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Dr lalit-mohan-parashar laryngeal-surgery-an-overview-ncas_2011

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  • 1. Nova Medical Centers KAILASH COLONY©2009. Nova Medical Centers. Strictly private and confidential
  • 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. 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. 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. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  • 6. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  • 7. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy
  • 8. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy Room Normal larynx during phonation3.flv
  • 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. ©2009. Nova Medical Centers. Strictly private and confidential Video –endoscopy- stroboscopy
  • 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. ©2009. Nova Medical Centers. Strictly private and confidential Vocal Cord Growth
  • 13. ©2009. Nova Medical Centers. Strictly private and confidential Dysphonia Plica Venticulare
  • 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. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  • 16. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  • 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. 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. 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. 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. 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. 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. ©2009. Nova Medical Centers. Strictly private and confidential Microflap Excision
  • 24. ©2009. Nova Medical Centers. Strictly private and confidential Microdebrider
  • 25. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  • 26. ©2009. Nova Medical Centers. Strictly private and confidential Robotics
  • 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. ©2009. Nova Medical Centers. Strictly private and confidential Injection Medialisation
  • 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. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  • 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. ©2009. Nova Medical Centers. Strictly private and confidential Thyroplasty (Laryngeal Framework Surgery)
  • 33. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 34. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 35. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 36. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  • 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. 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. 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. 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. 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. 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. ©2009. Nova Medical Centers. Strictly private and confidential Laryngo Tracheal Trauma
  • 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. Group II Intact endolarynx + Displaced thyroid # • Open reduction + internal fixation ORIF • Method – Sutures©2009. Nova Medical Centers. Strictly private and confidential – Wires – Miniplates
  • 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. 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. 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. 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. 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. 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. 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. 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. Group III Large mucosal lacerations • Situation 3 • Arytenoid cartilage dislocated – Reduce it back – Repair mucosa©2009. Nova Medical Centers. Strictly private and confidential
  • 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. ©2009. Nova Medical Centers. Strictly private and confidential Thank You