Phonosurgery

presentation on phonosurgery

1. Phonosurgery Dr Vaibhav

2. The Laryngeal Musculature Intrinsic Muscles Abductor – Posterior Cricoarytenoid (PCA) Adductors – Lateral Cricoarytenoid (LCA) Interarytenoid (IA) Thyroarytenoid (TA) Tensors – Cricothyroid (CT) ---- SLN Vocalis (internal part of TA) Openers – Thyroepiglottic (part of TA) Closers - Interarytenoid – oblique part (IA) Aryepiglottic – (AE)

3. Laryngeal surgery was initially concerned with merely the diagnosis and removal of malignant disease from the larynx , whereas benign disease and its effect on voice was considered to be of secondary importance. The last 50 years has seen the expansion of phonosurgery which is defined as ‘ any surgery designed primarily for the improvement or restoration of the voice’. It was first popularized by Hans von Leden in the late 1950s. Phonosurgery includes ; Microlaryngoscopic surgery Vocal fold injection Laryngeal framework surgery Nerve grafting Neuromuscular surgery

4. VOCAL FOLD INJECTION

5. Historical aspects: Bruning ( 1911 ) - the first to describe injection of vocal folds He injected paraffin via a direct laryngoscopy approach under LA. Arnold (1962 ) - popularized the use of Teflon.

6. Indications Temporary correction in cases of u/l vocal cord palsy, when prognosis for recovery is uncertain. Immediate improvement of voice required. Permanent correction of glottic insufficiency Vocal fold atrophy Adjunctive augmentation after prior surgery Trial basis Note: Done when there is absence of arytenoid fixation and there is adequate residual vocal fold structure to allow for needle placement.

7. Ideal injection material Readily available Inexpensive Inert Easy to use Completely biocompatible Injectable materials are broadly classified into temporary and permanent types.

8. Temporary injectable substances Material Length of effect Adv. Disadv . Gelfoam 4-6 wks Long track record Short duration Carboxymethylcellulose 2-3 months FDA approved Not long lasting Bovine collagen 3-4 months Long track record Allergy test 2-4 wk delay Human derived collagen 3-4 months No allergy test Limited experience Micronized Alloderm ( Cymetra ) 2-3 months No allergy test Little/no inflammatory response. More preparation time Hyaluronic acid gel 4-6 months No allergy test Limited experience 8

9. Long term/ permanent injectable substances Material Length of effect Adv. Disadv . Calcium hydroxyapatite 2-5 years FDA approved Associated with foreign body granulomatous reaction. l/t dysphonia, pain and VC erythema. Teflon Permanent Long lasting Irreversible Vocal stiffness Granuloma Autologous fat (harvested more commonly from lower abdomen and inner thigh. ) Permanent Own tissue Time, morbidity from fat harvest Silicon – polydimethyl sialoxane Permanent Long lasting Should be placed deep inside body of vocal fold to prevent migration Note: Cymetra and autologus fat are the most commonly used injectables .

10. Vocal Cord Injection techniques It may be done under GA or LA through following routes: Peroral : performed in selected patients. topical 4% LA applied on laryngeal and pharyngeal mucosa. Curved inj. device in clinical setting; under indirect visualization of larynx by holding the tongue forward . Bevelled end directed away from midline to minimize risk of intramucosal injection.

11. Injection techniques Percutaneous :  can be performed under sedation or LA  visualization is with a flexible fibreoptic nasopharyngoscope with digital imaging system.  For optimum results needle placed just anterior and lateral to vocal process on a plane level with the lower border of medial edge. 11

12. Routes of administration are: Translaryngeal – through inferior half of thyroid cartilage . performed through lateral appraoch . level of vocal fold determined by palapting thyroid notch and inferior border of thyroid cartilage. 2. CT membrane puncture – becoming popular method. performed through anterior approach. vocal folds approached from below. TH membrane puncture: usually not done routinely. danger of injection into Reinke’s space.

13. Laryngoscopic Injection(telescopic visualization): Indications: Patients who do not tolerate flexible fibreoptic examination. During ablative procedures where RLN or Vagal nerve resection is anticipated.This provides temporary medialization decresing immidiate post operative symptoms. Position: Supine Anaesthesia : GA or LA Instruments: 1.0/30 degree 5mm laryngeal telescope 2.Digital video system 3.23-gauge butterfly needle for Cymetra Injection gun( Bruning’s syringe) for Autologus fat Needle is inserted anterior and lateral to vocal process appr . 2 mm deep or at the plane level with the lower margin of the true folds. After injection massage is done over vocal fold to distribute the material.

