1. Nova Medical Centers
KAILASH COLONY
©2009. Nova Medical Centers. Strictly private and confidential

2. Laryngeal Surgery
an Overview
Dr. Lalit Mohan Parashar
Senior Consultant OTORHINOLARYNGOLOGY &
©2009. Nova Medical Centers. Strictly private and confidential
Dr. Lalit Mohan Parashar
Head and Neck Surgery
(ORL&HNS)
Deptt of Otorhinolaryngology and
Head & Neck Surgery

3. The Problem spectrum
• Hoarseness and Voice Disorders
• Breathing difficulty & stridors
• Malignancies and cancers
• Iatrogenic- Thyroid surgery and ICU survivers
&
• Traffic and other accidents.
©2009. Nova Medical Centers. Strictly private and confidential

4. Effective Diagnosis
• Begins at OPD
• Clinched in Endoscopy Rooms
• Confirmed with/ without Stroboscopy &
• Refined in Voice Lab
©2009. Nova Medical Centers. Strictly private and confidential

5. ©2009. Nova Medical Centers. Strictly private and confidential
THE ENT OPD

6. ©2009. Nova Medical Centers. Strictly private and confidential
THE ENT OPD

7. ©2009. Nova Medical Centers. Strictly private and confidential
Endoscopy

8. ©2009. Nova Medical Centers. Strictly private and confidential
Endoscopy Room
Normal larynx during phonation3.flv

9. Laryngoscopy workout
• Sustained eee….
• Quiet Respiration
• Glide- Sustained eee at low & High pitch
• Cough / laugh
• Stroboscopic Evaluation
©2009. Nova Medical Centers. Strictly private and confidential

10. ©2009. Nova Medical Centers. Strictly private and confidential
Video –endoscopy- stroboscopy

11. Recording and Replay
• Much More Informative.
• Longitudinal Comparison
• Pre-op planning
• Patient Education
• Medical / Legal uses
©2009. Nova Medical Centers. Strictly private and confidential

12. ©2009. Nova Medical Centers. Strictly private and confidential
Vocal Cord Growth

13. ©2009. Nova Medical Centers. Strictly private and confidential
Dysphonia Plica Venticulare

14. Laryngeal Surgery
Kotby's classification
1. Extirpation endolaryngeal microsurgery.
2. Vocal fold augmentation.
3. Vocal fold repositioning.
4. Neurophonosurgery.
5. Glottal reconstruction after partial laryngectomy.
6. Postlaryngectomy surgery.
7. Laryngo Tracheal Trauma
©2009. Nova Medical Centers. Strictly private and confidential

15. ©2009. Nova Medical Centers. Strictly private and confidential
Micro Laryngeal Surgery

16. ©2009. Nova Medical Centers. Strictly private and confidential
Micro Laryngeal Surgery

17. Extirpation Endolaryngeal Microsurgery
conventional microsurgery(MLS)
• Indications:
• Congenital Lesions:
• Sulcus vocalis & vergeture. Laryngeal web
• Epidermoid cysts & laryngoceles. Laryngeal
stenosis
©2009. Nova Medical Centers. Strictly private and confidential
• Acquired lesions
• Granulomata. :Benign neoplasm
• • VF hemorrhage. • Papillomatosis.
• • Dysplasia of VF. & Carcinoma in situ. •

18. G.A. considerations
• Oral Intubation with MLS tube ( high volume low pressure
Cuff ) or
• Jet Ventilation – Sub –Glottic Ventury or
-- Supra Glottic Ventury via
laryngoscope
©2009. Nova Medical Centers. Strictly private and confidential

19. Tube Position
• Anterior Vocal cords 2/3rd :- small ETT
• Posterior Vocal Cords :- Anterior ETT or
» Jet Ventillation or
» Apneic Techniques
©2009. Nova Medical Centers. Strictly private and confidential

20. Other Considerations
• Laser Protected ETT
• Care of Sub Glottis and
• Care of tracheal Stoma
• Difficult Per Oral exposure
©2009. Nova Medical Centers. Strictly private and confidential

21. Difficult Per Oral exposure
• Short Thick Neck
• Retrognathia
• Trismus
• Restricted Neck Extention
• Lingual Hypertrophy
• Poor Palatal visualisation
©2009. Nova Medical Centers. Strictly private and confidential

