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Dr lalit-mohan-parashar laryngeal-surgery-well-suited-to-ambulatory-practice-ncas_2011
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Dr lalit-mohan-parashar laryngeal-surgery-well-suited-to-ambulatory-practice-ncas_2011

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  • 1. Nova Medical Centers KAILASH COLONY New Delhi©2009. Nova Medical Centers. Strictly private and confidential
  • 2. LARYNGEAL SURGERY IS WELL SUITED TO AMBULATORY PRACTICE©2009. Nova Medical Centers. Strictly private and confidential Dr. Lalit Mohan Parashar Deptt of Otorhinolaryngology and Dr. Lalit Mohan Parashar Senior Consultant OTORHINOLARYNGOLOGY & Head & Neck SURGERY HEAD and NECK Surgery (ORL&HNS)
  • 3. The Problem • Laryngeal Surgery involves airway • And thereby the problems • Requiring immediate solutions • Trained staff • Tracheostomy may be required©2009. Nova Medical Centers. Strictly private and confidential
  • 4. The Problem • Most of the ENT Surgery involves airway • And thereby the problems • Requiring immediate solutions • Trained staff • Tracheostomy may be required©2009. Nova Medical Centers. Strictly private and confidential
  • 5. ENT Surgeries:- THROAT -: Nose -: EAR -: Tonsillectomy- Adenoidectomy- endoscopic Septoplasty- guidance to ensure complete Septorhinoplasty- removal Cochlear Implants - Micro-Laryngeal Surgeries- Myringotomy and Grommet Uvulo – Palatoplasty- insertion- Tympanoplasties- Functional Endoscopic Sinus treatment of snoring/ OSA Stapedectomy with piston Surgery- polyposis Obstructive Sleep Apnoea placement Mastoidectomy- Trans Nasal Neuro Pharyngoplasty- Sac Decompression- Facial Surgeries- including pituitary Laryngofissure and other Nerve Decompression and tumours and skullbase voice box surgeries repair. surgery Tracheal Surgeries Optic Nerve Decompression- Orbital decompression- Endoscopies: Head & Neck Surgeries –©2009. Nova Medical Centers. Strictly private and confidential Parotidectomy laryngoscopy, Sub- Mandibular Excision Neck Dissections bronchoscopy Thyroidectomies oesophagoscopy and Parathyroidectomies nasopharyngoscopy with flexible fibreoptic or rigid scopes.
  • 6. E.N.T. Surgery :-How can the patient go home ?
  • 7. ©2009. Nova Medical Centers. Strictly private and confidential
  • 8. ©2009. Nova Medical Centers. Strictly private and confidential E.N.T. Surgery :- •So What has changed ?
  • 9. ©2009. Nova Medical Centers. Strictly private and confidential TELECOMMUNICATION E.N.T. Surgery :-So What has changed ?
  • 10. ©2009. Nova Medical Centers. Strictly private and confidential E.N.T. Surgery :-So What has changed ? TRANSPORT
  • 11. ©2009. Nova Medical Centers. Strictly private and confidential E.N.T. Surgery :- Particularly Laryngeal Surgery
  • 12. E.N.T. Surgery :- Particularly Laryngeal Surgery • There have been certain advances:- • 1. In Diagnosis • 2. In understanding Disease • 3. In the Technology in Surgery • 4. Others©2009. Nova Medical Centers. Strictly private and confidential
  • 13. 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
  • 14. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  • 15. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  • 16. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy
  • 17. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy Room Normal larynx during phonation3.flv
  • 18. ©2009. Nova Medical Centers. Strictly private and confidential Video –endoscopy- stroboscopy
  • 19. ©2009. Nova Medical Centers. Strictly private and confidential Vocal Cord Growth
  • 20. 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
  • 21. 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. •
  • 22. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  • 23. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  • 24. 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 1. Predictable Post op/ recovery 2. Hypotensive Anaesthesia
  • 25. 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
  • 26. ©2009. Nova Medical Centers. Strictly private and confidential Microflap Excision
  • 27. ©2009. Nova Medical Centers. Strictly private and confidential Microdebrider
  • 28. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  • 29. ©2009. Nova Medical Centers. Strictly private and confidential Robotics
  • 30. Laryngeal Surgery is more than that. Kotbys classification 1. Extirpation endolaryngeal microsurgery. 2. Vocal fold augmentation. 3. Vocal fold repositioning. 4. Neurophonosurgery. 5. Glottal reconstruction after partial laryngectomy.©2009. Nova Medical Centers. Strictly private and confidential 6. Postlaryngectomy surgery. 7. Laryngo Tracheal Trauma
  • 31. 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
  • 32. ©2009. Nova Medical Centers. Strictly private and confidential Injection Medialisation
  • 33. 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.
  • 34. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  • 35. 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
  • 36. ©2009. Nova Medical Centers. Strictly private and confidential Thyroplasty (Laryngeal Framework Surgery)
  • 37. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 38. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 39. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 40. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 41. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 42. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 43. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 44. 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.
  • 45. 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
  • 46. 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.
  • 47. ©2009. Nova Medical Centers. Strictly private and confidential Laryngo Tracheal Trauma
  • 48. 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
  • 49. 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
  • 50. 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
  • 51. 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
  • 52. 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
  • 53. 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
  • 54. 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
  • 55. ©2009. Nova Medical Centers. Strictly private and confidential Thank You