Phonosurgery

This is a presentation I used for my seminar on 'Phonosurgery' on 4th November, 2015. I hope they are useful to you. Constructive as well as Destructive criticism welcomed.

1. Phonosurgery By Dr. Yousuf F. Choudhury Post Graduate Trainee, ENT Dept. Silchar Medical College Moderated by Prof. Dr. Shamsuddin , M.S Head of Department, ENT Dept. Silchar Medical College

2. Brief Anatomy of Larynx Embryology of larynx : Larynx develops from laryngotracheal groove, a midline diverticulum of foregut. Development starts in the 4 th week of embryonic life. Most of the anatomical structures develop by the 3 rd month of fetal life. Development of cartilages Developed from Thyroid cartilage 4 th Branchial Arch Arytenoids 6 th Branchial Arch Corniculate 6 th Branchial Arch Epiglottis Hypobranchial eminence Cricoid and tracheal cartilages 6 th Branchial Arch

3. Location of the larynx : Larynx is situated at the cranial end of the trachea. It extends from the 3rd to the 6th cervical vertebra. This level may be somewhat higher in women and children. Dimension of the larynx : The size of the larynx is almost the same in boys and girls till puberty. After puberty the antero posterior diameter of the larynx virtually doubles in males. Dimension of Adult Larynx Sexes Length Anterior posterior diameter Transverse diameter Male 44 mm 36 mm 43 mm Female 36 mm 21 mm 41 mm

4. Laryngeal framework : Larynx has 9 cartilages. Paired Unpaired Arytenoid Thyroid Corniculate Cricoid Cuneiform Epiglottis Laryngeal Joints Cricothyroid Joint Cricoarytenoid Joint Larynx has 2 joints

5. Ligaments and Membranes of Larynx

6. Name of Extrinsic Muscle and functions Origin Insertion Innervation Infrahyoid group Thyrohyoid Elevates the larynx on a fixed hyoid or depresses the hyoid on a fixed Larynx Oblique line of thyroid lamina Inferior border of the greater cornu of the hyoid Hypoglossal (C1 root) Sternothyroid Depresses the larynx Posterior surface of manubrium and edge of the first costal cartilage Oblique line of the thyroid lamina Ansa cervicalis (C2, 3 roots) Sternohyoid Depresses the larynx by lowering the hyoid Clavicle and posterior surface of the manubrium Lower edge of the body of the hyoid Ansa cervicalis (C1, 2, 3 roots) Suprahyoid group Mylohyoid Raises and pulls the hyoid anteriorly Mylohyoid line on inner aspect of the mandible Midline raphe and body of the hyoid Nerve to mylohyoid (inferior alveolar branch of V3) Geniohyoid Raises and pulls the hyoid forwards Genial tubercle on mandible Upper border of the body of the hyoid Hypoglossal (C1 root)

7. Name of the Extrinsic Muscle and functions Origin Insertion Innervation Stylohyoid Retractor and elevator of the hyoid for swallowing Back of the styloid process (splits around the digastric tendon) Base of greater cornu of the hyoid Facial nerve Digastric Anterior belly pulls the hyoid anteriorly and up Posterior belly pulls the hyoid posteriorly and up Digastric notch on the medial surface of the mastoid Process Lower border of the mandible (fibrous sling holds the tendon to the lesser cornu of the hyoid) Anterior belly – nerve to mylohyoid Posterior belly – facial nerve Stylopharyngeus Elevates the larynx Medial aspect of the styloid process Posterior border of the lamina of the thyroid cartilage (side wall of the pharynx) Glossopharyngeal nerve Palatopharyngeus Helps tilts the larynx forwards Palatine aponeurosis and posterior margin of hard palate Posterior border of thyroid alar and cornua Accessory nerve (pharyngeal plexus Salpingopharyngeus Elevates the larynx Eustachian tube Posterior border of the thyroid cartilage Pharyngeal plexus

8. Intrinsic Muscle Name of the Intrinsic Muscle and function Origin Insertion Open and close the glottis Posterior cricoarytenoid Lower and medial surface of the back of the cricoid lamina It fans out to be inserted into the back of the muscular process of the arytenoid Lateral cricoarytenoid Superior border of lateral part of the arch of the cricoid Muscular process of arytenoid Transverse arytenoids – unpaired Posterior surface of the muscular process and outer edge of the arytenoid Crosses over and attaches to the same point on the other arytenoid Oblique arytenoids – paired Posterior aspect of the muscular process (superficial to the transverse arytenoid ) Apex of the other arytenoid

