This document provides an overview of laryngeal surgery. It discusses various problems affecting the larynx that may require surgery, including hoarseness, breathing difficulties, and cancers. Effective diagnosis involves examination in the ENT clinic and use of endoscopy with or without stroboscopy. Surgeries described include extirpation of lesions, vocal fold augmentation, repositioning, and framework manipulation. Complicated cases like laryngotracheal trauma are also discussed, along with approaches for managing different types and severities of injury. The goal of surgical techniques is to restore normal laryngeal function and cover exposed cartilage to prevent resorption or granulation.

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KAILASH COLONY
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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.
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4. Effective Diagnosis
• Begins at OPD
• Clinched in Endoscopy Rooms
• Confirmed with/ without Stroboscopy &
• Refined in Voice Lab
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THE ENT OPD

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THE ENT OPD

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Endoscopy

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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
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Video –endoscopy- stroboscopy

11. Recording and Replay
• Much More Informative.
• Longitudinal Comparison
• Pre-op planning
• Patient Education
• Medical / Legal uses
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Vocal Cord Growth

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Dysphonia Plica Venticulare

14. Laryngeal Surgery
Kotby's 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
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Micro Laryngeal Surgery

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Micro Laryngeal Surgery

17. Extirpation Endolaryngeal Microsurgery
conventional microsurgery(MLS)
• Indications:
• Congenital Lesions:
• Sulcus vocalis & vergeture. Laryngeal web
• Epidermoid cysts & laryngoceles. Laryngeal
stenosis
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• 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
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19. Tube Position
• Anterior Vocal cords 2/3rd :- small ETT
• Posterior Vocal Cords :- Anterior ETT or
» Jet Ventillation or
» Apneic Techniques
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20. Other Considerations
• Laser Protected ETT
• Care of Sub Glottis and
• Care of tracheal Stoma
• Difficult Per Oral exposure
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21. Difficult Per Oral exposure
• Short Thick Neck
• Retrognathia
• Trismus
• Restricted Neck Extention
• Lingual Hypertrophy
• Poor Palatal visualisation
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22. Long list of requirements
• Largest Bore Laryngoscope + ant. & post. Comm.
• Suspension Systems
• Specialized Instruments
• Mouth/ dental Guard
• Subepithelial Infusion needle
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• Operating Microscope – 400mm lense
• Optical Telescope – 4mm x 20 cms
• Microdebrider/ laser system

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Microflap Excision

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Microdebrider

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Laser Assisted

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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.
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• Transoral or percutaneous approaches.
• Silicon, Teflon, Gelfoam, Autologous Fat

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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.
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Sharp dissection
Laser excision.

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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).
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Thyroplasty
(Laryngeal Framework Surgery)

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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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
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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.
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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.
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• Anterior commissure advancement.

43. Laryngeal Surgery
Kotby's classification
1. Extirpation endolaryngeal microsurgery.
2. Vocal fold augmentation.
3. Vocal fold repositioning.
4. Neurophonosurgery.
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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
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• Ansa cervicalis to RLN anastomosis
• Infrathyroid - suprathyroid techniques
• Neuromuscular pedicle Transplantation.

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Laryngo Tracheal Trauma

46. Laryngo Tracheal Trauma
• Increasing accidents
• Time to prepare ourselves is NOW
• Minor Ones or Group I need conservative management
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47. Group II
Intact endolarynx + Displaced thyroid #
• Open reduction + internal fixation ORIF
• Method
– Sutures
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– Wires
– Miniplates

48. Group II
Intact endolarynx + Displaced thyroid #
• ORIF
• AIM – preservation of AP diameter
Maintain Normal position of cords
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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
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50. Group III
Large mucosal lacerations
• AIM
– Return all remaining tissue to appropriate location
– Cover all cartilage
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• 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
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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
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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
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• 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
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– 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
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– Skin flaps
– Mucosal grafts

56. Group III
Large mucosal lacerations
• Situation 3
• Arytenoid cartilage dislocated
– Reduce it back
– Repair mucosa
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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.
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• ORIF if required

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Thank You