ENT Güncelleme Tarihi: 07 Mayıs 2019

Microlaryngoscopy

 

  • Definition
  • Presurgery
  • Risks
  • Consent
  • Surgery
  • Recovery
  • Pain
  • Instructions during healing
  • References

 

Endoscopic Cordectomy
Overview
Pre-procedure
Technique
Post-procedure

 

1. Myringotomy & insert of tube through tympanic membrane (bilateral)
Overview
A myringotomy is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid or to drain pus from the middle ear.
A tympanostomy tube is inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks. Depending on the type of tube used, it is either naturally extruded in 6 to 12 months or removed during a minor procedure.
Those requiring myringotomy usually have an obstructed or dysfunctional Eustachian tube that is unable to perform drainage or ventilation in its usual fashion. Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe acute otitis media (middle ear infection).

 

Indications

There are numerous indications for tympanostomy in the pediatric age group, the most frequent including chronic otitis media with effusion (OME) which is unresponsive to antibiotics, and recurrent otitis media. Adult indications differ somewhat from the pediatric population and include Eustachian tube dysfunction with recurrent signs and symptoms, including fluctuating hearing loss, vertigo, tinnitus, and a severe retraction pocket in the tympanic membrane. Recurrent episodes of barotrauma, especially with flying, diving, or hyperbaric chamber treatment, may merit consideration.

 

Procedure
Myringotomy is usually performed as an outpatient procedure. General anesthesia is preferred in children, while local anesthesia suffices for adults. The ear is washed and a small incision made in the eardrum. Any fluid that is present is then aspirated, the tube of choice inserted, and the ear packed with cotton to control any slight bleeding that might occur. This is known as conventional (or cold knife) myringotomy and usually heals in one to two days.
A new variation (called tympanolaserostomy or laser-assisted tympanostomy) uses CO2 laser, and is performed with a computer-driven laser and a video monitor to pinpoint a precise location for the hole. The laser takes one tenth of a second to create the opening, without damaging surrounding skin or other structures. This perforation remains patent for several weeks and provides ventilation of the middle ear without the need for tube placement.
Though laser myringotomies maintain patency slightly longer than cold-knife myringotomies (four weeks for laser and two to three days for cold knife without tube insertion) [9], they have not proven to be more effective in the management of effusion. One randomized controlled study found that laser myringotomies are safe but less effective than ventilation tube in the treatment of chronic OME.[10] Multiple occurrences in children, a strong history of allergies in children, the presence of thick mucoid effusions, and history of tympanostomy tube insertion in adults, make it likely that laser tympanostomy will be ineffective.
Various tympanostomy tubes are available. Traditional metal tubes have been replaced by more popular silicon, titanium, polyethylene, gold, stainless steel, or fluoroplastic tubes. More recent ones are coated with antibiotics and phosphorylcholine.

 

Complications
The placement of tubes is not a panacea. If the middle ear disease has been severe or prolonged enough to justify tube placement, there is a strong possibility that the child will continue to have episodes of middle ear inflammation or fluid collection. There may be continued drainage through the tube (tube otorrhea) in about 15% of patients for the first two weeks after placement, and in 30% beyond that. Otorhea is considered to be secondary to bacterial colonization. The most commonly isolated organism is Pseudomonas aeruginosa, while the most troublesome is Methicillin-resistant Staphylococcus aureus (MRSA). Some practitioners use topical antibiotic drops in the postoperative period, but research shows that this practice does not eradicate the bacterial biofilm.

 

Efficacy
Evidence suggests that tympanostomy tubes only offer a short-term hearing improvement in children with simple OME who have no other serious medical problems. No effect on speech and language development has yet been shown.

 

2. Endoscopic sinus surgery (functional surgery)
A basic knowledge of the anatomy and physiology of the nose and sinuses is necessary to understand nasal and sinus disorders.
The nose and sinuses are a part of the upper respiratory tract. The three-dimensional anatomy of this area is complex. The function of the nose in addition to smell is to warm, humidify and filter air that passes through it. The external nose consists of a bony and cartilaginous framework. The nostrils, or anterior nares, form the external opening to the nose. The nasal septum is a midline internal structure that separates the left and right nasal cavities. It is composed of cartilage and bone. A deviated nasal septum can cause nasal obstruction.

 

There are four sets of paired sinuses. The maxillary sinuses are located beneath the cheeks and under the eyes. The frontal sinuses are above the eyes behind the forehead. The ethmoids are honeycomb shaped sinuses located between the eyes and the sphenoid sinuses are located behind the nose and below the brain. Each of these sinuses is an enclosed space that drains through an ostium or opening into the nose. The sinuses are lined by mucosa that is similar to the lining of the nose. These ostia can become blocked by inflammation or swelling of the mucosa as well as by tumors or bony structures.

 

The lateral nasal wall internally contains the three turbinate bones. These scroll-like structures are covered in a mucous membrane that contains vascular channels which can swell under certain conditions, such as allergy or inflammation. The tear duct or nasolacrimal duct drains tears from the eyes into the nose where it enters beneath the inferior turbinate. Blockage of this duct from injury or disease causes excess tearing of the eye, or epiphora. The middle meatus is a space under the middle turbinate. Within the middle meatus is the osteomeatal complex which is the common pathway for the drainage of the maxillary (cheek) sinus, frontal (forehead) sinus, and anterior ethmoid sinus. Inflammation or swelling of these key areas may cause blockage of the sinuses.

 

The superior turbinate is a small structure located high in the nose. Behind the superior turbinate is the opening of the sphenoid sinus, located near the back portion of the septum. The pituitary gland is located directly above and behind the sphenoid sinus. Pituitary surgery is performed through the sphenoid sinus.
Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical treatment of sinusitis and nasal polyps, including bacterial, fungal, recurrent acute, and chronic sinus problems. Ample research supports its record of safety and success.