14. Precautions - Vocal Cord Injection Avoid unnecessary tension at the anterior commisure . Superior laryngeal nerve block should be avoided as it alters vocal fold tension by paralyzing cricothyroid muscle. The appropriate amount of overcorrection used for most injectables (15–30%, or an additional 0.1–0.2 ml of material). Injection into the superficial lamina propria ( Reinke’s space) is to be avoided – l/t granuloma formation in space hampering mobility. For vocal fold medialization materila is placed in paraglottic space lateral to vocalis muscle and For intracordal injection , site is superficial , just deep to lamina propria avoiding Reinke’s space.

15. Complications of vocal fold injection- Under injection requiring repeat procedures Over injection causing airway compromise – Immediate m/n  incise mucosa and remove excess materialwith suction Late m/n  CO2 laser or cupped forcep removal or thyrotomy . Improper placement causing subglottal extension and stenosis. If given in R einke’s space – cause granuloma formation leading to impaired VC vibrations .

16. Laryngeal Frame Work Surgery

17. Introduction Payr in 1915 first described medialyzing paralyzed vocal fold by inward displacement of overlying thyroid cartilage with cartilage wedge. Isshiki in 1974 first described the 4 types of thyroplasty . 1990’s: Medialization Thyroplasty was a well-accepted commonly-performed operation

18. Classification 1 . Approximation Laryngoplasty - Medialization thyroplasty (Type I) Arytenoid Adduction Roatation (pull) technique (Lateral cricoarytenoid pull technique ) Fixation technique (Adduction arytenopexy ) 2.Expansion laryngoplasty Laterlization Thyroplasty Lateral approach ( Thyroplasty type II a) Medial approach ( Type II b ) or Midline lateralization thyroplasty . Vocal fold abduction Suture technique. Resection Technique. ( Thyroarytenoid myectomy )

19. 3. Relaxation Laryngoplasty - Shortening Thyroplasty - Lateral approach ( Type III) - Medial approach ( Anterior commissure retrusion ) 4.Tensioning Laryngoplasty Cricoid Approximation (Type IV a) Elongation Thyroplasty - Lateral approach (Type IV b) - Medial approach (Springboard advancement or Anterior commissure advancement)

20. Type I Thyroplasty Indications: - Symptomatic glottic insufficiency ( dysphonia , aspiration). - U/L vocal fold paralysis. - Vocal fold atrophy, including age related atrophy. - Vocal fold bowing d/t 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.

21. Type I Thyroplasty : Indications Dysphonia or aspiration due to Vocal Fold Paralysis/Paresis Dysphonia due to Vocal Fold Atrophy

22. Manual Compression Test this test results in a preoperative improvement in voice suggest that surgery will be successful

23. Type I Thyroplasty : Theory In paralyzed or atrophic vocal fold, the medial bulge from the Thyroarytenoid (TA) muscle contraction is inadequate. The thyroplasty implant medializes the midmembranous vocal fold to mimic the activity of the TA muscle. Goals: To improve voice quality and prevent aspiration.

24. Set-up

25. Pre- Op Surgery done under local anaesthesia with patient AWAKE -patient need to phonate -Use 1% lignocaine with Epi 1:100,000 with an amp of bicarbonate as b icarbonate makes it hurt less. -Inject broadly EVERYWHERE you are going to dissect! Positioning: Shoulder roll with neck extended

26. Technique A paramedian horizontal incision over the middle aspect of thyroid lamina. Superior and inferior flaps elevated in subplatysmal plane

27. Cont… Sternohyoid muscle is elevated off the thyroid Cartilage.

28. Cont… The muscle is retracted posterior to thyroid lamina. A cautery template marks the fenestra (6 x 10 mm), and the superior aspect of the window is at the vocal fold level.

29. Type I Thyroplasty : Window Outline before cutting. Goal : Window at the level of the TVF, to medialize only the TVF. If carving the implant, or using Gore-Tex can be free-hand. If using pre-formed implant (i.e. Montgomery or titanium), use window sizer to mark window.

30. Type I Thyroplasty : Window Superior edge of window most important (because if too high will medialize false VF) Half way between the thyroid notch and the inferior border of the thyroid cartilage, parallel to the inferior border

31. -The size of the window is dependent on the size of the larynx, men > women - Anterior border should be about 5-7mm posterior to midline in female and 8-10mm in male. - Posterior border should be just anterior to the oblique line (width usually about 10-13mm) - Inferior border should be about 2-3 mm superior to the inferior border to prevent fracturing (height usually 4- 6mm)

32. Cutting the window - Marks are made with electrocautery and gentian violet

33. If cartilage is soft use #15 blade If calcified: use oscillating saw. or use otologic drill 2mm burr to outline window and then a Kerrison bone punch to remove remaining cartilage. - inner perichondrium elevated in circumferential fashion by means of laryngeal elevator.

