
rest can be used after vocal fold nodules removal if the patient tection, prevalence, and significance. Laryngoscope 104(Pt.
will be compliant with light voice use instead of total voice rest. 1):1369–1375
As an example, for an extremely compliant patient, voice rest 6 Holmberg EB, Doyle P, Perkell JS, Hammarberg B, Hillman RE
may be needed only 1 or 2 days, proceeding to light voice use if (2003) Aerodynamic and acoustic voice measurements of pa-
the patient is continuing to be compliant, and the stroboscopy tients with vocal nodules: variation in baseline and changes
results are favorable. across voice therapy. J Voice 17:269–282
Complications from vocal fold nodules surgery are: 7 Holmberg EB, Hillman RE, Hammarberg B, Sodersten M, Doyle
P (2001) Efficacy of a behaviorally based voice therapy protocol
■ Excessive scarring
for vocal nodules. J Voice 15:395–412
■ Submucosal hemorrhage
8 Pontes P, Kyrillos L, Behlau M, De Biase N, Pontes A (2002) Vocal
■ Residual vocal fold pathology
nodules and laryngeal morphology. J Voice 16:408–414
■ Excessive removal of vocal fold tissue, resulting in a
9 Shah RK, Woodnorth GH, Glynn A, Nuss RC (2005) Pediatric
“cookie bite” defect of the vocal fold
vocal nodules: correlation with perceptual voice analysis. Int J
Pediatr Otolaryngol 69:903–909
The latter complication can be prevented with very careful
submucosal excision of the vocal fold lesion and utilizing great
precision and control to prevent the surgical excision from en-
tering into the deeper aspects of the lamina propria or vocal
ligament.
Chapter 17
Vocal Fold Cyst

and Vocal Fold Fibrous Mass 17
Please see Chaps. 3, 4, 8, 10, 11, and 12 for further informa-

tion.
17.2 Diagnostic Characteristics

A vocal fold cyst is a sac-like structure within the lamina pro-

pria of the vocal folds, typically yellow or white in color (Fig.
17.1). Vocal fold fibrous mass is an accumulation of fibrous
material within the lamina propria of the vocal fold. It can be
quite difficult to detect in some cases, and videostroboscopy
is usually needed to make the diagnosis (see Chap. 3, “Vid-
eostroboscopy and Dynamic Voice Evaluation with Flexible Fig. 17.1 Vocal fold cyst (left)
Laryngoscopy”). Stroboscopy shows significantly reduced mu-
cosal wave where the lesion is present. Both lesions are usually
found in the midmembranous vocal fold and can be either in
the subepithelial (SE) space or near the ligament (lig) of the vo-
cal fold. Vocal fold cysts have a distinct and confined sac-like
boundary, and in contrast, vocal fold fibrous masses are more
diffuse and often have extensions anteriorly and/or posteriorly The surgical equipment required is a standard phonomicrosur-
within the vocal fold. gery instrument set (see Chap. 10, Table 10.1).
Differential diagnosis for vocal fold cyst or fibrous mass is:
■ Vocal fold polyp
■ Rheumatologic lesion of the vocal fold 17.5 Surgical Procedure
■ Vocal nodules
■ Reactive lesion
The surgical approach to a vocal fold cyst or vocal fold fibrous
mass uses a microflap (see Chap. 10, “Principles of Phonomi-
crosurgery”). There is little difference in the surgical technique
for a cyst or fibrous mass. The technique described below ap-
plies to both lesions unless otherwise noted.
1. Microflap approach to a cyst or fibrous mass in the subepi-
thelial location
Indications for surgery are symptomatic dysphonia and lack a) Intubation with 5.0 microlaryngeal endotracheal tube
of resolution with maximum nonsurgical treatment (voice b) Expose larynx with laryngoscope
therapy). i. Use the largest laryngoscope that will adequately ex-
Contraindications for surgery comprise: pose the entire vocal fold (see Chap. 10, “Principles
of Phonomicrosurgery”).
■ Patients medically unable to tolerate general anesthesia
c) Incision
■ Inability to obtain proper visualization of vocal folds
i. Make incision just lateral to, or directly over the le-
during microlaryngoscopy
sion, in a posterior-to-anterior direction or anterior-
■ A patient without vocal functional limitations
to-posterior direction.
110 Vocal Fold Cyst and Vocal Fold Fibrous Mass
ii. Keep the incision superficial by maintaining a slight d) Separate the epithelial cover from the cyst/fibrous mass
pull on the knife superiorly (toward yourself), which (Fig. 17.3).
“tents” up the mucosa, protecting the deeper layers i. Use the 30° flap elevator to develop a plane as super-
(Fig. 17.2). ficially as possible between the overlying epithelium
iii. The incision should be slightly longer than the actual and the cyst/fibrous mass.
lesion to afford adequate space in which to work. ii. The instrument can usually be visualized through the
thin, semitranslucent flap (0.2-mm thick) during this
step. The tip of the elevator should be pointing medi-
ally.
iii. Often there is adherence between the flap and cyst
wall. It is best to start creating the dissection in un-
distorted tissue planes anterior and posterior to the
lesion before dissecting directly over the lesion.
iv. The dissection is continued to the inferior-most por-
tion of the lesion.
v. Use caution with the flap elevator inferiorly, as the tip
of the instrument may perforate the delicate epithe-
lial flap; gentle pressure laterally with the “back” of
the flap elevator helps avoid perforation.
vi. It is important to perform the medial aspect of the
dissection first, when natural “counter-traction” is
provided by adherence of the lesion wall to the vocal
ligament. If the epithelial cover is separated as the last
step, then this dissection becomes much more difficult.
e) Separate the lesion from the vocal ligament.
i. Dissect between the cyst/fibrous mass and the vocal
ligament with a 30° flap elevator (Fig. 17.4).
ii. The fibers of the vocal ligament run parallel to the
long axis of the vocal fold and are white in color,
with little vascularity. Great care should be taken to
Fig. 17.2 Mucosal cordotomy with sickle knife. Note how tip of knife
“tents up” mucosa to prevent possible injury to deep structures in the
17 vocal fold
Fig. 17.3 Dissection between the epithelial cover and the cyst Fig. 17.4 Dissection of plane deep to the vocal fold cyst, adjacent to
the vocal ligament
Chapter 17 111
avoid violation of the vocal ligament. Some scant ge- g) Special considerations for vocal fold cyst/fibrous mass
latinous-appearing material (SLP) can often be seen, near the vocal ligament
and should be preserved. i. After cordotomy and the start of the microflap eleva-
iii. Avoidance of cyst wall rupture is tantamount to a tion, the vocal fold cyst/fibrous mass will be clearly
successful surgery, as cyst dimensions may be diffi- visible in the “deep” portion of the vocal fold near or
cult to define after rupture occurs. on the vocal ligament.
iv. If there is penetration of the cyst, then an attempt ii. When ligamentous pathology is present, the micro-
to prevent complete evacuation of the cyst should flap is usually quite easily elevated, given that the le-
be done by grabbing the cyst at the penetration site sion is deep to the area of dissection.
with a small microalligator, and then dissection can iii. A triangular forceps can then be used to retract the
be continued. If the cyst is ruptured completely, then microflap medially while a fine-angled elevator is
careful and meticulous dissection and removal of all used to dissect off the vocal fold cyst/fibrous mass
the cyst wall contents should be done. from the vocal ligament (see Fig. 17.7).
f) Removal of lesion iv. Microscissors are sometimes required to complete
i. Some sharp dissection with scissors may be neces- the dissection of the lesion off the vocal ligament.
sary, if fibrous connections between the lesion and v. The lesion is removed and the microflap redraped
ligament cannot be bluntly dissected with the flap into its anatomic position.
elevator. These fibrous connections are most com- vi. The vocal fold should be palpated, feeling for persis-
monly present anterior and posterior to the vocal tent pathology causing irregularity of the vocal fold.
fold cyst/fibrous mass and will need to be carefully
lysed before the lesion can be removed (Fig. 17.5).
ii. Often a fibrous mass will have fibrous extensions an-
teriorly and/or posteriorly. Depending on the thick-
and Complications
ness, these extensions can be left alone or removed. It
is often best to cut these extensions at the location(s)
of their attachment to the fibrous mass and then re- Postoperative care includes:
drape the microflap to determine by palpation and vi-
■ Complete voice rest for 1 week
sual inspection if any additional excision is required.
■ Proton pump inhibitors (PPIs), pain medications as
Once all attachments of the lesion are freed, the le-
needed (tongue pain from suspension)
sion is removed and the flaps are replaced and al-
■ Follow-up in 1 week, begin graduated voice use under
lowed to coapt (Fig. 17.6).
supervision of SLP (if possible)
iii. Epithelial resection is normally not necessary.
Fig. 17.5 Release of fibrous attachments to the vocal fold cyst Fig. 17.6 Redraping of microflap
112 Vocal Fold Cyst and Vocal Fold Fibrous Mass
Key Points
■ Diagnosis of vocal fold cyst and vocal fold fibrous

mass may be difficult preoperatively; however, vid-
eostroboscopy greatly improves the chances of de-
tection. Often exploratory cordotomy is required
to differentiate between the diagnoses of a fibrous
mass versus vocal fold cyst.
■ Delicate handling of the cyst is necessary to avoid
rupture, which will complicate the removal.
■ Surgical dissection between the epithelial cov-
ering and cyst wall (medial dissection) should
precede dissection between the lesion and vocal
ligament (lateral dissection).
■ Postoperative recovery may be slower for vocal
fold cyst and vocal fold fibrous mass lesions that
are on or near the vocal ligament compared to le-
sions in the subepithelial space.
Fig. 17.7 Retraction of microflap demonstrating vocal fold fibrous
mass on vocal ligament
1 Courey MS, Garrett CG, Ossoff RH (1997) Medial microflap for
excision of benign vocal fold lesions. Laryngoscope 107:340–344
Complications can include (see Chap. 12, “Management and 2 Courey MS, Shohet JA, Scott MA, Ossoff RH (1996) Immuno-
Prevention of Complications Related to Phonomicrosurgery”): histochemical characterization of benign laryngeal lesions. Ann
■ Chipped teeth (typically maxillary)
3 Dikkers FG, Nikkels PG (1995) Benign lesions of the vocal folds:
■ Anesthesia/hypoesthesia of tongue, loss of taste
histopathology and phonotrauma. Ann Otol Rhinol Laryngol
■ Due to pressure neuropathy of lingual nerve from
104(Pt. 1):698–703
suspension laryngoscope
17 ■ Resolves in 2–3 weeks typically, may persist for 3
4 Johns MM (2003) Update on etiology, diagnosis, and treatment
of vocal fold nodules, polyps and cysts. Curr Opin Otolaryngol
months or more
Head Neck Surg 11:456–461
■ Minimize by keeping suspension time to less than
5 Rosen CA, Lombard LE, Murry T (2000) Acoustic, aerodynamic
2 hours
and videostroboscopic features of bilateral vocal fold lesions.
■ Prolonged postoperative dysphonia
Ann Otol Rhinol Laryngology 109:823–828
■ Seen in cases where extensive scarring/adhesions are
6 Shohet JA, Courey MS, Ossoff RH (1996) Value of videostrobo-
present, especially if cyst rupture has occurred prior
scopic parameters in differentiating true vocal fold cysts from
to surgery. Occasionally, a sulcus vocalis deformity is
polyps. Laryngoscope 106(Pt. 1):19–26
seen, where the cyst extends into the vocal ligament,
7 Thekdi AA, Rosen CA (2003) Surgical treatment of benign
requiring dissection into the ligament and in some
vocal fold lesions. Curr Opin Otolaryngol Head Neck Surg
cases resection of vocal ligament fibers to remove the
10:492–496
entire cyst wall. In these cases, prolonged hoarseness
8 Zeitels SM, Hillman RE, Desloge R, Mauri M, Doyle PB (2002)
and slow recovery in voice quality can be expected.
Phonomicrosurgery in singers and performing artists: treatment
We recommend intensive voice therapy, oral corti-
outcomes, management theories, and future directions. Ann Otol
costeroid taper, and reassurance. The use of steroids
Rhinol Laryngol 190(Suppl.):21–40
is especially indicated if erythema is present at the
operative site.
■ Cyst recurrence
■ This is unusual except in the case of anterior com-
missure mucous retention cysts or type III sulcus
vocalis. Recurrence is generally seen within 6–12
weeks after surgery. Revision phonomicrosurgical
removal can be carried out after the third postop-
erative month, with meticulous detail paid to the
removal of all cystic wall remnants; this may require
limited vocal ligament fiber resection in some cases.
Chapter 18
Polypoid Corditis
18
wave is often amplified or increased due to the pliable nature
of the gelatinous material in the SLP; however, with growth of
the lesions, vibratory characteristics can be dampened and/or
Please see Chaps. 4, 7, 8, 10, 11, and 12 for further informa- absent due to mass effect. One of the distinctive characteristics
tion. of polypoid corditis is the “saddle-bag” appearance the vocal
folds take on, as the heavy, rounded vocal folds prolapse inferi-
orly with inspiration (Fig. 18.1).

Polypoid corditis (commonly referred to as Reinke’s edema)
is an alteration of the lamina propria that results in dyspho-
nia, lowered pitch, and vocal instability (Fig. 18.1). The char-
acteristic low-pitched, gravelly voice tends to be more easily Indications for surgical intervention include:
identified in females because it is gender incongruous. It is a 1. Symptomatic dysphonia (generally more noticeable in fe-
condition commonly associated with smoking—in fact, 97% of males)
patients with polypoid corditis are smokers. In addition, LPR 2. Lack of response to anti-reflux management with PPIs,
and phonotrauma are thought to be important contributing voice therapy, and smoking cessation
cofactors. In contrast to most other benign laryngeal lesions, Smoking cessation does not lead to resolution of the disease,
polypoid corditis is a global, as opposed to focal, process of the but does halt its progression.
vocal folds. The condition is almost exclusively bilateral, and 3. Airway obstruction due to advanced disease
involves expansion of Reinke’s space by an inflammatory gelat- This may occur when a patient has a preexisting severe pol-
inous amorphous material that extends from anterior commis- ypoid corditis and develops unilateral vocal fold immobili-
sure to the vocal process. The disease can be quite subtle in the ty, or upper airway edema from an additional inflammatory
early stages, but over a period of years can grow to such pro- process such as an upper respiratory infection. The inabil-
portions that the airway is compromised. Initially, the mucosal ity to improve the airway via abduction can lead to airway
compromise.
4. Concern of malignancy
Some cases of polypoid corditis have overlying epithelial
changes (e. g., leukoplakia) and can be worrisome for malig-
nancy. In these cases, preservation of vibratory parameters
does not guarantee benign disease because a microinvasive
process can be camouflaged by the deep layer of gelatinous
pliable material. In these cases, the diseased epithelial must
be treated as displayed in Chap. 20, “Vocal Fold Leuko
plakia.”
Contraindication for surgical intervention include continued

smoking, which will almost assuredly result in a recurrence
of the disease postoperatively—though it may take months to
years to recur. This is a relative contraindication, and must be
exercised on a case-by-case basis. Obviously, suspicion of ma-
lignancy or airway concerns overrides this contraindication.
Special consideration should be given (either preoperatively
or intraoperatively) to whether to operate on both vocal folds
or to stage the surgeries, one side at a time. A carefully planned
incision (Fig. 18.2) can be used with bilateral surgery to avoid
formation of an anterior glottic web. However, if this is not
Fig. 18.1 Polypoid corditis (bilateral)
114 Polypoid Corditis
possible, then a conservative approach is advocated, where 4. Raise the microflap between the epithelium and the polyp-
unilateral surgeries are performed to avoid complications. oid material (Fig. 18.4).
Patients should be counseled preoperatively that the pitch Using a 30° flap elevator, the epithelium is separated from
of the voice will increase, they will likely have a short period of the underlying polypoid tissue, taking great care not to per-
breathiness, and that voice therapy postoperatively will usually forate the epithelial flap, which can be quite thin. As the dis-
be required. section extends inferiorly, it is necessary to put lateral pres-
sure on the flap elevator to get adequate visualization of the
flap. In some cases, an extensive flap is required, extending
well into the infraglottis, and from “stem-to-stern” of the
entire membranous vocal fold.
5. Raise a plane between the vocal ligament and the overlying
Standard phonomicrosurgery instrument set (see Chap. 10, polypoid material (Fig. 18.5)
Table 10.1), high-powered suction (typically a liposuction de- Again, using a 30° flap elevator, the vocal ligament is identi-
vice). fied at the superior/lateral aspect of the vocal fold, and a
plane is developed between the vocal ligament and the dis-
eased polypoid tissue. Once the material has been freed, it
is ready for removal. It should be noted that some mild-to-
moderate cases of polypoid corditis might not require much
flap elevation (as described in this and step 4); in these cas-
1. Intubation with a 5 or 5.5 MLT es, the material may aspirate more readily without the need
Special care must be exercised to avoid vocal fold injury or for extensive flap elevation.
damage, due to the limited space that is available for tube 6. Removal of polypoid material
placement. Much of the polypoid tissue can be removed with suction;
2. Expose larynx with suspension laryngoscope. however, suction with a strong negative pressure is essential.
3. Incision (Fig. 18.3) Routine operating room suction units are frequently inad-
a) Use a fresh sickle knife equate, and the liposuction units are generally employed.
b) Incision at the superior/lateral aspect of the vocal fold, The larger suction tubing used in the units can be adapted
beginning at the vocal process and extending to within 3 to the smaller suction tubing using a “Christmas tree” adap-
mm of the anterior commissure tor. In general, a 5- or 7-French microsuction with closed
thumb port is used (Fig. 18.6). Care is taken to retract the
flap so it is not caught in the suction. One must allow a few
seconds for the maximum pressure to be achieved after
placing the suction into the polypoid material. Frequently,
there are loculations of more fibrous material mixed in with
18
Fig. 18.2 Planned bilateral incisions in a typical case of polypoid Fig. 18.3 Sickle-knife incision running in an anterior-to-posterior di-
corditis. Note the lack of anterior extension on the left side, which is rection at the superior/lateral aspect of the vocal fold
designed to minimize the chances of anterior glottic web formation
postoperatively
Chapter 18 115
the gelatinous polypoid material, which cannot be removed corditis. This mucosa should be conservatively trimmed so
by suction. This material must be manually extracted with that the epithelial edges coapt at the end of the case. (Fig.
a straight or up cups forceps (Fig. 18.7). One must resist 18.8). It is best to redrape the flap prior to planning the
the temptation to remove all the polypoid material, as some trimming of mucosa. In cases of massive polypoid corditis,
SLP must be left behind to regenerate Reinke’s space, and it is not infrequent to sacrifice this mucosa with a large ex-
maintain vibratory properties. cisional removal of polypoid material. In many cases, how-
7. Trimming of redundant mucosa ever, the epithelial removal will be the last portion of the
There is usually a certain amount of redundant mucosa, case. It is best to try to trim the mucosa conservatively at
which can be quite extensive in advanced cases of polypoid first; more mucosa can always be removed later if needed.
Fig. 18.4 A 30° flap elevator is used to separate the polypoid disease Fig. 18.5 Elevation is carried out between the vocal ligament and the
from the epithelium polypoid disease
Fig. 18.6 Suction removal of polypoid disease Fig. 18.7 Supplemental cup forceps removal of disease
116 Polypoid Corditis
Fig. 18.8 Trimming of redundant epithelium with up-cutting scissors Fig. 18.9 After epithelial removal with minimal mucosal dehiscence
Long cuts across the mucosa are preferable to short cuts,

■ Scarring of the vocal folds can also occur. A risk factor
and these tend to give a jagged contour to the cut edge. The
for unfavorable scarring is the removal of excessive
incised edges of the flap should coapt closely, without a sig-
amounts of the SLP/gelatinous material. The result is
nificant mucosal dehiscence (Fig. 18.9).
stiffness/loss of vibratory properties with rough, breathy
dysphonia, vocal fatigue, and lack of projection.

18 and Complications Key Points
Postoperative care should include PPIs, pain medicine, and ■ Polypoid corditis is a bilateral process character-
voice rest for 5–7 days. Smoking should be discontinued or
ized by expansion of Reinke’s space with ge-
significantly reduced in the postoperative period.
latinous inflammatory material throughout the
Expected postoperative course:
entire vocal fold, and is seen almost exclusively in
■ The patient will experience a breathy voice postopera- smokers.
tively, primarily due to the preoperative high subglot- ■ Surgical indications for polypoid corditis include
tal pressures that are used to drive the vibration of the symptomatic dysphonia despite medical manage-
polypoid material. In addition, the pitch of the voice ment, airway encroachment/partial obstruction, or
will be significantly higher due to the loss of mass after concern of malignancy.
the surgery. In general, recovery and stabilization of ■ Microflap surgery can be performed bilaterally,
voice takes longer than with most other benign lesions, but incisions should not extend to the anterior
typically 6–8 weeks. vocal fold to avoid web formation. Alternatively, it
■ Complications are generally related to technical errors is acceptable to operate unilaterally and stage the
in the surgical procedure. The most serious complica- second procedure.
tion is anterior glottic web, which can occur when raw ■ Removal of the polypoid material may require a
surfaces are left at the anterior free edge of both vocal high-vacuum suction device and/or manual ex-
folds. The best way to avoid this complication is to make traction of loculated portions of the disease.
the incisions on the lateral aspect of the vocal fold, and ■ It is critical that some gelatinous material in the
not to extend the incisions to the anterior most aspect SLP should be left behind to reconstitute Reinke’s
of both vocal folds. space and preserve vibratory characteristics.
Chapter 18 117
1 Lumpkin SM, Bishop SG, Bennett S (1987) Comparison of surgi- 3 Courey MS, Gardner GM, Stone RE, Ossoff RH (1995) Endo-
cal techniques in the treatment of laryngeal polypoid degenera- scopic vocal fold microflap: a three-year experience. Ann Otol
tion. Ann Otol Rhinol Laryngol 96:254–257 Rhinol Laryngol 104:267–273
2 Lumpkin SM, Bennett S, Bishop SG (1990) Postsurgical follow- 4 Zeitels SM, Bunting GW, Hillman RE et al (1997) Reinke’s edema:
up study of patients with severe polypoid degeneration. Laryngo- phonatory mechanisms and management strategies. Ann Otol
scope 100:399–402 Rhinol Laryngol 106:533–543
Chapter 19
Vocal Fold Granuloma

19
be laryngopharyngeal reflux, vocal misuse or hyperfunction,
glottal incompetence with severe hyperfunction often associ-
ated with vocal fold paresis, vocal fold atrophy, vocal fold pa-
Please see Chaps. 1, 4, 5, 10, 11, and 12 for further informa- ralysis, vocal fold scar, and chronic cough.
tion. Patients with a vocal fold granuloma can experience glo-
bus sensation, dysphonia, and/or odynophonia. If the vocal
fold granuloma is extremely large, then shortness of breath
and dyspnea on exertion and other airway related symptoms
can be present. The postintubation granulomas typically occur
in females more than in males and are often associated with a
comorbid condition of laryngopharyngeal reflux disease. Typi-
Vocal fold granuloma is inflammatory tissue arising from the cally, these lesions can be treated expectantly as long as the LPR
perichondrium near the arytenoid cartilage (Fig. 19.1). The is controlled. This patient subgroup will do quite well and often
granuloma typically arises in the area where the vocal process not require surgical excision of the vocal fold granuloma.
adjoins the body of the arytenoid cartilage. Vocal fold granu- Differential diagnosis for vocal fold granuloma include: (It
loma can occur unilaterally or bilaterally. Granulation tissue should be noted that all of the below diagnoses almost never
can form on other locations of the vocal folds; however, these present as isolated lesions at the vocal process/arytenoid):
are different clinical entities and are not discussed in this chap-
■ Squamous cell carcinoma
ter. Vocal fold granulomas are thought to occur from a peri-
■ Carcinoma in situ
chondritis of the arytenoid cartilage. For perichondritis of the
■ Dysplasia
arytenoid cartilage to occur, it is thought that there needs to be
■ Amyloidosis
a two-step process of (1) mucosal injury and (2) subsequent
■ Tuberculosis of the larynx
injury to the perichondrium of the arytenoid cartilage.
Vocal fold granuloma is classically seen after endotracheal
intubation. The intubation or endotracheal tube causes mu-
cosal injury, and subsequent injury to the perichondrium can
occur from persistence of the endotracheal tube or LPR. The
most common causes of vocal fold granulomas are thought to
Indications for vocal fold granuloma surgical removal include:

■ To rule out malignancy or infectious etiologies (e. g.,
tuberculosis, Klebsiella)
■ Airway obstruction
■ Symptoms of persistent disease despite nonsurgical
treatment methods
■ Growth of lesion despite medical treatment
Contraindication of vocal fold granuloma surgery comprise

surgical removal without addressing the possible underlying
etiologic conditions preoperatively (LPR, voice misuse and/or
glottal insufficiency).
The surgical equipment required is a standard phonomicrosur-

gery instrument set (see Chap. 10, Table 10.1), and a posterior-
Fig. 19.1 Vocal fold granuloma commissure laryngoscope (as needed).
120 Vocal Fold Granuloma
net result of keeping the endotracheal tube in an anterior

location while the surgeon works in the posterior glottis
(Fig. 19.2). The slight angulation of the laryngoscope also
1. Philosophical overview for vocal fold granuloma removal keeps the endotracheal tube anterior and provides optimal
The overall goal for surgical removal of vocal fold granu- exposure of the arytenoid and posterior membranous vocal
loma is to remove the vocal fold granuloma lesion in as an fold. The ideal exposure for vocal fold granuloma surgery
atraumatic fashion as possible. It is important recognize that is to have exposure and good visualization of the posterior
after vocal fold granuloma removal, success of the opera- aspect of the midmembranous vocal fold and the entire ary-
tion (no recurrent granuloma disease) is dependent on the tenoid and posterior glottic area on the side of the lesion.
race between the underlying inflamed perichondrium and 3. After the laryngoscope is suspended and adequate exposure
the surrounding normal mucosa. If the mucosa “wins” this of the posterior glottis is achieved, examine the lesion at
race, then the patient will not have a recurrent granuloma; high-powered magnification, specifically gently retracting
however, if the perichondrial inflammation continues, then the lesion from its attachment from the arytenoid to view,
a recurrent granuloma is highly likely. With this in mind, it and gain a sense of the size and location of the stalk. This
is important that all aspects of the surgical removal of the can also be done by passing a small curved alligator be-
vocal fold granuloma are aimed at: tween the vocal fold granuloma and the arytenoid cartilage;
a) Maintaining as much normal mucosa surrounding the this will allow the surgeon to identify the exact location and
surgical site as possible nature of the vocal fold granuloma stalk.
b) Minimizing all possible irritation or trauma to the un- 4. For removal of the vocal fold granuloma, it is best to use
derlying arytenoid cartilage perichondrium a curved alligator (curved in the opposite direction of the
2. Exposure and preparation for vocal fold granuloma excision side that the vocal fold granuloma is on) and gently grab the
If the vocal fold granuloma is large or the anesthesiologist stalk that runs between the vocal fold granuloma and the
refuses to use a small endotracheal tube (5.0), then the sur- arytenoid cartilage. Preferably, the alligator will grasp the
geon should position the endotracheal tube anterior to the stalk on its most medial aspect. The vocal fold granuloma
laryngoscope during laryngoscope suspension. This will al- stalk can then be gently retracted towards the midline, and
low an unfettered view of the posterior commissure, which a curved microscissors (curved in the same direction as the
is required for this surgery. The Pilling posterior-commis- curved alligator) is then used to release or cut the stalk im-
sure laryngoscope facilitates the anterior displacement of mediately lateral to the curved alligator, thus allowing the
the endotracheal tube because it has a slight notch to hold removal of the vocal fold granuloma (Fig. 19.3).
the endotracheal tube anterior during laryngoscope sus- 5. Application of epinephrine-soaked pledgets (1:10,000 dilu-
pension. The other method to keep the endotracheal tube tion) will achieve hemostasis without any difficulty.
in an anterior position is to slightly alter the angle of the en-
dotracheal tube as it goes through the larynx so it lays non-
parallel to the longitudinal axis of the laryngoscope, with a
19
Fig. 19.2 Nonparallel placement of the laryngoscope and endotra- Fig. 19.3 Retraction of vocal fold granuloma stalk with curved alliga-
cheal tube tor and cutting of stalk
Chapter 19 121
6. Careful examination and palpation of the operative site will

Key Points
reveal if there is any residual granulation tissue or inflam-
matory tissue. If this tissue is present, it is best to remove it
very carefully and conservatively with l-mm cup forceps or ■ Vocal fold granuloma is a perichondritis of the ary-
the micro-ovoid cup forceps. Great care should be taken at
tenoid cartilage from various insults (voice misuse,
this juncture to fully remove obvious exophytic tissue and
endotracheal intubation, LPR, etc.).
not remove any surrounding normal mucosa or to reach ■ Surgery should be performed if concern exists
deeply into the operative site. This will minimize the risk of
regarding a malignancy or infection, or all nonsur-
traumatizing the underlying arytenoid perichondrium.
gical treatment options have been exhausted.
7. Adjunctive procedures to vocal fold granuloma surgery ■ Underlying glottal insufficiency is a common cause
After the successful removal of the vocal fold granuloma,
of recurrent vocal fold granuloma, and patients
depending on the exact clinical situation, one should fully
should be carefully evaluated for the most com-
evaluate the size and nature of the vocal fold to consider if
mon causes of glottal insufficiency and treated at
the patient requires vocal fold augmentation. If vocal fold
the same time as vocal fold granuloma excision if
augmentation is warranted, then vocal fold augmentation
appropriate.
should be strongly encouraged and performed simultane- ■ Careful surgical excision of the vocal fold granu-
ously to the vocal fold granuloma excision (see Chap. 31,
loma with minimal trauma to the underlying peri-
“Vocal Fold Augmentation via Direct Laryngoscopy”).
chondrium and surrounding mucosa is essential to
Another adjunctive treatment option especially for recur-
successful surgery for vocal fold granuloma.
rent vocal fold granuloma surgery is to consider a vocal fold
Botox injection to chemically “splint” or put the voice “at
rest” after the vocal fold granuloma excision. Botox can be
done during microlaryngoscopy by injecting into the TA-
LCA muscle complex—direct the Botox needle lateral and
slightly outward from the vocal process on the side of the
vocal fold granuloma. However, ideally Botox injection 1 Benjamin B, Roche J (1993) Vocal granuloma, including sclerosis
should be done 3 days prior to the surgical excision of the of the arytenoid cartilage: radiographic findings. Ann Otol Rhi-
granuloma (see Chap. 35, “Botulinum Toxin Injection”). nol Laryngol 102:756–760
Thus, the vocal fold is “at rest” at the time of the excision. 2 Devaney KO, Rinaldo A, Ferlito A (2005) Vocal process granu-
loma of the larynx: recognition, differential diagnosis and treat-
ment. Oral Oncology 41:666–669
3 Hoffman HT, Overholt E, Karnell M, McCulloch TM (2001) Vo-
cal process granuloma. Head Neck 23:1061–1074
and Complications
4 Leonard R, Kendall K (2005) Effects of voice therapy on vo-
cal process granuloma: a phonoscopic approach. Am J Otol
Postoperative care typically involves voice rest for a variable 26:101–107
number of days (6–10 days). In addition, LPR treatment (de- 5 Ylitalo R, Hammarberg B (2000) Voice characteristics, effects of
spite the clinical history) should be implemented, including voice therapy, and long-term follow-up of contact granuloma pa-
behavior modification and PPI therapy. Voice rest is indicated tients. J Voice 14:557–566
to maximize the chance of successful healing of the operative 6 Ylitalo R, Lindestad PA (2000) Laryngeal findings in patients
site and minimize a chance for recurrent vocal fold granuloma with contact granuloma: a long-term follow up study. Acta Oto-
formation. laryngol 120:655–659
Complications after vocal fold excision surgery include: 7 Ylitalo R, Lindestad PA (1991) A retrospective study of contact
granuloma. Laryngoscope 109:433–436
■ Recurrent lesion
8 Ylitalo R, Ramel S (2002) Extraesophageal reflux in patients with
■ Severe cartilaginous or membranous vocal fold defects
contact granuloma: a prospective controlled study. Ann Otol
from excessive or overly aggressive surgical excision of
Rhinol Laryngol 111(Pt. 1):441–446
the vocal fold granuloma
To address the problem associated with a recurrent vocal fold

granuloma, it is important that all different etiologic pos-
sibilities are carefully and systematically reviewed prior to
proceeding with a repeated surgical procedure. This includes
speech–language pathology evaluation and voice therapy, LPR
treatment, and assessment and treatment for glottal insuffi-
ciency.
Chapter 20
Vocal Fold Leukoplakia

and Hyperkeratosis 20
give valuable information regarding the potential for malignant
invasion, as noninvasive pathology tends to preserve mucosal
wave, whereas invasive disease leads to the loss of vibratory
Please see Chaps. 3, 4, 7, 8, and 10 for further information. characteristics. Notable exceptions to this rule are the presence
of coexisting polypoid corditis and microinvasive carcinoma
of the vocal fold. In this example, the mucosal wave may be
preserved due to extensive expansion of the SLP.

Vocal fold leukoplakia (Fig. 20.1) and keratosis are clinical dis-
ease processes of the vocal fold epithelium. The physical find-
ings consist of a white plaque on the surface of the vocal fold.
Histopathologically, leukoplakia can vary from the very benign Indications include:
(hyperkeratosis of the epithelium) to frankly malignant (mi-
■ Leukoplakia of the vocal folds, where histopathology
croinvasive squamous cell carcinoma). The differential diag-
has not been established (especially in cases where
nosis of leukoplakia includes papillomatosis, fungal infections
mucosal wave is reduced or absent at the lesion site)
(especially candidiasis) and occasionally, tenacious mucous.
■ Change in the appearance or nature of preexisting leu-
Patients with vocal fold leukoplakia are typically smokers;
koplakia
however, other inflammatory conditions may contribute to the
development of this epithelial change, such as LPR or possibly
viral infection. The patient typically presents with a rough or A (relative) contraindication is a patient who is high-level vo-
coarse voice, but vocal fold leukoplakia may be found in an cal professional (i. e., singer) before attempting conservative
“asymptomatic” patient on routine flexible laryngoscopy. management (antifungals, PPIs, etc.).
Videostroboscopy is essential in the evaluation of leuko-
plakia of the membranous vocal folds. Tenacious mucous can
easily be distinguished from a leukoplakic plaque by observing
the characteristic movement of the mucous during vibratory
activity. More importantly, videostroboscopic characteristics
The surgical equipment required is a standard phonomicrosur-
gery instrument set (see Chap. 10, Table 10.1).
1. Intubate with 5.0 or 5.5 microlaryngeal endotracheal tube

2. Expose larynx with suspension laryngoscope.
3. Infiltrate into the submucosal space—superficial lamina pro-
pria or Reinke’s space—using a 27-g needle (Fig. 20.2).
a) The mucosa will be distended, and generally, noninvasive
leukoplakia will be noted to lift up from the underlying
vocal ligament. Invasive areas of mucosa can sometimes
be noted to remain adherent to the underlying vocal lig-
ament, creating a depression, or “divot” (Fig. 20.3).
b) The infiltration should be done slowly; generally, 0.1–
0.3 ml is all that is necessary.
c) Ensure that the needle is primed, so that air is not infil-
Fig. 20.1 Leukoplakia of the vocal fold trated under the flap.
124 Vocal Fold Leukoplakia and Hyperkeratosis
Fig. 20.3 Invasion of epithelial lesion into the vocal ligament, creating
a focal depression or “divot” within the otherwise distended SLP after
Fig. 20.2 Submucosal infusion of 1:10,000 epinephrine in vocal fold submucosal infiltration
4. Incision (Fig. 20.4) 6. Make posterior, then anterior epithelial incisions (Fig. 20.7)
a) Use a fresh sickle knife. a) Using an up-cutting scissors held sideways in one hand
b) Make the initial incision just lateral to the area of leuko- and a flap elevator in the other, the leukoplakic flap is
plakia, in a posterior-to-anterior direction. lifted up and the posterior boundary of epithelium is in-
i Note that if a diagnosis of malignancy has not been cised, followed by the anterior.
established, no “margins” are required. 7. Complete the excision by making the inferior epithelial cut.
ii Keep the incision superficial by maintaining a slight a) It is often helpful to check that the microflap incision
pull on the knife superiorly (toward you), which encompasses the entire diseased epithelium by periodi-
“tents up” the mucosa, protecting the deeper layers. cally redraping the flap (Fig. 20.8) and rechecking the
5. Undermine the diseased epithelial layer from the underlying incisional line.
structures (Fig. 20.5). b) The epithelial lesion is retracted with a microflap using a
a) Use the 30° flap elevator to develop a plane in the sub- triangular forceps, while an up-cutting scissor is used to
20 epithelial space, taking care to be as superficial as pos- excise the lesion in a posterior to anterior direction. (Fig.
sible. 20.9)
b) Very early in the dissection, one must identify the vocal
ligament. It is relatively easy to place the flap elevator into Special consideration should be given to:
of the fibers of the vocal ligament, and begin the plane
■ Pinning and orienting the specimen for the pathologist
too deep. This is especially true in cases of re-excision
can be very helpful in guiding future therapy. This can
for recurrent leukoplakia and inflammatory leukoplakic
be accomplished by placing the epithelial specimen on a
processes.
tongue blade, indicating the medial/lateral and anterior/
c) Caution must be exercised when extending the dissec-
posterior orientation (Fig. 20.10). It is recommended
tion inferiorly, as the surgical plane does not continue in
that the surgeon review the histopathology personally
the same direction, but instead extends laterally. Because
with the pathologist, taking note of any anatomic re-
of this, it is easy to perforate the epithelial flap, if one is
gions that are severely dysplastic/and or invasive. Using
not careful. To avoid this tendency, one must push the
this information, future endoscopic treatment can be
back end of the flap elevator against the vocal ligament
directed to the specific region of the vocal fold that is
laterally, which improves exposure for inferior flap eleva-
involved.
tion (Fig. 20.6a, b)
■ Multiple patches of leukoplakia can be addressed in the
d) Ensure that the entire extent of the leukoplakia is under-
same setting; however, one must be cautious to avoid
mined freely prior to proceeding. This is done by visual-
bilateral anterior epithelial removal, which may result in
izing the flap elevator through the flap as the dissection
anterior glottic web formation.
proceeds.
Chapter 20 125
Fig. 20.4 Sickle knife incision immediately lateral to leukoplakia Fig. 20.5 Flap elevation (undermining) of leukoplakic lesion
Fig. 20.6 Coronal section of vocal fold depicting lateral pressure on Fig. 20.7 Anterior flap incision is made after the posterior incision
the flap elevator to improve visualization of infraglottic flap
126 Vocal Fold Leukoplakia and Hyperkeratosis
Fig. 20.8 Redraping of flap to ensure complete removal of pathology Fig. 20.9 Final (inferior) flap incision
Complications can include:

■ Chipped teeth, hypoesthesia of tongue
■ Recurrence of leukoplakia
Recurrence of leukoplakia is common in those patients
that continue to smoke postoperatively; therefore, this
should be part of pre operatively counseling. Patients
may have other cofactors leading to the recurrence of
leukoplakia, such as LPR, glottic incompetence, or HPV
infection. These areas should be aggressively treated if
they are suspected.
20
Key Points
■ Videostroboscopy is an important component of

the preoperative evaluation of vocal fold leukopla-
Fig. 20.10 Typical orientation of excised leukoplakic specimen for pa-
kia.
thologist (A = Anterior, L = Lateral, P = Posterior, M = Medial)
■ Loss of mucosal wave can be seen with invasive
forms of leukoplakia, while noninvasive forms tend
to have preservation of vibratory characteristics.
■ Subepithelial infusion is a very helpful adjunct in
20.6 Postoperative Care the surgical armamentarium, as it reduces intraop-
and Complications erative bleeding and lifts the diseased epithelium
away from the vocal ligament, thus protecting it.
■ Complete excision of the area of leukoplakia
Postoperative management includes:
should be checked by redraping the flap during
■ Complete voice rest for 3–7 days the final excisional step.
■ PPIs, pain medication ■ Pinning and orienting the epithelial specimen can
■ Follow-up 1–2 weeks to review pathology results be very helpful in guiding any additional therapy.
Chapter 20 127
1 Zeitels SM, Vaughan CW (1991) A submucosal true vocal fold 3 Zeitels SM (1993) Microflap excisional biopsy for atypical and
infusion needle. Otol Head Neck Surg 105:478–479 microinvasive cancer. Operat Tech Otolaryngol Head Neck Surg
2 Zeitels SM (1995) Premalignant epithelium and microinvasive 4:218–222
cancer of the vocal fold: the evolution of phonomicrosurgical 4. Schweinfurth JM, Powitzky E, Ossoff RH (2001) Regression of la-
management. Laryngoscope 105:1–51 ryngeal dysplasia after serial microflap exision. Ann Otol Rhinol
Laryngeal Sep; 110(9):811–4
Chapter 21
Surgical Treatment of Recurrent

Respiratory Papillomatosis 21
of the Larynx
the surgical management of this disease. Often recurrent RRP

patients have 50–100 surgeries in their lifetimes, and thus the
surgeon must constantly remember that the primary goal for
Please see Chaps. 4, 9, 10, 11, 12, and 13 for further informa- surgery is to remove the disease and minimize the sequela of
tion. surgery (vocal fold scar, web formation, etc.). With the recur-
rent nature of RRP disease and the need for multiple repeated
surgeries, phonomicrosurgery principles, concepts, and tech-
niques are ideal for the surgical therapy of RPP (see Chap. 10,
“Principles of Phonomicrosurgery”).
Differential diagnosis for RRP is:
■ Squamous cell cancer
Recurrent respiratory papilloma (RRP) is characterized by be-
■ Verrucous carcinoma
nign epithelial growths that are recurrent in nature after sur-
■ Leukoplakia
gical removal. The lesions often have a distinct vascular “dot”
■ Granuloma
in the center of individual papilloma growth (Fig. 21.1). RRP
growths can be exophytic and/or superficial “spreading.” RRP
can occur anywhere in the laryngotracheal area; however, the
glottis is the most common site. It has been found that RRP
tends to favor growth at the epithelial transition sites such as
at the level of the glottis where the epithelium changes from
stratified squamous epithelium to pseudostratified columnar
epithelium. The etiologic agent of RRP is human papilloma vi- Indications include:
rus (types 6–11 are the most common). Given the recurrent
■ In pediatric cases of RPP, airway considerations are
nature of RRP, careful and conservative surgery is crucial to
primal. For this reason, parent education on the
importance of compliance with doctor’s visits and
monitoring of symptoms and signs of airway difficulties
are essential. Adult RRP surgery is usually indicated to
rule out malignancy initially and to make a pathologic
diagnosis. Subsequent to establishing the diagnosis of
RRP, voice disturbance is the most common indication
for surgical treatment of RRP.
■ A key management principle in RRP is to focus atten-
tion and efforts on preventing the need for a trache-
otomy. Tracheotomy creates a new epithelial transition
site in the trachea and may lead to new RRP growth
at the tracheotomy site. The presence of new RRP at
the tracheotomy site significantly increases the level
of complexity of the surgical management of these
patients.
Contraindications include surgical excision without any voice,

swallowing, or airway symptoms.
Fig. 21.1 Recurrent respiratory papilloma

130 Surgical Treatment of Papillomatosis
b) Submucosal infusion of epinephrine throughout the in-

tended surgical area (see Chap. 10)
c) A sickle knife is then used to incise the epithelium im-
1. Standard phonomicrosurgery instrument set (see Chap. 10, mediately lateral to the recurrent respiratory papilloma
Table 10.1) disease.
2. Microdebrider (optional; described in Chap. 10) Note that no margin is required in removing the recurrent
3. CO2 or pulsed KTP laser (see Chap. 13, Sect. 13.4) respiratory papillomatosis, however, gross disease should
not be left, and thus the incision should be immediately
adjacent to the interface of RRP and normal mucosa.
d) Subepithelial dissection (undermining of the RRP dis-
ease is then done with curved and angled elevators and
sometimes with microcurved scissors). Great care should
1. Overview be exercised to stay very superficial (Fig. 21.2). Not stay-
RRP is a recurrent disease process (99% of the time), and ing as superficial as possible will result in unnecessary
the most aggressive surgical excision does not equal better loss of vocal fold lamina propria and scar formation.
results, cure, or longer interval between surgical treatments. e) Incision through the epithelium can then be made an-
Thus, conservative removal and focus of improving func- teriorly and posteriorly to the RRP, once again, with no
tional improvement (airway, voice) not complete removal need for a mucosal margin.
of the disease is important. This chapter describes the dif- f) The RPP that is contained within the microflap can then
ferent surgical methods for RRP removal and then discuss- be held with triangular forceps or a curved alligator, and
es surgical removal of RRP by different subsites within the then superficial dissection underneath the RRP can then
larynx. When cidofovir injection is being combined with be performed until the entire RRP has been incorporated
surgical excision, it can be done with any of the below de- within the microflap.
scribed techniques (see “Cidofovir Laryngeal Injection for g) Immediately redraping the microflap to assess the extent
RPP,” below). of the dissection and to determine if the entire papilloma
2. Microflap Removal of RRP (see Chaps. 10, “Principles of Pho- area is included within the microflap is extremely help-
nomicrosurgery” and 20, “Vocal Fold Leukoplakia and Hy- ful. Inferior incision underneath the area of the micro-
perkeratosis”) flap containing the RRP can then be done with a sickle
a) Place the largest laryngoscope over the RRP site (note knife or microscissors. This releases the RRP completely
that the surgeon may have to reposition the laryngo- and specimen can be sent for pathologic examination
scope multiple times to work on several different loca- (Fig. 21.3).
tions within the larynx to address all RRP locations on h) Hemostasis can be obtained with an epinephrine-soaked
an as needed basis). pledget.
21
Fig. 21.2 Microflap removal of RRP Fig. 21.3 Release of microflap containing RRP
Chapter 21 131
i) Inspection (visual and by palpation) for RPP at the op- from the first instrument. This cycle can be continued
erative site is important. This should be done with both until all the RRP is removed in a fairly rapid fashion.
high-power microlaryngoscopy as well as with angled g) Epinephrine-soaked pledgets can be applied to the op-
telescopes (see Chap. 10). erative site to obtain hemostasis on an as needed basis.
j) If more RRP is present, then further surgical removal 4. Laser surgery for RRP
can be done using another microflap approach or micro- a) Exposure of RRP with the largest possible laser laryngo-
forceps removal technique (see below). scope
3. Microforceps removal of RRP b) Submucosal infusion of epinephrine to intended area of
a) Inject epinephrine subepithelially throughout the in- RRP excision.
tended RRP excision site. This allows for hydrodissec- c) Implementation of all laser safety precautions (see Chap.
tion of the RRP from the deeper structures of the vocal 13, “Principles of Laser Microlaryngoscopy”)
fold as well as enhances hemostasis. d) It is best to use a “defocused spot size” 0.5–0.75 mm,
b) Place epinephrine-soaked pledgets on the RRP site for with a low power (2–4 W) on intermittent superpulse
several minutes. setting.
c) Gently and precisely grab a part of the RRP to be re- e) The laser is used to vaporize the RRP; care should be
moved (depending on size of lesion) with 1–2 mm mi- taken to only ablate the RRP tissue and not the deeper
croforceps (cup/or ovoid). Make sure that the forceps are aspect of the vocal fold. Power, spot size, and duration
only holding on to the most superficial aspect of the RRP of exposure can be adjusted to prevent damage to deeper
and not any deeper part of the mucosa or vocal fold. structures and transmission of thermal injury to sur-
d) The RRP within the forceps can then be gently avulsed rounding regions. This surgery should be performed
by pulling the tissue in either a cephalad or caudal di- at high power magnification for maximum control and
rection. Superior or inferior direction of avulsion is the precision of the RRP removal.
safest (Fig. 21.4). f) Carbonaceous material from the laser ablation site
e) Avoid pulling the RRP anteriorly or posteriorly since this should be removed frequently with suction cannulas
may result in “stripping” of normal adjacent mucosa in- (5 or 7 French).
advertently. g) Surrounding areas not intended for excision (i. e., contra-
f) These steps can be repeated until all the intended RRP lateral, vocal fold, anterior commissure, false vocal fold,
has been carefully removed. It is most expedient to have etc.) should be retracted or covered with saline-soaked
two microforceps available of similar size and nature to pledgets to protect inadvertent injury or damage.
perform this type of surgical removal. This allows the sur- h) Laser ablation should be done in a controlled fashion
geon to hand the RRP-laden instrument to the surgical and great care is required to insure that repeated “doses
assistant and receive the second instrument to continue of laser energy” are not delivered to the same exact loca-
the RRP removal while the assistant removes the RRP tion consecutively. This can be achieved by moving the
Fig. 21.4 Cup forceps removal of RRP Fig. 21.5 Microdebrider removal of RRP. Note blunt probe adjacent to
disease, which is used to “pin” the vocal fold so that deeper structures
are not drawn into the microdebrider
laser beam in a smooth, controlled, and expedient fash-

ion, thus preventing the same location from receiving
repeated laser energy, which may result in deep tissue
injury.
5. Microdebrider removal of RRP
a) Placement of the largest laryngoscope to expose the area
of RRP removal
b) Submucosal injection of epinephrine
c) Epinephrine-soaked pledgets placed on the area of the
RRP intended for excision and then removed
d) The smallest and most conservative microdebrider blade
should be placed on the microdebrider handle, especial-
ly at the start of the case. This is especially true for the
subglottis, glottis, and posterior glottis.
e) The microdebrider starting setting should be 800–1200
and then can be adjusted accordingly.
f) The safest method for RRP removal is to hold the micro-
debrider “blade or port” 1–2 mm over the RRP disease
and allow the suction from the instrument to draw the
RRP tissue away from the deeper aspects of the laryn-
geal tissue and be removed by the internal blades of the
microdebrider. It is often helpful to “pin” the vocal fold
in a stationary position with an adjacent blunt probe to
prevent the deeper tissues (e. g., ligament) from being Fig. 21.6 Removal of RRP at the anterior commissure. (Note that the
suctioned into the microdebrider chamber (Fig. 21.5). blue shaded region should be preserved to prevent anterior glottic web-
g) As the settings are adjusted and comfort level of the sur- bing)
geon is increased, the microdebrider can be placed clos-
er to the RRP tissue, always attempting to apply minimal
pressure to the RRP tissue with the microdebrider hand
piece. Controlled removal of the RRP can be done in a papilloma disease from all other areas in the supraglot-
fairly expedient fashion due to the rapid RRP removal tis can be done in an expedient and safe fashion using a
afforded by the microdebrider. microdebrider (preferred technique). Cold-steel surgical
h) Apply epinephrine-soaked pledget to the surgical site to excision of papilloma of supraglottic or CO2 laser area
obtain hemostasis after removal of the RRP. also all reasonable options for this region. Care should
i) To “capture” the RRP tissue for pathologic examination, be taken to avoid demucosalization of the anterior aspect
a suction trap can be placed “inline” with the microde- of the free edge of each false vocal fold to prevent supra-
brider suction and at the end of the procedure sent for glottic stenosis.
pathologic examination. b) Glottis
6. Recurrent respiratory papilloma sites: technical aspects and The region of the glottis incorporates the superior sur-
methods for surgical removal: telescopic RRP surgery face of the vocal fold, the free edge of the vocal fold, and
Standard microlaryngoscopy visualization can be limited the infraglottic region. It also encompasses the anterior
21 in several locations (ventricle, subglottis) Angled telescopes commissure. This area is of prime importance given the
can be used for telescopic removal of the RRP utilizing a phonatory dependent nature of these tissues and because
30 or 70° telescope and angled cup forceps and/or a micro of the known predilection of RRP to occur in this zone.
debrider. Angled telescopic examination of this area is ab- The preferred surgical removal of RRP in this region is a
solutely essential at the end of each surgical procedure for cold-steel approach (microflap, microforceps or micro-
RRP to ensure thorough removal of gross disease in this debrider usually after submucosal infusion). It must be
region. stressed and remembered that RRP is a superficial dis-
a) Supraglottis ease, and thus only epithelium needs to be removed. If
The anatomic components of the supraglottis include la- RRP is extensively located on the superior surface of the
ryngeal ventricles, false vocal fold, anterior face of the vocal fold, then the complete visualization and subse-
arytenoid cartilage, supraglottic portion of the arytenoid quent removal can be further facilitated with submuco-
cartilages and the laryngeal surface of the epiglottis. The sal infusion to medialize the disease for better visualiza-
laryngeal ventricles are clearly the most difficult ana- tion.
tomic area to visualize and operate on within the larynx. Specifically in the anterior commissure, the importance
Thirty and 70° telescopes are important adjuncts for vi- of precise and conservative surgical removal of disease
sualization of this area and sometimes may need to be in a unilateral nature to prevent glottic web formation is
used for surgical removal of a papilloma in this area (see paramount. Telescopic examination is of further value for
above telescopic RRP surgery). Surgical removal of gross complete assessment of the disease at the anterior com-
Chapter 21 133
missure and in the infraglottic regions. When working at The surgical technique associated with cidofovir injection
the anterior commissure, in addition to not violating the involves a two key principles. First, it is important to re-
contralateral mucosal or RRP covered tissue, careful remember that the etiologic viral agent of RRP, human papil-
traction of the vocal fold for full exposure of the anterior loma virus, is known to be present throughout the mucosa
commissure is essential (see Fig. 21.6). This can be done of the entire upper airway. For this reason, it is prudent to
with a contralateral hand instrument or a self-retaining inject cidofovir in normal appearing mucosa in a wide re-
retraction instrument. When surgically removing RRP gion around and inside the larynx. Secondly, cidofovir can
from only one side of the anterior commissure, it is wise be injected submucosally prior to a surgical excision as well
to make an initial “incision” or “cut” through the RRP as immediately after the surgical excision. This is strictly up
at the anatomic midline. Then unilateral RRP removal to the surgeon’s preference and based on the total dose of
can proceed with little chance of accidental bilateral RRP cidofovir to be used and the specific nature and location of
removal. the RRP. Cidofovir injection can be done with a fine-gauge
c) Level of the subglottis needle (25–27 g) and should be done in a superficial (sub-
RRP disease in the subglottis is of great concern due to epithelial) fashion. Cidofovir injection is done in this loca-
the airway limitations and minimal dimensions of this tion, given that past research has identified the human pap-
region. Optimal surgical technique and removal of dis- illoma virus in the epithelium of the upper airway.
ease in this area involves either cold steel excision or mi- Cidofovir intralaryngeal injection after surgical excision can
crodebrider. If visualization is particularly difficult, a CO2 be done in anatomic subunits to insure wide mucosal dis-
laser can have an advantage given that hand instruments tribution of the antiviral agent. Cidofovir injection should
can be used for retraction while the CO2 laser is used for be done in a caudal to cephalad direction. The typical se-
excision or ablation of the RRP. It must be stressed that quence of intralaryngeal cidofovir injection will cover the
the CO2 laser must be used in a conservative fashion, in- following areas in this order: subglottis, posterior commis-
cluding protection of surrounding laryngeal tissues and sure (bilateral), free edge of vocal fold (bilateral), superior
using the laser in a low-power and intermittent delivery surface of vocal fold and ventricle (bilateral), false vocal fold
mode. (bilateral), and supraglottic larynx on an as-needed basis.
d) Posterior commissure When there is mucosa present in the area to be injected, the
The posterior commissure is the region of the larynx injection needle should be placed in the subepithelial plane.
extending from the arytenoid region down into the Often cidofovir can be infused submucosally in a large area
subglottis. Careful examination of this region is manda- of the laryngeal subunits described above with a single in-
tory during all operative procedures relating to RRP and jection.
typically will require anterior displacement of the endo- Cidofovir injection into areas without mucosa, due to recent
tracheal tube for complete and detailed examination of RRP removal, should be done in the most superficial plane
this region (if an endotracheal tube is being used). To possible. In these settings, multiple superficial injections
facilitate further exposure in this region, often instru- are required since the tissue planes are absent or distorted,
mentation is required to retract the arytenoid cartilages negating the ability to distribute cidofovir over a large area
to examine fully this region. Telescopic examination (30 with a single injection.
and 70° telescopes) is helpful to visualize this area and
determine the nature and extent of the RRP disease.
Surgical removal in this area should be in a conserva-
tive fashion given that excessive surgical removal by any
and Complications
technique can lead to significant posterior glottic steno-
sis. Microforceps or microdebrider are good methods for
unilateral, staged excision of RRP to prevent posterior Postoperative care includes:
glottic stenosis.
■ Intravenous and oral steroids can be used as clinically
7. Cidofovir laryngeal injection for RPP
indicated
Cidofovir is an antiviral agent that has been used exten-
■ LPR treatment if necessary (proton pump inhibitor and
sively recently as an adjunct treatment for RPP. This anti-
behavior modification)
viral agent has been used as sole therapy without removal
■ Pain medicine on an as-needed basis
of disease and has been used at the same time as recurrent
■ Limited or no voice rest as indicated
respiratory papillomatosis is surgically removed. Presently,
the most common method of cidofovir use is laryngeal in-
jection of cidofovir after conservative surgical removal of Complications include:
the RRP. The best RRP disease control occurs with repeated
■ Laser fire and thermal injury to larynx
cidofovir injection at the same time that staged surgical ex-
■ Glottic web (anterior/posterior)
cision is performed. Typically, patients receive intralesional
■ Excessive vocal fold scar formation or tissue destruction
cidofovir injection on a monthly basis for three or more to-
tal injections times. There is no standard dose of concentra-
tion of cidofovir for injection, however, 5 mg/ml is a reason-
able dose used by many.
1 Kashima H, Mounts P, Leventhal B et al (1993) Sites of predi-

■ RRP is a recurrent disease that requires precise and
lection in recurrent respiratory papillomatosis. Ann Otol Rhinol
conservative surgical removal.
Laryngol 102:580–583
■ RRP surgical removal often requires different
2 Lee AS, Rosen CA (2004) Efficacy of cidofovir injection for
surgical methods (microflap, microforceps, laser, or
the treatment of recurrent respiratory papillomatosis. J Voice
microdebrider).
18:551–556
■ Angled telescopes especially (30 and 70°) are help-
3 Mounts P, Sha KV, Kashima H (1982) Virtual etiology of juve-
ful in evaluating laryngeal RRP immediately prior
nile and adult onset squamous papilloma of the larynx. Proc Natl
to excision, during surgical excision, and at the
Acad Sci USA 79:5425–5429
completion of RRP removal.
4 Steinberg B, Topp W, Schneider P et al (1983) Laryngeal pap-
illoma virus infection during clinical remission. N Engl J Med
308:1261–1264
5 Zeitels SM, Sataloff RT (1999) Phonomicrosurgical resection of
glottal papillomatosis. J Voice 12:1323–1327
21
Chapter 22
Surgical Management
of Vocal Fold Vascular Lesions 22
tion.

of Vocal Fold Varicosities
In healthy vocal folds, blood vessels run parallel to the vibra-

tory margin and are somewhat tortuous. The parallel arrange-
ment helps prevent obstruction of the microcirculatory sys-
tem of the vocal fold mucosa during high-pressure shearing
movement during phonation; the tortuosity helps the vessels
maintain functional patency when the vocal fold length is al-
tered during pitch changes. Although there are numerous arte- Fig. 22.1 Vocal fold varix (see arrow)
riovenous anastomoses, there is little or no direct connection
between the microvasculature of the superficial lamina propria
of the vocal fold, and the thyroarytenoid muscle. This arrange-
ment helps optimize the mucosal cover’s flexibility during
shearing, permitting the shearing motions required for normal
mucosal wave motion without vasculature accidents. Consid-
ering the delicacy of vocal fold blood vessels and the force to
which they are subjected, it is not surprising that vascular pa-
thologies occur.
It is convenient to divide common vascular lesions into
three categories. A varix is an enlarged vein, or a large, acutely
tortuous vessel. Varices may be parallel to the vibratory mar-
gin (normal orientation) or more perpendicular to the edge of
the vocal fold (Fig. 22.1). A papillary ectasia is a blood-filled
venous enlargement that appears similar to a spheroid heman-
gioma. Papillary ectasias may occur in small clusters and ap-
pear similar to coalescent hemangiomas (Fig. 22.2). A spider
telangiectasia is a delicate network of inappropriately oriented
blood vessels (Fig 22.3). Diagnosis is generally based on visual
inspection. Examination should include high-quality, magni-
fied visualization of the vocal fold. Strobovideolaryngoscopy is
helpful not only in defining the extent of a lesion and its mo- Fig. 22.2 Vocal fold papillary ectasia
bility or fixation to underlying tissues, but also the presence
of surrounding stiffness that may have resulted from previous
traumatic hemorrhage. Most varicosities and ectasias occur on with a laryngeal telescope during office evaluation, and to ob-
the superior surface of the vocal fold, particularly near the mid serve the vocal folds using 0, 30, and 70° laryngeal telescopes
portion of the musculomembranous portion of the vocal fold, intraoperatively in order to map the vasculature accurately.
where shearing forces are greatest. However, these lesions may True hemangiomas of the vocal fold are rare, but have oc-
occur on the vibratory margin and below the vibratory margin, curred. In addition, other structures that may be mistaken for
as well. Hence, it is helpful to view the vocal fold tangentially varicosities or ectasias include:
136 Surgical Management of Vocal Fold Vascular Lesions
1. Standard phonomicrosurgery set (Chap. 10, Table 10.1).