Technique
Telescopes with diameters of 4mm (adult use) and 2.7mm (pediatric use) and with a variety of viewing angles (0 degrees to 30, 45, 70, 90, and 120 degrees) provide good illumination of the inside of the nasal cavity and sinuses. High definition cameras, monitors and a host of tiny articulating instruments aid in identifying and restoring the proper drainage and ventilation relationships between the nose and sinus cavities. Cultures (putting abnormal sinus secretions into an incubator to check for bacteria and fungi) and biopsies (examining small bits of tissue under a microscope) can be easily obtained to yield valuable diagnostic information to guide postoperative therapy for optimal long term results.

 

All the sinuses can be accessed at least to some degree by means of this surgery: The frontal sinuses located in the forehead, the maxillary sinuses in the cheeks, the ethmoid sinuses between the eyes, and the sphenoid sinuses located in the back of the nasal cavity at the base of the skull.

 

CT Navigation
Computed tomography (CT) navigation is a tool that may be used by surgeons to better correlate surgical anatomy with pre-operative CT imaging. A computer is used to identify the 3-dimensional location of a probe tip placed within the patient’s nose or sinuses. Bleeding, disease processes and anatomical variants among individuals can alter a surgeon’s view of landmarks during surgery. Hence, CT-navigational assistance in sinus surgery is used to improve anatomical identification and avoid damage to vital neighboring structures such as the brain and eyes.
Definitive proof that CT navigation improves outcomes and decreases complications is lacking.
Complications
Extreme care is required with this surgery due to the proximity of the sinuses to the eyes, optic nerves, brain and internal carotid arteries. However, these possible serious risks are rare occurrences and there are potentially many benefits from a well-performed endoscopic sinus surgery with appropriate indications. While a surgeon must have adequate training and experience to manage the procedure, endoscopic sinus surgery is one of the most common procedures performed day to day by the average ear, nose and throat specialist physician in private practice.

 

Tonsillectomy
Tonsillectomy is a 3,000-year-old surgical procedure in which, traditionally, each tonsil is removed from a recess in the side of thepharynx called the tonsillar fossa. The procedure is performed in response to repeated occurrence of acute tonsillitis, obstructive sleep apnea, nasal airway obstruction, diphtheria carrier state, snoring, or peritonsillar abscess. For children, the adenoids are removed at the same time, a procedure called adenoidectomy, or tonsilloadenoidectomy, when combined. Adenoidectomy is uncommon in adults in whom the adenoids are usually vestigial.

 

Indications

 

Most recently, American Academy of Otolaryngology-Head and Neck Surgery Foundation has published clinical practice guidelines.The panel made a strong recommendation for:

 

    1. Watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years;
    2. Assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess;
    3. Asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems;
    4. Counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing;
    5. Counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management;
    6. Advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and
    7. Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.

Morbidity and Mortality

 

The morbidity rate associated with tonsillectomy is 2% to 4% due to post-operative bleeding;

the mortality rate is 1 in 15,000, due to bleeding, airway obstruction, or anesthesia complications.

 

Post-operative care

 

A sore throat will persist approximately two weeks following surgery while pain following the procedure is significant and may necessitate a hospital stay.Recovery can take from 7 to 10 days and proper hydration is very important during this time, since dehydration can increase throat pain, leading to a vicious circle of poor fluid intake.

At some point, most commonly 7–11 days after the surgery (but occasionally as long as two weeks (14 days) after), bleeding can occur when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1%–2%. It is higher in adults, especially males over age 70 and three quarters of bleeding incidents occur on the same day as the surgery.Approximately 3% of adult patients develop significant bleeding at this time which may sometimes require surgical intervention.

 

Post-operative pain relief is subject to change. Traditionally, pain relief has been provided by relatively mild narcotic analgesics such as Acetaminophen with codeine, for milder pain, and stronger narcotic analgesics for more severe pain. Recently (January 2011), the FDA reduced the recommended total 24 hour dose because of concern about liver toxicity from the Acetominophen component. An alternative is the use of non-steroidal anti-inflammatory agents, themselves giving rise to concerns that their effect on platelets might increase the risk of post-operative bleeding.In turn, this has renewed interest in techniques other than traditional ‘extra-capsular excision’ in the hope that post-operative pain might be reduced.

 

Tonsillectomy appears to be more painful in adults than children, although there will be individual variations in response.

 

Surgical Procedure

 

For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding fascia, a so-called ‘total’ , or extra-capsular tonsillectomy. Problems include pain and bleeding leading to a recent resurgence in interest in sub-total tonsillectomy or ‘tonsillotomy’ which was popular 60-100 years ago, in an effort to reduce these complications.The generally accepted procedure for ‘total’ tonsillectomy uses a scalpel and blunt dissection or electrocautery, although harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation by sutures, and the topical use of thrombin, a protein that induces blood clotting.

 

It has already been stated that the benefits of tonsillectomy for sore throat are controversial and time limited. Consequently, the main question of importance becomes whether or not the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. It appears that this may be the case although most observers agree that further time and study is required.

 

Other Methods

 

The scalpel is the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other techniques and a brief review of each follows:

Dissection and snare method: Removal of the tonsils by use of a forceps and scissors with a wire loop called a ‘snare’ was formerly the most common method practiced byotolaryngologists, but has been largely replaced in favor of other techniques. The procedure requires the patient to undergo general anesthesia; the tonsils are completely removed and the remaining tissue surface is cauterized. The patient will leave with minimal post-operative bleeding.

 

Electrocautery: Electrocautery uses electrical energy to separate the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400°C) may result in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.