34. Video – Window

35. Type I Thyroplasty : Implant Pre-formed Montgomery, Titanium Calcium Hydroxylapatite ) Hand carved silicone. layered Gore-Tex.

36. Originally, after the window was cut, the cartilage of the window was pushed in by a cartilage shim or later an implant. It was later found that the cartilage migrated or degraded over time causing the voice to worsen as it gets smaller. Now, we remove the cartilage before placing an implant.

37. Type I Thyroplasty : Implant Montgomery Set window size for men and women, 5 implants sizes for each window. Use an implant sizer to decide which implant to use Has inner and outer phalanges securing in place.

38. Features : Eliminates need to hand-fashion Implants. Self-retaining implant. No suturing is necessary. Reduced trauma and surgery time Reversible

39. Type I Thyroplasty : Implant Titanium VF medialization Implant: Secured in place at varying depths depending on voice with titanium screw system.

40. Type I Thyroplasty : Implant Free-form: Gore-Tex ( ePTFE ) - Homopolymer of polytetrafluoroethylene in minute beads in a fine fiber mesh. - Minimal tissue reaction - Cut into long 3mm wide sheet for use - Undermining of perichondrium 4-5mm posterior and inferior to window prior to insertion

41. Type I Thyroplasty : Implant Hand-carved: Silastic : Firm silicone block carved by the surgeon during operation to appropriate shape. Hand-carved: one technique with inner phalanges.

42. Hand-Carved: with outer phalanges Carved based on window size, and amount of medialization needed. Bevel medial surface to be divergent.

43. Implants Calcium Hydroxylapatite ( VoCoM implant): Osteogenesis occurs in fenestra Firm in nature, modification by diamond drill. Not used in individuals in removal is anticipated

44. Depending upon shin used, the implant can be variably placed along the anterior/posterior and superior/inferior axis of fenestra .

45. Place implant external to inner perichondrium . Rotate implant into four orientation to determine the optimal position. Most common position : inferior posterior quadrant in vertical orientation . Before placement, perform valsalva maneuver. If air bubble present, procedure is terminated.

46. Type I Thyroplasty Advantages - under local anesthesia. - positioning is more anatomic, better assessment of voice - Reversible. - prosthesis is placed lateral to the inner perichondrium of the thyroid lamina. - structural integrity of the vocal fold is preserved, allowing medialization with effective closure of the prephonatory gap . Disadvantages - open procedure. - technically more difficult. - closure of the posterior glottis may be limited.

47. Factors affecting output of surgery Size and shape of the implant Position of the implant Maintaining proper position of the implant Limiting the duration of surgical procedure Deterioration of voice quality after thyroplasty with implant in place – - resolving oedema in postoperative period - surgery performed early after paralysis - d/t muscle atrophy

48. Type I Thyroplasty : Complications Penetration of endolaryngeal mucosa - assess air leak before placement of implant in window. If air leak is present , then terminate the procedure. Wound infection Chondritis Airway obstruction – most danger – overnight monitoring is required. Implant extrusion Can become displaced and even extrude into the airway, more commonly with Gore-Tex and with implants without outer phalanges

49. Type I Thyroplasty : Pitfalls Window is too high . Then implant is too high, false VF is medialized and voice is poor. Implant is too big or too small . Makes voice either pressed or breathy. Voice is still poor after Procedure because of posterior glottal insufficiency .( Arytenoid adduction can correct this.)

50. Limitations of medialization Mechanical nature of 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.

51. Incomplete glottal closure after type I thyroplasty – Occurs in patients undergoing acute implanation after paralysis of vocal cords due to atrophy of muscles with time. Management include ; Revision thyroplasty Vocal fold injection with cymetra and autologous fat Re innervation procedure Arytenoid adduction Revision thyroplasty is surgically feasible and result in high rate of improvement over the pre existing condition.

52. Modification of medialization thyroplasty – Modified techinque done by Nishiyama and colleagues in 1999 . Implant used: autologus temporalis fascia . Procedure: implant harvested, dehydrated, rolled and inserted into vocal fold under microlaryngoscopy guidence . Indications: 1.Large glottic gaps. 2.U/l vocal fold palsy. 3.Atrophic vocal fold. 4.Post RT scar tissue . Result: Significant improvement in phonation time.