2. Sataloff vascular knife (Medtronic-ENT, Jacksonville, Fla.),
or custom-made vascular knife, fashioned by bending a 30-
mm laryngeal injection needle
3. CO2 laser with a microspot delivery system (Chap. 13)
4. Pulsed dye laser or pulsed-KTP laser (Chap. 13)
There are three primary approaches to vascular lesions includ-

ing operative resection, operative CO2 laser coagulation or va-
porization and pulsed laser therapy. This chapter concentrates
on intraoperative resection, but all three options are addressed
Fig. 22.3 Vocal fold spider telangiectasia at least briefly below.
1. Operative resection
a) Intubation with a 5.0 laser-safe endotracheal tube
Although the laser will not be required in most cases, it is
appropriate in some patients; and it is prudent for it to be
■ Limited acute hemorrhage
available, and for appropriate airway precautions to be in
■ Posthemorrhagic vocal fold cyst
place (see Chap. 13, “Principles of Laser Microlaryngos-
■ Vocal fold fibrous mass
copy”).
■ Normal blood vessels that are dilated from causes such
b) Expose the larynx with suspension laryngoscopy.
as inflammation, premenstrual hormonal influences,
Use the largest laryngoscope that exposes the entire vo-
pregnancy, recent extensive voice use, and other factors
cal fold adequately (see Chap. 10, “Principles of Phono-
■ Hemorrhagic vocal fold polyp
microsurgery”) Anterior laryngeal pressure (stabilized
with silk tape) can be used to bring the anterior com-
missure into view, if necessary. However, this maneuver
alters vocal fold tension, slackens, and distorts the blood
vessels, and can make blood vessel resection more dif-
ficult. It is preferable to obtain anterior commissure ex-
posure through optimal laryngoscope selection.
Indications for surgery comprise: c) Careful evaluation of the vocal fold should be done with
the 30 and 70° telescope through the suspended laryngo-
■ Hemorrhage from the lesion, particularly recurrent
scope. Care should be taken to identify abnormal vascu-
hemorrhage
lar lesions at the anterior commissure, midmembranous
■ Dysphonia caused by a lesion on or near the vibratory
vocal fold region and near the vocal process. These are
margin, interfering with vibration or glottic closure
the areas in which vascular lesions are most commonly
■ Dysphonia or fatigue caused by a vascular lesion that
seen. The angled telescopes are especially useful for iden-
engorges (“pumps up”) during heavy voice use, altering
22 tifying vascular lesions arising in the infraglottic portion
the mass and vibratory characteristics of the vocal fold
of the vocal folds.
d) Vocal fold palpation should be done under high-power
Relative contraindications include: magnification looking for associated vocal fold pathol-
ogy (sulcus vocalis, scar, polyp, etc.).
■ Vascular abnormalities that occur only premenstrually
e) Incision
and are unassociated with hemorrhage
A superficial epithelial incision should be made imme-
■ It is usually possible to control these with hormonal
diately adjacent to the blood vessel. This can be made
manipulation.
with a laryngeal sickle knife, but use of the knife is rarely
■ Lesions associated with Osler–Weber–Rendu syndrome.
required. The tip of the vascular knife is a sharp point. If
■ Minimally symptomatic lesions that have not bled, in
the vascular knife is oriented parallel to the blood vessel
high sopranos (coloraturas), because of increased risks
and placed adjacent to it, then slight downward pressure
of adverse effects on performance from even minimal
with the back surface of the vascular knife tip is usually
postoperative stiffness.
sufficient to create a small incision (2–3mm) adjacent to
■ Asymptomatic lesions that pose no significant risk of
the varicosity (or other vascular lesion) (Fig. 22.4).
hemorrhage
Chapter 22 137
f) Elevate the vessel – The specimen is grasped gently with a microlaryngeal

Turn the vascular knife 90° and insert it underneath the alligator forceps, and the second end of the vessel is
vessel, hugging the vessel as closely as possible. The un- resected in a similar manner (Fig. 22.6). The lesion is
dersurface of the vascular knife is blunt and should not removed and sent for histopathologic analysis.
damage underlying tissues. The crook of the vascular g) There is usually no bleeding. If there is mild hemorrhage,
knife is a right angle, and the vessel should rest in the it can be controlled with one of the methods described
crook of the instrument. In performing this maneuver, in step f), above. More severe hemorrhage can also be
the point of the instrument is brought up through the controlled with cautery or the laser. This is not desirable
epithelium on the other side of the blood vessel, allowing near the vibratory margin, but in the lateral half of the
epithelial isolation with little or no epithelial resection vocal fold, this technique can be used safely when nec-
(Fig. 22.5). essary. CO2 lasers are not effective at controlling vessels
– With gentle downward pressure (toward the vocal larger than 0.6 mm in diameter.
fold), the vascular knife is advanced anteriorly and h) If topical anesthetic was not applied to the larynx at the
posteriorly under the vessel, isolating and elevating beginning of the case, it should be applied at the end of
it. The principle is similar to that used when placing a the case.
right angle clamp under a jugular vein to isolate and 2. Operative CO2 laser cautery/vaporization
resect it during radical neck dissection. a) Intubation and exposure are performed as described in
– Although there are no deep, penetrating vessels in above
normal anatomy, such vessels occur occasionally b) Instrumentation includes a CO2 laser with a microspot,
during resection of varicosities and ectasias. If pos- suction, forceps and Cottonoid (see Chaps. 10, “Princi-
sible, it is best to allow them to bleed until resection ples of Phonomicrosurgery” and 13, “Principles of Laser
of the vessel is completed, and then to control them Microlaryngoscopy”).
using a Cottonoid with topical epinephrine (ideally), c) All laser safety precautions should be implemented in-
further resection if the bleeding vessel is superfi- cluding wet Cottonoids or wet gauze strips over the cuff
cial, or CO2 laser cautery (1 or 2 W, 0.1 s, 30–40 mJ, of the endotracheal tube (see Chap. 13).
slightly defocused). d) In general, this author prefers not to use the laser for
– Separate the vessel. Once the vessel has been elevated lesions on the vibratory margin or on the medial half
beyond the limits of abnormality, it is resected and of the vocal fold. Thermal injury in this area can cause
preserved for histopathologic analysis. stiffness that impairs vibration and can lead to perma-
– Either the anterior or the posterior limit can be divid- nent scarring. If the laser is used in the medial half of the
ed first. Simply cutting the vessel with the scissors is musculomembranous vocal fold, then great care should
usually sufficient and bleeding from the normal ves- be taken to be certain that the laser beam is tangential
sel stops spontaneously. However, dividing the vessel to the vibratory margin. When possible, an alligator or
with a brief CO2 laser burst is equally acceptable. heart-shaped forceps should be used to gently retract the
Fig. 22.4 Incision immediately lateral to vascular lesion Fig. 22.5 Dissection underneath vascular lesion
138 Surgical Management of Vocal Fold Vascular Lesions
Fig. 22.6 Excision of isolated vascular lesion Fig. 22.7 Vascular lesion along free edge of the vocal fold; the mu-
cosa/varix is manipulated laterally with the alligator forceps by lateral
traction
vibratory margin vessel into the glottis, so that the laser sias. They are utilized in an outpatient setting through
contact point is as far as possible from the vocal ligament a flexible endoscope with a working channel or passed
(Fig. 22.7). For lesions on the superior surface, an alliga- peroral during simultaneous flexible laryngoscopy. As
tor and small Cottonoid can be used to gently retract the additional research is completed and clinical experi-
mucosal laterally, so that the laser impact on the vessel is ence is acquired, laryngologists should consider this
occurs not over the medial portion of the vocalis muscle, technology as a possible adjunct to, or replacement
but rather lateral to the midline of the superior surface for, the options detailed above.
vocal fold. Lesions that occur laterally on the vocal fold
(beyond the halfway point) can be treated effectively ei-
ther by resection or vaporization. Chilling the vocal fold
with ice, and using submucosal infusion of saline/adren-
and Complications
aline 1:10,000 solution, also help limit thermal injury.
e) There are two approaches to CO2 laser management of
varicosities and ectasias. The classic approach is cau- (See also Chap. 11, “Perioperative Care for Phonomicrosur-
tery using 1–2 W, 0.1 second exposure time, 30–40 mJ, gery”)
22 slightly defocused. This creates superficial cauterization If the lesion is on the vibratory margin, then voice rest for
of the vessel and minimizes thermal transfer to underly- up to approximately 1 week is recommended. If the surgery
ing tissues. The disadvantage of this technique is a fairly has been limited to the superior surface of the vocal fold, voice
substantial recurrence rate (the vessel is found present a rest generally is limited to 2–3 days, to be followed by gentle
few months after surgery). Other laser surgeons (includ- voice use. In some cases, voice rest is not prescribed at all (par-
ing Abitbol) use a focused beam and divide the vessel ticularly if the cut ends of the offending vessel are in the ante-
completely at several points. This may increase the risk rior and posterior thirds of the vocal folds, where the shearing
of deeper thermal injury and stiffness, but it decreases forces are much less likely to disrupt a blood clot than they are
the likelihood of recurrence. in the middle third of the vocal fold).
3. Pulsed dye laser/pulsed-KTP laser For patients placed on voice rest, a session with a speech–
The pulse dye and pulsed KTP laser are relatively new language pathologist is arranged to bring the patient off voice
instruments, currently being evaluated for safety and rest at the appropriate time. After voice rest has been complet-
efficacy in the treatment of various vocal fold lesions. ed, gentle voice use is employed for at least 3–6 weeks from
They have an affinity for vascular structures. Prelimi- the time of surgery, to permit firm healing of the blood vessels
nary experience suggests that these lasers may be an before they are subjected to the phonatory forces of loud pho-
excellent tool for management of varicosities and ecta- nation or singing.
Chapter 22 139
Postoperative care includes anti-reflux medications that ■ Only vascular lesions that have caused bleeding
were started prior to surgery and are continued after surgery.
or other symptoms should be treated surgically in
Pain medications that do not alter coagulation are prescribed.
most cases.
Drugs that do affect clotting are discontinued prior to surgery ■ Some vascular lesions respond to hormonal ma-
(the patient is provided with a list), and not resumed until at
nipulation or are asymptomatic and do not require
least 1 week after surgery, unless there is compelling medical
surgical intervention.
necessity to start medications sooner (such as Coumadin). An- ■ Resection of vascular lesions with minimal distur-
tibiotics and steroids are not used routinely.
bance of surrounding tissues provides the best
chance to avoid scarring and recurrence.
■ Dental injury ■ The CO2 laser can be used for varicosities, particu-
■ Pain, anesthesia/hypoesthesia of the tongue larly those not in the medial half of the vocal fold,
■ Dysgeusia but it adds an additional risk of thermal injury.
■ Recanalization or recurrence of the vessel (particularly Precautions must be used to minimize these risks if
after laser cauterization) CO2 laser treatment is utilized.
■ Vocal fold stiffness, scarring, and consequent dysphonia ■ Office-based treatment using pulsed dye laser/
pulsed KTP laser treatment is possible and should
be considered in appropriate clinical settings.
Postoperative pain and neurologic dysfunction usually re- ■ Postoperative dysphonia is not common, particu-
solves spontaneously. Most commonly, recovery occurs within
larly after resection with cold instruments but may
2–3 weeks, but recovery may take 3 months.
occur, and patients should be counseled accord-
All patients receive preoperative and postoperative voice
ingly.
therapy.
Vocal fold scarring is extremely rare with excision of vascu-
lar lesions. It occurs more commonly after laser treatment of
vascular lesions. Scarring may produce disruption of the mu-
cosal wave and substantial dysphonia when it occurs near the
vibratory margin. However, scarring that occurs laterally also
may impair voice function and be troublesome, especially to 1 Hirano S, Yamashita M, Kitamura M, Takagita S (2006) Photoco-
high-performance voice users. Adhesion of the mucosa to un- agulation of microvascular and hemorrhagic lesions of the vocal
derlying tissues along the superior surface prevents the normal fold with the KTP laser. Ann Otol Rhinol Laryngol 115:253–259
excursion and reflexion of the mucosal wave. Care should be 2 Hochman I, Sataloff RT, Hillman RE, Zeitels SM (1998) Ectasias
exercised to minimize operative trauma at any point along the and varices of the vocal folds: clearing the striking zone. Ann
vocal fold, using cold or laser techniques, especially in singers. Otol Rhinol Laryngol 108:10–16
3 Hsiung MW, Kang BH, Su WF, Pai L, Wang HW (2003) Clearing
microvascular lesions of the true vocal fold with the KTP/523
laser. Ann Otol Rhinol Laryngol 112:534–539
Key Points
4 Postma GN, Courey MS, Ossoff RH (1998) Microvascular lesions
of the true vocal fold. Ann Otol Rhinol Laryngol 107:472–476
5 Zeitels SM, Akst LM, Burns JA, Hillman RE, Broadhurst MS, An-
■ Vocal fold vascular lesions may occur at any loca-
derson RR (2006) Pulsed angiolytic laser treatment of ecstasies
tion on the vocal fold and are categorized as:
and varices in singers. Ann Otol Rhinol Laryngol 115:571–580
■ Varix
■ Papillary ectasia
■ Spider telangiectasia
Chapter 23
Vocal Fold Scar

and Sulcus Vocalis 23
(Fig. 23.3). Frequently, this mucosal bridge causes diplophonia
and severe dysphonia because of its separate vibratory charac-
teristics from the main vocal fold.
tion.

Vocal fold scar (Fig. 23.1) and sulcus vocalis (Fig. 23.2) are two
similar pathologic processes that involve derangement and ab-
normalities of the lamina propria resulting in dysphonia, glot-
tic insufficiency, and severe abnormality in the pliability of the
vocal fold. The primary difference between vocal fold scar and
sulcus vocalis is the type of alteration that occurs within the
lamina propria. Sulcus vocalis is characterized by an absorp-
tion or loss of the lamina propria resulting in a deep, linear
furrow along the free edge of the vocal fold. Vocal fold scar
is characterized by a deposition of abnormal tissue within the
lamina propria, typically thick, fibrous tissue.
The symptoms of patients with vocal fold scar and sulcus
vocalis include dysphonia, decreased volume, effortful phona-
tion, diplophonia, increased pitch, and a breathy, severe, harsh
voice quality. The etiology of sulcus vocalis is usually associ-
ated with an acquired condition due to excessive voice use or Fig. 23.1 Sulcus vocalis
trauma to the vocal folds. There are also reports of a congenital
deformation of the vocal fold resulting in sulcus vocalis; how-
ever, this is a much rarer condition. Vocal fold scar is an ac-
quired condition from some type of traumatic activity of the
vocal folds. This can occur from repeated vocal fold hemor-
rhage, external laryngeal trauma, intubation injury, and exces-
sive laser or cold-steel phonomicrosurgery. The most com-
mon cause of vocal fold scar, and most likely sulcus vocalis,
is phonotraumatic behavior characterized by misuse, overuse,
or inappropriate use of the voice. This typically occurs over a
prolonged period, resulting in either absorption of the lamina
propria (sulcus vocalis) or deposition of abnormal tissue with-
in the lamina propria (vocal fold scar).
A variety of associated lesions can occur with sulcus vocalis
and vocal fold scar, most notably, vocal fold cyst and fibrous
mass. These two lesions can occur in a subepithelial or liga-
mentous area (see Chap. 4, “Pathological Conditions of the Vo-
cal Fold”). Unique to sulcus vocalis is the formation of a mu-
cosal bridge. A mucosal bridge is a thin band of mucosa that
runs parallel to the vocal fold. It is connected anteriorly and
posteriorly but not attached to the free edge of the vocal fold Fig. 23.2 Vocal fold scar
142 Vocal Fold Scar and Sulcus Vocalis
Often the first surgical step is a diagnostic microlaryngoscopy.

This is important for planning purposes and to determine the
severity of the vocal fold pathology and the severity of the con-
dition as well as to remove associated lesions such as fibrous
mass, cysts, and/or mucosal bridge. One of the key aspects of
the indications for surgery and the surgical approach for the
treatment of patients with vocal fold scar/sulcus vocalis is to
ascertain the degree of glottal insufficiency associated with the
vocal fold scar and sulcus vocalis as well as the symptoms of
vocal fatigue and decreased volume. For patients with a signifi-
cant amount of glottal insufficiency and the primary symptoms
of vocal fatigue and decreased volume, a vocal fold augmen-
tation procedure or medialization procedure is often the ap-
propriate first step for patients with vocal fold scar and sulcus
vocalis (see Chaps. 31, “Vocal Fold Augmentation via Direct
Laryngoscopy”; 33, “Peroral Vocal Fold Augmentation in the
Clinic Setting”; 34, “Percutaneous Vocal Fold Augmentation
Fig. 23.3 Mucosal bridge associated with sulcus vocalis in the Clinic Setting”; 38, “Silastic Medialization Laryngoplasty
for Unilateral Vocal Fold Paralysis”; and 39, “GORE-TEX® Me-
dialization Laryngoplasty”).
After the patient’s glottal insufficiency has been addressed
Differential diagnosis of vocal fold scar and sulcus vocalis by vocal fold augmentation or medialization if needed, often
include: a direct approach to the lamina propria deficit associated with
vocal fold scar and sulcus vocalis is indicated. This can be
■ Fibrous mass
achieved with the following different approaches:
■ Polyp
1. Excision of associated lesion (Chaps. 10, “Principles of Pho-
■ Vocal fold cyst
nomicrosurgery” and 17, “Vocal Fold Cyst and Vocal Fold
■ Rheumatologic lesions of the vocal folds
Fibrous Mass”)
2. Excision of sulcus vocalis/vocal fold scar and mucosal reap-
Vocal fold atrophy due to muscle loss and a thinned lamina proximation (see below)
propria can have a similar appearance on laryngeal exam to 3. Vocal fold fat graft reconstruction (see below)
sulcus vocalis, given that in both entities the vocal fold will 4. Superficial vocal fold injection of collagen based materials
have a “bowed” appearance. The difference between vocal (Chap. 32, “Superficial Vocal Fold Augmentation via Micro-
fold atrophy and sulcus vocalis is the lamina propria stiffness laryngoscopy”)
that occurs in sulcus vocalis but is not present in vocal fold 5. Gray minithyrotomy (Chap. 48, “Gray Minithyrotomy for
atrophy. Vocal Fold Scar/Sulcus Vocalis”)
Contraindications comprise:
23.3 Surgical Indications ■ Unreasonable expectations regarding voice quality im-
and Contraindications provement (i. e., complete resumption of normal voice)
■ Persistent phonotraumatic behavior
■ Untreated LPR
The medical and surgical approaches to patients with vocal fold
■ Active rheumatologic disease (rheumatoid arthritis,
scar and sulcus vocalis are very similar. As in the approach to
Wegener’s granulomatosis, etc.)
most voice disorders, maximum nonsurgical approach should
■ Anatomic factors resulting in poor laryngoscope visual-
23 be utilized for the treatment of voice disorders for patients with
ization (relative)
sulcus vocalis and vocal fold scar. This typically includes treat-
ment of medical conditions such as LPR and allergic disease, as
well as optimizing speaking and singing techniques with voice In summary, a comprehensive approach to patients with sulcus
therapy and singing voice therapy (see Chap. 7, “Nonsurgical vocalis and vocal fold scar involves the following:
Treatment of Voice Disorders”). After maximum nonsurgi- 1. Detailed, multidisciplinary evaluation (may include diag-
cal therapeutic applications, a careful evaluation of the func- nostic microlaryngoscopy)
tional limitations associated with the patient’s voice disorder 2. Maximum nonsurgical rehabilitation
should be undertaken, especially by using a multidisciplinary 3. Proper assessment of functional voice limitations and es-
approach with a medical and a speech–language pathology tablishment of reasonable goals with surgical therapy
evaluation. Surgery is indicated if the significant functional 4. Excision of associated lesions
limitations remain after nonsurgical treatment (see Chap. 8, 5. Augmentation or medialization of the vocal folds if war-
“Timing, Planning, and Decision Making in Phonosurgery”). ranted
Chapter 23 143
6. Direct reconstruction of lamina propria using: f) Subepithelial dissection of a superiorly based flap (back
a) Superficial vocal fold injection (Chap. 32, “Superficial elevation) and subepithelial elevation of an inferiorly
Vocal Fold Augmentation via Microlaryngoscopy”) based mucosal flap in preparation for reapproximation
b) Fat graft reconstruction via microlaryngoscopy (see be- g) Suture reapproximation of cut edges of the mucosa re-
low) sulting in approximation of the mucosal cut surfaces (see
c) Gray minithyrotomy (Chap. 48, “Gray Minithyrotomy part 4., below)
for Vocal Fold Scar/Sulcus Vocalis”) 2. Vocal fold slicing technique via microlaryngoscopy (as de-
scribed by Paulo Pontes)
The objective of the vocal fold slicing technique is to reduce
the glottal gap and to increase vocal fold vibration in order
to improve phonation in cases presenting with severe sulcus
vocalis and vocal fold scar.
Surgical equipment includes the following: Contraindications
a) Lack of patient understanding of the procedure
■ Standard phonomicrosurgery set (Table 10.1)
b) Lack of acceptance of aphonia for 4 months
■ Knot pusher
c) Limitations for receiving postoperative voice therapy
■ Regular insulin (100-U bottle)
Surgical procedure: methods and techniques
■ Lactated ringers (l liter)
The main principle of this technique is to “break” the ten-
■ 5.0, 6.0, and 7.0 absorbable suture with a variety of
sion caused by the ligamental alteration in order to obtain
small microsurgical needles (often found in ophthal-
vibration and to reduce the glottal gap, which is achieved
mology operating room supplies)
by the resultant displacement of a more flexible and bulky
■ Microlaryngoscopy needle holder
tissue from the free edge of the vocal fold.
a) General anesthesia and orotracheal intubation
b) Endolaryngeal exposure with suspension microlaryn-
goscopy
c) Incision on the superior surface of the vocal fold (ante-
rior–posterior), parallel to the free edge of the vocal fold
1. Excision with reapproximation via microlaryngoscopy The cordotomy should be made 3–4 mm lateral to the
The goal of this procedure is to remove invaginated epithelial free edge of the vocal fold (Fig. 23.4).
tissue associated with sulcus vocalis and reapproximate ad-
jacent normal mucosa with sutures. This approach can also
be used with vocal fold scar, using a microflap approach,
excising abnormal vocal fold scar in the subepithelial plane
and then reapproximating adjacent normal mucosa with
microsutures. A concern regarding this approach should
be the eventual “rounding” of the vocal fold morphology,
especially along the free edge of the vocal fold. Thus, this
approach is indicated when there is only small epithelial de-
fects or when there has been no mucosal excision required
as part of the approach. The advantage to this approach is
that it will result in a straight, smooth vocal fold edge, which
is often a preparatory step for later reconstruction using fat
graft reconstruction or Gray’s minithyrotomy or superficial
vocal fold injection with collagen based material.
a) Complete exposure of vocal folds with a large laryngo-
scope (see Chap. 10)
b) Endoscopic visualization with angled endoscopes and
vocal fold palpation with high-powered microlaryngos-
copy assessing the severity and nature of the vocal fold
pathology
c) Subepithelial infusion of 1:10,000 epinephrine in at-
tempt to hydrodissect and clearly delineate the area of
the sulcus vocalis/vocal fold scar
d) Mucosal cordotomy at the junction of normal vocal fold
epithelium and the sulcus vocalis deformity at both the
upper and lower aspect of the deformity
e) Submucosal excision of the sulcus vocalis Fig. 23.4 Sulcus vocalis with proposed incision lines (dashed) for the
slicing technique of Pontes
Fig. 23.5 Raising deep flap with flap elevator Fig. 23.6 Slicing of deep flap
d) Deep dissection to create a mucosal flap

The vocal ligament is included inside this flap and, if it
remains thin, a portion of the muscle may be also in-
cluded to preserve arterial supply (Fig. 23.5).
e) The dissection should extend inferiorly to approximately
3 mm beneath the inferior border of the sulcus.
f) Place small incisions, caudally oriented, in the superior
margin of the flap to create three or four smaller flaps
(inferiorly based) (Fig. 23.6). Gradually deepen the inci-
sions to avoid retraction of the initial flap (Fig. 23.7).
g) The central microflaps should be of different lengths and
should pass over the ligament in the inferior lip. Differ-
ent lengths are useful to maintain ligament fragments
in different heights, which must be intraoperatively ob-
23 served as soon as the microflaps retract themselves.
h) The technique should be done bilaterally when there is bi-
lateral disease not dependent on the sulcus asymmetry.
i) Care is taken to preserve intact mucosa on both sides
around the anterior commissure.
j) Glue or sutures are not useful or needed.
Postoperative care
a) Prophylactic oral antibiotics
b) Voice rest for 3 days
c) Vocal exercise, speech therapy
i. Vocal exercises should begin around the seventh
postoperative day, initially with vibration exercises to
Fig. 23.7 Asymmetric superior-inferior incisions through the vocal make tissues flexible and to help remove fibrin, thus
fold microflap avoiding adherences.
Chapter 23 145
Fig. 23.8 Placement for incision and area of proposed elevation of Fig. 23.9 Elevation of pocket in preparation for fat graft implantation
overlying microflap for vocal fold fat graft reconstruction
ii. Voice quality will remain poor for 3–4 months. c) Vocal fold palpation to assess vocal fold scar and sulcus
When healing has completed (~4 months), the vocal vocalis pathology and severity (during the palpation and
fold surfaces appear more regular compared to the angled visualization steps, potential surgical incisions on
preoperative pattern. The vocal folds exhibit greater the vocal folds should be considered)
flexibility and vibration in spite of the reduction or d) An incision is then made with a microknife (sickle)
absence of the mucosal wave. The glottic gap disap- through the mucosa immediately lateral to the area of
pears or is dramatically reduced. the vocal fold scar/sulcus vocalis. The placement of the
Complications incision should be carefully done to allow enough mu-
a) Thin adherences can occur and should be cut in 2–3 cosa medial and lateral to the incision for microsuture
weeks. placement. It is wise to make this incision longer in the
b) Granulomas can occur but can be left intact because anterior–posterior dimension than typically required to
spontaneous remission typically occurs, avoiding the have complete exposure of the area of vocal fold scar/sul-
creation of depressions. They should only be resected if cus vocalis (Fig. 23.8).
too large and/or fibrotic. e) Carefully elevate the mucosa off the ligament and under-
3. Vocal fold fat graft reconstruction via microlaryngoscopy lying vocal fold scar. This should be done in a slow, careful
This procedure is aimed at developing a pocket in the patho- fashion, making great effort to avoid fenestration of the
logic lamina propria with or without excision of the associ- overlying mucosa. This will significantly hamper the success
ated vocal fold scar and laying small grafts of autologous fat or ability to perform fat graft reconstruction (Fig. 23.9).
into the pocket for “reconstruction” of the lamina propria f) Remove any associated lesion or scar once the microflap
and improved lamina propria function postoperatively. This elevation is performed.
entire procedure is done via microlaryngoscopy with simul- g) Verify that there is a wide pocket in the area of the vocal
taneous fat graft harvest. The fat graft harvest technique is fold scar/sulcus vocalis, in both the anterior–posterior
discussed separately (see below). dimension as well as the superior–inferior dimension.
a) Place largest possible laryngoscope for allowing full vi- h) Place suture through the cut mucosal edges both medial
sualization of the vocal fold. (Note: This procedure is dif- and lateral but not tying or throwing any knots with this
ficult to perform via a small laryngoscope because of the suture now (Fig. 23.10). Each free end of the suture can
complexity of the dissection and the need for placement be secured outside the laryngoscope with a small bull-
of sutures within the vocal fold.) dog clamp (see below section on placement of sutures in
b) Angled visualization of the vocal fold pathology via vocal fold.)
telescopes (see Chap. 10, “Principles of Phonomicro i) Directly implant fat grafts into the pocket. The pocket
surgery”) should be filled with the maximum amount of fat graft
Fig. 23.10 Pocket in area of vocal fold scar elevated and sutures placed Fig. 23.11 Placement of fat grafts into pocket of previously elevated
through mucosal edges vocal fold scar
possible, allowing complete or close approximation of 4. Placement of sutures in the vocal fold
the mucosal edges at the incision location (fat harvest Placement of sutures in the vocal fold is intended to assist
techniques as described below) (Fig. 23.11). the reapproximation of mucosal flaps in the vocal fold. This
j) Tie three knots of the previously thrown suture through is most commonly used for fat graft reconstruction but can
the mucosal cut edges (see below) (Fig. 23.12). also be used for a variety of microflaps associated with glot-
k) Palpate free edge of vocal fold to ensure the fat graft im- tic web surgery. Placement of sutures should be carefully
plants are stable in the pocket and do not easily come planned to allow adequate mucosal closure of the vocal fold
out of the mucosal incision with a moderate amount of without distortion of the shape of the vocal fold. If too “ag-
pressure along the free edge of the vocal fold. gressive” placement of a suture on either side of the mucosal
23
Fig. 23.12 Postoperative result after fat graft reconstruction Fig. 23.13 Placement of needle through mucosa during suturing of
the vocal fold mucosa
Chapter 23 147
incision is done, a “pinching” of the vocal fold will occur to maintain a “relaxed” tension on the suture arms, thus
at the suture site and this will be counter productive to the allowing the knot to be slipped down into position at the
surgical procedure at hand. vocal fold (Fig. 23.14b).
The direction of passing from right to left or left to right g) Once the knot is close to the vocal fold, the free ends of
depends on which vocal fold is being sutured and the hand- the suture are released by the surgeon and the assistant.
edness of the surgeon. In general, it is difficult to backhand h) The two strands of the suture coming off the knot near
the suture via a microlaryngoscopy approach and thus, a the knot are then grasped with a straight and/or curved
right-handed surgeon will typically pass the suture through alligator under visualization with high-powered micro-
the cut edges of the mucosa right to left (vice versa for a left- laryngoscopy.
handed surgeon). The needle should be placed within 1–1.5 i) The knot is then slowly tightened with the alligators,
mm of each mucosal edge. with great care taken to not overtighten the knot. If the
a) Typically, the microsuture is placed through each mu- knot is too tight, then the vocal fold morphology will be
cosal edge in a separate pass of the needle and thus, the significantly distorted and will then result in a poor vocal
surgeon should plan not to pass the needle through both outcome (Fig. 23.14c).
cut edges in one movement of the needle. This allows j) The knot should be tightened enough to allow close ap-
for more control of the placement of the needle through proximation of the mucosal edges, but not strangulation
the mucosal edge, which is essential. Furthermore, the of the associated tissue and deformation of the mor-
mucosal free edge does usually not need to be held with phology of the vocal fold. An approximately 1-mm gap
another instrument while the needle is placed, given that should be preserved between the mucosal surface of the
with the proper angle preparation of the microsurgi- vocal fold and the tied knot (Fig. 23.12).
cal needle, it will pass quite easily through the mucosal k) Scissors can be used to cut the ends of the suture, ap-
flap. The needle is typically held and passed through the proximately 2–3 mm away from the knot, after two more
mucosal flap using a microlaryngoscopy needle holder. additional knots have been thrown in the exact same
Another option is using a straight alligator, however, fashion.
the microlaryngoscopy suture holder has somewhat Alternate method of suture placement/knot tying
broader jaws, which will hold the needle in a more stable a) Both ends of the suture are grasped with mosquito he-
fashion and allow better control of the needle as it pass- mostats, and an additional hemostat is placed between
es through the mucosal flap. After the first part of the sutures distal, close to the opening of the laryngoscope
needle has penetrated and passed completely through (Fig. 23.15a).
the mucosal surface, the suture holder is released and b) The left (white suture in Fig. 23.15a) suture is looped
either the suture holder or a curved alligator is used to around the right suture a total of three times clockwise.
complete the passing of the needle through the mucosal The free end of the left (white) suture is advanced toward
edge. As the needle is drawn through the mucosal edge, the initial (distal) crossing of the two strands of suture
the curve of the needle should be continued in a care- (Fig. 23.15b).
ful and gentle fashion to avoid applying undue stress or c) The free ends of the left (white) suture are used to create
trauma to the vocal fold, which may tear the mucosal a slipknot around the open loop adjacent to the distal
flap (Fig. 23.13). stationary hemostat. Microlaryngeal alligator forceps are
b) After the needle is passed through each side of the free used to grasp the left (white) suture at its final “cross-
edge of the mucosa, both ends of the suture are brought ing”; this step prevents the knot from forming prema-
out through the proximal portion of the laryngoscope. turely and subsequently breaking. The end of the suture
c) A moderate amount of tension should be placed on the is marked with a pen for easier identification under the
suture during high-powered microlaryngoscopy visual- microscope during knot tying (Fig. 23.15c).
ization to ensure that the suture has been placed through d) The loose knot assembly is advanced down the laryn-
the free edges of the mucosa in the appropriate fashion. If goscope by pushing distally with microalligator forceps
the surgeon is dissatisfied with the suture location, then while pulling back on the other (black) suture. When the
the suture should be removed and the process repeated. level of the vocal folds is reached, the knot assembly is
d) Using the two ends of the suture outside the laryngo- released, taking care not to allow the loose knot assembly
scope, a simple knot can be tied using a straight alligator to untie (Fig. 23.15d).
and a free hand (Fig. 23.14a). e) The microscope is then brought into the field and the
e) After a single knot has been tied, one end of the suture free end of the left (white) suture is grasped with micro-
is held with the surgeon’s nondominant hand outside the alligator forceps and advanced distally, while providing
laryngoscope, and the other end can be loosely held by counter-tension with the opposite (black) suture. A se-
an assistant. cure knot will form at the level of the vocal folds, as de-
f) The knot pusher is then placed around the knot outside picted (Fig. 23.15e).
of the laryngoscope and slowly used to pass the knot 5. Fat graft harvest and preparation
down the laryngoscope towards the vocal fold. As the A small amount of fat of various sizes is required for fat
knot pusher moves the knot down the laryngoscope, graft vocal fold reconstruction. The harvest locations can be
the assistant and the surgeon’s other hand can be used the ear lobe, axilla, umbilicus, or prior scar location. The fat
23.14 a Tying of suture outside proximal end of the laryngoscope. b Knot pusher passing knot down the laryngoscope. c Final position and
tension applied to the knot with bimanual control of the two suture ends
23
is typically taken from subcutaneous area. The axilla is the d) Harvest fat with scissors, taking care not to include any as-
author’s preferred site, making a small incision at the ante- sociated dermis, hair follicles, or to use electric cautery
rior axillary line, because this area is easily accessible during e) Cut fat into small pieces approximately 1 × 1 × 1 mm.
microlaryngoscopy and the incision is hidden in the axilla. f) Rinse the harvested fat with approximately 1 liter of sa-
a) Inject local anesthesia at the proposed harvest site. line.
b) Prepare the skin with antiseptic. g) Soak the fat in regular insulin for 5 min (see Chap. 31,
c) A small skin incision is used to expose the subcutaneous “Vocal Fold Augmentation via Direct Laryngoscopy”)
fat (approximately 5 mm).
Chapter 23 149
Fig. 23.15a–e Initial configuration of alternate knot tying method. b Counterclockwise looping of suture. c Addition loop is passed proxi-
mally, while the end of the suture is marked. d The knot assembly is advanced down the laryngoscope. e Final tying of knot under the micro
scope
23.6 Postoperative Care Selected Bibliography

and Complications
1 Fleming DJ, McGuff S, Simpson CB (2001) Comparison of mi-
To avoid possible complications postoperatively: croflap healing outcomes with traditional and microsuturing
techniques: initial results in a canine model. Ann Otol Rhinol
■ Strict voice rest for 6–7 days and subsequently gradu-
ated voice use
2 Ford CN, Inagi K, Khidr A, Bless DM, Gilchrist KW (1996) Sul-
■ Perioperative antibiotic use is appropriate
cus vocalis: a rational analytical approach to diagnosis and man-
■ There is no indication for prolonged use of periopera-
agement. Ann Otol Rhinol Laryngol 105:189–200
tive steroids
3 Neuenschwander MC, Sataloff RT, Abaza MM, Hawkshaw
■ Continue LPR treatment, which is optimally started
MJ, Reiter D, Spiegel JR (2001) Management of vocal fold scar
perioperatively and continued postoperatively for a
with autologous fat implantation: perceptual results. J Voice
short period
15:295–304
4 Pinho SR, Pontes P (2002) Escala de avaliação perceptive da fonte
Complications associated with vocal fold fat graft reconstruc- glótica: RASAT. Vox Brasilis 8:11–13
tion microlaryngoscopy include (see Chap. 12, “Management 5 Pontes P, Behlau M (1993) Treatment of sulcus vocalis: auditory
and Prevention of Complications Related to Phonomicrosur- perceptual and acoustical analysis of the slicing mucosa surgical
gery”): technique. J Voice 7:365–376
6 Pontes PAL, Behlau M (1993) Treatment of sulcus vocalis: au-
■ Fat extrusion at the mucosal cut edge
ditory perceptual and acoustical analysis of the slicing mucosa
■ Fat reabsorption
surgical technique. J Voice 7:365–376
■ Further vocal fold scar at the operative site. This is a
7 Rosen CA (2000) Vocal fold scar: evaluation and treatment. Oto-
theoretical complication and has not been seen.
laryngol Clin N Am 33:1081–1086
8 Sataloff RT, Spiegel JR, Hawkshaw M, Rosen DC, Heuer RJ (1997)
Autologous fat implantation for vocal fold scar: a preliminary re-
Key Points
port. J Voice 11:238–246
9 Woo P, Casper J, Griffin B, Colton R, Brewer D (1995) Endoscop-
ic microsuture repair of vocal fold defects. J Voice 9:332–339
■ Surgery for vocal fold scar and sulcus vocalis can
be very rewarding to the severely impaired voice
patient. Reasonable expectations and willingness
to have several surgeries are required in most
cases.
■ Maximum nonsurgical therapy should be done
prior to proceeding with surgery for vocal fold
scar/sulcus vocalis.
■ Patients with vocal fold scar and sulcus vocalis
with significant glottic insufficiency related symp-
toms (vocal fatigue, decrease volume, etc.) should
strongly consider having vocal fold augmentation
or medialization as the first step of treatment and
potentially the only treatment needed.
■ Direct rehabilitation of the injured lamina propria
can be done via superficial vocal fold injection,
excision of the vocal fold scar/sulcus vocalis and
23 reapproximation, fat graft vocal fold reconstruc-
tion or a Gray’s minithyrotomy.
Chapter 24
Endoscopic Management
of Teflon Granuloma 24
Contraindications are:
■ Attempted complete removal of granuloma—this is not
possible endoscopically with these lesions
Please see Chaps. 8, 10, 13, and 42 for further information.
■ Severe medical comorbidities that preclude surgery

In every Teflon injection, an inflammatory response to the Tef-
lon occurs. In most cases, the inflammatory response remains Equipment comprises standard laser microlaryngoscopy set
localized, and no significant clinical complications are noted. (Chap. 13, “Principles of Laser Microlaryngoscopy”).
However, there is a risk of clinically evident expansile granu-
loma formation in these patients. Often this occurs years after
the initial injection, after a prolonged period of good voice.
Anecdotal evidence suggests that subsequent laryngeal trauma
(i. e., intubation) may contribute to growth of the granuloma.
Teflon granuloma is typically a submucosal smooth mass The procedure is performed as follows:
that presents as a bulge in the false vocal cord, ventricular mu- 1. Intubate patient with laser-protected tube. Protect patient,
cosa and/or the true vocal fold (Fig. 24.1). The granuloma may ETT, and OR personnel, (see Chap. 13., “Principles of Laser
grow inferiorly resulting in a subglottic bulge as well. Video- Microlaryngoscopy”).
stroboscopy is quite consistent in these patients, revealing a 2. Palpate involved vocal fold, and examine with angled tele-
stiff, nonvibratory vocal fold mass. This is due to either mass ef- scopes to define the extent of the granuloma in a vertical
fect (stretching of vocal fold mucosa with dampening of wave) plane.
or, more commonly, the infiltration of the granuloma into the
lamina propria and/or mucosa. Glottic incompetence is com-
monly present, secondary to the mass lesion. Occasionally, the
patient’s airway is compromised, especially if the granuloma is
subglottic.
It is helpful to obtain a CT scan of the neck with contrast to
assess the location of the Teflon and the extent of granuloma
formation. In this way, superficial Teflon granulomas can be
distinguished from granulomas that are more extensive. Typi-
cal CT appearance is a brightly enhancing, fairly well-circum-
scribed mass in the paraglottic space.

Indications include:
■ Dysphonia due to expanding Teflon granuloma, espe-
cially if the granuloma appears to extend to the medial
edge of the vocal fold
■ Airway compromise due to expanding granuloma
Fig. 24.1 Photo of Teflon granuloma on the left vocal fold. Note con-
■ Desire for subtotal removal of granuloma
vex bulge due to expansile granuloma
152 Endoscopic Management of Teflon Granuloma
Fig. 24.2 Planned incision for Teflon granuloma removal Fig. 24.3 Laser ablation of Teflon mass
Fig. 24.4 Coronal diagram of Teflon granuloma Fig. 24.5 Diagram depicting the area of proposed removal of the
granuloma (pink) at the medial edge of the vocal fold, from superior
to inferior. Note the lateral extension of the excision infraglottically
24
3. The CO2 laser with the micromanipulator should be placed 5. The laser can be used to ablate the Teflon mass in the para-
on a setting between 4 and 8 W superpulse or intermittent glottic space (Fig. 24.3). The most medial portion of the
with an on time of 0.1 s/off time of 0.5 s. granuloma should be first obliterated in an even fashion
4. Outline the incision (using spaced laser marks) at the lateral from superior to inferior.
aspect of the superior surface of the true vocal fold (Fig. 6. The mucosa/lamina propria portion of the vocal fold that
24.2). Dissection with the CO2 laser and/or microlaryngeal is retracted for preservation and exposure purposes can be
instrumentation is performed until the Teflon is encoun- intermittently redraped to assess the morphology of the in-
tered—recognized by its characteristic “sparkle” when va- fraglottic and true vocal fold.
porized by the laser.
Chapter 24 153
Fig. 24.8 Postoperative photograph after typical endoscopic Teflon

granuloma removal. Note reduction of convex bulge compared to pre-
Fig. 24.6 Immediately after CO2 laser ablation, showing infraglottic operative (Fig. 24.1) and intact tissue at free edge of vocal fold
contour

and Complications
■ The most feared complication is a laser fire. Laser

precautions must be followed, especially the use of a
laser-protected tube and oxygen concentrations of 35%
or less.
■ Voice rest should be between 3 and 7 days, depending
on the clinical situation.
■ PPIs and pain medicine. Antibiotics are optional.
■ There is a small risk of igniting the granuloma with the
CO2 laser, but this is minimized to a negligible level us-
ing lower-power setting.
■ Because the Teflon is often exposed with this approach,
there can granulation tissue formation post operatively.
This is managed conservatively with PPIs and observa-
tion. It should resolve over several weeks. Preserving
intact mucosa on the free edge and infraglottic surface
of the vocal fold will minimize this complication.
Fig. 24.7 Postoperative result

Key Points
■ Teflon granuloma typically present many years

7. An adequate amount of Teflon should be removed to create
after injection, with slowly worsening dysphonia
an anatomically correct infraglottic anatomy (inverted cone)
that may progress to airway difficulties.
and a straight free edge of the vocal fold (Fig. 24.5, 24.6). ■ Although complete removal of Teflon granuloma
8. Completion of the procedure is achieved when the vocal
is frequently not possible using an endoscopic
fold soft tissue is redraped over the residual Teflon mass
approach, symptomatic improvement can be
operative site. Sutures can be place at the cordotomy site as
achieved.
needed; however, this is usually not necessary. ■ The goal of endoscopic treatment for Teflon granu-
9. Completed excision, showing relatively symmetric appear-
loma of the larynx is to recontour a straight edge
ance of the operated an uninvolved vocal fold (Figs. 24.7,
to the involved vocal fold.
Fig. 24.8).
154 Endoscopic Management of Teflon Granuloma
1 Dedo HH (1992) Injection and removal of Teflon for unilateral 3 Ossoff RH, Koriwchak MJ, Netterville JL et al (1993) Difficul-
vocal cord paralysis. Ann Otol Rhinol Laryngol 101:81–86 ties in endoscopic removal of teflon granulomas of the vocal fold.
2 Nakayama M, Ford CN, Bless DM (1993) Teflon vocal fold aug- Ann Otol Rhinol Laryngol 102:405–412
mentation: failures and management in 28 cases. Otolaryngol
24
Chapter 25
Endoscopic Excision of Saccular Cyst

25
increased incidence of dilated saccules in patients with squa-
mous cell carcinoma of the larynx.
Fine cut (1–1.5 mm) CT scan of the larynx with contrast
Please see Chaps. 10, 11, 12, 13, and 43 for further informa- is recommended to confirm the diagnosis, and to define the
tion. extent of the cyst (Fig. 25.3).

The normal saccule arises as a diverticulum originating at the

anterior portion of the ventricle, and extending upward into
the supraglottis. It is sandwiched between the false vocal fold
medially and the aryepiglotticus muscle and thyroid cartilage
laterally. The saccule contains numerous mucus-secreting
glands, and acts as a reservoir, expressing secretions onto the
vocal folds due to the squeezing action of the surrounding su-
praglottic musculature.
A saccular cyst is a mucous-filled dilation of the laryngeal
saccule, and can be categorized as congenital or acquired. Two
anatomic types of saccular cysts exist: anterior and lateral. An-
terior saccular cysts tend to be smaller in size, and project into
the laryngeal lumen in the anterior ventricular region. Lateral
saccular cysts are typically larger and present as a bulge in false Fig. 25.2 Saccular cyst, lateral
vocal fold and/or aryepiglottic fold. (Figs. 25.1, 25.2) In rare
cases, the cyst can extend into the neck through the thyrohyoid
membrane, although this is more typical of a laryngopyocele.
Although most saccular cysts are benign in nature, there is an
Fig. 25.1 Saccular cyst, anterior Fig. 25.3 CT scan of bilateral saccular cysts
156 Endoscopic Excision of Saccular Cyst
25.3 Surgical Indications 25.5 Surgical Procedure for Saccular Cyst

The following procedure is adapted from Hogikyan et al.:
Indications for excisional intervention include: 1. Intubation with 5 or 5.5 laser-protected ETT
1. Hoarseness 2. Expose supraglottis on involved side widely (Lindholm or
2. Airway compromise bivalve laryngoscope often needed) (Fig. 25.4) and place
3. Concern of malignancy (especially in patient with smoking in suspension. The distal tip of the Lindholm laryngoscope
history) rests in the vallecula to achieve wide supraglottic exposure.
3. Observe standard laser precautions (see Chap. 13, “Prin-
In nonsmoking asymptomatic patients, and medically infirm ciples of Laser Microlaryngoscopy”)
patients for whom elective surgery is contraindicated, observa- a) Moist eye pads, and towels covering patient fully
tion is acceptable. Periodic reexamination of the larynx with b) Moist Cottonoid placed above ETT balloon
photodocumentation and/or CT scanning may be warranted c) O2 concentration 35% or less
to monitor for any changes of the cyst. d) Protective eyewear for OR personnel
Relative contraindications include: 4. A curvilinear laser mucosal incision is made over the lateral
aspect of the false vocal fold. A lateral relaxing incision may
■ Pediatric cases (external approach favored)
be required into the aryepiglottic fold in some cases, if lat-
■ Extension of the cystic mass into the neck (external ap-
eral extension is extensive (Fig. 25.5).
proach recommended)
5. The lateral extension of the cyst is dissected, retracting
the mucosa medially, and using blunt dissection with a 5-
French suction (a 30° dull flap elevator can be used, but is
likely to cause perforation of the cyst, which may complicate
the resection) (Fig. 25.6). This lateral dissection can extend
to the thyroid ala, and branches of the superior laryngeal
Equipment needed includes: vasculature may cause troublesome bleeding. Suction and
bipolar laryngeal cautery are often useful, as the laser may
■ Standard laser microlaryngoscopy set (Chap. 13)
be ineffective in stopping bleeding from larger vessels such
■ Laryngeal bipolar device (Instrumentarium, Montreal,
as these.
Quebec, Canada)
6. The dissection is continued around the inferior aspect of the
■ Lindholm or bivalue type laryngoscope
cyst, using blunt dissection with 5-French suction, and scis-
■ CO2 laser
sors as needed (Fig. 25.7).
25
Fig. 25.4 Lindholm laryngoscope (Karl Storz, Tuttlingen, Germany) Fig. 25.5 Incision locations
Chapter 25 157
7. Taking care to protect the underlying true vocal fold using 8. Excision of anterior saccular cysts utilizes the same ap-
platform suction, the anterior and posterior cuts are made proach and techniques as described above. These lesions are
with the laser (Fig. 25.8). These cuts encompass the full usually easier to remove because of their size and favorable
extent of the cyst, and include the attached mucosa of the location.
ventricle and false vocal fold (FVF) with the specimen, to
prevent recurrence. A suture is occasionally needed to reat-
tach the false vocal fold laterally, but trimming of redundant
mucosa is often all that is needed.
and Complications
■ Consider overnight admission for airway observation/

precautions in cases where extensive dissection and
suspension were used.
■ Postoperative care should include PPIs (to reduce the
chance of granuloma formation), pain medicine, and a
normal diet as tolerated.
■ Adverse outcomes
■ Cyst recurrence is a risk with endoscopic excision,
and great care must be taken to include all of the
ventricular mucosa with the specimen by removing
the entire inferior FVF and ventricle.
■ In cases of recurrence, an open approach is indicated
for re-excision. Care should be taken to avoid dissec-
tion into the paraglottic space at or below the level of
the true vocal fold.
Fig. 25.6 Exposed cyst after initial incisions
Fig. 25.7 Blunt dissection of cyst with suction Fig. 25.8 Final cuts of cyst, including inferior false vocal fold
158 Endoscopic Excision of Saccular Cyst
1 Danish MN, Meleca RJ, Dworkin JP, Abbarah TR (1998) Laryn-

■ Saccular cysts of the larynx in the adult can usually
geal obstructing saccular cysts: a review of this disease and treat-
be managed endoscopically.
ment approach emphasizing complete endoscopic carbon dioxide
■ Saccular cysts in infants and children are generally
laser excision. Arch Otolaryngol Head Neck Surg 124:593–596
approached externally.
2 DeSanto LW, Devine KD, Weiland LH (1970) Cysts of the larynx:
■ Two anatomic types of saccular cysts occur
classification. Laryngoscope 80:145–176
■ Anterior
3 Hogikyan ND, Bastian RW (1997) Endoscopic CO2 laser excision
■ Smaller in size
of large or recurrent laryngeal saccular cysts in adults. Laryngo-
■ Presents as a ventricular mass in the anterior
scope 107:260–265
half of the larynx
■ Lateral
■ Larger
■ Presents as a bulge in the FVF/ aryepiglottic
fold
■ Endoscopic CO2 laser and cold dissection are used
to remove the cyst.
■ The dissection should include a complete removal
of the FVF and underlying ventricle, to reduce the
chance of recurrence.
25
Chapter 26
Anterior Glottic Web

26
superior–inferior plane. The latter can often involve web for-
mation from the glottis to the supraglottis and/or web forma-
tion from the glottis into the subglottis.
Please see Chaps. 1, 4, 10, and 13 for further information. A variety of conditions are associated with anterior glottic
webs; specifically, laryngeal framework stenosis should be care-
fully examined and considered when evaluating a patient with
an anterior glottic web. This can involve supraglottic stenosis,
thyroid cartilage constriction resulting in glottic stenosis, and
subglottic stenosis from cricoid cartilage deformation and loss
of normal dimensions, specifically in the anterior–posterior
An anterior glottic web formation (Fig. 26.1) can occur from plane.
either congenital or acquired causes. A congenital anterior glot- Vocal fold scar is frequently associated with an anterior
tic web is quite rare, and the symptoms are usually identified at glottic web because of the traumatic nature of the etiology of
birth or in a young child if the web is large, causing stridorous most of these conditions.
breathing. Smaller congenital webs are often identified later in Differential diagnosis for an anterior glottic web is:
life and are associated with exercise restriction and/or dyspho-
■ Wegner’s granulomatosis
nia. Acquired anterior glottic webs are the most common type
■ Sarcoidosis
of glottic web, and these typically occur from a traumatic in-
■ Amyloidosis
jury to the larynx, be it surgical, iatrogenic, external trauma, or
intubation related. Anterior glottic webs range in size from be-
ing extremely small (a microweb) to encompassing the entire
length of the membranous vocal folds. Obviously, the symp-
toms, severity, and surgical procedures will vary significantly
based on the etiology and size of the web.
Anterior glottic webs should be evaluated in two specific
dimensions: from an anterior–posterior dimension and in a Indications include:
■ Airway restriction
■ Abnormally elevated phonatory pitch
■ Dysphonia
Contraindications include:
■ No functional voice limitations and no airway restric-
tion
■ Uncontrolled LPR
■ Active RRP without any airway restriction
Equipment needed includes:

■ Standard phonomicrosurgery set (see Chap 10, Table
10.1)
■ Standard laser microlaryngoscopy set (see Chap. 13)
■ Silastic sheet and/or premade laryngeal keel
Fig. 26.1 Anterior glottic web
160 Anterior Glottic Web
■ Endo-extra laryngeal needle passer (Richard Wolf Med- 26.5 Surgical Procedure
ical, Knittingen, Germany) or 18-g angiocatheter/2-cm
18-g needle (Fig 27.7)
The two approaches most often used for the release and remov-
■ 0 Prolene suture
al of an anterior glottic web are endoscopic flap or endoscopic
■ Silicone surgical button(s)
placement of a keel. The endoscopic flap approach is best used
■ Mitomycin C (optional)
for smaller anterior glottic webs and involves the asymmetric
division of the anterior glottic web, with utilization of the web
for mucosal coverage on one side of the anterior commissure.
This operation involves delicate surgical handling. Elevation
and preservation of the anterior glottic web mucosa is per-
formed, and then the flap is sutured over one side of the ante-
rior commissure.
For larger anterior glottic webs and for patients that do not
have adequate tissue for an endoscopic flap, release of the ante-
rior glottic web and endoscopic placement of a keel is required.
Patients undergoing this procedure need to be informed of the
need for two surgical procedures (placement of keel and re-
moval of keel.) They also need to be prepared for moderate
pain and discomfort as well as globus sensation for the 7- to
10-day period that the keel is in position.
1. Endoscopic flap for anterior glottic web
a) Laryngoscopic exposure of the anterior glottic web and the
anterior commissure region with suspension laryngos-
copy (see Chap. 10, “Principles of Phonomicrosurgery”)
b) Visualize and assess superior and inferior depth of an-
terior glottic web and plan incision location(s) using
angled telescopes (Fig. 26.2).
c) Incise the anterior glottic web in an asymmetric fashion
at either the free edge of the vocal fold or onto the supe-
rior surface of the vocal fold that will then be incorpo-
Fig. 26.2 Endoscopic assessment of superior–inferior extent of glottic rated into the flap (Fig. 26.3).
web
26
Fig. 26.3 Incision for asymmetric division of anterior glottic web Fig. 26.4 Elevation of the anterior glottic web flap and release of web/
scar up to inner aspect of the thyroid cartilage
Chapter 26 161
d) Preservation of flap mucosa, complete release of the an- c) Release or excision of the anterior glottic web can be
terior glottic web all the way up to the anterior commis- done either with a CO2 laser (smallest spot size and low
sure/thyroid cartilage is then performed using cold-steel power) or with straight-up scissors and/or a sickle knife.
instrumentation or the CO2 laser (Fig 26.4). When incising the anterior glottic web, it is important
e) Often demucosalization of the undersurface of the flap to put tension on the vocal folds with lateral retraction
and the subglottis in the region of the anterior commis- and stay in the midline between the two vocal folds to
sure and anterior third of the vocal fold is then required. minimize any further lamina propria damage. Cold-steel
It can be done with either cold steel or a CO2 laser using excision is preferable to minimize laser surgery-related
a defocused beam on low-power settings (Fig. 26.5). scar formation (Fig. 26.8).
f) The endoscopic flap can now be draped down into the d) After excision or release of the anterior glottic web up to
subglottis and secured in place with a single 5.0 or 6.0 the anterior commissure, the CO2 laser can then be used
absorbable suture. It is a rare endoscopic flap that does to make an approximately 1-mm deep groove into the
not need suturing to stay in the proper location. Tissue inner aspect of the thyroid cartilage, extending 3–4 mm
glue has not been adequate, in the authors’ past experi- above the anterior commissure and 4–5 mm below the
ence, to secure the endoscopic flap into location (Figs. anterior commissure. This groove will be used for place-
26.6. 26.7). ment of the keel in an anterior-most location (Fig. 26.9).
g) The application of mitomycin C onto the contralateral e) Thirty and 70° telescopes can then be used to visualize
anterior commissure and anterior third of the vocal fold the superior and inferior extent of the anterior glottic
in the demucosalized area is optional (see Chap. 29). web release and determine the superior–inferior extent
2. Release of the anterior glottic web with endoscopic keel place- of the intended keel. When visualizing this area with a
ment 30 or 70° telescope, the telescope should be passed to the
a) Suspend the laryngoscope with adequate false vocal fold superior-most location to which the keel will need to be
retraction and complete exposure of the anterior glottic secured, and then the telescope shaft can be marked at
web and anterior commissure. It is important to suspend the location of the junction of the shaft and the proximal
the laryngoscope with adequate space above the anterior laryngoscope. The 30° telescope is then moved to the in-
commissure for placement of the superior position of the ferior limit of the planned keel location. The telescope is
planned keel (approximately 3–4 mm above the level of held at this position; a mark on the telescope shaft can
the glottis). be placed at the junction of the shaft and the proximal
b) Visualize the anterior glottic web with 30 and 70° tele- laryngoscope. The distance between the two marks on
scopes. During this visualization it is important to evalu- the telescope shaft is measured and this distance will be
ate the web in a cephalocaudal dimension given that this used to determine the superior–inferior length of the
will determine the minimum length of the planned keel keel (Fig. 26.10).
(Fig. 26.2).
Fig. 26.5 Demucosalization of the undersurface of the flap Fig. 26.6 Inferior reflection of flap to cover one side of the anterior
commissure
Fig. 26.7 Securing the endoscopic flap with suture placement Fig. 26.9 CO2 laser vaporization of a 1-mm thyroid cartilage groove at
the anterior commissure
f) After trimming the keel to the required superior–infe-

rior dimension as well as the anterior–posterior dimen-
sion, the keel can be placed with a heavy cup forceps into
the larynx to evaluate the appropriate size and fit.
g) A 0 Prolene suture can then be passed from the subglot-
tis to the anterior neck with the Lichtenberger endo-ex-
tralaryngeal needle passer. This can be done with micro-
laryngoscopy or endoscopically with a 30° telescope. A
clamp should be placed on the free end of the suture that
comes out of the anterior neck (Fig. 26.11).
Alternative Method
i. Have an assistant pass an 18-g angiocatheter or 2.5-
cm needle from the anterior neck to the desired loca-
tion in the anterior subglottis during simultaneous
microlaryngoscopy or telescopic visualization of the
larynx. Once the needle is in the proper location into
the subglottis, then a 0 Prolene suture can be passed
in through the tip of needle and out through the neck
where it is secured with a clamp.
h) Pass the free end of the suture through the laryngoscope.
Secure the keel at two locations along the spine of the
keel with the suture. The placement of the suture through
the keel will ultimately determine the exact location of
26 Fig. 26.8 Midline division of the anterior glottic web down to inner the keel in the larynx. Thus, it is helpful to place the keel
aspect of the thyroid cartilage into the appropriate location and obtain endoscopic vi-
sualization with the 70° telescope of where the fixation
sutures should be placed onto the keel.
i) Load the suture coming from the keel into the endo-ex-
tra laryngeal needle passer and place down the laryngo-
scope to pass the suture from the region superior to the
anterior commissure to the anterior neck (Fig. 26.11).
Chapter 26 163
Alternative Method superior portion of the keel. A large cup forceps is then
i. After passing the suture through the keel, place the used to grasp the keel. Once the endoscopist is confident
18-g angiocatheter or 2.5-cm needle through the an- that he has a firm grasp of the keel, the anterior neck
terior neck into a location above the anterior com- sutures can be cut and the keel can then be removed via
missure with simultaneous microlaryngoscopy or the laryngoscope.
telescopic visualization. c) After adequate mask ventilation of the patient, a repeat
ii. Pass a 0 Prolene suture into the shaft of the angio- direct laryngoscopy and endoscopic visualization of the
catheter/needle until an assistant can see the suture operative site is performed. If there is severe granulation
emerging from the angiocatheter. The assistant can tissue or a reformation of the anterior glottic web, then
then remove the angiocatheter or needle and clamp the endoscopic glottic web procedure can be repeated.
the suture that has been passed from the larynx to
the anterior neck.
j) Guide the keel into position in the endolarynx as an as-
sistant applies equal tension to the sutures coming out of
the anterior neck.
k) Place a moderate and equal amount of tension on the
two sutures coming out of the anterior neck and confirm
the proper location of the keel using 30 and 70° telescop-
ic visualization.
l) If the keel is not in the proper location from either a su-
perior, inferior, or lateral perspective, then the passing
of the sutures and placement of the sutures through the
keel should be repeated.
m) Secure the endoscopic keel in place by tying the sutures
coming out of the anterior neck over surgical buttons
with a simultaneous visualization of the keel during the
suture tying procedure (Fig. 26.12).
3. Keel removal (10–14 days post-placement)
a) Apneic anesthesia is the preferred method of anesthesia
for this procedure, given that endotracheal intubation
can complicate the endoscopic keel removal and injure
the operative site.
b) Direct laryngoscopy is then performed, and a 0° tele- Fig. 26.10 30° telescope is used to measure the length of the keel from
scope is used to visualize the endolarynx, specifically the superior to inferior
Fig. 26.11 Passing inferior fixation suture from endolarynx through the anterior neck and place-
ment of suture through keel
Complications comprise:
■ Anterior glottic web reformation
■ Dislodgement of keel
■ Scar or erosion of the vocal fold from malposition of the
keel
■ Granulation at the keel suture location
Key Points
■ Anterior glottic web most commonly is an ac-

quired condition from surgical trauma.
■ Anterior glottic web surgery is indicated for airway
restriction or symptomatic dysphonia.
■ Endoscopic flap release of anterior glottic web can
be done successfully with good laryngeal expo-
sure and a small glottic web.
■ Release of anterior glottic web and placement of
endoscopic keel requires skill from the surgeon
and can be successfully performed if attention to
technical details are observed.
Fig. 26.12 Visualization of proper placement of the keel with 30 and
70° telescopes, with keel secured together over button on the neck
Also at this juncture, if indicated, mitomycin C can be
applied at the operative site. These decisions are made
based on the amount of mucosalization that has oc- 1 Benninger MS, Jacobson B. Vocal nodules, microwebs and sur-
curred at the anterior glottis. gery (1997) J Voice 11:238–246
2 Casiano RR, Lundy DS (1998) Outpatient transoral laser vapor-
ization of anterior glottic webs and keel placement: risks of air-
way compromise. J Voice 12:536–539
3 Dedo HH (1979) Endoscopic Teflon keel for anterior glottic web.
and Complications
Ann Otol Rhinol Laryngol 88(Pt. 1):467–473
4 Ford CN, Bless DM, Campos G, Leddy M (1994) Anterior com-
Postoperative care includes: missure microwebs associated with vocal nodules: detection, prev-
alence, and significance. Laryngoscope 104(Pt 1.):1369–1375
■ Intravenous antibiotics (perioperatively only)
5 Hsiao TY (1999) Combined endolaryngeal and external approach-
■ Intravenous steroids perioperatively
es for iatrogenic glottic web. Laryngoscope 109:1347–1350
■ Laryngopharyngeal reflux disease treatment
6 Liyanage SH, Khemani S, Lloyd S, Farrell R (2006) Simple keel
■ Pain medicine as needed
fixation technique for endoscopic repair of anterior glottic steno-
■ Overnight observation in the hospital
sis. J Laryngol Otol 120:322–324
■ Reevaluation of the patient in approximately 8–10 days
7 Milczuk HA, Smith JD, Everts EC (2000) Congenital laryngeal
in the office with flexible laryngoscopy or indirect la-
webs: surgical management and clinical embryology. Int J Pediatr
ryngoscopy to determine the amount of mucosalization
that has occurred underneath the keel
8 Schweinfurth J (2002) Single-stage, stentless endoscopic repair of
anterior glottic webs. Laryngoscope 112:933–935
26
Pathology
III Laser Microlaryngeal
Surgery (Airway/
Neoplastic Conditions)
Chapter 27
Bilateral Vocal Fold Paralysis

27
tion of the cricoarytenoid joint as described below is helpful
to determine which cricoarytenoid joint has the worst range of
motion and mobility and would then be best choice for surgi-
Please see Chaps. 3, 5, 9, 10, 13, and 28 for further informa- cal procedure to widen the posterior glottic airway.
tion.
27.3 Surgical Indication

27.2 Disease Characteristics and Contraindications
An indication for surgery is symptomatic airway obstruction.
Patients with bilateral vocal fold paralysis (BVFP) generally fall Contraindications to treatment of BVFP include:
into two categories, (1) iatrogenic recurrent laryngeal nerve
■ Rapidly progressive neurologic disorder
injury (typically from a thyroidectomy), or (2) progressive
■ Unrealistic patient expectations (improvement in both
neurological disorder (Shy-Drager Syndrome, syringomelia,
airway and voice)
Guillian-Barré syndrome, etc.). In contrast to unilateral vocal
fold paralysis, with which the patient principally complains of
voice and swallowing difficulties, bilateral vocal fold paralysis Relative contraindications to treatment include:
(BVFP) causes airway restriction and not vocal dysfunction.
■ Presence of aspiration
In patients with BVFP, treatment is directed at maximizing the
■ Compromised pulmonary status
airway, while attempting to limit the negative effects of treat-
■ Diabetes (more true for open procedures than endo-
ment on vocal function.
scopic)
It can be difficult to distinguish BVFP from posterior glottic
■ Previous radiation therapy to the neck/larynx
stenosis. In some ways, the distinction is not essential, because
posterior transverse cordotomy and/or partial arytenoidecto-
my are often effective for both conditions. However, a correct Treatment options for BVFP include:
diagnosis greatly facilitates patient counseling and appropriate
■ Tracheotomy
treatment, therefore a careful examination to evaluate crico-
■ Microlaryngoscopy with laser posterior transverse
arytenoid joint fixation and posterior glottic stenosis should be
cordotomy
carried out prior to surgical intervention (see Chap. 28, “Pos-
■ Microlaryngoscopy with laser medial arytenoidectomy
terior Glottic Stenosis”).
■ Microlaryngoscopy with laser total arytenoidectomy
The most reasonable approach to patients with bilateral
■ Endoscopic suture lateralization
vocal fold paralysis is a step-wise approach to enlarge the
■ Open arytenoidectomy
glottic airway. The least aggressive and safest procedures are
the posterior transverse cordotomy (PTC) or medial aryte-
noidectomy (MA). After these procedures, an extended ver- In general, rapidly progressive neurologic disorders (such as
sion of either (or a combination) can be performed, or a total Shy–Drager) tend to be treated with tracheotomy, due to co-
arytenoidectomy. Please note the procedure historically called morbid conditions. However, most other causes of BVFP can
a total arytenoidectomy does not involve complete anatomic be treated more conservatively with endoscopic techniques.
removal of the arytenoid cartilage. Its aim is to remove all ary- Posterior transverse cordotomy or medial arytenoidectomy
tenoid cartilage that effects the airway. Selection of the side to are generally the ideal endoscopic treatment options, because
perform surgery for bilateral vocal fold paralysis is based on voice results tend to be better, and aspiration is less likely, as
a variety of factors. The most important factor for selection is compared with total arytenoidectomy. Endoscopic suture lat-
presence of any purposeful motion either adductory or abduc- eralization is useful if temporary treatment is warranted. Open
tory. If there is no motion of either vocal fold, then laryngeal arytenoidectomy is reserved for cases where endoscopic tech-
electromyography can assist in determining which side has the niques have failed or are impossible due to anatomic limita-
worst neuromuscular status and thus is the best location for tions, and thus is rarely required.
the surgical procedure. In addition to these methods, palpa-
168 Bilateral Vocal Fold Paralysis
(Figs. 27.1, 27.2). During this maneuver, careful evaluation

of the posterior commissure should be done. If the entire
posterior commissure moves with lateralization of the vo-
Equipment includes: cal process, then this suggests that posterior glottic stenosis
may be present. This same procedure should be done on the
■ Laser microlaryngoscopy equipment (Chap. 13)
contralateral side and used to compare the degree of stiff-
■ Laryngeal bipolar/monopolar cautery (not essential)
ness and range of motion of both cricoarytenoid joints. This
■ Mitomycin C (0.4 mg/ml)
maneuver can be helpful in selecting which side is optimal
■ Also for suture lateralization only:
for surgery to improve the posterior glottic airway. One
■ Endo-extralarnygeal needle carrier by Lichtenberger
should select the arytenoid with the worst cricoarytenoid
(Richard Wolf Medical, Knittingen, Germany)
joint mechanics to operate on.
■ Silicone buttons
2. Posterior transverse cordotomy
■ 0 or 2.0 Prolene sutures
a) Intubation with 5.0 or 5.5 laser safe endotracheal tube
(ETT)
Alternately, a subglottic jet catheter (Hunsaker tube,
Medtronic Xomed, Jacksonville, Fla.) can be used.
b) Expose larynx with laryngoscope and place into suspen-
sion.
1. Palpation of cricoarytenoid joint i. Ensure that the ETT is in posterior commissure, and
Direct laryngoscopy should be performed. It is best to that there is still good vocal process visualization
perform cricoarytenoid joint palpation without an endo- with the ETT in a posterior position. If the ETT ob-
tracheal tube in place. Anesthesia should induce complete structs the surgical site, then the EET can be moved
muscle paralysis and the posterior larynx is viewed with mi- anteriorly with the laryngoscope securing the ETT
crolaryngoscopy or a 0° endoscope. Care should be taken to anteriorly (see Chap. 19, “Vocal Fold Granuloma”).
ensure that suspended laryngoscope is positioned cephalad ii. It is often helpful to angle the laryngoscope toward
in the larynx to avoid the laryngoscope limiting the range the side where the cordotomy is being performed to
of motion of the arytenoid cartilages. Palpation of the cri- maximize the exposure of the lateral aspect of the
coarytenoid joint is performed by using a sturdy instrument true vocal fold/false vocal fold (see Chap. 19, Fig.
such as a large cup forceps and placing it adjacent to the 19.2).
vocal process and pushing the vocal process laterally swiftly. c) Laser precautions are implemented (see Chap. 13, “Prin-
With this maneuver, the surgeon can gauge the degree of ciples of Laser Microlaryngoscopy”).
effort required to displace laterally the vocal process as well d) Laser incision
as the speed of the recoil of the tissue in a medial direction
27
Fig. 27.1 Palpation of a mobile (nonfixed) cricoarytenoid joint: lateral Fig. 27.2 Release of arytenoid, resulting in recoil of arytenoid medi-
displacement of arytenoid with blunt instrument ally. This would be observed in a patient with BVFP
Chapter 27 169
i. A CO2 laser setting typically is 4 W, superpulse with vi. The residual vocal fold will retract anteriorly and ap-
a very small spot size. An intermittent firing of 0.1-s pears shortened (Fig 27.4).
on/0.5-s off time will also minimize collateral ther- vii. The degree of lateral extension of the cordotomy can
mal damage. be adjusted based on (1) tissue response to the initial
ii. A platform suction device (or a moist Cottonoid) is cordotomy and (2) the amount of airway improve-
placed below the surgical site to protect distal struc- ment needed by the patient.
tures. f) Application of LTA
iii. The vocal process location is confirmed by palpa- i. 4% lidocaine is sprayed on the vocal folds/trachea to
tion. minimize laryngospasm postoperatively.
iv. Incision is started just anterior to vocal process, be- g) Application of mitomycin C (optional)
ing careful not to expose the cartilage, to avoid gran- i. Topical mitomycin C is placed (typically 0.4 mg/ml)
ulation tissue postoperatively. via a soaked pledget for 5 min.
v. Laser char (carbonaceous debris) should be removed 3. Medial arytenoidectomy
by rubbing a saline soaked Cottonoid over the surgi- a) Placement of laser laryngoscope
cal site periodically. The CO2 laser is ineffective in a i. Place laser laryngoscope (with built-in suction) to
heavily charred area or bleeding operative site. allow exposure of the posterior membranous vocal
e) Extension of cordotomy fold, arytenoid cartilage and posterior glottic space
i. Once the entire vocal fold is separated from the vo- on the intended side of the surgical procedure.
cal process, the cordotomy is extended into the false b) Laser safety precautions
vocal fold tissue. i. All laser safety precautions should be put into place
ii. Frequently, a branch of the superior laryngeal artery prior to starting the use of the laser (see Chap. 13,
is encountered, and troublesome bleeding can oc- “Principles of Laser Microlaryngoscopy”).
cur. c) Laser incision
iii. Suction and bipolar laryngeal cautery are effective in i. The CO2 laser setting should involve a small spot
stopping the bleeding. size (0.25–0.4 μm) at a setting of 2–4 W, super-pulse
iv. A complete cordotomy extends laterally 3–4 mm mode, and used to obliterate the medial-most por-
into the false vocal fold tissue/musculature (see Figs. tion of the arytenoid cartilage for approximately 2–3
27.3, 27.5, shaded portion no. 1). mm in width.
v. Confirmation of complete cordotomy is achieved via ii. The anterior–posterior dimensions of this area of
endoscopic evaluation with a 0 and/or 30° telescope, obliteration should be posterior to the tip of the vo-
confirming that the cordotomy site is flush with the cal process preserving all or most of the vocal pro-
lateral subglottic wall. cess.
iii. The area of the obliteration should not extend to the
posterior arytenoid tissue and should spare adjacent
mucosa in the intra-arytenoid area (Fig. 27.5, shad-
ed portion no. 2).
iv. Titration of the amount of arytenoid cartilage that
is obliterated is based on the amount of airway im-
Fig. 27.3 Lateral extent of transverse cordotomy at both the level of Fig. 27.4 Surgical result immediately after a right posterior transverse
true and false vocal fold cordotomy; note how the residual vocal fold retracts anteriorly and
appears very thick and shortened
provement that is required by the patient and tissue

response after the initial aspect of the medial aryte-
noidectomy.
v. This is a clinical judgment and should initially be
done in a very conservative fashion with an expecta-
tion that some patients may require repeat surgery
to further enlarge the posterior glottic airway to a
satisfactory level. If adequate surgical enlargement
of the posterior glottic airway is not obtained with a
conservative medial arytenoidectomy, then further
arytenoid lateral to the initial defect can be removed
all the way to the lateral aspect of the cricoid ring
resulting in a total arytenoidectomy (see below).
vi. To further improve the posterior glottic airway, the
area of ablation can be taken anteriorly to include
the vocal process and a partial posterior cordecto-
my to the level of the lateral ventricle (see Fig. 27.5,
shaded portion no. 3).
vii. Remove all laser char from the operative site with
suction and moist cotton pledget.
viii. Obtain hemostasis with epinephrine-soaked (1–
10,000 concentration) pledget.
ix. Apply mitomycin C to the operative site (0.4 mg/ml
for 5 min) (optional). Fig. 27.5 Diagram of different degrees of arytenoid removal (medial,
x. Spray the endolarynx with 4% plain lidocaine. total) compared to transverse cordotomy (shaded area no. 1). Laser
xi. Suction esophagus and stomach with oral gastric ablation of the medial arytenoid for medial arytenoidectomy is shown
tube placement. in shaded area no. 2. Laser ablation of total arytenoidectomy is shaded
4. Total arytenoidectomy area no. 3
a) Follow the preparatory steps listed above for medial ary-
tenoidectomy.
b) Continuous CO2 laser ablation of arytenoid tissue until
the operative defect is flush with the walls of the cricoid
ring, both posteriorly and laterally. Tissue removal pos-
teriorly should not remove any interarytenoid mucosa.
Evaluation of this goal can be done by:
i. Placement of a curved elevator on the lateral aspect
of the subglottis and then slowly drawing the instru-
ment in a cephalad direction feeling for a glottic level
“overhang” of arytenoid tissue. If there is an “over-
hang,” additional arytenoid tissue can be removed
(Fig. 27.6).
ii. In addition, the endoscopic evaluation of the poste-
rior glottic airway with a 70° telescope, can identify
if there is any residual arytenoid overhang that needs
further laser ablation to maximize the glottic airway
to complete the total arytenoidectomy procedure
5. Endo-extralarnygeal suture lateralization (based on the tech-
nique of Lichtenberger)
a) Special consideration
i. This procedure is best suited as a temporizing mea-
sure for airway improvement in early BVFP cases,
ideally in the first 2 months after onset.
b) Indications:
27 i. Early, symptomatic BVFP (first 2 months) with un-
certain prognosis for recovery
c) Contraindications
i. Recent trauma to the posterior glottis from indwell-
ing endotracheal tube
ii. Indwelling tracheostomy tube
d) Procedure Fig. 27.6 Palpation of residual arytenoid overhang
Chapter 27 171
i. Suspension laryngoscopy is performed (jet ventila-

tion is initiated or a small 5.0 or 5.5 endotracheal
tube can be used).
ii. The skin overlying the neck on the side of the pro-
posed suture lateralization is prepped and draped in
a sterile fashion.
iii. The most medialized vocal fold is selected in this
procedure. An endo-extralaryngeal needle carrier
device (Richard Wolf; Fig 27.7) is loaded with a 2.0
or 0 Prolene suture. Under microscopic or telescop-
ic visualization, the needle is positioned below the
posterior vocal fold at a point just anterior to the vo-
cal process (Fig 27.8). Using the carrier device, the
needle is pushed through the larynx until the tip of
the needle appears externally through the skin of
the neck. The needle is grasped, and the suture is
advanced through the skin and temporarily secured
with a clamp (Fig 27.9). Fig. 27.7 Endo-extralaryngeal needle carrier device (Richard Wolf)
iv. The proximal end of the same Prolene suture is then
threaded through the free needle, which is designed
to be used with the endo-extralaryngeal needle car-
rier. The procedure as in step (iii) is performed at
the same location of the posterior glottis, this time
at a level slightly superior to the true vocal fold (Fig
27.10). The needle is again advanced externally
through the skin of the neck (Fig 27.11). A second
lateralization suture is placed in a similar fashion,
1–2 mm anterior to the first suture.
v. Traction is now placed on the two sutures to create
lateralization of the posterior vocal fold and expan-
sion of the static airway dimensions (Fig 27.12).
vi. A 2-cm horizontal incision is made in the neck. The
sutures are then pulled deep to the skin incision. The
two ends of the suture are then tied with a surgeon’s
knot over the sternohyoid muscle, using a silicone
button as an anchoring point (Fig 27.13).
vii. The skin incision is closed in a standard fashion.
A permanent version of this surgery can be performed by Fig. 27.8 Infraglottic placement of suture just below the level of the
combining this suture lateralization technique with an ip- vocal process
silateral partial submucosal laser resection of the TA/LCA
complex and/or a partial arytenoidectomy. This technique is
illustrated in Chap. 28, (“Posterior Glottic Stenosis”).

and Complications
Care immediately postoperatively includes:

■ Twenty-four hour observation in a monitored setting
may be indicated, although these procedures can be
performed on an out-patient basis, especially if a stable
tracheotomy is present.
■ Voice rest is not essential.
■ Proton-pump inhibitor(s)
■ Pain medications
■ Corticosteroid taper
■ Antibiotics, as per the surgeon’s discretion
Fig. 27.9 The suture is grasped by an assistant and pulled through the
skin
Fig. 27.10 The same initial suture is now placed above the vocal fold Fig. 27.11 One completed lateralization suture. This sequence will
(through the ventricle) at the region of the vocal process be repeated once more, slightly anterior to the previous suture place-
ment
Fig. 27.13 The two sutures are

brought deep to the skin through a
separate incision and tied over the
strap muscles, using a silicone button
is a small posterior glottal notch in the case of posterior trans-

verse cordotomy (Fig. 27.14). Although the notch may appear
to have only increased the airway 2–3 mm, this results in sig-
nificant improvement in the patient’s airway, and only mild
Fig. 27.12 After completion of the suture lateralization. Note lateral- worsening of the patient’s voice.
ization of the vocal fold with two sutures slightly anterior to the vocal Complications related to posterior transverse cordotomy,
process medial, and total arytenoidectomy:
1. Granuloma formation
a) Granuloma formation at the operative site is not uncom-
27 mon, and should be treated by maximizing antireflux
During the (expected) postoperative course, the patient will medication.
experience significant worsening of the voice, which will im- b) The granuloma tend to resolve over time, but may need
prove over a 2- to 3-month period and then stabilize. Follow- to be excised if still present 3–4 months after surgery.
up at 2–3 week intervals for reexamination and reassurance is c) These granulomas may also cause return of airway symp-
important during the healing phase. The expected final result toms, and must be monitored carefully.
Chapter 27 173
Key Points
■ Bilateral vocal fold paralysis should be differenti-

ated from posterior glottic stenosis, even though
static glottic enlargement procedures such as
medial arytenoidectomy, posterior transverse
cordotomy and total arytenoidectomy are often
helpful for both conditions.
■ Patients undergoing glottic enlargement proce-
dures for bilateral vocal fold paralysis must be
counseled regarding the exchange of improved
airway for decreased voice quality and volume.
■ A variety of surgical procedures are available for
treatment of bilateral vocal fold paralysis. The most
conservative, limited procedure should be se-
lected initially, and then further surgery and more
extensive surgery can be tailored to the patient’s
Fig. 27.14 Long-term postoperative result after a right transverse cor-
airway and voice needs.
dotomy
■ Pre-, intra- and post-operative angled telescopic
(30 and 70°) evaluation of the posterior glottic
airway is an essential aspect of surgery for bilateral
vocal fold paralysis.
2. Excessive scar tissue obliterating operative site ■ All laser char should be removed from the opera-
a) Occasionally, the operative site heals completely, without
tive site at the end of the surgical procedure to
the characteristic “notch.”
minimize post-operative granulation tissue forma-
b) The operation can be repeated on the same side with re-
tion.
application of mitomycin C. ■ Post-operative reflux treatment should be imple-
c) It is quite rare to need additional surgery after a second
mented to reduce post-operative granulation
surgical procedure.
formation.
Complications related to suture lateralization include:
a) Trauma to the posterior vocal fold from excessive ten-
sion on the lateralization suture.
b) The suture may “cut into” the vocal fold, separating the
muscular vocal fold from the vocal process.
c) This complication can be avoided by: 1 Lichtenberger G, Toohill RJ (1997) Technique of endo-extrala-
i. Not operating on vocal folds after “fresh” ETT trau- ryngeal suture lateralization for bilateral abductor vocal cord pa-
ma ralysis. Laryngoscope 107:1281–1283
ii. Placing the first suture anterior to the vocal process, 2 Bosley B, Rosen CA, Simpson CB, McMullin BT, Gartner-
thus avoiding the temptation to lateralize the vocal Schmidt JL (2005) Medial arytenoidectomy versus transverse
process/arytenoid tissue. The sutures must be re- cordotomy as a treatment for bilateral vocal fold paralysis. An-
moved promptly if significant vocal fold trauma is nals of Otology, Rhinology & Laryngology 114:922–926
present. 3 Hillel AD, Benninger M, Blitzer A et al (1999) Evaluation and
management of bilateral vocal cord immobility. Otolaryngol
4 Dray TG, Robinson LR, Hillel AD (1999) Idiopathic bilateral vo-
cal fold weakness. Laryngoscope 109:995–1001
5 Crumley RL (1993) Endoscopic laser medial arytenoidectomy
for airway management in bilateral laryngeal paralysis. Ann Otol
Rhinol Laryngol 102:81–84
6 Dennis DP, Kashima H (1980) Carbon dioxide laser posterior
cordectomy for treatment of bilateral vocal cord paralysis. Ann
Chapter 28
Posterior Glottic Stenosis:

Endoscopic Approach 28
mobility and leads to “mature” PGS. The diagnosis is often
complicated by the presence of a tracheotomy, which increases
the bacterial count in the tracheobronchial tree and may ex-
Please see Chaps. 6, 9, 10, 13, 27, and 29 for further informa- acerbate problems with granulation tissue development. Since
tion. the patient breathes through the tracheotomy, the effect of the
granulation tissue obstructing the airway goes unnoticed until
it has had a chance to mature and form a scar contracture. This
process typically occurs over 4–8 weeks.
Even minimal injury to the mucosa over the cricoarytenoid
(CA) joint can be associated with loss of cricoarytenoid joint
function for vocal fold abduction. In an animal model, laser
Posterior glottic stenosis (PGS) presents as progressive airway depithelialization over the CA joint was associated with a 25%
obstruction, which develops 4–8 weeks after extubation from a reduction in vocal fold abduction after healing. Deeper inju-
period of extended mechanical ventilation (Fig. 28.1). PGS has ries were associated with a greater reduction in motion and
been reported as a complication that can occur after intubation injuries into the cricoarytenoid joint capsule were associated
times as short as 4 days and has been linked to LPR. Often the with fusion of the arytenoids to the cricoid.
patient complains of dysphonia after extubation. Examination The differential diagnosis of posterior glottic stenosis is:
will frequently reveal granulation tissue in the area of the ary-
■ Bilateral vocal fold paralysis
tenoid cartilage or over the interarytenoid cleft. This tissue pre-
■ Cricoarytenoid joint ankylosis (e. g., autoimmune from
vents vocal fold approximation for voice production, and the
rheumatoid arthritis)
voice is breathy or whispered. The granulation tissue itself can
■ Interarytenoid synchiae
grow to obstruct the glottis. When this occurs, the patient is of-
ten seen by the otolaryngologist. Prompt evaluation, diagnosis,
and debridement of the granulation tissue can be associated Severe injury with erosion of the CA joint from pressure due
with reduction in mature scar tissue formation and lessens the to prolonged intubation can lead to CA joint fusion. This is
overall risk of the stenosis of the airway. Frequently, however, usually noted in the endoscopic exam, which reveals a normal
patients are not seen acutely and as the granulation tissue re- posterior glottis associated with CA joint ankylosis. Often this
solves, mature scar tissue develops which impairs vocal fold finding can be appreciated on careful flexible laryngoscopy ex-
amination in the office under topical anesthesia. In the PGS
patient, there is also a history of relatively recent intubation.
Laryngeal electromyography (EMG) can be used to distin-
guish PGS from immobility due to previous bilateral neuro-
logical injury or bilateral paralysis (see Chap. 2, “Principles of
Clinical Evaluation for Voice Disorders”). In PGS, the EMG
activity of the thyroarytenoid–lateral cricoarytenoid muscle
complex will be normal, while in bilateral paralysis, even of
chronic origin, there will be evidence of old neurological inju-
ry with partial recovery. EMG activity in bilateral paralysis will
show reduced interference pattern often with reduced recruit-
ment and large polyphasic motor unit potentials. Frequently,
there will be active recruitment of additional motor units with
voluntary activity, but this will not be normal in amount and
the amplitude of the individual potentials will be increased.
Severe scarring with CA joint fixation can be distinguished
from loss of mobility due to mucosal scar contraction only via
an endoscopic examination and exploration. Therefore, the
initial management strategies in all patients with suspected
PGS should include diagnostic and staging endoscopy, with
Fig. 28.1 Posterior glottic stenosis planned palpation and potential mucosal flap elevation (see
176 Posterior Glottic Stenosis: Endoscopic Approach
also Chap. 27, “Bilateral Vocal Fold Paralysis”). If mucosal scar a) Posterior commissure exposure is usually obtained with-
contraction is the sole reason for loss of vocal fold abduction, out the need for anterior counter pressure.
then mucosal flap elevation will be associated with at least b) To help spread the vocal folds apart, it may be beneficial
temporary improvement in vocal fold abduction and airway. to insert the tip of the laryngoscope through the vocal
The patient will notice an immediate improvement in their folds. This needs to be done with extreme caution or not
ability to breathe in the recovery room. If this improvement at all if the patient does not have a tracheotomy.
does not occur, then it is unlikely that restoration of active CA c) If the patient does not have a tracheotomy, then inserting
joint function will be achieved, and management then needs to the tip of the laryngoscope through the vocal fold or over
proceed to either (1) ablative endoscopic procedures such as manipulation may cause postoperative edema requiring
posterior transverse cordotomy, partial arytenoidectomy, total tracheotomy. Therefore, in patients without tracheotomy,
arytenoidectomy, suture lateralization or (2) open approaches manipulation, even palpation of uninvolved tissue needs
with posterior glottic grafting (see Chaps. 27 “Bilateral Vocal to be minimized.
Fold Paralysis” and 46, “Glottic and Subglottic Stenosis: Cri- d) After exposure is obtained, the posterior commissure is
cotracheal Resection with Primary Anastomosis”). examined with 0, 30, and 70° angles telescopes. The mu-
cosal integrity in terms of granulation tissue and scar-
ring is assessed.
3. Visualize the operative field with the binocular operating mi-
croscope.
a) High magnification will help to evaluate mucosal integ-
rity.
Indications for surgery include: 4. Assess passive cricoarytenoid (CA) joint mobility (see Chap.
27, “Bilateral Vocal Fold Paralysis”).
■ Airway obstruction due to PGS
a) Palpate the arytenoids.
■ Patient desire for tracheotomy decannulation
b) Pushing lightly on the laryngeal surface of the mid body
of the arytenoid should result in translocation or lateral-
Relative contraindications include: ization of the ipsilateral vocal process and vocal fold (see
Chap. 27, Figs. 27.1 and 27.2).
■ Presence of aspiration
c) If joint mobility is impaired, then this maneuver will re-
■ Compromised pulmonary status
sult in minimal vocal process displacement, and the en-
■ Diabetes (more true for open procedures than endo-
tire larynx will move.
scopic)
d) After assessment of the posterior commissure mucosa
■ Previous radiation therapy
and passive CA joint mobility, decisions regarding inter-
■ Unrealistic patient expectations (improvement in both
vention can be made.
airway and voice)
5. Surgical options
■ Uncontrolled laryngopharyngeal reflux
a) Interarytenoid synchiae
i. If a bridge of mucosa between the arytenoids is iden-
tified, then this should be excised and removed (Fig.
28.2).
ii. Mitomycin C may be applied to the raw surfaces to
reduce the risk of reformation of the scar band.
Equipment needed for surgery includes: iii. If this procedure results in restoration of passive mo-
bility, then the procedure is likely to be successful,
and the case should be terminated.
■ Mitomycin C (0.4 mg/ml)
iv. Approximately 50% of patients with an interaryte-
noid synchiae will regain mobility after this type of
intervention. If mobility is not restored, then it is
likely that injury process has resulted in exposure of
the cricoarytenoid joint, with remodeling and pos-
sible fusion of the arytenoid to the cricoid. Thus, a
1. Intubate with laser safe endotracheal tube through existing glottic enlargement procedure will be needed such as
tracheotomy, perform new tracheotomy, or expose larynx a posterior transverse cordotomy (PTC) or medical
with suspension laryngoscope and commence jet ventilation arytenoidectomy (MA) (see Chap. 27), or permanent
(see Chap. 13,” Principles of Laser Microlaryngoscopy”). suture lateralization as described in this chapter.
2. Suspension laryngoscope details b) Posterior scar—microtrap-door flap
The procedure is begun by obtaining exposure with the i. Through palpation of the CA joints, the joint with
28 largest possible laryngoscope. If the patient does not have the best mobility should be identified.
a tracheotomy, then jet ventilation can be used to support ii. The laser or a knife is used to make an incision in
respiration. the mucosa over the contralateral arytenoid starting
Chapter 28 177
Fig. 28.2 Interarytenoid synchiae, with dashed line indicating surgical Fig. 28.3 Initial incision for microtrap-door flap
plane of division
Fig. 28.4 Ablation of posterior glottic scar, with CO2 laser Fig. 28.5 Draping of microtrap-door flap
near the vocal process, extending over the body and iv. The underlying scar tissue is vaporized or excised
into the interarytenoid cleft over the interarytenoidi- (Fig. 28.4).
us muscle (Fig. 28.3). v. Troublesome bleeding is stopped by applying epineph-
iii. Scissors or the CO2 laser is used to separate a flap of rine (1:10,000) on 0.5 × 3-cm Cottonoids. These are
epithelium and submucosal tissue from the underly- held in place for 1–3 min until the bleeding stops.
ing scar.
vi. The flap is elevated and the scar removed until mo- ix. Mitomycin C (0.4 mg/ml) may be applied to the
bility is restored or the limits of the dissection are exposed CA joint to lessen scar tissue formation in
reached. Often the flap is elevated over the contra- this region.
lateral CA joint and 4–5 mm below the vocal folds in x. If joint mobility is not obtained, then it is unlikely
the interarytenoid cleft. that the procedure will be successful, and consider-
vii. The flap is then repositioned over the ipsilateral CA ation should be given to additional procedures that
joint (Fig. 28.5). enlarge the posterior glottis, such as PTC, MA, total
viii. Sutures may be required to hold the flap in place. arytenoidectomy (see Chap. 27), or irreversible su-
ture lateralization as depicted in this chapter.
These procedures are best used when attempts at
restoration of joint mobility have failed and the
cartilaginous glottis is relatively well preserved. If
the cartilaginous portion of the arytenoid has been
resorbed by the healing process, then identification
of the vocal process will be difficult. Since the area
is filled in with scar tissue, incision in this area will
usually result in scar reformation, without signifi-
cant airway improvement.
c) Permanent suture lateralization
This technique, as described by Lichtenberger, is more
appropriately performed in cases of BVFP. Only in care-
fully selected cases, and when the surgeon has exten-
sive experience in the endoscopic management of PGS
should one attempt this treatment for PGS. That being
said, this procedure, especially if performed bilaterally
can be successfully used in recalcitrant cases of PGS that
do not respond to other methods such as PTC and sub-
total arytenoidectomy.
xi. The skin overlying the neck is prepped and draped
in a sterile fashion.

Fig. 28.6 Outline of extent of excision in permanent suture lateraliza-

tion technique
28
Fig. 28.7 CO2 laser excision of lateral arytenoid and lateral vocal fold Fig. 28.8 After completed excision, with extension of the excisional
tissue margin below the free edge of the vocal fold
Chapter 28 179
xii. As depicted in Fig. 28.6, the procedure involves a

■ The patient is reevaluated in the office at 1 month,
subtotal arytenoidectomy, as well as a partial re-
with flexible laryngoscopy. If mobility of one or both
moval of lateral vocal fold musculature.
arytenoids has been achieved, then consideration for
xiii. Grasping the mucosa overlying the arytenoid, the
decannulation can be undertaken.
CO2 laser is used to excise the lateral aspect of the
■ With the suture lateralization technique: The patient
arytenoid, extending the incision anteriorly into
is brought to the operating room 3–4 weeks later for
the lateral aspect of the vocal fold for a distance of
removal of sutures. Mitomycin C may be placed in the
3–4mm beyond the vocal process. The vocal process
posterior commissure as well as conservative removal of
and medial aspect of the arytenoid, along with the
any granulation tissue at that time.
mucosa overlying these structures are preserved
(Fig. 28.7).
xiv. The excision of arytenoid and lateral vocal fold mus-
Key Points
culature should continue inferiorly such that the de-
fect extends infraglottically below the free edge of
the vocal fold (Fig. 28.8). ■ PSG needs to be distinguished from bilateral true
xv. Two sutures are used to lateralize the posterior vocal
vocal fold paralysis. Ninety-five percent of the time
fold, as described in Chap. 27. “Bilateral Vocal Fold
a history of previous prolonged intubation, fol-
Paralysis”. Traction is placed on the sutures by an
lowed by a 4- to 8-week time course of progressive
assistant, while the posterior glottic scar is divided
airway obstruction, is associated with stenosis.
with a CO2 laser (Fig. 28.9).
Careful physical examination will document abnor-
xvi. The sutures are then secured over a silicone but-
malities of the cartilaginous glottis in over 80% of
ton, or a modified curved plastic oral airway device
these patients.
(with drill holes) (Fig. 28.10). ■ Laryngeal electromyography may be undertaken
xvii. Often, the same process is repeated on the contralat-
if the airway is safe or tracheotomy has been per-
eral side to obtain maximal airway results.
formed. EMG will usually show normal activity in
PGS patients.
■ Direct laryngoscopy with palpation can be used to
28.6 Postoperative Care confirm the suspected diagnosis.
■ At the time of direct laryngoscopy, attempts to
release the posterior scar band through simple
Relative to the postoperative course are the following:
excision or mucosal flaps can be undertaken.
■ Voice rest is not necessary. ■ Surgical success is usually associated with an
■ The patient is encouraged to ambulate and plug their immediate noticeable improvement in passive
tracheotomy (if present) while awake if possible. mobility of one or both vocal folds. Patients will
■ Regular diet may be resumed when the effects of anes- also notice improvement in respiratory status im-
thesia are resolved mediately after the operation.
■ LPR medical therapy is essential
Fig. 28.9 After suture lateralization, traction is placed on the sutures, Fig. 28.10 Final result, with lateralization sutures tied over a modified
while the posterior glottic scar is divided with the CO2 laser oral airway device external to the skin of the neck
■ Endoscopic attempts to restore CA joint mobil- Selected Bibliography

ity will fail if the causative injury has resulted in
cartilaginous disruption with loss of the normal
1 Koufman JA, Aviv JE, Casiano RR, Shaw GY (2002) Laryngopha-
arytenoid structure or fusion of the arytenoids to
ryngeal reflux: position statement of the committee on speech,
the cricoid ring.
voice, and swallowing disorders of the American Academy of
■ Destructive procedures such as irreversible suture
Otolaryngology-Head and Neck Surgery. Otolaryngol Head
lateralization, posterior transverse cordotomy,
Neck Surg 127:32–35
partial arytenoidectomy, or total arytenoidectomy
2 Courey MS, Bryant GL Jr, Ossoff RH (1998) Posterior glot-
(Chap. 27, “Bilateral Vocal Fold Paralysis”) may be
tic stenosis: a canine model. Ann Otol Rhinol Laryngol 107
used but are usually less successful in patients
(Pt. 1):839–846
with PGS than patients with bilateral vocal fold pa-
3 Lichtenberger G (1999) Endoscopic microsurgical management
ralysis. This is due to erosion of the posterior carti-
of scars in the posterior commissure and interarytenoid region
laginous glottis with loss of the normal dimension
resulting in vocal cord pseudoparalysis. Eur Arch Otorhinolar-
and preexisting scar tissue, which predisposes to
yngol 256:412–414
recurrent scar formation.
4 Dedo HH, Sooy CD (1984) Endoscopic laser repair of posterior
■ Mitomycin C may be beneficial in reducing scar
glottic, subglottic and tracheal stenosis by division or micro-
tissue reformation.
trapdoor flap. Laryngoscope 94:445–450
5 McIlwain JC (1991) The posterior glottis. J Otolaryngol
20(Suppl.):1–24
28
Chapter 29
Subglottic/Tracheal Stenosis:
Laser/Endoscopic Management 29
29.1 Fundamental and Related Chapters 29.3 Surgical Indications
Please see Chaps. 6, 9, 10, 13, 45, 46, and 47 for further infor-
mation. Indications include endoscopic treatment of subglottic/tracheal
stenosis for cases of symptomatic cicatricial narrowing of the
upper airway (Fig. 29.2).
Absolute contraindications to laser excision/dilation of SGS
include airway narrowing due to external compression, and
tracheomalacia, or significant cartilage collapse (Fig. 29.3).
Relative contraindications include:
Subglottic stenosis (SGS) (Fig. 29.1) and tracheal stenosis (TS)
■ Extensive length of stenosis > 2–3 cm
are terms that after often used interchangeably to describe
■ Absence of identifiable airway lumen
symptomatic airway narrowing below the vocal folds. Strictly
■ Stenosis involving the trachea at the level of the trache-
speaking, the “subglottic region” refers to the infraglottic air-
ostomy tube
way from the free edge of the true vocal folds down to the in-
ferior border of the cricoid cartilage. From a practical point of
view, many cases of upper-airway stenosis overlap the subglot-
tis/upper tracheal boundary, rendering anatomic distinctions
impractical.
Subglottic/tracheal narrowing is usually caused by scarring
within the lumen of the airway. This must be distinguished
from collapse secondary to weakened or absent cartilaginous
framework (usually tracheal), or external airway compression.
In addition, narrowing of the airway from neoplastic condi-
tions (e. g., chondrosarcoma of the cricoid) can be confused
clinically with scar in the subglottis. A more complete differ-
ential diagnosis is included in Chap. 6, “Glottic and Subglottic
Stenosis: Evaluation and Surgical Planning”.
Fig. 29.2 Diagram of tracheal stenosis due to intraluminal scar forma-

tion. Cartilaginous tracheal arches are intact. Arrow depicts the region
of stenosis adjacent to the tracheo-esophageal party wall, where care
must be taken during laser radial incisions, to avoid esophageal lumen
Fig. 29.1 Subglottic stenosis entry
182 Laser Treatment for Subglottic Stenosis
Fig. 29.3 Tracheal airway narrowing due to collapse of cartilaginous Fig. 29.4 Mapping of the stenosis using a 0° telescope. The marks are
framework (commonly seen after tracheotomy). Note the limited made on the telescope and measurements are taken directly off the
amount of airway expansion that could be achieved intraluminally telescope
d) The diameter of stenotic region is estimated in millime-

ters (the telescope diameter can be used as a guide).
e) The remainder of the trachea and proximal bronchial tree
Equipment needed for surgery includes: is visualized (and additional sites of stenosis mapped, if
appropriate).
f) A ruler is placed along the telescope:
■ 3.5 or 4.0 endotracheal tube wrapped with Cottonoid
i. The measurement from “a” to “b” represents the
externally (for mitomycin C application)
proximity of the stenosis from the true vocal folds
(useful for treatment planning if external procedures
are entertained).
The measurement from “b” to “c” represents the
length of the stenosis (in general, 1–2 cm is ideally
The example given below is typical for SGS/TS treatment in the suited for endoscopic treatment).
absence of a tracheostomy tube. 4. Pre-laser precautions (see Chap. 13, “Principles of Laser Mi-
1. The patient is anesthetized via mask induction, and the table crolaryngoscopy”)
is turned 90° to allow the surgical team to obtain visualiza- a) Protect the patient
tion of the upper and lower airway. i. Moistened eye pads
Endotracheal intubation (which can be traumatic to the ste- ii. Wrap the head in moist surgical towels.
notic region) is avoided. b) Protect the endotracheal tube (if used)
2. The tooth guard is placed, and suspension laryngoscopy is es- i Use a laser-safe tube.
tablished. ii O2 concentration of 30% or less
The laryngoscope/subglottiscope should be positioned iii Protect tube balloon by covering with a moist
proximal to the vocal folds initially (for evaluation and Cottonoid.
mapping of the stenosis), and jet Venturi ventilation (with iv If jet ventilation is used, then make sure that it is sus-
100% O2) initiated through the laryngoscope channel. pended during laser firing (note: 100% O2 concentra-
3. “Mapping” of the stenosis is carried out as follows: tions are used with jet ventilation).
a) The 0° telescope is advanced to the level of the vocal c) Protect OR personnel
folds, and a mark is made on the telescope shaft where i Safety eye wear
it intersects the proximal end of the laryngoscope (Fig. 5. Laser radial incision (CO2 laser settings 4–8 W, superpulse, or
29.4, “a”). intermittent pulse)
b) The telescope is then advanced to the upper edge of the ste- The laryngoscope should be advanced past the true vocal
notic region, and another mark is made (Fig. 29.4, “b”). folds (for protection), and positioned just above the stenotic
29 c) The telescope is then placed at the distal edge of the ste- region. The platform suction device is placed through the
nosis for the final mark (Fig. 29.4 “c”). stenosis and used to protect the distal tissues while the laser
Chapter 29 183
Fig. 29.5 Schematic view of laryngotracheal region. Note placement Fig. 29.6 Perspective view of laser radial incisions. Note planned inci-
of laryngoscope distal to the vocal folds for protection. Platform suc- sions at 12, 3, 6, and 9 o’ clock, with sparing of intervening mucosa
tion is placed underneath the stenotic shelf providing protection of
distal trachea
incisions are made. The platform suction device is engaged

by “hooking” the stenotic “shelf ” that characterizes most
upper airway stenosis (Fig. 29.5). As most stenotic lesions
are asymmetrical, the initial laser radial incision is used to
open the most severely affected portion, usually the region
that has the most extensive shelf.
While the laser is being fired, jet ventilation is suspended.
The incision should begin centrally and extend in a radial
fashion, like the spokes on a bicycle wheel. It is impor-
tant to keep the incision precise (narrow), so that a maxi-
mal amount of surrounding mucosa is preserved, which
will promote more rapid re-epithelialization. The incision
should be extended through fibrous scar tissue only. When
characteristic “sparking” of the tissue is encountered (indi-
cating the presence of cartilaginous framework), the laser
incision is terminated. Further extension of the incision
could expose cartilage leading to granulation/further scar-
ring and/or cartilage loss. Fig. 29.7 Example of predominantly right sided SGS with only three
6. Additional laser radial incisions are made. laser radial incisions needed at 12, 3, and 6 o’ clock
The orientation of the incision is commonly compared to
the hands of a clock. In the case of a perfectly symmetric
stenosis, a maximum of four laser radial incisions are typi-
cally made at 12, 3, 6 and 9 o’clock (Fig. 29.6). Again, it is be exercised when making laser incisions in the trachea at
important to maintain a strip of uninjured mucosa between 6 o’clock due to the risk of esophageal entry along the party
the incisions to facilitate re-epithelialization. From a practi- wall (see Fig. 29.2, arrow).
cal point of view, most stenotic lesions are asymmetric, and 7. The laryngoscope is advanced distally and resuspended to ex-
two to three strategically placed laser radial incisions in the pose the more inferior extent of the stenosis.
stenotic region with preservation of a normal quadrant of The 0° telescope (30° telescopes are helpful as well) is then
airway are often all that is needed (Fig. 29.7). Caution must passed through the stenosis to evaluate the extent of the
Fig. 29.8 Schematic illustration of airway after laser radial incisions (left), during rigid broncho-
scopic dilation (center), and after serial dilations are complete (right)
laser incisions. The laser radial incisions are extended dis-

tally, if indicated. Failure to extend the laser radial incisions
through the entire distal aspect of the stenosis is a common
error. This is likely due to the inherent limitations of a fixed
visual field used in microlaryngoscopy. The dynamic view
provided through the telescope provides a better view of
this distal stenotic region.
8. Rigid dilation of stenosis
Refixed-wire balloon dilators (Boston Scientific, Boston,
Mass.) are much easier and expeditious for dilatation com-
pared with rigid dilatation.
a) A series of rigid ventilating bronchoscopes (nos. 5–9) is
now used to gradually dilate the airway (Fig. 29.8). Prior
to dilation, each bronchoscope should be connected to
the anesthesia circuit via flexible rubber tubing, so that
endotracheal ventilation can be performed during dila-
tion. This is an important step due to the accumulation
of CO2 that tends to occur during prolonged jet ventila-
tion.
b) Generally, a no. 5 bronchoscope is used initially, plac-
ing the bronchoscope directly through the laryngoscope Fig. 29.9 Cottonoid-wrapped ETT segment (saturated in mitomycin
opening, and advancing past the stenosis. Surgical lubri- C) in place, allowing jet ventilation to proceed
cant placed on the tip of the bronchoscope is sometimes
helpful. The bronchoscope is then rotated 90° to achieve
maximal dilation from its eccentric shape.
c) Serial dilations are then carried out using progressively
larger bronchoscopes, stopping with the largest size that a) Application of mitomycin C to the surgical site is an im-
can be comfortably advanced past the stenosis. How- portant adjunct in the endoscopic treatment of airway
ever, bronchoscopes sized no. 6 and larger will not pass stenosis. Usually a concentration of 0.4mg/ml is used,
through most other laryngoscopes; therefore, they may but concentrations of up to 10mg/ml (supersaturated)
be passed using a sliding Jackson laryngoscope or “free- may occasionally be employed if a tracheostomy tube is
hand” without the aid of laryngoscopic guidance. A bet- in place. Two options for mitomycin c application can be
ter suited alternative is the use of a large bore Lindholm utilized:
laryngoscope (Karl Storz, Knittigen, Germany), which i. A mitomycin c–saturated Cottonoid is placed on the
will allow passage of all bronchoscope sizes (see Fig. surgical site, taking care that the entire surgical site is
25.4) Clinically successful results usually occur if dila- in contact with the pledget. The Cottonoid is left in
tion to #7 or greater bronchoscope is achieved, although place for 4–5 min, under apneic conditions, and then
dilation to #6 in females is sometimes adequate. removed. The time can be split up if the patient de-
9. Suspension laryngoscopy with application of mitomycin C saturates during the mitomycin-application period.
29 (0.4 mg/ml) ii. A Cottonoid-wrapped 3.5 or 4.0 ETT segment (2–
3 cm in length) can be saturated with mitomycin and
Chapter 29 185
placed into the airway in contact with the surgical

29.7 T-Tube Stenting of SGS
site (Fig. 29.9). This seems to provide better contact
with the surgical site as well as a providing an airway
for jet ventilation during the 4–5 min of treatment. Placement of a T-tube represents an “intermediate” step be-
The device is removed prior to returning the patient tween endoscopic and open treatments for SGS/tracheal ste-
to the anesthesia team. nosis.
10. The patient is returned to the care of the anesthesia team. Jet T-tube placement is indicated for tracheotomized patients
ventilation can be continued until the team is prepared to with subglottic/tracheal narrowing (from any cause) who have
switch to mask ventilation. The patient is awakened using failed serial CO2 radial incisions/dilation treatment.
mask ventilation and an oral airway preferably, although T-tube placement is contraindicated for patients on ventila-
other nontraumatic techniques such as laryngeal mask tory support. The open-ended design does not allow positive
ventilation are acceptable. Intubation is not recommended pressure ventilation through the external limb of the T-tube.
at the termination of the case, in an effort to avoid any SGS involving the infraglottic aspect of the vocal folds (un-
further trauma to the operative site. dersurface) is not well-suited for T-tube stenting (and is a relative
contraindication), because the proximal limb of the T-tube will
If tracheostomy is present distal to the stenotic region, then likely either interfere with vocal fold closure or lead to granula-
the case is significantly simplified—the airway is maintained tion tissue formation and obstruction of the proximal T-tube.
with standard general anesthesia delivered through the tra-
cheostomy site with a laser safe tube. The tube need only be
removed briefly for endoscopic viewing of the entire upper
airway at the beginning of the case, and again for dilation at
the end of the case. An apneic technique is used during tube
removal for the tracheal evaluation and dilation aspect of the Surgical equipment needed includes the following:
procedure. 1. All of the equipment listed for CO2 laser radial incisions
and dilation
2. Commercially produced standard T-tube stents:
a) Hood adult sizes 10–16 (size indicates outer diameter in
millimeters)
and Complications
b) Montgomery adult sizes 10–16 (size indicates outer di-
ameter in millimeters)
Postoperatively, management includes: 3. One of the following to occlude/bypass the proximal end of
the T-tube for ventilation:
■ The patient is observed overnight in an ICU or step-
a) Fogarty catheter with 3- to 5-ml balloon capacity
down unit. With experience, and especially with pa-
b) Hemostat/clamp
tients who are having repeated endoscopic treatments,
c) Small-diameter ETT (4.0)
such monitoring may not be necessary.
4. Connector piece from a small bore (4.5–6.0) ETT (i. e., the
■ Chest x-rays should be obtained if the patient has any
detachable piece of the ETT in which you connect your ven-
unexpected findings postoperatively, such as SpO2
tilation circuit). Ensure that this piece fits snuggly into the
values less than 95%, shortness of breath, chest/pleuritic
ventilation port of the T-tube to be used.
pain, or subcutaneous crepitance in the neck.
■ Perioperative steroids are important:
■ 10 mg Decadron intravenously
■ Oral steroid-taper 29.9 Surgical Procedure
■ Additional postoperative meds:
■ PPIs for at least 2 months, until healing is complete
A preexisting tracheostomy is required to perform T-tube place-
■ Antibiotics for 5–7 days (optional)
ment.
■ Pain medications (usually from tongue compression)
1. Steps 1–8 of CO2 laser radial incisions and dilations are first
■ Cough suppressants (Tessalon Perles 100 mg three
performed (as outlined in Sect. 29.5), until an adequate air-
times daily, as needed)
way caliber is obtained.
2. Suspension laryngoscopy is performed, and an assistant plac-
Complications can include: es a rigid endoscope, connected to a camera/monitor to visu-
alize the airway during the placement of the T-tube stent, and
■ Laser fire
to assist in positioning the stent (Fig. 29.10).
■ Tracheal penetration with pneumomediastinum/pneu-
3. An appropriate T-tube stent is selected according to the diam-
mothorax
eter of the airway after dilation.
■ Late postoperative edema/granulation/fibrinous exu-
In general, sizes 11–14 (Hood) are used. The stent is steril-
dates with airway obstruction
ized prior to placement (Fig. 29.11).
■ Tracheoesophageal fistula (exceedingly rare)
4. A nasogastric (NG) tube is placed through the external limb
■ Reccurent stenosis
of the T-tube, and up through the proximal (shorter limb). A
Fig. 29.10 An assistant provides visualization (with a 0° telescope) of Fig. 29.11 T-tube stent prior to placement
the airway during T-tube placement
Fig. 29.12 An NG tube is placed through the external limb of the T- Fig. 29.13 The proximal end of the T-tube is passed into the
tube, up through the proximal (shorter limb), and clamped in place airway and the NG tube is grasped by the assistant via endo-
scopic visualization
clamp is placed at the external limb of the tube, which fixes tracheal airway (Fig. 29.15). This step may be difficult, and
the T-tube to the indwelling NG tube (Fig. 29.12). The tip of might need to be attempted a few times before the T-tube
the NG tube is then placed through the tracheal stoma and can be successfully positioned in the distal airway.
advanced into the proximal trachea. Working through the 6. The assistant uses the rigid telescope to visualize the entire
laryngoscope, the assistant grasps the NG tube with a large length of the T-tube to insure patency and adequate position-
laryngeal cup forceps/grasper. The NG tube is pulled into ing in the airway (Fig. 29.16).
the upper trachea, seating the proximal end of the T-tube in The T-tube should not be kinked, twisted, partially occluded,
the airway (Fig. 29.13). or “loose” in the airway. In addition, the proximal end of the
29 5. The distal end of the T-tube is crimped (Fig. 29.14) with a he- T-tube should not come within 5 mm of the undersurface of
mostat, and advanced through the stoma, and into the distal the vocal folds. The distal end should not come in contact with
Chapter 29 187
Fig. 29.14 The distal end of the tube is crimped with a curved clamp Fig. 29.15 The clamped distal end of the tube in advanced into the
distal trachea through the stoma
Options include:
a) LMA (laryngeal mask ventilation)
b) Occlusion of the proximal end of the T-tube with a endo-
scopically positioned Fogarty catheter. A connector from
an ETT is placed into the external limb of the T-tube for
ventilation distally (Fig. 29.17).
c) Occlusion of the proximal end of the T-tube using a he-
mostat/clamp placed through the stoma at the proximal
end of the T-tube (care must be taken not to also occlude
the external limb). Again, a connector from an ETT is
Fig. 29.16 The assistant passes the telescope through the T-tube into placed into the external limb of the T-tube for ventilation
the distal trachea to insure good placement and patency of the lumen distally (Fig. 29.18).
of the tube 8. Once the patient is breathing spontaneously, without ventila-
tory support, the external limb of the T-tube should be capped
(closed), so that the patient is now moving air oronasally.
the carina. A properly seated T-tube should fit snuggly in the Inability to cap the T-tube (for any reason) when the patient
airway and maintain its shape/patency regardless of patient is fully awake and recovered from anesthesia, is cause for
position/neck movement. If the above conditions are not met, concern. An uncapped T-tube can lead to drying/crusting
then T-tube placement will ultimately fail due to granulation of airway secretions within the tube, and ultimately luminal
tissue formation and occlusion of the tube. A good indicator obstruction of the stent. Successful maintenance of long-term
of successful T-tube placement is the ability of the patient to T-tube stent in the airway cannot be achieved unless the tube
maintain good air exchange with the T-tube capped at the is capped during the majority of the patient’s waking hours.
end of the surgical case and in the recovery room. Patients with coexisting obstructive sleep apnea can often un-
7. Once the T-tube is positioned, the patient must be ventilated cap the T-tube at night, as long as humidified air is used by
until he/she is able to breathe spontaneously. the bedside.
Fig. 29.17 Occlusion of the proximal end of the T-tube with a Fogarty catheter to allow venti
lation
29 Fig. 29.18 Occlusion of the proximal end of the T-tube with a curved clamp to allow ventilation
Chapter 29 189
Complications include the following:

■ T-tube occlusion due to poor position/incorrect size of
T-tube
Postoperatively:
■ Granulation tissue at proximal or distal end of T-tube
1. Observation of the patient in a monitored setting for 24 h
■ This presents within the first 2 months postopera-
(ICU or step-down unit)
tively, and must be dealt with by either removal/
2. Ten milligrams intravenous Decadron preoperatively, and
cryotherapy of the granulation tissue, or by replacing
every 8 h (×2) during hospitalization
the stent with a more appropriate T-tube. Patients
– Consider prednisone/methylprednisone oral taper at dis
are at higher risk for this complication if the T-tube
charge
is “modified” by cutting off a portion of the proximal
3. Additional postoperative medications:
or distal tube. This modification replaces the inert,
– PPIs for at least 2 months, until healing is complete
smooth “factory” edge of the tube with a sharper, re-
– Antibiotics for 5–7 days (optional)
active surface—often resulting in granulation tissue
– Pain medications (usually from tongue compression)
formation at the tube/tissue interface. If customiza-
– Cough suppressants (Tessalon Perles 100 mg three times
tion of the T-tube cannot be avoided, it is important
a day, as needed)
to bevel and smooth the cut edges, as described by
Montgomery et al.
4. Tracheostomy tube at bedside, one size smaller than that of
■ Hoarseness/aphonia due to extension of the proximal
the T-tube:
end of the T-tube into or through the glottis
■ Edema and granulation tissue of the vocal folds can
T-tube size Tracheotomy tube size (Shiley) result, as well as incomplete glottal closure. If trans-
10 2 glottic extension of the superior limb of the T-tube
11 2 cannot be avoided, then the upper limb should be
located at the ventricle/inferior false vocal fold level.
12 4
■ Accidental T-tube displacement/removal
13 4 ■ The use of large bore suction catheters (10 French
14 6 or greater) can lead to this. Nine French or less is
recommended for cleaning/suctioning.
15 6
■ Cracking/splintering of the T-tube
16 8 ■ Although uncommon, this can occur with prolonged
(>3 years) T-tube placement. To avoid this, replace-
ment of the T-tube should be performed every 2
5. Humidified air at bedside, especially during sleep
years.
6. Suctioning of the upper and lower limb of the T-tube every
8 h and as needed
• An excellent nursing/patient instruction manual is in-
cluded with the Hood T-tube package
29.11 Special Considerations
7. Prior to discharge from the hospital, educated patient/care-
in T-Tube Stenting
givers regarding emergency measures in the event that the
T-tube becomes obstructed at home:
• Uncap T-tube first; if this does not improve breathing, T-tube stenting of the airway is intended as long-term man-
then suction upper and lower limb of T-tube/irrigate agement strategy for patients with SGS/tracheal stenosis, who
with 2 ml normal saline. have failed endoscopic laser treatments. However, in select cas-
• If still unable to move air adequately, then grasp and pull es, removal of the T-tube can be attempted, after a minimum
firmly on external limb of T-tube to remove it. period of 1–2 years of stenting. The T-tube should be removed
• Come to the Emergency Department immediately; page in the OR, and careful postoperative monitoring should be un-
the surgeon. A tracheostomy tube can be placed through dertaken for at least 2–3 month/hs after stent removal to check
the stoma as a temporizing airway until arrangements to for recurrence of stenosis.
replace the T-tube (in the OR) can be made.
8. Follow up in the office frequently in the first 2 months post-
operatively (every 1–2 weeks depending on patient’s reli-
Key Points
ability/family support/anxiety level)
• The inside of the T-tube should be inspected each visit,
using a flexible laryngoscope to insure upper and lower ■ Endoscopic treatment of subglottic and tracheal
limb patency and to check for reactive granulation tis-
stenosis is an excellent management option, and
sue. Crusting in the external limb can be cleaned with a
in most cases, is the first method attempted before
cerumen loop.
embarking on open surgical treatment.
• Review importance of suctioning/cleaning of tube and
humidification
■ Absolute contraindications for endoscopic treat- ■ Placement of a T-tube stent represents a interme-
ment of stenosis include airway narrowing due to diate step between pure endoscopic treatment
external compression and tracheomalacia/carti- and open procedures for laryngotracheal stenosis.
lage collapse of the airway ■ A good indicator of successful T-tube placement
■ Relative contraindications for endoscopic treat- is the ability of the patient to maintain good air
ment of airway stenosis include extensive length exchange with the T-tube capped at the end of the
of stenosis (greater than 2–3 cm in length), com- surgical case.
plete stenosis (no identifiable lumen), and stenosis ■ Careful follow-up for cleaning and inspection of
at the level of the tracheostomy. the T-tube in required in the first 2 months after
■ “Mapping” of the stenosis is an important part T-tube placement.
of the initial evaluation of airway stenosis, and is
helpful for determining treatment planning.
■ The CO2 laser is generally the workhorse laser for
endoscopic airway management. Selected Bibliography
■ Laser radial incisions are used to open the steno-
sis, while simultaneously preserving surrounding
1 Montgomery WW, Montogomery SK (1990) Manual for use of
mucosa for re-epithelialization.
Montgomery laryngeal, trachea and esophageal prostheses: up-
■ Topical application of mitomycin C after endo-
date 1990. Ann Otol Rhinol Laryngol 99:2–28
scopic treatment greatly increases the chance for
2 Shapshay SM, Beamis JF, Hybels RL et al (1987) Endoscopic
success.
treatment of subglottic and tracheal stenosis by radial laser inci-
sions and dilation. Ann Otol Rhinol Laryngol 96:661–664
29
Chapter 30
Carcinoma of the Vocal Fold

30
fold carcinoma prior to surgical excision should ensure that
the cancer has not spread laterally into the ventricle, the infra-
glottis, or the supraglottis. The spread of the cancer to the an-
Please see Chaps. 4, 10, and 13 for additional information. terior or medial border of the arytenoid cartilage is somewhat
controversial regarding resectability via a microlaryngoscopy
approach. Normal vocal fold motion must be assured to con-
firmed early glottic disease.
The most common method for excision of early vocal fold
carcinoma is using the CO2 laser via a microlaryngoscopy ap-
proach. Cold-steel excision can also be used either in combi-
This chapter discusses the surgical treatment of squamous cell nation with CO2 laser or exclusively, depending on the loca-
carcinoma of the glottis (T1N0M0). Nonglottic laryngeal sites tion and depth of the cancer. The CO2 laser has the advantage
of cancer and advanced laryngeal cancer disease that spreads of precision, small spot size and its hemostatic properties for
from the level of the vocal fold to other sites are not discussed. excision of the vocal fold cancer. A cold-steel excision is best
Vocal fold cancer involves epithelial migration or invasion via suited for relatively superficial lesions that have neither deep
malignant transformation into the lamina propria and muscle muscle involvement nor cartilage involvement (arytenoid).
of the vocal fold. Differential diagnosis of early vocal fold carcinoma is:
The most common symptoms associated with vocal fold
■ Hyperkeratosis/dysplasia
carcinoma include hoarseness, change in pitch, and rough-
■ Carcinoma in situ
ness of the voice. For most patients with early vocal fold car-
■ Recurrent Respiratory Papillomatosis
cinoma (Fig. 30.1), the more advanced head and neck cancer
■ Verrucous carcinoma
related symptoms of odynophagia, otalgia, neck mass, or dys-
■ Spindle cell carcinoma
phagia are rarely present. Early vocal fold carcinoma can oc-
■ Tuberculosis
cur unilaterally (T1aN0M0) or bilaterally (T1bN0M0). The
■ Fungal disease (histoplasmosis, blastomyocosis)
specific anatomic sites of the vocal fold that are important to
take into consideration when assessing early vocal fold carci-
noma include the anterior commissure, laryngeal ventricle,
infraglottis, and the arytenoids. The assessment of early vocal
Indications for surgery include T1aN0M0 SCCa of the vocal

fold.
■ Inadequate microlaryngoscopic exposure of the entire
vocal fold lesion
■ T2N0M0 staging with > 5-mm supraglottic or intraglot-
tic extension, partial vocal fold fixation, or arytenoid
involvement (note: patient counseling must include the
treatment option of radiation therapy).
Equipment needed includes:

■ Tongue blade with fine gauge needles
Fig. 30.1 Early carcinoma of the vocal fold
192 Carcinoma of the Vocal Fold
30 even fashion (similar depth) for best exposure during the

excision (Fig. 30.3).
7. Complete the anterior, posterior, and lateral borders of
the excision down to the appropriate depth that will allow
complete excision of the cancer without excessive removal
of normal deep laryngeal tissue. Once the anterior, poste-
rior and lateral borders of the excision are completed, the
cancer excision can be retracted with a triangular forceps
or curved alligator medially for exposure of the inferior
border for excision.
8. Prior to the release of inferior excision, it is important to
make a mental note of the exact location of the retraction
instrument on the specimen, specifically, which border
and where on the border the instrument is. This is very
helpful for the orientation of the cancer excision imme-
diately after the release of the inferior attachment of the
excision (Fig. 30.3).
9. With the cancer excision specimen retracted medially,
straight-up scissors or the laser can be used to release
the inferior border of the excision and remove the lesion
for orientation (Fig. 30.3). This lesion can be placed on a
tongue blade and fixed into position with anatomic ori-
entation. The deep margin of the excision lays on the sur-
Fig. 30.2 Vocal fold cancer seen via microlaryngoscopy with CO2 la- face of the tongue blade and then the anterior, lateral, and
ser created marks for proposed excision boundaries (anterior, poste- posterior borders of the excision are noted on the tongue
rior, and lateral) blade. Small-gauge pins are used to secure the excision
specimen to the tongue blade (Fig. 30.4). It is best to physi-
cally review the preoperative cancer excision photographs
and the tongue blade orientation with the pathologist im-
mediately after the excision in the operating room. Serial
sectioning (using routine histopathology processes) can
be used to map the nature of the pathology throughout
1. Exposure of vocal fold cancer via suspension microlar- the specimen and especially at the margins.
yngoscopy should allow complete visualization of the le- 10. Carefully evaluate the margins of the excision via high-
sion. power microlaryngoscopy and the angled telescopes,
2. Detailed and angled visualization with telescopes, specifi- looking for other areas of abnormal epithelium or tissue
cally, 30 and 70° telescopes, is essential. Using this meth- that would require biopsy or further excision.
od, it is very important to evaluate the borders of the vocal 11. Microcup forceps can be used to take selected margins
fold cancer from an anterior–posterior, lateral, and infra- (lateral, anterior, posterior, inferior, deep) as indicated.
glottic perspective. These can be sent for frozen section analysis or permanent
3. Implement all laser safety procedures including protection pathological evaluation. Frozen section processing of the
of the endotracheal tube cuff, patient head and neck pro- excisional tissue is generally avoided due to inherent in-
tection, and eye protection for all individuals in the OR accuracies in determining margins in a small specimen,
(see Chap. 13, “Principles of Laser Microlaryngoscopy”). especially with laser artifacts.
4. With vocal fold palpation, a decision should be made be-
tween using the CO2 laser and cold-steel excision.
5. Using the CO2 laser on a single-fire setting, outline the area
of excision anteriorly, posteriorly and laterally around the
and Complications
vocal fold cancer with approximately 1- to 2-mm margins
of excision (Fig. 30.2).
6. Using the CO2 laser on a repeat superpulse mode with Immediately postoperatively:
a relatively small spot size (approximately 0.3 mm), in-
■ Same-day surgery discharge on an outpatient basis is
cisions can be made around the vocal fold cancer in an
typical for this type of vocal fold cancer excision.
anterior, lateral, and posterior dimension. Care should be
■ No voice rest indicated.
taken to make these initial cuts perpendicular to the su-
■ Laryngopharyngeal reflux treatment with PPIs may
perior surface of the vocal fold, without any medial or lat-
reduce granuloma formation at the operative site.
eral “skiving” of the incisions. Also, it is best to incise the
■ Follow-up with patient, depending on the results of the
anterior, posterior and lateral excision borders in a fairly
final pathology report
Chapter 30 193
Fig. 30.4 Orientation and pinned vocal fold cancer excision specimen
on tongue blade
Fig. 30.3 Medial retraction of vocal fold cancer excision with expo-
sure of the inferior border for excision (with scissors in place for final
excision)
Complications include:
■ Bleeding from the deep excision location Selected Bibliography
■ This can be treated with an application of topical epi-
nephrine on a Cottonoid and/or using the CO2 laser
1 Myers EN, Wagner RL, Johnson JT (1993) Microlaryngoscopic
with a defocused beam for coagulation purposes.
surgery for T1 glottic lesions: a cost effective option. Ann Otol
■ Granulation tissue at operative site
■ This granulation tissue commonly occurs within
2 Zeitels SM (1993) Microflap excisional biopsy for atypia and mi-
2–4 weeks and will slowly involute over time. If the
croinvasive glottic cancer. Operat Tech Otolaryngol Head Neck
granulation tissue is slow to involute, causing signifi-
Surg 4:218–222
cant dysphonia or breathing problems, then this can
3 Zeitels SM (1995) Premalignant epithelium and microinvasive
be re-excised either in the operating room or in an
cancer of the vocal fold: the evolution of phonomicrosurgical
office-based setting.
management. Laryngoscope 105(Pt. 2):1–51
■ Residual tumor/recurrence
4 Zeitels SM, Hillman RE, Franco RA, Bunting GW (2002) Voice
and treatment outcome from phonosurgical management of ear-
ly glottic cancer. Ann Otol Rhinol Laryngol 190(Suppl.):3–20
Key Points
■ Exposure is essential to successful microlaryngos-

copy excision of vocal fold carcinoma.
■ Orientation of the excision specimen on a tongue
blade is extremely helpful to further management
of any positive margins that occur on the final
pathologic analysis and to minimize the amount
of tissue that is damaged or removed during the
treatment of early vocal fold carcinoma.
Pathology
IV Laryngeal Injection
Techniques
Chapter 31
Vocal Fold Augmentation

via Direct Microlaryngoscopy 31
This technique is discussed in Chap. 32, “Superficial Vocal Fold
Augmentation via Microlaryngoscopy.”
Injection augmentation can also be carried out in a deep
Please see Chaps. 5, 8, 10, 14, 32, 33, and 34 for further infor- or lateral vocal fold position. This injection location is used to
mation. augment globally the vocal fold for cases of significant glottal
incompetence due to:
■ Vocal fold paralysis
31.2 Disease Characteristics ■ Vocal fold paresis
■ Vocal fold atrophy
■ Sulcus vocalis
Vocal fold injection can be an extremely useful treatment
■ Severe vocal fold scar
method for a variety of voice disorders. There are different lo-
■ Soft tissue loss of the vocal fold(s)
cations, injection materials and methods to perform vocal fold
injection (see Chap. 14, “Principles of Vocal Fold Augmenta-
tion”). The advantage of injection augmentation versus open
laryngeal procedures (laryngeal framework surgery) is the
endoscopic and minimally invasive nature. Other advantages
31.2.1 Material Selection
include a more direct visualization of the vocal fold pathology
requiring treatment.
Injection augmentation can be divided into two specific The ideal vocal fold injection material would be readily avail-
anatomic locations, with subsequent different indications, ma- able, inexpensive, easy to use and completely biocompatible.
terials, and methodologies applied to all of these locations. A The search for such a material has been ongoing for close to a
superficial or medial vocal fold injection is performed for the 100 years, and significant advances in vocal fold injection ma-
treatment of vocal fold scarring or focal loss of lamina propria. terial availability and design have occurred in the last 10 years.
The original injection material was paraffin, which resulted in
a significant foreign body response and rejection. Similar re-
sponses have occurred with Silicone injections as well as more
recently with Teflon® vocal fold injections. An additional re-
quirement of all future vocal fold injection materials will be a
matching of the biomechanical properties of the material with
the biomechanical properties of either the superficial aspect of
the vocal fold (superficial layer of the lamina propria) or the
deep aspect of the vocal fold (vocalis, thyro-arytenoid and lat-
eral cricoarytenoid muscle).
The materials presently available for vocal fold injection
include (see Chap. 14, “Principles of Vocal Fold Augmenta-
tion”):
■ Autologous
® fat
■ Radiesse (calcium hydroxylapatite)
■ Teflon
■ Gelfoam®
■ Radiesse Voice Gel®
■ Bovine collagen–based products (Zyplast®, Zyderm®)
■ Human collagen–based ®products
(Cymetra®, Cosmoplast , Cosmoderm)
■ Hyaluronic acid–based products
(Hyalaform®, Hyalaform Plus®, Restylane®, Perlane®)
■ Autologous fascia (minced)
Fig. 31.1 Deep vocal fold augmentation locations
198 VF Augmentation – Microlaryngoscopy
All of these materials other than Cymetra and other collagen-

■ Vocal fold injection needle and device
based produces have been designed and used for deep vocal
■ Zero degree Hopkins telescope (4–5 millimeters in
31 fold augmentation. Bovine collagen, autologous collagen, and
diameter and 30 cm long)
human-based collagen are all products that have been used in
■ C-mount camera and video monitor
the past or are presently being used for superficial vocal fold
augmentation (see Chap. 32, “Superficial Vocal Fold Augmen-
tation via Microlaryngoscopy”).

Selection of the vocal fold augmentation technique is deter-
mined by the underlying etiology, the vocal fold injection loca-
Vocal fold augmentation is indicated for the patient with glot- tion, comfort level of the surgeon, and the vocal fold injection
tal incompetence; however, the degree, nature, and cause of the material. The options for vocal fold injection methodology in-
glottal incompetence need to be further elucidated. Incomplete clude percutaneous, transoral, endoscopic direct laryngoscopy,
vocal fold closure is divided into global or focal deficit of the and via microlaryngoscopy (see Chaps. 33, “Peroral Vocal Fold
vocal fold. Furthermore, the nature of the glottal incompetence Augmentation in the Clinic Setting” and 34, “Percutaneous
can be identified as to either a lack of muscle bulk or of lamina Vocal Fold Augmentation in the Clinic Setting”).
propria (or both). For disorders that cause global glottal in-
competence and/or lack of vocal fold bulk such as vocal fold
paralysis, vocal paresis, and vocal fold atrophy, a deep vocal
31.5.1 Principles of Deep Vocal
fold augmentation is the preferred injection approach.
Fold Augmentation
Prior to vocal fold augmentation, careful evaluation and
consideration of the patient’s airway is warranted. Patients with
poor abductory range of motion on the contralateral vocal fold Principles of deep vocal fold augmentation comprise the fol-
or with poor bilateral vocal fold abduction are at significant lowing:
risk for airway compromise postoperatively. This contraindi- 1. The vocal fold should be injected at the intersection of two
cation is especially true for vocal fold lipoinjection, which re- anatomic landmarks:
quires significant overinjection of the vocal fold (see Chap. 14, a) At the level of the vocal process
“Principles of Vocal Fold Augmentation”). b) At the transition zone from the superior surface of the
vocal fold to the ventricle (superior arcuate line). The
junction of these two anatomical locations is the optimal
location for a deep vocal fold injection (Fig. 31.1).
2. The vocal fold injection needle should be angled slightly lat-
erally and placed approximately 3–5 millimeters deep to the
Vocal fold augmentation via microlaryngoscopy requires follow- mucosa prior to the injection. Injection can then be done
ing: in a graded or step-wise fashion, observing the immediate
impact of the vocal fold injection on vocal fold size, bulk,
■ Standard phonomicrosurgery equipment (see Chap. 10)
position, and glottic closure. Optimal needle placement is
■ Vocal fold injection needle and device
confirmed when the initial augmentation is seen at the level
of the infraglottis. After reasonable infraglottic augmenta-
Lipoinjection of the vocal fold requires: tion, further injection will often spread superiorly to aug-
ment the vocal fold at the level of the glottis or the injection
■ Standard phonomicrosurgery set (See Chap. 10)
needle can be withdrawn 1–2 mm to finish the vocal fold
■ Brunings syringe vocal fold injection device with
augmentation in the region of the midmembranous vocal
18- and 19-g needles (Storz, St. Louis, Mo.) or Instru-
fold (Fig. 31.2).
mentarium lipoinjection device (Instrumentarium
3. Often, a second injection site is required along the superior
Surgical Corp., Inc., Montreal, Quebec, Canada).
arcuate line in the region of the midmembranous vocal fold
■ Liposuction device (large bore, low pressure) (Tulip™)
(Fig. 31.1).
or small “plastics” instrument tray for open harvest
4. It is important to remember that the best deep vocal fold
■ Sterile funnel
injection is placed lateral within vocal fold, and this is opti-
■ Merocel™ sponges
mally achieved with a slightly angled injection needle that
(Medtronic-Xomed, Jacksonville, Fla.)
is not completely parallel to the longitudinal axis of the la-
ryngoscope (thus the advantage of using a slotted laryngo-
Endoscopic vocal fold injection requires the following: scope). This can be further enhanced by purposefully posi-
tioning the laryngoscope to visualize the lateral aspect of the
■ Slotted small laryngoscope (anterior commissure laryn-
vocal fold ventricle as opposed to the midline of the glottis.
goscope; Pilling, Fort Washington, Pa.)
Chapter 31 199
6. Over-correction as depicted on Fig. 31.7 should be

31.5.2 Vocal Fold Augmentation
achieved.
via Microlaryngoscopy
7. Lidocaine is sprayed on the larynx after the vocal fold in-
jection is completed to help prevent postoperative laryngo-
Suspension microlaryngoscopy with general anesthesia can be spasm.
used to perform vocal fold augmentation. The advantages of
this approach are outstanding visualization and precise vocal
fold injection placement. The disadvantage is the lack of an
31.5.3 Endoscopic Vocal Fold Injection
endpoint due to the inability to assess vocal fold closure.
1. Review of the preoperative videolaryngoscopy and/or vid-
eostroboscopy is an important start to vocal fold augmenta- Endoscopic vocal fold injection is used for a deep vocal fold
tion. augmentation. This technique allows the surgeon a magni-
2. After adequate general anesthesia and complete muscle re- fied, detailed view during vocal fold augmentation, with the
laxation has been achieved by the anesthesiology team, a patient awake. This allows visualization of vocal fold motion
large bore laryngoscope is suspended, providing complete and closure before, during, and after the injection. This injec-
visualization of the vocal fold (see Chap. 10, “Principles of tion technique is also advantageous given that it allows the vo-
Phonomicrosurgery”). cal fold injection to be performed with complete visualization
3. Angled telescopes (0, 30, and 70°) are used to visualize the of the procedure by both student and mentor simultaneously.
entire larynx in a “three-dimensional fashion,” which al- Endoscopic vocal fold injection involves a deep vocal fold
lows one to fully assess the lack of bulk and exact pathology augmentation using a small slotted laryngoscope under a lo-
that is to be corrected with the vocal fold augmentation (see cal anesthesia (with minimal intravenous sedation). A surgical
Chap. 10). telescope provides endoscopic visualization for the procedure.
4. Deep vocal fold augmentation should be performed at this 1. Preoperative anesthesia is a crucial aspect of this proce-
vocal fold injection site approximately 3–5 mm deep to the dure. Topical nebulized 4% plain lidocaine should be ad-
mucosa, and the needle should be angled as lateral as pos- ministered for 10–15 min prior to the operative procedure.
sible as it is placed through the laryngoscope. To ensure a Additional 4% plain lidocaine can be directly applied to
lateral vocal fold injection site, it is wise to position the la- the oropharynx and endolarynx via indirect laryngoscopy
ryngoscope with the suspension device angled in a lateral and/or direct laryngoscopy. Alternative anesthesia methods
facing direction (Fig. 31.3). include trans-tracheal lidocaine injection and/or superior
5. Visualization of the vocal fold during the vocal fold injec- laryngeal nerve block (either percutaneous or via the pyri-
tion allows one to determine the ideal amount and location form sinus).
of the injection by observing immediate changes in the vo- 2. Preoperative anesthesia will allow the slotted anterior com-
cal fold contour during and after the injection. missure laryngoscope (Pilling) to be passed through the
Fig. 31.2 Depth of injection needle for deep vocal fold augmentation Fig. 31.3 Angled laryngoscope position for deep vocal fold augmenta-
tion via microlaryngoscopy
oral cavity and oropharynx and to pick up the tip of the 4. A 0° telescope (30 cm, 4- to 5-mm diameter) is then passed
epiglottis. With this visualization, 4% plain lidocaine can be through the manually suspended laryngoscope. The vocal
31 applied directly to the endolaryngeal region and intended fold motion, closure pattern, and the glottal incompetence
vocal fold. deficit are noted by visualization through either the endo-
3. After adequate laryngeal anesthesia is achieved and a small scope or a camera attached to the endoscope (Fig. 31.4).
amount of intravenous sedation is given, the slotted laryn- 5. The injection device is then passed into the laryngoscope
goscope is then advanced with the nondominant hand, parallel with the endoscope, using the visualization achieved
immediately over the vocal fold to be injected and manu- by the endoscope for guidance. Deep vocal fold injection is
ally suspended. The laryngoscope is positioned to slightly performed (Figs. 31.5, 31.6).
retract the false vocal fold to allow complete visualization 6. Once adequate vocal fold augmentation is obtained by di-
of the entire length of the membranous vocal fold and the rect visualization (Fig. 31.7), the needle can be retracted
ventricle of the intended site for injection. and kept sheathed within the laryngoscope, and vocal fold
closure is visualized during the patient’s phonation. The
need for any further injection is determined.
31.5.4 Lipoinjection of the Vocal Fold
Lipoinjection of the vocal fold is designed to be a deep/lateral

vocal fold injection, resulting in medialization and augmenta-
tion of the vocal fold by deposition of autologous fat. Lipoin-
jection can be done via an endoscopically guided peroral ap-
proach or a microlaryngoscopy approach (see above). Given
the viscous nature of the fat, a pressurized injection device
such as a Brunings syringe or the lipoinjection device designed
by Instrumentarium is required. Fat harvest for lipoinjection
can be done either through open incision with harvesting sub-
cutaneous fat or via liposuction. Liposuction is the preferred
technique because it is expedient, less invasive, and provides
perfectly sized injection material. For patients with only “mod-
est” amounts of subcutaneous fat, open harvest is recommend-
ed. The most reasonable location for open harvest is in the in-
Fig. 31.4 Overview of endoscopic vocal fold injection fra-umbilical region or through a preexisting abdominal scar.
The former area of the body typically has a plentiful amount
of material and an incision immediately inside the umbilicus
can be easily hidden. Fat harvest can be done under local or
general anesthesia.
1. Open fat harvest
a) The abdomen is prepped and draped in a sterile fashion.
b) Local injection of lidocaine with epinephrine is done as
a regional block for local anesthesia, or only at the pro-
posed incision site for hemostasis if under general anes-
thesia.
c) A curvilinear incision is made at the junction of the
umbilicus and the infra-umbilical region, from approxi-
mately 4 to 8 o’clock.
d) Subcutaneous elevation of the dermis proceeds in an
inferior direction, releasing the subcutaneous fat off the
subdermal plane.
e) The fat is sharply dissected out with cold-steel instru-
ments, taking care not to violate the skin above or the
peritoneum below.
f) Hemostatis is attained with electric cautery as needed,
and tacking sutures are placed in the deeper aspect of the
wound to the subdermal plane.
g) The harvested fat is then carefully cut into small pieces
with scissors, approximately 1 × 2 × 1 mm in size. (This
Fig. 31.5 Endoscopic vocal fold injection method aspect of the procedure is time consuming and laborious
Chapter 31 201
but important. If the fat graft is not properly prepared,

then it will not flow smoothly through the injection nee-
dle.)
h) The fat graft material is then handled in a similar manner
as the liposuction harvest material (described below).
2. Liposuction fat harvest for lipoinjection
Liposuction should be performed using a large bore, low-
pressure liposuction technique. Small-gauge and high-pres-
sure liposuction devices should be avoided to minimize
trauma to the fat during the harvest process. An excellent
liposuction cannula is made by Tulip™ (San Diego, Calif.)
that includes a 4.6-mm diameter, single-hole liposuction
cannula with low-pressure suction applied to the cannula.
Liposuction from the subcutaneous abdominal space can
be done under general or local anesthesia. The latter re-
quires local anesthesia injection in the area of the intended Fig. 31.6 Endoscopic vocal fold injection method
liposuction.
a) The abdominal skin is prepped and draped in a sterile
fashion.
b) A small skin incision (approximately 5 mm) is made in
the right upper quadrant of the abdomen.
c) The liposuction cannula is passed through the skin and
into the subcutaneous space, and negative pressure is ap-
plied to the liposuction cannula.
d) The liposuction cannula is then moved rapidly in the
subcutaneous space in a transverse direction across the
patient’s abdomen, with great care taken to control the
plane and location of the liposuction tip to avoid pene-
tration into the peritoneum or the overlying skin. Pinch-
ing the skin to create “tunnels” helps develop a safe plane
for fat harvest (Fig. 31.8).
3. Preparation of fat for lipoinjection
Fat harvested by any method is covered with free fatty acids,
blood, and serum. The free fatty acids are from ruptured li-
pocytes and induce an intense inflammatory response if not
removed prior to lipoinjection. This inflammatory response
will diminish the graft survival. The fat must be carefully Fig. 31.7 Photo demonstrating the appropriate amount of overcorrec-
and thoroughly rinsed and carefully handled prior to li- tion (15–30%, or an additional 0.1–0.2 ml of material) used for most
poinjection to maximize graft survival. injectables
a) Fat from either open or liposuction harvest is placed in
a sterile funnel that is lined with strips of Merocel (Fig.
31.9). previously described deep vocal fold injection techniques
b) Suction tubing is applied to the downward spout of the (see above). Great care should be taken to avoid injection of
funnel, and 2 liters of saline is used to rinse and irrigate fat material into the:
the blood and fatty acids from the surface of the har- a) Ventricle
vested fat. b) Subglottis
c) The fat is then transferred into a small dish with 100 U c) Superficial planes of the lamina propria
of regular insulin and soaked for 5 min (the insulin is Lipoinjection of the vocal fold should be performed with
theorized to stabilize the lipocyte cell membranes and the goal of substantial overinjection of the vocal fold to
thus improve cell survival during the transplantation allow for expected fat loss during the transplantation
process). process (Fig. 31.11).
d) To remove excess moisture, the fat is then placed on a Care should be taken to restrict lipoinjection unilaterally
dry Merocel sponge and partially dried by air for several if the patient has vocal fold paralysis and poor abduction
minutes. of the contralateral vocal fold. More aggressive lipoinjec-
e) The harvested material can then be loaded into the injection can be carried out safely when both vocal folds are
tion device in preparation for lipoinjection (Fig. 31.10). mobile. Often, bilateral lipoinjection patients with mobile
4. Lipoinjection of the vocal fold vocal folds will be done to the extent that after immediate
The approach and exposure of the vocal fold and injection completion of the procedure the membranous vocal folds
sites for Lipoinjection of the vocal folds are identical to all will be in complete approximation.
Airway obstruction is rare and can be treated with oral or

intravenous steroids, antibiotics, airway observation, and hu-
and Complications
31 midification. If the airway obstruction is severe, then the treat-
ment options include intubation to allow laryngeal edema to
The voice rest requirement of postoperative care for patients resolve or tracheotomy to bypass the airway obstruction.
with deep vocal fold injection is highly variable. After lipoin- Swallowing difficulties can also occur from the irritation
jection of the vocal fold, 3–6 days of voice rest, and a course of and pain associated with vocal fold injection. Most pain and
oral steroids are recommended. Other deep vocal fold injec- swallowing difficulties are minor and are treated with Tylenol
tions require significantly fewer days of voice rest or no voice or nonsteroidal over-the-counter medicine.
rest. For nonautologous material injections (CaHA, Teflon, Complication of over- or underinjection for deep vocal fold
Gelfoam), a single dose of antibiotics is used, given that a non- injection can occur. Approximately 3–6 months should be al-
human material is placed in the body. lowed for the injected vocal fold material to settle completely
Complications of deep vocal fold injection include: before deciding whether excessive vocal fold injection mate-
rial has been deposited. Removal of overinjected material can
■ Airway obstruction
be done via suspension microlaryngoscopy, and performing
■ Infection at the injection site
a lateral cordotomy and cold steel dissection down to the in-
■ Overinjection
jected material and removing the material partially to correct
■ Underinjection
■ Allergic reaction
■ Superficial injection
Fig. 31.9 Fat in Merocel-lined funnel
Fig. 31.8 Liposuction technique
Fig. 31.10 Fat from lipoinjection needle Fig. 31.11 The appropriate amount of overcorrection (100%) used for
autologous lipoinjection
Chapter 31 203
the over injection of material (see Chap. 12, “Management 2 Cantarella G, Mazzola RF, Domenichini E, Arnonr F, Maras-
and Prevention of Complications Related to Phonomicrosur- chi B (2005) Vocal fold augmentation by autologous fat injec-
gery”). Accidental injection of augmentation material into the tion with lipostructure procedure. Otolaryngol Head Neck Surg
superficial aspect of the vocal fold is possible when a fine gauge 132:239–243
needle is used and the depth of the injection is not controlled. 3 Chen YY, Pai L, Lin YS, Wang HW, Hsiung MW (2003) Fat aug-
One must take great care to control the depth of the injection mentation for nonparalytic glottic insufficiency. ORL J Orothino-
needle. If superficial injection occurs, the material should be laryngol Relat Spec 65:176–183
removed as soon as possible. The material can usually be easily 4 Hsiung MW, Lin YS, Su FW, Wang HW (2003) Autogenous fat
removed via a microflap approach (see Chapter 10, “Principles injection for vocal fold atrophy. Eur Arch Otorhinolaryngol
of Phonomicrosurgery”). 260:469–474
5 Laccourreye O et al (2003) Intracordal injection of autologous fat
in patients with unilateral laryngeal nerve paralysis, long-term re-
sults from the patient’s perspective. Laryngoscope 113:541–545
Key Points
6 Mikaelian DO, Lowry LD, Sataloff RT (1991) Lipoinjection for
unilateral vocal cord paralysis. Laryngoscope101:465–468
7 Shaw GY et al (1997) Autologous fat injection into the vocal folds:
■ Vocal fold augmentation (deep) is a versatile and
technical considerations and long-term follow-up. Laryngoscope
essential procedure for a variety of voice disorders
107:177–186
associated with glottal insufficiency.
8 Mikus JL, Koufman JA, Kilpatrick SE (1995) Fate of liposuc-
■ Vocal fold augmentation has an advantage of
tioned and purified autologous fat injections in the canine vocal
avoiding an open surgical procedure and involves
fold. Laryngoscope 105:17–22
a quick and prompt recovery.
9 Nakayama M, Ford CN, Bless DM (1993) Teflon vocal fold aug-
■ Vocal fold augmentation (deep) can be performed
mentation: failures and management in 28 cases. Otolaryngol
via microlaryngoscopy (via general anesthesia) or
Head Neck Surg 109(Pt. 1):493–498
endoscopically under local anesthesia.
10 Remacle M, Lawson G, Delos M, Jamart J (1999) Correcting vo-
■ Precise needle placement and careful attention to
cal fold immobility by autologous collagen injection for voice
the vocal fold tissue during injection are critical to
rehabilitation. A short-term study. Ann Otol Rhinol Laryngol
successful vocal fold injection.
108:788–793
11 Rihkanen H (1998) Vocal fold augmentation by injection of au-
tologous fascia. Laryngoscope 108(Pt. 1):51–54
12 Rosen CA (1998) Phonosurgical vocal fold injection: Indica-
tions and techniques. Oper Tech Otolaryngol Head Neck Surg
9:203–209
1 Brandenburg JH, Unger JM, Koschkee D (1996) Vocal cord injec- 13 Schramm VL, May M, Lavorato AS (1978) Gelfoam paste injec-
tion with autogenous fat: a long-term magnetic resonance imag- tion for vocal cord paralysis: temporary rehabilitation of glottic
ing evaluation. Laryngoscope 106(Pt. 1):174–180 incompetence. Laryngoscope 88(Pt. 1):1268–1273
Chapter 32
Superficial Vocal Fold Injection

32
Please see Chaps. 8, 10, and 23 for further information.
■ Mild-to-moderate vocal fold scar
32.2 Disease Characteristics ■ Focal lamina propria defect
and Differential Diagnosis ■ A positive saline-infusion trial
Superficial vocal fold injection involves placement of a lamina Contraindications include:

propria replacement substance into the superficial aspect of the
■ Need for global augmentation, such as seen in patients
vocal fold to restore pliability. This procedure is done via high-
with vocal fold paresis, vocal fold paralysis, vocal fold
powered microlaryngoscopy with a fine-gauge needle (27–30 g).
atrophy
This procedure is aimed at correcting vibratory deficits of the
■ Negative saline-infusion trial
vocal fold(s), not providing global augmentation.
■ Sulcus vocalis (relative)
The most commonly used materials presently available for
superficial vocal fold injection are collagen based materials
such as Cymetra, Zyplast, or Cosmoplast. These materials are
all temporary in nature but can last up to 1 year. In addition,
these materials may induce new, native extracellular matrix
protein recruitment. It is likely that new lamina propria substi-
tutes/replacement will be developed in the near future, which Equipment needed comprises:
may be able to be delivered via a superficial vocal fold injection
■ Phonomicrosurgery tray (see Table 10.1)
approach. Cross-linked hyaluronic acid-based substances have
■ A fine-gauge injection needle and device (27 or 30 g)
proven not to be of any value when placed superficially, and
■ Injection device can be designed from a fine-gauge
thus are contraindicated for this procedure.
butterfly needle, with the wings of the needle
The best prediction of success is a positive saline-infusion
removed and cup forceps used to deliver the needle
trial. A saline-infusion trial involves superficial injection of
down to the vocal fold. Alternatively, an orotracheal
saline or diluted epinephrine underneath the epithelium to
injector with a disposable 27-g needle attached
determine if a substance such as collagen could be subsequent-
(Medtronic Xomed, Jacksonville, Fla.) serves the
ly injected into the vocal fold in the area of the focal lamina
purpose for a superficial vocal fold injection ex-
propria defect or vocal fold scar. If the saline-infusion trial is
tremely well.
positive, then it is best to wait several minutes and/or “milk”
the saline out of the vocal fold and then proceed with the su-
perficial vocal fold injection. If the scar is too severe in nature,
then the saline will track to locations other than those desired,
and the patient will not respond well to a superficial vocal fold
injection.
Superficial vocal fold injection is used in select cases of vocal Superficial vocal fold injection via microsuspension laryngos-
fold scar. In addition, there are instances of a very focal defect copy allows for the precise and controlled placement of vocal
of the lamina propria that would be suitable for augmentation fold injection material (collagen, etc.) into the most superfi-
via a superficial vocal fold injection approach. cial aspect of the vocal fold. This procedure is done with high
power microlaryngoscopy and a fine-gauge injection needle
(27–30 g).
1. Review most recent preoperative videostroboscopy imme-
diately before or during the operation to identify the specif-
ic pathology and location that requires vocal fold injection.
206 Superficial Vocal Fold Injection
2. Placement of a large-bore laryngoscope (see Chap. 10) area of the deficit as well as the severity of the scar (Fig.
3. Vocal fold palpation with a slightly curved blunt instru- 32.1).
ment is helpful to identify completely the area of the vocal 5. Under high-power magnification, the vocal fold injection
fold pathology and the nature of the pathology (vocal fold is done using a 27- or 30-g needle. The entry site should
32 scar). be 3–5 mm away from the intended vocal fold injection de-
4. If there is a concern or question about the exact nature and position to prevent extrusion of the injection material. It is
severity of the vocal fold scar, then often a preliminary in- best to have the entry site away from the proposed area of
jection with 1:10,000 epinephrine or saline placed superfi- infiltration and then tunnel the needle submucosally to the
cially in the area of the pathology will clearly delineate the intended area of injection (Fig. 32.2).
6. The vocal fold injection needle should be as superficial as
possible after its entry through the epithelium, and is often
visible through the mucosa as the needle is tunneled for-
ward to the vocal fold pathology site.
7. There is no preset volume of material to be injected. The
defect to be addressed will determine the volume to be in-
jected. Typically, these injections only require 0.2–0.4 ml of
material (Fig. 32.3).

and Complications
Postoperatively:
■ No need for antibiotics
■ No indication for steroids
■ Voice rest for approximately 6 days
■ Voice therapy can start shortly after the resumption of
voice use.
Fig. 32.1 Saline-infusion trial
Fig. 32.2 Superficial vocal fold injection with needle tunneled to area Fig. 32.3 Appearance after superficial vocal fold injection
of intended deposit
Chapter 32 207
With regard to complications, if there is an overinjection of

superficial vocal fold injection that is not resolved with a short
period (approximately 1–2 months) and inhibits vocal fold
function and voice quality, then the superficial material can 1 Ford CN, Bless DM, Loftus JM (1992) Role of injectable collagen
be removed by making a small incision over the most lateral in the treatment of glottic insufficiency: a study of 119 patients.
aspect of the injection location and removing part or all of the Ann Otol Rhinol Laryngol 101:237–247
material. 2 Ford CN, Staskowski PA, Bless DM (1995) Autologous collagen
vocal fold injection: a preliminary clinical study. Laryngoscope
105(Pt. 1):944–948
3 Kass ES, Hillman RE, Zeitels SM (1996) The submucosal infu-
Key Points
sion technique in phonomicrosurgery. Ann Otol Rhinol Laryn-
gol 105:341–347
4 Zeitels SM, Vaughan CW (1991) A submucosal vocal fold infu-
■ Superficial vocal fold injection can be done to cor-
sion needle. Otolaryngol Head Neck Surg 105:478–479
rect mild vocal fold scar or a focal lamina propria
defect.
■ Saline-infusion trial predicts the suitability for
superficial vocal fold injection.
■ Collagen-based materials are presently best suited
for superficial vocal fold injection.
■ In the future, new lamina propria replacement
materials may be delivered via a superficial vocal
fold injection approach.
Chapter 33
Peroral Vocal Fold Augmentation

in the Clinic Setting 33
Peroral vocal fold augmentation in the clinic setting is indi-
cated in treatment of symptomatic glottal insufficiency due to
any of the following factors:
and Differential Diagnosis ■ Unilateral vocal fold paralysis
Transoral vocal fold augmentation in the clinic setting is used
■ Vocal fold scar
to provide global vocal fold augmentation into the deep aspect
■ Sulcus vocalis
of the vocal fold for patients with glottal insufficiency. Chapters
5 and 14 (“Glottic Insufficiency: Vocal Fold Paralysis, Paresis,
and Atrophy” and “Principles of Vocal Fold Augmentation,”
respectively) discuss the pertinent issues regarding glottal Injection in the clinic setting can be used as a temporizing
insufficiency and their subsequent treatment with vocal fold treatment to correct the patient’s glottal insufficiency or for
augmentation. Information regarding the specific indications permanent correction. A typical example is a patient with id-
and nature of the current materials available for augmentation iopathic unilateral vocal fold paralysis who presents early (1–3
are discussed in detail in Chaps. 5 and 14. The most common months after onset) in the course of the disease. If the patient
symptoms associated with patients with glottal insufficiency is aspirating, or significantly dysphonic and has significant vo-
include the following: cal demands, then temporary augmentation via peroral vocal
fold augmentation in the clinic is an excellent option. This ad-
■ Dysphonia
dresses the patient’s vocal/swallowing needs, while allowing
■ Decreased volume
for spontaneous recovery of function and avoids a surgical
■ Vocal fatigue
procedure in the hospital or general anesthesia.
■ Odynophonia
Vocal fold augmentation can also be offered to a patient as
■ Dysphagia/Aspiration of liquids
a minimally invasive opportunity to “test drive” their voice af-
■ Compensated falsetto
ter correction of glottic insufficiency. This may help the patient
decide if a permanent treatment option for their glottic insuf-
Several advantages to performing peroral vocal fold augmen- ficiency is desirable. This approach is referred to as a trial vocal
tation in a clinic setting exist. The patient does not have to ar- fold augmentation.
range transportation to and from the hospital nor undergo a Contraindications involve:
general anesthetic, and does not have to be NPO before the
■ Unstable cardiopulmonary status
surgical procedure. Furthermore, since the procedure is per-
■ Inability to tolerate procedure under local anesthesia
formed with the patient completely awake and in the upright
(i. e., hyperactive gag response or high level of anxiety)
position, vocal fold augmentation can be tailored to optimize
■ Use of anticoagulants (aspirin, nonsteroidal anti-in-
the patient’s voice result by intermittently testing the voice
flammatories, Coumadin)
throughout and at the completion of the procedure.
■ Ideally, the patient should be taken off any antico-
All patients should be counseled prior to injection regard-
agulant medication prior to any planned injection;
ing the expected duration of augmentation from injection. Du-
however, clinical experience has shown that the
ration varies with technique as well as with the type of material
procedure can be performed if medically unable to
injected.
stop anticoagulant therapy.
■ Inability to visualize the larynx adequately during the
time of injection
■ This may occur if the patient has significant hooding
of the arytenoid or severe supraglottic constriction.
210 Peroral VF Augmentation – Clinic
33.3.1 Suitability for Peroral Vocal Fold 33.5 Surgical Procedure

Augmentation in the Clinic Setting
Peroral vocal fold augmentation comprises the following:
In order to be a suitable candidate for peroral vocal fold aug- 1. Topical anesthesia nasal/oropharynx
mentation: a) Topical oxymetazoline/Pontocaine 2% spray to nasal
33 cavities (medication-soaked cotton nasal pledgets placed
■ The patient must tolerate a flexible laryngoscopy endo-
intranasally are also very helpful).
scopic exam, without excessive gag. Monitoring with a
b) Topical Cetacaine spray to oral cavity (palate/posterior
flexible endoscope is key to maintaining visualization,
pharynx)
and a hyper-responsive gag may render any procedures
2. Videomonitoring/topical anesthesia of larynx
impossible. However, it should be noted that gagging
a) A video camera is attached to a flexible laryngoscope
with a mirror or rigid peroral endoscope is not a contra-
(distal chip flexible laryngoscope system preferred) is
indication.
inserted through the nasal cavity (typically the side op-
■ The patient must have an adequate oral opening (at
posite the intended vocal fold to be injected) by an as-
least 2-cm intermaxillary distance).
sistant, employing a “videocart system.” The scope is
■ The patient must be able to remain reasonably still and
generally maintained slightly below the palate so that the
upright in the exam chair for the duration of the proce-
tongue base and larynx can be easily viewed on the video
dure (typically 5–15 min). Patients with severe torticol-
monitor.
lis or head tremor are sometimes difficult to treat.
b) Four percent lidocaine drip onto larynx under flexible
laryngoscope guidance (3–6 ml)
The patient is bent forward at the waist with the neck ex-
tended in a “sniffing” position to maximize laryngeal expo-
sure. The tongue is grasped with gauze with the surgeon’s left
hand. A 3-ml syringe of 4% lidocaine attached to an Abra-
Surgical equipment needed (Fig. 33.1): ham cannula is passed from the oral cavity into the pharynx
under flexible laryngoscopy guidance. Approximately 1 ml
■ Flexible laryngoscope (fiberoptic or distal chip)
is deposited over the tongue base, and 2–4 ml are dripped
■ C-mount camera (attaches to flexible scope)
onto the vocal folds during phonation, producing the
■ Videomonitor for visualization
characteristic “laryngeal gargle” (Fig. 33.2). The maximum
■ 3–6 ml of 4% lidocaine
recommended dose of 4% lidocaine is approximately 7–8 ml
■ Curved Abraham cannula for delivery to topical lido-
(4.5 mg/kg; approximately 300 mg in 70-kg patient).
caine
The initial dose is usually followed by a brisk cough, as the
■ Cetacaine spray (benzocaine/tetracaine topical)
anesthetic is aspirated and then distributed over the laryn-
■ Oxymetazoline and/or 2% Pontocaine (for nasal decon-
gotracheal mucosa. Absence of the laryngeal gargle and
gestant and anesthesia)
cough may indicate that the patient has swallowed the anes-
■ Cotton nasal pledgets
thetic, and additional topical applications may be indicated
■ Disposable nebulization device
until the desired effect is obtained.
Fig. 33.1 Equipment used for transoral vocal fold augmentation in the
clinic (cotton pledgets, 4% plain lidocaine, Neosynephrine, Bioform in- Fig. 33.2 “Laryngeal gargle” of 4% lidocaine delivered via an Abraham
jection needle filled with Radiesse, Abraham cannula, drip catheter) cannula
Chapter 33 211
of the flexible laryngoscope and used to deliver 4% plain

lidocaine to the endolarynx during sustained phonation
to achieve the “laryngeal gargle” as described above (Fig.
33.4). This catheter allows direct application of the anesthe-
sia to the specific areas intended for the vocal fold injection
and is very well tolerated by patients.
3. Transoral passage of the needle into the endolaryngeal region
a) The two most commonly used needles for peroral vocal
fold augmentation in a clinic setting are the orotracheal
injector device (Medtronic Xomed) and the injection
needle developed by Bioform Medical (Bioform Medi-
cal, San Mateo, Calif.). Each of these injection devices
use fine-gauge needles (27- and 25-g, respectively.) The
former device is curved for transoral injection, and the
latter is malleable and can be bent to the appropriate di-
Fig. 33.3 Nebulization of 4% plain lidocaine for laryngeal anesthesia mensions and curvature needed for transoral vocal fold
augmentation. In preparation for vocal fold injection,
the intended injection material should be attached to
the injection needle and “primed” to eliminate the dead
space within the needle.
b) The patient holds his/her own tongue with gauze, or the
surgeon grasps the tongue with the left hand. The needle
is passed through the oral cavity and then advanced into
the oropharynx under direct visualization from the flex-
ible laryngoscope. The patient is instructed to phonate
/a/ as the needle enters the oral cavity, which results in
palatal raising, clearing the path into the oropharynx.
The assistant should position the fiberoptic scope just
above the palate, until the needle is visualized in the oro-
pharynx.
c) The needle is then guided into the oropharynx and the
endolarynx under endoscopic visualization, as the assis-
tant follows closely behind with the flexible laryngoscope
(Fig. 33.5). The assistant must be adept at manipulating
Fig. 33.4 Drip catheter for applying 4% plain lidocaine to larynx via the flexible scope; consistent visualization of the needle
flexible laryngoscope with a working channel can be challenging in a narrow airway with copious se-
cretions. The flexible scope should be positioned a few
millimeters above the true vocal folds, providing a clear,
An alternative method to obtain anesthesia of the larynx in- well-illuminated view before, during, and immediately
volves nebulization of lidocaine, using a simple disposable after the injection (Fig. 33.6).
nebulization device (frequently used in the hospital for re- 4. Vocal fold injection
spiratory therapy) and an external source of pressurized air a) For unilateral vocal fold paralysis, the injection should
(often from an oxygen tank). Four percent plain lidocaine be placed at two sites (Fig. 33.7): (1) the posterior aspect
can be nebulized and inhaled peroral by the patient (Fig. (lateral to the vocal process) and (2) the midmembra-
33.3). This method of anesthesia provides a simple and less nous vocal fold.
physician-involved method for obtaining laryngeal anesthe- b) The initial injection should be at the posterior aspect of
sia. Typically, 4–5 ml of plain lidocaine is nebulized over a the vocal fold, where, typically, the most correction is
5- to 10-min period to achieve anesthesia of the larynx and needed.
pharynx. After the nebulization process, a curved Abraham c) The depth of injection should be into the substance of
cannula can be used to supplement any further need for the vocal fold in a lateral position (see Chap. 14, “Princi-
laryngeal anesthesia on an as-needed basis and to test for ples of Vocal Fold Augmentation”). Care should be taken
complete anesthesia of the larynx and, specifically, the vocal to avoid superficial placement into Reinke’s space, which
folds. will result in a stiff vocal fold and poor voice quality (Fig.
Another technique to deliver anesthetic agent to the larynx 33.8).
is using a small Silastic, flexible cannula through the work- d) If the subglottis begins to bulge during injection, then
ing channel of the flexible laryngoscope or an Endosheath™ the needle should be withdrawn slightly. Once the pos-
with a working channel (Medtronic Xomed, Jacksonville, terior vocal fold is adequately medialized, a smaller ad-
Fla.). This Silastic catheter (Olympus America, PW-2L-1.B, ditional amount can be deposited at the mid vocal fold,
Center Valley, Pa.) is passed through the working channel if needed.
212 Peroral VF Augmentation – Clinic
33
Fig. 33.5 Transoral vocal fold augmentation in the clinic. Surgeon on Fig. 33.6 Flexible laryngoscope image during peroral injection aug-
the left with the assistant on the right and patient holding her own mentation. The scope should be positioned a few millimeters above
tongue the true vocal folds, providing a clear, well-illuminated view
Fig. 33.7 Injection location(s) for deep vocal fold augmentation Fig. 33.8 Injection depth for deep vocal fold
e) If the injected substance extrudes from the puncture of the procedure (long duration of the temporary agent ver-
hole, then the material can be cleared by instructing sus immediate need for optimal voice function.) In general,
the patient to cough or clear their throat (this is rarely a the vocal fold is medialized until the voice is maximally
problem when a fine-gauge needle is used). improved, and then an additional 0.1–0.2 ml is injected to
f) The injection should be carried out in a stepwise fashion, achieve overcorrection. This overcorrection is necessary, be-
checking for improvement in the patient’s voice periodi- cause all injectables have a small aqueous component that will
cally. be absorbed 3–5 days after injection. The total amount nec-
essary for unilateral augmentation is typically less than 1 ml,
For most injectables, the medialized vocal fold should be but amount injected should be determined by the sound of
overinjected (past midline) to a variable degree, depending the voice and appearance of the vocal fold, not by the volume
on the specific nature of the material and the primary goal injected.
Chapter 33 213
For patients with a bowed vocal fold due to atrophy/paresis If these inappropriate locations of vocal fold injection are rec-
or presbylaryngis, the injection differs slightly from the previ- ognized during the procedure, then often the material can be
ous technique. These cases typically require injection princi- “milked” out of the vocal fold with the use of an Abraham can-
pally in the midportion of the vocal fold, where the maximal nula, applying gentle lateral pressure to the vocal fold. If this is
glottal gap usually occurs. In severe cases of muscular atrophy, not possible, then it would be advisable that the vocal fold ma-
the posterior vocal fold can be augmented to fill in the atrophy terial, if permanent in nature (such as calcium hydroxylapatite)
that occurs just anterior to the vocal process. Again, overcor- be removed under microlaryngoscopy with general anesthesia
rection is the rule, even in the case of bilateral injections. Air- in the near future.
way compromise should not be a concern, because the poste-
rior (respiratory) glottis remains patent and in cases of vocal
fold atrophy both vocal folds are usually fully mobile.
Key Points
33.6 Postoperative Care ■ Peroral vocal fold augmentation in a clinic setting

and Complications provides the patient an opportunity for permanent
or temporary vocal fold augmentation under local
anesthesia, obviating a trip to the operating room
Postoperative care includes:
and general anesthesia.
■ Immediately after vocal fold injection in the clinic, pa- ■ Appropriate patient selection is the key to suc-
tients should be observed for a short period to monitor cessful peroral vocal fold augmentation. Patients
for any complications of the vocal fold injection, most should be cooperative and should not have a
notably, airway difficulties. hyperactive gag reflex.
■ Patients need to be instructed that they should not take ■ Adequate anesthesia can be easily obtained for
anything orally for approximately 2 hours after vocal peroral vocal fold augmentation, with topical
fold injection to allow adequate time for the local anes- lidocaine and does not necessitate nerve blocks or
thesia to wear off. In addition, patients should take care sedation (orally or intravenously).
as they resume oral intake to ensure that all aspects of ■ Peroral vocal fold augmentation offers the unique
the anesthesia are gone. advantage of having the patient unsedated and
■ The use of strict voice rest after vocal fold injection is positioned in an upright position to monitor voice
not standardized and is often determined by the size quality and vocal fold closure pattern during the
of the vocal fold injection needle used and the indi- injection. This allows for customization and maxi-
vidual surgeon’s preferences. Given that most vocal fold mum control of the vocal fold augmentation to
injections are now performed with a fine-gauge needle, optimize postoperative voice quality and function.
prolonged voice rest (exceeding 24 hours) is most likely
not indicated. Some surgeons use no voice rest; others
will use a 24-hour period of voice rest. The rationale for
voice rest after vocal fold injection is to minimize loss of Selected Bibliography
the injected material being extruded through the injec-
tion site(s) if immediate phonation is allowed.
1 Arad-Cohen A, Blitzer A (1999) Office-based direct fiberoptic
■ Antibiotics and steroids associated with the vocal fold
laryngoscopic surgery. Oper Tech Otolaryngol Head Neck Surg
injection are not typically indicated for this procedure.
9:238–242
■ Patients should be instructed that, because of the vocal
2 Bové MJ, Jabbour N, Krishna P, Rosen CA et al (2007) Operating
fold edema associated with the procedure, as well as
room versus office-based injection laryngoplasty: a comparative
possibly the overinjection of the augmentation material,
analysis of reimbursement. Laryngoscope 117:226–230
optimal voice quality is typically not achieved for 1–2
3 Chu PY, Chang SY (1997) Transoral Teflon injection under flex-
weeks after vocal fold injection.
ible laryngovideostroboscopy for unilateral vocal fold paralysis.
Ann Otol Rhino Laryngol 106:783–786
Complications of peroral vocal fold injection include inappro- 4 Simpson CB, Amin MR (2004) Office-based procedures for the
priate placement of the vocal fold injection material comprise: voice. Ear Nose Throat J 83(Suppl.):6–9
5 Simpson CB, Amin MR, Postma GN (2004) Topical anesthesia of
■ Either too superficially into Reinke’s space
the airway and esophagus. Ear Nose Throat J 83(Suppl.):2–5
■ Very lateral into the paraglottic space
■ Inferior into the subglottis
Chapter 34
Percutaneous Vocal Fold