 

Thermal Welding: A new technology which uses pure thermal energy to seal and divide the tissue. The absence of thermal spread means that the temperature of surrounding tissue is only 2-3 °C higher than normal body temperature. Clinical papers show patients with minimal post-operative pain (no requirement for narcotic pain-killers), zero edema (swelling) plus almost no incidence of bleeding. Hospitals in the US are advertising this procedure as “Painless Tonsillectomy”. Also known as Tissue Welding.

 

Carbon dioxide laser: Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils. The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in 2-5% of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are averse to outpatient procedures without sedation.

 

Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device. The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule.

 

A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.

 

Tympanoplasty

 

Tympanoplasty can be performed through the ear canal (trascanal approach), through an incision in the ear (endaural approach) or through an incision behind the ear (postaurciular approach).

 

A graft may be taken to reconstruct the tympanic membrane. Common graft sites include the temporalis fascia and the tragus.

 

The surgery takes ½ to 1 hour if done through the ear canal and 2⅓ to 3 hours if an incision is needed. It is done under local or general anesthesia. It is done on an inpatient or day case basis and is successful 85-90% of the time.

 

Mastoidectomy

 

A Mastoidectomy is a procedure performed to remove the mastoid air cells. This can be done as part of treatment for mastoiditis, chronic suppurative otitis media or cholesteatoma. In addition, it is sometimes performed as part of other procedures (cochlear implant). There are essentially 5 different types of Mastoidectomy:

 

    1. Radical Mastoidectomy – Removal of posterior and superior canal wall, meatoplasty and exteriorisation of middle ear.
    2. Canal Wall Down Mastoidectomy – Removal of posterior and superior canal wall, meatoplasty. Tympanic membrane left in place.
    3. Canal Wall Up Mastoidectomy – Posterior and superior canal wall are kept intact. A facial recess approach is taken.
    4. Cortical Mastoidectomy (Also known as schwartze procedure) – Removal of Mastoid air cells is undertaken without affecting the middle ear. This is typically done for mastoiditis
    5. Modified Radical Mastoidectomy – This is confusing because it is typically described as a radical mastoidectomy while maintaining the posterior and superior canal wall which reminds the reader of the Canal Wall Up Mastoidectomy. However, the difference is historical. Modified radical mastoidectomy typically refers to Bondy’s procedure which involves treating disease affecting only the epitympanum. Diseased areas as well as portions of the adjacent superior and posterior canal are simply exteriorised without affecting the uninvolved middle ear.

Microlaryngoscopy

 

Surgical microlaryngoscopy

 

Information for patients considering a microscopic surgery on their vocal folds

 

  • Definition
  • Presurgery
  • Risks
  • Consent
  • Surgery
  • Recovery
  • Pain
  • Instructions during healing
  • References

 

Definition

 

Microlaryngoscopy is a procedure that means the vocal folds are looked at in great detail with magnification. The magnification may be with a microscope, endoscope or by video enlargement. It is often accompanied by some additional procedure such as removal of a mass, swelling or tumor. Long delicate instruments or a laser may be utilized. It is sometimes performed in the office, though more typically it is performed in the operating room.

 

Presurgery

 

Before the surgery, a PARQ conference is held with you. This is an acronym for Procedures, Alternatives, Risks and Questions. It means your surgeon has discussed with you in full detail the reasons for going to surgery and that you are satisfied with those reasons. The surgeon generally needs to see you within a week or two prior to surgery since your problem may have changed, especially if there has been a long interval between the exam and a surgery. There is nothing quite like going to sleep, not needing surgery and getting charged a few thousand dollars for that brief sleep – I don’t think you even get a good dream out of it. You can go over any questions during this pre-surgery visit as well as again on the morning before surgery in the pre-surgery waiting area.

 

Risks

 

The main risks of the procedure are anesthesia, chipping a tooth, a sore or numb tongue, and a less-than-expected beneficial outcome. Other potential risks could be bleeding, infection, or breathing difficulties. If a laser is used, additional risks should be mentioned.

 