9. Name of the intrinsic muscle and function Origin Insertion Control the tension of the vocal folds Thyroarytenoid ( vocalis ) A broad sheet of muscle which lies lateral to and above the free edge of the cricovocal ligament. The lower part of the muscle is thicker and forms a distinct bundle called the vocalis muscle Back of the thyroid prominence and cricothyroid ligament Vocal process of arytenoid and anterolateral surface of the body of the arytenoid Cricothyroid This is the only intrinsic muscle that lies outside the cartilaginous framework of the larynx Lateral surface of the anterior arch of the cricoid . Fibres fan out and pass backwards in two groups Lower oblique fibres pass backwards and laterally to the anterior border of the inferior cornu of the thyroid cartilage. Anterior straight fibres ascend to the posterior part of the lower border of the thyroid Lamina Alter the shape of laryngeal inlet Aryepiglotticus A continuation of the oblique arytenoid Posterior aspect of the muscular process of the arytenoid Fibres pass around the apex of the opposite arytenoid and insert into the aryepiglottic fold Thyroepiglotticus A continuation of the thyroarytenoid Back of the thyroid prominence and cricothyroid ligament Fibres pass upwards into the aryepiglottic fold

10. Laryngeal Muscles : All muscles are paired except transverse arytenoid Action Muscle Responsible Abductor Posterior Cricoarytenoid Adductor Lateral Cricoarytenoid Interarytenoid ( transverse arytenoids ) Thyroarytenoid ( external part ) Tensor Cricothyroid Vocal Cord relaxation Thyroarytenoid ( internal part) Vocalis Opener of the laryngeal inlet Thyroepiglotticus Closure of the laryngeal inlet Aryepiglotticus Inter arytenoids ( oblique part )

11. Nervous supply of Larynx Nerve (CN X) Superior laryngeal nerve Internal branch: sensation to supraglottis External branch: motor innervation to cricothyroid muscle Recurrent laryngeal nerve Loops around subclavian artery on right/aorta on left and back up in neck in tracheoesophageal groove Motor innervation of all intrinsic muscles of larynx (except cricothyroid ) Sensation to subglottis Superior laryngeal nerve Internal branch External branc h Recurrent laryngeal nerve

12. Arterial supply : Up to vocal folds : By superior laryngeal artery , a branch of superior thyroid artery. ( Cricothyroid artery is a branch of superior laryngeal artery ) Below vocal folds : By inferior laryngeal artery, a branch of inferior thyroid artery Venous supply : Superior laryngeal veins drains to internal jugular vein Inferior laryngeal veins drains to inferior thyroid vein Lymphatic Drainage : Above the vocal cords : Lymphatics here drains to upper deep cervical nodes. Below the vocal cords : The lymphatics drains to the pre-tracheal and pre-laryngeal nodes, enter the lower deep cervical nodes.

13. Histology of Vocal Fold Histologically the vocal fold is said to contain 5 layers: Layer 1: Squamous epithelial lining . It is very thin and helps to hold the shape of the vocal fold. This layer doesnot contain any mucous glands, and hence the mucoid secretions lining the cord must travel from the glands located anteriorly , superiorly and posteriorly to the edges of the vocal fold. Layer 2: Superfical layer of the lamina propria . It is composed of loose fibers and matrix. In clinical parlance it is also referred to as the Reinke's space . This layer contains only minimal elastic and collagenous fibers and offers least resistance to vibration. The integrity of this layer is vital for proper phonatory function.

14. Layer 3: Intermediate layer of lamina propria . It contains a higher concentration of elastic and collagenous fibers when compared to layer 2. This layer is thickened at the anterior and posterior ends of the vocal folds. These thickened regions are known as anterior and posterior macula flava . These structures provide protection to the vocal folds from mechanical damage. Layer 4: Deep layer of lamina propria . It contains a dense collection of elastic and collagenous fibers. This layer along with the intermediate layer constitute the vocal ligament . The vocal ligament is considered to be the upper most portion of conus elasticus ( cricothryoid ligament). Some of the collagenous fibers present here gets inserted into the vocalis muscle. The intermediate and the deep layers of lamina propria cannot be easily separated. Layer 5: Vocalis muscle . The fibers of this muscle run parallel to the direction of the vocal fold. Vocalis muscle is infact a portion of thyro arytenoid muscle.

15. Hirano: cover-body theory of vocal fold vibration • The cover is composed of the overlying epithelium combined with the superficial layer of the lamina propria . •The intermediate and deep layers of the lamina propria , known as the vocal ligament, form a transition zone. •The body is composed primarily of the thyroarytenoidmuscle . •The contrasting masses and physical properties of the vocal fold coverand the bodycauses them to move at different rates as air passes between the vocal folds. • Glotticwave driven by the Bernoulli effect

16. Physiology of the larynx: Respiration. 2. Protection of the lower air passages. 3. Phonation. 4. Fixation of the chest. 5. Sphincteric action.

