Nova Medical Centers                          KAILASH COLONY©2009. Nova Medical Centers. Strictly private and confidential
Laryngeal Surgery                                                                       an Overview                       ...
The Problem spectrum                                                                 •   Hoarseness and Voice Disorders   ...
Effective Diagnosis                                                                 • Begins at OPD                       ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Laryngoscopy workout                                                                 •   Sustained eee….                  ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Recording and Replay                                                                 • Much More Informative.             ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Laryngeal Surgery                                                                  Kotbys classification                  ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Extirpation Endolaryngeal Microsurgery                                                                 conventional micros...
G.A. considerations                                                                 • Oral Intubation with MLS tube ( high...
Tube Position                                                                 • Anterior Vocal cords 2/3rd :- small ETT   ...
Other Considerations                                                                 • Laser Protected ETT                ...
Difficult Per Oral exposure                                                                 •   Short Thick Neck          ...
Long list of requirements                                                                 •   Largest Bore Laryngoscope + ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Vocal Fold Augmentation                                                                 •   Indications:                  ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Repositioning of the Vocal Fold                                                                  Medialization surgeries (...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Thyroplasty                                                                 (Laryngeal Framework Surgery)                 ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Type II - Lateralization                                                                 Release the tight closure of the ...
Type III - Relaxation (shortening)                                                                 Aimed at lowering the v...
Type IV - Stretching (lengthening)                                                                 CT approximation to ele...
Laryngeal Surgery                                                                  Kotbys classification                  ...
Neurophonosurgery                                                                  •   Reinnervating the PCA muscle       ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Laryngo Tracheal Trauma                                                                 • Increasing accidents            ...
Group II                                                                 Intact endolarynx + Displaced thyroid #          ...
Group II                                                                  Intact endolarynx + Displaced thyroid #         ...
Group III                                                                   Large mucosal lacerations                     ...
Group III                                                                 Large mucosal lacerations                       ...
FUNCTIONAL PRINCIPLES                                                                 • BLOOD IN CONTACT WITH CARTILAGE LE...
Group III                                                                 Large mucosal lacerations                       ...
MIDLINE THYROTOMY                                                                  •   Horizontal skin incision at crico-t...
Group III                                                                 Large mucosal lacerations                       ...
Group III                                                                 Large mucosal lacerations                       ...
Group III                                                                 Large mucosal lacerations                       ...
Group III                                                                 Large mucosal lacerations                       ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
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Dr lalit-mohan-parashar laryngeal-surgery-an-overview-ncas_2011

  1. 1. Nova Medical Centers KAILASH COLONY©2009. Nova Medical Centers. Strictly private and confidential
  2. 2. Laryngeal Surgery an Overview Dr. Lalit Mohan Parashar Senior Consultant OTORHINOLARYNGOLOGY &©2009. Nova Medical Centers. Strictly private and confidential Dr. Lalit Mohan Parashar Head and Neck Surgery (ORL&HNS) Deptt of Otorhinolaryngology and Head & Neck Surgery
  3. 3. The Problem spectrum • Hoarseness and Voice Disorders • Breathing difficulty & stridors • Malignancies and cancers • Iatrogenic- Thyroid surgery and ICU survivers & • Traffic and other accidents.©2009. Nova Medical Centers. Strictly private and confidential
  4. 4. Effective Diagnosis • Begins at OPD • Clinched in Endoscopy Rooms • Confirmed with/ without Stroboscopy & • Refined in Voice Lab©2009. Nova Medical Centers. Strictly private and confidential
  5. 5. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  6. 6. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  7. 7. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy
  8. 8. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy Room Normal larynx during phonation3.flv