  • Anesthesia
  • The risk of anesthesia is that you would have a major life threatening reaction to some medication. This is very uncommon and I would compare it to getting in your car and driving some distance with the risk of an accident and dying. Even though the risk is serious, it is apparently, acceptably small, as most of us continue to drive. In the case of surgery, you even have the added benefit of life support equipment and trained personnel standing by. Still it is a risk for you to consider.
  • If you have no teeth the worst you can expect is a sore upper gum. For others, when the laryngoscope is inserted it puts pressure on the upper jaw. Several variables enter into the amount of pressure put on your upper teeth. The bigger your tongue, the narrower your lower jaw, the greater your overbite, the tighter the fit may be and the more pressure on your upper teeth. Additionally, if you have spent your children’s inheritance on caps on your incisors, you may be at additional risk since they may be a little weaker. Large cavities or other degradation of your tooths strength may put you at risk for a chip. All this, even though your surgeon will likely place some type of plastic or rubber guard over your upper teeth. This is an uncommon complication, happening perhaps once a year or less in the surgeons I know.
  • The opposing pressure to your upper teeth is the tongue. It gets pinched between the laryngoscope and the lower jaw. Often, it gets pushed more toward one side. Just like your leg going to sleep, the nerve to one or both sides of your tongue may fall asleep from the pressure on it. In my experience, this happens to perhaps 20% (a guess) of people and may last for several weeks. My experience has also been that normal sensation eventually returns to the tongue.
  • Unfortunately, your body is not a car and we cannot go to the body shop and just put on a brand new fender. The surgeons skills, your bodys healing capabilities, tendency to scar and the type of disease present all enter into the equation of that attempted perfect result. Therefore, while everyone; surgeon, anesthesiologist, nurses and other staff strive to provide excellent care, in all likelihood perfection is tempered by the human condition. Still many results are excellent, some are good and rarely the outcome is poor. Your surgeon will likely temper your expectations based on the type of disease being treated as that has a major effect on the expected outcome.
  • This has not been a significant risk in my experience. Anytime a cut is made; there is the risk of bleeding. If you are on any medication that may thin the blood, that can increase the risk. Examples of medications that might prolong bleeding include Coumadin, aspirin or even vitamin E. You should go over all medications that you take with your physician before surgery. Even given these risks, the cuts in microlaryngoscopy are typically exceedingly small and though under the microscope, it may look like a lot, it is typically miniscule. The exception might be in the case where you have some unusual tumor made up of blood vessels.
  • This almost seems like a theoretical risk, it has been so uncommon in my experience. Certainly, any time a cut is made, that becomes a route for bacteria to potentially enter into the body. For some reason this is extremely rare in laryngoscopy. Perhaps because the cuts are small, perhaps because the upper airway has a very good defense system. Still, it is possible.
  • This has been much less common in my experience than it would seem to be based on logic. The voice box and windpipe are of a limited size and even the somewhat common infection of laryngitis can occasionally turn severe enough to make breathing difficult. There is almost always some swelling after working on the voice box. Your surgeon will usually be able to predict the risk based on how much is being done. Medications, particularly steroids, can help decrease swelling if it occurs.
  • The laser is a wonderful, precise tool that cuts and stops bleeding at the same time. This controlled burn can cause harm. Many safety measures have been put in place because of the laser’s capabilities. Because of these safety measures, the risk of a complication is very small, but here are some of the potential risks. The typical laser used is the CO2 laser; other types of lasers may have special roles. The CO2 laser can injure the eye, so the eyes of the staff and the patient are covered with protective eye gear. If inadvertently fired, the laser will burn whatever it contacts. Therefore, everything near the laryngoscope is typically covered with wet towels. Since the breathing tube contains oxygen, it is at particular risk of burning. Special (read expensive) tubes have been designed that have a protective metal or other coating on them. Your anesthesiologist will use the lowest concentration of oxygen possible during lasering. The surgeon may put wet cotton sponges behind the vocal folds to catch any stray laser beams. You might wonder how could my surgeon miss my vocal folds? Even though you are asleep, you are still breathing and that generates some movement that can be significant under the microscope or the lesion to be removed may be on the very edge of the vocal fold and the last cut will pass out the backside of the fold. Still, the laser is a safe tool when used properly.

 

  • Chipped tooth
  • Numb tongue
  • Less-than-expected beneficial outcome
  • Bleeding
  • Infection
  • Breathing difficulties
  • Laser complications

 

Consent

 

I will ask you to sign an informed consent form before going to surgery.

 

Surgery

 

Anesthesia

 

When microlaryngoscopy is performed in the operating room, it is usually done with the patient asleep. You may hear by phone from your anesthesiologist the night before or you may meet him/her the morning of surgery. You should tell them of any problems you have had in the past or any concerns you have about having anesthesia. In particular, if you have had trouble with nausea or vomiting in the past, your anesthesiologist may be able to adjust your medications to decrease the chance of stomach acid irritating your vocal folds as it comes back up.

 

Preanesthesia room

 

In the preanesthesia area, you get to wear that famous “open back” gown. You will be there for about an hour answering many questions for the tenth or perhaps the twentieth time. You learn that you actually lead a very interesting life judging from the thickness of the stack of papers representing you in the medical record. From there, you leave your family and ride on your back, staring at the ceiling, to the operating room.

 

The operating room

 

The operating room table is often pre-chilled (I warned you). You will be put to sleep with medicine through a vein and may have a mask on to breathe some oxygen while falling asleep. After you are asleep, your head is tipped quite far back. The surgeon sits at the head of the table, essentially above your head. An instrument called a laryngoscope is inserted through your mouth so the surgeon can see down your throat past the back of your mouth. The laryngoscope is a hollow metal tube that when placed in the proper position allows a direct view of your voice box. It pushes the teeth and the tongue out of the way. To protect your teeth from chipping, a rubber or plastic tooth guard is placed over your upper teeth. Your neck is extended so that the surgeon has a view straight down your throat from above. It is a bit like sword swallowing. Your eyes are closed and padded for protection.

 

If the laser is used, wet towels are placed over and cover your face completely to absorb the laser beam if inadvertently fired. The surgery is delicate and a bit tedious but not difficult. It may take about an hour to perform a typical surgery, though this varies a lot. Many types of procedures can be performed during a microlaryngoscopy. Some typical procedures would include using long (about 12 inches) delicate forceps to grasp and hold a nodule. Then microscissors are used to remove the bump.

 

Sometimes fluid is injected into the vocal fold to push a surface bump away from the underlying structures before it is cut. The laser may be used to vaporize an unwanted blood vessel. A tumor may be cut out with the laser. Scar tissue may be cut with a knife, fat may be implanted, the incision in the vocal fold may be left open, and in uncommon cases, it may be sewn shut. A biopsy or small sample may be taken to find out what disease is present. I cannot personally think of an occasion to strip a vocal fold. Use caution, if you hear that term. That procedure can cause more harm than good.

 

Recovery

 

You wake up rather quickly and find yourself still in the operating room or in the recovery room. You stay in the recovery room until the nurses and anesthesiologist are certain the majority of the anesthetic is gone from your system. You then return to the day surgery area where you started. When you can stand steadily, keep liquids down without nausea or vomiting and can go to the bathroom (essential human activities) you may go home. The whole process takes up a good part of the day.