22. Long list of requirements
• Largest Bore Laryngoscope + ant. & post. Comm.
• Suspension Systems
• Specialized Instruments
• Mouth/ dental Guard
• Subepithelial Infusion needle
©2009. Nova Medical Centers. Strictly private and confidential
• Operating Microscope – 400mm lense
• Optical Telescope – 4mm x 20 cms
• Microdebrider/ laser system

23. ©2009. Nova Medical Centers. Strictly private and confidential
Microflap Excision

24. ©2009. Nova Medical Centers. Strictly private and confidential
Microdebrider

25. ©2009. Nova Medical Centers. Strictly private and confidential
Laser Assisted

26. ©2009. Nova Medical Centers. Strictly private and confidential
Robotics

27. Vocal Fold Augmentation
• Indications:
• Correction of glottic incompetence due to:
• Unilateral vocal fold paralysis.
• Sulcui or after surgery or trauma.
• Autologous and alloplastic materials.
©2009. Nova Medical Centers. Strictly private and confidential
• Transoral or percutaneous approaches.
• Silicon, Teflon, Gelfoam, Autologous Fat

28. ©2009. Nova Medical Centers. Strictly private and confidential
Injection Medialisation

29. Repositioning of the Vocal Fold
Medialization surgeries (Mediopexy)
1. Surgical augmentation
2. Arytenoid adduction
Lateralization (Lateropexy)
1. Arytenoid repositioning.
2. Arytenoidectomy with posterior partial cordectomy.
©2009. Nova Medical Centers. Strictly private and confidential
Sharp dissection
Laser excision.

30. ©2009. Nova Medical Centers. Strictly private and confidential
Laser Assisted

31. Thyroplasty
(Laryngeal Framework Surgery)
Altering VF position, shape and tension by
manipulating the cartilagenous framework.
Isshiki’s functional classification:
• Type I - Medialization.
• Type II - Lateralization.
• Type III - Relaxation (shortening).
• Type IV - Stretching (lengthening).
©2009. Nova Medical Centers. Strictly private and confidential

32. ©2009. Nova Medical Centers. Strictly private and confidential
Thyroplasty
(Laryngeal Framework Surgery)

33. ©2009. Nova Medical Centers. Strictly private and confidential
Medialisation Laryngoplasty

34. ©2009. Nova Medical Centers. Strictly private and confidential
Medialisation Laryngoplasty

35. ©2009. Nova Medical Centers. Strictly private and confidential
Medialisation Laryngoplasty

36. ©2009. Nova Medical Centers. Strictly private and confidential
Medialisation Laryngoplasty

37. ©2009. Nova Medical Centers. Strictly private and confidential
Medialisation Laryngoplasty

38. ©2009. Nova Medical Centers. Strictly private and confidential
Medialisation Laryngoplasty

39. ©2009. Nova Medical Centers. Strictly private and confidential
Medialisation Laryngoplasty

40. Type II - Lateralization
Release the tight closure of the glottis.
Approaches:
• A vertical incision in the thyroid cartilage and
lateralizing the posterior segment over the anterior
one.
• Two paramedian vertical incisions and interpose
©2009. Nova Medical Centers. Strictly private and confidential
the lateral segments beneath the anterior segment.
Indication:
• Spastic dysphonia.

41. Type III - Relaxation (shortening)
Aimed at lowering the vocal pitch.
The VF is relaxed by A-P shortening of the thyroid ala.
Indications:
• Males with high pitch voice, resistant to voice therapy.
• Stiff VF with high pitched breathy voice.
• Spastic dysphonia.
©2009. Nova Medical Centers. Strictly private and confidential

42. Type IV - Stretching (lengthening)
CT approximation to elevate pitch.
Other Techniques to elevate the pitch:
• Inferiorly based anterior cartilage flap.
• Superiorly based cartilage flap.
©2009. Nova Medical Centers. Strictly private and confidential
• Anterior commissure advancement.