Augmentation in the Clinic Setting 34
A variety of percutaneous vocal fold augmentation ap-
34.1 Fundamentals and Related Chapters
proaches exist for in-office procedures. These percutaneous
approaches include:
■ Transthyroid cartilage
■ Transcricothyroid membrane
■ Transthyrohyoid membrane
The transthyroid cartilage and cricothyroid membrane ap-
proaches are very similar. Ossification of the thyroid cartilage
Percutaneous vocal fold augmentation in the clinic setting is can prevent passage of the injection needle through the thyroid
used to provide global vocal fold augmentation into the deep cartilage and thus, a cricothyroid or thyrohyoid approach may
aspect of the vocal fold for patients with glottal insufficiency. be required. All of these approaches require anesthesia of the
Chaps. 5 and 14 (“Glottic Insufficiency: Vocal Fold Paralysis, overlying skin, a skilled endoscopist as an assistant, and a 23-
Paresis, and Atrophy” and “Principles of Vocal Fold Augmen- to 25-g needle (1.5 in. long).
tation,” respectively) discuss the pertinent issues regarding The thyrohyoid approach can be used for vocal fold aug-
glottal insufficiency and their subsequent treatment with vocal mentation as well as for injection of therapeutic substances
fold augmentation. The most common symptoms associated such as cidofovir and Botox. The transthyrohyoid approach
with patients with glottal insufficiency include the following: was developed by Milan Amin, M.D., and is as well tolerated
as other percutaneous approaches, but provides unique visual-
■ Dysphonia
ization and precision compared to transthyroid cartilage and
■ Decreased volume
cricothyroid approach.
■ Vocal fatigue
■ Odynophonia
■ Dysphagia
■ Compensatory falsetto 34.3 Surgical Indications
A variety of major advantages to performing percutaneous vo-
cal fold augmentation in the clinic setting exist. Specifically, Percutaneous vocal fold augmentation in the clinic setting is
it is a significant advantage to the patient, given that the pa- indicated in the treatment of symptomatic glottal insufficiency
tient does not have to arrange transportation to and from the (dysphonia and/or dysphagia) due to any of the following fac-
hospital nor undergo a general anesthetic, and does not have tors:
to be NPO before the surgical procedure. Furthermore, since
■ Unilateral vocal fold paralysis
the procedure is performed with the patient completely awake
and in the upright position, vocal fold augmentation can be
tailored to optimize the patient’s voice result by intermittent-
■ Vocal fold scar
ly testing the voice throughout and at the completion of the
■ Sulcus vocalis
procedure. Information regarding the specific indications and
nature of the current materials available for augmentation are
discussed in detail in Chaps. 5 and 14.
Awake, percutaneous vocal fold augmentation in the clini- Injection in the clinic setting can be used as a temporizing
cal setting is a viable option for many patients with glottal treatment to correct the patient’s glottal insufficiency or for
insufficiency. Vocal fold augmentation using a percutaneous permanent correction. A typical example is a patient with id-
approach in the clinic or at the bedside has been successfully iopathic unilateral vocal fold paralysis who presents early (1–3
performed with a number of different materials and can be months after onset). If the patient is aspirating, or dysphonic
performed with either temporary or permanent augmentation and has vocal demands, then temporary augmentation via a
materials. See Chap. 14 for a discussion of different augmenta- percutaneous vocal fold augmentation in the clinic is an ex-
tion materials. cellent option. This addresses the patient’s vocal/swallowing
216 Percutaneous Augmentation
needs, while allowing for spontaneous recovery of function

■ Local anesthetic/decongestant mix (e. g., oxymetazoline
without having to perform a surgical procedure in the hospital
and 2% Pontocaine) for nasal passage in order to facili-
with general anesthesia.
tate flexible laryngoscopy
Vocal fold augmentation can also be offered to a patient as
■ Injection material (see Chap. 14)
a minimally invasive opportunity to “test drive” their voice af-
■ Alcohol prep pad or topical prep solution such as povi-
ter correction of glottic insufficiency. This may help the patient
done–iodine
decide if a permanent treatment option for their glottic insuf-
ficiency is desirable. This approach is referred to as a trial vocal
34 fold augmentation.
Contraindications comprise:
■ Unstable cardiopulmonary status
■ Inability to tolerate procedure under local anesthesia
1. Percutaneous vocal fold augmentation in the clinic setting in
(i. e., high level of anxiety)
a transthyroid cartilage or transcricothyroid membrane ap-
■ Use of anticoagulants (aspirin, nonsteroidal anti-in-
proach.
flammatories, Coumadin)
a) The area overlying the injection site may be cleaned with
■ Ideally, the patient should be taken off any antico-
an alcohol prep pad or povidone–iodine prep.
agulant medication prior to any planned injection;
b) The patient is positioned in the sitting position with the
however, clinical experience has shown that the
neck in neutral position and the head slightly extended
procedure can be performed if medically unable to
on the neck (i. e., the sniffing position).
stop anticoagulant therapy.
c) It is important to anesthetize both the skin over the area
■ Inability to visualize the larynx adequately during the
to be injected as well as the upper airway in preparation
time of injection
for flexible laryngoscopy. To anesthetize the skin and
■ This may occur if the patient has significant hooding
subcutaneous tissues, approximately 0.5 ml of local an-
of the arytenoid or severe supraglottic constriction.
esthetic is sufficient. The skin and subcutaneous tissues
■ Poorly defined or obstructing neck landmarks
overlying the cricothyroid membrane are injected as well
as the area over the inferior aspect of the thyroid ala on
the side(s) intended for injections. Overinjection of this
area with anesthetic may transiently impair cricothyroid
34.3.1 Suitability for Percutaneous
function, thus clouding the picture of paresis/paralysis at
Vocal Fold Augmentation
the time of injection.
in the Clinic Setting
d) The nasal cavity is anesthetized and decongested as is
customary for the surgeon. Topical anesthesia to the en-
To be a suitable candidate: dolarynx (see Chap. 33, “Peroral Vocal Fold Augmenta-
tion in the Clinic Setting”) is helpful per the surgeon’s
■ The patient must tolerate a flexible laryngoscopy endo-
preference but is usually not necessary for the percutane-
scopic exam without excessive gag. Monitoring with a
ous approach.
flexible endoscope is key to maintaining visualization,
e) Flexible laryngoscopy is performed by the assistant and
and a hyper-responsive gag may render any procedures
the preprocedure diagnosis/diseases are confirmed. Ide-
impossible. However, it should be noted that gagging
ally, the tip of the scope is maintained over the contralat-
with a mirror or rigid transoral endoscope is not a con-
eral arytenoid, as posteriorly as possible to avoid stimu-
traindication.
lating the supraglottic structures. This position allows
■ The patient must be able to remain reasonably still and
for some visualization of the infraglottic surface of the
upright in the exam chair for the duration of the proce-
vocal fold to be injected.
dure (typically 5–15 min). Patients with severe torticol-
f) The cricothyroid membrane is palpated by the inject-
lis or head tremor are sometimes difficult to treat.
ing surgeon. In many patients, it is possible to see (en-
doscopically) the depression of the underlying mucosa
during this maneuver (Fig. 34.1). This is very helpful in
estimating the height of the vocal fold relative to the cri-
cothyroid membrane. If the impression from the palpat-
ing finger is not seen, then this maneuver may be per-
formed with the injection needle without penetrating
■ Skilled endoscopist to assist surgeon
into the airway.
■ Flexible laryngoscope (chip-tip preferred to fiber optic)
g) The vertical and horizontal distance from this point to
the midpoint of the membranous vocal fold is estimated
■ Local anesthetic (1% Lidocaine with epinephrine) to
by the surgeon. The needle (23 or 25 g, or 1.5 in. long)
anesthetize skin over the cricothyroid membrane and
is placed along a vertical line approximately 6–12 mm
thyroid ala on the side to be injected
from the midline; this distance depends on the size of the
Chapter 34 217
larynx. The needle should be oriented perpendicularly in

relation to the thyroid ala.
h) The needle is placed against the thyroid ala at the desired
vertical level along this line. In most females and young-
er males, gentle steady pressure will allow the needle to
pass through the cartilage (Fig. 34.2). Care should be
taken not to “past point” as the needle is passed through
the thyroid cartilage. This will avoid entering the air-
way. If the needle meets significant resistance, then the
needle is kept in the same line and “walked” down the
thyroid ala until the inferior aspect of the thyroid car-
tilage is reached. The needle is then advanced medially,
again perpendicular to the thyroid ala for approximately
3–4 mm through the junction of the thyroid ala and the
cricothyroid membrane. At this point, the tip of the nee-
dle is in the infraglottic vocal fold and is directed nearly
straight up, vertically (Fig. 34.3). All attempts should be
made to avoid entering the airway. The needle may be
seen indenting the infraglottic mucosa or penetrating
the floor of the ventricle. To facilitate identifying where
the needle has entered into the endolarynx, the needle
can be moved back and forth rapidly several times over a
short distance. The tip of the needle is then redirected if
found not to be located in the membranous vocal fold.
i) Once the needle location is confirmed, vocal fold injec-
tion is started slowly. Good visualization of the vocal fold
is essential at this stage. As the material is injected, the
vocal fold will swell. The endpoint for injection will be
Fig. 34.1 Palpation of cricothyroid space during simultaneous flexible determined by the endoscopic appearance of the vocal
laryngoscopy fold as well as by the patient’s voice. Depending on the
Fig. 34.3 Transcricothyroid

Fig. 34.2 Transthyroid cartilage placement of injection needle into membrane placement of injec-
vocal fold tion needle into vocal fold
nature of the injectate, modest to moderate overcorrec- ible laryngoscopic guidance and the ability to draw back
tion is often desirable (see Chap. 14). The patient may air into the syringe. Three milliliters of topical lidocaine
immediately notice the improvement in the voice—it is is deposited in the larynx. Note that absence of a laryn-
important in most cases to overcorrect past this point, if geal gargle or cough suggests the patient swallowed the
possible, to allow for a longer duration of overall benefit anesthetic, and additional 4% lidocaine may be needed.
for temporary augmentation materials (see Chap. 14). Adequate anesthesia is achieved after 3–5 min. Alterna-
j) If the contour is not ideal (focally overinjected) immedi- tively, topical laryngeal anesthesia may be administered
ately after injection, then a hard cough may “straighten through a working channel of the flexible laryngoscope
34 out” the vocal fold as seen during the endoscopy. if this is available or a peroral approach (see Chap. 33,
k) In the case of bilateral vocal fold pathology, there is gen- “Peroral Vocal Fold Augmentation in the Clinic Set-
erally no limitation to treating both sides at the same setting”).
ting. f) Prepare implant/injectable material in appropriate sy-
2. Thyrohyoid approach to the larynx (of Milan Amin, M.D.) ringe attached to a 25- or 23-g (1.5-inch needle) and
a) Spray (topical 50:50 mix of oxymetazoline/Lidocaine “prime” the needle with material.
spray to nasal cavities) g) The needle is passed in the midline just above the thyro-
b) Inject skin and subcutaneous tissues overlying the thyrohyoid notch in a downward, acute angle just under the
hyoid notch using a 25-g needle with 1% lidocaine with patients’ chin. It may help to have the patient turn his/
1:100,000 epinephrine. her head slightly away from the surgeon to obtain the
c) Ensure the patient is positioned sitting upright with neck proper angle. The tip of the needle passes through the
extended to expose the thyrohyoid notch. pre-epiglottic space and enters the larynx at the petiole
d) An assistant passes the flexible laryngoscope through the of the epiglottis (Figs. 34.4, 34.5).
nasal cavity (usually left side) and positions the scope so h) Under direct guidance on the monitor, the assistant ad-
the tongue base and larynx are clearly visualized. vances the flexible scope to follow the needle as it is guid-
e) A 25-g needle (1.5 in. long) and syringe with topical 4% ed to the appropriate injection site(s) (Figs. 34.6, 34.7).
Lidocaine is passed into the airway above the vocal folds If necessary, bilateral vocal fold injection is achieved by
via the thyrohyoid membrane. The needle is passed im- backing the needle out slightly (without removing it)
mediately above the thyroid notch and directed acutely and redirecting the needle tip under direct visualization
downward until the needle enters the airway in the area to the other side.
of the petiole. Proper positioning is confirmed by flex-
Fig. 34.4 Needle path for the thyrohyoid approach to the larynx Fig. 34.5 Placement of needle through thyrohyoid membrane (endo-
scopic view)
Chapter 34 219
Fig. 34.6 Injection location for deep vocal fold Fig. 34.7 Injection depth for deep vocal fold augmentation
Complications comprise:
and Complications ■ Injection should be aborted at the first sign of airway
embarrassment or unexpected vocal fold swelling. Dra-
matic swelling may occur if air is inadvertently injected.
■ Bleeding into the airway occurs in many patients. It is
■ Immediately after vocal fold injection in the clinic, pa- typically minimal though when it leads to coughing, the
tients should be observed for a short period to monitor endolarynx may be covered with a thin film of blood
for any complications of the vocal fold injection, most and limit visibility. The patient is asked to gargle (if pos-
notably, airway difficulties. sible) and the procedure is usually continued.
■ Patients need to be instructed that they should not take ■ Hematoma in the skin overlying the injection site
anything orally for approximately 2 h after vocal fold
injection to allow adequate time for the local anesthesia
to wear off. In addition, patients should take care as
they resume oral intake to insure that all aspects of the Key Points
anesthesia are gone.
■ The use of strict voice rest after vocal fold injection is
not standardized and is often determined by the size ■ Percutaneous vocal fold augmentation in the clinic
of the vocal fold injection needle used and the indi- setting is an excellent alternative for patients who
vidual surgeon’s preferences. Given that most vocal fold prefer not to undergo general anesthesia or will
injections are now performed with a fine-gauge needle, not tolerate transoral vocal fold injection in the
prolonged voice rest (exceeding 24 hours) is most likely clinic setting for either temporary or permanent
not indicated. Some surgeons use no voice rest; others vocal fold augmentation.
will use a 24-hours period of voice rest. The rationale ■ Providing the patient with information and sup-
for voice rest after vocal fold injection is to minimize portive reassurance before and during the proce-
loss of the injected material being extruded through the dure is very important.
injection site(s) if immediate phonation is allowed. ■ Identification of the needle in the mid to posterior
■ Antibiotics and steroids are not typically indicated for membranous vocal fold is essential for successful
this procedure. percutaneous vocal fold augmentation in the clinic
■ Patients should be instructed that, because of the vocal setting.
fold edema associated with the procedure, as well as the ■ Patient positioning, skilled endoscopy of the as-
overinjection of the augmentation material, optimal sistant, and knowledge of multiple approaches to
voice quality is typically not achieved for 1–2 weeks the vocal fold will provide the highest chance of
after vocal fold injection. success for vocal fold augmentation.
1 Amin, MR (2006) Thyrohyoid approach for vocal fold augmenta- 4 Grant JR, Hartemink DA, Patel N, Merati AL (2006) Acute and
tion. Ann Otol Rhinol Laryngol 115:699–702 subacute awake injection laryngoplasty for thoracic surgery
2 Berke GS, Gerratt B, Kreiman J, Jackson K (1999) Treatment of patients. J Voice. 2006 Oct [Epub ahead of print]
Parkinson hypophonia with percutaneous collagen augmenta- 5 Lipton RJ, McCaffrey TV, Cahill DR (1989) Sectional anatomy of
tion. Laryngoscope 109:1295–1299 the larynx: implications for the transcutaneous approach to en-
34 3 Chhetri DK, Blumin JH, Shapiro NL, Berke GS (2002) Office-
based treatment of laryngeal papillomatosis with percutaneous in- 6
dolaryngeal structures. Ann Otol Rhinol Laryngol 98:141–144
Rosen CA, Thekdi AA (2004) Vocal fold augmentation with
jection of Cidofovir. Otolaryngol Head Neck Surg 126:642–648 injectable calcium hydroxylapatite: short-term results. J Voice
18:387–391
Chapter 35
Botulinum Toxin Injection

of the Larynx 35
the toxin is affected by accuracy of needle placement as well as
by volume of the injectate, which can be varied as necessary.
Systemic effects from botulinum toxin are very unlikely, par-
Please see Chaps. 7, 33, and 34 for further information. ticularly at doses used to treat laryngeal diseases.
Development of antibody resulting in clinical resistance to
toxin is very rare with recent preparations of toxin, and may
be tested for with an antibody assay, or, more practically, with
an injection into an area where muscle effect is obvious, such
as the forehead. Technical issues rather than resistance remain
the most likely reason for an ineffective laryngeal injection. For
35.2.1 Botulinum Toxin Fundamentals
a more in-depth description of the pharmacology of botulinum
toxin, the reader is referred to article by Aoki cited in “Selected
Botulinum toxin is a naturally occurring clostridial neurotoxin Bibliography,” below.
that reversibly inhibits release of acetylcholine into the synap-
tic cleft of the neuromuscular junction, thereby causing flaccid
paralysis. Clinically, this results in a reversible, dose-dependent
35.2.2 Spasmodic Dysphonia
weakening of injected muscles. In addition to its muscle weak-
and Essential Tremor
ening effect, botulinum toxin has been hypothesized to have
an effect on efferent feedback to the central nervous system,
although whether this is by means of a direct effect on intra- Dystonia is a chronic neurologic disorder of central motor pro-
muscular gamma motor neurons or an indirect consequence cessing characterized by task-specific, action-induced muscle
of muscle weakening remain matters of speculation. This ef- spasms. Spasmodic dysphonia is a focal dystonia involving
ferent effect may be an important part of the broad success of the larynx. It is usually classified into adductor, abductor, and
botulinum toxin in the treatment of dystonia, particularly in mixed forms, the first two characterized by hallmark clinical
comparison to surgical denervation. features and the latter being a combination of the first two. Ad-
Although seven different serotypes of botulinum toxin are ductor spasmodic dysphonia, the more common form, causes
known, only two are available for clinical use, type A (Botox®, inappropriate glottic closure and as a result, produces strangled
Allergan, Irvine, Calif., and Dysport®, Ipsen, Ltd., Slough, UK) breaks in connected speech. Abductor spasmodic dysphonia,
and type B (Myobloc®, Elan Pharmaceuticals, Dublin, Ireland). in contrast, causes inappropriate glottal opening that produces
Type A appears to have a slightly longer duration of effect (ap- breathy breaks and hypophonia. Although clinical features are
proximately 90 days) than has type B, and the Botox prepa- not always typical, the classification of spasmodic dysphonia
ration diffuses less from the point of injection than the other into adductor and abductor varieties remains essential to treat-
two, both factors with practical clinical consequences. Dose is ment: Botulinum toxin is injected into the thyroarytenoid/lat-
expressed in mouse units (U) and differs substantially among eral cricoarytenoid muscles (TA-LCA) in adductor spasmodic
the commercial preparations; the reader should note that dos- dysphonia, and into the posterior cricoarytenoid muscle in
ages discussed in this chapter refer to Botox. abductor spasmodic dysphonia.
Adverse effects of botulinum toxin treatment may result Essential voice tremor is an age-related disorder of invol-
from overweakening of the intended target muscle as well as untary muscle contraction, which can affect the voice to a de-
unintended weakening of surrounding muscles. Therefore, bilitating extent in some patients. Clinical examination reveals
both appropriate dosing and the tissue distribution of the rhythmic, oscillatory movement of the portions of the vocal
toxin are crucial. In general, dose is proportional to targeted tract (i. e., velum, base of tongue, pharynx, larynx, vocal folds),
muscle mass, although the range of therapeutic dosing is typi- which typically involves a wide variety of muscles of the upper
cally highly variable. There is no standard botulinum toxin aerodigestive tract. No pharmacologic intervention has been
dose for patients with spasmodic dysphonia. Some patients get documented to be effective in essential voice tremor, and botu-
the best results from a unilateral dose and others from bilat- linum toxin chemodenervation has provided symptomatic
eral treatment. In bilateral injections for adductor spasmodic relief in selected patients. Administered much as in adductor
dysphonia, for example, therapeutic doses range from 0.3 to spasmodic dysphonia, botulinum toxin symptom control is
15 U per thyroarytenoid muscle, although most dysphonia is usually not as dramatic in essential tremor, probably due to
well controlled with doses of 0.625–2.5U. The distribution of differences in the pathophysiology of the two diseases. The
222 Botulinum Toxin Injection of the Larynx
areas of tremor most responsive to the botulinum toxin injec-

tion from a symptom perspective are the true vocal folds and
the false vocal folds.
Indications comprise:
35.2.3 Different Botulinum Toxin ■ Spasmodic dysphonia
Injection Approaches ■ Essential voice tremor
■ Vocal fold granuloma
There are a variety of injection approaches to deliver botuli-
35 num toxin to the larynx: Muscle selection, injection strategies, and dosing involves the
following:
■ Percutaneous injection with EMG guidance (most
1. Spasmodic dysphonia
traditional)
The standard treatment for adductor spasmodic dysphonia
■ Percutaneous with laryngoscopic guidance
(SD) is bilateral EMG-guided, percutaneous injections of
■ Supraglottic botulinum toxin injection with laryngo-
the TA-LCA muscles, using equal amounts of botulinum
scopic guidance
toxin, based on the understanding that the motor control
disorder is bilateral and symmetric (see Blitzer et al. 1998).
Distinct advantages and disadvantages exist for these ap- In patients with abductor spasmodic dysphonia, bilateral
proaches (see below). Selection of the best injection approach posterior cricoarytenoid muscles are treated, although in-
is determined by surgeon’s training, equipment availability, jections are staggered for reasons of airway safety. For both
patient’s disease characteristics and preference. forms of SD, the dose is adjusted based on the severity of
Percutaneous injection under EMG guidance is the quick- the disease and on response to treatment, and the value of
est and most precise method of botulinum toxin delivery into bilateral versus unilateral treatment is reassessed. It is clear
the larynx. However, this technique also has a learning curve from reports in the literature that unilateral injection may
and can take a considerable amount of time and practice to provide essentially equivalent symptomatic relief in patients
master. In addition, the technique requires the purchase of ad- with adductor spasmodic dysphonia, although the dose is
ditional equipment (EMG machine) and moderate technical usually increased and may not provide the same duration of
mastery of EMG interpretation. Given these barriers, some benefit.
surgeons who perform laryngeal botulinum toxin injections A reasonable initial dose in adductor spasmodic dyspho-
on an infrequent basis may wish to consider an alternative nia is 1.25 U per side, which represents a low-average dose.
method, a percutaneous or peroral injection technique, us- Dosing at subsequent treatment is adjusted based on pa-
ing laryngoscopic (visual) guidance. Given that this approach tients response. For abductor spasmodic dysphonia, the
(without EMG guidance) is less precise, often the toxin dose first posterior cricoarytenoid (PCA) muscle is injected with
used is slightly higher than EMG-guided percutaneous injec- 5 U; voice result and vocal fold mobility is evaluated 2 weeks
tion. later. The contralateral dose is determined in light of this,
Supraglottic botulinum toxin injection with laryngoscopic so that the dose in inversely proportional to the degree of
guidance for spasmodic dysphonia offers the advantages of: muscle weakness observed. Asymmetric dosing is the rule
in abductor spasmodic dysphonia.
■ More gradual/smooth onset of action
Botulinum toxin treatment results in an initial period of
■ Smoothing of vocal fold “peaks and troughs” associated
marked muscle weakness lasting several days, followed by
with true vocal fold injections
a 3- to 4-month-long plateau of milder weakening, which
■ Less severe (minimal to none) breathy voice
constitutes the principal therapeutic effect. This effect prob-
■ Preserves singing voice/pitch control in many patients
ably occurs because of the two-stage mechanism of neural
recovery from botulinum toxin administration. The tran-
The disadvantages of this approach include a shorter duration sient, breathy dysphonia that usually follows bilateral TA-
(typically 6–8 weeks), less predictable voice results and more LCA injections is a clinical manifestation of this pattern,
involved injection procedure. The unreliable voice results most and is to some extent inevitable. In general, the length of
likely occur from variable supraglottic muscular anatomy and the period of breathiness and the length of the therapeutic
variable needle location during the supraglottic injection. Su- effect are approximately proportional, so that attempts to
praglottic botulinum toxin injection with laryngoscopic guid- shorten the breathiness may compromise the duration of
ance may be preferred in professional voice users afflicted with therapeutic effect. Naturally, patients prefer to minimize the
adductor spasmodic dysphonia, given the reduced number of frequency of their injections, but each will have a different
days with a soft, weak, breathy voice. tolerance for the initial breathy voice phase of their treat-
ment.
Dyspnea is the equivalent early treatment effect in abductor
SD. Because this may be life threatening, only one side is
treated at a time, to allow partial recovery of the first prior
to denervation of its counterpart. Alternate explanations
Chapter 35 223
for greater difficulty and less satisfactory results in abductor

■ Ground and reference electrodes
SD patients are (1) the PCA muscle injection is technically
■ Tuberculin syringe
more difficult and/or (2) some patients thought to have ab-
■ (Optional) local anesthetic for skin (1% lidocaine with
ductor SD have mixed SD, a combination of adductor and
1:100,000 epinephrine) and tracheal use
abductor SD. Even so, the potential for dyspnea imposes
important treatment limitations in abductor spasmodic
dysphonia, which may account for the generally less satis- Additional equipment necessary for percutaneous injection
factory results in these patients. with laryngoscopic guidance and/or peroral supraglottic injec-
2. Essential voice tremor tion with laryngoscopic guidance:
Essential voice tremor is typically treated with bilateral
■ Flexible laryngoscope (with working channel or
symmetric muscle injections of the TA-LCA muscles in the
endosheath with channeled sheath (Vision Sciences,
similar manner of adductor spasmodic dysphonia. These
Orangeburg, New Jersey)
patients are more likely to be troubled by prolonged post
■ C-mount camera (attaches to flexible laryngoscope)
injection breathiness; thus, a lower dose is preferred by
most patients. Essential voice tremor usually involves the
■ Three to 6 ml of 4% plain lidocaine
muscles of the upper aerodigestive tract more broadly, but
■ 27-g needle, 37 mm in length (percutaneous injection
no systematic attempt to treat other involved muscles, such
with laryngoscopic guidance
as the strap muscles, has been made, and the functional re-
■ Orotracheal injector device for peroral injection ap-
quirements of swallowing prevent treatment of still others,
proach (Medtronic Xomed)
such as pharyngeal constrictors. When the tremor is found
■ Cetacaine spray (benzocaine/tetracaine topical)
to be predominantly at the level of the true and false vo-
■ Curved Abraham cannula
cal folds, botulinum toxin injection of the TA-LCA muscles
■ Fine-gauge injection needle for use with working chan-
and/or the supraglottis can be very effective.
nel in flexible laryngoscope
3. Vocal fold granuloma
Botulinum toxin injection has been advocated by some to
weaken the vocal adductory force of the arytenoid to al-
low better healing and resolution of vocal fold granuloma.
35.5 Procedure
Botulinum toxin is injected into ipsilateral or bilateral TA-
LCA muscles, in doses ranging from 1.25 to 20 U. Most
often 5 U injected unilaterally is adequate. In most cases, 1. Botulinum toxin reconstitution and dilution
a single application, either alone or in conjunction with Botox is supplied as a freeze-dried powder in 100-U vials.
surgical removal, has been sufficient to permit resolution It is reconstituted with preservative-free saline. The prod-
of the granuloma. It should be noted that patients treated uct insert provides dilution instructions to achieve a wide
with this approach will have a severe breathy, weak voice for variety of concentrations (1.25–10 U/0.1 ml). Injection vol-
several months, and this may have a major impact on the ume should be limited to minimize diffusion. Preferable
functional voice capacity (work and social). volume is 0.1 ml per vocal fold; however, a volume of 0.2 ml
is also acceptable. At that volume, there is virtually no risk
Contraindications to injection include: of airway difficulty from vocal fold engorgement. A needle
larger than 21 g should be used for reconstitution, dilution,
■ Pregnancy
and transfer from vial to injection syringe. After the correct
■ Breast feeding
dose is prepared, the insulated 26-g injection needle is at-
■ Impaired abduction of vocal fold for PCA injection
tached to the syringe.
(relative)
2. Percutaneous EMG-guided botulinum toxin injection
■ Neuromuscular diseases (e. g., myasthenia gravis)
a) Connecting EMG electrodes
■ Concurrent aminoglycoside treatment
A ground and a reference electrode are attached to the
patient’s skin at a convenient site so as not to obstruct
the injection or inconvenience the injector. The insulated
injection needle, which serves as a monopolar sampling
35.4 Equipment
electrode during the injection, is attached to an EMG re-
cording device.
Equipment for botulinum toxin injection: b) Thyroarytenoid–lateral cricoarytenoid muscle complex
localization and injection for Adductor SD
■ EMG device (AccuGuide® [Medtronic Xomed, Jackson-
The patient is positioned in a semirecumbent position,
ville, Fla.] is a hand-held device that offers principally
with the chin raised and the head back. If the neck is
acoustic output which may used as a lower-cost alterna-
thin and laryngeal landmarks are easily palpable, then
tive to more expensive traditional electromyography
a shoulder roll may be omitted. If the neck is short and
machines.)
stocky, or the larynx is canted forward, then a shoulder
■ Botulinum toxin
roll is helpful. Alternatively, the headpiece of the chair
■ Insulated 26-g needle electrode
can be positioned to allow neck extension (Fig. 35.1).
The patient is asked to breathe quietly and to try not to It is helpful to bend the needle upward some 30–45°, es-
swallow during the procedure. Both skin and intratra- pecially when injecting the female larynx, as the shorter
cheal anesthetic may be injected, the latter via a cricothy- anterior–posterior distance requires a more acute angle
roid puncture. of entry under the inferior rim of the thyroid cartilage.
The anesthetic approach is highly variable among expe- The needle is inserted into the cricothyroid space some
rienced clinicians. Some argue that the discomfort to the 2–3 mm off the midline toward the side to be injected
patient from the anesthetic injection is approximately and advanced superiorly and laterally (Fig. 35.2). A
equivalent to that from the toxin injection itself, while more lateral entry point is used to attempt to avoid the
others will perform the skin injection (30-g needle using airway, because traversing endolaryngeal mucosa is un-
1% lidocaine with 1:100,000 epinephrine and sodium bi- comfortable for the patient and may cause cough or even
35 carbonate). laryngospasm during the procedure. If it is possible to
remain entirely submucosal, then the patient finds the
procedure much less painful and stimulating to airway
reflexes. Entry into the airway produces a characteristic
“buzz” in the EMG signal, which should alert the injector
to redirect the needle more laterally, or even begin again.
The location where the needle penetrates the cricothy-
roid membrane from a superior–inferior perspective is
determined by the surgeon’s preference. Some will enter
the larynx at the junction of the inferior border of the
thyroid cartilage and the membrane while others prefer
to be at the halfway point of the membrane.
The needle is maneuvered within the tissue until the tip
lies in an area of crisp motor unit potentials. The pa-
tient is asked to phonate and a brisk recruitment and
a full interference pattern confirms placement, and the
botulinum toxin is injected. It is especially good to see
Fig. 35.1 Position of patient for percutaneous TA-LCA muscle botu-

linum toxin injection
Fig. 35.2 Insertion of needle through cricothyroid membrane into the Fig. 35.3 Placement of EMG needle into the posterior cricoarytenoid
TA-LCA muscle complex for botulinum toxin injection muscle, using a retrolaryngeal approach
Chapter 35 225
a characteristic prephonatory burst of EMG activity for

optimal injection localization.
c) Posterior cricoarytenoid muscle localization and injec-
tion for Abductor SD
i. Retrolaryngeal approach
The patient is seated upright, and the injector places
his or her thumb at the posterior border of the thy-
roid cartilage on the side to be injected. Using coun-
terpressure on the opposite side of the thyroid carti-
lage from the other four fingers, the larynx is gently
rotated to expose its posterior aspect. The needle
pierces the skin along the lower half of the posterior
border of the thyroid cartilage and is advanced until
it stops against the posterolateral surface of the cri-
coid. The needle is then pulled back slightly, and the
patient is asked to sniff to confirm placement (Fig.
35.3). When this produces brisk recruitment, the
toxin is injected.
ii. Translaryngeal approach
In this approach, the needle must cross the endolar
yngeal mucosa so an intratracheal injection of 4% Fig. 35.4 Placement of EMG needle into the posterior cricoarytenoid
plain lidocaine is useful to prevent coughing and muscle, using a translaryngeal approach
discomfort. The needle is inserted through the cri-
cothyroid membrane in the midline, and directed
posteriorly across the lumen of the glottis (identified manipulating the needle with the other. The patient
by the characteristic airway buzz on EMG) angled (or an assistant) must stabilize the tongue to facilitate
toward the side to be injected. Using gentle pres- good transoral visualization.
sure, it is pushed through the lamina of the cricoid iii. A 1-ml syringe filled with botulinum toxin is at-
cartilage until the opposite side is reached (due to tached to a 27-g needle. The needle is placed through
cricoid cartilage calcification, this approach may not the cricothyroid membrane near the midline, using
be possible in the older patient). The first electrical videomonitoring to confirm the location of the nee-
signal encountered on the far side represents poste- dle tip in the subglottic airway.
rior cricoarytenoid muscle. Placement is confirmed iv. The needle is angled toward the posterior aspect
by muscle activation during sniffing, and the toxin is of the vocal fold, piercing the infraglottic mucosa,
injected (Fig. 35.4). It is often useful (especially when and advancing the needle laterally into the adduc-
learning the technique) to employ an assistant to pro- tor musculature of the vocal fold (TA-LCA complex)
vide flexible laryngoscopy visualization on a monitor (Fig. 35.2). The posterior third of the membranous
during PCA injections (see Chap. 33, “Peroral Vo- vocal fold is the targeted region for Botox placement.
cal Fold Augmentation in the Clinic Setting”). The A similar injection is then performed on the oppo-
surgeon should be aware that fragments of cartilage site vocal fold through the same approach via the
might plug the needle lumen as it crosses the cricoid, cricothyroid membrane. Visual confirmation, via the
and expelling them to permit injection may require flexible laryngoscopic monitoring is used to confirm
considerable force on the plunger of the syringe; a correct placement and to insure that inadvertent
luer-lock syringe will prevent toxin leakage around “loss” of the Botox does not occur.
the needle hub. e) Supraglottic botulinum toxin injection with laryngo-
d) Botulinum toxin injection with laryngoscopic guidance scopic guidance for Adductor SD.
for Adductor SD Supraglottic botulinum toxin injection with laryngo-
i. Local anesthesia is obtained by performing a punc- scopic guidance is effective for treatment of adductor
ture through the cricothyroid membrane, and instill- spasmodic dysphonia as well as essential tremor involv-
ing approximately 3 ml of 4% lidocaine into the air- ing the supraglottis. Two different injection approaches
way. can be used to perform supraglottic botulinum toxin in-
ii. The nasal cavity is anesthetized and a flexible laryngo- jection, (1) peroral approach or (2) an approach using a
scope, attached to videomonitor, is inserted through working channel of a flexible laryngoscope. Each of these
the nasal cavity and advanced to a level slightly above two approaches are equally efficacious, and the decision
the vocal folds. An assistant maintains the scope in to use one approach or the other is usually determined
position in order to provide constant visual feedback by the availability of the equipment to the surgeon. From
during the procedure. a patient-comfort perspective, the injection through the
Alternatively, the surgeon may use a rigid telescope working channel of a flexible laryngoscope is better tol-
for laryngeal visualization (nondominant hand) while erated.
35
Fig. 35.5 False vocal fold site(s) for trans-oral botulinum toxin Fig. 35.6 Characteristic submucosal bleb immediately after transoral
injection botulinum toxin injection
1. Topical anesthesia nasal/oropharynx curved needle. Disposable 27-g needles are used
a) Topical oxymetazoline/Pontocaine 2% spray to with this system.
nasal cavities b) The needle is advanced into the oropharynx un-
b) Topical Cetacaine spray to oral cavity (palate/pos- der direct visualization. The patient is instructed
terior pharynx) to phonate /a/ as the needle enters the oral cavity,
2. Videomonitoring/topical anesthesia of larynx which results in palatal raising, clearing the path
a) A video camera is attached to a flexible laryngo- into the oropharynx. The assistant should posi-
scope or a distal chip flexible laryngoscope, insert- tion the flexible scope just above the palate until
ed through the nasal cavity (typically the left side) the needle is visualized in the oropharynx.
by an assistant, employing a “videocart system.” c) The injector is then advanced, and the needle tip
The scope is generally maintained slightly below is then guided into the hypopharynx, under endo-
the palate so that the tongue base and larynx can scopic visualization, as the assistant follows closely
be easily viewed on the video monitor. behind with the flexible scope The assistant must
b) Four percent lidocaine drip onto larynx under be adept at manipulating the scope; consistent
flexible guidance (3–5 ml; see Chap. 33) visualization of the injector can be challenging
The patient is bent forward at the waist with the in a narrow airway with copious secretions. The
neck extended in a “sniffing” position to maximize flexible scope should be positioned a few millime-
laryngeal exposure. The tongue is grasped with a ters above the false vocal folds providing a clear,
4 × 4 gauze with the surgeon’s left hand. A 3-ml well-illuminated, magnified view of the false vo-
syringe of 4% lidocaine (40 mg/ml) attached to an cal folds.
Abraham cannula (Pilling, Fort Washington, Pa.) 4. Laryngeal injection of Botox
is advanced into the oropharynx. Approximately a) The needle is guided into the posterolateral and/
1 ml is deposited over the tongue base, and 2–4 ml or mid-lateral false vocal fold under laryngoscop-
is dripped onto the vocal folds during phonation, ic visualization (Fig. 35.5).
producing the characteristic “laryngeal gargle”. b) Botox is injected into a superficial (submucosal)
The maximal recommended dose of 4% lidocaine plane, forming a characteristic bleb (Fig. 35.6).
is approximately 7–8 ml (4.5 mg/kg; approximate- c) Five to 7.5 U are typically deposited in both false
ly 300 mg for a 70-kg patient). vocal folds (total of 10–15 U).
3. Peroral passage of the needle into the endolaryngeal An alternative way to perform supraglottic botuli-
region num toxin injection with laryngoscopic guidance
a) The Botox is drawn up in a 1-ml syringe, and is to use a flexible laryngoscope with a working
secured into the orotracheal injector device channel, or a flexible laryngoscope with an en-
(Medtronic ENT, Jacksonville, FL) with the dosheath working channel apparatus. After ad-
equate anesthesia to the larynx has been achieved
Chapter 35 227
via the approach described above, a fine-gauge in-

laryngeal injections infrequently because it is
jection needle can be passed through the working
easier to master and relies on visual confirma-
channel of the flexible laryngoscope (NM-9L-1,
tion of the target, rather than blind needle
Olympus America, Center Valley, Pa.) and the su-
placement. However, it does require an assistant
praglottic larynx can be injected with botulinum
to hold the flexible laryngoscope.
toxin as discussed above. ■ The response to botulinum toxin is similar with
this technique when compared to EMG guided
technique, except:
35.6 Postprocedure Care ■ Higher doses are required
and Complications ■ Delayed onset of action (up to 5 days) occurs
■ Toxin effect that is less consistent
■ Supraglottic botulinum toxin injection with flex-
Patients may be discharged immediately after the injection.
ible laryngoscope guidance
Patients receiving TA-LCA injections should be cautioned re- ■ Supraglottic peroral Botox injection with flex-
garding an initial period of (1) breathiness and (2) dysphagia,
ible laryngoscopic guidance is indicated in
especially to liquids, as discussed above. Patient receiving their
selected patients with adductor spasmodic
second posterior cricoarytenoid injection should be advised
dysphonia (especially professional voice users
regarding dyspnea and stridor.
and supraglottic-based essential tremor).
Patients that received laryngeal anesthesia should be ad- ■ Advantages of supraglottic botulinum toxin
vised to retrain from any peroral intake for 2 hours (or until
(over EMG-guided approach) for spasmodic
sensation returns to the larynx/pharynx) to avoid the risk of
dysphonia
aspiration. ■ Smoothing of the vocal “peaks and troughs”
associated with serial EMG-guided Botox
injections
Key Points ■ Less severe (minimal-to-no) breathy voice
after injection
■ Disadvantages of supraglottic botulinum toxin
■ Percutaneous, EMG-guided botulinum toxin injec- for spasmodic dysphonia
tion ■ Shorter duration of effect (6–8 weeks)
■ Effective administration of botulinum toxin ■ Variable patient response (variable supra-
depends on glottic muscular anatomy)
■ Accuracy of injection
■ Minimizing diffusion to neighboring muscles
■ Appropriate dosing
■ When using EMG, confirmation of needle place- Selected Bibliography
ment by muscle activation during appropriate
activity (e. g., sustained “ee” or Valsalva for the
1 Aoki KR (2004) Pharmacology of botulinum neurotoxins. Oper
thyroarytenoid, sniffing for the posterior crico-
Techniques Otolaryngol 15:81–85
arytenoid) is essential to accuracy.
2 Blitzer A, Brin MF, Stewart CF (1998) Botulinum toxin manage-
■ Diffusion is minimized by injecting a small vol-
ment of spasmodic dysphonia (laryngeal dystonia): a 12-year expe-
ume of solution, ideally 0.1 ml.
rience in more than 900 patients. Laryngoscope 108:1435–1441
■ Approximate dosing is determined by muscle
3 Blitzer A, Sulica L (2001) Botulinum toxin: basic science and
mass and experience treating a given muscle.
clinical uses in otolaryngology. Laryngoscope 111:218–226
Precise dosing for each patient is determined by
4 Bové M, Daamen N, Rosen C et al (2006) Development and
careful assessment of clinical result and adjust-
validation of the vocal tremor scoring system. Laryngoscope
ment of subsequent treatment.
116:1662–1668
■ Percutaneous injection of botulinum toxin with
5 Simpson CB, Amin MR (2004) Office-based procedures for the
laryngoscopic guidance
voice. Ear Nose Throat J 83(Suppl.):6–9
■ Percutaneous injection of Botox under flexible
6 Sulica L, Blitzer A (2004) Botulinum toxin treatment of spas-
(or rigid) laryngoscopic guidance is an ideal
modic dysphonia. Oper Tech Otolaryngol 15:76–80
technique for the practitioner who performs
Part C Laryngeal Framework
Surgery
Chapter 36
Principles of Laryngeal
Framework Surgery 36
ranted in making feeding recommendations after medializa-
tion in such individuals. A complete reevaluation of swallow-
ing function is prudent after medialization in such patients.
Please see Chaps. 1, 5, 8, 37, 38, 39, 40, 41, and 42 for further Medialization laryngoplasty has been advocated by some
information. as a treatment for glottic insufficiency due to soft tissue loss
in the aspect of the superficial vocal fold, such as is found in
postsurgical scarring or sulcus vocalis. However, it is not well
suited for these conditions, as it in no way addresses the lack
36.2 Introduction
of tissue pliability and may not yield significant voice improve-
ment. It is worth noting that there is considerable evidence
The general goal of laryngeal framework surgery is to improve to suggest that at least part of the so-called “bowing” that has
phonatory glottal closure by altering vocal fold position. Me- been accepted as the clinical correlate of vocal fold aging may
dialization laryngoplasty, also called type I thyroplasty, is the also be due to changes in the lamina propria and loss of vocal
most commonly performed laryngeal framework surgery, fold muscle bulk, and thus medialization may represent only a
typically used to correct glottic insufficiency from a variety partial solution.
of causes, but most often from unilateral vocal fold paralysis. Indications for ML include:
Whereas injection augmentation techniques principally im-
■ Symptomatic glottic insufficiency (dysphonia and/or
prove glottal closure by expansion of the thyroarytenoid (TA)
aspiration), especially if there is little chance of return of
muscle, laryngoplasty techniques employ implant material in
normal neurologic function
the paraglottic space to displace the affected vocal fold(s) medi-
Glottic insufficiency can be due to:
ally into a more favorable phonatory position. These materials
■ Unilateral vocal fold paralysis
include Silastic, hydroxylapatite, polytetrafluoroethylene rib-
■ Unilateral or bilateral vocal fold paresis
bon (GORE-TEX®) and titanium. Medialization laryngoplasty
■ Vocal fold atrophy, including age-related atrophy
may be used in conjunction with an arytenoid repositioning
procedure, an adjunctive technique that can be used to alter
vocal fold height and tension by manipulating the arytenoid Contraindications include:
along its physiologic axis of rotation (see also Chaps. 40, “Ary-
■ Previous history of radiation therapy to the larynx (rela-
tenoid Adduction” and 41, “Cricothyroid Subluxation”).
tive)
■ Malignant disease overlying the laryngotracheal com-
plex
36.3 Surgical Indications ■ Poor abduction of the contralateral vocal fold (due to
and Contraindications airway concerns)
■ Because medialization inevitably leads to some
narrowing of the airway, patients with moderate-
36.3.1 Medialization Laryngoplasty to-severe bilateral vocal fold paresis may not be
candidates for medialization. At least one vocal fold
should have intact inspiratory vocal fold abduction
The primary indication for medialization laryngoplasty (ML) is
for a medialization procedure to be considered
symptomatic glottic insufficiency. The goals of the surgery are
to improve voice quality and protect the airway by achieving
improved glottic closure during phonation and swallowing.
36.3.2 Arytenoid Adduction
Nevertheless, it is important to understand that vocal fold
medialization does not always provide a sure remedy. In the
presence of other motor or sensory deficits, as in a high vagal Arytenoid adduction and arytenopexy as described by Zei-
nerve lesion, the ability to close the glottis does not necessarily tels is an important adjunct in selected cases of vocal fold pa-
mean that this will occur appropriately during deglutition. Me- ralysis. The physiologic effects of arytenoid adduction are not
dialization is indeed likely to help, but many patients continue completely understood, and some debate continues. However,
to have medically significant aspiration. Due caution is war- there is consensus concerning the following basic premises.
232 Principles of Laryngeal Framework Surgery
Arytenoid adduction/re-position: tion via Direct Microlaryngoscopy”; 33, “Peroral Vocal Fold
Augmentation in the Clinic Setting”; and 34, “Percutaneous
■ Rotates the arytenoid cartilage
Vocal Fold Augmentation in the Clinic Setting”).
■ Medializes and stabilizes the vocal process
Because medialization laryngoplasty is performed under
■ Lowers the position of the vocal process
local anesthesia, anxious/uncooperative patients, and pediatric
■ Lengthens the foreshorted vocal fold
patients are not ideally suited for this technique.
In patients with vocal fold paralysis who have a lack of vocal

process contact during phonation (large posterior gap) and
36.5 Timing of Medialization
those with vocal folds at different levels, arytenoid adduction
Laryngoplasty
should be considered in addition to medialization laryngo-
plasty. Videostroboscopy often provides valuable informa-
36 tion about vocal process contact and vocal fold height, and If the status of the nerve injury is unknown or LEMG data are
therefore is useful preoperatively in assessing which patients equivocal or favorable for spontaneous recovery, then medial-
may need an arytenoid adduction. A maximum phonation ization surgery is best delayed until 6–12 months after nerve
time of < 5 seconds has also been identified as a predictor injury to allow for spontaneous recovery. The patient with
of the need for arytenoid adduction in cases of vocal fold troublesome symptoms may be treated by any of a number
paralysis. of temporary measures in the meantime principally injection
augmentation (see Chaps. 31, “Vocal Fold Augmentation via
Direct Microlaryngoscopy”; 33, “Peroral Vocal Fold Augmen-
tation in the Clinic Setting”; and 34, “Percutaneous Vocal Fold
36.3.3 Cricothyroid Subluxation
Augmentation in the Clinic Setting”).
Most surgeons advocate waiting at least 3 months after a
Cricothyroid subluxation was developed by Steve Zeitels to known vagal or recurrent nerve transection before performing
address the problems of a shortened vocal fold frequently seen medialization laryngoplasty. Early or “primary” medialization
in unilateral vocal fold paralysis. The concept of the procedure (performed within the first 3 months after nerve injury) has
is to lengthen the vocal fold by increasing the distance from fallen into disfavor, due to progressive atrophy of the vocal fold
the cricoarytenoid joint (cricoid) to the anterior commissure from ongoing nerve degeneration, which results in a return of
(thyroid cartilage) by subluxing the cricothyroid joint on the glottal insufficiency weeks to months after medialization.
side of the unilateral vocal fold paralysis. This results in a rota- In select cases, medialization between 3 and 9 months can
tion of the anterior commissure away from the midline in a be considered, especially if electromyography shows severe
direction contralateral to the side of the unilateral vocal fold neuronal degeneration without evidence of neural recovery or
paralysis. the history strongly suggests nerve transection. In these cases,
Cricothyroid subluxation is an adjunct procedure to me- the patient should be counseled that the implant might need
dialization laryngoplasty. This can be done with arytenoid to be removed if vocal fold function returns. It is worth not-
adduction also, but is typically only used with medialization ing that in the very rare cases of recovery of vocal fold motion
laryngoplasty. Cricothyroid subluxation addresses the com- after laryngoplasty that have been observed, the implant does
monly seen problem of a shortened vocal fold associated with not appear to interfere with function, and has rarely required
unilateral vocal fold paralysis. The only other procedure that removal.
can lengthen a paralyzed vocal fold is arytenoid adduction (see
Chap. 40, “Arytenoid Adduction”).
36.6 Technical Notes and Pertinent
Anatomic Landmarks for
36.4 Patient Selection for Laryngeal Medialization Laryngoplasty
Framework Surgery
Although many techniques and implant materials for medial-
Although any patient with symptomatic glottic insufficiency ization laryngoplasty exist, certain general principles of laryn-
is technically a candidate for framework surgery, medializa- geal anatomy can be universally applied. The level of the vocal
tion laryngoplasty is not necessarily the best approach in ev- fold lies closer to the lower border of the thyroid cartilage lam-
ery case. The ideal candidate for medialization laryngoplasty ina than to the upper, and not at its midpoint, as is frequently
is a patient with moderate to severe glottic insufficiency (2–3 (and erroneously) stated. It is important to place the thyroplas-
mm or greater glottic gap on phonation) manifested by weak, ty window at the most inferior location possible. This will usu-
breathy dysphonia and/or dysphagia. Conversely, most patients ally encompass the level of the vocal fold and make successful
with minor degrees of glottic insufficiency (<1-mm glottic gap medialization possible with appropriate implant positioning.
on phonation) who have minimal voice symptoms (e. g., vocal The inferior limit of placement is determined by the integrity
fatigue) may be better suited for voice therapy and/or injection of the cartilaginous strut below the window, which should be at
augmentation (see Chaps. 5, “Glottic Insufficiency: Vocal Fold least 3 mm high to prevent fracture, which destabilizes the im-
Paralysis, Paresis, and Atrophy”; 31, “Vocal Fold Augmenta- plant in a way that usually prevents effective medialization. As
Chapter 36 233
Fig. 36.1 Gender differences in medial-

ization laryngoplasty. The more oblique
angulation of the thyroid cartilage in
females, along with the shorter length of
the vocal folds requires that the medializa-
tion window be placed more anteriorly (5
mm in females, 7 mm in males)
Fig. 36.2 Diagram showing the incorrect

(left) and correct (right) method of expos-
ing the inferior thyroid ala. On the left, the
cricothyroid fibers have not been divided
from the inferior border, and an incorrect,
downwardly sloping line is used to trace
the proposed horizontal plane of the vocal
fold. On the right, a thorough dissection
of the inferior thyroid ala allows the true
horizontal plane of the vocal fold to be
outlined, ensuring correct window place-
ment. In this case, the inferior muscular
tubercle (arrow) is ignored when deter-
mining the plane
a result of this limit, the implant often needs to be carved such traoperatively by means of flexible laryngoscopy, and auditory
that medialization occurs at the inferior limit of the window to perceptual evaluation is essential to understanding the reason
avoid ventricular mucosa/false cord displacement. for a poor phonatory result in time to correct it, therefore, a
Another important anatomic consideration is the gender- flexible laryngoscope, its light source, a camera, and a monitor
related differences in the configuration of the thyroid cartilage. should be used for every case.
In males, the vocal folds are longer, and the thyroid ala form a Conflicting advice regarding the inner perichondrium has
more acute angle when compared with the female larynx These appeared in the literature. Maintaining the perichondrium
anatomic differences require a more posterior location of the intact effectively prevents medial migration and extrusion of
cartilaginous window in the male larynx to avoid excessive the implant, and minimizes the possibility of endolaryngeal
or disproportionate displacement of the anterior third of the bleeding. Isshiki continues to advise its preservation in com-
vocal fold, which will result in strained or “pressed” voice. In bination with Silastic and a cartilage island, as do McCullough
general, the leading edge of the window is placed 7 mm back and Hoffman when using expanded polytetrafluoroethylene
from the midline of the thyroid cartilage in males and 5 mm ribbon. However, the medial projection of many preformed
in females (Fig. 36.1). Many implants are shaped to medialize implants makes their insertion impossible unless the internal
tissue in a plane exactly parallel to the long axis of the thyro- perichondrium is opened. In addition, an intact perichondri-
plasty window; its orientation is thus an important factor for um tends to distribute the vector of medialization throughout
surgical success. The inferior border of the thyroid lamina is the window, leading to less precise medialization.
the most reliable guide to determining the plane of the long It is important to conceptualize medialization of the vocal
axis of the vocal fold. To accurately identify this plane, the infe- fold in three dimensions. The most obvious dimension is me-
rior tubercle should be completely exposed and excluded from dial/lateral, because the amount of medial displacement must
the determination of the plane along the long axis of the vocal be precisely determined to close the glottic gap. Just as impor-
fold (Fig. 36.2). tant, however, is the anterior–posterior dimension. Anterior
Preserving some flexibility in medialization laryngoplasty displacement must be avoided, while a well-defined “sweet
technique to allow for individual variations in laryngeal anat- spot” at the posterior aspect of the vocal fold is key to opti-
omy is necessary to achieve consistently satisfactory surgical mizing results. The superior–inferior dimension is often the
results. Being able to check on the result of medialization in- least discussed, but no less important. This dimension is also
234 Principles of Laryngeal Framework Surgery
the most difficult to judge intraoperatively. A minor error in

tion, severe neuronal degeneration as seen with
medialization within the superior–inferior plane can result in
laryngeal electromyography, or in a clinical setting
height mismatch during vocal fold closure. This mismatch is
where there is little chance for recovery of vocal
difficult to detect during intraoperative flexible laryngoscopy,
fold mobility (e. g., UVFP due to a malignancy). In
and may only later be discovered with videostroboscopy post
these cases, a delay of 3 months from the time of
operatively.
injury is recommended to allow vocal fold atrophy
Details of technique specific to various implant materials
to occur. Temporary vocal fold injection can be
and steps and modifications required to perform arytenoid
used acutely in these patients prior to proceeding
repositioning surgery in conjunction with medialization la-
with laryngeal framework surgery
ryngoplasty are covered elsewhere (see Chaps. 38, “Silastic ■ The level of the vocal fold lies closer to the lower
Medialization Laryngoplasty for Unilateral Vocal Fold Paraly-
border of the thyroid cartilage lamina, and not at
sis”; 39, “GORE-TEX® Medialization Laryngoplasty”; and 40,
its midpoint. The thyroplasty window should be
36 “Arytenoid Adduction”)
placed as inferior as possible.
■ Gender-related difference in the thyroid lamina
requires a more posterior location for the medial-
Key Points ization window in males.
■ The inner perichondrium of the thyroid lamina
should be incised to gain access to the paraglottic
■ Medialization laryngoplasty and arytenoid adduc- space during medialization. An intact inner peri-
tion are the primary laryngeal framework tech- chondrium limits the depth and precision of vocal
niques used to correct glottic insufficiency fold displacement.
■ The indications for laryngeal framework surgery
include:
■ Unilateral vocal fold paralysis Selected Bibliography
■ Bilateral vocal fold atrophy/paresis
■ The ideal candidate for medialization laryngo-
1 Cohen JT, Bates DD, Postma GN (2004) Revision Gore-Tex
plasty is a patient with moderate to severe glottic
medialization laryngoplasty. Otolaryngol Head Neck Surg
insufficiency (2- to 3-mm or greater glottic gap on
131:236–240
phonation) manifested by weak, breathy dyspho-
2 Isshiki N, Morita H, Okamura H, Hiramoto M (1974) Thyroplasty
nia and/or dysphagia. Conversely, most patients
as a new phonosurgical technique. Acta Otolaryngol 78:451–457
with minor degrees of glottic insufficiency (<1-mm
3 Netterville JL, Stone RE, Luken ES, Civantos FJ, Ossoff RH (1993)
glottic gap on phonation) who have minimal voice
Silastic medialization and arytenoid adduction: the Vanderbilt
symptoms (e. g., vocal fatigue) may be better
experience. A review of 116 phonosurgical procedures. Ann Otol
suited for injection augmentation and/or voice
therapy.
4 Netterville JL, Billante CR (2004) The immobile vocal fold. In:
■ Medialization laryngoplasty can be performed
Ossoff RH, Shapshay SM, Woodson GE, Netterville JL (eds)
with a variety of implant substances, including
The larynx. Lippincott, Williams & Wilkins, Philadelphia, pp
Silastic, GORE-TEX, Hydroxylapatite, and Titanium.
269–305.
■ In unilateral vocal fold paralysis (UVFP), framework
5 Rosen CA (1998) Complications of phonosurgery: results of a
surgery is generally performed after a waiting
national survey. Laryngoscope 108:1697–1703
period of 6–12 months to allow for spontaneous
6 Woo P. Arytenoid adduction and medialization laryngoplasty
recovery.
(2000) Otolaryngol Clin N Am 33:817–839
■ Early medialization can be considered in select
7 Woodson GE, Picerno R, Yeung D et al (2000) Arytenoid ad-
cases including: complete nerve transec-
duction: controlling vertical position. Ann Otol Rhinol Laryngol
109:360–364
Chapter 37
Perioperative Care for Laryngeal

