Atlas of Endoscopic Laryngeal Surgery

Atlas of
Endoscopic
Laryngeal Surgery
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Atlas of
Endoscopic
Laryngeal Surgery
Robert T Sataloff MD DMA FACS

Professor and Chairman
Department of Otolaryngology – Head and Neck Surgery
Senior Associate Dean for Clinical Academic Specialties
Drexel University College of Medicine
Philadelphia, Pennsylvania, USA
Farhad Chowdhury DO
Assistant Professor
Shruti Joglekar MBBS MD DORL

Instructor
Mary J Hawkshaw BSN RN CORLN

Research Associate Professor
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Atlas of Endoscopic Laryngeal Surgery
© 2011, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or
by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors
and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error (s). In case
of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2011

ISBN: 978-93-5025-092-1
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Printed at
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This book is dedicated to
Dahlia, Ben and John Sataloff
Saba, Mikael, Shahed and Irfat Chowdhury
Siddharth and Rayva Joglekar, and
Dr JoglekarÊs parents and teachers
and
Judy Hawkshaw Johnson
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Contributors
Jean Abitbol MD Yolanda D Heman-Ackah MD

Otorhinolaryngologiste - Phoniatre Associate Professor
Ancien Assistant des Hôpitaux de Paris Department of Otolaryngology
Ancien Chef de Clinique à la Faculté de Médecine de Paris Head and Neck Surgery
Chirurgie Laser-Chirurgie Cervico-Faciale Drexel University College of Medicine
Chevalier de la Légion d’Honneur Philadelphia, Pennsylvania, USA
President of the International Society for Laser Surgery and
Medicine Shruti Joglekar MBBS MD DORL
Adjunct Professor, Department of Otolaryngology Instructor
Head and Neck Surgery Department of Otolaryngology
Drexel University College of Medicine Head and Neck Surgery
Philadelphia, Pennsylvania, USA Drexel University College of Medicine
Timothy D Anderson MD
Director Adam D Rubin MD
Voice and Swallowing Center Director
Department of Otolaryngology Lakeshore Professional Voice Center
Lahey Clinic, Burlington, MA, USA St Clair Shores, MI
Assistant Professor Adjunct Assistant Professor
Boston University School of Medicine University of Michigan
Boston, MA, USA Department of Otolaryngology
Head and Neck Surgery
Farhad Chowdhury DO Ann Arbor, MI, USA
Assistant Professor
Department of Otolaryngology Robert T Sataloff MD DMA FACS
Head and Neck Surgery Professor and Chairman
Drexel University College of Medicine Department of Otolaryngology
Philadelphia, Pennsylvania, USA Head and Neck Surgery
Senior Associate Dean for Clinical Academic Specialties
Carole M Dean MD FRCS(c) PC Drexel University College of Medicine
President Philadelphia, Pennsylvania, USA
The Voice Institute
Atlanta, Georgia, USA Joseph R Spiegel MD
Associate Professor
Mary J Hawkshaw BSN RN CORLN Department of Otolaryngology
Research Associate Professor Head and Neck Surgery
Department of Otolaryngology Thomas Jefferson University
Head and Neck Surgery Jefferson Medical College
Drexel University College of Medicine Philadelphia, Pennsylvania, USA
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Preface
The Atlas of Endoscopic Laryngeal Surgery is intended as a practical resource for physicians in practice and those in
training. It includes not only a general overview of various aspects of voice surgery but also previously unpublished
intraoperative photographs. These are accompanied by detailed descriptions of surgical technique, including “pearls”.
In addition to the new surgical material, much of the text has been modified from previously published works written
by the senior author (Robert T Sataloff ). For the convenience of surgeons seeking an efficient, practical guide to
voice surgery, much of this material has been condensed, reorganized, republished, rewritten and/or modified from
“Professional Voice: The Science and Art of Clinical Care, 3rd edition” by Robert T Sataloff, a nearly 1,800 page
compendium published by Plural Publications, Inc. (San Diego, CA) in 2005. We are grateful to Plural Publications,
Inc. for permission to reuse material from that book which is distributed throughout this atlas.
Section 1 on Basic Principles and Procedures provides a brief introduction to the evolution of phonomicrosurgery, and
contains practical guidelines on patient selection, evaluation and treatment, informed consent, anesthesia for voice
surgery, selection of instrumentation and postoperative care, as well as other subjects. Section 2 on Benign Structural
Lesions offers information on the nature of nodules, cysts, polyps and other structural abnormalities (often includ-
ing histological descriptions and figures) and provides detailed descriptions of surgical techniques and intraopera-
tive photographs to guide the surgeon interested in performing such procedures. Section 3 on Premalignant and
Malignant Lesions of the Larynx is primarily limited to endoscopic surgery. Laryngectomy is reviewed briefly, but is
not covered comprehensively in this book. Section 4 on Neurogenic Disorders includes not only endoscopic surgery, but
also information about laryngeal framework surgery to treat motion disorders of the larynx. Section 5 on Laryngeal
Trauma also focuses primarily on endoscopic management, the primary mission of this atlas, although the chapter
on Laryngotracheal Trauma provides an overview of relevant external procedures as well.
We hope that this atlas will provide useful insights for voice surgeons. The inclusion of “tricks of the trade” that
have never been published before is intended to assist all otolaryngologists in our efforts to provide state-of-the-art
surgical care to our patients with voice disorders and to optimize treatment outcomes. We trust that our readers will
find the information interesting.
Robert T Sataloff
Farhad Chowdhury
Shruti Joglekar
Mary J Hawkshaw
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Contents
Section 1 Basic Principles and Procedures
1. Introduction: The History, Evolution and