43. Laryngeal Surgery
Kotby's classification
1. Extirpation endolaryngeal microsurgery.
2. Vocal fold augmentation.
3. Vocal fold repositioning.
4. Neurophonosurgery.
©2009. Nova Medical Centers. Strictly private and confidential
5. Glottal reconstruction after partial laryngectomy.
6. Postlaryngectomy surgery.
7. Laryngo Tracheal Trauma

44. Neurophonosurgery
• Reinnervating the PCA muscle
• Nerve anastomosis. Phrenic nerve /ansa cervicalis.
• Phrenic nerve implantation.
• Neuromuscular pedicle Transplantation.
• Reinnervating the TA muscle
©2009. Nova Medical Centers. Strictly private and confidential
• Ansa cervicalis to RLN anastomosis
• Infrathyroid - suprathyroid techniques
• Neuromuscular pedicle Transplantation.

45. ©2009. Nova Medical Centers. Strictly private and confidential
Laryngo Tracheal Trauma

46. Laryngo Tracheal Trauma
• Increasing accidents
• Time to prepare ourselves is NOW
• Minor Ones or Group I need conservative management
©2009. Nova Medical Centers. Strictly private and confidential

47. Group II
Intact endolarynx + Displaced thyroid #
• Open reduction + internal fixation ORIF
• Method
– Sutures
©2009. Nova Medical Centers. Strictly private and confidential
– Wires
– Miniplates

48. Group II
Intact endolarynx + Displaced thyroid #
• ORIF
• AIM – preservation of AP diameter
Maintain Normal position of cords
©2009. Nova Medical Centers. Strictly private and confidential
Austin technique

49. Group III
Large mucosal lacerations
• Or even small Lacerations involving
– Anterior commissure
– Free margins of TVC
– Exposed cartilage
– Multiple #
– TVC immobility
• Managed by ORIF + Open laryngeal exploration within 24 hours
©2009. Nova Medical Centers. Strictly private and confidential

50. Group III
Large mucosal lacerations
• AIM
– Return all remaining tissue to appropriate location
– Cover all cartilage
©2009. Nova Medical Centers. Strictly private and confidential
• FUNCTIONAL PRINCIPLES

51. FUNCTIONAL PRINCIPLES
• BLOOD IN CONTACT WITH CARTILAGE LEADS TO RESORPTION
• CARTILAGE IN CONTACT WITH SECRETIONS LEADS TO INFLAMMATION
WHICH LEADS TO GRANULATIONS
MESSEGE
©2009. Nova Medical Centers. Strictly private and confidential
CARTILAGE HAS TO BE COVERED AT ALL COSTS

52. Group III
Large mucosal lacerations
• MIDLINE THYROTOMY or
• Pramedian if vertical # within 3mm of midline
• Steps of MIDLINE THYROTOMY
©2009. Nova Medical Centers. Strictly private and confidential

53. MIDLINE THYROTOMY
• Horizontal skin incision at crico-thyriod m.
• Sub platysmal flaps
• Separate strap muscles & expose thyroid c.
• Midline Thyrotomy saw or drill
• Retract laminae laterally
©2009. Nova Medical Centers. Strictly private and confidential
• Achieve haemostasis

54. Group III
Large mucosal lacerations
• Situation 1
– Primary closure is generally possible
– 5-0 or 6-0 absorbable sutures
– Minimal undermining to move mucosa
– Dibridement should be kept to minimum
– DRAIN BLOOD COLLECTIONS
©2009. Nova Medical Centers. Strictly private and confidential
– Keep mucosa down by quilting sutures

55. Group III
Large mucosal lacerations
• Situation 2
– Primary closure is not possible
– Rotate flaps from - Epiglottis
- pyriform sinuses
©2009. Nova Medical Centers. Strictly private and confidential
– Skin flaps
– Mucosal grafts

56. Group III
Large mucosal lacerations
• Situation 3
• Arytenoid cartilage dislocated
– Reduce it back
– Repair mucosa
©2009. Nova Medical Centers. Strictly private and confidential

57. Group III
Large mucosal lacerations
• Reconstruct anterior commissure
– 4-0 absorbable sutures from anterior TVC to outer perichondrium - keel
• Close thyrotomy
– Non absorbable sutures
– SS wire
– Wire tube tech.
©2009. Nova Medical Centers. Strictly private and confidential
• ORIF if required

58. ©2009. Nova Medical Centers. Strictly private and confidential
Thank You