17. Phonation Definition :   phonation  is the process by which the vocal fords produce certain sounds through quasi-periodic vibration Theories of Phonation : Myoelastic theory The myoelastic theory states that when the vocal cords are brought together and breath pressure is applied to them, the cords remain closed until the pressure beneath them—the subglottic pressure—is sufficient to push them apart, allowing air to escape and reducing the pressure enough for the muscle tension recoil to pull the folds back together again. Pressure builds up once again until the cords are pushed apart, and the whole cycle keeps repeating itself. The rate at which the cords open and close—the number of cycles per second—determines the pitch of the phonation

18. Aerodynamic theory The aerodynamic theory is based on the  Bernouille Theory . The theory states that when a stream of breath is flowing through the glottis while the arytenoid cartilages are held together by the action of the interarytenoid muscles, a push-pull effect is created on the vocal fold tissues that maintains self-sustained oscillation. The push occurs during glottal opening, when the glottis is convergent, whereas the pull occurs during glottal closing, when the glottis is divergent. Such an effect causes a transfer of energy from the airflow to the vocal fold tissues which overcomes losses by dissipation and sustain the oscillation. During glottal closure, the air flow is cut off until breath pressure pushes the folds apart and the flow starts up again, causing the cycles to repeat

19. PHONOSURGERY

20. Introduction As per Scott-Brown textbook of otolaryngology, phonosurgery is defined as “any surgery designed primarily for the improvement or restoration of the voice”. The term is firstly adopted by Godfrey Arnold and Hans von Leden in 1971.

21. Evaluation of Voice Disorders For evaluation of voice disorders, a thorough assessment is essential both s ubjective and objective measures as well as pre and postoperative settings . I . Elementary Diagnostic Procedures II . Clinical Diagnostic Aids. III . Additional Instrumental Measures.

22. Elementary Diagnostic Procedures Patient’s interview. Auditory Perceptual Assessment. (APA) Visual assessment of the vocal tract. External laryngeal examination Clinical Diagnostic Aids . Indirect laryngoscoy & Videostroboscopy . Rigid telescope or nasofibroscope .

23. Additional Instrumental Measures. Acoustic analysis. Aerodynamic analysis. Electromyography. Glottal wave studies: Electroglottography (EGG). Photoglottography (PGG). Inverse filtering technique. videokymography . Radiological Studies -Plain X-ray, -CT scanning -MRI. Videofluroscopy .

24. Goals : Aetiological categoriztion of the pathology. Determine the nature and severity of the disorder. Choice the type and sequence of intervention. Drawing prognostic anticipation. Monitoring the effect of intervention . ( Kotby et al., 1989)

25. Classification Kotby's classification (1995 ) 1 . Extirpation endolaryngeal microsurgery. 2. Vocal fold augmentation. 3. Vocal fold repositioning. 4. Neurophonosurgery . 5. Glottal reconstruction after partial laryngectomy . 6. Postlaryngectomy surgery.

26. Extirpation endolaryngeal microsurgery Prof. Rosemarie Albrecht - Germany (1954) described the first microscopic visualization of the Vocal Folds . Prof. Oskar Kleinsassar - Germany (1962) introduced the modern state of the art method of microlaryngosurgery . Dr. Geza Jako – USA (1962) designed a series of microlaryngeal instruments .

27. Extirpation endolaryngeal microsurgery Instrumentations : Conventional microsurgery/ Laser Indications : Congenital Lesions : Sulcus vocalis Laryngeal web Epidermoid cysts & laryngoceles . Laryngeal stenosis Acquired lesions Granulomata . VF hemorrhage. Papillomatosis . Dysplasia of VF. & Carcinoma in situ. Benign neoplasm

28. Conventional Microlaryngeal surgery Proper instrumentations with a wide range of laryngoscopes and micro-instruments is required. Instruments need to be fine, sharp and well maintained to allow precise removal of lesion with less scaring and without injuring of vocal ligament. A selection of endoscopes with a wide proximal end and distal illumination is desirable and internal distension of the larynx by using largest laryngoscope possible is recommended. Cheap and easily available. Gives similar result in expert hands in comparison to Laser microsurgery.