Development of Phonomicrosurgery 3
Robert T Sataloff, Farhad Chowdhury, Shruti Joglekar, Mary J Hawkshaw
Introduction to phonosurgery, phonating larynx, mirror laryngoscopy,
laryngeal skeleton
2. Patient Selection 5
Patient selection and consent, preoperative objective voice assessment,
documentation, timing of voice surgery, obvious vocal fold vascular engorgement,
premenstrual vocal fold hemorrhages, vocal fold cysts and polyps, coagulopathy
3. Anatomy and Physiology of the Voice: A Brief Overview 8

Anatomy of the voice, larynx, laryngectomy, intrinsic muscles of the larynx,
glottis, arytenoid cartilages, false vocal folds, lubricated squamous epithelium,
lamina propria, supraglottic vocal tract, infraglottic vocal tract, neural control,
extrapyramidal and autonomic nervous systems, sound production, resonance,
pitch and loudness control, mucosa assessment
4. Preoperative Voice Evaluation and Care 16

The history, comprehensive discussion on proper patient selection and
preparation, surgical field, laryngopharyngeal reflux, muscle tension dysphonia,
strobovideolaryngoscopy, flexible laryngoscopy, voice measures, informed consent,
timing of voice surgery and related considerations
5. Indirect Laryngoscopy 18
Indirect laryngoscopic surgery, topical anesthesia, flexible fiberoptic laryngoscope,
external injection, transoral injection, surgical techniques
6. Direct Laryngoscopy 21
Suspension microlaryngoscopy, stereoscopic vision, anterior commissure,
laryngoscope suspension system
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7. Anesthesia 25
Local anesthesia, greater cornu of the thyroid cartilage, greater cornu of the hyoid
bone, glossopharyngeal nerve blocks, endotracheal intubation, mucosal irritation,
methemoglobinemia, general anesthesia, intubation and extubation
8. Instrumentation 28
Magnification, long-handled laryngeal instruments, laryngeal telescopes, contact
endoscopy, microlaryngeal instruments, nonreflective instruments, powered
instruments, microdissection
9. Submucosal Infusion and Laryngeal Microsurgery 35

Concept of laryngeal infusion, submucosal infusion, complications
10. Laryngeal Laser Surgery 36

Jean Abitbol, Robert T Sataloff
Laser surgery, characteristics of lasers, phonomicrosurgery, argon laser, Nd-YAG
laser, KTP (potassium, titanyl, phosphate) crystal laser, dye laser photodynamic
therapy, pulsed dye laser, pulsed KTP laser, diode laser and its limitations, CO2
laser and its limitations, laser tissue interaction, phonomicrosurgical procedures,
microlaryngoscopy procedures, anesthesia techniques, risks and complications,
principles of CO2 laser phonomicrosurgery, laser phonomicrosurgical techniques
for types of lesions, complications of laser phonomicrosurgery
11. Voice Cosmesis: The Voice Lift 52

Voice lessons, vocal habilitation, neuromuscular retraining, injection laryngoplasty,
voice lift
12. Postoperative Voice Care 54
Voice rest, scar formation, steroids, antireflux medications, voice therapy,
individual considerations
Section 2 Benign Structural Lesions
13. Vocal Fold Cysts 59

Congenital cysts, acquired cysts, differentiation of cysts, management of vocal fold
cysts, microflap technique, contralateral vocal fold, surgical techniques
14. Vocal Fold Nodules 69
Position of vocal fold nodules, striking zone, voice therapy, vocal fold nodules in
children, surgical techniques
xii
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Contents
15. Vocal Fold Polyps 76

Polyps, functional effect of polyps, surgical techniques
16. Varicosities, Ectatic Vessels and Vocal Fold Hemorrhage 85

Hemorrhage in the vocal folds and mucosal disruption, ectasias and varices,
surgical techniques
17. ReinkeÊs Edema 91

Polypoid degeneration, polypoid corditis, edematous hypertrophy, localized
compensatory Reinke’s edema, surgical techniques
18. Granulomas and Vocal Process Ulcers 98

Occurrence of granulomas, etiologies of granulomas, uses of botulinum toxin,
surgical techniques
19. Papilloma 106
Diagnosis of papillomas, resection of laryngeal papilloma, use of cidofovir, surgical
techniques
20. Supraglottoplasty 115

Cause of stridor, effects of laryngomalacia, children with laryngomalacia,
supraglottic mucosal redundancy, surgical techniques
21. Vocal Fold Scar 119
Symptomatic vocal fold scar, therapy for vocal fold scar, surgery for vocal fold
scar, medialization techniques, surgical techniques
22. Sulcus Vocalis 130

Introduction of sulcus vocalis, etiologies of sulcus vocalis, pseudosulcus vocalis,
sulcus vergeture, treatment of sulcus vocalis, mucosal bridge, uses of numerous
techniques
23. Laryngeal Webs 133

