Phonosurgery

Introduction
• Phonomicrosurgery encompasses a variety of operations that has the
primary goal of improving voice quality.
• These are elective operations that involve precision microsurgical
removal of benign vocal fold pathology — most often from the
subepithelial space of the vocal fold.
• Maintenance of good acoustic and visual records is important in order
to make an objective assessment of modifications produced by surgery.

Introduction
3
The concept of
phonosurgery emerged in
early 1970s with the
introduction of suspension
microlaryngoscopy and the
operating microscope.

Anatomy …
• Cartilages &
membranes -
4

Anatomy …
• Cricothyroid joint -• Cricoarytenoid joint movements -
5

Anatomy …
• Intrinsic muscles of larynx -
6

Anatomy …
• Actions of intrinsic muscles -
7

Anatomy …
• Nerves of larynx -
8

Anatomy …
• Microstructure of VF –
9

Anatomy …
• Endoscopic view -
10

Stroboscopy
• Stroboscopy is a special method used to visualize vocal fold vibration.
It uses a synchronized, flashing light passed through a flexible or rigid
telescope.
• Characteristics of VF that are to be seen are –
• VF closure (pattern and duration)
• Mucosal wave movement (propagation)
• Symmetry of vibration
• Amplitude of VF vibration
• Periodicity
11

Vocal nodules singer’s or screamer’s nodes
• Commonly seen in teachers, actors, vendors, school children
• In children it appears as spindle shaped thickenings of the edges of the
vocal cords
• In adults they appear as more localised thickenings, varying from small
points to nodules.
• They typically appear at the junction of the anterior and middle 1/3 of
the vocal cords.
• They appear almost always symmetrically.

Vocal nodules singer’s or screamer’s nodes …
• Submucosal edema occurs first followed by neovascularisation. Till this
phase, it is reversible nonsurgically.
• If fibrinous change has occurred, then surgical method required.
Stroboscopy -
• Hourglass closure pattern
• Local oedematous swelling of recent onset vibrates
in phase with the whole vocal fold
• Older fibrous swelling can impede the vibrations so
much that only a part of the cord is seen to vibrate.

Clinical features:
• 1.Change in voice
• 2.Fatiguability of voice
• 3.Decreased pitch range
Management:
• 1.Voice rest plays a main role in the management of vocal nodule
• 2.Speech therapy
• 3.If the vocal nodule becomes permanent then microlaryngeal removal
is advocated.

• Lesion grasped with a small
curved alligator and pulled
medially with a microscissors
lesion excised
• Any residual mucosal irregularities
at the excision site excised with
microscissors while holding with a
cup forceps.

VOCAL FOLD POLYP …
• Exophytic lesion with thin mucosa.
• Typically unilateral but can be bilateral.
• Stroboscopic features – minimal dampening of overall mucosal wave
and an hourglass closure pattern.
• Physically, at the time of surgery, a disorganized
gelatinous material is found within the
sub-epithelial space.

VOCAL FOLD POLYP …
• Changes in voice – harsh quality, deeper pitch and achieving high tones
is almost impossible
• Microflap technique is employed to remove the VF polyp.

VOCAL FOLD POLYP
• Polyp material is now removed
with a cup forceps
• Redrape the microflap back over
the vocal fold

VOCAL FOLD POLYP
• Trim abnormal mucosa having
polyp material that will not serve
as normal mucosa during the
postoperative healing.
Postoperative care –
• Voice rest ranging from 2 to 7 days.
• Perioperative laryngopharyngeal reflux,
consisting of proton pump inhibitor
Complications :
• Excessive vocal fold scar formation
• Granulation tissue at the operative site
• Vocal fold hemorrhage in the region of
the surgery

REINKE’S OEDEMA …
• Polypoid corditis or Reinke’s edema is a diffuse collection in the sub-
epithelial space of VF
• 97% of patients with polypoid corditis are smokers.
• In addition, LPR and phonotrauma are thought to be important
contributing cofactors.
• Saddle-bag appearance of vocal cords seen.

• Stroboscopy shows enlarged vocal fold and abnormal wave pattern.
• Voice changes – harsh voice quality with deeper pitch
• Treatment is by microflap technique.