 

Pain

 

Typically there is minimal pain after surgery. Since this varies from person to person and procedure to procedure, I prescribe Vicodin. Vicodin is essentially Tylenol and a narcotic, hydrocodone. For some, this is a less nauseating option than codeine. This may be used for either throat pain or for a throat tickle or cough. Many find that Tylenol is sufficient for the pain. An over the counter option for cough is dextromethorphan. It is the DM in medications such as Robitussin DM. There are extensive options for management of pain.

 

Instructions during healing

 

These are my particular inclinations and I vary them depending on what I am doing on the voice box and what the vocal needs are of the patient. Expect a wide variation in recommendations from myself as well as others.

 

    • First week
    • Feel free to drink plenty of fluids to keep secretions thin. I suggest that you rest your voice for one to seven days depending on what lesion was removed. This means essentially no talking. My belief is that the raw edges of tissue need an initial chance to heal. You know that if you pick at a cut on your skin, it will keep bleeding and make for an uglier scar, likewise the vocal folds. If you have reflux, be sure to take your antireflux medication in the coming days to aid in healing without inflammation. I suggest that during these days you sigh gently about six times a day for a minute to get some gentle vibrations massaging the vocal folds. Then, as the edges of the cuts are stuck down, you may begin talking. Some of my patients sneak in a few words, as they can’t resist the desire to talk. While I don’t recommend talking, here is what you might experience. On the afternoon of the surgery, you voice will be pretty good, usually better than before surgery. Then, swelling sets in since your vocal folds are bruised and your voice will sound deep, rough and laryngitis-like. It will require a little extra effort to talk.
    • You may begin talking, though I would like you to pretend that you do not like to talk and keep it to a minimum for the first weeks. Talk perhaps 10% of your normal amount. Pretend that you are a 1 on the 7-pointtalkativeness scale. Ask your close friends and family if you are behaving like a 1. Their answer will likely surprise you. If you sing, you may do five minutes of easy warm up per day. I will see you back sometime the week after surgery. I expect to see some swelling and bruising but would like to monitor your healing phase. Your voice will sound like you have laryngitis from the swelling. This improves quickly at first, then more slowly.
    • Now begin using your voice about 25% of your normal quantity of speaking. Pretend you are a 2 on the 7-pointtalkativeness scale. You may sing 10 minutes a day.
    • You are getting there. Talk about 50% of normal, sing, but not at a performance level. I have had people sing a performance this early, but I am nearly certain they do not get as good a surgical result. If you talk all day, you could vibrate your vocal folds one or two million times. That is asking a lot from a healing incision. Be patient. Your voice should continue to improve. If you are a singer, you should gradually be reaching some higher notes with greater ease. Pretend you are a 4 on the 7-point talkativeness scale.
    • I will see you back again. If everything is healed, go up to about 75% of normal. Otherwise, it will be healed soon. If you saw a speech therapist before surgery, it would be a good idea for a follow up visit to confirm that you are doing the appropriate behaviors. When your physician feels you are ready and that will often be about 4 weeks after surgery, resume your singing. I would consider the warmup recommendations of one of the country’s most outstanding vocal scientists, Ingo Titze. You might have your therapist interpret some of his suggestions if you are unfamilar with any of the terms.
    • Return for a follow up visit to see if you are healed. If I operated on you for a lesion that was caused by talking often (you are a 6 or 7 on the talkativeness scale), remember, I have not operated on your brain. It is up to you to give your voice the chance to rest that it needs. Being innately talkative is a wonderful personality, but can be vocally expensive. If you are a singer, you should be performing the swelling tests to monitor your vocal folds. Follow up recommendations vary a lot depending on my judgement about the underlying problem and its likelihood of recurrence.
  • Mid term evaluation
  • Long term evaluation of your surgery.
  • After several days
  • After 7 days
  • After 2 weeks
  • After three weeks
  • Six weeks
  • Six months
  • One year

 

References

    • Bastian RW, Vocal fold microsurgery in singers., J Voice 1996 Dec;10(4):389-404
    • Bastian RW, Thomas, JP. Talkativeness and Vocal Loudness: Do They Correlate With Laryngeal Pathology? – A Study of the Vocal Overdoer/Underdoer Continuum

Endoscopic cordectomy

 

Cordectomy involves removal of the entire membranous vocal fold with the vocalis muscle. The inner perichondrium of the thyroid cartilage can be included and the arytenoids cartilage can also be removed, either partially or completely.[1]Cordectomy via thyrotomy is the oldest surgical procedure for the treatment of early glottic carcinoma.[2] It remains the standard by which all other surgical treatments of small glottic cancers are measured.[1]

 

Cordectomy can be performed by the following 2 methods:

 

    1. Cordectomy through laryngofissure
    1. Endoscopic laser cordectomy

In 1908, Citelli introduced the so called cordectomy externa through thyrofissure.[3, 4] Chevalier Jackson described total cordectomy to treat patient with airway obstruction from bilateral vocal folds inability (1922) but the procedure was hampered by the resultant poor voice quality.[5] In 1932, Hoover published the results with similar approach through laryngofissure.[6]

 

An important new concept was the submucosal dissection, which later became a standard. The preservation of the overlying mucosal allowed primary wound closure. Surjan further improved the concept of the submucosal approach through laryngeal fissure.[7, 4] Dennis and Kashima described posterior cordectomy for the treatment of bilateral vocal folds inability in 1989.[8, 9]

 

Images depicting cordectomy can be seen below.

 

Diagram showing the incision line (blue dotted line) for right posterior cordectomy in cases of bilateral abductor paralysis.

 

Diagram showing the result of right posterior cordectomy in cases of bilateral abductor paralysis.