Symptomatic webs, endoscopic resection
24. Posterior Glottic Stenosis 136
Joseph R Spiegel, Robert T Sataloff, Farhad Chowdhury, Mary J Hawkshaw
Arises from posterior larynx, factors affecting postintubation complications, types
of stenosis, EMG of the intrinsic laryngeal muscles, endolaryngeal procedures,
open laryngeal procedures, surgical techniques
xiii
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25. Subglottic Stenosis 142

Effects of stenosis, congenital subglottic stenosis, goals of correcting subglottic
stenosis, surgical techniques
26. Bowed Vocal Folds and Presbyphonia 146
Bowed vocal folds, superior laryngeal nerve paralysis, presbyphonia
Section 3 Premalignant and Malignant Lesions of the Larynx
27. Premalignant Lesions of the Larynx 149

Carole M Dean, Robert T Sataloff, Farhad Chowdhury, Mary J Hawkshaw
Terminology (clinical terms, histologic terms), epidemiology and etiological
factors, malignant transformation, carcinoma in situ (CIS), laryngeal papillomas,
human papilloma virus epidemiology and molecular biology, surgical techniques
28. Laryngeal Cancer 161

Timothy D Anderson, Robert T Sataloff, Farhad Chowdhury
Supraglottic tumors, treatment considerations, surgical procedures, glottic tumors,
surgical treatment (excisional biopsy, endoscopic surgery, cordectomy, endoscopic
laser-assisted vertical hemilaryngectomy, vertical hemilaryngectomy, reconstruction
after partial laryngectomy, supracricoid hemilaryngectomy, total laryngectomy),
subglottic cancer, surgical techniques
Section 4 Neurogenic Disorders
29. Vocal Fold Paresis/Paralysis 183

Adam D Rubin, Robert T Sataloff, Farhad Chowdhury
Effects of vocal fold paralysis, avoidance of Teflon injection, gelfoam injection,
collagen, alloderm and fascia injection, autologous fat injection, removal of Teflon,
surgical techniques
30. Thyroplasty 198

Type I thyroplasty, revision thyroplasty, other types of thyroplasty, nomenclature,
surgical techniques
31. Arytenoid Cartilage Adduction/Rotation, Cricothyroid Subluxation

Arytenoidopexy and Arytenoidectomy 210
Arytenoid cartilage adduction/rotation, arytenoidopexy and cricothyroid
subluxation, cricothyroid joint, cricothyroid subluxation, Gore-Tex silastic block,
nerve anastomosis, arytenoidectomy
xiv
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Contents
32. Nerve Muscle Pedicle Surgery 220

Involvement of nerve muscle pedicle surgery, limitations of reinnervation, other
techniques
33. Other Techniques for Bilateral Vocal Fold Paralysis 222

Arytenoidopexy, alternative placement of suture/arytenoidectomy, vocal fold
paralysis, posterior cordotomy, synkinesis
34. Throarytenoid Neurectomy 224

Robert T Sataloff
Procedural development of thyroarytenoid neurectomy for adductor spasmodic
dysphonia, variations on thyroarytenoid neurectomy, anatomy of the
thyroarytenoid branch, potential for abductor spasmodic dysphonia
Section 5 Laryngeal Trauma
35. Laryngotracheal Trauma 229

Yolanda D Heman-Ackah, Robert T Sataloff
Blunt injury, evaluation of the blunt trauma patient without airway distress,
evaluation of the blunt trauma patient with airway distress, surgical evaluation,
open exploration and repair, penetrating injuries, caustic and thermal injuries,
iatrogenic injuries
36. Vocal Process Avulsion 246

Occurrence of vocal process avulsion, result of vocal process avulsion, treatment of
the vocal process avulsion, surgical techniques
37. Cricoarytenoid and Cricothyroid Joint Injury: Evaluation and

Treatment 249
Cricoarytenoid joint injury, embryology and anatomy, arytenoid dislocation/
subluxation (diagnosis), adjunctive measures, cricothyroid joint injury
Index 259
xv
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SECTION 1
Basic Principles and