Framework Surgery 37
Please see Chaps. 1, 5, 8, 36, 38, 39, 40, and 41 for further in-
formation. The principal complications specific to medialization laryngo-
plasty include airway obstruction and implant extrusion. The
results of a survey of American otolaryngologists performed in
1998 revealed incidences generally in line with those reported
37.2 Perioperative Issues in Laryngeal
in various series.
Framework Surgery
Medialization necessarily results in a narrowing of the glot-
tic airway. In combination with postoperative edema or he-
Vocal fold edema may have a marked effect on voice quality matoma, this can result in significant airway obstruction—the
and prolong recovery of normal voice, thus intravenous Decad-
ron (10 mg) is given preoperatively, followed by two additional
doses at 8 and 16 h postoperatively. In rare instances, a patient
undergoing framework surgery may develop laryngeal edema
to such a degree that partial or complete airway obstruction
occurs. Patients undergoing bilateral medialization procedures
and/or arytenoid adduction are at increased risk for this com-
plication, as are those with a history of irradiation to the neck.
Generally, maximal airway edema occurs within the first 24 h
after surgery; however, edema may continue to progress up to
72 h postoperatively in rare cases. All cases are admitted for
overnight observation, with pulse oximetry. Patients may be
fed the evening of surgery, with the diet advanced to regular as
tolerated. In cases of significant postoperative edema, a peroral
corticosteroid taper may be used at discharge.
Use of a surgical drain is not necessary in most medializa-
tion cases; however, with arytenoid adduction a drain is pru-
dent. If a drain is placed, then it is typically removed the next
morning before discharge.
An intravenous antibiotic such as Ancef 1 gm is given pre-
operatively. Postoperative antibiotics are usually not necessary
unless there is a history of irradiation to the neck, in which case
a fluroquinalone may be use for 7–10 days postoperatively.
Most patients have good-to-excellent voicing intraopera-
tively, but develop varying degrees of postoperative dysphonia
as a result of edema or submucosal hemorrhage. Within hours,
a good postoperative voice will become rough and hoarse. The
patient should be warned of this before the surgery. The period
of postoperative dysphonia is variable, but may last between
2 and 6 weeks. Rare cases may persist up to 3 months. Voice
conservation is advocated; total voice rest is unnecessary.
Fig. 37.1 Violation of ventricular mucosa at the anterior aspect of the

medialization window (cross-section). Note the close proximity of the
ventricular mucosa to the thyroid lamina at the anterior aspect of the
window
236 Perioperative Care for LFS
most dangerous postoperative complication of medialization performed. There is some doubt that the vocal process of the
laryngoplasty. Surgeons surveyed reported some airway com- arytenoid can be medialized effectively and consistently by a
promise in 13.8% of cases. Usually, this was minor, and tended posterior extension of the medialization implant. Furthermore,
to occur more often after medialization laryngoplasty aryte- the arytenoid and its vocal process move in three dimensions,
noid adduction rather than medialization laryngoplasty alone. a fact not always obvious during laryngoscopic examination,
However, some 0.6% of patients undergoing medialization which renders height differences notoriously difficult to assess.
laryngoplasty and 2.2% of patients undergoing medialization A denervated vocal fold may thus rest at a different vertical
with arytenoid adduction required intubation or tracheosto- position from its functioning counterpart. In fact, with muscle
my. traction diminished or even absent, it may even lie outside of
Extrusion of the implant was extremely rare (0.8%) and pre- this trajectory, as in the case of a so-called prolapsed arytenoid,
dominantly into the airway rather than transcutaneous, as one when the vocal process lies below the plane of glottic closure.
would expect on comparison of internal and external tissue Simple medialization cannot remedy a height mismatch. A
covering of the implant. It is likely that at least some of the air- height mismatch is often accompanied by unequal vocal fold
way extrusions, particularly those that occur within a few weeks tension, which causes the folds to react differently to phona-
37 of surgery, are the result of intraoperative unidentified perfora- tory air pressure, resulting in dysphonia.
tions through the mucosa. If perforation goes unrecognized at Undercorrection is another relatively frequent cause of poor
the time of surgery, then the implant is at risk for exposure and results. This is especially likely to occur in cases that last longer
contamination. The implant then acts as a foreign body and than usual and allow normal intraoperative vocal fold edema
may extrude, potentially precipitating an airway foreign-body to accumulate. Even mild edema can create enough medial dis-
emergency. The delicate ventricular mucosa is often located in placement of the vibratory margin of the vocal fold to cause
close proximity to the inner aspect of the anterior thyroid ala, the surgeon to underestimate of the degree of medialization
and can be easily torn when working at the anterior aspect of required. In these cases, the patient will report good voice im-
the window (Fig. 37.1). The key to preventing airway entry is mediately after surgery, only to fade 1–2 weeks later, when the
to avoid undermining of the paraglottic space anterior to the edema begins to resolve. The key to avoiding this complication
window and to use care when removing the anterior portion of is to keep the time from intralaryngeal elevation until final im-
the cartilaginous window. If accidental mucosal violation does plant placement as short as possible. The window should be
occur, then the tear can usually be closed with absorbable su- probed, and medialization measurements should be obtained
tures. One can test that the closure is complete by flooding the as soon as the window is opened. In addition, preoperative in-
operative field with irrigation and looking for air bubbles dur- travenous corticosteroids (Decadron, 10 mg) and application
ing a Valsalva maneuver. If the tear is successfully closed, then of epinephrine-soaked Cottonoids within the medialization
an implant can be safely placed in select cases. Securing the window during implant carving can help lessen edema. It is
implant to the cartilage with sutures is thought to significantly important to recognize the onset of vocal fold edema intraop-
reduce the risk of airway foreign body. In cases where delayed
implant exposure within the airway is encountered, the patient
should be taken back to the operating room for removal of the
implant, either externally or endoscopically. In these cases, re-
vision framework surgery should not be considered for at least
another 3 months.
37.4 Suboptimal Results/Surgical Errors
An unsatisfactory voice result rather than any airway problem

or extrusion is the most common cause of revision medializa-
tion surgery. Revision rates, reported to be 5.4% in the survey
of complications, can reach 16%. When secondary procedures
such as fat injection are included, revision rates have been re-
ported to be as high as 33%. Certain causes of poor voice re-
sults occur regularly and with greater frequency than others
in most reported series, as well as in the authors’ experience.
These include:
■ Persistent posterior glottic gap
■ Undermedialization
■ Superior implant malposition
■ Anterior implant malposition
Fig. 37.2 Flexible laryngoscopy demonstrating prolapse of the left
ventricular mucosa and false vocal fold from an implant that is placed
Persistent posterior glottic gap can account for up to 50% of “too high” (superior to the correct plane of the long axis of the vocal
revisions in cases in which arytenoid adduction has not been fold)
Chapter 37 237
eratively. If more than 30–45 min elapse between the opening plane of the true vocal fold prior to attempting the use of any
of the cartilaginous window and placement of the implant, depth-measuring devices. The image from an indwelling flex-
then significant vocal fold edema may have developed. Clues ible laryngoscope is extremely useful to confirm the correct
that vocal fold edema has developed include: medialization plane; a bulging ventricular fold or everted ven-
tricular mucosa (or, more rarely, subglottis) indicates an in-
■ The patient’s baseline voice (nonmedialized) sounds sig-
correct medialization plane (Fig. 37.2). Overmedialization of
nificantly better than it did before the case began.
the anterior vocal fold, caused by too anterior a placement of
■ Good voice quality is obtained during medializa-
the medialization implant, results in a distinctive pressed or
tion with depth gauge immediately after opening the
strained vocal quality from early contact and “overclosure” of
window, but cannot be replicated later (30 + min) in the
the anterior part of the membranous vocal fold during phona-
case.
tion (Fig. 37.3). To prevent this, glottic tissues overlying the an-
terior third of the window are generally not medialized. This is
When vocal fold edema is suspected, one must rely on visu- especially true in men, in whom the extremely thin glottic tis-
al clues more than auditory clues in determining the correct sue overlying this area is prone to overmedialization from even
amount of medialization. In other words, it is more important small amounts medial displacement. It is not uncommon for
to confirm a well-medialized vocal fold (using an indwelling a well-carved implant to cause a slight amount of unintended
flexible laryngoscope) in a patient with a mildly stained voice, anterior medial displacement. If a pressed voice is noted af-
rather than settling for a normal voice with a slightly undercor- ter implant placement, forceps can be used to pull the anterior
rected vocal fold. portion of the implant partially out of the window, and retest
A subset of patients may be noted to have voice deteriora- the voice. If the voice improves with this maneuver, reshaping
tion months to years after surgery. This is probably best ex- of the anterior portion of the implant is necessary.
plained by continued atrophy of the vocal fold musculature
from prolonged denervation, or bilateral age-related atrophy.
Implant malposition of the implant generally accounts for
37.4.1 Revision Surgery
the balance of revisions. Netterville and Billante have identified
placing the implant too far superior, which results in medial-
ization of the ventricular mucosa or the false vocal fold, as the The approach for revision surgery does not deviate much from
most common overall cause for revision. This can be avoided that taken with primary surgery. The location of the original
by placing the window no more than 3 mm above the inferior cartilaginous window from the previous surgery is not taken
border of the thyroid ala, or as low as possible while maintain- into consideration when planning the location of the revision
ing a stable inferior frame of cartilage below the window. Also, window. The same meticulous exposure of the thyroid ala and
one should carefully probe within the window to confirm the precise measurements should be used to establish the “new”
window location. The new window is then created, even if
there is some overlap between this and the original window.
In some cases, this may result in a larger window, or one with
an irregular shape. As long as the revision implant occupies
the new window location, and is secured within this space, the
unusual window dimensions do not present a problem (Figs.
37.4, 37.5).
Most implants can be removed easily as the new window
is opened, using two single-prong hooks. Once the revised
window is created, the fibrous capsule that has formed deep
to the implant must be incised (Fig. 37.6). This fibrous tissue
creates tethering of the thyroarytenoid muscle and must be in-
cised along the perimeter of the window (Fig. 37.7). Finally, the
paraglottic space is entered and undermined, similar to prima-
ry medialization techniques, to permit unencumbered medial
displacement of the vocal fold. This is similar to the release of
the internal perichondrium that is performed in most medial-
ization surgery. The remainder of the surgical case proceeds in
a similar fashion to primary medialization laryngoplasty.
In many cases, the reason for failure may be related to vocal
fold height differences, or lack of posterior glottic closure con-
ditions that medialization surgery cannot correct. Therefore,
it is not surprising that substantial number of medialization
revisions require arytenoid adduction. If an adequate voice
Fig. 37.3 Flexible laryngoscopy demonstrating excessive medializa- quality cannot be obtained by medial displacement of the vo-
tion of the anterior third of the left vocal fold after medialization la- cal fold intraoperatively, then arytenoid adduction should be
ryngoplasty performed in conjunction with medialization.
238 Perioperative Care for LFS
37
Fig. 37.4 Original window/implant and the outline of the “new” ideal Fig. 37.5 Combined revision window that is created. Note the secure
window dimension superimposed position of the implant
Fig. 37.6 Fibrous capsule within the paraglottic space after implant Fig. 37.7 Sharp incision through the fibrous capsule along the margin
removal. Note adherence of the capsule along the inner aspect of the of the window
thyroid lamina
Chapter 37 239
37.5 Long-Term Surgical Issues Selected Bibliography
Patients who have undergone successful medialization laryn- 1 Anderson TD, Spiegel JR, Sataloff RT (2003) Thyroplasty revi-
goplasty, with or without arytenoid adduction often express sion: frequency and predictive factors. J Voice 17:442–448
concerns about the safety of endotracheal intubation for sur- 2 Cohen JT, Bates DD, Postma GN (2004) Revision Gore-Tex medial-
gical procedures in the future. A waiting period of 6 months ization laryngoplasty. Otolaryngol Head Neck Surg 131:236–240
postsurgery (if the proposed surgery is elective) is advised. The 3 Cotter CS, Avidano MA, Crary MA, Cassisi NJ, Gorham MM
anesthesiologist should place the smallest endotracheal tube (1995) Laryngeal complications after type 1 thyroplasty. Otolar-
that he or she feels is safe—ideally, size 6.0 or smaller—prin- yngol Head Neck Surg 113:671–673
cipally to avoid inducing laryngeal edema from a slightly con- 4 Hong KH, Jung KS (2001) Arytenoid appearance and vertical
stricted glottic aperture. height difference between the paralyzed and innervated vocal
folds. Laryngoscope 111:227–232
5 Maragos NE (2001) Revision thyroplasty. Ann Otol Rhinol Lar-
yngol 110:1087–1092
Key Points
6 Netterville JL, Stone RE, Luken ES, Civantos FJ, Ossoff RH. Si-
lastic medialization and arytenoid adduction: the Vanderbilt ex-
perience. A review of 116 phonosurgical procedures. Ann Otol
■ Corticosteroids should be given in the preopera-
tive and immediate postoperative period to help
7 Rosen CA (1998) Complications of phonosurgery: results of a
minimize potential complications.
national survey. Laryngoscope 108:1697–1703
■ Major complications/ risk factors of framework
8 Weinman EC, Maragos NE (2000) Airway compromise in thyro-
surgery include:
plasty surgery. Laryngoscope 110:1082–1085
Complication Risk factor(s) 9 Woo P, Pearl AW, Hsiung MW, Som P (2001) Failed medializa-
tion laryngoplasty: management by revision surgery. Otolaryn-
Airway compromise/ Arytenoid adduction
gol Head Neck Surg 124:615–621
obstruction Bilateral medialization
Prior history of neck irradiation
Implant extrusion/exposure Violation of airway mucosa
■ Suboptimal results with framework surgery are

usually due to one or more of the following:
■ Persistent posterior glottic gap
■ Undermedialization
■ Implant malposition:
■ Anteriorly
■ Superiorly
■ Vocal fold height mismatch
■ A good voice after framework surgery that begins
to “fade” or weaken 1–2 weeks postoperatively
suggests undercorrection.
■ Revision surgery for medialization laryngoplasty
failures often requires arytenoid adduction to
achieve maximal voice results.
■ Endotracheal intubation is safe in patients who
have undergone framework surgery in the past,
but should be delayed until 6 months postopera-
tively, if possible. A smaller diameter ETT (6.0 or
smaller) is recommended.
Chapter 38
Silastic Medialization Laryngoplasty

for Unilateral Vocal Fold Paralysis 38
procedure should be used as a permanent treatment not a tem-
porary method of medialization.
Please see Chaps. 1, 5, 9, 14, 36, 37, 39, 40, and 41 for further Indications comprise:
information.
■ Symptomatic glottic insufficiency (dysphonia, aspira-
tion), especially if there is little to no chance of return of
vocal fold motion
Patients with unilateral vocal fold paralysis (UVFP) typically
tive)
complain of breathy dysphonia, vocal fatigue, and aspiration
of liquids. The etiology of the paralysis is frequently vagal/re-
plex
current laryngeal nerve injury secondary to iatrogenic causes
■ Poor abduction of the contralateral vocal fold (due to
or nonlaryngeal malignancy. Laryngoscopy generally shows an
airway concerns)
immobile vocal fold, although a slight amount of adduction
■ Presence of lesion on the vocal folds
can be present due to contralateral innervation of the inter-
arytenoid muscle. The position of the paralyzed vocal fold can
vary from median position to lateralized, and the height from
slightly above to below the contralateral vocal fold. This varia-
tion of the position of the vocal fold is probably related to the
degree of reinnervation that has occurred subsequent to the
nerve injury, as well as the differing anastomotic connections No single implant material is superior to the others for per-
between the RLN and SLN that are variable from patient to forming ML. It is really a matter of surgeon preference and
patient. experience. We advocate hand carving of a medium-grade Si-
Differential diagnosis of an immobile vocal fold includes lastic block (available from Medtronic ENT, Jacksonville, Fla.),
vocal fold paralysis, cricoarytenoid joint fixation (usually due using the surgical technique described by Netterville. This
to trauma or rheumatologic disease), and cricoarytenoid dis- leads to precise medialization, superior voice results, and a bet-
location (very rare, and almost exclusively related to severe ter understanding of the dynamics of vocal fold medialization.
external trauma—not intubation). Cricoarytenoid joint abnor- However, other systems (such as the preformed implants in
malities can be differentiated from vocal fold paralysis using the Montgomery Thyroplasty Implant System (Boston Medi-
laryngeal electromyography and vocal fold palpation. cal Products, Westborough, Mass.) or strip GORE-TEX® (W.L.
Gore and Associates, Flagstaff, Ariz.) and VoCoM hydroxyl-
apatite (Smith and Nephew, Bartlett, Tenn.) can be employed
successfully as well.
38.3 Surgery Indications
and Contraindications ■ Netterville Medialization Tray (Medtronic ENT)
■ Drill with 2- or 3-mm cutting burr
■ Kerrison rongeurs tray (1- to 3-mm-sized tips)
It is important to note that Silastic medialization laryngoplasty
■ Medium-grade Silastic block (Medtronic ENT)
(ML) is designed to be a long-term treatment for symptomatic
■ Partially preformed blocks are used in this proce-
UVFP. Experimental and clinical evidence supports the efficacy
dure, referred to as “silicone strips” by the manufac-
of Silastic ML over a prolonged period. However, it should be
turer
noted that Silastic ML is fully reversible—that is, the implant
■ Ruler (15-mm section of plastic ruler at tip of hemostat)
can be removed if return of vocal fold mobility occurs, or if a
■ Flexible laryngoscope
revision surgery needs to be performed later. There is minimal
■ C-mount camera with videocart/monitor
tissue reactivity to Silastic over time; generally, a thin fibrous
■ Clear overdrape for laryngoscope (1010 drape)
capsule surrounding the implant is all that is seen months to
■ Local anesthetic (nasal and subcutaneous)
years after ML. Even though the implant can be removed, this
242 Silastic Medialization Laryngoplasty
38
Fig. 38.1 Diagram of typical prep/drape

for medialization laryngoplasty
the patient’s head. The neck is then prepped and draped,

including a clear overdrape to allow manipulation of the
flexible laryngoscope during the case (Fig. 38.1).
4. A horizontal incision is placed in a skin crease at the level
of the midthyroid cartilage, typically 5–6 cm in length
(Fig. 38.2).
4. Subplatysmal flaps are raised to the hyoid superiorly and
the upper portion of the cricoid below; retention hooks
are used to secure the flaps out of the way.
5. The midline raphae is divided between the strap muscles
with cautery, exposing the laryngeal cartilage (Fig. 38.3).
6. A single-prong hook is placed under the thyroid notch,
and the larynx is retracted towards the side opposite the
paralysis, bringing the entire hemilaryngeal cartilage into
view (Fig.38.4).
Fig. 38.2 Horizontal skin incision: typically midthyroid cartilage and 7. The outer perichondrium of the thyroid cartilage is then
5 cm in length incised with a 15 blade, and a posteriorly-based flap is
raised with a cottle or freer elevator. This requires serial
release of the perichondrium superiorly and inferiorly
(Fig. 38.5).
8. The inferior border of the thyroid ala has muscle fibers
from the cricothyroid muscle inserting onto it, so these
1. The surgical region is liberally infiltrated with 1% lido- must be divided (typically with bipolar cautery followed
caine with 1:100,000 epinephrine, from the hyoid down by 15-blade division). This exposes the inferior border, so
to the cricoid cartilage, on the side of the intended sur- that the correct orientation of the window can be properly
gery. Typically, 15 ml are used. Preoperative intravenous determined (Fig. 38.6).
Decadron (10 mg) is administered. 9. The exposure of the inferior thyroid cartilage border must
2. Four percent lidocaine and oxymetazoline nasal spray is extend posterior to the muscular tubercle (an inferior-
applied to the most patent nasal cavity. projecting extension of the thyroid ala), as the angula-
3. Placement of an indwelling flexible laryngoscope with tion of this process can cause mistaken orientation of the
videomonitoring of the larynx during the entire surgical medialization window. The downward projection of the
case. The visual feedback of the larynx is invaluable when muscular tubercle must be ignored when determining the
performing this surgery. One-inch tape is used to secure horizontal plane of the inferior border of the thyroid car-
the flexible scope to a modified i.v. pole hanging above tilage (Fig. 38.7).
Chapter 38 243
Fig. 38.4 Single-prong hook under the thyroid notch to gain exposure
to thyroid ala
Fig. 38.3 Division of midline raphae of the strap muscles
Fig. 38.5 Posteriorly based outer perichondrial flap elevation Fig. 38.6 Bipolar cautery and sharp dissection are used to expose the
inferior border of the thyroid ala
10. A window is outlined in the thyroid cartilage, measuring cal fold, which may result in “pressed” voice (Fig. 38.8).
6 × 13 mm, using the window-size gauge instrument. The After the window is outlined, one can pass a needle (21
window is placed 3 mm above the inferior border of the gauge) through the anterior-superior corner of the pro-
thyroid cartilage. Placement of the window any higher posed ML window during simultaneous flexible laryngos-
(superior) may result in medialization of the false vocal copy. Care is taken to not “pass point” with the needle as it
fold or ventricular mucosa, with poor voice results. The goes through the cartilage, thus avoiding the airway. The
window is “set back” from the midline of the thyroid car- needle can usually be seen immediately or can be rapidly
tilage by a distance of 5 mm in women and 7 mm in men. jostled to aid the identification of the needle location. The
This setback helps avoid medialization of the anterior vo- needle location can aid in optimal window localization. If
Fig. 38.7 Diagram showing the incor-

rect (left) and correct (right) method of
exposing the inferior thyroid ala. On the
left, the cricothyroid fibers have not been
divided from the inferior border, and an
incorrect, downwardly sloping line is used
to trace the proposed horizontal plane of
the vocal fold. On the right, a through dis-
section of the inferior thyroid ala allows
the true horizontal plane of the vocal fold
to be outlined, insuring correct window
placement. In this case, the inferior mus-
38 cular tubercle (arrow) is ignored when
determining the plane
Fig. 38.9 A small triangle of cartilage is removed from the posterior

window using a 15 blade and a Woodson elevator
Fig. 38.8 Correct placement of the medialization window, 5–7 mm

from the midline of the thyroid ala (5 mm in females, 7 mm males),
and 3 mm above the inferior border. The window-size gauge instru- 12. The inner perichondrium that lies deep to the window is
ment is 6 × 13 mm in area removed, exposing the thyroarytenoid muscle fascia. Of-
ten this inner perichondrium is removed piecemeal with
the Kerrison rongeur during primary cartilage removal of
the needle is seen too anteriorly or superiorly, the planned the window. However if it is intact, then it may be incised
ML window can be adjusted appropriately. superiorly, posteriorly, and inferiorly (Fig. 38.13). A surgi-
11. The window of cartilage is then removed (with a 15 blade, cal plane is then developed, with the right-angle elevator
Kerrison rongeur, or drill, depending on laryngeal calcifi- within the paraglottic space (just superficial to the TA fas-
cation). In younger patients, the cartilage is soft, and can cia) in all directions around the window except anterior
be removed with a 15 blade, being cautious to avoid pen- (Fig. 38.14). Dissection anterior to the window may re-
etration of the cartilage with resultant paraglottic bleed- sult in perforation into the airway through the very thin
ing. Often, a triangle of cartilage can be incised and then (and closely adherent) ventricular mucosa and should be
removed from the posterior superior aspect of the window avoided. Incising the inner perichondrium and establish-
using a Woodson elevator (Fig. 38.9). Once an entry point ing a surgical plane in the paraglottic space is important
through the thyroid cartilage is established, a Kerrison to successful medialization. An intact perichondrium re-
rongeur can be used to complete the window (Fig. 38.10). mains tightly bound to the thyroid cartilage (even with
When drilling the window, a 2- to 3-mm cutting burr is undermining) and often provides great resistance to
used, first outlining the perimeter of the window. Once medialization; it is analogous to trying to displace a tram-
the entire rectangular section of cartilage is thinned, a poline. In contrast, the paraglottic space allows for unen-
Woodson elevator can be used to gain entry into the para- cumbered medialization, once the inner perichondrium is
glottic space (Figs. 38.11, 38.12). incised.
Chapter 38 245
38.10 Kerrison rongeur is then used to remove the remainder of the Fig. 38.11 A cutting burr is used to outline the window in cases where
cartilage the cartilage is calcified
Fig. 38.12 A Woodson elevator is then used to gain entry into the Fig. 38.13 Release of the inner perichondrium, with a 15 blade supe-
paraglottic space, when the cartilage is sufficiently thinned riorly, posteriorly, and inferiorly
38
Fig. 38.14 Undermining within the paraglottic space (deep to the in- Fig. 38.15 Undermining the paraglottic space from below, to insure
ner perichondrium) superiorly, posteriorly, and inferiorly release of cricothyroid fibers. This will allow space for the flanges of
the implant to rest
13. The inferior paraglottic surgical plane should extend below window to the point of maximal displacement (i. e., the tip
the inferior strut of the thyroid ala. This can be achieved of the depth gauge), which is referred to as the “A” mea-
by undermining from below the strut, using the long or surement in the corresponding illustration. This is often
a cottle elevator. The TA fascia in the window should be 10–13 mm in length, as posterior medialization most of-
displaced medially to avoid perforation/penetration of the ten is used (in women this measurement is typically closer
TA muscle fibers (Fig. 38.15). to mid aspect of the window, 6–8 mm) (Fig. 38.17). The
14. The TA muscle is then displaced within the window while other measurement is the depth of medialization, and is
visualizing the effects on vocal fold displacement on the read off the depth gauge instrument. The measurement is
videomonitor. This helps establish the correct plane of taken off the inner table of the cartilage, not the outer table
medialization. Within the window, the inferior aspect (Fig. 38.18). Typically, 5–7 mm of medialization is needed
generally is the most desirable for medialization, and cor- at the posterior aspect of the window. It is rare that any
responds to the free edge of the vocal fold. Displacement medialization is needed at the anterior aspect of the win-
within the superior aspect of the window usually medial- dow, except in females.
izes the false vocal fold or ventricular mucosa, and results 16. Once the appropriate measurements are made, 3 × 0.5-inch
in suboptimal results in most cases. Cottonoids soaked in 1:10,000 epinephrine are placed in-
15. A depth gauge is used to displace the paralyzed TA muscle side the window to aid in hemostasis while the implant is
medially, while the patient counts to “10” (Fig. 38.16). A carved.
combination of visual feedback from the videolaryngos- 17. An implant is then carved out of medium-grade Silastic
copy monitor and the patient’s vocal quality are used to wedge on the back table to meet the specifications pro-
judge the correct amount of medialization needed. Ideally, vided by the depth gauge measurements.
the paralytic vocal fold will assume a straight contour in a) Carving the Silastic implant
the midline, allowing for complete glottic closure and sig- The implant may be carved from a medium-grade Silas-
nificant voice improvement. Two principle measurements tic block to meet the specifications provided by the depth
are obtained. The first is the distance from the anterior gauge measurements. A preformed 20-mm wedge block
Chapter 38 247
Fig. 38.16 Displacement of TA muscle with the depth gauge. Note

the displacement is generally at the posterior, inferior border of the
window
(“silicone strip” by Medtronic ENT) simplifies this task Fig. 38.17 Distance from the anterior window to the point of maximal
and shortens surgical time. This section describes its displacement of the depth gauge. This is generally 10–13 mm in males
proper preparation for implantation. and 3–8 mm in females. This is referred to as the “A” length during
The distance from the anterior edge of the window to implant carving
the point of maximal medialization (typically 11–13 mm
in males and 3–8 mm in females) is measured along the
block (measurement “A” on the diagram), and a dot is
placed with a marking pen (Fig. 38.19).
From the dot, a line is extended into the substance of
the block (measurement “B” in the diagram) which cor-
responds to the depth of medialization (Fig. 38.20). This
measurement was obtained using the depth gauge and is
typically 5–7 mm in most patients. Lines are then drawn
connecting the tip of line B with both the anterior and
posterior portions of the block (“C” and “D,” respec-
tively) (Fig. 38.21). This creates a characteristic triangu-
lar shape of the implant, with the edge C corresponding
to the portion of the implant that displaces the vocalis
muscle medially, and segment D corresponding to the
posterior extension of the implant that helps to hold it in
place.
A 10 blade is used to cut along lines C and D, removing Fig. 38.18 Measuring the depth of medialization using the depth
the excess portion of the block (Fig. 38.22). One must gauge. This is typically 5–7 mm. The measurement should be taken of
be careful to make these cuts at 90° angles to maintain the inner (deep) aspect of the cartilage. This is referred to as the “B”
the integrity of the depth of the implant. The implant measurement during implant carving
is placed in a customized implant holder for further
shaping.
The plane of medialization (lower, middle, or upper por-
tion of the window) that corresponds to the plane of of the implant (Fig. 38.24). Using a 15-blade, the excess
the true vocal fold is marked with a line along the im- Silastic is removed superior and inferior to the plane of
plant border (Fig. 38.23). In general, this is the inferior medialization, preserving an approximately 3-mm strip
or lower border of the window space. The line must be of material along the indicated line (Figs. 38.25, 38.26).
drawn along the medialization “zone” in the middle of The extreme upper and lower edges of the implant must
the implant, not on the upper or lower “flange” portions be thinned considerably to make the flanges flexible. This
38 Fig. 38.19 Carving a left-sided implant. A mark is made on the im-

plant corresponding to the point of maximal medialization (“A” length
from Fig. 38.17)
Fig. 38.20 A line is drawn perpendicular, beginning from the “A”

mark, extending the distance determined by the depth of medializa-
tion (“B” length from Fig. 38.18)
Fig. 38.21 A triangular implant is then created
Fig. 38.23 Marking the plane of medialization (corresponding to the

Fig. 38.22 Trimming excess Silastic, using a 10 blade inferior border in most implants)
Chapter 38 249
Fig. 38.24 Medialization should only occur within the “medialization Fig. 38.25 Removal of Silastic, using a 15 blade
zone” indicated. The implant material above and below this zone is
strictly used as flanges to hold the implant in place
Fig. 38.26 Sculpting the final implant contour. Note the line of medi-
alization is at the inferior aspect of the medialization zone Fig. 38.27 Posterior 7-mm slot is removed from the implant to allow
placement
“pressed” or “strained,” then the anterior portion of the

implant should be grasped and pulled out of the window
slightly. If this improves the voice, then there is too much
medialization anteriorly, and the implant should be re-
moved and reduced by an appropriate amount. On the
other hand, if the voice sounds breathy, then the implant
can be displaced posteriorly. One must be patient to try a
variety of maneuvers to insure the implant is ideally suited
to improve the voice. This may take an extra 10–15 min,
but pays dividends.
20. Trim the excess implant lateral to the thyroid ala to make
it flush with the cartilage (Fig. 38.28).
21. Secure the implant to the thyroid cartilage with perma-
nent sutures (4.0 Prolene) around the inferior “strut” of
cartilage (Fig. 38.29).
22. Ensure the wound is dry, and close all layers including
38 outer perichondrium, strap muscles, platysmal, and skin.
In general, a drain is not necessary, but may be placed de-
pending on the surgeon’s preference.
Fig. 38.28 Trimming of excess implant

and Complications
Postoperative care after medialization includes:

■ Overnight, 23-h observation
■ Pain management
■ Intravenous steroids at 8-hour intervals (Decadron,
8 mg, then 4 mg)
■ Elevation of the head of bed
■ A return to clinic is scheduled 2–4 weeks after surgery.
■ In general, the patient’s voice is poor within 6–8 h after
surgery, due to edema.
Common mistakes include medialization too far superiorly

within the window. In this instance, the indwelling laryngo-
scopic image will show a medialized false vocal fold or bulging
of the ventricular mucosa—sometimes a subtle finding. An-
other common mistake is excess medialization of the anterior
commissure. In this case, the voice has a distinctive “pressed”
Fig. 38.29 Securing the implant to the lower strut with two 4-0 or “strained” quality.
Prolene sutures Implant extrusion or exposure is another potential compli-
cation. Implant extrusion probably arises due to unrecognized
tear in the ventricular mucosa and soiling of the wound with
will facilitate easier placement of a large implant through respiratory secretions. The implant may extrude through the
the window. The A and B measurements are rechecked skin incision or into the airway, possibly precipitating an air-
for accuracy. way foreign body emergency. Securing the implant with su-
Finally, the implant is removed from the holder, and the tures significantly reduces the risk of this complication.
posterior 7 mm of the “slot” is removed from the implant Yet another complication is undermedialization. This prob-
(Fig. 38.27). The implant is now ready for placement. ably occurs when excessive edema of the vocal fold occurs pri-
18. Place the implant through the window using two Adson’s or placement of the implant. The patient is noted to have an ex-
forceps with teeth. The posterior inferior part of the im- cellent voice interoperative when the implant is placed, but the
plant should be advanced into the paraglottic space first. voice begins to fade 1–2 weeks post operatively, as the edema
19. Once the implant is in place, the patient’s voice should resolves. In cases where a prolonged period elapses between
be rechecked, and the laryngoscopic image should be the opening of the window and final placement of the implant,
observed to insure that the medialization recreates what one must anticipate the vocal fold will be slightly overmedial-
was achieved with the depth gauge. If the voice sounds ized, and the voice slightly strained to account for this edema.
Chapter 38 251
1 Koufman JA (1986) Laryngoplasty for vocal cord medialization:

■ Silastic ML is a long-lasting treatment for symp-
an alternative to Teflon. Laryngoscope 96:726–731
tomatic UVFP.
2 Netterville JL. Stone RE. Luken ES. Civantos FJ (1993) Ossoff
■ The procedure is performed under local anesthesia
RH. Silastic medialization and arytenoid adduction: the Vander-
with an indwelling flexible laryngoscope so that
bilt experience. A review of 116 phonosurgical procedures. Ann
vocal fold position and the patient’s voice can be
used as feedback to optimize results.
3 Wanamaker JR, Netterville JL, Ossoff RH (1993) Phonosurgery:
■ The inferior muscular tubercle must be exposed
Silastic medialization for unilateral vocal fold paralysis. Oper
to define the true lower border of the thyroid
Tech Otolaryngol Head Neck Surg 4:207–217
cartilage; this will aid in correctly identifying the
horizontal plane of the true vocal fold.
■ The inner perichondrium of the thyroid cartilage
must be divided to achieve unencumbered medi-
alization.
■ The paraglottic space should not be undermined
anteriorly so as to avoid violation of the ventricular
mucosa.
Chapter 39
GORE-TEX® Medialization
Laryngoplasty 39
Unilateral GORE-TEX ML can be used in cases of symp-
tomatic glottal insufficiency due to:
■ Unilateral vocal fold immobility, paralysis paresis, or
Please see Chaps. 5, 36, 37, 38, 40, for 41 further information.
atrophy
■ Unilateral vocal fold scarring or soft tissue loss

Bilaterally, GORE-TEX ML can be used to correct mild to se-
vere degrees of glottal insufficiency in cases of:
■ Presbylaryngis (vocal fold atrophy)
Gore-Tex® medialization laryngoplasty is an effective treat-
■ Bilateral vocal fold paresis
ment option for many conditions that cause glottal imcompe-
■ Select cases of Parkinson’s disease with vocal fold atro-
tence. This can be due to vocal fold atrophy, paresis or paraly-
phy
sis. Often patients will be found to have a “bowed” appearance
of the vocal fold with these conditions.
Vocal fold “bowing” is a term referring to a scalloped con- Contraindications for GORE-TEX ML include:
tour to the vocal fold. Bowing is a descriptive term, not a di-
agnostic one. Vocal fold bowing is most often due to age-re-
tive)
lated changes, or deinnervation of the vocal folds (complete
paralysis, or partial paresis). A differential diagnosis of vocal
plex
fold bowing includes:
■ Poor abduction of the contralateral vocal fold (due to
■ Deinnervation (vocal fold paralysis/paresis) airway concerns)
■ Age-related changes (presbylaryngis/vocal fold atrophy) ■ Presence of lesion on the vocal folds
■ Tissue loss from ablative/destructive vocal fold proce-
dures
■ Vocal fold scar
■ Sulcus vocalis deformity 39.4 Surgical Equipment
■ Myopathic disease (rare)
Needed equipment comprises:
39.3 Surgical Indications ■ Drill with 2- to 3-mm cutting burr
and Contraindications ■ Kerrison rongeurs tray (1- to 3-mm-sized tips)
■ Ruler
The use of GORE-TEX® as a medialization laryngoplasty (ML)
implant material was first reported by McCulloch and Hoffman
■ Overdrape for laryngoscope (1010 drape)
in 1998 and its ease of handling has made it use in this proce-
dure increasingly common. Many surgeons prefer GORE-TEX
■ GORE-TEX strip
for ML, especially in the bowed, mobile vocal fold. For some,
it is faster than using Silastic, creates less edema, and there-
fore decreases the chance of overcorrecting the anterior com- The implant itself is a GORE-TEX cardiovascular patch (0.4 mm
missure (particularly if performing a bilateral ML) and allows in thickness) cut in strips 3- to 4-mm wide (as described by
placement of the implants closer to the vocal process without McCullough) and soaked in 50,000 U of bacitracin in saline.
limiting their abduction. Creating the GORE-TEX ribbon prior to patient contact al-
GORE-TEX ML provides an excellent option for surgical lows the remainder of the patch to be reprocessed for future
treatment of symptomatic patients with moderate to severe vo- use. Preformed GORE-TEX ribbon for thyroplasty (0.6-mm
cal fold atrophy/bowing or paresis (glottal gap > 1 mm), as well thickness) is also available (Medtronic ENT, Jacksonville Fla.).
as unilateral vocal fold paralysis.
254 GORE-TEX® Medialization Laryngoplasty
1. The surgical region is liberally infiltrated with 1% lido-

caine with1:100,000 epinephrine, from the hyoid down to
the cricoid cartilage, on the side of the intended surgery.
Typically, 15 ml is used. Preoperative intravenous Decad-
ron (10 mg) is administered.
2. Four percent lidocaine and oxymetazoline nasal spray is
applied to the most patent nasal cavity. An indwelling flex-
ible laryngoscope with videomonitoring of the larynx is
used during the entire surgical case. The visual feedback
of the larynx is invaluable when performing this surgery.
One-inch tape is used to secure the fiberoptic scope to a
modified i.v. pole hanging above the patient’s head. The
neck is then prepped and draped, including a clear over-
drape to allow manipulation of the scope during the case
(see Chap. 38, Fig. 38.1).
39 3. A horizontal incision is placed in a skin crease at the level
of the midthyroid cartilage, typically 3–5 cm in length (see
Chap. 38, Fig. 38.2).
5. The midline raphae are divided between the strap muscles
with cautery, exposing the laryngeal cartilage (see Chap.,
Fig. 38.3).
6. An inferiorly based cathedral arch–shaped outer peri-
chondrial flap is elevated from the thyroid ala (Fig. 39.1).
7. The laryngoplasty window location is determined by
needle localization under direct vision with the flexible
laryngoscope. An 18-g needle is used to bore gently only
through the cartilage, and then a 27-g needle or intrave-
nous catheter is passed through the hole in the cartilage to
Fig. 39.1 Inferiorly based perichondrial flap is raised precisely localize the level of the vocal fold (Fig. 39.2). This
is easily observed on the monitor.
8. Using that as a guide, a small rectangular window is then
marked on the thyroid cartilage approximately 4–6 mm
posterior to the midline of the thyroid cartilage and usu-
ally 2–3 mm superior to the inferior border of the thyroid
ala. The most common technical error is placing the win-
dow too high. The pilot-hole technique allows the surgeon
to be certain of the height of the vocal fold and avoid this.
A 2- to 3-mm cutting burr is used to initiate this window
placement (Fig. 39.3).
9. These windows are usually 3 × 6–12 mm in size, placed
parallel to the lower border of the thyroid ala, and are cre-
ated using a scalpel or a drill. A small Kerrison rongeur is
often helpful in removing residual cartilage (Fig. 39.4).
10. After creating the cartilage window, the inner perichon-
drium is incised along the inferior border with a scalpel.
Incising the perichondrium allows a more precise control
of medialization (particularly adjacent to the vocal pro-
cess) with less chance for medialization of ventricular mu-
cosa. A small pocket is formed using the Woodson eleva-
tor between the muscle and cartilage inferiorly, anteriorly,
and posteriorly as needed, and the vocal fold is medial-
Fig. 39.2 Axial view of 27-g needle penetrating thyroid ala as a “pilot ized with an elevator (note: there is no reason to elevate
hole” superiorly). The effect is observed on the video monitor
Chapter 39 255
and acoustically evaluated using vocal feedback from the

patient.
11. The GORE-TEX implant is placed as a stacked strip using
jeweler’s forceps (or middle ear alligator forceps), and its
shape can be easily adjusted for optimal vocal fold medi-
alization (Fig. 39.5). Care is taken to insert the ribbon into
the window and when possible, medial to the edge of the
anterior, inferior, and posterior edges of the cartilage. This
helps maintain the implant’s position. Once the optimum
voice is obtained, the vocal folds are slightly overcorrected
to compensate for intraoperative edema and implant com-
pression (Fig. 39.6).
12. The implant is stabilized by suturing the outer perichon-
drial flap back into place using 4-0 nylon sutures. The
wound is closed in layers, and drains are rarely required.

and Complications
Postoperative care after medialization includes:

■ Overnight, 23-hr observation
■ Pain management
■ Oral antibiotics for 7 days
Fig. 39.3 Cutting burr is used to enlarge the pilot opening
8 mg, then 4 mg)
■ In general, the patient’s voice is poor within 6–8 h after
surgery, due to edema.
A common mistake includes medialization too far superiorly

within the window. In this instance, the indwelling laryngo-
scopic image will show a medialized false vocal fold or bulging
of the ventricular mucosa—sometimes a subtle finding. An-
other common mistake is excess medialization of the anterior
commissure. In this case, the voice has a distinctive “pressed”
or “strained” quality. It is important to note that the technique
of bilateral GORE-TEX ML used for the treatment of bowed
(but mobile) vocal folds is not the same as the standard ML
for unilateral vocal fold paralysis. The technique differs in im-
portant ways. (1) Overcorrection anteriorly must be carefully
avoided, since excessive anterior medialization will cause a
harsh, strained voice. This error can easily occur during bilat-
eral ML surgery. (2) The posterior extent of the implant must
not contact the vocal process of the arytenoid cartilage. Since
the vocal folds are mobile, an implant projecting too far pos-
teriorly could impinge on the arytenoid, and thus restrict ary-
tenoid motion. In active individuals, this can result in dyspnea
with exertion.
Implant extrusion or exposure is another potential compli-
cation. Implant extrusion probably arises due to unrecognized
tear in the ventricular mucosa and soiling of the wound with
respiratory secretions. The implant may extrude through the
skin incision or into the airway, possibly precipitating an air-
way foreign body emergency. The implants should be fixed in Fig. 39.4 Further enlargement of the window using a Kerrison ron-
place via replacement of the perichondrial flap. geur to a final size of 3 × 6–12 mm
256 GORE-TEX® Medialization Laryngoplasty
Key Points
■ GORE-TEX laryngoplasty is a long-lasting, but read-

ily reversible treatment for symptomatic glottal
insufficiency, and can be performed bilaterally.
■ The procedure is performed under local anesthe-
sia, with an indwelling flexible laryngoscope so
that vocal fold position and the patient’s voice can
be used as feedback to optimize results.
■ Overcorrection anteriorly must be carefully avoid-
ed (especially when bilateral ML is performed) to
avoid a harsh, pressed voice.
■ The posterior extent of the GORE-TEX implant
must not contact the vocal process of the aryte-
noid cartilage, as this may restrict arytenoid mo-
tion and lead to airway difficulties.
39
Fig. 39.5 Folding in GORE-TEX ribbon through the thyroid cartilage
window
1 McCulloch TM, Hoffman HT (1998) Medialization laryngoplasty
with expanded polytetrafluoroethylene. Surgical techniques and
preliminary results. Ann Otol Rhinol Laryngol 107:427–432
2 Giovanni A, Gras R, Grini MN, Robert D, Vallicioni JM, Triglea
JM (1997) Medialization of paralysed vocal cord by expansive
polytetrafluoroethylene implant (GORE-TEX). Ann Otolaryngol
Chir Cervicofac 114:158–164
3 Giovanni A, Vallicioni JM, Gras R, Zanaret M (1999) Clinical
experience with GORE-TEX for vocal cord medialization. La-
ryngoscope 109:284–288
4 Zeitels SM (2000) New procedures for paralytic dysphonia: ad-
duction arytenopexy, Goretex medialization laryngoplasty,
and cricothyroid subluxation. Otolaryngol Clin North Am
33:841–854
5 McCulloch TM, Hoffman HT, Andrews BT, Karnell MP (2000)
Arytenoid adduction combined with GORE-TEX medialization
thyroplasty. Laryngoscope 110:1306–3111
6 Zeitels SM, Mauri M, Dailey SH (2003) Medialization laryngo-
plasty with GORE-TEX for voice restoration secondary to glottal
incompetence: indications and observations. Ann Otol Rhinol
Fig. 39.6 Final contour of vocal fold after GORE-TEX is layered into Laryngol 112:180–184
the window (axial view) 7 Cohen JT, Bates DD, Postma GN (2004) Revision GORE-TEX
medialization laryngoplasty. Otol Head Neck Surg 131:236–240
8 Koufman JA (1989) Surgical correction of dysphonia due to bow-
ing of the vocal cords. Ann Otol Rhinol Laryngol 98:41–45
9 Postma GN, Blalock PD, Koufman JA (1998) Bilateral medializa-
tion laryngoplasty. Laryngoscope 108:1429–1434
10 Koufman JA, Postma GN (1999) Bilateral medialization laryngo-
plasty. Oper Tech Otolaryngol Head Neck Surg 10:321–324
11 Cashman S, Simpson CB, McGuff HS (2002) Soft tissue response
of the rabbit larynx to GORE-TEX implants. Ann Otol Rhinol
Chapter 40
Arytenoid Adduction
40
40.1 Fundamental and Related Chapters ■ Inability to achieve good voice intraoperatively with ML
alone
tion. Contraindications include:
■ Intact vocal fold mobility
■ Vocal fold paralysis with the chance of recovery of mo-
40.2 Fundamentals of Arytenoid tion (“early” paralysis)
Adduction ■ Limited abduction of contralateral vocal fold
Arytenoid adduction (AA) is used in the treatment of glot-

tal insufficiency. Unlike medialization laryngoplasty, AA acts
through direct traction on the arytenoid cartilage at the mus-
cular process, mimicking the action of the lateral cricoaryte-
noid muscle. AA is an important adjunct in selected cases of Surgical equipment needed comprises:
vocal fold paralysis. The physiologic effects of AA include the
■ Medialization instruments (see Chap. 39)
following:
■ Kerrison rongeurs
■ Lowers the position of the vocal process ■ Sewell retractors
■ Medializes and stabilizes the vocal process ■ 4-0 monofilament permanent suture
■ Lengthens the vocal fold (Prolene or Tevdek) on a double-armed needle
■ Rotates the arytenoid cartilage ■ Straight drill bit (e. g., 1-mm wire-passing drill bit)
■ Kitner dissector (peanut)
In patients with vocal fold paralysis who have a lack of vocal
process contact during phonation (large posterior gap), short-
ened immobile vocal fold, and those with vocal folds at differ-
ent levels, AA should be considered in addition to ML. Video-
stroboscopy often provides valuable information about vocal
process contact, vocal fold height and length, and therefore is Arytenoid adduction is usually performed in conjunction
useful preoperatively in assessing whether a patient may need with the ML procedures (see Chaps. 38, “Silastic Medializa-
an AA. A maximal phonation time (MPT) of less than 5 section Laryngoplasty for Unilateral Vocal Fold Paralysis” and 39,
onds has also been identified as a predictor of the need for AA “GORE-TEX® Medialization Laryngoplasty”). The procedure
in cases of vocal fold paralysis. is performed under local anesthesia, with an indwelling flex-
ible laryngoscope. To prevent unnecessary duplication, the key
portions of the ML up to the point of the AA are not illustrated
in the chapter; however, certain additional steps that are need-
ed to help achieve adequate exposure of the posterior laryngeal
framework and arytenoid complex are included for clarity.
1. After the midline raphae are divided between the strap
Arytenoid adduction for unilateral vocal fold paralysis is indi- muscles, approximately 1 cm of the medial aspect of the
cated in the following cases: sternohyoid muscle is sectioned below its insertion onto the
hyoid. The step is necessary to improve posterior exposure
■ Large posterior glottic gap
of the laryngeal framework for AA (Fig. 40.1).
■ Lateralized vocal fold during phonation
2. The outer perichondrium of the thyroid cartilage is then in-
■ Vertical height differences (generally the paralyzed vo-
cised with a 15 blade, and a posteriorly based flap is raised
cal fold is superiorly located)
with a cottle or freer elevator, including the inferior border
■ Severely foreshortened vocal fold
of the thyroid ala.
258 Arytenoid Adduction
3. A window is outlined in the thyroid cartilage, and opened chondrium is incised with a 15 blade along the posterior
as previously indicated in Chap. 38. A surgical plane is border of the cartilage to prevent elevation of the inner
then developed in the paraglottic space (just superficial perichondrium. The incision is continued to the level of
to the TA fascia) in all directions around the window ex- the superior cornu above and the inferior cornu below
cept anteriorly. In general, preliminary measurements are (Fig. 40.2).
taken for the ML portion of the case, before proceeding to 5. The surgical plane of the medialization window (paraglot-
the arytenoid exposure (see Chap. 38, Figs. 38.7–38.15 for tic space) should then be connected to the posterior la-
details). ryngeal dissection, so that there is one continuous surgical
4. The outer perichondrial flap is then extended all the way plane. A cottle or freer elevator is used to achieve this (Fig.
to the posterior border of the thyroid ala. The outer peri- 40.3).
6. A skin hook is placed on the posterior border of the carti-
lage to aid in retraction. Access to the arytenoid can then
be achieved with one of two methods:
a) Creation of a window in the posterior thyroid ala
A window of cartilage is removed from the posterior
border of the thyroid cartilage, using a 2-mm Kerrison
rongeur. The cartilage is removed until the muscular
process of the arytenoid is palpable and the anterior
extension of the pyriform sinus can be visualized (Fig.
40.4). The size of the window ranges from 10 to 15 mm
40 in height and extends approximately 10 mm anteriorly,
although the dimensions vary. The posterior aspect of
this window should be located on the same level of the
ML window. It is important not to allow the anterior
and posterior windows to “connect,” as this will likely
lead to framework instability.
b) Separation of the cricothyroid joint
Another way to gain exposure is by separation of the
cricothyroid joint along with lateral thyroid ala retrac-
tion. A small dissection scissor (tenotomy) is used to
separate the cricothyroid joint. Skin hook retractors are
placed, and the thyroid ala is gently retracted laterally.
Often, additional muscular or perichondrial attach-
ments along the inferior and superior cornu must be
divided to facilitate lateral alar retraction (Fig. 40.5).
7. The pyriform sinus mucosa must be identified and retract-
Fig. 40.1 Partial division of sternohyoid muscle 1 cm below its inser- ed posteriorly before the muscular process of the aryte-
tion noid is identified. Great care must be taken with this step
Fig. 40.2 A posteriorly based flap is separating the mus-

cle away from the posterior cartilaginous border.
Chapter 40 259
Fig. 40.3 The paraglottic space is connected between the posterior

cartilage border and the ML window
Fig. 40.4 Posterior “cookie-bite” window is created with a Kerrison

to avoid perforation of this delicate mucosa. The pyriform rongeur
mucosa can be seen extending anteriorly onto the poste-
rior cricoarytenoid (PCA) muscle. To aid in its identifica-
tion, the patient is asked to blow against pursed lips (“blow
out the birthday candles”), which results in distension and
easy identification of the pyriform mucosa. The mucosa
is grasped and dissected posteriorly, using blunt dissec-
tion with a Kitner (Fig. 40.6). The pyriform can then be
shielded under a Sewell retractor (Fig. 40.7).
8. The muscular process can then be identified using a num-
ber of landmarks. The muscular process is usually at the
same vertical height of the vocal fold and found by trac-
ing the fibers of the PCA muscle anterior/superiorly to its
tendinous insertion (Fig. 40.8). The muscular process is
small (about the size of a grain of rice), but can be pal-
pated. In addition, if the cricothyroid joint is separated as
in step 6b, then this can be used as a nearby landmark, as
the muscular process can be reliably found within 1 cm
above this point. By grasping the muscular process with
a toothed forceps, and rotating the arytenoid (anteriorly),
one should be able to easily rotate the arytenoid into a me-
dial position while confirming this with the endolaryngeal
image on the monitor (Fig. 40.9).
9. In order to obtain a secure purchase on the muscular pro-
cess, a 4-0 monofilament suture (double armed) is passed
through the lateral edge of the muscular process in a figure
of eight fashion (Fig. 40.10).
10. Both needles are brought through the dissected paraglot-
tic space into the medialization window, taking great care
not to inadvertently catch any tissue with the needle tips, Fig. 40.5 Alternately, the cricothyroid joint can be divided for poste-
which could adversely affect the vector of pull for the AA rior exposure
stitch. Generally, the needles are passes with the dull end
as the leading edge (Fig. 40.11).
11. One of the needles is passed through the cartilage anterior arytenoid, and the effect on the voice is tested by having
to the medialization window, using a 1-mm wire-passing the patient count from 1 to 10. In addition, at this time the
drill bit if the cartilage is calcified (Fig. 40.12). The other effects of medialization, using the previously mentioned
needle is passed underneath the inferior strut and is se- depth gauge instrument are tested both in isolation, and
cured anteriorly through the anterior cricothyroid mem- with the addition of tension of the AA suture.
brane (Fig. 40.13). 13. Once the implant is created, it is placed through the win-
12. The two ends of the suture are then clamped with hemo- dow, taking care to keep the AA suture lines deep to the
stats. The sutures are gently pulled anteriorly to adduct the implant (Fig. 40.14).
Fig. 40.6 The pyriform mucosa is dissected posteriorly using a Kitner
40
Fig. 40.7 Axial representation of larynx after posterior pyriform mu-

cosa dissection/protection with Sewell retractor
Fig. 40.8 Muscular process of the arytenoid is identified
Fig. 40.10 A 4-0 double-armed Prolene suture is passed through the Fig. 40.9 Axial representation of manual traction on the muscular
muscular process in a figure of eight fashion process to demonstrate adduction of the vocal fold
Chapter 40 261
Fig. 40.11 Passage of the suture through the ML window

