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Laryngeal framework surgery
This document provides an overview of laryngeal framework surgery techniques. It discusses the anatomy of the laryngeal cartilages and muscles involved in voice production. It then describes the history and types of thyroplasty procedures developed to improve voice, including type 1-4 thyroplasties. Type 1 involves medialization of the vocal fold while types 2-4 are used to expand, relax or increase tension on the vocal folds. Other techniques discussed include arytenoid adduction, thyroarytenoid myomectomy, cricothyroid approximation and femlar surgery. Complications and limitations of the procedures are also summarized.
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Laryngeal framework surgery
- 1. Laryngeal Framework Surgery DR SAFIKAZAMAN DEPT OF ENT & HNS RKMSP, VIMS
- 2. Introduction Voice –identity of a person. Production of voice Pulmonary reserve. Resonance created in the nose , PNS, oral cavity and pharynx. Movement of cord, shape , size and structural integrity of cord.
- 3. History 1911- Brunnings, made the 1st attempt to medialize vocal fold by injecting paraffin. 1915- Payr – pedicle flap of cartilage. 1974- Isshiki –proposed different type of thyroplasty for different dysphonia. http://www.entandaudiologynews.com/
- 4. Definition Surgical proceduresperformed on the laryngeal skeleton and the insertion of muscles to correct vocal fold positioning and tension. Objective: improve the voice without directly intervening in the vocal folds.
- 5. Laryngeal framework Cartilages Ligaments Membranes Muscles
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- 7. Thyroid cartilage Mostprominent cartilage Two laminae Thyroid notch Superior and inferior cornua Vocal fold lies closer to the inferior border of the thyroid cartilage
- 8. Muscles The intrinsicmuscles- 1. adductors 2.abductors 3. tensor Adductors – lateral cricoarytenoid, thyroarytenoid, interarytenoid. Abductor – posterior cricoarytenoid Tensor – cricothyroid
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- 10. Europian laryngological society classification Approximationlaryngoplasty Type 1 Thyroplasty with or without arytenoid adduction Expansion laryngoplasty Type 2 Thyroplasty Relaxation laryngoplasty Type 3 Thyroplasty Tensioning laryngoplasty Type 4 Thyroplasty
- 11. Approximation laryngoplasty /Type 1 thyroplasty Indications: - Symptomatic glottic insufficiency (dysphonia, aspiration). U/L vocal fold paralysis. Vocal fold atrophy, including age related atrophy. Vocal fold bowing due to ageing and cricothyroid joint fixation. Sulcus vocalis - Soft tissue defect resulting from excision of pathological masses. Contraindications: -Malignant disease overlying laryngotracheal complex. -Poor abduction of C/L vocal fold. -h/o radiation therapy to larynx.
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- 14. Treatment options forunilateral VFP Observation Voice therapy Surgical intervention Injection augmentation Laryngeal frame work surgery Re-innervation
- 15. Procedure Positioning Anasthesia Thyroid cartilage is palpated Midline is also marked on the chin, neck and sternal notch. Incision -horizontal with about 3-4 cm Thyroid cartilage widely exposed
- 16. Type 1 thyroplastywindow
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- 19. Cont.. Textbook of Laryngology– N K Narukar, A Roychoudhury
- 20. Complication Penetration ofendo-laryngeal mucosa - assess air leak before placement of implant in window. Wound infection – Chondritis. Airway obstruction – overnight monitoring is required. Implant extrusion-Can become displaced and even extrude into the airway.
- 21. Limitation Mechanical natureof the procedure. Imparts only static change to laryngeal framework with no effect on dynamic function. No effect on vocal fold muscle mass, innervation and mobility. Closure of posterior glottis limited. No effect on vocal fold level in vertical plane.
- 22. Adduction of arytenoid Lower the vocal process Stabilize and medialize the vocal process Suture mimics TA-LCA muscle complex . Textbook of Laryngology – N K Narukar, A Roychoudhury
- 23. Expansion laryngoplasty Indication -adductor spasmotic dysphonia( involuntary muscle spasms in the intrinsic muscles of larynx). Treatment options – botulinum toxin injection , recurrent nerve avulsion and expansion laryngoplasty
- 24. Type 2 thyroplasty– lateral approach purpose of this procedure is to increase the transverse diameter of the thyroid cartilage, extending the glottic space. Catani GSA, Catani MEC, Kinasz LRS, et al. Laryngeal framework surgery. J Otolaryngol ENT Res. 2020;12(5):151‒154
- 25. Type 2 Thyroplasty– medial approach Thyroid cartilage is split in the midline. Split ala kept apart with the help of 3 mm sialastic shims or titanium miniplate. Catani GSA, Catani MEC, Kinasz LRS, et al. Laryngeal framework surgery. J Otolaryngol ENT Res. 2020;12(5):151‒154
- 26. Thyroarytenoid myomectomy Endoscopicor open approach Vocal cord abduction by suture method Partial arytenoidectomy
- 27. Advantage and disadvantageof type 2 Advantages: Optimal glottal closure can be adjusted and readjusted - No damage of physiologic function - Reversible Disadvantages: Technically difficult Shim displacement Does not relieve cause of Spasmodic Dysphonia.
- 28. Relaxation laryngoplasty Tensionof the vocal folds reduced by antero-posterior shortening of thyroid ala. Lowers the pitch.
- 29. Relaxation laryngoplasty Indication– 1.Males with high pitch voice resistant to voice therapy.( Puberphonia/ Mutational falsetto) 2. Stiff VF with high pitched breathy voice. 3. Spastic dysphonia
- 30. Cont … Lateral approach: ( Type III) Thyroid ala is incised at about junction of anterior and middle one third, and 2-5 mm cartilage strip is excised.
- 31. Cont… Medial approach:( Anterior commissure retrusion) - Retrusion of the middle portion of the thyroid cartilage and leads to reduction in the length of vocal folds. - Vertical incision was made either side of the midline of the thyroid cartilage.
- 32. Type 4 thyroplasty Increases the vocal pitch. It increases the distance between the vocal fold attachments and thus raise the tension of vocal fold. Indications: Androphonia -Abnormally low pitched voice in female. - Male to female trans-sexualism - Abnormallly lax or bowed vocal folds (presbyphonia)
- 33. Cricothyroid approximation CricothyroidApproximation : - increases vocal pitch by simulating the contraction of cricothyroid muscle with sutures. The cricoid and thyroid cartilage is approximated as closely as possible. Non absorbable monophilic sutures are placed to draw the cricoid and thyroid cartilages together.
- 34. Anterior commissure advancement Potentiallythe comfortable speaking pitch is higher . Catani GSA, Catani MEC, Kinasz LRS, et al. Laryngeal framework surgery. J Otolaryngol ENT Res. 2020;12(5):151‒154
- 35. Webbing of theant vocal fold Microlaryngoscopy under general anaesthesia. Vocal fold mucosa from ant half of vocal fold removed, then sewn together. https://els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/c1e59191-23f6-4dfd-b306- d6018364c3e1/gr1.jpg
- 36. Femlar Anterior 25%of false cords and 50% of true cords are removed Upper part of thyroid cartilage removed Larynx suspended high in the neck by sutureing to hyoid bone Advantage: physical size and location of the larynx in the neck is close approximation of a female larynx.
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