Procedures
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Chapter Introduction: The History,
1 Evolution and Development of
Phonomicrosurgery
Phonosurgery is a term that was adopted in the fall of chapter to production of voice and voice disturbances.
1963 over a conversation about the surgical potential for Five hundred years after its publication, the Quanun was
enhancement of vocal function between Hans von Leden still a required textbook at the University of Vienna and
and Godfrey Arnold in a bar of the Roosevelt Hotel in other major continental and British universities.
New York. Phonosurgery refers to any surgery designed The phonating larynx was visualized directly only
primarily for the improvement or restoration of the voice. recently. Bozzini was the first individual to report on
The term is often confused with phonomicrosurgery, a mirror visualization of the larynx in 1807. He designed
term referring to the convergence of theories that guide an ingenious handle that housed a candle with a reflector
endoscopic vocal fold surgery with theories that explain as an artificial light source. A variety of speculae could be
voice production. The underlying premise of the surgical attached to the universal handle for examining different
approach of phonomicrosurgery is that optimal postop- body cavities, including one speculum that had a self-
erative voice will be achieved, if there is maximal pres- contained mirror for examining the larynx. Bozzini’s bril-
ervation of the vocal fold’s structure. liant concept of employing an extracorporeal light source
Phonomicrosurgery is one of the newer surgical to illuminate the internal body cavities is the guiding
modalities in the armamentarium of the otolaryngologist premise of all endoscopy.
and is fundamentally rooted in the historical development In 1854, a Professor of Voice of the Conservatoire in
of improved visualization and surgical manipulation of Paris, Manuel Garcia, used a small dental mirror to reflect
the vocal folds. An attempt at understanding the con- the light of the sun on his own larynx and visualized
cept of voice production can be traced back to ancient the phonating organ on a hand mirror. This independent
Egypt dating to 3000 BC, when the voice was believed discovery of mirror laryngoscopy was presented to the
to be a magic or religious phenomenon originating in the Royal Society of Medicine in a report on the Physiological
lungs. The Egyptians had a great respect for the lungs Observation on the Human Voice on March 13, 1855, and
and depicted them often, but they may not have had any stimulated new interest in the medical community in
awareness of the relation between respiration and voice. the application of this technique for the management of
The Greek physician Claudius Galen (Clarissimus, laryngeal disease.
130-200) was probably the most influential medical Ludwig Türck was the first physician subsequent to
author of all time. He is accepted as the founder of Garcia’s presentation to adopt mirror laryngoscopy; how-
laryngology and certainly the godfather of phoniatrics ever, he depended on sunlight for illumination. The ability
and voice science. Galen taught that the “trachea prepares to see the larynx well was catalytic for making transoral,
and prearranges the voice for the larynx (the cartilages) mirror-guided surgical manipulation reliable and effective.
increase it and it is still further augmented by the vault The adaptation of the surgical microscope for mag-
of the throat, which acts like a sounding board” (De usu nification of the endolarynx was a key to the evolution
partium VII, 5). of phonomicrosurgery. Microlaryngoscopy arose from
Galen’s work undoubtedly influenced the great Persian the need and desire to perform more precise vocal fold
physician, philosopher, statesmen and poet, Abu Ali Al surgery. Microscopic visualization of the vocal folds was
Husayn Ibn Sina (Avicenna, 980-1037). Ibn Sina’s senti- described first in 1954 by Professor Rosemarie Albrecht
nal work, Al-Qanun fi al-Tibb or Canon of Medicine, was of the Medical Academy in the German city of Erfurt.
considered a Medical Bible for a longer period than any Albrecht adapted the microscope for laryngeal diagnosis
other work and some argue that it is the most famous as an attempt to emulate the success of her gynecologic
book ever written. The Quanun includes important data colleagues in diagnosing early malignancies of the uter-
on laryngeal anatomy and physiology and devotes a whole ine cervix. The credit for the perfection of this technique
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Basic Principles and Procedures
Section
and popularizing the art and science of microlaryngos- may be safer to leave selected benign lesions untreated or
copy belongs to the Austrian, Professor Oskar Kleinsasser. to treat the pathology through an external approach.
Initially, he used different loupes for magnification but This atlas reviews selected approaches and procedures
the results were less than encouraging. Gradually, he for vocal fold surgery. While it focuses almost exclusively
enlarged and tapered the laryngoscope until he was able on endoscopic surgery, a few of the most common nonen-
1 to accomplish binocular vision and bimanual surgery. By doscopic procedures have been included as well. Extensive
1962, Kleinsasser had adapted the Zeiss microscope for additional information on these topics is available in other
selected cases of laryngeal diagnosis. Shortly thereafter, literature.2-9
Zeiss developed a 400 mm focal length lens that permit-
ted the use of the long-handled laryngeal instruments for CONCLUSION
precision surgery on the vocal folds with vastly improved
functional results. The large part of the history of laryngeal surgery is
Surgical improvement of the human voice by a sys- devoted to the removal of neoplasms with potential
tematic approach to surgery of the laryngeal skeleton improvement in voice as only an afterthought. Additional
was presented by Nobuhiko Isshiki. In a seminal article, information can be found in other sources.10 Although
Isshiki and colleagues described four basic procedures there have been attempts to improve the voice in the past,
to alter the laryngeal skeleton and thereby, the resulting only during the last 30 years have concerted international
voice. These four operations lengthen or shorten the vocal efforts established reliable and effective procedures for
folds and compress or expand the interior of the larynx. transforming the human voice. Improved understanding
Since his original description, Isshiki has modified some of the physiology of voice among surgeons has led to
of these basic steps to improve the functional results and enlightened advances in surgical technique theory. These
has also designed a series of new procedures to achieve principles have been joined with the technological devel-
this objective. A more comprehensive review of the his- opments of microlaryngeal surgery and have led to cur-
tory of voice surgery can be found elsewhere.1 rent concepts of phonomicrosurgery.
4 Phonomicrosurgery reflects the convergence of theo-
ries that guide endoscopic vocal fold surgery with theories REFERENCES
that explain voice production and the contributions of the
numerous physicians to this science far exceed the breadth 1. von Ledon HL. A Cultural History of the Larynx and
Voice. In: Sataloff RT. Professional Voice: The Science and
of this chapter. The underlying premise of this surgical
Art of Clinical Care, 3rd edition. San Diego, CA: Plural
approach is that optimal postoperative voice, which is
Publishing, Inc.; 2005. pp. 9-88.
observed as a pliable vocal fold cover, will be achieved if 2. Sataloff RT. Professional Voice: The Science and Art
there is maximal preservation of the vocal fold’s layered of Clinical Care, 3rd edition. San Diego, CA: Plural
microstructure. Today, the laryngologist may select from Publishing, Inc.; 2005.
a variety of instrumentation to help achieve the optimal 3. Rubin J, Sataloff RT, Korovin G. Diagnosis and Treatment
surgical result. of Voice Disorders, 3rd edition. San Diego, CA: Plural
Laryngeal surgery may be performed endoscopically Publishing, Inc.; 2006.
(indirect or direct) or through an external approach. 4. Fried MP, Ferlito A (Eds). The Larynx. San Diego, CA:
Laryngeal surgeons should understand and master all Plural Publishing, Inc.; 2009.
approaches in order to provide optimal care. Most surgi- 5. Ossoff RH, Shapshay SM, Woodson GE, et al. The Larynx.
cal procedures for voice disorders can be performed endo- Philadelphia, PA: Lippincott, Williams and Wilkins; 2003.
scopically, obviating the need for external incisions and 6. Rosen CA, Simpson CB. Operative Techniques in
minimizing the amount of tissue disruption. Although Laryngology. Berlin: Springer-Verlag; 2008.
endoscopic microsurgery seems intuitively more “conserva- 7. Tucker HM. The Larynx, 2nd edition. New York, NY:
Thieme; 1993.
tive”, this supposition holds true only when the equipment
8. Zeitels SM. Atlas of Phonomicrosurgery. San Diego, CA:
provides good exposure of the surgical site and the abnor- Singulair Publications; 2001.
mality can be treated meticulously and thoroughly with 9. Isshiki N, et al. Thyroplasty as a New Phonosurgical
endoscopic instruments. When endoscopic visualization is Technique. Acta Otolaryngol. 1974; 78(5-6):451-7.
not adequate because of patient anatomy, disease extent 10. Zeitels SM. The History and Development of
or other factors, the surgeon should not compromise the Phonomicrosurgery. In: Sataloff RT. Professional Voice:
results of treatment or risk patient injury by attempting The Science and Art of Clinical Care, 3rd edition. San
to complete an endoscopic procedure. In such patients, it Diego, CA: Plural Publishing, Inc.; 2005. pp. 1115-36.
Ch-01.indd 4 9/8/2010 3:01:40 Gopal