  9. 9. Laryngoscopy workout • Sustained eee…. • Quiet Respiration • Glide- Sustained eee at low & High pitch • Cough / laugh • Stroboscopic Evaluation©2009. Nova Medical Centers. Strictly private and confidential
  10. 10. ©2009. Nova Medical Centers. Strictly private and confidential Video –endoscopy- stroboscopy
  11. 11. Recording and Replay • Much More Informative. • Longitudinal Comparison • Pre-op planning • Patient Education • Medical / Legal uses©2009. Nova Medical Centers. Strictly private and confidential
  12. 12. ©2009. Nova Medical Centers. Strictly private and confidential Vocal Cord Growth
  13. 13. ©2009. Nova Medical Centers. Strictly private and confidential Dysphonia Plica Venticulare
  14. 14. Laryngeal Surgery Kotbys classification 1. Extirpation endolaryngeal microsurgery. 2. Vocal fold augmentation. 3. Vocal fold repositioning. 4. Neurophonosurgery. 5. Glottal reconstruction after partial laryngectomy. 6. Postlaryngectomy surgery. 7. Laryngo Tracheal Trauma©2009. Nova Medical Centers. Strictly private and confidential
  15. 15. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  16. 16. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  17. 17. Extirpation Endolaryngeal Microsurgery conventional microsurgery(MLS) • Indications: • Congenital Lesions: • Sulcus vocalis & vergeture. Laryngeal web • Epidermoid cysts & laryngoceles. Laryngeal stenosis©2009. Nova Medical Centers. Strictly private and confidential • Acquired lesions • Granulomata. :Benign neoplasm • • VF hemorrhage. • Papillomatosis. • • Dysplasia of VF. & Carcinoma in situ. •
  18. 18. G.A. considerations • Oral Intubation with MLS tube ( high volume low pressure Cuff ) or • Jet Ventilation – Sub –Glottic Ventury or -- Supra Glottic Ventury via laryngoscope©2009. Nova Medical Centers. Strictly private and confidential
  19. 19. Tube Position • Anterior Vocal cords 2/3rd :- small ETT • Posterior Vocal Cords :- Anterior ETT or » Jet Ventillation or » Apneic Techniques©2009. Nova Medical Centers. Strictly private and confidential
  20. 20. Other Considerations • Laser Protected ETT • Care of Sub Glottis and • Care of tracheal Stoma • Difficult Per Oral exposure©2009. Nova Medical Centers. Strictly private and confidential
  21. 21. Difficult Per Oral exposure • Short Thick Neck • Retrognathia • Trismus • Restricted Neck Extention • Lingual Hypertrophy • Poor Palatal visualisation©2009. Nova Medical Centers. Strictly private and confidential
  22. 22. Long list of requirements • Largest Bore Laryngoscope + ant. & post. Comm. • Suspension Systems • Specialized Instruments • Mouth/ dental Guard • Subepithelial Infusion needle©2009. Nova Medical Centers. Strictly private and confidential • Operating Microscope – 400mm lense • Optical Telescope – 4mm x 20 cms • Microdebrider/ laser system
  23. 23. ©2009. Nova Medical Centers. Strictly private and confidential Microflap Excision
  24. 24. ©2009. Nova Medical Centers. Strictly private and confidential Microdebrider
  25. 25. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  26. 26. ©2009. Nova Medical Centers. Strictly private and confidential Robotics
  27. 27. Vocal Fold Augmentation • Indications: • Correction of glottic incompetence due to: • Unilateral vocal fold paralysis. • Sulcui or after surgery or trauma. • Autologous and alloplastic materials.©2009. Nova Medical Centers. Strictly private and confidential • Transoral or percutaneous approaches. • Silicon, Teflon, Gelfoam, Autologous Fat
  28. 28. ©2009. Nova Medical Centers. Strictly private and confidential Injection Medialisation
  29. 29. Repositioning of the Vocal Fold Medialization surgeries (Mediopexy) 1. Surgical augmentation 2. Arytenoid adduction Lateralization (Lateropexy) 1. Arytenoid repositioning. 2. Arytenoidectomy with posterior partial cordectomy.©2009. Nova Medical Centers. Strictly private and confidential Sharp dissection Laser excision.
  30. 30. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  31. 31. Thyroplasty (Laryngeal Framework Surgery) Altering VF position, shape and tension by manipulating the cartilagenous framework. Isshiki’s functional classification: • Type I - Medialization. • Type II - Lateralization. • Type III - Relaxation (shortening). • Type IV - Stretching (lengthening).©2009. Nova Medical Centers. Strictly private and confidential
  32. 32. ©2009. Nova Medical Centers. Strictly private and confidential Thyroplasty (Laryngeal Framework Surgery)
  33. 33. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  34. 34. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  35. 35. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  36. 36. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  37. 37. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  38. 38. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  39. 39. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  40. 40. Type II - Lateralization Release the tight closure of the glottis. Approaches: • A vertical incision in the thyroid cartilage and lateralizing the posterior segment over the anterior one. • Two paramedian vertical incisions and interpose©2009. Nova Medical Centers. Strictly private and confidential the lateral segments beneath the anterior segment. Indication: • Spastic dysphonia.
  41. 41. Type III - Relaxation (shortening) Aimed at lowering the vocal pitch. The VF is relaxed by A-P shortening of the thyroid ala. Indications: • Males with high pitch voice, resistant to voice therapy. • Stiff VF with high pitched breathy voice. • Spastic dysphonia.©2009. Nova Medical Centers. Strictly private and confidential
  42. 42. Type IV - Stretching (lengthening) CT approximation to elevate pitch. Other Techniques to elevate the pitch: • Inferiorly based anterior cartilage flap. • Superiorly based cartilage flap.©2009. Nova Medical Centers. Strictly private and confidential • Anterior commissure advancement.