Fig. 40.12 A 1-mm wire-passing drill bit is used to create an anterior
passage for one arm of the AA suture near the midline
Fig. 40.13 After successful passage of both arms of the AA suture

through the midline
Fig. 40.15 Final tying of a surgeon’s knot over the thyroid ala Fig. 40.14 Axial representation of AA sutures deep to ML implant
14. Finally, the AA suture tension is adjusted and the knot is ■ Lengthens the vocal fold
secured over the anterior thyroid cartilage, again assessing ■ Rotates the arytenoid cartilage
the voice. In general, only a small amount of tension is ■ AA is used as an adjuvant surgical treatment along
required for this (Fig. 40.15).
with ML in cases of vocal fold paralysis where one
15. Sternohyoid muscle is re-attached. Wound is closed in lay-
of the following occurs:
ers. Drain is placed at the surgeons discretion. ■ Posterior glottic gap/lateralized vocal fold dur-
ing phonation
■ Vertical height differences between vocal folds
40.6 Postoperative Care (generally the paralyzed vocal fold is superiorly
and Complications located)
■ Severely foreshortened vocal fold
■ Inability to achieve good voice intraoperatively
Postoperatively, care should encompass:
with ML alone
■ Overnight, 23-hours observation ■ AA requires a posterior dissection technique sepa-
■ Pain management rate from ML, where either a posterior window in
■ Intravenous corticosteroids at 8-hour intervals (Decad- created in the thyroid ala, or the cricothyroid joint
ron, 8 mg, then 4 mg) is divided to allow outward retraction of the poste-
■ Elevation of the head of bed rior thyroid ala.
■ A return to clinic is scheduled 2–4 weeks after surgery ■ The pyriform mucosa must be dissected off the
■ In general, the patient’s voice is poor within 6–8 hours muscular process of the arytenoid to allow proper
40 after surgery, due to edema. exposure of this structure.
■ An additional corticosteroid taper may be warranted on ■ A double-armed needle is secured at the muscular
discharge from the hospital. process of the arytenoid and passed anteriorly
near the midline of the thyroid ala to recreate the
pull of the LCA muscle. The sutures lie deep to the
Complications and common surgical errors include laryngeal
medialization implant.
edema with airway compromise, which is more common with ■ The needles from the AA sutures should be passed
framework surgery that involves AA. The additional retraction
through the paraglottic space carefully (dull end
and dissection necessary for exposure and manipulation of the
as the leading edge) to avoid picking up soft tis-
arytenoid complex results in increased paraglottic and aryte-
sue, which may change the vector of pull.
noid edema post operatively. Additional corticosteroids may ■ Only mild–moderate tension is required on the AA
be warranted in patients undergoing ML and AA.
suture to achieve desirable arytenoid positioning.
Pharyngocutaneous fistula is a possible complication with
AA, although it is quite uncommon. Careful handling of the
pyriform mucosa and protection of the mucosa with a retrac-
tor should prevent this complication. If an injury to the mu-
cosa is suspected, then the field can be irrigated and the patient
instructed to perform the Valsalva maneuver. If air bubbles oc-
cur during this maneuver, then the pyriform mucosa should
be repaired with absorbable suture, and the patient should be 1 McCulloch TM, Hoffman HT, Andrews BT et al (2000) Aryte-
retested for air leakage. One should consider whether it is pro- noid adduction combined with Gore-Tex medialization thyro-
dent to proceed with the ML and/or AA at this point. plasty. Laryngoscope 110:1306–1311
Excessive tension on the AA suture can create over-rotation 2 Woo P. Arytenoid adduction and medialization laryngoplasty
of the arytenoid and worsening of the voice. The tension need- (2000) Otolaryngol Clin N Am 33:817–839
ed on this suture is actually minimal in most cases; therefore, 3 Noordzij JP, Perrault DF, Woo P (1998) Biomechanics of com-
the surgeon should err on the side of light tension on the AA bined arytenoids adduction and medialization laryngoplasty in
suture. an ex vivo canine model. Otol Head Neck Surg 119:634–642
4 Woodson GE, Picerno R, Yeung D et al (2000) Arytenoid ad-
duction: controlling vertical position. Ann Otol Rhinol Laryngol
109:360–364
Key Points
5 Isshiki G (1978) Arytenoid adduction for unilateral vocal cord
paralysis. Arch Otolaryngol 104:555–558
6 Miller FR, Bryant GL, Netterville JL (1999) Arytenoid adduction
■ Arytenoid adduction (AA) is a framework surgery
in vocal fold paralysis. Oper Tech Otolaryngol Head Neck Surg
where the pull of the LCA muscle is recreated to
10:36–41
achieve vocal fold repositioning. The physiologic
effects of AA include the following:
■ Lowers the position of the vocal process
■ Medializes and stabilizes the vocal process
Chapter 41
Cricothyroid Subluxation
41
41.1 Fundamental and Related Chapters 41.4 Surgical Equipment
Please see Chaps. 5, 36, 37, 38, 39, and 40 for further informa- Surgical equipment needed for cricothyroid subluxation com-
tion. prises:
■ See “Surgical Equipment” sections in Chaps. 38, “Si-
lastic Medialization Laryngoplasty for
® Unilateral Vocal
41.2 Disease Characteristics Fold Paralysis” and 39, “GORE-TEX Medialization
and Differential Diagnosis Laryngoplasty.”
■ Right-angle clamp (vascular clamp)
■ 2-0 Prolene suture with narrow diameter, semicircle
Cricothyroid subluxation was developed by Steve Zeitels to
needle
address the problems of a shortened vocal fold frequently seen
■ Surgical headlight
in unilateral vocal fold paralysis. The concept of the procedure
is to lengthen the vocal fold by increasing the distance from
the cricoarytenoid joint (cricoid) to the anterior commissure
(thyroid cartilage) by subluxating the cricothyroid joint on
the side of the unilateral vocal fold paralysis. This results in a
rotation of the anterior commissure away from the midline in 1. Cricothyroid subluxation is done as a planned procedure
a direction contralateral to the side of the unilateral vocal fold in conjunction with medialization laryngoplasty, or done
paralysis. immediately after a medialization laryngoplasty due to a re-
Cricothyroid subluxation is an adjunct procedure to medi- stricted pitch range despite a well-positioned medialization
alization laryngoplasty. This can be done with arytenoid ad- laryngoplasty implant.
duction also, but is typically used with medialization laryngo- 2. Further dissection than what is typically performed for a
plasty. Cricothyroid subluxation addresses the commonly seen medialization laryngoplasty approach alone is required.
problem of a shortened vocal fold associated with unilateral Complete skeletonization of the inferior cornu of the thy-
vocal fold paralysis. The only other procedure that can length- roid cartilage should be performed using electric cautery
en a paralyzed vocal fold is arytenoid adduction (see Chap. 40, or cold steel instrumentation. This will involve removal of
“Arytenoid Adduction”). the cricothyroid muscle immediately anterior and inferior
to the inferior cornu and release of the inferior constrictor
muscle off the posterior aspect of the inferior cornu. The
recurrent laryngeal nerve is at risk in this region; thus, it
is wise to keep dissection close to the inferior cornu of the
thyroid cartilage to avoid deinnervation of the immobile
but partially reinnervated vocal fold.
Indications for cricothyroid subluxation involve: 3. Soft tissue overlying the superior and inferior aspect of the
cricoid cartilage at the midline should be removed.
■ Unilateral vocal fold paralysis associated with vocal
4. Separation of the cricothyroid joint
fold shortening with resultant glottal insufficiency and
This can be done using a scissors or a cottle elevator. Care
reduced pitch range (preoperative assessment)
should be taken during this step not to fracture the inferior
■ Poor pitch range and/or significantly shortened vocal
cornu. The use of scissors to separate the cricothyroid joint
fold, as seen on endoscopy during medialization laryn-
is most likely less traumatic to the inferior cornu. The blades
goplasty after adequate implant positioning (intraopera-
of the scissors are placed up against the posterior, lateral as-
tive)
pect of the cricoid cartilage to allow the tips of the scissors
to be positioned on either side of the cricothyroid joint (Fig.
Contraindications include present or impending laryngeal 41.1).
fracture of thyroid ala from the associated medialization la- 5. After separation of the cricothyroid joint, care should be
ryngoplasty procedure. taken to insure the inferior cornu of the thyroid cartilage is
completely free of any soft tissue attachments.
264 Cricothyroid Subluxation
41
Fig. 41.1 Separation of cricothyroid joint with scissors Fig. 41.2 Placement of cricothyroid subluxation suture submucosally
at the midline of the anterior cricoid cartilage
6. A 2-0 Prolene suture is then passed around the neck of the

inferior cornu. This can be done with a relatively narrow di-
and Complications
ameter, semicircle needle, or by using a right-angled clamp
(vascular clamp) to pass the free end of the suture around
the neck of the inferior cornu. The suture should be posi- Postoperative care is identical to that of medialization laryngo-
tioned as superior as possible on the neck of the inferior plasty. The reader is referred to Chaps. 38, “Silastic Medializa-
cornu and then tied with relatively equal lengths of the su- tion Laryngoplasty for Unilateral Vocal Fold Paralysis” and 39,
ture on both sides of the knot. “GORE-TEX® Medialization Laryngoplasty” for details.
7. The arm of the suture with the needle is then passed under- Complications involve:
neath the cricoid cartilage anteriorly at the midline. Care
■ Fracture of the inferior cornu
should be taken not to fracture the cricoid cartilage and to
■ To remedy this complication, a suture can be placed
pass the needle in a submucosal plane under the anterior
through the thyroid cartilage near the fracture line
aspect of the cricoid ring (Fig. 41.2).
and then be used in a similar fashion as described
8. The free end of the suture tied at the inferior cornu is then
above to complete the cricothyroid subluxation.
tied to the end of the suture passed underneath the anterior
■ Fracture of the main aspect of the thyroid cartilage ala
cricoid cartilage. The voice and vocal fold length (endoscop-
■ If fractures of the thyroid cartilage ala occur, then all
ically) should be evaluated as tension is applied to the knot
fractures should be reduced and secured with either
(Fig. 41.3). Typically, only moderate tension is required to
suture or plating and the cricothyroid subluxation
position the inferior cornu into an anterior, subluxated po-
procedure should be aborted (see Chap. 44, “Repair
sition. This anterior subluxation of the inferior, cornu of the
of Laryngeal Fracture”).
thyroid cartilage results in vocal fold lengthening and an ex-
panded pitch range (Fig. 41.4). Once an optimal tension is
found (predominantly by perceptual voice assessment), the
suture is secured with several surgical knots.
Chapter 41 265
Key Points
■ Cricothyroid subluxation is an adjunctive pro-

cedure to medialization laryngoplasty which
lengthens the shortened vocal fold associated
with unilateral vocal fold paralysis.
■ Cricothyroid subluxation rotates the anterior com-
missure attachment of the vocal fold away from
the cricoarytenoid joint, thus lengthening the
vocal fold.
■ Care should be taken not to fracture the inferior
cornu of the thyroid cartilage during the proce-
dure.
■ Excessive tension applied to the suture securing
the cricothyroid subluxation position may worsen
voice quality.
Bibliography
1 Zeitels SM (2000) New procedures for paralytic dysphonia: ad-

duction arytenopexy, Goretex medialization laryngoplasty,
and cricothyroid subluxation. Otolaryngol Clin North Am
33:841–854
2 Zeitels SM, Hillman RE, Desloge RB, Bunting GA (1999) Crico-
thyroid subluxation: a new innovation for enhancing the voice
with laryngoplastic phonosurgery. Ann Otol Rhinol Laryngol
108:1126–1131
Fig. 41.3 Suture fixation of cricothyroid subluxation
Fig. 41.4 Axial view of vocal fold position

before and after cricothyroid subluxation
Chapter 42
Translaryngeal Removal
of Teflon Granuloma 42
evidence suggests that subsequent laryngeal trauma (i. e., intu-
bation) may contribute to growth of the granuloma.
Teflon granuloma is typically a submucosal smooth mass
Please see Chaps. 24, 36, 37, 38, and 40 for further informa- that presents as a bulge in the false vocal cord, ventricular
tion. mucosa, and/or the true vocal fold. The granuloma may grow
inferiorly resulting in a subglottic bulge as well. Videostro-
boscopy is quite consistent in these patients, revealing a stiff,
nonvibratory vocal fold mass. This is due to either a mass ef-
fect (stretching of vocal fold mucosa with dampening of wave)
or, more commonly, the infiltration of the granuloma into the
lamina propria and/or mucosa. Glottic incompetence is com-
In every Teflon injection, an inflammatory response to the Tef- monly present, secondary to the mass lesion. Occasionally, the
lon occurs. In most cases, the inflammatory response remains patient’s airway is compromised, especially if the granuloma is
localized, and no significant clinical complications are noted. subglottic.
However, there is a risk of clinically evident expansile granu- It is helpful to obtain a CT scan of the neck with contrast
loma formation in these patients if long-term follow up (10 to assess the location of the Teflon and extent of granuloma
years or more) is used. Often this occurs years after the initial formation. In this way, superficial Teflon granulomas can be
injection, after a prolonged period of good voice. Anecdotal distinguished from more extensive granulomas, which guides
the surgeon in choosing the appropriate approach (endoscopic,
see Chap. 24 “Endoscopic Management of Teflon Granuloma”)
versus the external approach described in this chapter). Typi-
cal CT appearance is a brightly enhancing, fairly well-circum-
scribed mass in the paraglottic space.

■ Symptomatic Teflon granuloma in a patient with UVFP
in which there is sparing of the free edge of the vocal
fold (vocal ligament/mucosa appear uninvolved with
granuloma) (Fig. 42.1)
■ Desire for complete removal of granuloma
Relative contraindications although these are not absolute

contraindications to this approach, include the following:
■ Extensive granuloma infiltration along the medial
edge of the vocal fold (vocal ligament involvement)
(Fig. 42.2)
■ Minimally symptomatic patient
■ These clinical settings may be better suited for endo-
scopic treatment (see Chap. 24)
Fig. 42.1 Coronal section of larynx with Teflon granuloma sparing

the vocal fold mucosa and vocal ligament (arrow)
268 Translaryngeal Removal of Teflon Granuloma
1. The surgical region is liberally infiltrated with 1% lido-

caine with1:100,000 epinephrine, from the hyoid down to
the cricoid cartilage, on the side of the intended surgery.
Typically, 20–25 ml is used.
2. Four percent lidocaine and oxymetazoline nasal spray is
applied to the most patent nasal cavity. Placement of an
indwelling flexible laryngoscope, allows videomonitoring
of the larynx during the entire surgical case. The visual
feedback of the larynx is invaluable when performing this
surgery.
3. After sterile prep of the neck and flexible laryngoscope
placement, a horizontal incision is placed in a skin crease
at the level of the cricothyroid membrane extending past
the midline, in a cervical skin crease, typically 7–8 cm in
length.
5. A randomly pedicled flap is raised that is composed of the
superficial layer of the deep cervical fascia covering the
strap muscles, with its overlying fat. This flap is posteriorly
based and has a wide base lateral to the omohyoid muscle
(Fig. 42.3). The flap should be raised with cold dissection
and bipolar cautery to avoid thermal damage. Once re-
42 flected, the flap is covered with moist gauze.
Fig. 42.2 Coronal section of the larynx with Teflon granuloma involv- 6. The midline raphae is divided between the strap muscles
ing the free edge of the vocal fold (arrow). This is a relative contraindi- with cautery, exposing the thyroid lamina on the involved
cation for translaryngeal removal side.
7. A single-prong hook is placed under the thyroid notch,
and the larynx is retracted to the side opposite the paraly-
sis, bringing the entire hemilaryngeal cartilage into view.
8. A vertical parasagittal laryngotomy is performed 5–7 mm
posterior to the midline on the ipsilateral side, using a 15
Equipment includes: blade or a powered sagittal saw (Fig. 42.4).
9. The thyroid lamina is retracted laterally with hooks allow-
■ Netterville medialization tray
ing for wide exposure of the paraglottic space (Fig. 42.5).
(Medtronic ENT, Jacksonville, Fla.)
Dissection of the granuloma can now proceed (Fig. 42.6).
■ Drill with 2- or 3-mm cutting burr
Identification of the correct plane of dissection between
■ Kerrison rongeurs tray (1- to 3-mm-sized tips)
the granuloma and normal paraglottic tissue is frequently
■ Medium-grade Silastic block (Medtronic ENT)
difficult; surgical loops may be helpful during this por-
■ 4-0 monofilament suture, double-armed needle
tion of the case. A variety of dissection tools may be em-
■ Ruler (15-mm section of plastic ruler at tip of hemostat)
ployed; Jamison scissors, Freer, and Woodson elevators
are useful for the gross dissection, while middle ear in-
struments (no. 2 House knife) can be used for dissection
■ Overdrape for laryngoscope (1010)
with surgical loops. The mucosa of the ventricle should be
avoid anteriorly where is may be adherent to the granu-
■ High-power surgical loops (optional)
loma. Care is taken to preserve the vocal ligament/conus
■ Middle ear instrument tray
elasticus and lamina propria, as their integrity has proven
(especially a no. 2 House knife; optional)
an important prognostic indicator of postoperative voice
quality. The granuloma often encases most of the paraglot-
tic laryngeal musculature (thyroarytenoid/vocalis, lateral
cricoarytenoid), such that complete removal may result in
an “empty” paraglottic space. Not infrequently, defects in
the ventricular or subglottic mucosa may be created dur-
This advanced framework technique requires experience with the ing dissection. These mucosal defects should not compro-
techniques of ML and AA. The surgeon should be well versed mise the end result. In contrast, removal of the vocal fold
in the techniques of Chaps. 38, “Silastic Medialization Laryn- mucosa and/or vocal ligament should be avoided as this
goplasty for Unilateral Vocal Fold Paralysis” and 40, “Arytenoid has a detrimental effect on the voice result.
Adduction” before attempting this technique.
Chapter 42 269
Fig. 42.3 Posteriorly based fat flap is raised
Fig. 42.6 Dissection of granuloma from the paraglottic space
Fig. 42.4 Vertical laryngotomy is performed 5–7 mm off the midline

for exposure of the paraglottic space
Fig. 42.7 After removal of the granuloma, the laryngotomy is repaired

with 2-0 Prolene sutures, and windows are made for medialization
Fig. 42.5 Axial view of parasagittal laryngofissure laryngoplasty and arytenoid adduction
270 Translaryngeal Removal of Teflon Granuloma
42 Fig. 42.8 The patient’s voice is tested while simultaneously putting

traction on the arytenoid adduction suture and depressing the depth
gauge within the thyroplasty window. A Cottonoid is placed in the
paraglottic space for cushioning Fig. 42.9 Axial view of fat flap advanced into the paraglottic space
10. The lateral laryngotomy is reduced and secured with two

to three 2-0 Prolene sutures. Windows are made for me-
dialization and arytenoid adduction (both posterior and
anteriorly) as described in Chaps. 38 and 40 (Fig. 42.7).
11. An arytenoid adduction suture (4-0 Prolene, double-
armed) is placed through the muscular process, secured,
and the two ends are passed through separate holes in
the anterior (midline) of the thyroid lamina, similar
to the technique of arytenoid adduction described in
(Chap. 40).
12. A Cottonoid is then placed within the thyroplasty window
to provide cushioning to the paraglottic space (approxi-
mating the effect that the fat flap will provide), while a
depth gauge is used to medialize the vocal fold. The effects
of medialization and tension on the arytenoid adduction
suture should be used to gauge the best vocal outcome
(Fig. 42.8).
13. The fat flap is tucked deep to the strap muscles and ad-
vanced into paraglottic space via the posterior thyroid
cartilage window (Fig. 42.9). The flap’s apex should be
brought as anteriorly as possible to reconstitute the true
vocal fold at the anterior commissure. The voice should
be tested as the flap is manipulated within the paraglot-
tic space in a variety of configurations. The flap serves the
important function of providing bulk to the paraglottic
Fig. 42.10 Final configuration of the fat flap within the paraglottic tissues, which is vital to the success of the primary surgery
space. Note sutures securing the flap both anteriorly and inferiorly and any additional augmentative procedures attempted in
Chapter 42 271
the future. The flap is secured to the thyroid and cricoid complication is encountered months after surgery. The fat flap
cartilages using 3- or 4-0 Prolene sutures through 1-mm may slowly atrophy over several month-years, resulting in
drill bit holes as needed (Fig. 42.10). glottic insufficiency eventually. Additional procedures can be
14. The patient is asked to phonate, while tension on the ary- attempted when this happens, including lipoinjection and/or
tenoid adduction suture is adjusted, until optimal voice revision Silastic medialization. In addition, implant exposure,
result (or vocal fold positioning in the midline position) infection, and/or extrusion are more likely in the setting of
is obtained. The suture is secured over the thyroid lamina Teflon granuloma removal due to the higher risk of mucosal
near the midline. violation within the endolarynx.
15. Medialization should be deferred until a later date if there
is a mucosal tear, to avoid complications of foreign body
contamination. However, if no mucosal defect is present,
Key Points
then a Silastic implant may be placed at this time. Medial-
ization measurements are obtained by displacing the pos-
terior/mid aspect of the window using a depth gauge. The ■ Laryngotomy is the only surgical approach that
vocal fold should be slightly overmedialized to account
allows for complete removal of granuloma in most
for inevitable fat flap atrophy. It is important to emphasize
cases.
that a number of possible combinations using one or all of ■ The ideal case for laryngotomy/fat flap reconstruc-
the three techniques (fat flap, ML, AA) can be employed at
tion is symptomatic Teflon granuloma in a patient
the same time to achieve the best vocal result. This takes a
with UVFP in which there is sparing of the free
fair amount of trial and error to optimize the vocal results.
edge of the vocal fold (vocal ligament/mucosa ap-
Wound irrigation, layered closure over a closed suction
pear uninvolved with granuloma).
drain is then performed. ■ The surgeon should master the techniques of ML
and AA before attempting this procedure.
■ The pedicled fat flap may atrophy over time, ne-
42.6 Postoperative Care cessitating additional procedures to restore glottal
and Complications competence, such as lipoinjection or revision
Silastic ML.
Postoperative care comprises:
■ Overnight, 23-hour observation
■ Pain management Selected Bibliography
8 mg, then 4 mg)
1 Netterville JL, Coleman JR, Chang S et al (1998) Lateral laryn-
gotomy for the removal of Teflon granuloma. Ann Otol Rhinol
2 Conoyer MJ, Netterville, Chen A et al (2006) Pedicled fat flap
Complications include those seen in medialization laryngo- reconstruction of the atrophic or “empty” paraglottic space after
plasty and arytenoid adduction (Chaps. 38 “Silastic Medi- resection of Teflon granuloma or oversized implant. Ann Otol
alization Laryngoplasty for Unilateral Vocal Fold Paralysis” Rhinol Laryngol 115:837–845
and 40, “Arytenoid Adduction”); however, the most common
Chapter 43
Excision of Combined Laryngocele

43
2. Combined (external and internal) laryngoceles originate
in the endolarynx as with internal laryngoceles, but extend
through the thyrohyoid (TH) membrane, into the neck (Fig.
Please see Chaps. 25, 36, and 37 for further information. 43.2). A foramen in the TH membrane where the superior
laryngeal nerve (internal branch) and vessels enter provides
the pathway for extension of the laryngocele into the neck.
This constriction at the TH membrane gives combined
laryngoceles their characteristic “dumbbell” appearance
(Fig. 43.3). These lesions are usually removed externally
through a transthyroid approach, as described in this chap-
43.2.1 Anatomy and Classification
ter.
The normal saccule arises as a diverticulum originating at the

anterior portion of the ventricle, and extending upward into
the supraglottis. It is sandwiched between the false vocal fold
medially and the aryepiglotticus muscle and thyroid cartilage
laterally. The saccule contains numerous mucus-secreting
glands, and acts as a reservoir, expressing secretions onto the
vocal folds due to the squeezing action of the surrounding su-
praglottic musculature.
A laryngocele represents an abnormal dilation or hernia-
tion of the saccule. In contrast to a saccular cyst (Chap. 25,
“Endoscopic Excision of Saccular Cyst”), a laryngocele com-
municates with the lumen of the larynx and is distended with
air. Any factor that increases intralaryngeal pressure can lead
to development of a laryngocele:
■ Coughing
■ Straining
■ Playing wind instruments
■ Glass blowing
Another etiology in the development of laryngoceles may be

air trapping due to ball-valve closure of the neck of the sac-
cule, allowing for entry of air into the saccule, but preventing
its egress. This “valve-like” effect can occur from inflammatory
or neoplastic processes in the ventricle or false vocal fold. For
this reason, neoplastic causes should be ruled out, especially in
high-risk patients (tobacco/alcohol users). Laryngoceles occur
predominantly in males, most often in the fifth or sixth decade
of life.
Laryngoceles are categorized based on anatomic extension
of the lesion:
1. Internal laryngoceles are contained entirely within the en-
dolarynx. They originate in the anterior ventricular mem-
brane, and extend posteriorly–superiorly into the paraglot-
tic space (Fig. 43.1). This creates are characteristic bulge in
the false vocal fold and aryepiglottic fold. The lesions can
usually be managed endoscopically, similar to the treatment
of a saccular cyst (see Chap. 25). Fig. 43.1 Coronal representation of internal laryngocele
274 Excision of Combined Laryngocele
Fig. 43.3 CT scan depicting combined laryngocele, with characteris-

tic dumbbell appearance
43
Fig. 43.2 Coronal representation of combined laryngocele

A CT scan should be obtained to define the extent of the lesion
(internal versus combined), and to delineate the internal con-
tent of the mass. Laryngoceles will contain air (black), while
saccular cysts will contain mucous (gray/soft tissue signal). A
biopsy is rarely indicated due to the unique nature of the le-
43.2.2 Clinical Presentation
sion. However, a ductal lavage/biopsy may be indicated in the
anterior ventricular region, if malignancy is suspected.
Most laryngoceles are asymptomatic and may be incidental

findings on radiographic studies of the neck. When symptoms
arise, hoarseness is the most common clinical presentation, al-
though cough or globus sensation are also seen. Patients with
combined laryngoceles may present with a neck mass. The
neck mass often appears only intermittently, and may be re- Absolute indications are symptomatic combined laryngo-
produced by asking the patient to valsalva. cele (hoarseness/airway compromise) and suspicion of malig
Office laryngoscopy will typically reveal a submucosal full- nancy.
ness or bulge in the false vocal fold/ aryepiglottic fold region. A relative indication is cosmetic concerns (especially in
If a neck mass is present it is typically located at the superi- large combined laryngoceles in horn players).
or/lateral aspect of the thyroid cartilage, and is soft and easily Contraindications include asymptomatic lesions found in-
compressible. cidentally/radiographically
Differential diagnosis of a laryngocele includes: Caution should be exercised in the rare case of bilateral
combined laryngoceles. Bilateral injury to the internal branch
■ Saccular cyst
of the superior laryngeal nerve can lead to aspiration. The
■ Mucous retention cyst
surgeon may wish to “stage” their resections, insuring intact
■ Hemangioma
sensation (via functional endoscopic evaluation of swallowing
■ Laryngeal neoplasm (e. g., squamous cell carcinoma,
and sensory testing) on the operated side before proceeding
neuroendocrine/neural tumors)
with the contralateral laryngocele.
Chapter 43 275
capsule; this area is grasped with a Babcock retractor (Fig.

43.5).
8. The laryngocele is retracted gently as blunt dissection is
used to define the external (extralarnygeal) portion of the
■ Microlaryngoscopy equipment
laryngocele capsule (Fig. 43.6). Some sharp dissection
■ Neck dissection tray
with hemostat/15 blade is usually necessary as well. It is
■ Blunt dissection instruments (Kitner/peanut)
important to “hug” the laryngocele capsule closely during
dissection. This is especially important posteriorly within
the TH membrane region, where the SLN branch is im-
mediately adjacent to the laryngocele.
9. The “back wall” of the laryngocele should be well defined
before proceeding with dissection of the intralaryngeal
1. Perform a direct microlaryngoscopy, examining the ante- portion of the dissection.
rior false vocal fold, ventricular region, to rule out ma- 10. An inferiorly based flap is created from the outer peri-
lignancy (note: 30 and 70° telescopes are well suited for chondrium of the thyroid ala by incising at the superior
this).
2. A horizontal incision (5–7 cm) is made at the superior as-
pect of the thyroid cartilage, in a skin crease.
3. Subplatysmal flaps are raised from the upper aspect of the
cricoid to just superior to the hyoid. Skin retraction hooks
are placed.
4. The midline raphae are identified, and divided from the
hyoid down to the cricoid, exposing the thyroid ala.
5. The infrahyoid strap muscles (sternohyoid, omohyoid, and
thyrohyoid) are identified on the side of the lesion, and di-
vided superiorly near their origin. A small cuff of fascially
encased muscle should be preserved at its attachment to
the hyoid, to aid in reapproximation of each muscle near
the end of the case (Fig. 43.4).
6. The ipsilateral hemilarynx is rotated into the field by re-
traction at the thyroid notch, using a single-prong hook.
7. The external component of the laryngocele is identified
within the thyrohyoid region. The lateral aspect of the la-
ryngocele is defined by carefully excising the soft tissue
covering on its surface, until the glistening capsule of the
laryngocele is clearly identified. A small amount of soft
tissue covering is left in place at the superior aspect of the
Fig. 43.4 Sectioning of strap muscles to allow exposure
of the TH space
Fig. 43.5 Identification of laryngocele capsule within the TH mem- Fig. 43.6 Blunt dissection of the external component of the laryngo-
brane cele
276 Excision of Combined Laryngocele
border of the thyroid lamina and using a freer elevator for 12. Dissection continues inferiorly, defining the internal com-
dissection. ponent of the laryngocele. Sharp dissection through the
11. A triangular section of the thyroid ala is marked out, with ventricularis and aryepiglotticus muscles facilitates the
its base superiorly, and its apex at a point half way along identification of the capsule in the paraglottic space (Fig.
the vertical distance of the thyroid lamina. This segment 43.8).
of cartilage is removed with a 15 blade and/or Kerrison 13. The termination of the laryngocele is identified at the base
rongeurs. The inner perichondrium is then incised and re- of the saccule. This is typically located at the anterior ven-
moved from the triangular region, exposing the paraglot- tricular mucosa. This corresponds with a point 3–5 mm
tic space (Fig. 43.7). The cartilage can be discarded after posterior to the midline of the thyroid lamina at the mid-
removal. way point along its vertical height (Fig. 43.9).
43
Fig. 43.7 Inferiorly based outer perichondrial flap is Fig. 43.8 Sharp dissection of muscular/fibrous tissue off
raised and triangular portion of the thyroid ala is removed the internal (paraglottic) portion of the lesion
for exposure of the internal component of the lesion
Fig. 43.9 The termination of the laryngocele is identified at the base Fig. 43.10 A figure-eight suture is used to close the mucosal defect
of the saccule. The airway is entered, excising a cuff of ventricular mu- (4.0 chromic)
cosa around its entry into the endolarynx.
Chapter 43 277
14. The airway is entered, excising a cuff of ventricular muco-

Key Points
sa around its entry into the endolarynx. A figure-eight su-
ture is used to close the mucosal defect (4.0 chromic) (Fig.
43.10.) If the saccular base cannot be clearly identified, ■ A laryngocele is an air-filled dilation or herniation
then a clamp may be placed at the base of the laryngocele,
of the saccule. Any factor that increases intralaryn-
and a silk ligature placed prior to removing the specimen.
geal pressure such as coughing, straining, playing
15. The wound is thorough irrigated and closed in layers,
wind instruments, or glass blowing can lead to
along with placement of a closed suction drain:
development of a laryngocele.
a) Outer perichondrium to superior thyroid lamina ■ Neoplasm in the ventricle or false cord should
b) Sternohyoid, omohyoid, thyrohyoid reanastamosed
be ruled out with microlaryngoscopy in high-risk
c) Skin closed
patients (tobacco/alcohol users).
16. A close suction drain is placed. ■ Laryngoceles are categorized as:
17. A tracheostomy is rarely indicated, but may be performed ■ Internal: confined to the endolarynx; usually
at the end of the case if there are airway concerns.
removed endoscopically (see Chap. 25, “Endo-
scopic Excision of Saccular Cyst”)
■ Combined: extension of internal laryngocele
43.6 Postoperative Care into the neck through the TH membrane. These
and Complications are usually removed through an external ap-
proach.
■ During dissection of the external component of
a combined laryngocele, care should be taken to
■ Overnight, 23-h observation (consider pulse oximetry avoid trauma to the SLN as it enters the TH mem-
monitoring) brane posteriorly.
■ Pain management ■ The internal dissection of the laryngocele is facili-
■ Intravenous steroids at 8-hour intervals (Decadron, tated by removing a triangular wedge of thyroid
8 mg, then 4 mg) lamina. This provides wide exposure to the para-
■ Elevation of the head of bed glottic space.
■ Diet can be advanced as tolerated. ■ The saccular opening into the airway is located
in the anterior ventricular mucosa. The saccular
opening into the airway should be included in the
laryngocele resection to insure complete excision
■ Laryngeal edema or hemorrhage with respiratory com- of the lesion.
promise
■ Recurrence of the laryngocele
■ Incomplete removal of the base of the saccule can
lead to recurrence. Therefore, one must enter the Selected Bibliography
airway, removing a cuff of ventricular mucosa sur-
rounding the base of the saccule if possible.
1 Holinger LD, Barnes DR, Smid LJ et al (1978) Laryngocele and
■ Damage to the internal branch of the SLN with dyspha-
saccular cysts. Ann Otol Laryngol Rhinol 87:675–685
gia or aspiration
2 Thome R, Thome DC, De La Cortina RAC (2000) Lateral thyrot-
■ Elderly patients are more susceptible to the effects of
omy approach on the paraglottic space for laryngocele resection.
sensory deficits in the larynx, and may be more likely
Laryngoscope 110:447–450
to have dysphagia as a result of SLN injury.
Chapter 44
Repair of Laryngeal Fracture

44
A “close-line” injury can suggest laryngotracheal separation; a
strangulation injury can cause delayed edema in an otherwise
benign appearing clinical setting. Furthermore, specific histo-
Please see Chaps. 6, 10, 36, 37, and 45 for further information. ry should be found regarding intubation indications, who per-
formed the intubation, where the intubation was performed,
why it was performed, and what was seen on initial intubation.
Also, initial airway and voice quality symptoms are helpful in
the assessment process.
The overriding key principal to laryngeal fracture evalua-
Laryngeal fractures (Fig. 44.1) are most commonly associated tion and treatment is assessment and protection of the airway,
with external blunt trauma, often caused by a severe or vio- followed by assessment and preservation of voice quality and
lent body trauma such as a motor vehicle accident. Laryngeal function. The former is crucial given that proper evaluation
fractures can also occur from isolated or direct injuries to the and treatment of laryngeal fractures in the acute and possibly
larynx such as falls, gunshot or knife wounds, or traumatic subacute setting can prevent severe laryngeal stenosis, which
emergency airway procedures (i. e., cricothyrotomy). Laryn- is extremely difficult to treat. The key variables of assessment
geal fractures incorporating either the thyroid cartilage and/or for a thyroid cartilage fracture are the exact location and de-
the cricoid cartilage can range from minimal, (nondisplaced gree of displacement of the fractures. Furthermore, laryngeal
fractures) to severe disruption of the integrity of the larynx palpation should identify if the thyroid and cricoid cartilages
with avulsion of portions of the thyroid and/or cricoid carti- are stable to gentle palpation. Other key variables when assess-
lage. The ABC’s of emergency care must be first attended to for ing patients with a laryngeal fracture include vocal fold mobil-
patients with a suspected laryngeal fracture. After the airway, ity, tension, and length, and if there is any exposed cartilage
circulatory, cervical spine and neurologic systems have been or mucosal lacerations within the larynx. If the patient is not
stabilized, the laryngeal fracture(s) can be evaluated. initially evaluated prior to intubation, then many of the endo
The mechanism of injury and patient’s initial and present laryngeal key variables mentioned above are difficult to assess
airway status are extremely important historical data to obtain until direct laryngoscopy can be performed.
when evaluating a patient with a suspected laryngeal fracture. Essential components of a complete assessment for laryn-
geal fracture include:
■ Flexible laryngoscopy (if possible) to assess vocal fold
mobility and airway potency
■ Fine cut CT imaging of the larynx/cervical trachea
■ Microlaryngoscopy, tracheoscopy and esophagoscopy

■ Thyroid cartilage fracture involving:
■ Displaced thyroid cartilage with airway lumen com-
promise and/or negative voice implications
■ Exposed intralaryngeal cartilage (anterior two thirds
of cartilage)
■ Shortened or avulsed vocal fold(s)
■ Cricoid fracture
■ Displaced fracture with lumen encroachment
Fig. 44.1 Laryngeal trauma (fracture on left ala)
280 Repair of Laryngeal Fracture
Contraindications comprise: through any preexisting neck wound in the laryngeal

area.
■ Unstable vital systems (sepsis, head injury, etc.) or cer-
iii. Dissection down through the soft tissues of the neck
vical spine injury
to preserve strap muscles and expose the thyroid car-
■ Nondisplaced thyroid cartilage fracture
tilage (strap muscles that are avulsed or dislocated
■ Fracture limited to posterior third of thyroid cartilage
should be reattached into their anatomic position
■ Nondisplaced cricoid fracture, no encroachment of the
as much as possible). Exploration of the thyroid car-
subglottic airway
tilage fracture with minimal disruption of the sur-
rounding tissue is then performed with the goal of
reducing the fractures, if possible. With this expo-
sure, palpation directly of the thyroid cartilage as a
whole from externally can be performed to assess the
three dimensional integrity of the structure, and to
Surgical equipment needed includes: determine if the patient will require internal laryn-
geal stenting.
■ Standard microlaryngoscopy set up and equipment (see
iv. As the thyroid cartilage fractures are explored and
Chap. 10)
reduced, minimal tissue should be removed from
■ Laryngeal/bronchial telescopes (0, 30, and 70°)
the area. This will help reduce and stabilize the frac-
■ Soft tissue neck surgical instrument tray
tures.
■ Maxillofacial fracture plating system (microplates with
v. 0 Prolene sutures or small mini-reconstruction
emergency screws)
plates can be used across the fracture to secure the
■ Internal laryngeal stent devices
reduced laryngeal fracture into a stable position (Fig.
■ Montgomery internal laryngeal stent
44.2). When noncalcified thyroid ala occurs (seen
(Boston Medical, Boston, Mass.)
commonly in younger patients), the larger diameter
■ Rolled Silastic sheeting
“emergency” screws should be employed to improve
■ Aboulker stent
purchase to the cartilage.
■ Sterile glove and surgical foam
vi. A small drain is placed in the dependent portion of
■ T-tube stenting devices
the wound and removed within 24 hours.
44 b) Displaced thyroid fracture with internal mucosal lacera-
tions, exposed cartilage or arytenoid displacement
i. Same approach to the thyroid cartilage as described
above.
1. Initial assessment of laryngeal fracture

The most important initial surgical assessment technique
for patients with suspected laryngeal fracture include gentle
palpation of the thyroid and cricoid cartilage. This palpa-
tion should assess the overall integrity and strength of the
three-dimensional configuration of the thyroid and cricoid
cartilage. This assessment is crucial for decision making
regarding the need for internal laryngeal stenting of the
larynx. Microlaryngoscopy and bronchoscopy are also es-
sential features of the initial assessment. This assessment
should include any mucosal injury, specifically avulsion
injuries, looking for exposed thyroid and cricoid cartilage.
In addition, the anterior commissure tendon and the aryte-
noid position should be carefully evaluated and document-
ed. Finally, the overall length and tension of the vocal folds
should be carefully assessed with flexible laryngoscopy and/
or direct laryngoscopy (see Chap. 10, “Principles of Phono-
microsurgery”). Tracheoscopy and esophagoscopy may also
need to be considered.
2. Thyroid fracture exploration and repair
a) Isolated thyroid cartilage fracture
i. Secure airway with tracheotomy or endotracheal in-
tubation.
ii. Horizontal incision is placed in the closest deep rhy- Fig. 44.2 Laryngeal fracture repaired with a miniplate, inferiorly and
tid to the inferior border of the thyroid cartilage or superiorly
Chapter 44 281
ii. If there is a preexisting laryngotomy from the pen- much cartilaginous covering as possible (Fig. 44.5).
etrating neck wound, then the internal laryngeal Free mucosal grafts or perichondrium can be used
structures can be explored through this wound (it to resurface the internal larynx.
can be expanded if absolutely required). It is impor- vi. External palpation of the thyroid cartilage can be
tant to limit the size of the laryngotomy to as small used to determine the strength/support of the thy-
as possible. roid cartilage to determine if the patient will require
iii. A midline laryngofissure can be performed if no internal laryngeal stenting. If laryngeal stenting
laryngotomy is present from the injury itself. Great is required, then a stent size should be selected or
care must be obtained to stay in the midline protect- created that will allow adequate internal laryngeal
ing the right and left anterior commissure and the stenting without placing excessive pressure on the
vocal fold attachments to the thyroid cartilage (Figs. internal laryngeal mucosa.
44.3, 44.4). vii. The internal laryngeal stent options in order of pref-
iv. Exploration of mucosal injury is then performed. erence are the following:
v. Absorbable sutures (5.0 or smaller) are used to re- 1. Montgomery laryngeal stent (Fig. 44.6)
place avulsed or lacerated mucosal flaps to obtain as 2. Aboulker stent
Fig. 44.4 Completed laryngofissure with exposed vertical transglottic

laceration
Fig. 44.3 Planned laryngofissure incision. Note lateral extension of
incision superior to the thyroid ala
Fig. 44.5 Repaired laceration Fig. 44.6 Placement of Montgomery internal laryngeal stent
282 Repair of Laryngeal Fracture
d) Microlaryngoscopy and telescopic examination of the

larynx and upper trachea should then be performed to
evaluate the structural integrity and mucosal integrity of
the larynx.
e) Mitomycin C can be applied (as need; see Chap. 29,
“Subglottic/Tracheal Stenosis: Laser/Endoscopic Man-
agement”). Endoscopic replacement of the stent can be
done on an as-needed basis (see Chap. 26, “Anterior
Glottic Web”).

and Complications
Postoperative care comprises:

■ Tracheotomy care and education (as needed)
■ Intravenous antibiotics for 24 hours
■ Removal of drain within 24 hours
■ Maintain internal laryngeal stent for approximately
14–30 days
Fig. 44.7 External fixation of Montgomery stent
■ Microlaryngoscopy/bronchoscopy and stent removal
(see above)
3. Rolled Silastic sheeting Complications can include:

4. Sterile glove finger packed with foam
■ Laryngeal infection
viii. Suture or miniplates can be used to repair the laryn-
■ Stent migration (superior–inferior dimension)
44 gofissure/fracture sites at the laryngotomy.
■ Stenotic laryngeal airway (anterior–posterior dimen-
ix. After the stent has been placed, supporting sutures
sion and/or lateral dimension)
that go through the stent should be drawn out
■ Anterior commissure blunting/webbing
through the thyroid cartilage and to the outside of
■ Granuloma formation
the neck and secured over buttons to hold the inter-
nal laryngeal stent in place (Fig. 44.7).
3. Cricoid fracture exploration and repair
a) Same exposure as described above
Key Points
b) Exposure and reduction of the cricoid fracture(s)
c) After reduction of the cricoid fracture(s), cricoid ring
stability should be assessed with external palpation. ■ All evaluation and treatment of laryngeal fractures
d) Suture or miniplate fracture repair can then be per-
should focus on:
formed (with 0 Prolene), after the reduction and repair ■ Airway lumen protection
of the cricoid fracture. The internal stability of cricoid ■ Voice quality and function
ring should be once again assessed with external palpa- ■ Mucosal coverage is crucial for obtaining the best
tion.
possible results after laryngeal fracture and injury.
e) If the cricoid ring is unstable, then placement of an inter- ■ Internal laryngeal stenting should be performed
nal stent endoscopically or through an injury-induced
if the lumen integrity of the laryngeal airway is
laryngofissure can be performed. The best and preferred
compromised due to laryngeal fractures.
laryngeal stent options are listed above.
4. Internal laryngeal stent removal (Two-three weeks post-op-
eratively)
a) General anesthesia is induced via the preexisting trache-
otomy.
b) Direct laryngoscopy is performed to visualize the inter-
nal laryngeal stent. 1 Thor A, Linder A (2007) Repair of a laryngeal fracture using
c) A large cup forceps is used to grasp the stent and then miniplates. Int J Oral Maxillofac Surg 36:748–750
the securing sutures of the stent can be released from the
neck and the stent removed.
Chapter 45

Laryngotracheal Reconstruction 45
with Grafting

■ Failed endoscopic treatment of laryngotracheal stenosis
45.2 Disease Characteristics ■ Cartilage collapse/tracheomalacia with obstruction
and Differential Diagnosis ■ Laryngotracheal stenosis> 2–3 cm in length
Subglottic stenosis is a narrowing of the subglottic airway, seen Contraindications (relative) comprise:
as both a congenital and an acquired lesion. The subglottis is
■ Diabetes
the narrowest section of the airway, and it is contained entirely
■ Steroid dependency (especially in autoimmune pa-
within a nonflexible cartilaginous ring. In contrast, the trachea
tients)
has C-shaped cartilage anteriorly with an intervening posterior
■ Moderate–severe lung disease (COPD/restrictive dis-
membranous section. Narrowing in this segment of the airway
ease)
is termed tracheal stenosis.
■ Moderate–severe heart disease
Subglottic stenosis may be caused by a multitude of factors,
■ Obstructive sleep apnea
depending on the age of occurrence and the presence of incit-
■ Renal failure
ing factors. Congenital stenosis is caused by a failure of recan-
■ Untreated autoimmune disease (e. g., Wegener’s granu-
alization of the laryngeal lumen during embryogenesis. This
lomatosis)
type of stenosis is divided into membranous or cartilaginous
■ Untreated LPR
types. The membranous type is marked by circumferential fi-
brous tissue, sometimes extending upwards to include the true
vocal folds. The cartilaginous type is comprised of a sheet of
cartilage extending posteriorly from the inner surface of the
anterior cricoid ring, with a small posterior airway.
Acquired subglottic stenosis accounts for 95% of cases sub-
glottic stenosis, of which 90% is intubation related. Subglot- Equipment needed for surgery includes:
tic stenosis after prolonged or repeated intubations occurs in
■ Standard neck dissection tray
3–8% of children and adults. While intubation is the leading
■ Cottle and freer elevators
cause of stenosis, other potential internal and external disease
■ Drill with cutting burr (optional)
processes may lead to the development of stenosis. A more
■ Nonabsorbable, monofilament suture with taper needle
comprehensive list of these etiologies is included in Chap. 6,
(such as Prolene or nylon)
“Glottic and Subglottic Stenosis: Evaluation and Surgical Plan-
■ Malleable retractors
ning.”
■ Montgomery laryngeal stent of appropriate size (Boston
Although endoscopic methods are often employed in the
Medical, Boston, Mass.)
treatment of subglottic and tracheal stenosis, there are clearly
■ Sterile buttons and 0 or 2-0 permanent suture to secure
cases where these methods will fail. In these instances, exter-
stent
nal techniques such as laryngotracheal reconstruction with
■ Tracheotomy tube of appropriate size
grafting (described in this chapter) or cricotracheal/tracheal
resection with primary anastomosis (Chaps. 46, “Glottic and
Subglottic Stenosis: Cricotracheal Resection with Primary
Anastomosis” and 47, “Tracheal Stenosis: Tracheal Resection
with Primary Anastomosis”) are commonly used.
284 Laryngotracheal Reconstruction
ately sized cartilage piece is exposed. In this region, the

surgeon will encounter fibers from the rectus abdominus
muscle, which must be dissected off the rib to expose the
1. The airway is obtained preferably by endotracheal intubation cartilage. Care should be taken to preserve the overly-
using a small-bore tube (4.0 ETT). ing perichondrium. The perichondrium is then incised
2. The neck and chest are prepped and draped. along the superior, inferior, and lateral borders of the
3. A 5- to 6-cm horizontal incision is made over the seventh or proposed graft.
eighth rib as indicated (Fig. 45.1). 4. Using a cottle or Freer elevator, the perichondrium is elevated
a) Both of these ribs have adequate bulk for fashioning along the periphery of the proposed graft (Fig. 45.2).
grafts. In addition, they are located in a region where the a) Elevation should continue around the undersurface of
diaphragm is thicker, so there is less risk of pneumotho- the rib, until the rib is freed circumferentially. It is cru-
rax. Dissection should be carried out until an appropri- cial in this dissection to remain in the subperichondrial
plane to avoid injury to the nerves and vessels running
on the inferior surface of the rib and to avoid pneumo-
thorax.
5. Malleable retractors are placed below the exposed rib to pro-
tect the underlying pleura.
a) Using a no. 10 blade, the rib graft is incised laterally and
medially to free it from the rest of the rib (Fig. 45.3).
The inner perichondrium should remain intact deep to
45
Fig. 45.1 Diagram demonstrating the site of costal cartilage harvest,

typically the medial aspect of the seventh or eighth rib
Fig. 45.2 The rib is freed circumferentially, staying in a subperichon-

drial plane on the undersurface of the rib
Fig. 45.3 Malleable retractors are placed below the exposed rib to pro- Fig. 45.4 The inner perichondrium should remain intact deep to the
tect the underlying pleura while sharp dissection is used to free the rib, after graft removal
rib graft
Chapter 45 285
the rib, after graft removal (Fig. 45.4). The graft is then 10. The previously harvested costal cartilage graft is now pre-
soaked in a saline solution. pared.
6. The wound is closed in layers over a suction drain. a) The cartilage is modified to the appropriate size and
7. An incision is made in the skin of the neck horizontally over- shape using a scalpel and/or drill with cutting bur. The
lying the cricoid and trachea. ideal shape is either a modified boat shape or hexagon
a) If there is a previous tracheostomy, then one should in- (Fig. 45.9). The beveled design prevents the graft from
corporate the superior aspect of tracheostoma into the falling into the airway. Care should be taken to preserve
incision (Fig. 45.5). The incision should be wide enough the perichondrium; since this will serve as the internal
to allow exposure of the lower portion of the thyroid car- lining of the reconstructed airway and a scaffold for
tilage and the first few tracheal rings. epithelialization.
8. Elevation of subplatysmal flaps is carried out, the midline 11. A Montgomery stent (appropriate for size/gender) is placed
raphae are divided, and the strap muscles are separated and in the wound to help keep the lumen patent (Fig. 45.10).
retracted laterally to expose the laryngotracheal complex 12. The graft is inserted such that the perichondrium is oriented
(Fig. 45.6). toward the lumen, and the graft is sutured into place.
9. Using a 15 blade, a midline cricoidotomy is performed and ex- a) Suture material is typically non-absorbable and mono-
tended into the upper two to three tracheal rings (Fig. 45.7). filament (3-0 or 4-0 Vicryl). Sutures should be placed
a) The extent of the incision is dependent on the length of submucosally to reduce the incidence of granulation
stenosis. The cricothyroid membrane is divided horizon- tissue formation. The sutures are not tied until the graft
tally to facilitate retraction of the cricoid segments later- placement and position are confirmed (Fig. 45.11). The
ally. Using this method, the entire length of stenosis is perichondrial surface of the graft should sit flush with
exposed, with extension of the incision above and below the edges of the cricoidotomy.
the stenotic site as well. The superior aspect of the inci- 13. The Montgomery stent is secured in place by passing two
sion may be extended into the inferior thyroid cartilage permanent sutures (0 or 2-0 Prolene) through the skin on
as depicted in Fig. 45.7. If not already present, a trache- one side, piercing the stent, and coming out on the skin of
ostomy is then performed two or more rings below the the opposite side.
inferior-most incision through the affected airway (Fig. a) These two suture ends are then tied over a button on
45.8). Ideally, the tracheostomy site is separate from the the skin, taking care not to tie the ends too tightly, al-
stented region, but this is not always possible. Having a lowing for some postoperative edema (Fig. 45.12).
tracheostomy site adjacent to the rib graft can lead to graft
infection, granulation tissue formation, and restenosis.
Fig. 45.5 A horizontal incision is made at approximately the second Fig. 45.6 Exposure of the laryngotracheal complex and proposed
tracheal ring midline incision through the stenotic region
Fig. 45.7 The stenotic region

has been exposed prior to graft
placement
Fig. 45.8 Location of tracheostomy. This should be separate from the

graft site to lessen the chance of infection
45
Fig. 45.9 Proposed configuration of the costal cartilage graft after Fig. 45.10 Montgomery stent is placed prior to suturing the graft
shaping. The perichondrium should be left intact at the diamond
shaped portion of the graft
Chapter 45 287
Fig. 45.11 Securing of the graft with multiple sutures extraluminally Fig. 45.12 The stent is stabilized with percutaneous sutures tied over
buttons

are also seen, including pneumothorax, pneumomediastinum,
and Complications
emphysema, and chest or neck wound infections. Infection is
also of concern, particularly in its role in the development of
Postoperative care involves: a laryngocutaneous fistula. The most feared complication after
any such surgery is loss of control of the airway. Emergent air-
■ Broad-spectrum antibiotics (first-generation cephalo-
way compromise may develop, in a patient with a tracheotomy
sporin, possibly clindamycin for coverage of anaerobes)
by plugging or accidental decannulation. Finally, failure of the
■ A nasogastric tube is often placed during the initial
reconstruction with the need for a revision surgery is always a
postoperative period. This permits suctioning of the
possibility of which patients and their families must be aware.
gastric contents to diminish the possibility of nausea
The most common complication is failure to correct the steno-
and vomiting that put the surgical site at risk. It later
sis. This is attributable to several aspects of the initial surgery,
serves as a vehicle for feeding.
including inappropriate choice of graft or stent, inappropri-
■ Acid-suppression medication (PPIs)
ate stent length, insufficient duration of stenting, inadequate
■ Routine tracheostomy care
endoscopic follow-up, slipped stent, persistent LPR or keloid
■ Pain management
formation.
■ Return to OR in 3–4 weeks for stent removal endoscop-
ically
Key Points
■ Voice alteration
■ Pneumothorax or pneumomediastinum ■ Laryngotracheal reconstruction with costal cartilage rib
■ Loss of airway graft is indicated in the following cases:
■ Graft failure ■ Failed endoscopic treatment of laryngotracheal
stenosis
■ Cartilage collapse /tracheomalacia with airway ob-
Voice alterations can occur if a laryngofissure is performed as
struction
a part of the surgery. Even small displacements of the anterior
■ Laryngotracheal stenosis > 2–3 cm in length
cartilage can disrupt voice quality. Pulmonary complications
■ Patients with significant co-morbid medical conditions Selected Bibliography

are generally poor candidates for open laryngotracheal
treatment of airway stenosis. This is due to a high
1 Pena J, Cicero R, Marin J, Ramirez M, Cruz S, Navarro F (2001)
failure rate and tendency toward restenosis, as well as
Laryngotracheal reconstruction in subglottic stenosis: an ancient
higher morbidity/mortality.
problem still present. Otolaryngol Head Neck Surg 125:397–400
■ Costal cartilage is an ideal graft material for laryngotra-
2 Cotton RT (2000) Management of subglottic stenosis. Otolaryn-
cheal reconstruction.
gol Clin N Am 33:111–130
■ The ideal shape for the costal cartilage graft is a modi-
3 Gray S, Miller R, Myer CM, Cotton RT (1987) Adjunctive mea-
fied boat shape or hexagon. The beveled design prevents
sures for successful laryngotracheal reconstruction. Ann Otol
the graft from falling into the airway. The preserved
perichondrium on the graft serves as the internal lining
4 Little FB, Koufman JA, Kohut RI, Marshall RB (1985) Effect of
of the reconstructed airway and a scaffold for epithelia
gastric acid on the pathogenesis of subglottic stenosis. Ann Otol
lization.
■ A Montgomery stent is used to maintain the airway
5 Simoni P, Wiatrak BJ. Microbiology of stents in laryngotracheal
lumen during the healing process, and is removed
reconstruction. Laryngoscope 114:364–367
endoscopically 3–4 weeks later in the operating room.
6 Zalzal GH, Cotton RT (1986) A new way of carving cartilage
grafts to avoid prolapse into the tracheal lumen when used in
subglottic reconstruction. Laryngoscope 96(Pt. 1):1039
45
Chapter 46

Cricotracheal Resection 46
with Primary Anastomosis
reserve, prior radiation to the larynx or trachea and patients

taking immunosuppressive agents, i. e., high-dose steroids.