 

Diagram showing the result of right posterior cordectomy in cases of bilateral abductor paralysis.

 

Indications

 

Vocal cord cordectomy is indicated in the treatment of the following:

 

  • Dysplastic lesions of the vocal cords
  • Vocal cord malignancies- T1 lesions
  • Bilateral abductor paralysis

 

Contraindications

 

Cordectomy is contraindicated in the following cases:

 

  • When the vocal cords’ mobility is impaired.
  • When the thyroid cartilage is invaded by the tumor.
  • When supraglottic or subglottic extension exists.[1]

 

Endoscopic laser surgery is contraindicated if general anesthesia is a threat to the patient’s life, such as in the following cases:

 

  • Recent infarct
  • Patient with aneurysms
  • Bradycardia, etc

 

But, an increased risk is justified in patients with suspected malignancy.[10]

 

Endoscopic laser surgery is not possible in patients with the following conditions:

 

    • Ankylosing spondylitis
    • Fracture of cervical spine
    • Mandibular deformity
    • Patients with short thick neck associated with marked prognathism.[10]

Types of Cordectomy

 

Cordectomy can be performed by the following 2 methods depending on the indication:

 

  • Endoscopic laser cordectomy
  • Laryngofissure with cordectomy

 

A classification of laryngeal endoscopic cordectomies was first proposed by European laryngology society in 2000.The classification described 8 types of cordectomies, as follows:[11, 12]

 

  • Type I: Subepithelial cordectomy, which is the resection of vocal cord epithelium passing through the superficial layer of lamina propria .
  • Type II: Subligamental cordectomy, which is resection of epithelium, or Reinke’s space and vocal ligament.
  • Type III: Transmuscular cordectomy, which proceeds through vocalis muscle.
  • Type IV: Total cordectomy, which extends from vocal process to the anterior commissure.
  • Type Va: Extended cordectomy encompassing the contralateral vocal fold.
  • Type Vb: Extended cordectomy encompassing the arytenoids.
  • Type Vc: Extended cordectomy encompassing the ventricular fold.
  • Type Vd: Extended cordectomy encompassing the subglottis.

 

This classification did not propose any specific management for the lesions arising from the anterior commissure, which are being included among the indications for type Va cordectomy. To solve this problem, new cordectomy, encompassing the anterior commissure and anterior part of vocal cord, was proposed by European laryngology society working committee on nomenclature. This is classified as type VI.

 

Type VI is indicated for cancer originating in the anterior commissure involving one or both the vocal cords, without infiltrating the thyroid cartilage.[11]

 

European Laryngological Society classification allows one to define and clearly distinguish the extent of excision, which facilitates making meaningful comparisons between vocal outcomes after different types of cordectomy.

 

Preparation

 

Anesthesia

 

Atropine is always included in premedication. Anesthesia is induced by intravenous injection of barbiturates or by application of gas mixture via a mask. Relaxation is usually achieved by a bolus of succinyl choline. A long term relaxant is preferred for cordectomy. The anesthetic usually consists of gas mixture such as halothane, nitrous oxide and oxygen.[10]For more information, see general anesthesia.

Equipment

 

  • Various laryngoscopes, including bivalve adjustable laryngoscopes are used to expose the larynx.
  • Two suction devices: one is mounted on to the operating microscope and the other suction is used by the surgeon to evacuate the plume and to manipulate the tissue.
  • Microlaryngeal surgery instruments
  • Carbon dioxide laser coupled to an operating microscope
  • Laser safe endotracheal tubes.[13]

 

Positioning

 

The correct position is essential for the optimal introduction of laryngoscope. The patient should preferably lie horizontally flat on operating table, with neither head ring nor sand bag under the shoulders. The dental plate is put in place before the laryngoscope is introduced.[10]

 

Technique

 

Approach

 

Endoscopic laser cordectomy

 

The procedure begins with the orotracheal intubation with a laser-safe endotracheal tube. The patient’s eyes are then taped and padded and a head drape and upper tooth guard is applied.[14] When the patient is fully relaxed and sufficiently anaesthetized, a largest possible laryngoscope is introduced to get a good view of larynx.[10]

 

Before introducing the laryngoscope, the patient’s head is fully extended, and the laryngoscope is introduced between the endotracheal tube behind and lower jaw in front. Under visualization, laryngoscope is gently pushed forwards following the endotracheal tube between the epiglottis and the tube until the point reaches the petiole of epiglottis. If laryngoscope is passed too deeply into the larynx, both the vestibular fold and vocal folds are displaced laterally, whereas if the scope is not passed deeply enough the vestibular folds obscure the vocal cords. Once the laryngoscope is correct position, the chest holder is put in place to fix the scope in position. After exact adjustment of the scope, both vocal cords can be seen as far as the apex of vocal process. Once the laryngoscope is in the desired position, the light carrier is removed and an operating microscope is used.[10]

 

The patient’s head and face are protected with moist towels and the operating microscope, which is fitted with a microspot carbon dioxide laser and 400 mm lens is brought into position. To protect the endotracheal tube cuff, a moist cottonoid sponge is placed in the subglottis. Dissection is begun posteriorly and laterally. Medial retraction of the edge of the lesion shows the plane of dissection as the surgeon dissects anteriorly and inferior edge is resected at the end. A curved trajectory that parallels the contour of the normal vocal fold is used, and the depth of the excision is tailored to the lesion.[14]

 

The 30º or 70º angle telescope introduced through laryngoscope can be used with the advantage of examining the laryngeal surface of epiglottis, lateral wall of larynx, and subglottic space.[10]

 

A brief description of different types of cordectomies is given below.[11, 12, 13]

 

Type I: Subepithelial cordectomy

 

This involves the resection of vocal fold epithelium, passing through the superficial layer of the lamina propria. It is performed for premalignant lesions and lesions that show malignant transformation. Usually entire vocal cord epithelium is resected and in rare cases, clinically normal epithelium may be preserved. Since subepithelial cordectomy ensures histopathological examination of entire vocal cord, the main role of this surgical procedure is diagnostic. This procedure can also be therapeutic if histological results confirm hyperplasia, dysplasia, or carcinoma in situ without signs of microinvasion.