Chapter
2 Patient Selection
PATIENT SELECTION AND CONSENT breathiness and instability. If she gives in to the tempta-
tion to compensate by slightly retracting her tongue and
Prior to performing voice surgery, it is essential to be lowering her larynx, the breathiness will be controlled
certain that patient selection is appropriate and that the because of increased adductory forces, but she will lose
patient understands the limits and potential complications the ability to perform rapid, agile runs and trills. Similar
of voice surgery. Appropriate patients for voice surgery problems may occur from compensatory maladjustments
not only have voice abnormalities but also really want in response to other lesions, such as vocal fold cysts. In
to change their voice quality, effort and/or endurance. such instances, the artist may be served better by surgical
For example, not all people with “pathological” voices correction of the underlying problem than by long-term
are unhappy with them. Sports announcers, female trial use of hyperfunctional compensation (bad technique) that
attorneys with gruff, masculine voices and others some- can itself cause other performance problems, as well as
times consult a physician only because of fear of cancer. vocal fold pathology. The patient must understand all of
If there is no suspicion of malignancy, restoring the voice these considerations clearly, including the risks of sur-
to “normal” (e.g. by evacuating Reinke’s edema) may be gery. He or she needs to acknowledge the risk that any
a disservice and even jeopardize a career. Similarly, it is voice surgery may make the voice worse permanently and
essential to distinguish accurately between organic and the patient must consider this risk acceptable in light of
psychogenic voice disorders before embarking upon laryn- ongoing vocal problems.
geal surgery. Although a breathy voice may be caused by Even in the best hands, an undesirable scar may
numerous organic conditions, it is also commonly found develop, resulting in permanent hoarseness. The patient
in people with psychogenic dysphonia. The differentiation must be aware that there is a possibility that the voice
may require evaluation by a very skilled voice team. may be worse following surgery. Naturally, other compli-
Although all reasonable efforts should be made to cations must also be discussed, including (among others)
avoid operative intervention in professional voice users, complications of anesthesia, dental fracture, recurrence of
particularly singers, there are times when surgery is appro- laryngeal lesions, airway compromise, vocal fold webbing
priate and necessary. Ultimately, the decision depends and other untoward occurrences. In addition to the hospi-
on a risk-benefit analysis. If a professional is unable to tal’s standard surgical consent, the authors provide patients
continue his or her career and if surgery may restore with additional written information prior to surgery. The
vocal function, surgery certainly should not be withheld. patient keeps one copy of the “Risks and Complications
Sometimes, making such judgments can be challenging. of Surgery” document and one signed copy remains in the
A rock or pop singer with a vocal fold mass may have sat- chart. Specialized informed consent documents may be
isfactory voice quality with only minimal technical adjust- used also for other selected treatments such as injection of
ments. Pop singers perform with amplification, obviating cidofovir, topical application of mitomycin-C, and injec-
the need to sing loudly and to project the voice in some tion of botulinum toxin, even though such documents are
cases (depending on the artist’s style). Such a patient not really required. If medications are used for treatment
may be able to “work around” pathology safely for many purposes (rather than research purposes) and are off-label
years. However, even minor pathology may be disabling uses of medicines approved by the FDA for other pur-
in some classical singers. For example, if a high soprano poses, their use does not necessarily require Institutional
specializing in Baroque music develops a mild to moder- Review Board (IRB) approval. However, these authors
ate superior laryngeal nerve paresis, she may experience believe it is helpful and prudent to provide patients with
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Section
as much information as possible and to document that hemorrhages, it may be better to avoid elective surgery
they have been so informed. during the premenstrual period. Except in patients in
It is often helpful for the laryngologist, speech-lan- whom surgery is intended to treat vessels that have hem-
guage pathologist, singing voice specialist and patient to orrhaged repeatedly and that are only prominent prior
1 involve the patient’s singing teacher in the decision-mak- to menses, it may be best to perform surgery between
ing process. Everyone must understand not only the risks approximately days 4 and 21 of the menstrual cycle.
of surgery but also the risk involved in deciding against While it appears unnecessary to time surgery in this way
surgery and relying upon technical maladjustments. In for all patients, the issue has not been studied fully.
many cases, there is no “good” or “right” choice and the Timing of surgery with regard to voice therapy and
voice care team must combine great expertise with insight performance commitments can be especially difficult in
into the career and concerns of each individual patient to busy voice professionals. The surgeon must be careful to
help the voice professional make the best choice. avoid letting the patient’s professional commitments and
pressures dictate inappropriate surgery or surgical timing
DOCUMENTATION that is not in the patient’s best interest. For example,
some professional voice users will push for early surgery
Preoperative objective voice assessment and documenta- for vocal nodules and promise to appear for voice therapy
tion are essential in addition to routine documentation after a busy concert season ends. This is not appropriate,
of informed consent discussions. As a bare minimum, a because therapy may cure the nodules and avoid surgi-
high-quality tape recording of the patient’s voice must cal risks altogether. However, professional commitments
be done before surgery. Auditory memories of physicians often require that appropriate surgery be delayed until a
and patients are not good in general, and both the doctor series of concerts or the run of a play is completed. In
and the postoperative professional voice user are often treating vocal fold cysts, polyps and other conditions, such
surprised when they compare postoperative and preop- delays are often reasonable. They are made safer through
6 erative recordings. Frequently, the preoperative voice is
worse than either person remembers. In addition, such
ongoing voice therapy and close laryngologic supervision.
Sometimes individualized treatments may help temporize.
documentation is invaluable for medicolegal purposes. For example, aspiration of a cyst as an office procedure
Photographs or videotapes of the larynx obtained dur- can provide temporary relief from symptoms, although
ing strobovideolaryngoscopy (SVL) are extremely help- the cyst is likely to return and require definitive surgery
ful. Ideally, complete objective laboratory voice assessment eventually.
and evaluation by a voice team should be performed. At least a brief period of preoperative voice therapy
Proper documentation is essential for assessing outcomes, is also helpful. Even when therapy cannot cure a lesion,
even for the physician who is not interested in research it ameliorates the abuses caused by compensatory hyper-
or publication. function and good preoperative therapy is the best post-
operative voice therapy. It is also invaluable in educating
TIMING OF VOICE SURGERY the patient about vocal function and dysfunction and in
making sure that he or she is fully informed about sur-
The time of voice surgery is important and can par- gery and other options. Following surgery, voice therapy
ticularly be challenging in professionals with demanding is medically necessary for many conditions. It is extremely
voice commitments. Many factors need to be taken into important to long-term surgical outcome to time surgery
account including preoperative and postoperative voice so that the patient will be able to comply with postopera-
therapy, concurrent medical conditions, psychological tive voice rest and postoperative rehabilitation.
state, professional voice commitments and others. Many other conditions must be taken into account
The premenstrual cycle and hormonal considerations when deciding upon the timing of voice surgery. Concurrent
may be important, especially in female patients with medical conditions such as uncontrolled laryngopharyn-
symptomatic laryngopathia premenstrualis. In patients geal reflux, allergies that produce extensive coughing or
who have obvious vocal fold vascular engorgement or sneezing (which may injure vocal folds following sur-
those who have a history of premenstrual vocal fold gery), a coagulopathy (even temporary coagulopathy from
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Patient Selection
Chapter
aspirin use) and other physical factors may be important patient to work with the voice team. There are very few
contributors to voice results. Psychological factors should indications for benign voice surgery that contraindicate
also be considered. The patient must not only understand a delay of several weeks. It is generally worth taking the
the risks and complications of surgery, but also be as time to optimize the patient’s comfort and preparedness.
psychologically prepared as possible to accept them and Indeed, the patient is the most important part of the voice 2
to commit to the therapeutic and rehabilitation process. rehabilitation team. Realistic, committed collaboration by
Sometimes psychological preparation requires a delay the patient is invaluable in achieving consistent, excellent
in surgical scheduling to allow increased time for the surgical results.
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Chapter
Anatomy and Physiology of the
3 Voice: A Brief Overview
INTRODUCTION muscle), extends on each side from the arytenoid carti-