• Incision at the superior aspect of
the vocal fold, beginning at the
vocal process and extending to
within 3mm of the anterior
commissure.
• Raise the microflap between the
epithelium and the polypoid
material.

• Polypoid material removed with
a suction of strong negative
pressure.
• Trimming of redundant mucosa
which can be quite extensive in
advanced cases of polypoid
corditis. This mucosa should be
conservatively trimmed so that
the epithelial edges coapt at the
end of the case.

• The incised edges of the flap
should coapt closely, without a
significant mucosal dehiscence.
• Stroboscopy after the surgery -

• The patient will experience a breathy voice postoperatively, primarily
due to pre-op high subglottic pressures that are used to drive the
vibration of the polypoid material.
• The pitch of the voice will be significantly higher due to the loss of
mass after the surgery.
• Recovery and stabilization of voice takes longer than with most other
benign lesions, typically 6–8 weeks.
• Most serious complication is anterior glottic web, best way to avoid this
complication is not to extend the incisions to the anterior most aspect
of both vocal folds.

VOCAL FOLD GRANULOMA …
• Inflammatory tissue arising from the perichondrium
near the arytenoid cartilage.
• Classically seen after endotracheal intubation.
• Most common causes - laryngopharyngeal reflux, vocal misuse or
hyperfunction, glottal incompetence with severe hyperfunction
• Patients experience globus sensation, dysphonia, and/or odynophonia.
• Surgery should be performed if concern exists regarding a malignancy
or infection, or all nonsurgical treatment options have been exhausted.

VOCAL FOLD GRANULOMA …
• For removal of the vocal fold granuloma, it is
best to use a curved alligator (curved in the
opposite direction of the side that the vocal
fold granuloma is on) and gently grab the
stalk that runs between the vocal fold granuloma and the arytenoid
cartilage.
• Preferably, the alligator will grasp the stalk on its most medial aspect.
• The vocal fold granuloma stalk can then be gently retracted towards
the midline, and a curved microscissors (curved in the same direction
as the curved alligator) is then used to release or cut the stalk
immediately lateral to the curved alligator, thus allowing the removal
of the vocal fold granuloma.

SULCUS VOCALIS …
• Sulcus vocalis – absorption or loss of lamina propria
resulting in a deep, linear furrow along the free edge
of the vocal fold.
• Unique to sulcus vocalis is formation of mucosal bridge, a thin band of
mucosa that runs parallel to vocal fold.
• The pathologic process involve derangement
and abnormalities of lamina propria resulting
in dysphonia, glottic insufficiency and severe
abnormality in the pliability of the vocal fold.

SULCUS VOCALIS …
Stroboscopic findings –
• Mucosal wave altered
• Bowed or curved vocal fold
• Increased stiffness
• Glottic incompetence – air leakage through
the midline
Voice quality – strained with vocal fatigue.

SULCUS VOCALIS …
Incision line along lateral and
superior edge of the sulcus
Excision of the tissue through the
incised line
Dissection continued between
vocal ligament and epithelium
which is carefully retracted
medially

SULCUS VOCALIS …
Collagen injected into the
vocal ligament
Redraping of the epithelium
Final contour

Thyroplasty …
• Definition – phonosurgical technique designed to improve the voice by
altering the thyroid cartilage of the larynx thereby changing the
position or the length of the vocal cords.
• Isshiki classification –
• Type 1 - Medialisation laryngoplasty
• Type 2 - Lateralisation laryngoplasty
• Type 3 - Shortening of the VF
• Type 4 - Lengthening of VF
• General goal – to improve phonatory glottal closure by altering VF
position.

Type 1 thyroplasty (medialisation)
• Indications – U/L VF paralysis
• Complaints – breathy dysphonia, vocal fatigue, aspiration of fluids
• Position of paralysed VF – median to lateralised, height slightly above
to contralateral VF
• Techniques –
• Injection techniques using autologous fat, Teflon and gelfoam.
• Using silastic prosthesis or goretex

Silastic medialisation thyroplasty
• Horizontal incision at level of midthyroid cartilage
5-6 cm in length.
• Flaps elevated exposing laryngeal cartilage.
• Larynx retracted with a single
prong hook.