46.2 Diagnostic Characteristics for Open

Equipment needed for this procedure includes:
Treatment of Subglottic Stenosis
■ Standard head and neck surgery set
■ Kerrison rongeurs
Numerous surgical procedures have been described to im-
■ Drill with 3-mm cutting burr
prove airway function in patients with benign acquired sub-
■ T-tube (sizes 11–14, Hood)
glottic/tracheal stenosis, and the reported outcomes of these
■ 2 endotracheal tubes
techniques vary, with no consensus on the optimal treatment.
■ 35 gauge wire, 4-0 Vicryl
In patients with cricotracheal stenosis, a one-stage procedure
that includes circumferential resection of the subglottis and
tracheal region with primary thyrotracheal anastomosis has
resulted in excellent outcomes.
As outlined in Chaps. 6, “Glottic and Subglottic Stenosis:
Evaluation and Surgical Planning” and 29, “Subglottic/Tra-
cheal Stenosis: Laser/Endoscopic Management,” endoscopic 1. The airway is generally secured with endotracheal intuba-
treatments are often used as a first-line treatment of glottic and tion using a small-caliber endotracheal tube (ETT), such
subglottic stenosis. In cases where this approach fails, or condi- as a 4.0 microlaryngeal tube (MLT). If this is not possible,
tions in which endoscopic treatment is not possible (e. g., car- then an ETT can be placed though a tracheostomy during
tilaginous collapse of the airway), open treatment with either the resection portion of the case, and replaced by a oral
laryngotracheal reconstruction (Chap. 45, “Glottic and Sub- endotracheal tube just prior to the re-anastomosis.
glottic Stenosis: Laryngotracheal Reconstruction with Graft- 2. Under general anesthesia, the patient is placed in a supine
ing”) or cricotracheal resection with primary anastomosis is position, and a shoulder roll is placed to extend the neck.
indicated. 3. A standard, low-collar incision is utilized and the flaps are
developed in the subplatysmal plane, exposing the airway
from the hyoid bone superiorly to the manubrium inferi-
orly (Fig. 46.1). The strap muscles are then retracted and
the thyroid isthmus divided in the midline.
4. The distal end of the stenosis is then identified, and the
trachea is circumferentially mobilized to the inferior bor-
The primary indication for the procedure is laryngotracheal der of the cricoid cartilage (Fig. 46.2). Blunt dissection is
stenosis contained within the cervical region, which fails en- used along the anterior wall of the trachea to the level of
doscopic management. the aortic arch/carina, which then permits further mobi-
Contraindications include: lization of the trachea and a reduction of tension on the
anastomosis. To maintain the vascular supply to the tra-
■ Stenosis at the glottic level (within 5 mm of free edge of
chea, minimum lateral dissection is performed.
the vocal folds)
5. The cricothyroid muscle is then identified and reflected su-
■ “Active” autoimmune or inflammatory process
periorly. The perichondrium on the upper and lower bor-
(e. g. Wegener’s granulomatosis)
der of the cricoid cartilage is then incised, and the anterior
■ Stenosis that includes > 6.5 cm of the trachea
segment is excised (Fig. 46.3). Dissection then continues
on the inner aspect of the cricoid cartilage to protect the
Relative contraindications can comprise associated comorbidi- recurrent laryngeal nerves, which are located posteriorly
ties including severe vascular dysfunction, poor pulmonary and inferiorly. A Kerrison rongeur is used to excise further
290 Cricotracheal Resection
the thickened area of stenosis (Fig. 46.4). The dissection

is within the lumen of the cricoid, preserving the outer
perichondrium of the cricoid plate. The cricoid plate is
thinned posteriorly using a sharp burr with preservation
of 50% of the posterior aspect (Fig. 46.5).
6. The distal and proximal margins of the stenosis are identi-
fied, and the stenotic segment is resected en bloc as de-
scribed in Chap. 47. When the site of stenosis extends
superiorly close to the vocal folds, a laryngofissure is
Fig. 46.1 Wide exposure of the laryngotracheal complex Fig. 46.3 Diagrammatic representation of the amount of cricoid ring
that is excised, sparing the posterior third of the ring and protecting
the recurrent laryngeal nerves (arrow)
46
Fig. 46.2 The distal end of the stenosis is identified and the trachea is Fig. 46.4 Further intraluminal removal of the stenotic region with a
circumferentially mobilized to the inferior border of the cricoid car- Kerrison rongeur, sparing the outer perichondrium and underlying
tilage recurrent laryngeal nerves
Chapter 46 291
Fig. 46.5 A cutting burr is used to thin the posterior cricoid plate
Fig. 46.7 Cricotracheal anastomosis into the posterior glottic region
Fig. 46.6 Prior to cricotracheal anastomosis. Dashed lines in-

dicate the incision of posterior glottic scar (if present) and the
corresponding posterior tracheal mucosa that is to be advanced
into this region
Fig. 46.8 Completed cricotracheal anastomosis. Note how the trache-

al rings are completely contained within the cricoid shell
292 Cricotracheal Resection
performed to provide greater visualization and to permit 11. The closure includes reapproximation of the strap muscles,
resection closer to the vocal folds and enables the surgeon the platysma, and the soft tissue in the subcutaneous plane
to complete the anastomosis. Posterior glottic stenosis can using 4-0 Vicryl. The skin is closed in standard fashion.
be treated by division of interarytenoid adhesions and ad-
vancement of posterior tracheal mucosa into the interary-
tenoid region (Figs. 46.6, 46.7).
46.6 Postoperative Management
7. Once proximal and distal clearance has been achieved,
an anastomosis is performed approximating the proximal
margin of the trachea to the immediate subglottic area, us- Postoperative care involves the following:
ing no. 35 gauge wires posteriorly and 4-0 Vicryl laterally
■ Airway patency is maintained and the suture line pro-
and anteriorly (Fig. 46.8).
tected by a soft Silastic T-tube. The T-tube must be kept
8. During the completion of the anastomosis, a T-tube is in-
capped to prevent drying of secretions and obstruction
serted and placed at least 6–7 mm cephalic to the vocal
of the tube.
folds, through a tracheostomy that is located inferior to
■ To protect the anastomosis, the chin suture is removed
the anastomotic site (Fig. 46.9).
4–5 days after surgery.
9. The proximal end of the T-tube is occluded to permit ven-
■ Dietary intake is initiated 48 hours postoperatively, be-
tilation distally through its horizontal arm. This can be
ginning with carbonated fluids and progressed gradu-
accomplished with a bronchial block or a Fogarty cath-
ally as tolerated.
eter placed into the proximal end of the T-tube (Chap. 29,
■ The T-tube is removed 3–6 weeks postoperatively, de-
“Subglottic/Tracheal Stenosis: Laser/Endoscopic Manage-
pending on the extent and complexity of the resection.
ment”). Occasionally, a no. 4 distal tracheostomy tube is
used rather than a T-tube.
10. At the end of the procedure, a heavy suture is placed from Complications can comprise:
the submental area to the anterior chest wall to main-
■ Patients with significant comorbidities (i. e., diabetes
tain the patient’s cervical spine in a flexed position and
mellitus) are at an increased risk of complications, and
to eliminate tension on the tracheal anastomosis, thereby
these comorbidities should be treated and/or consid-
minimizing the risk of dehiscence.
ered preoperatively to minimize this risk.
■ Dehiscence of the anastomotic suture line
■ Restenosis of the airway
■ Recurrent laryngeal nerve injury
■ Granulation tissue from the T-tube
■ Post-operative decrease in pitch (speech) can occur and
46 is related to cricothyroid muscle division.
■ Dysphagia
■ A moderate number of patients develop dysphagia
for up to 2 weeks postoperatively, especially when
the tracheal resection exceeds 4 cm.
Key Points
■ In the authors’ experience, definitive decannula-

tion of 92% of patients with no evidence of recur-
rence, and excellent airway and vocal function
supports the efficacy of cricotracheal resection
with primary thyrotracheal anastomosis. A suc-
cessful outcome depends on the following factors:
■ Patient selection is critical and must include the
consideration of the level, site, and extent of
the lesion and the known patient comorbidities.
■ This procedure should be performed only in
patients with mature cricotracheal stenosis in
which the acute inflammatory stage has sub-
Fig. 46.9 Indwelling T-tube.
sided.
Note that the proximal end of
■ A complete segmental cricotracheal resection
the tube extends beyond the true
of the stenotic tissue is essential.
vocal folds into the supraglottis
Chapter 46 293
■ The addition of a laryngofissure provides excel- Selected Bibliography

lent exposure for patients with a cricotracheal
stenosis that is located close to the vocal folds.
1 Ashiku SK, Kuzucu A, Grillo HC, Wright CD, Wain JC, Lo B,
This therefore permits excision of all patho-
Mathisen DJ (2004) Idiopathic laryngotracheal stenosis: Effec-
logic tissue and meticulous anastomosis of the
tive definitive treatment with laryngotracheal resection. J Thorac
trachea to the immediate subglottic region
Cardiovasc Surg 127:99–107
in close proximity to the vocal folds. Another
2 Couraud L, Brichon PY, Velly JF (1988) The surgical treatment of
advantage of a laryngofissure includes the
inflammatory and fibrous laryngotracheal stenosis. Eur J Cardio-
accurate placement of the T-tube, which de-
thorac Surg 2:410–415
creases the risk of postoperative complications
3 Delaere PR, Blondeel PN, Hermans R, Guelinckx PJ, Feenstra L
associated with T-tube misplacement. Correct
(1997) Use of a composite fascial carrier for laryngotracheal re-
placement of the T-tube is imperative to main-
construction. Laryngoscope 106:175–181
tain a patent airway and provide support to the
4 Gerwat J, Bryce DP (1974) The management of subglottic laryn-
anastomosis in the early postoperative period.
gotracheal stenosis by resection and direct anastomosis. Laryn-
■ Release of the suprahyoid or infrahyoid muscles
goscope 84:940–947
is not routinely performed, as it appears to
5 Grillo HC (1982) Primary reconstruction of airway after resec-
exacerbate dysphagia postoperatively.
tion of subglottic laryngeal and upper tracheal stenosis. Ann
■ To avoid injury to the recurrent laryngeal
Thorac Surg 33:3–18
nerves, it is imperative to perform the dissec-
6 Grillo HC, Mark EJ, Mathisen DJ, Wain JC (1993) Idiopathic
tion on the inner aspect of the remaining cri-
laryngotracheal stenosis and its management. Ann Thorac Surg
coid cartilage after excision of its anterior arch.
56:80–87
■ In general, the use of a T-tube is superior to a
7 Grillo HC, Mathisen DJ, Ashiku SK, Wright CD, Wain JC (2003)
tracheostomy because is provides a physiologic
Successful treatment of idiopathic laryngotracheal stenosis by
airway stent and is less traumatic to the airway.
resection and primary anastomosis. Ann Otol Rhinol Laryngol
112:798–800
8 Maddaus MA, Toth JL, Gullane PJ, Pearson FG (1992) Subglottic
tracheal resection and synchronous laryngeal reconstruction. J
Thorac Cardiovasc Surg 104:1443–1450
9 Pearson FG, Cooper JD, Nelems JM, Van Nostrand AW (1975)
Primary tracheal anastomosis after resection of the cricoid car-
tilage with preservation of recurrent laryngeal nerves. J Thorac
Cardiovasc Surg 70:806–816
10 Pearson FG, Gullane PJ (1996) Subglottic resection with primary
tracheal anastomosis: including synchronous laryngotracheal re-
constructions. Semin Thorac Cardiovasc Surg 8:381–391
Chapter 47
Tracheal Stenosis: Tracheal Resection

with Primary Anastomosis 47
47.1 Fundamental and Related Chapters ■ Subglottic stenosis with involvement of vocal cords (see
Chaps. 45, “Glottic and Subglottic Stenosis: Laryngotra-
cheal Reconstruction with Grafting” and 46, “Glottic and
Subglottic Stenosis: Cricotracheal Resection with Pri-
mary Anastomosis” for the treatment of this condition)
■ Multiple levels of tracheal stenosis or configuration not
47.2 Background Information amenable to primary anastomosis
and Diagnosis of Tracheal Stenosis ■ Uncontrolled mucosal inflammation secondary to LPR,
Wegener’s disease, or infection
Tracheal stenosis is a complex and difficult problem to manage.
Patient health and comorbidities, degree and length of steno-
sis, and propensity for restenosis need to be considered when
determining the best treatment option for tracheal stenosis.
Most cases of benign tracheal stenosis are caused by prolonged
tracheal intubation or tracheotomy. Patients will typically pres- Surgical equipment needed includes:
ent with reports of exertional dyspnea or progressive shortness
■ Monopolar and bipolar electrocautery
of breath along with a history of previous intubation(s) or tra-
■ Standard soft tissue or neck dissection tray
cheotomy.
■ A no. 15 scalpel (occasionally no. 10 or 20 for severely
Diagnostic information can be obtained from CT scans to
scarred, calcified tracheal wall, particularly during
determine the length, site, and degree of tracheal involvement.
tracheotomy under local anesthesia)
This information should be used in conjunction with tracheo-
bronchoscopy to identify the extent and length of stenosis, and
the number of tracheal rings or length proximal and distal to
the site of stenosis. It is also important to determine if multi-
level obstruction exists. Flexible laryngoscopy should be per-
formed to determine the status of vocal fold mobility. This al-
lows for surgical planning to determine the manner and extent 1. Intubation
of the surgical resection. a) Patients without tracheotomy are orotracheally or naso-
tracheally intubated with appropriately sized endotra-
cheal tubes (4.0 MLT) if possible.
b) Some patients with severe stenosis must be managed
with bronchoscopic dilation, jet ventilation, or trache-
otomy under local anesthesia until safe intubation of the
distal trachea is achieved.
Indications for tracheal resection with primary anastomosis 2. Positioning of patient
include: Patients are placed in a supine position with shoulder roll
for full neck extension.
■ Symptomatic tracheal stenosis after failure of endoscop-
3. Incision
ic management
a) A low collar or U-shaped incision is made that extends
■ Focal (short-segment) tracheomalacia/cartilage collapse
from the anterior borders of the sternocleidomastoid
■ Primary tracheal neoplasm
muscles.
b) If the stenotic segment involves the tracheotomy site,
Contraindications can comprise: then the incision should include the tracheotomy tract
and will be removed with the stenotic tracheal segment.
■ Stenotic tracheal segment > 5 cm (without the use of
c) Preserve the tracheotomy in patients that have an unre-
additional laryngeal releasing maneuvers)
lated stenotic tracheal segment.
296 Tracheal Resection with Primary Anastomosis
4. Exposure of stenosis c) In patients without tracheotomy, the stenotic segment is

a) Subplatysmal flaps are elevated and the strap muscles are easily identifiable by external changes.
identified. d) The trachea is isolated by careful sharp dissection directly
b) Strap muscles are separated in the midline and retracted on the cartilage (Fig. 47.2). Bipolar cautery is used if nec-
laterally to expose the trachea (Fig. 47.1). essary. The recurrent laryngeal nerves are not identified.
It is not necessary to dissect the membranous trachea at
this time.
e) A vertical incision is then made in the midline of the
stenotic segment and extended inferiorly and superiorly
until normal mucosa and an acceptable lumen caliber is
achieved (Fig. 47.3).
f) In patients with tracheotomy site involvement, the tra-
chea can be incised vertically through the stoma site
inferiorly and superiorly until normal mucosa and tra-
cheal caliber is identified; most of the stenotic segment
in these cases, however, is at the tracheostomy site itself.
5. Excision of stenosis
a) Horizontal incisions are then made superiorly and infe-
riorly at the margins of the stenotic segment (Fig. 47.4).
b) An endotracheal tube is then used to intubate the distal
trachea through the neck.
c) If present, the orotracheal endotracheal tube is then
withdrawn until the tip is above the proximal or superior
resection line. It is not removed completely, as it is useful
later in the procedure.
d) The superior and inferior circumferential resection inci-
sions are then completed.
e) Dissection is then completed around the stenotic seg-
ment to be resected.
Fig. 47.1 Wide exposure of stenotic region of trachea

47
Fig. 47.3 Vertical incision through stenotic region to define its bound-
aries
Fig. 47.2 Dissection of stenotic segment Fig. 47.4 Proximal and distal division of stenotic segment
Chapter 47 297
f) The posterior aspect of the stenotic segment is separated

from the esophagus using blunt and sharp dissection.
This is done from the endotracheal side (Fig. 47.5).
g) If the posterior trachea in uninvolved and the stenotic
segment does not involve more than two or three tra-
cheal rings, then a wedge resection, leaving the posterior
tracheal wall intact can be performed.
It is important to perform the dissection close to the trache-
al wall to avoid injury to the recurrent laryngeal nerves.
It is also important not to dissect more than 1 or 2 cm of
normal trachea above and below the resected stenotic seg-
ment. This will allow for a successful the anastomotic clo-
sure and will minimize the risk for devascularization of
the healthy tracheal tissue.
6. Anastomosis
a) The shoulder roll is then removed to allow the neck to
move to a more flexed position. This “crowds” the clo-
sure and may be saved for the last few sutures.
b) The posterior membranous trachea is closed first, using
3-0 Vicryl sutures on an RB-1 needle. Submucosal su-
tures are placed in the posterior midline and laterally on
both sides. Three sutures are all that is typically required. Fig. 47.6 Posterior re-anastomosis. Note tying of the knots extralu-
Sutures should be placed so that the knots will be outside of minally
the trachea lumen both for the posterior membranous and
cartilaginous closure (Fig. 47.6).
c) Once all of the posterior sutures are placed, the lateral
most sutures in this area are tied simultaneously by the
surgeon and assistant to reduce tearing.
d) The cartilaginous trachea is closed using 2-0 Prolene su-
tures on an SH needle (taper) in a similar fashion (Fig.
47.7).
e) Additional methods for gaining extra length for a pri-
mary anastomosis include mobilization of the distal
trachea from the thorax, suprahyoid laryngeal release,
and infrahyoid laryngeal release. These techniques are
Fig. 47.5 Blunt dissection of posterior tracheoesophageal party wall, Fig. 47.7 Completed anastomosis with additional sutures externally
with complete removal of stenotic region. Note placement of an endo- spanning two tracheal rings for additional support
tracheal tube into the distal trachea
298 Tracheal Resection with Primary Anastomosis
typically not required for tracheal stenosis segments less Complications can comprise:
than 5 cm and are not included in this chapter.
■ Wound dehiscence/infection. This is minimized by the
f) Prior to closing the anterior and lateral portion of the
use of perioperative antibiotics and by maintaining
anastomosis, the distal endotracheal tube is withdrawn
cervical flexion.
and the oral or nasotracheal tube is passed distally to
■ Stenosis at site of anastomotic closure
bridge the anastomosis and eventual primary closure.
■ Tracheobronchoscopy may be used to identify and
g) The anastomotic closure is then leak tested by flooding
treat. Granulation tissue can be removed, and ste-
the field with saline solution and deflating the cuff on the
notic sites can be dilated.
endotracheal tube while ventilating the patient.
7. Closure
a) A Penrose drain is used and positioned at the anastomo-
sis.
Key Points
b) The wound is then closed in three layers. The strap mus-
cles are reapproximated, followed by platysma and der-
mis, and finally skin closure. ■ Cervical flexion is necessary to decrease anasto-
c) A 2-0 Prolene suture is placed between the submentum
motic tension during the initial phases of wound
and anterior chest wall to keep the neck in a flexed posi-
healing.
tion. ■ Minimize the amount of tracheal dissection that is
8. Extubation
performed superior and inferior to the anastomot-
a) Patients are extubated the following day in the operating
ic site. This will decrease the amount of devascu-
room or monitored intensive care unit. Many surgeons
larization and improve healing.
prefer immediate extubation. One theoretical advantage ■ All sutures for closure are placed with the knots
to overnight intubation is to reduce air leak at the closure
extraluminally.
site in case of cough or need for ventilatory support. ■ For select patients with sites of stenosis < 5 cm, tra-
cheal resection with primary anastomosis can be
performed without the need for additional laryn-
47.6 Postoperative Care geal releasing maneuvers. The need for laryngeal
and Complications release needs to be made intraoperatively and
depends on the degree of anastomotic tension.
Postoperative management includes:
■ Postoperative chest radiograph to evaluate for pneu-
mothorax and to confirm that the endotracheal tube (if Selected Bibliography
present) is below the anastomosis
47 ■ Keep neck in flexed position.
1 Grillo HC, Mark EJ, Mathisen DJ, Wain JC (1993) Idiopathic
■ Voice rest for 3–5 days to minimize glottic pressure and
laryngotracheal stenosis and its management. Ann Thorac Surg
subsequent airflow at the site of the anastomosis.
56:80–87
■ Empiric antibiotic coverage for 5–7 days
2 Grillo HC, Mathisen DJ, Ashiku SK, Wright CD, Wain JC (2003)
■ If inflammation or infection is suspected at the time
Successful treatment of idiopathic laryngotracheal stenosis by
of surgery, then antibiotic coverage can be deter-
resection and primary anastomosis. Ann Otol Rhinol Laryngol
mined by culture of these organisms.
112:798–800
■ PPIs
3 Laccourreye O, Brasnu D, Cauchois R et al (1996) Tracheal re-
■ Antiemetics
section with end-to-end anastomosis for isolated postintubation
■ Pain medication
cervical trachea stenosis: long-term results. Ann Otol Rhinol
■ Soft diet may begin after extubation, usually postop-
erative day 1. Feeding tubes are rarely required unless
4 Har-El G, Chaudry R, Shaha A et al (1993) Resection of tracheal
extensive releasing maneuvers are performed. Diet is
stenosis with end-to-end anastomosis. Ann Otol Rhinol Laryn-
advanced as tolerated.
gol 102:670–674
■ Penrose drain removal on day 3 if no complications or
5 Merati AL, Rieder AA, Patel N, Park DL, Girod D (2005) Does
evidence or air leak/crepitus.
successful segmental tracheal resection require releasing maneu-
■ Skin sutures are removed at 1 week.
vers? Otolaryngol Head Neck Surg 133:372–376
■ Chin flexion suture is removed at 2 weeks.
Chapter 48
The Gray Minithyrotomy

for Vocal Fold Scar/Sulcus Vocalis 48
tion. The patient with a loss of pliability of the mucosal cover of the
vocal fold, but with normal gross vocal fold motion is an ideal
candidate for this procedure. Conditions meeting these criteria
include:
48.2 General Considerations
■ Vocal fold scar
■ Sulcus vocalis
The Gray minithyrotomy offers:
■ Mild vocal fold bowing, especially when associated with
■ Access to physiologically important subepithelial vocal age-related alterations in lamina propria thickness and
fold tissue without epithelial incision pliability
■ The ability to carry out delicate dissection of areas of
adhesion/fibrosis under excellent visualization
The Gray minithyrotomy is not intended to provide substan-
■ A means of introducing shorter dissecting instruments
tial medialization, as required to correct typical cases of glot-
into the vocal fold mucosa that may be easier to handle
tic insufficiency related to vocal fold paralysis and vocal fold
than the usual microlaryngoscopic tools
atrophy for example.
■ Dissection orientation in a practical direction along the
long axis of the vocal fold

The Gray minithyrotomy is designed for access to subepithelial
tissue planes of the membranous vocal fold. The integrity of
the layered structure of the membranous vocal fold, essential Equipment for the Gray minithyrotomy need is:
for normal phonation, is compromised in sulcus vocalis, vocal
■ Suspension microlaryngology equipment (see Chap. 10)
fold scar, and other clinical conditions. Surgical repair is chal-
■ Zero degree endoscope (30 and 70° are also useful),
lenging because of the possibility of additional tissue injury
camera, and video monitor (Chap. 10)
and the technical difficulty of placing and stabilizing appropri-
■ C-mount camera and video monitor
ate replacement tissue or grafts via a mucosal incision using
■ Standard neck surgery instrument set, including small
microlaryngoscopic instrumentation.
self-retaining retractor
The Gray minithyrotomy requires a skin incision, and does
■ 22-g needle
not correct epithelial abnormalities, such as changes associ-
■ Powered drill with 3-mm cutting burr
ated with the sulcus vergeture deformity. The procedure does
■ Mastoid curette
not permit substantial medialization of the vibratory margin,
■ Tympanoplasty instrument tray, especially:
as the implant space is limited in volume. It has also not been
■ Duckbill and Gimmick elevators
used to remove subepithelial lesions; its principal utility has
■ Blunt probes
been to divide epithelial-deep tissue adhesion and implant ap-
■ Bellucci scissors, straight and angled
propriate replacement tissue or grafts.
■ Alligator forceps
The Gray minithyrotomy is named for Steven Gray, M.D.,
who, together with his colleagues, developed the operation
in anticipation of the availability of bioengineered superficial
lamina propria replacement material.
1. Preoperative measures and anesthesia

a) Anesthesia
The procedure is performed under a general anesthetic,
as the delicate and precise nature of the dissection places
300 The Gray Minithyrotomy
a premium on patient immobility and optimal visual- 2. Patient positioning and surgical exposure
ization via rigid rod-lens endoscope or surgical micro- a) Laryngoscopy
scope. A laryngoscope which offers exposure of the full length
b) Intubation of the membranous vocal folds is introduced and stabi-
The patient should be intubated with a 5.0 (female) or lized using a Lewy-type arm on a table-mounted Mayo
5.5 (male) cuffed endotracheal tube so as not to obstruct stand or suspended using a Boston gallows, in the same
visualization of the membranous vocal fold from the an- manner as if performing laryngeal phonomicrosurgery
terior commissure to the vocal process of the arytenoid (see Chap. 10, “Principles of Phonomicrosurgery”).
cartilage. b) Prep and drape.
c) Intravenous steroids The neck is prepped and draped, anticipating a 2-3cm
d) Because the minithyrotomy usually involves dissection horizontal incision overlying the thyroid cartilage. The
of the lamina propria along the entire length of the vocal arm of the laryngoscope suspension/stabilization device
fold, edema begins early and accumulates quickly, ren- overlies the surgical field and must be draped, as inad-
dering the effects of surgery difficult to assess by the end vertent contact with it is almost inevitable during the
of the typical case. To minimize this, 10–12 mg of intra- procedure. The primary surgeon will be most comfort-
venous Decadron is administered intravenously before able working from the patient’s right if right-handed,
the case begins. and from the left if left-handed.
Fig. 48.1 The patient is placed

under suspension laryngoscopy
and a horizontal incision is made
overlying the thyroid cartilage
48
Fig. 48.2 Harvest of 8- to 15-mm
strips of fat from the incisional site
Chapter 48 301
c) Visualization
The assistant introduces a 0° endoscope connected to a
camera into the laryngoscope and performs a prelimi-
nary inspection to:
i. Correlate the appearance of the vocal folds with that
noted on preoperative stroboscopy and confirm pre-
operative diagnosis
ii. Check laryngoscope position. The leading tip of the
laryngoscope must not interfere with the anatomy of
the anterior commissure. If positioned too distally,
then the tip can slightly evert the vocal folds and give
a false impression of the location of their vibratory
margin.
The video monitor must be positioned so that it may
be seen by both surgeon and assistant. The video
tower is best placed on the side of the patient con-
tralateral to the surgeon, at the level of the thorax,
rotated slightly cephalad.
iii. Video monitoring of internal view of the ante- Fig. 48.3 A 22-g needle is passed through thyroid cartilage to localize
rior commissure and the vocal folds can be done the level of the vocal folds
throughout the procedure via microlaryngoscopy
with a camera attached to the microscope or try an
assistant using a zero or thirty degree telescope with
a camera.
3. Extralaryngeal dissection
a) Incision
A 2- to 3-cm horizontal incision is centered over the
prow of the thyroid cartilage at the anticipated level of
the vocal folds (Fig. 48.1).
b) Dissection
Gentle dissection proceeds through subcutaneous tis-
sues and fat until the strap muscles are encountered.
These are divided along the midline and retracted later-
ally. A Kitner dissector (peanut) can be used to sweep re-
maining connective tissue off of the underlying thyroid
cartilage. Needle tip cautery may be used cautiously for
hemostasis, taking care not to excessively cauterize adja-
cent fat.
c) Fat harvest and preparation
Adequate fat for implantation may be harvested from the
area of the incision and approach to the thyroid cartilage
in most cases. No more than 1 to 2 ml of fat is neces-
sary per vocal fold. Every effort should be made to mini-
mize mechanical and thermal trauma to the graft, as this
likely decreases graft survival. Ideally, the fat is harvested
as strips the length of the vocal fold (8–15 mm, or area Fig. 48.4 Endoscopic view of correct orientation of the 22-g needle
to be augmented), which are as homogenous as possible at the anterior commissure (at the level of the free edge of the vocal
(Fig. 48.2). Fascial fibers or bands are trimmed from the folds)
grafts, and the graft is placed into saline to await implan-
tation.
4. Making the minithyrotomy ed level of the vocal folds. Using a zero degree endoscope
a) Perichondrial elevation the assistant visualizes the needle as it enters the larynx
The external perichondrium of the thyroid cartilage is near the anterior commissure. The needle is reinserted as
incised in the midline and elevated superiolaterally to necessary under endoscopic guidance to definitively es-
expose an area about 1 cm2 on each side of the prow of tablish the level of the glottis, and the surgeon marks this
the cartilage. on the thyroid cartilage (Figs. 48.3, 48.4). As greater ex-
b) Needle localization of vocal fold level perience is gained with placement of the minithyrotomy,
Using gentle pressure, a 22-g needle is passed through the the needle localization angle can be done to simulate/
anterior midline of the thyroid cartilage at the anticipat- identify the optimal path of the minithyrotomy. Thus,
Fig. 48.5 A cutting burr is used to gain

access to the subepithelial space of the
vocal fold. Note the special angle of the
minithyrotomy to allow longitudinal access
to the vocal fold
tion through the internal cartilaginous cortex is felt, the

drill is promptly withdrawn. A mastoid curette may be
used to finish the inside margin of the minithyrotomy
to avoid a “saucerized configuration.” It is important that
the minithyrotomy be oriented to the long axis of the
vocal fold (and thus somewhat obliquely—not perpen-
dicular—to the plane of the thyroid lamina) so as not to
restrict the mobility of the dissecting instruments.
5. Endolaryngeal dissection
a) Entering the correct tissue plane
Initial entry into the subepithelium is best made gently
with a blunt instrument such as a probe. The tip of the
dissecting instrument should be visible endoscopically
underneath the epithelium of the vocal fold.
b) Subepithelial dissection
A tympanoplasty set contains a variety of instruments of
the right size and length for efficient dissection via the
48 minithyrotomy. It is usually possible to do most of the
dissection with blunt instrumentation of varying thick-
ness, like a Gimmick elevator. Bellucci scissors are used in
only the most severe cases of adhesion. Surgeons who do
not routinely use the tympanoplasty set should note that
the duckbill is usually kept quite sharp, and may easily
Fig. 48.6 Subepithelial dissection of the vocal fold through the tear the mucosa if used in a cavalier manner (Fig. 48.6).
minithyrotomy (endoscopic view) c) Creating the implant pocket
The surgeon should have a good idea of the size and
shape of the implant pocket preoperatively from careful
study of the patient’s stroboscopic examination. The ex-
tent of defects in mucosal pliability may be very difficult
to assess during surgery, when the vocal fold mucosa is
instead of placing the localizing needle perpendicular to not engaged in phonatory oscillation. The implant pock-
the thyroid cartilage in the midline, the needle is passed et should be limited as much as possible to the area of
at the suspected angle and level of the anterior commis- pathology. This takes considerable lightness of touch, as
sure while visual inspection is performed to provide normal superficial lamina propria offers little resistance
feedback on the needle placement. to dissecting instruments. It is not difficult to elevate too
c) The minithyrotomy widely, and this creates areas into which a fat graft may
The minithyrotomy is centered some 3–5mm off the mid- migrate under phonatory forces, away from where it is
line at the level of the vocal fold (Fig. 48.5). A powered needed. This is a particular problem if dissection pro-
drill with a 3-mm cutting burr is used to create a tunnel ceeds too far laterally along the superior surface of the
through the thyroid cartilage. Once the “give” of penetra- vocal fold.
Chapter 48 303
Fig. 48.7 Placement of fat graft into pocket (endoscopic view) Fig. 48.8 Assistant smoothing medial margin of the vocal fold after fat
graft implantation (endoscopic view)
d) Inserting the fat graft The area is irrigated and checked for hemostasis. If this
The fat graft is inserted via the minithyrotomy to lie seems satisfactory, then the wound may be closed with-
evenly in the area to be augmented. Ideally, only one fat out a drain; if not, a rubber band drain may be placed, to
graft per side is used. This is a technically troublesome be removed the next morning.
step, as the fat tends to bunch in the subepithelial plane
and adhere to the instruments used to insert it. An alli-
gator is useful to pull the leading edge of the graft (which
lies posteriorly on the vocal fold) into place, and a blunt
and Complications
probe is used where necessary to push it into place (Fig.
48.7). The assistant may also use the shaft of a microlar-
yngoscopic instrument to smooth the medial margin of Postoperative care entails:
the vocal fold and help position the graft (Fig. 48.8). An
■ Overnight, 23-hour observation
alternative method of graft placement is to use the out-
■ Pain management
side, plastic sheath of an angiocatheter (~ 16 gauge) the
fat graft(s) can be placed into a 3rc luer lock syringe and
8 mg, then 4 mg)
attached to the angiocatheter sheath. The sheath is then
passed through the mini thyrotomy and into the pocket
■ A week of voice rest
previously dissected along the free edge of the vocal fold.
After visual confirmation of the angiocatheter position,
■ Prolonged phonatory recovery times are typical (around
the fat can be gently “injected” into the vocal fold.
1 month).
e) Because of the edema that accumulates during dissec-
tion, it is difficult to assess the effect of the graft on vocal
fold contour, but this should in no way discourage the As this is a relatively new procedure, there are limited data on
surgeon into using less fat. Most unsatisfactory outcomes long-term (>6 months) voice results. Clearly, any improvement
have resulted from using too little fat. in voice quality post-operatively may deteriorate in certain cases
6. Closure after several months, and these late changes have been attributed
a) The minithyrotomy may be sealed with fibrin glue or to poor fat graft survival.
bone wax. The perichondrial flap is replaced if possible.

Key Points
■ Vocal fold epithelial perforation
■ In cases of severe scar, it is not difficult to perforate
the vocal fold epithelium. Pinhole perforations do ■ The Gray minithyrotomy offers access to subepi-
not require that the procedure be terminated. Care- thelial tissues of the vocal folds, without the need
ful fat implantation may proceed, although if the for mucosal incision.
defect is enlarged, it may result in graft extrusion. ■ Dissection and fat implantation are performed via
Small perforations may be patched using a piece of a neck incision under endoscopic guidance, which
perichondrium from the outside of the thyroid car- offers advantages over microlaryngoscopic tech-
tilage. In the presence of a large tear, the procedure niques.
is probably best abandoned, to be reattempted after ■ The angle and approach of the minithyrotomy
healing of the defect. must allow dissection along the longitudinal axis
■ Suboptimal results of the vocal fold and not be perpendicular to the
■ Fat implantation via the Gray minithyrotomy does thyroid cartilage.
not restore normal voice in most cases. In part, this ■ The Gray minithyrotomy has been especially well
is because fat is not a perfect rheologic replacement suited to rehabilitation of sulcus vocalis and scar,
for absent or altered lamina propria tissues. Alterna- conditions associated with superficial lamina pro-
tives and substitutes currently under development pria disturbance.
may offer superior results via this same surgical ap-
proach. Furthermore, as in all clinical applications of
autologous fat, graft survival is somewhat unpredict- Selected Bibliography
able. This may account for some deterioration over
the long term in certain cases. Finally, scar, sulcus,
1 Gray SD, Bielamowicz SA, Titze IR, Dove H, Ludlow C (1999)
and similar conditions may involve more than just
Experimental approaches to vocal fold alteration: Introduction
alterations in the superficial lamina propria, and may
to the minithyrotomy. Ann Otol Rhinol Laryngol 108:1–9
involve epithelial and deep tissue changes as well,
2 Paniello RC, Sulica L, Khosla SM, Smith ME (2008) Clinical ex-
neither of which the Gray minithyrotomy addresses.
perience with Gray’s minithyrotomy procedure. Ann Otol Rhinol
48
Subject Index
A B
abductor spasmodic dysphonia 221 Babcock retractor 275
Abraham cannula 210, 226 beclomethasone dipropionate 44
acetylcholine 221 Bell’s palsy 30
adductor spasmodic dysphonia 221, 225 Bellucci scissor 302
adenopathy 31 bilateral vocal fold paralysis (BVFP) 167
Adson’s forcep 250 Björk flap 37
air trapping 54 Boston gallow 300
airway Botox 215, 221
– edema 235 – injection 121
– foreign body 236 botulinum toxin (BTX) 43, 45, 221
– obstruction 235 – dilution 223
– vocal fold injection 202 – injection approach 222
airway anatomy 38 – laryngoscopic guidance 225
airway management – percutaneous EMG-guided injektion 223
– equipment 53 – reconstitution 223
airway protection 7 – retrolaryngeal approach 225
airway stenosis 37, 38 – supraglottic injection 225
allergic rhinitis 46 – translaryngeal approach 225
amyloidosis 44 botulinum toxin injection
anastomosis 297 – laryngeal injection 226
ANCA. see antinuclear cytoplasmic antibody – topical anesthesia 226
angiocatheter 162 – videomonitoring 226
anterior commissure 133, 161 Bouchayer forcep 65
– microweb 106 breathiness 9, 12
anterior glottic web 113, 116, 124, 159 breathy dysphonia 45
– endoscopic flap 160 bronchiogenic carcinoma 30
– endoscopic keel placement 161 bronchoscopic dilation 184
– keel removal 163 Broyles’ ligament 5
antinuclear cytoplasmic antibody (ANCA) 44 budesonide 44
aryepiglottic fold 155 BVFP. see bilateral vocal fold paralysis
aryepiglotticus muscle 155
arytenoid 4 C
– cartilage 3, 25 calcium hydroxylapatite (Radiesse) 94, 213
– dislocation 31 candidiasis 123
– edema 262 carcinoma
– perichondrium 25 – vocal fold 191
– prolapsed 236 carcinoma in situ
arytenoid adduction 231, 235, 237, 257, 263 – of the vocal fold 22
– suture 270 cardiopulmomary resuscitation (CPR) 22
arytenoid cartilage 169, 175 cartilage collapse 39
– perichondritis 119 cartilage graft 285
arytenoidectomy 88, 167, 170, 176 cartilaginous collapse 55
arytenopexy 231 cartilaginous trachea 297
aspiration of liquid 241 Cetacaine spray 210, 226
autoimmune disorder 44 chemical laryngitis 44
autologous fat 93 chemodenervation 221
306 Subject Index
chondrosarcoma of the cricoid 181 difficult airway exposure 56

christmas tree adaptor 114 diplophonia 141
chromophore 85 drip catheter 211
chronic obstructive pulmonary disease (COPD) 10 dynamic voice assessment 19
Cidofovir 130, 133, 215 – base of tongue 19
CO₂ laser 67, 85, 86, 133, 136, 152, 153, 169, 192 – larynx (global) 19
– thermal injury 137 – nasopharynx 19
– vascular lesion 137 – vocal fold (focal) 19
– vocal fold carcinoma 191 dysarthria 45
collagen 92, 198 dysgeusia 81
conazole 44 dysphagia 45, 292
consensus auditory-perceptual evaluation of voice (CAPE- dysphonia 9, 10, 30, 34, 109, 119
V) 13 – breathy 241
conus elasticus 5 – glottal insufficiency 29
COPD. see chronic obstructive pulmonary disease – inhaler-related 44
cordotomy 101, 111, 153, 167, 202 – postoperative 81, 112, 235
– extension 169 – psychogenic 46
corniculate 3 – spasmodic 12, 45, 221, 222
corticosteroid 47 – vocal fold polyp 99
Cosmoderm 92 dysplasia 21
Cosmoplast 92, 205 – carcinoma in situ 22
Cottonoid 89, 100, 137, 138, 156, 169, 246, 270 dyspnea 222
– epinephrine-soaked 236 – with exertion 255
– mitomycin c-saturated 184
Coumadin 77, 139 E
CPR. see cardiopulmomary resuscitation ee-sniff maneuver 31, 33
cranial neuritis 30 electroglottography 18
cricoarytenoid 7 electromyography 30
cricoarytenoid (CA) arthritis 44 EMG
cricoarytenoid (CA) joint 4, 167 – interpretation 222
– ankylosis 175 – machine 222
– palpation 168 endo-extralarnygeal suture lateralization 170
cricoarytenoid (CA) joint arthritis 32 endo-extralaryngeal needle carrier 171
cricoarytenoid muscle 225 endolaryngeal bleeding 233
cricoid endolaryngeal dissection 302
– cartilage 3, 4, 264, 268, 289 endolarynx 47, 66, 68, 69, 103
cricoid fracture 279 – telescope for visualization 71
– exploration 282 endoscopic flap 160
– repair 282 endotracheal intubation 182
cricoidotomy 285 endotracheal tube (ETT) 37, 53, 67, 69, 133, 176
cricothyroid 7 – laser protected 54
cricothyroid joint 4 epiglottis 4, 68, 69
cricothyroid membrane 215, 216, 224 epinephrine 66, 130, 206, 242, 254
cricothyroid muscle 5, 263, 289 epinephrine-soaked pledget 120, 130
cricothyroid space 217 epithelial hypertrophy 21
cricothyroid subluxation 232, 263 epithelium 6
cricotracheal anastomosis 291 essential tremor 45
cricotracheal stenosis 289 essential voice tremor 223
cuneiform cartilage 3 ETT. see endotracheal tube (ETT)
cup forcep 70 extra-esophageal reflux disease 175
curved alligator 106, 120, 192 extralaryngeal dissection 301
Cymetra 92, 205 extrathoracic airway obstruction 40
cyst
– of left vocal fold 24 F
false vocal fold (FVF) 157
D fat flap 270
Danazol 47 fat graft 303
Decadron 189, 235, 236, 242, 300 – harvest 147
deep brain stimulation 45 – implantation 145
deep vocal fold augmentation. see vocal fold augementation fat harvest 200
Subject Index 307
FEESST 274 I
fiber optic airway examination 39 IA. see interarytenoid muscle
fibrous mass iatrogenic nerve injury 29
– ligamentous 24 inferior cornu 263
– subepithelial 24 informed consent 51
flap elevation 124 infrahyoid strap muscle 275
flexible endoscope 216 injection augmentation 197
flexible laryngoscope 31, 211, 223, 234, 257 interarytenoid muscle (IA) 5
flexible laryngoscopy 18, 39, 210 interarytenoid synchiae 176
Fogarty catheter 188 intubation granulomas 43
framework surgery
– monitored anesthesia 58 J
Freer elevator 268, 284 Jamison scissor 268
functional aphonia 46 jet ventilation 54, 67, 171, 183
functional dysphonia 46
fungal laryngitis 44 K
keratosis 22
G Kerrison rongeur 244, 254, 258, 259, 276, 289
gallows suspension device 70 Kitner 259
gastroesophageal reflux disease (GERD) 10, 43 Kitner dissector 301
Gelfoam 92 KTP laser 130
GERD. see gastroesophageal reflux disease (GERD)
Gimmick elevator 302 L
globus sensation 119 lamina propria 6, 17, 24, 27, 63
glottal – benign lesion 50
– hyperfunction 9 laryngeal
– incompetence 198 – amyloidosis 44
– insufficiency 91, 142, 209, 215 – cancer 43
glottic – edema 235
– enlargement procedure 51 – electromyography (LEMG) 32, 175
– insufficiency 29, 33, 94, 231 – examination 19
– stenosis 38, 289 – fracture 279
GORE-TEX 253 – initial assessment 280
– implant 255 – framework stenosis 159
granuloma 172 – framework surgery 91, 197, 231
Gray minithyrotomy 142, 143, 299 – function 7
– Pinhole perforation 304 – gargle 210
GRBAS scale 12 – inflammation 10
Guaifenesin 47 – injection 221
– nerve 297
H – stenosis 279
hematoma 219 – stent 281
hemilarynx 275 – stent removal 282
hemostasis 73 – trauma 38, 267, 279
herbal remedy 47 – vestibule 4
histamine type 2 receptor antagonist 43 laryngitis 44
hoarseness 9, 10, 12, 13 laryngocele 273
holmium:YAG (Ho:YAG) laser 86 – combined 273
Hopkins rod telescope 67 – internal 273
horizontal belly 5 – recurrence 277
human papilloma virus 133 – termination 276
Hunsaker Mon–Jet catheter 55 – transthyroid excision 274
Hyalaform 93 laryngocutaneous fistula 287
Hyaluronic acid 92 laryngofissure 281, 287, 290
hyperkeratosis 123 – parasagittal 269
hypernasality 12 laryngopathia premenstrualis 10
hyponasality 12 laryngopharyngeal reflux (LPR) 10, 43, 119
hypopharynx 226 laryngopharyngeal reflux disease 25, 49, 75
hypophonia 45 laryngoplasty 231
hypothyroidism 10 – window 254
308 Subject Index
laryngoscope liposuction 200

– flexible 210 – cannula 201
– optimal position 70 LPR. see laryngopharyngeal reflux (LPR)
– placement 81 lung capacity 7
– positioning 81
laryngoscopic guidance 223 M
laryngoscopy malleable retractor 284
– flexible 19, 216 mask ventilation 185, 187
– placement 68 maximal phonation time (MPT) 31, 257
laryngospasm 7, 224 Mayo stand 72, 300
laryngotomy 281 medial arytenoidectomy (MA) 167, 169
– vertical parasagittal 268 medialization
laryngotracheal reconstruction with grafting 283 – depth 247
laryngotracheal stenosis 289 – implant extrusion 255
laryngovideostroboscopy 50 – postoperative care 250
larynx – window 258
– age-related change 34 – zone 249
– allergic disease 46 medialization laryngoplasty (ML) 32, 231, 263, 264
– difficult exposure 56 – airway obstruction 235
– extrinsic muscle 5 – complications 235
– innervation 6 – edema 236
– intrinsic muscle 4 – GORE-TEX 253
– squamous cell carcinoma 155 – implant material 232
– thyrohyoid approach 218 – patient selection 232
– vasculature 6 – revision surgery 237
– videocart system 210 – Silastic 241
– videomonitoring 210 – undercorrection 236
– visualization 17 medical laser 85
laser micro-ovoid cup forcep 65, 121
– CO₂ 86 microalligator 111
– contraindication 86 microalligator forcep 147
– damage 88 microcup forcep 65, 75, 106, 192
– equipment 87 microcurved scissor 74
– fire 89 microdebrider 66, 130, 132
– indication 86 microelevator 65, 75
– nonspecific thermal damage 85 microflap 24, 73, 109, 114, 143, 146
– safety 88 – injury 73
– setting 88 – vocal fold polyp 101
– smoke evacuation 88 microforcep 133
– surgery 85 microlaryngeal instrumentation 64
– tissue interaction 85 microlaryngoscopy 41, 53, 131, 142, 143, 145
– type 85, 86 – vocal fold cancer 192
– vaporization 88 microscissor 66, 106, 111, 130
– wavelength 85 microsuture 147
lateral cricoarytenoid muscle (LCA) 4 microtrap-door flap 177
LCA. see lateral cricoarytenoid muscle Midazolam 58
Lee Silverman voice treatment (LSVT) 45 midmembranous vocal fold lesion 23
LEMG. see laryngeal electromyography (LEMG) mitomycin C 161, 170, 176, 179, 184, 282
leukoplakia 21, 43, 123 monitored anesthesia care 58
– multiple patch 124 Montgomery stent 281, 282, 285, 286
– recurrence 126 MPT. see maximal phonation time
Lichtenberger endo-extralaryngeal needle passer 162, 170 MTD. see muscle-tension dysphonia
lidocaine 38, 199, 218, 242, 254, 268 mucosa
– nebulization 211 – perforation 236
Lindholm laryngoscope 156 mucosal cordotomy 110, 143
lipoinjection 200 mucosal flap elevation 176
– liposuction fat harvest 201 mucosal wave 8, 17, 33
– preparation of fat 201 muscle-tension dysphonia (MTD) 45
Subject Index 309
N – microflap approach 73
nasogastric (NG) tube 185 – microscope 67
nasolaryngoscopy 38 – patient position 68
neck mass 274 – physical complication 82
neodymium-coupled YAG (Nd:YAG) laser 86 – polypoid corditis 113
neurological disorder 10 – recurrent respiratory papilloma (RRP) 129
neurotoxin 221 – sulcus vocalis 141
nonlaryngeal malignancy 30 – surgical microscope 72
nucleus ambiguus 6 – timing 49, 77
– total voice rest 78
O – vascular lesion 136
odynophonia 119 – vocal fold cyst 109
oropharynx 211, 226 – vocal fold fibrous masses 109
Ossoff-Pilling laryngoscope 56, 65 – vocal fold granuloma 119
otolaryngology 9 – vocal fold nodule 105
oxyhemoglobin absorption band 86 – vocal fold polyp 100
oxymetazoline 210, 218, 226, 242, 254, 268 – vocal fold scar 141
– voice therapy 77
P phonosurgery 49
palatal paralysis 31 – decision-making process 50
papillary ectasia 135 – elective 50
papilloma virus infection 21 phonotrauma 25, 43, 47, 105, 113
paradoxical vocal fold motion disorder (PVFMD) 46 photolysis 85
paraffin 197 Pilling posterior-commissure laryngoscope 120
paralytic dysphonia 4 Plavix 77
paralytic falsetto 31 pneumomediastinum 54
paraplegia 30 pneumothorax 54, 89
Parkinson’s disease (PD) 34, 45 polypoid corditis. see also Reinke’s edema
patient – phonomicrosurgery 113
– history 9 – polypoid material removal 114
– occupational history 11 – redundant mucosa 115
– social history 11 – saddle-bag appearance 113
– speaking voice 11 polytetrafluoroethylene (Teflon) 93
PCA. see posterior cricoarytenoid muscle Pontocaine 210, 226
Penrose drain 298 posterior commissure 133
percutaneous vocal fold augmentation 215 posterior cricoarytenoid muscle (PCA) 5, 259
perichondrial flap 258, 303 posterior glottic scar 179
perichondrial inflammation 120 posterior glottic stenosis (PGS) 37, 167, 175
perichondritis of the arytenoid cartilage 119 posterior transverse cordotomy (PTC) 167, 168, 172
perichondrium 233, 244, 254, 284, 301 postviral vagal neuropathy 46
periodicity 18 potassium–titanyl–phosphate (KTP) laser 86
PGS. see posterior glottic stenosis (PGS) PPI. see proton pump inhibitor
pharyngocutaneous fistula 262 presbylaryngis 34, 213
phonation 7 presbyphonia 91
phonatory glottal closure 231 primidone 45
phonomicrosurgery 49, 63 propofol 55, 58
– anesthesia 67 propranolol 45
– anterior glottic web 159 proton pump inhibitor (PPI) 43
– apneic technique for anesthesia 67 pseudosulcus 43
– CO₂ laser 67 pulmonary function 40
– cold-steel 141 pulsed-KTP laser 138
– complication 75, 81 pulsed dye laser (PDL) 86, 138
– equipment 65, 105 – therapy 136
– informed consent 51 pyriform mucosa 259, 262
– laryngoscope 65
– laryngoscope placement 68 Q
– leukoplakia of the vocal fold 123 quadrangular membrane 5
– medical complication 82
310 Subject Index
R – excision 296
RA. see rheumatoid arthritis – rigid dilation 184
Radiesse Voice Gel 93 – subglottic 181, 283
raspiness 9 – tracheal 181
re-anastomosis 297 sternocleidomastoid muscle 295
rectus abdominus muscle 284 steroid inhaler 44
recurrent respiratory papilloma (RRP) 21, 82, 129 strain 12
– Cidofovir laryngeal injection 133 stroboscopy 17, 18, 105
– glottis 132 – after phonomicrosurgery 78
– laser surgery 131 – preoperative 63
– microdebrider removal 132 strobovideolaryngoscopy 135
– microflap removal 130 subepithelial dissection 302
– microforcep removal 131 subglottic jet ventilation tube 54
– phonomicrosurgery 129 subglottic stenosis 38, 54, 55, 181, 283, 289
– posterior commissure 133 subplatysmal flap 242, 254, 275, 285, 296
– supraglottis 132 sulcus vocalis 27, 91, 231, 299
– telescopic surgery 132 – excision with reapproximation 143
reflux symptom index (RSI) 10 – phonomicrosurgery 141
Reinke’s edema 25, 43 – vocal fold slicing technique 143
Reinke’s space 6, 95, 115 superficial vocal fold injection 205
residual arytenoid overhang 170 superior laryngeal nerve (SLN) 6
Restylane 93 supraglottis stenosis 159
rheumatoid arthritis (RA) 44 Surgifoam 92
rheumatological disorder 26 suspension laryngoscope 114, 176
rough voice 9 suspension laryngoscopy 136, 171, 185
RRP. see recurrent respiratory papilloma (RRP) suspension microlaryngoscopy 199
RSI. see reflux symptom index suture lateralization 178, 179
systemic lupus erythematosus (SLE) 44
S
saccular cyst T
– endoscopic excision 155 T-tube 187, 292
– recurrence 157 – Hood package 189
saline-infusion trial 205, 206 – occlusion 189
scant gelatinous-appearing material 111 – placement 185
sevoflurane 54 – stenting 185, 189
Sewell retractor 260 T-tube stent 42
sickle knife 66, 73, 124, 130 T-tube stenting 41
Silastic 253 TA. see thyroarytenoid muscle (TA)
– block 241, 246 Teflon 93, 197
– catheter 211 – granuloma 151, 267
– medialization 271 – injection 151, 267
– medialization laryngoplasty 241 – mass
– T-tube 292 – laser ablation 152
silent cough 78 Teflon injection 32
silicone 197 testosterone 47
silk tape 71 thalamotomy 45
singing voice 12 throat clearing 78
singing voice therapy 78 throat pain 81
sinonasal allergic disease 49 thyroarytenoid muscle (TA) 5, 135
SLE. see systemic lupus erythematosus thyrohyoid membrane 155, 273
Sliding Jackson laryngoscope 57 thyroid
SLN. see superior laryngeal nerve – artery 6
sound production 7 – notch 3
spasmodic dysphonia (SD) 45, 222 thyroid ala 217, 233, 237, 250
speech–language pathologist 78, 138 thyroid cartilage 3, 4, 155, 160, 161, 242, 243, 250, 263, 275,
speech–language pathology 142 301
spider telangiectasia 135 – fracture 279, 280
squamous cell carcinoma of the glottis 191 thyroid fracture
stenosis – exploration 280
– congenital 283 – repair 280
Subject Index 311
thyroid lamina 268 visual analogue scale 12

thyroid mass 31 visualization
thyroplasty 3 – stroboscopic 17
– GORE-TEX ribbon 253 vocal
– type I 231 – fatigue 9, 13, 33, 241
– window 6 – hygiene 47
thyrotracheal anastomosis 289 – ligament 6, 110
total arytenoidectomy 170, 172 – pathology 9
total voice rest 78 – professional 11
tracheal – testing 12
– intubation 295 – tickle 13
– stenosis 295 – tremor 45
– stoma 39 vocal fold 6
tracheal airway narrowing 182 – amplitude 18
tracheal stenosis 38, 54, 55, 181, 283 – atrophy 142, 213
– intrathoracic 55 – augmentation 91, 92, 142, 198
tracheal stoma 38 – microlaryngoscopy 199
tracheobronchoscopy 41, 298 – bamboo lesion 26
tracheomalacia 39, 40, 181 – bilateral paralysis (BVFP) 167
tracheostomy 37, 55, 185, 285 – bowing 34, 253
– placement 38 – carcinoma 22, 191
– T-tube placement 185 – cookie cutter defect 107
– tube 54, 182 – cyst 23, 74
tracheotomy 21, 129, 167, 175, 176, 295, 296 – phonomicrosurgery 109
Tramadol 47 – recurrence 112
trans cricothyroid membrane – edema 237
– placement of injection needle 217 – endoscopic injection 199
transnasal esophagoscope 86 – epithelial perforation 304
transthyroid cartilage 215 – ETT trauma 173
– placement of injection needle 217 – fat graft reconstruction 145
triangular forcep 65, 111, 192 – fibrous mass 74
tympanoplasty 299, 302 – phonomicrosurgery 109
– granuloma 25, 43, 223
U – phonomicrosurgery 119
unilateral vocal fold paralysis (UVFP) 29, 91, 241 – hemorrhage 47
– imaging study 32 – immobility 30, 31
– screening laboratory test 32 – injection 197, 211
– treatment 32, 33 – material 92, 197
upper airway stenosis 183 – keratosis 21
upper respiratory infection (URI) 9 – phonomicrosurgery 123
URI. see upper respiratory infection – knot tying 147
UVFP. see unilateral vocal fold paralysis – leukoplakia 21
– phonomicrosurgery 123
V – lipoinjection 94, 198, 200, 201
vagus nerve 29 – medialization 231
– herpes simplex infection 30 – midmembranous lesion 23
Valsalva maneuver 236, 262 – mobility testing 39
vascular knife 136 – mucosa 6
velcro strap 71 – nodule 23
ventricular mucosa 250, 255 – phonomicrosurgery 105
vertical belly 5 – surgery 105
VFP. see vocal fold paralysis – overmedialization 237
– treatment 32 – papillary ectasia 135
VHI. see voice handicap index – paralysis 29, 211, 232, 241, 257, 263
video examination 19 – paresis 11, 31, 33, 213
videolaryngoscopy 199 – pathologic condition 21
videostroboscopy 29, 109, 199 – pathology 72, 73, 82
– leukoplakia 123 – percutaneous augmentation 216
– VFP 31 – peroral augmentation
– vocal fold paresis 33 – in the clinic setting 215
312 Subject Index
– phonotrauma 22 vocalis muscle 5

– pinching 147 voice
– placement of sutures 146 – aesthenic 12
– pliability 18 – alteration 287
– polyp 24 – disorder 43
– microflap approach 100 – evaluation 17
– phonomicrosurgery 99 – quality 49
– truncation 101 – rest 107, 138
– truncation approach 100 – vocal fold polyp 103
– prevention of scar formation 82 – therapy 23, 33, 50
– reactive lesion 25 – preoperative 49, 63
– scar 27, 159, 205, 299 – prior to phonomicrosurgery 77
– phonomicrosurgery 141 – speech–language pathologist 47
– scarring 116, 139 – tremor 221, 223
– spider telangiectasia 136 – unloading 30
– stiffness after phonomicrosurgery 78 voice handicap index (VHI) 12
– subepithelial space 63
– superficial injection 205 W
– swelling 219 Wegener’s granulomatosis 44
– transoral augmentation 209 Woodson elevator 244, 254, 268
– trauma 10
– true hemangioma 135 Y
– undermedialization 250 YAG laser 86
– vascular lesion 26
– phonomicrosurgery 135 Z
– vibration 17 Zyplast 92, 205
– vibration symmetry 18

ORL Operative Techniques in Laryngology

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ORL Operative Techniques in Laryngology

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Clark A. Rosen, C.

Forewords by Hans von Leden

With 390 Figures and 11 Tables

ISBN 978-3-540-25806-3 e-ISBN 978-3-540-68107-6

Library of Congress Control Number: 2008926220

© 2008 Springer-Verlag Berlin Heidelberg

Cover design: eStudio Calamar, Spain

Printed on acid-free paper

This work is dedicated to my wife, Cristina, and my twin

C. Blake Simpson, M.D.

Part A Clinical Evaluation of Laryngeal Disorders 3 Videostroboscopy and Dynamic Voice

Part B Phonomicrosurgery for Benign 13.2.2 Tissue Interaction . . . . . . . . . . . . . . . . . . . . . . . . . 85

15 Vocal Fold Polyp . . . . . . . . . . . . . . . . . . . . . . . . . . 99

III Laser Microlaryngeal Surgery IV Laryngeal Injection Techniques

34 Percutaneous Vocal Fold Augmentation 37.5 Long-Term Surgical Issues . . . . . . . . . . . . . . . . . 239

40 Arytenoid Adduction . . . . . . . . . . . . . . . . . . . . . 257

Milan Amin, M.D. Patrick J. Gullane, M.D.

Albert Merati, M.D. Anthony Rider, MD

Anatomy and Physiology

The arytenoid cartilages are paired, pyramidal cartilages that

1.1.1.4 Accessory Cartilages:

The cuneiform cartilages are crico-arytenoid joint paired elas-

1 likely serve to provide additional structural support to the ary-

1.1.2.2 Cricoarytenoid Joint

The cricoarytenoid joint is the primary moving structure of the

1.1.3 Laryngeal Musculature

1.1.3.1 Intrinsic Laryngeal Muscles

The intrinsic muscles of the larynx are responsible for alter-

The Lateral Cricoarytenoid Muscle (LCA)

This paired laryngeal muscle is attached to the anterior part

Interarytenoid Muscle (IA)

1 1.1.5 Microanatomy of the Vocal Fold

The complex microanatomy of the true vocal fold allows the

The most primitive of the laryngeal functions is protection of

The most complex and highly specialized of the laryngeal

1 ryngeal, nasal, and oral anatomy, and subsequent mental status

Principles of Clinical Evaluation

lamina propria. An increase in acid mucopolysaccharides in

Table 2.1 Reflux Symptom Index

creasing the efficiency of vocal fold vibration. Certain foods and

Voice disorders affecting vocal professionals have considerably

Table 2.3 Symptoms suggestive of specific voice disorders

Symptoms Associated diagnoses

Table 2.4 Rainbow passage

Table 2.5 Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)

Table 2.6 Voice Handicap Index 10

My voice makes it difficult for people to hear me. 01234

6 Silverman EM, Zimmer CH (1978) Effect of the menstrual cycle

Stroboscopy helps elucidate specific lesions of the vocal folds,

Flexible laryngoscopy is an essential evaluation technique for

1. Patient task: rest, sustained phonation (/ee/) and speech

1. Patient task: rest and tongue protrusion

4.3.1 Recurrent Respiratory

Recurrent respiratory papillomatosis of the larynx is an epithe-

vocal folds. These lesions can be singular in nature or they can

4.3.3 Dysplasia–Carcinoma in Situ

Dysplasia or carcinoma in situ of the vocal folds represents a

4.3.4 Carcinoma of the Vocal Fold

Fig. 4.4 Carcinoma of the left vocal fold

improve without surgery (i. e., a large, pedunculated polyp). In

Midmembranous lesions of the vocal fold are abnormalities of

In most instances, patients with midmembranous vocal fold le-

rest or voice therapy, and the prognosis for prompt recovery of

4 4.4.6 Vocal Fold Polyp