lage to the inside of the thyroid cartilage just below and
Clinical anatomy and physiology are complex, and it is behind the “Adam’s apple”, forming the body of the vocal
critical for the surgeon to understand them in detail. folds (popularly called the vocal cords) (Figs 3.2A to D).
Comprehensive discussion is beyond the scope of The vocal folds act as the oscillator or voice source (noise
this atlas and, for a more complete review, the reader maker) of the vocal tract. The space between the vocal
is referred to other literature.1-5 The human voice is folds is called the glottis and is used as an anatomic refer-
remarkable, complex and delicate. It is capable of con- ence point. The intrinsic muscles alter the position, shape
veying not only sophisticated intellectual concepts but and tension of the vocal folds, bringing them together
also subtle emotional nuances. Although the uniqueness (adduction), moving them apart (abduction) or stretching
and beauty of the human voice have been appreciated them by increasing longitudinal tension. They are able
for centuries, medical science has begun to understand to do so because the laryngeal cartilages are connected
the workings and care of the voice only since the late by soft attachments that allow changes in their relative
1970s and 1980s. angles and distances, thereby permitting alteration in
the shape and tension of the tissues suspended between
ANATOMY OF THE VOICE them. The arytenoid cartilages are also capable of rocking,
and gliding, which permits complex vocal fold motion
Larynx (Figs 3.3A to E) and alteration in the shape of the vocal
The larynx is essential to normal voice production, but fold edge. All but one of the muscles on each side of the
the anatomy of the voice is not limited to the larynx. larynx is innervated by one of the two recurrent laryngeal
The vocal mechanism includes the abdominal and back nerves. Because this structure runs a long course from
musculature, the rib cage, the lungs, and the pharynx, oral the neck down into the chest and then back up to the
cavity and nose. Each component performs an important larynx (hence, the name “recurrent”), it is easily injured
function in voice production, although it is possible to by trauma, neck surgery and chest surgery (especially on
produce voice even without a larynx (e.g. in patients who the left), which may result in vocal fold paralysis. The
have undergone laryngectomy [removal of the larynx] remaining muscle (cricothyroid muscle) is innervated
for cancer). In addition, virtually all parts of the body by the superior laryngeal nerve on each side, which is
play some role in voice production and may be respon- especially susceptible to viral and traumatic injury. It pro-
sible for voice dysfunction. Even something as remote duces increase in longitudinal tension important in vol-
as a sprained ankle may alter posture, thereby impairing ume projection and pitch control. The “false vocal folds”
abdominal muscle function and resulting in vocal inef- are located above the vocal folds; unlike the true vocal
ficiency, weakness or hoarseness. folds, they do not make contact during normal speaking
The larynx is composed of four basic anatomic units: or singing.
skeleton, intrinsic muscles, extrinsic muscles and mucosa. Because the attachments of the laryngeal cartilages are
The most important parts of the laryngeal skeleton are flexible, the positions of the cartilages change with respect
the thyroid cartilage, cricoid cartilage and two arytenoid to each other when the laryngeal skeleton is elevated or
cartilages (Figs 3.1A to E). Intrinsic muscles of the larynx lowered. Such changes in vertical height are controlled by
are connected to these cartilages. One of the intrinsic the extrinsic laryngeal muscles, or strap muscles of the
muscles, the vocalis muscle (part of the thyroarytenoid neck.
Ch-03.indd 8 9/8/2010 3:02:35 Gopal