Silastic medialisation thyroplasty …
• Posteriorly based outer
perichondrial flap is raised with
an elevator
• A window outlined in the
thyroid cartilage, measuring 6 x
13 mm., placed 3mm above
inferior border of thyroid. Any
higher placement of window
may result in medialisation of
false VF

• This window of cartilage is
removed (15 blade or kerrison
rongeur or drill). A small triangle
of cartilage incised from
posterosup aspect using a
woodson elevator.

A cutting burr is used to outline
the window in cases where the
cartilage is calcified
A Woodson elevator is then
used to gain entry into the
paraglottic space, when the
cartilage is sufficiently
thinned

• Undermining within the
paraglottic space (deep to the
inner perichondrium) superiorly,
posteriorly, and inferiorly.
• Undermine the paraglottic space
from below, to ensure release of
cricothyroid
fibres using
long or cottle
elevator.

• A depth gauge is used to displace the
paralysed TA muscle medially, while patient
counts 1 to 10. Visual feedback from
videolaryngoscopy monitor and patient’s
vocal quality are used to judge correct
amount of medialisation needed.
• Prosthesis placed
through the window
and the length is
measured

• Sculpting of the
final implant
contour is done.
• Trimming of excess
implant
• Securing the
implant to the
lower strut with two
4-0 Prolene sutures

GORETEX medialisation laryngoplasty
• Mcculloch & Hoffman first reported it.
• Advantages over silastic – faster, creates less edema and therefore
decreases chance of overcorrecting anterior commissure and allows
placement of implants closer to the vocal process without limiting their
abduction.
• Gore-Tex is a waterproof, breathable fabric membrane, able to repel
liquid water while allowing water vapor to pass through, and is
designed to be a lightweight, waterproof fabric.
• It is composed of stretched polytetrafluoroethylene (PTFE).

GORETEX medialisation laryngoplasty …
Surgical procedure –
• Incision – 3-5cm Horizontal at the level
of midthyroid cartilage

• Subplatysmal flaps raised on both sides
• Strap muscles separated
• Laryngeal cartilage exposed
• Inferiorly based cathedral arch-shaped outer perichondrial
flap is elevated from the thyroid ala.

• Laryngoplasty window location is determined by needle localisation
under direct vision with flexible laryngoscope.
• Similar window to that of ML is created.
• Goretex is placed

• VF are slightly overcorrected to compensate for intraoperative edema
and implant compression.
• Implant stabilised by suturing the outer perichondrial flap back into
place using 4-0 nylon sutures.
• Final contour of VF after goretex is layered
into the window.

Common errors –
• Medialisation too far superiorly  laryngoscopic image shows
medialised false VF or bulging of ventricular mucosa.
• Excess medialisation of anterior commissure  pressed or strained
voice.
• Posterior extent of implant must not contact vocal process of arytenoid
cartilage, as it may restrict the arytenoid motion and lead to airway
difficulties.

Arytenoid adduction
• Outer perichondrium incised
along posterior border of cartilage to prevent
elevation of inner perichondrium.

Arytenoid adduction
Access to arytenoid –
• Through creation of window in posterior thyroid ala
Cartilage rem0ved with a kerrison
rongeur until muscular process
becomes palpable
Posterior aspect of
this window located
on the same level of
ML window
Both windows should not be allowed
to connect as this may lead to
framework instability

Arytenoid adduction
• Pyriform sinus mucosa identified and retracted
posteriorly avoiding it’s perforation
• This mucosa can be seen extending anteriorly
onto the posterior cricoarytenoid muscle
• To aid in its identification, patient asked to blow
against pursed lips which results in distension
• Mucosa grasped and and bluntly dissected posteriorly
with a kitner
• Pyriform then shielded under a sewell retractor
Axial view

Arytenoid adduction
• Muscular process identified, it is usually at the same vertical
height of VF and found by tracing the fibres of PCA muscle.
• Muscular process then grasped with a toothed forceps,
and rotating it anteriorly, arytenoid rotation
medially can be visualised in the monitor
• To obtain a secure purchase on the muscular process, a
4-0 monofilament suture (double armed) is passed
through the lateral edge of the muscular process in a
figure of 8 fashion
Axial view

Arytenoid adduction
• Needles passed through the ML window.
• A 1-mm wire-passing drill bit is used to create an anterior
passage for one arm of the AA suture near the midline.
• Other needle passed underneath the
inferior strut and secured anteriorly
through anterior cricothyroid membrane

Arytenoid adduction
• Finally, AA suture tension is adjusted and the knot is secured over
anterior thyroid cartilage, again assessing the voice.
• Sternohyoid muscle is reattached.
• Wound closed in layers.

