F081 Coclia 75 Phonosurgery

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  • 1. COCLIA Laryngology: PHONOSURGERY Samuel Ostrower January 14, 2008
  • 2. Recurrent Laryngeal Nerve
  • 3.  
  • 4. Cricoarytenoid Joint
  • 5. Intrinsic Musculature
  • 6. Intrinsic Musculature
  • 7. 1. A patient is referred from your favorite thoracic surgeon for hoarseness after aortic aneurysm repair. On exam, you find an immobile vocal fold. How can you determine the etiology?
  • 8. Patient Evaluation
    • Subjective assessment
    • Phonatory function tasks
    • Acoustic parameters
    • Phonatory airflow
    • Videostroboscopy
    • Electromyography (EMG)
  • 9. Videostroboscopy
    • Illusion of slow motion created using a strobe light to illuminate the vocal folds at different points of different vibration cycles
    • Evaluates:
      • Glottic closure
      • Symmetry
      • Undersurface of vocal fold edges
      • Stiffness, scar, submucosal injury
      • Relative depth of tumor invasion
      • Mucosal wave
        • Vocal fold vibration patterns/amplitude
        • Mucosal pliability
  • 10. Laryngeal Electromyography (EMG)
    • Only test available for evaluating integrity of laryngeal motor unit.
      • Voluntary action potentials, fibrillation potentials, electrical silence
    • Percutaneous or transoral placement of concentric bipolar needles
      • Thyroarytenoid m.
      • Posterior cricoarytenoid m.
      • Cricothyroid m.
  • 11. 2. Vocal fold injectional medialization Vs. Intrachordal injection. What is the difference?
  • 12.  
  • 13. Medialization vs Intrachordal Injection
    • Vocal fold medialization injection
      • Material injected lateral to vocalis m. in paraglottic space
    • Vocal fold intrachordal injection
      • Material is injected superficially, just deep to lamina propria, avoiding Reinke’s space
      • Used for elimination of soft tissue defects
  • 14. 3. Unilateral vocal fold medialization by injection – what materials are available? Indications and advantages?
  • 15. Injection Materials
    • Teflon (Polytef)
    • Human micronized alloderm (Cymetra)
    • Autologous fat
    • Gelfoam
    • Collagen
    • Hydroxyapatite
    • Hyaluronic acid formulations/Hylan B (Hylaform)
  • 16. Teflon Paste (Polytef ® )
    • Permanent, non-reabsorbable material
    • Viscous
    • Poor vibratory/phonatory results
    • Must be injected laterally
    • Migration, extrusion, progressive inflammatory response
      • Granuloma formation
  • 17. Human Micronized Dermis/AlloDerm (Cymetra ® )
    • Most commonly used injectable
    • Excellent phonatory results
    • Low viscosity
    • Temporary (effects last 6-12 months)
    • Acellular, non-antigenic material causing minimal inflammatory response
  • 18. Autologous Fat
    • No inflammatory response
    • Excellent phonatory results
    • Requires additional incision
    • Viscous, requiring Bruening syringe
  • 19. Bovine Collagen
    • Effective for management of vocal fold paralysis, sulcus vocalis and soft tissue deficits
    • Temporary material
    • Low viscosity
    • Delayed hypersensitivity possible
      • Skin testing recommended
      • May lead to inflammatory changes leading to increased vocal fold stiffness, but unlikely permanent sequelae
  • 20. Cross-Linked Hyaluronic Acid Gel (Hylaform ® )
    • Temporary
    • Low viscosity
    • Good phonatory results
  • 21. Calcium Hydroxyapatite Gel (Radiance FN ® )
    • Permanent, non-reabsorbable material
    • Phonatory results less well studied
    • Relatively large particles not taken up by macrophages (no granuloma formation)
  • 22. 4. Discuss the management of Teflon granulomas.