Anatomy and Physiology of the Voice: A Brief Overview
Chapter
3
Figs 3.1A to E: Cartilages of the larynx
Ch-03.indd 9 9/8/2010 3:02:36 Gopal

Section
10
Figs 3.2A to D: The intrinsic muscles of the larynx
When the angles and distances between cartilages contact when the two vocal folds are closed. It looks like
change due to this accordion effect, the resting length of the mucosa that lines the inside of the mouth. However,
the intrinsic muscles is also changed. Such large adjust- the vocal fold is not simply muscle covered with mucosa
ments in intrinsic muscle condition interfere with the (Fig. 3.4). The thin, lubricated squamous epithelium
fine control of smooth vocal quality. This is why clas- lines the surface. Immediately beneath it, connected by a
sically trained singers are generally taught to use their complex basement membrane, is the superficial layer of
extrinsic muscles to maintain the laryngeal skeleton at the lamina propria, also known as Reinke’s space, which
a relatively constant height regardless of pitch. That is, consists of loose, fibrous components and matrix. It tends
they learn to avoid the natural tendency of the larynx to to accumulate fluid, and it contains very few fibroblasts
rise with ascending pitch and fall with descending pitch, (cells involved in scar formation). The epithelium is con-
thereby enhancing uniformity of quality throughout the nected to the superficial layer of the lamina propria by
vocal range. Techniques may be different in certain Asian, a sophisticated basement membrane. The intermediate
Indian, Arabic and other musical traditions with different layer of the lamina propria contains primarily elastic fib-
aesthetic values. ers and a moderate number of fibroblasts. The deep layer
The soft tissues lining the larynx are much more of the lamina propria is rich in fibroblasts and consists
complex than was originally thought.6 The mucosa forms primarily of collagenous fibers. It overlies the thyroaryte-
the thin, lubricated surface of the vocal folds that makes noid or vocalis muscle. The various layers have different
Ch-03.indd 10 9/8/2010 3:02:36 Gopal