53. Arytenoid Adduction First described by Ishiki with modifications by Zeitels and others. Addresses posterior glottic gap by pulling arytenoid into adducted position . Most advocate use in combination with anterior medialization . Traction on muscular process of the arytenoid antero - medio -inferiorly .

54. Arytenoid Adduction – Modifications Suture Placed to Cricoid Cartilage Simulates action of lateral cricoarytenoid . Zeitels Modification – Arytenopexy More physiologic positioning of the arytenoid . Involves suturing the arytenoid in a more posterior and medial position to allow more tension on flaccid cord.

55. Video – Arytenoid Adduction

56. Type 2 Thyroplasty Vocal folds are displaced laterally away from the midline under local anaesthesia . Management of adductor spasmodic dysphonia ( AdSD ) - Type II a : Lateralization thyroplasty by lateral approach - Two paramedian vertical incisions and interpose the anterior segment beneath the lateral segments.

57. Type II b - Lateralization Thyroplasty By medial approach- a/k/a ( Midline lateralization Thyroplasty ) A vertical incision in the thyroid cartilage and lateralizing the posterior segment over the anterior one.

58. Video- Midline lateralization Thyroplasty

59. 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 (neuromuscular , parkinson’s , MND , MS)

60. Vocal Cord Abduction by Suture Method- Arytenoidopexy : Displacing the vocal fold and arytenoid without surgical removal of any tissue.  Suture passed around the vocal process of the arytenoid and secured laterally. Relatively high  failure rate.

61. 2.Resection Method- ( Arytenoidectomy ). Removal of some or all of the arytenoid cartilage.  - Endoscopically by Microsurgical technique- Thornell procedure - with Laser surgery- Jako’s procedure - With Thyrotomy approach- Scheer’s approach) - By lateral neck approach ( Woodman’s ) – Most popular approach.

62. Woodman procedure – - Lateral neck incision. - Exposure of the arytenoid cartilage posteriorly with removal of the majority of the cartilage, sparing the vocal process.  - Suture is then placed into the remnant of vocal process and fixed to the lateral thyroid ala.  - Cause less voice deficit.

63. Cordectomy :      Dennis and Kashima (1989) Posterior partial cordectomy by carbon dioxide laser.   Excising  a  C-shaped wedge from the posterior edge of one vocal cord.  If this posterior opening is not adequate, after 6-8 weeks,  procedure  can be repeated or a small cordectomy can be performed on the other vocal cord.  Relief of airway obstruction  with preservation of voice quality.

64. Types Type I : Subepithelial cordectomy , 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 .

65. Right posterior cordectomy in cases of bilateral abductor paralysis.

66. Type III Thyroplasty Lowers the vocal pitch. The VF is relaxed by A-P shortening of the thyroid ala. Indications: 1. Males with high pitch voice, resistant to voice therapy.( Puberphonia / Mutational falsetto) 2. Stiff VF with high pitched breathy voice. 3. Spastic dysphonia

67. Type III Thyroplasty 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.

68. Medial approach: ( Anterior commissure retrusion ) - Retrusion of the middle portion of the thyroid cartilage and leads to reduction in the length of vocal folds results in normal adult voice - Vertical incision was made either side of the midline of the thyroid cartilage.

69. Middle portion of the cartilage pushed posteriorly Free edges of the thyroid cartilage reapproximated with 2-0 vicryl

70. Video – Retrusion Thyroplasty .

71. Type IV 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 transsexualism Abnormallly lax or bowed vocal folds (as in presbyphonia )

72. Cricothyroid Approximation : - increases vocal pitch by simulating the contraction of cricothyroid muscle with sutures. - The cricoid and thyroid cartilage is approximated as closely as possible because postoperative reversion towards a lower pitch to some extent is inevitable.

73. - 4 nonabsorbable monophilic sutures are placed to draw the cricoid and thyroid cartilages together. - In thyroid cartilage, bolsters should be used to prevent cutting through sutures.

74. Video- Cricoid approximation

75. Advantages : No surgery on the vocal cords themselves. Theoretically reversible if the patient is dissatisfied.  Disadvantages : Requires neck incision. prolonged healing process. long-term results are inconsistent.

76. Cricothyroid Subluxation : By Steve Zeitels Indications : U/L vocal fold paralysis with vocal fold shortening with resultant reduced pitch range. Poor pitch range after adequate implant positioning in medialization laryngoplasty . Contraindications : Present or impending laryngeal fracture of thyroid ala from associated medialization laryngoplasty .