  43. 43. Laryngeal Surgery Kotbys classification 1. Extirpation endolaryngeal microsurgery. 2. Vocal fold augmentation. 3. Vocal fold repositioning. 4. Neurophonosurgery.©2009. Nova Medical Centers. Strictly private and confidential 5. Glottal reconstruction after partial laryngectomy. 6. Postlaryngectomy surgery. 7. Laryngo Tracheal Trauma
  44. 44. Neurophonosurgery • Reinnervating the PCA muscle • Nerve anastomosis. Phrenic nerve /ansa cervicalis. • Phrenic nerve implantation. • Neuromuscular pedicle Transplantation. • Reinnervating the TA muscle©2009. Nova Medical Centers. Strictly private and confidential • Ansa cervicalis to RLN anastomosis • Infrathyroid - suprathyroid techniques • Neuromuscular pedicle Transplantation.
  45. 45. ©2009. Nova Medical Centers. Strictly private and confidential Laryngo Tracheal Trauma
  46. 46. Laryngo Tracheal Trauma • Increasing accidents • Time to prepare ourselves is NOW • Minor Ones or Group I need conservative management©2009. Nova Medical Centers. Strictly private and confidential
  47. 47. Group II Intact endolarynx + Displaced thyroid # • Open reduction + internal fixation ORIF • Method – Sutures©2009. Nova Medical Centers. Strictly private and confidential – Wires – Miniplates
  48. 48. Group II Intact endolarynx + Displaced thyroid # • ORIF • AIM – preservation of AP diameter Maintain Normal position of cords©2009. Nova Medical Centers. Strictly private and confidential Austin technique
  49. 49. Group III Large mucosal lacerations • Or even small Lacerations involving – Anterior commissure – Free margins of TVC – Exposed cartilage – Multiple # – TVC immobility • Managed by ORIF + Open laryngeal exploration within 24 hours©2009. Nova Medical Centers. Strictly private and confidential
  50. 50. Group III Large mucosal lacerations • AIM – Return all remaining tissue to appropriate location – Cover all cartilage©2009. Nova Medical Centers. Strictly private and confidential • FUNCTIONAL PRINCIPLES
  51. 51. FUNCTIONAL PRINCIPLES • BLOOD IN CONTACT WITH CARTILAGE LEADS TO RESORPTION • CARTILAGE IN CONTACT WITH SECRETIONS LEADS TO INFLAMMATION WHICH LEADS TO GRANULATIONS MESSEGE©2009. Nova Medical Centers. Strictly private and confidential CARTILAGE HAS TO BE COVERED AT ALL COSTS
  52. 52. Group III Large mucosal lacerations • MIDLINE THYROTOMY or • Pramedian if vertical # within 3mm of midline • Steps of MIDLINE THYROTOMY©2009. Nova Medical Centers. Strictly private and confidential
  53. 53. MIDLINE THYROTOMY • Horizontal skin incision at crico-thyriod m. • Sub platysmal flaps • Separate strap muscles & expose thyroid c. • Midline Thyrotomy saw or drill • Retract laminae laterally©2009. Nova Medical Centers. Strictly private and confidential • Achieve haemostasis
  54. 54. Group III Large mucosal lacerations • Situation 1 – Primary closure is generally possible – 5-0 or 6-0 absorbable sutures – Minimal undermining to move mucosa – Dibridement should be kept to minimum – DRAIN BLOOD COLLECTIONS©2009. Nova Medical Centers. Strictly private and confidential – Keep mucosa down by quilting sutures
  55. 55. Group III Large mucosal lacerations • Situation 2 – Primary closure is not possible – Rotate flaps from - Epiglottis - pyriform sinuses©2009. Nova Medical Centers. Strictly private and confidential – Skin flaps – Mucosal grafts
  56. 56. Group III Large mucosal lacerations • Situation 3 • Arytenoid cartilage dislocated – Reduce it back – Repair mucosa©2009. Nova Medical Centers. Strictly private and confidential
  57. 57. Group III Large mucosal lacerations • Reconstruct anterior commissure – 4-0 absorbable sutures from anterior TVC to outer perichondrium - keel • Close thyrotomy – Non absorbable sutures – SS wire – Wire tube tech.©2009. Nova Medical Centers. Strictly private and confidential • ORIF if required
  58. 58. ©2009. Nova Medical Centers. Strictly private and confidential Thank You
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