  • 23. Teflon Granuloma
    • Foreign body giant cell reaction
    • Variable onset
      • May occur between 4 months and 18 years following injection
    • Therapeutic options
  • 24. Teflon Granuloma Therapeutic Options
      • Endoscopic with superior fold wedge resection/suction technique (Dedo, 1992)
      • Midline thyrotomy/”hemilaryngectomy” technique (Russell, et al. 1995)
      • Endoscopic with CO2 laser and superior VF microflap reconstruction (Ossoff, et al. 2003)
  • 25. Lateral Laryngotomy
    • Lateral laryngotomy (Netterville, 1998)
      • Allows full granuloma excision with preservation of uninvolved lamina propria
      • Sternothyroid muscle flap or silastic implant medializes remaining vocal fold after excision to optimize voice production
  • 26. 5. Describe transcutaneous vs. laryngoscopic injection in vocal fold medialization
  • 27. Transcutaneous Injection Thyroplasy
    • Lateral approach
      • Through thyroid ala at level of vocal fold (midway between thyroid notch and inferior margin of ala)
      • Local anesthesia
      • Direct visualization
      • using flexible
      • laryngoscopy
  • 28. Transcutaneous Injection Thyroplasy
    • Anterior approach
      • Through cricothyroid membrane
      • Local anesthesia
      • Direct visualization
      • using flexible
      • laryngoscopy
  • 29. Transcutaneous Injection Thyroplasy
    • Luer Lock 1-cc syringe with 1-inch, 23-gauge needle
    • Injection placed just anterior and lateral to vocal process on a plane level with lower border of medial edge of VF
    • Use 0.5 – 1cc of Cymetra ®
  • 30. Laryngoscopic Injection Thyroplasty
    • Patients who do not tolerate flexible fiberoptic exam with percutaneous approach
    • Used during ablative procedures when RLN or vagus sacrifice anticipated
    • Performed under general anesthesia with spontaneous ventilation, apnea or jet ventilation
  • 31. 6. Discuss the management of overinjection during vocal fold medialization
  • 32. Overinjection
    • Teflon overinjection
      • Immediate mucosal incision and suctioning of excess material
      • Delayed removal is problematic due to migration, scar and granuloma
  • 33. 7. Medialization thyroplasty–indications, advantages. Otolaryngol Head Neck Surg 1997;116:349
  • 34. Type I Thyroplasty
    • Term coined by Isshiki in the 1970’s
    • External medialization technique
    • Immediate & reversible results
    • Improves both voice & aspiration
    • Local anesthesia
  • 35. Indications
    • Procedure of choice for the paralyzed vocal fold when recovery unlikely
    • Vocal fold bowing from aging or cricothyroid joint fixation
    • Sulcus vocalis
    • Soft tissue defects from excision of pathologic tissue
  • 36. Timing of Surgery Otolaryngol Head Neck Surg 1997; 116:349-54
  • 37. Medialization Thyroplasty Materials
    • Silastic
      • Carved
      • Prefabricated (Montgomery)
    • Hydroxyapatite
      • VoCom
    • Gore-Tex
      • Composed of Teflon
  • 38. Surgical Technique
  • 39. Surgical Technique
  • 40. Surgical Technique
  • 41. Surgical Technique
  • 42. Surgical Technique
  • 43. 9. Goal of Arytenoid Adduction. Indications
  • 44. Arytenoid Adduction (AA)
    • Surgical therapeutic option for correction of significant glottal incompetence in patients with laryngeal paralysis
    • Mimics lateral cricoarytenoid m. to rotate the arytenoid vocal process medially
    • Correct for asymmetries in vertical height
  • 45. 10. Would you perform an arytenoid adduction without medialization procedure? Otolaryngol Head Neck Surg 2003;129:305-310
  • 46. Arytenoid adduction combined with medialization thyroplasty: an evidence-based review ( Otolaryngol Head Neck Surg 2003;129:305-310)
    • 219 articles
    • Majority of articles discussed the benefits of MT or AA as a single intervention
    • Only 3 articles directly evaluated the voice outcomes of MT plus AA versus MT alone
    • There was no clear benefit in subjective or objective outcomes for AA plus MT
  • 47. 11. How do you do an arytenoid adduction?
  • 48. Arytenoid Adduction Technique
  • 49. 12. What is the success of reinnervation procedures?
  • 50. Reinnervation Techniques
    • Neuromuscular pedicle (NMP)
    • Ansa cervicalis-to-recurrent laryngeal nerve (ansa-RLN) anastomosis
  • 51. Neuromuscular Pedicle Technique
  • 52. Ansa Cervicalis-to-Recurrent Laryngeal Nerve (ansa-RLN) Anastomosis Technique
  • 53. 13. Bilateral vocal fold paralysis in midline position. Patient refuses tracheostomy. What other surgical options can you offer? Ann Otol Rhinol Laryngol 1991; 100:717
  • 54. Bilateral Vocal Fold Paralysis - Surgical Options
    • Arytenoidectomy
    • Arytenoidopexy
    • Cordotomy
    • Cordopexy
    • Nerve-muscle transposition