29. Laser Microsurgery CO2 Laser is most commonly used laser in laryngeal microsurgery. Best used in vascular lesions or lesions that bleeds on removal such as papillomatosis or granulomas , removal of cartilage and excising large areas of tissue. Laser plume in the management of papillomas can be considered potential risk of infection. Laryngeal Microdebrider Power instruments such as microdebrider eliminates the risk of lasers listed above. Microdebrider has been used for various laryngeal lesions including papillomas and there is report that patients have less post-operative pain and quicker return to a usable speaking voice.

30. Laryngeal Microdebrider

31. Vocal Fold Augmentation Wilhelm Brunings (1911) developed the first technique by injecting paraffin using a special syringe. Autologous and alloplastic materials. Transoral or percutaneous approaches

32. Indications : Vocal fold paralysis Vocal fold paresis Vocal fold atrophy Vocal fold scar Adjunctive augmentation after prior surgery Trial basis Contraindication : Mobile or potentially mobile VF. Cricoarytenoid joint fixation. Post- hemilaryngectomy . Inflammatory diseases and medical conditions . Note: Done when there is absence of arytenoid fixation and there is adequate residual vocal fold structure to allow for needle placement.

33. The ideal injectable material : Readily available Inexpensive Inert Easy to use Completely biocompatible Injectable materials are broadly classified into temporary and permanent types.

34. Temporary injectable substances Material Length of effect Advantage Disadvantage Gel Foam 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 ) { Most commonly used } 2-3 months No allergy test Little/no inflammatory response. More preparation time Hyaluronic acid gel 4-6 months No allergy test Limited experience

35. Long term/ permanent injectable substances Material Length of effect Advanatge Disadvantage 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. ) { Most commonly used } 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

36. Arnold (1961) used teflon . Fukuda (1970) used silicon. Schramm et al. (1978) used gelfoam/glycerin paste. Ford and Bless (1986) used bovin collagen. Brandenburg et al. (1992) used autologous fat injection. Ford et al (1995) used autologous collagen . Tsunoda et al. (2001) implant harvested temporalis fascia.

37. 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.

38. 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. 47

39. Routes of administration : Transthyroid – through inferior half of thyroid cartilage. It’s performed through lateral approach , level of vocal fold is determined by palapting thyroid notch and inferior border of thyroid cartilage. Trans cricothyroid membrane puncture – becoming popular method. It’s performed through anterior approach, vocal folds approached from below. Transthyrohyoid membrane puncture - usually not done routinely because there is danger of injection into Reinke’s space.

40. 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 decreasing immediate 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.

41. Precautions - Vocal Cord Injection Avoid unnecessary tension at the anterior commissure . 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 materils is placed in paraglottic space lateral to vocalis muscle and For intra- cordal injection , site is superficial , just deep to lamina propria avoiding Reinke’s space .

42. Complications of vocal fold injection Under injection requiring repeat procedures Over injection causing airway compromise – Immediate management  incise mucosa and remove excess material with suction Late management  CO2 laser or cupped forcep removal or thyrotomy . Improper placement causing subglottal extension and stenosis . If given in Reinke’s space – cause granuloma formation leading to impaired Vocal Cord vibrations .

43. Vocal Fold repositioning Medialization surgeries ( Mediopexy ) 1. Surgical augmentation 2. Arytenoid adduction Lateralization ( Lateropexy ) 1. Arytenoid repositioning. ( Ejnell , 1984) 2. Arytenoidectomy with posterior partial cordectomy . Sharp dissection ( Kleinsasser , 1968) Laser excision. ( Ossff et al. 1984)

44. Medialization surgeries ( Mediopexy ) 1- Surgical augmentation Materials: autograft cartilage or alloplastic implant. Techniques: Anterior approach. ( Meurman , 1952) Anteroinferior approach. ( Hiroto , 1976 ) Window technique. ( Isshiki , 1977, Kaufman, 1986 ) 2- Arytenoid adduction( Isshiki , 1978) Traction of the muscular process of the arytenoid antero - medio -inferiorly. It can be augmented by simultaneous thyroplasty IV.

45. Laryngeal Framework Surgery History Payr (1915) reported the first medialization procedure by anteriorly based cartilage flap. Meurman (1952) implanted free rib grafts beneath the inner thyroid perichondrium . Opheim (1955) placed thyroid cartilage medial to the inner perichondrium . Montgomery (1966) repositioned the arytenoid and fixed it to the cricoid cartilage with a pin. Isshiki et al (1975) achieved medialization by displacing and stabilizing a rectangular window at the level of VF. Kaufman (1986) derived a formula for calculating the appropriate size of the window.