77. To lengthen the vocal fold by increasing the distance from the cricoarytenoid joint ( cricoid ) to the anterior commissure (thyroid cartilage) by subluxating the cricothyroid joint. - Results in rotation of anterior commissure away from midline in a direction C/L to unilateral vocal fold paralysis.

78. Separation of cricothyroid jt with scissors Placement of cricothyroid subluxation suture submucosally at the midline of anterior cricoid cartilage.

79. Elongation Thyroplasty : Lateral Approach (Type IV b) Vertical incision is taken at the junction of anterior and middle one-third of ala and silastic implant is fixed between cartilage edges by two mattress sutures. - If pitch elevation is insufficient, the same procedure may also be performed on the contralateral side.

80. Medial Approach: - By Le Jeune as “ springboard advancement” - Indication : Breathy voice due to bowed vocal folds. - After exposure of anterior portion of thyroid cartilage, an inferiorly based carilage flap is formed so as to include the anterior commissure . The upper end of flap is held in position by a tantalum shim. - Tucker modified this technique by reversing the pedicle and called it “ anterior commissure advancement”.

81. Laryngeal Reinnervation Surgeries

82. Laryngeal Reinnervation Surgeries  In 1909 , Horsely reported first successful vocal cord reinnervation . He performed neurorraphy of RLN and obtained nearly complete recovery of laryngeal function. Two most common reinnervation techniques are: Neuromuscular pedicle Ansa Cervicalis -RLN anastomosis

83. Neuromuscular pedicle The techique attempts to transfer a nerve with a portion of its motor units intact to denervated muscle. Small blocks of muscle at distal end of donor nerve are included. Successful results depend on :  ability of transplanted axons to reach receptive sites on recipient muscle :ability of muscle fibres to accept foreign nerves. Principle:Muscle reinnervation occurs from sprouts generated from intact motor neurons of partially denervated transferred nerve to the end plate sites of denervated muscle fibre .

84. Bilateral Vocal cord plasy Done when palsy persists for 6 months to one year. C/I when: cricoarytenoid joint fixation present. vocal cord palsy d/t CNS disease. Technique: Laryngoscopy with palpation of arytenoids Horizontal skin incision at level of lower border of thyroid cartilage Branch of ansa cervicalis identified by: a) finding the main trunk as it crosses IJV and tracing proximally and distally till appropriate branch recognized. b)mobilizing the medial border of omohyoid near its attachment to the hyoid bone carrying dissection in medial to lateral direction. If nerve injured branch to sternothyroid is also acceptable. NMP is sutured to PCA.

85. Unilateral Vocal Cord Palsy Laryngoscopy and harvesting of NMP is same as b/l palsy. Recipient muscle is LCA.

86. Complications 1.Failure to obtain satisfactory result. 2.Wound infections.

87. Ansa Cervicalis -RLN anastomosis Indicated for U/L VC palsy and offers an excellent oppurtunity for outstanding rehabilitation. Waiting period before reiinervation surgery is 12 months. No motion of the reinnervated vocal fold with respiration is expected. Advantages: Relatively easy to perform. Provides tone,position and bulk to vocal fold thus reducing the asymmetry b/w two cords. Sternothyroid muscle sacrifice is clinically insignificant which improves vocal function. Procedure is reversible as is primarily extralaryngeal . No limitation for use of vocal fold injection and thyroplasty as no violation of thyroid ala and laryngeal muscles. No permanent implant used.

88. Disadvantages: Requires deeper neck dissection. Lengthy procedure. Eliminates possibility of spontaneous recovery of VC. Delay of 5- 9 months before substantial improvement in voice occurs. Requires one intact ansa cervicalis and intact distal stump of the RLN. Pre-requisite: 1.Availblity of distal stump of RLN. 2.Availblity of donor nerve. 3.Patient must be able to tolerate GA 4.Pateint must be ready to wait for substantial improvement from reinnervation .

89. C/I: 1.Absolute:  glottic airway compromise  B/l VC palsy absence of distal RLN b/l absence of ansa cervicalis poor general health . 2.Life expectancy 3.Presence of scar,web or poylp over vocal folds. 4.VC plasy d/t CNS disease.

90. Procedure: Incision below the level of cricoid cartilage. In postoperative period after 2- 3 months voice may deteriorate. At 4- 6 moths after surgery gradullay improvement in voice quality occurs.

91. Thank You …)