 

Type II: Subligamental cordectomy

 

This is indicated for cases of microinvasive carcinoma or severe carcinoma in situ with possible microinvasion. In this procedure vocal cord epithelium, Reinke space, vocal ligament are resected by cutting between the vocal ligament and vocalis muscle. The resection may extend from the vocal process to the anterior commissure and vocalis muscle is preserved as much as possible.

 

Type III: Transmuscular cordectomy

 

This procedure is indicated for small superficial lesions of the mobile vocal folds that reaches the vocalis muscle and without deeply infiltrating it. This involves the resection of epithelium, lamina propria and the part of vocalis muscle. The resection may extend from the vocal process to the anterior commissure. In some cases, partial resection of the ventricular fold may be required for adequate visualization of the vocal fold

 

Type IV: Total or complete cordectomy

 

This procedure is indicated for T1a lesions infiltrating the vocalis muscle. The resection extends from the vocal process to the anterior commissure and attachment of vocal ligament to the thyroid cartilage should be cut. The depth of the surgical margins reaches the internal perichondrium of the thyroid cartilage and sometimes perichondrium is included with resection.

 

Type Va: Extended cordectomy encompassing the contralateral vocal fold

 

This surgical approach was meant to include the anterior commissure and, depending on the extent of tumor, either a segment or the entire contralateral vocal fold. This procedure is now replaced by type VI cordectomy.

 

Type Vb: Extended cordectomy encompassing the arytenoids

 

This procedure is indicated for vocal fold carcinoma involving vocal process or arytenoid cartilage posteriorly. For this type of resection, arytenoid cartilage should be mobile, and the cartilage is partially or fully resected.

 

Type Vc: Extended cordectomy encompassing the ventricular fold

 

This procedure is indicated for ventricular cancers or trans glottis cancers that spread from vocal fold to the ventricle. This involves the resection of ventricular fold and Morgani’s ventricle.

 

Type Vd: Extended cordectomy encompassing the subglottis

 

This procedure can be used for selected cases of T2 carcinoma with limited subglottic extension without cartilage invasion.

Procedure of type VI cordectomy

 

This procedure is indicated for cancer originating in the anterior commissure involving one or both the vocal cords, without infiltrating the thyroid cartilage. The surgery comprises anterior commissurectomy with bilateral anterior cordectomy. If the tumor is in contact with cartilage, resection can encompass anterior part of thyroid cartilage. Resection of the anterior commissure may include the subglottis mucosa and cricothyroid membrane, because cancers of anterior commissure tend to spread toward the lymphatic vessels of the subglottis.

 

The pharynx and teeth should be checked for damage before extubating from anesthesia.

Laryngofissure with cordectomy

 

Open cordectomy has been used in the surgical management of glottis malignancies with good cure rates. It can be used in patients with T1 lesions who are not amenable to laser cordectomy because of inadequate endoscopic visualization. After a preliminary tracheotomy, a horizontal skin crease incision is made at the middle part of the larynx. Subplatysmal flaps are elevated, and strap muscles are separated along the midline and larynx is exposed. Thyroid cartilage is examined for any signs of invasion. The perichondrium of the thyroid cartilage is elevated in the midline and elevated slightly to both side and thyroid cartilage is cut in the midline.[14]

 

If the anterior commissure is involved, the vertical thyrotomy incision is made off-center on the uninvolved side. After opening the larynx, the tumor is identified and involved cord is resected with a 1-2 mm mucosal margin. In rare cases, small lesions on both vocal cords can be resected simultaneously by this technique.[1]

 

For cases requiring superficial cordectomy, no reconstruction is required to achieve a good postoperative voice. If the surgical resection extends deeply in to the thyroarytenoid muscle or to the inner perichondrium, false vocal cord tissue may be swung down to fill the defect. The thyrotomy is closed with interrupted 3-0 Vicryl sutures.[14]

 

Posterior cordectomy for bilateral abductor palsy

 

Using carbon dioxide laser, 3.5-4 mm C-shaped wedge of posterior vocal cord is excised from the free border of the membranous cord, anterior to the vocal process, extending 4 mm laterally over ventricular band. Excision should be done anterior to the vocal process and cartilage should not be exposed. This surgical resection creates 6-7 mm transverse opening at the posterior larynx.[15]

 

Some authors recommend simultaneous bilateral posterior cordectomy for the management of bilateral abductor palsy.[16]

 

Post-Procedure

 

Complications

 

Complications of endoscopic cordectomies are as follows:[10]

 

    • General complications include circulatory and respiratory disorders resulting from anesthesia.
    • Local injuries such as injury to the teeth, tearing and laceration of palate. Laceration, hematoma of lips or tongue can usually be prevented by careful introduction of laryngoscope. These injuries are caused by pressure of the laryngoscope on the base of tongue or oropharynx. Deeper laceration should be sutured immediately and antibiotics should be given to prevent parapharyngeal extension of infection.
    • Bleeding from larynx during or after operation may be present after cordectomy. Hemostasis can usually be achieved by adrenaline-soaked pledgets or deliberate coagulation. Massive bleeding may demand ligation of superior laryngeal artery.
    • Postoperative edema is uncommon and prophylactic steroids can be used to prevent edema.
    • Granuloma scars and adhesions can develop after surgery.
    • Phonatory outcome after few types of transoral laser surgery may not be satisfactory and they may require an additional phonosurgical procedure.[13]
    • Cordectomy patients aspirate food and saliva if the edge of the scar is not in the midline and it cannot be swelled out with Teflon because it is very hard and elastic.[17]

Long-term monitoring

 

Endoscopy under general anesthesia should be carried out at least every 2 months for first two years after surgery and with decreasing frequency in the subsequent years.

