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Nova Medical Centers                 KAILASH COLONY                    New Delhi©2009. Nova Medical Centers. Strictly priv...
LARYNGEAL SURGERY IS                                                                    WELL SUITED TO                    ...
The Problem                                                                 • Laryngeal Surgery involves airway           ...
The Problem                                                                 • Most of the ENT Surgery involves airway     ...
ENT Surgeries:-                                                   THROAT -:                                               ...
E.N.T. Surgery :-How can the patient go home ?
©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                                                            ...
E.N.T. Surgery :- Particularly Laryngeal Surgery                                                                 • There h...
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                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
FUNCTIONAL PRINCIPLES                                                                 • BLOOD IN CONTACT WITH CARTILAGE LE...
Extirpation Endolaryngeal Microsurgery                                                                 conventional micros...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
G.A. considerations                                                                 • Oral Intubation with MLS tube ( high...
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                                                            ...
Laryngeal Surgery is more than that.                                                                  Kotbys classificatio...
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...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
Laryngo Tracheal Trauma                                                                 • Increasing accidents            ...
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                       ...
Group III                                                                 Large mucosal lacerations                       ...
©2009. Nova Medical Centers. Strictly private and confidential                                                            ...
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Transcript of "Dr lalit-mohan-parashar laryngeal-surgery-well-suited-to-ambulatory-practice-ncas_2011"

  1. 1. Nova Medical Centers KAILASH COLONY New Delhi©2009. Nova Medical Centers. Strictly private and confidential
  2. 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. 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. 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. 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. 6. E.N.T. Surgery :-How can the patient go home ?
  7. 7. ©2009. Nova Medical Centers. Strictly private and confidential
  8. 8. ©2009. Nova Medical Centers. Strictly private and confidential E.N.T. Surgery :- •So What has changed ?
  9. 9. ©2009. Nova Medical Centers. Strictly private and confidential TELECOMMUNICATION E.N.T. Surgery :-So What has changed ?
  10. 10. ©2009. Nova Medical Centers. Strictly private and confidential E.N.T. Surgery :-So What has changed ? TRANSPORT
  11. 11. ©2009. Nova Medical Centers. Strictly private and confidential E.N.T. Surgery :- Particularly Laryngeal Surgery
  12. 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. 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. 14. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  15. 15. ©2009. Nova Medical Centers. Strictly private and confidential THE ENT OPD
  16. 16. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy
  17. 17. ©2009. Nova Medical Centers. Strictly private and confidential Endoscopy Room Normal larynx during phonation3.flv
  18. 18. ©2009. Nova Medical Centers. Strictly private and confidential Video –endoscopy- stroboscopy
  19. 19. ©2009. Nova Medical Centers. Strictly private and confidential Vocal Cord Growth
  20. 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. 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. 22. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  23. 23. ©2009. Nova Medical Centers. Strictly private and confidential Micro Laryngeal Surgery
  24. 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. 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. 26. ©2009. Nova Medical Centers. Strictly private and confidential Microflap Excision
  27. 27. ©2009. Nova Medical Centers. Strictly private and confidential Microdebrider
  28. 28. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  29. 29. ©2009. Nova Medical Centers. Strictly private and confidential Robotics
  30. 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. 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. 32. ©2009. Nova Medical Centers. Strictly private and confidential Injection Medialisation
  33. 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. 34. ©2009. Nova Medical Centers. Strictly private and confidential Laser Assisted
  35. 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. 36. ©2009. Nova Medical Centers. Strictly private and confidential Thyroplasty (Laryngeal Framework Surgery)
  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. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  41. 41. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  42. 42. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  43. 43. ©2009. Nova Medical Centers. Strictly private and confidential Medialisation Laryngoplasty
  44. 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. 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. 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. 47. ©2009. Nova Medical Centers. Strictly private and confidential Laryngo Tracheal Trauma
  48. 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. 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. 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. 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. 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. 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. 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. 55. ©2009. Nova Medical Centers. Strictly private and confidential Thank You
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