46. Laryngeal framework surgery is altering vocal fold position, shape and tension by manipulating the cartilagenous framework. Isshiki’s functional classification of Thyroplasty : Type I - Medialization . Type II – Lateralization. II a – Lateral approach II b – Medial approach Type III - Relaxation (shortening). Type IV – Tensioning (lengthening). IV a – Cricoid approximation IV b – Tensioning by lateral approach

47. 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 Contralateral vocal fold. - h/o radiation therapy to larynx.

48. Manual Compression Test T his test results in a preoperative improvement in voice suggest that surgery will be successful

49. 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.

50. Pre- Operative Surgery done under local anaesthesia with patient AWAKE -patient need to phonate -Use 1% lignocaine with Epinephrine 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

51. Technique A para -median horizontal incision over the middle aspect of thyroid lamina. Superior and inferior flaps elevated in subplatysmal plane

52. Sternohyoid muscle is elevated off the thyroid cartilage.

53. 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.

54. Type I Thyroplasty: Window Outline before cutting. Goal : Window at the level of the True VF, to medialize only the True VF. 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.

55. 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

56. -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)

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

58. 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.

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

60. Originally, after the window was cut, the cartilage of the window was pushed in by a cartilage shim or later an implant. Ita 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.

61. 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.

62. 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.

63. Factors affecting outcome 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

64. 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 Type I Thyroplasty : Complications

65. 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.) 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.

66. Incomplete glottal closure after type I thyroplasty Occurs in patients undergoing acute implantation 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.

67. 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.Unilateral vocal fold palsy. 3.Atrophic vocal fold. 4.Post RT scar tissue. Result: Significant improvement in phonation time.

68. 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 .

69. 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.

70. Type II Thyroplasty Type II - Lateralization Release the tight closure of the glottis. Approaches: • Two paramedian vertical incisions and interpose the lateral segments beneath the anterior segment. ( Thyroplasty type Ia ) • A vertical incision in the thyroid cartilage and lateralizing the posterior segment over the anterior one ( Thyroplasty type IIa ) Indication: Spastic dysphonia .

71. 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)

72. Vocal Cord Abduction 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.

73. 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.

74. 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.

75. Types of Cordectomy 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 .

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

77. Type III Thyroplasty 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

78. 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.

79. 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.

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

81. Type IV Thyroplasty Type IV - Stretching (lengthening) Increases the vocal pitch. It increases the distance between the vocal fold attachments and thus raise the tension of vocal fold. Indications: • Abnormallly lax or bowed vocal folds (as in presbyphonia ) • Androphonias & Male to female transexualism

82. 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.

83. - 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.

84. 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.

85. Techniques to elevate the pitch: Inferiorly based anterior cartilage flap. ( LeJeune et al., 1983) Superiorly based cartilage flap. (Tucker, 1985) Anterior commissure advancement. ( LeJeune et al., 1987)

86. 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.

87. 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.

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

89. 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.

90. 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”.

91. Neurophonosurgery Reinnervating the PCA muscle Nerve anastomosis . Phrenic nerve / ansa cervicalis . Phrenic nerve implantation. ( Crumley , 1983) Neuromuscular pedicle Transplantation. (Tucker, 1977) Reinnervating the TA muscle Ansa cervicalis to RLN anastomosis . ( Crumley , 1991) Infrathyroid - suprathyroid techniques Neuromuscular pedicle Transplantation. ( Crumley , 1985)

92. Reconstructive Phonosurgery Reconstruct the resected VF after partial or hemilaryngectomy . Hirano et al. (1976) used the sternothyroid muscle covered by an island flap of the overlying neck muscle. Friedman et al. (1985) utilized the contralateral superior thyroid cornu . El Kahky et al. (1989) used the ipsilateral pyriform sinus mucosal flap with intact superior laryngeal neurovascular bundle.

93. Postlaryngectomy Surgery Shunting the tracheal air to the pharynx or esophagus. Neoglottis . TE mucosal lined canal. (Conley et al., 1958; Asia, 1972; Staffieri and Serafini, 1976 ; Roka et al., 1985) Voice Prothesis in TE puncture. - Blom-Singer voice prothesis. (Blom et al., 1982) - Panje voice button prothesis . ( Panje et al., 1981)

94. THANK YOU

95. Resources Drtbalu.com Textbook of Scott Brown’s otolaryngology: Head and Neck surgery 7 th edition Anatomy and physiology of Larynx ppt by Dr. Hiwa As’ad Phonosurgery ppt by ENT dept , Alexandria University Phonosurgery ppt by SUSAN NGUYEN, MD and JAMES DENNENY, MD Phonosurgery ppt by Dr. Vaibhav