Cricothyroid subluxation
• Principle – to lengthen VF by increasing distance from CA joint to
anterior commissure by subluxating CT joint on the side of U/L VF
paralysis.
• It is an adjunct procedure to ML mostly or AA
Separation of cricothyroid joint –
• Done by a scissors or cottle elevator
• Care should be taken to ensure inferior
cornu is completely free from soft tissue
attachments

• A 2-0 prolene suture is passed around neck of inferior
cornu with a clamp
• Suture positioned as superior as possible on the neck
of inferior cornu
• Needle passed in a submucosal plane under the
anterior aspect of the cricoid ring.

• Free end of the suture tied at inferior cornu is then tied to
end of the suture passed underneath the anterior cricoid
cartilage.
• Voice and VF length should be evaluated as tension applied
to the knot.
• Anterior subluxation results in VF length-
ening and expanded pitch range.
• Once an optimum tension is found, suture
secured with several surgical knots.
before after

Type 2 (Lateralisation) laryngoplasty …
Indications – bilateral VFP
Treatment options for BVFP –
• posterior transverse cordotomy
• medial arytenoidectomy
• total arytenoidectomy
• Endoscopic suture lateralisation – if temporary treatment needed
• Open arytenoidectomy – if endoscopic fails
Ideal, better
voice results

Posterior transverse cordotomy –
• Incision is started just anterior to vocal process, being careful not to
expose the cartilage, to avoid granulation tissue postoperatively.
• Extension of cordotomy –
• Once the entire VF is separated from vocal process, the cordotomy
is extended into false vocal tissue
• Frequently, a branch of SLA is encountered, and bleeding can occur
for which suction & bipolar laryngeal cautery used.

• A complete cordotomy extends laterally 3-4mm into false VF tissue.
• Residual VF will retract anteriorly and appears shortened.
• Topical mitomycin-c is placed (0.4mg/ml) via a soaked pledget for 5
min.

Endo-extralaryngeal suture lateralisation (based on the technique of
Lichtenberger) –
• It is a temporary measure for airway improvement in early BVFP cases
• So indicated in early BVFP cases with uncertain
prognosis for recovery
• Endo-extra laryngeal needle carrier device
(Richard wolf) is loaded with a 2-0 prolene suture.
• Under microscopic visualisation, needle is positioned
below posterior VF at a point just anterior to vocal process.

• Needle pushed through larynx
until tip of needle appears
externally through skin of the
neck and temporarily
secured with a clamp.
• Same initial suture is now placed
above the VF through the
ventricle at the region of vocal
process.

• Same lateralisation suture placed
in a similar fashion 1-2mm
anterior to the first suture.
• Traction placed on 2 sutures to
create lateralisation of posterior
VF and expansion of static
airway dimensions.
• A 2cm horizontal incision given
on the neck, sutures pulled deep
to the skin incision. 2 ends then
tied with a surgeon’s knot over
sternohyoid muscle,
using a silicone
button as an anchoring
point.

Type 3 (shortening) thyroplasty
• Indications – female to male transsexuals so that high pitched female
voice is converted into low pitched male voice.
• Procedure – bilateral vertical cuts made at junction of
anterior one-third and posterior two-thirds of thyroid.
• A 2-4mm wide vertical strip of cartilage resected and both
thyroid laminae reapproximated and fixed with titanium
miniplates.
• This shortens AP distance of glottis and
releases tightened VFs.

Type 4 (lengthening) laryngoplasty
• Indications – male to female transsexuals so that low pitched voice is
converted into high pitched voice.
• Procedure – after vertical cuts, a 4mm wide silicone strip is inserted
between 2 divided laminae and sutured with 4.0 nylon or by placing
miniplates so that expansion of thyroid ala is maintained.

Phonosurgery

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