Adjunctive phonosurgical treatment is not required after type I and II cordectomy because postoperative conversational voice obtained after a standard voice therapy protocol and vocal hygiene, including voice rest for at least 2 weeks after surgery. For type III cordectomy, Eckel et al recommends a primary intracordal autologous fat injection at the end of the endoscopic resection.[13] A potential shortcoming of this technique is the variable resorption rate of the injected fat. Some authors prefer to perform phonosurgical voice rehabilitation only following a disease-free interval of at least 6 months to 1 year. In patient with types IV and V cordectomy, a wider glottic gap usually reduces the possibility of good glottic closure, and the fibrotic nature of the neocord prevents any mucosal wave. These patients can be treated after one year by appropriate phonosurgical procedures.[13]

 

Patient Education

 

Most important prerequisite for endoscopic management of laryngeal tumors is ensuring adequate patient compliance to a compulsive postoperative follow-up.[13]

Postoperative care

 

    • Absolute voice rest
    • Coughing and clearing of throat, singing and shouting should be avoided
    • Coughing should be treated by cough suppressants and mucolytic agents
    • Steam inhalation should be done twice daily
    • Antibiotic therapy with appropriate antibiotics.

References

 

    1. Spiegel JR, Sataloff RT. Surgery for carcinoma of the larynx. In: Gould WJ, Sataloff RT, Spiegel JR. Voice Surgery. St. Louis: Mosby; 1993:307-337.
    2. De Diego JI, Prim MP, Verdaguer JM, Pérez-Fernández E, Gavilán J. Long-term results of open cordectomy for the treatment of T1a glottic laryngeal carcinoma. Auris Nasus Larynx. Feb 2009;36(1):53-6.[Medline].
    3. Citelli C. Chordectomia externa und Regeneration der Stimmlippen. Ueber eine neue Behandlungsmethode aller Kehlkopfverengungen infolge dauernder Medianstellung beider Stimmlippen. Arch Laryngol Rhinol. 1908;20:73-97.
    4. Sapundzhiev N, Lichtenberger G, Eckel HE, et al. Surgery of adult bilateral vocal fold paralysis in adduction: history and trends. Eur Arch Otorhinolaryngol. Dec 2008;265(12):1501-14. [Medline].
    5. Jackson C. Ventriculocordectomy: a new operation for the cure of goitrous paralytic laryngeal stenosis.Arch Surg. 1922;4:257–274.
    6. Hoover WB. Bilateral abductor paralysis: operative treatmentby submucous resection of the vocal cord.Arch Otolaryngol. 1932;15:337–55.
    7. Surján L. [Submucous chordectomy as a glottis-enlarging operation]. HNO. Aug 1965;13(8):231-3.[Medline].
    8. Dennis DP, Kashima H. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol. Dec 1989;98(12 Pt 1):930-4. [Medline].
    9. Benninger MS, Bhattacharya N, Fried MP. Surgical management of bilateral vocal fold paralysis. Operative Techniques in Otolaryngology-Head and Neck Surgery. 1998;9:224-9.
    10. Kleinsasser O. Microlaryngoscopy and endolaryngeal microsurgery. New Delhi: JP Medical Ltd; 1995:17-30.
    11. Remacle M, Van Haverbeke C, Eckel H, et al. Proposal for revision of the European Laryngological Society classification of endoscopic cordectomies. Eur Arch Otorhinolaryngol. May 2007;264(5):499-504. [Medline].
    12. Remacle M, Eckel HE, Antonelli A, et al. Endoscopic cordectomy. A proposal for a classification by the Working Committee, European Laryngological Society. Eur Arch Otorhinolaryngol. 2000;257(4):227-31.[Medline].
    13. Eckel HE, Perretti G, Remacle M, Werner J. Endoscopic Approach. In: Remacle M, Eckel HE. Surgery of larynx and trachea. Berlin, Germany: Springer-Verlag; 2010:107-214.
    14. Hogikyan ND, Batisan RW. Surgical therapy of glottic and subglottic tumors. In: Thawley SE, Panje WR, Batsakis JG, Lindberg RD. Comprehensive management of head and neck tumors. 2nd ed. WB Saunders Company; 1039-68.
    15. Oswal VH, Gandhi SS. Endoscopic laser management of bilateral abductor palsy. Indian J Otolaryngol Head Neck Surg. 2009;61:47–51.
    16. Khalifa MC. Simultaneous bilateral posterior cordectomy in bilateral vocal fold paralysis. Otolaryngol Head Neck Surg. Feb 2005;132(2):249-50. [Medline].
    17. Dedo HH. Surgery of the larynx and trachea. Philadelphia: BC Decker Inc; 1990:207-208.



Endoscopic Cordectomy

 

Overview

 

Pre-procedure

 

Technique

 

Post-procedure

 

Myringotomy & insert of tube through tympanic membrane (bilateral)

 

Overview

A myringotomy is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid or to drain pus from the middle ear.
A tympanostomy tube is inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks. Depending on the type of tube used, it is either naturally extruded in 6 to 12 months or removed during a minor procedure.
Those requiring myringotomy usually have an obstructed or dysfunctional Eustachian tube that is unable to perform drainage or ventilation in its usual fashion. Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe acute otitis media (middle ear infection)


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