Chapter
3
11
Figs 3.3A to E: Action of the intrinsic muscles. Figures B to E, the directional arrows suggest muscle actions, but may give a misleading
impression of arytenoid motion. These drawings should not be misinterpreted as indicating that the arytenoid cartilage rotates around a
vertical axis. The angle of the long axis of the cricoid facets does not permit some of the motion implied in this figure. However, the
drawing still provides a useful conceptualization of the effect of individual intrinsic muscles, so long as the limitations are recognized
mechanical properties important in allowing the smooth they act as a resonator and are largely responsible for
shearing action necessary for proper vocal fold vibration. vocal quality (or timbre) and the perceived character of all
Mechanically, the vocal fold structures act more like speech sounds. The vocal folds themselves produce only
three layers consisting of the cover (epithelium and super- a “buzzing” sound. During the course of vocal training
ficial layer of the lamina propria), transition (intermediate for singing, acting or healthy speaking, changes occur not
and deep layers of the lamina propria) and body (the only in the larynx but also in the muscle motion, control
vocalis muscle). and shape of the supraglottic vocal tract.
Supraglottic Vocal Tract Infraglottic Vocal Tract

The supraglottic vocal tract includes the pharynx, tongue, The infraglottic vocal tract serves as the power source
palate, oral cavity, nose and other structures. Together, for the voice. Singers and actors refer to the entire
Ch-03.indd 11 9/8/2010 3:02:37 Gopal

Section
which are not designed for power source functions. Such

behavior can result in decreased voice function, rapid
fatigue, pain and even structural pathology, including
vocal fold nodules. Current expert treatment for such
1 problems focuses on the correction of the underlying
malfunction. This often cures the problem, avoiding the
need for laryngeal surgery.
PHYSIOLOGY OF THE VOICE
Neural Control
The physiology of voice production is extremely com-
plex.1,7,8 Volitional production of voice begins in the
cerebral cortex of the brain. The command for vocaliza-
tion involves complex interaction among brain centers
for speech and other areas. For singing, speech directives
Fig. 3.4: The structure of the vocal fold must be integrated with information from the centers for
musical and artistic expression. The “idea” of the planned
power source complex as their “support” or “diaphragm”. vocalization is conveyed to the precentral gyrus in the
Actually, the anatomy of support for phonation is espe- motor cortex, which transmits another set of instructions
cially complicated and not completely understood, and to the motor nuclei in the brainstem and spinal cord.
performers who use the terms diaphragm and support do These areas send out the complicated messages neces-
12 not always mean the same thing. Yet, it is quite important
because deficiencies in support are frequently responsible
sary for coordinated activity of the larynx, the chest and
abdominal musculature and the vocal tract articulators.
for voice dysfunction. Additional refinement of motor activity is provided by
The purpose of the support mechanism is to generate the extrapyramidal and autonomic nervous systems. These
a force that directs a controlled airstream between the impulses combine to produce a sound that is transmitted
vocal folds. Active respiratory muscles work together with not only to the ears of the listener but also to those of the
passive forces. The principal muscles of inspiration are the speaker or singer. Auditory feedback is transmitted from
diaphragm (a dome-shaped muscle that extends along the ear through the brainstem to the cerebral cortex, and
the bottom of the rib cage) and the external intercostals adjustments are made that permit the vocalist to match
(rib) muscles. During quiet breathing, expiration is largely the sound produced with the sound intended, integrating
passive. The lungs and rib cage generate passive expiratory the acoustic properties of the performance environment.
forces under many common circumstances, such as after Tactile feedback from the throat and the muscles involved
a full breath. in phonation also helps in the fine tuning of vocal output,
Many of the muscles used for active expiration are although the mechanism and role of tactile (sense of feel-
also employed in “support” for phonation. Muscles of ing or touch) feedback are not fully understood. Many
active expiration either raise the intra-abdominal pressure, trained singers and speakers cultivate the ability to use
forcing the diaphragm upward, lower the ribs or sternum tactile feedback effectively because of expected interfer-
to decrease the dimensions of the thorax, or both, thereby ence with auditory feedback data from ancillary sound
compressing the air in the chest. The primary muscles of such as an orchestra, choir or band.
expiration are the abdominal muscles, but internal inter-
costals and other chest and back muscles are also involved. Sound Production
Trauma or surgery that alters the structure or function Phonation—the production of sound—requires interac-
of these muscles or ribs undermines the power source of tion among the power source, oscillator and resonator.
the voice, as do diseases that impair expiration such as The voice may be compared to a brass instrument, such
asthma. as a trumpet. Power is generated by the chest, abdomen
Deficiencies in the support mechanism often result and back musculature, and a high-pressure airstream is
in compensatory effects utilizing the laryngeal muscles, produced. The trumpeter’s lips open and close against
Ch-03.indd 12 9/8/2010 3:02:37 Gopal

Chapter
the mouthpiece, producing a “buzz” similar to the sound
produced by vocal fold contact. This sound then passes
through the trumpet, which has acoustic resonance char-
acteristics that shape the sound we associate with trumpet
music. The nonmouthpiece portions of a brass instrument 3
are analogous to the supraglottic vocal tract.
During phonation, the infraglottic musculature must
make rapid, complex adjustments because the resistance
changes almost continuously as the glottis closes, opens
and changes shape. At the beginning of each phonatory
cycle, the vocal folds are approximated, and the glottis is
obliterated. This permits infraglottic air pressure to build-
up, typically to a level of about 7 cm of water, for conver-
sational speech. At this point, the vocal folds are conver-
gent (Fig. 3.5A). Because the vocal folds are closed, there
is no airflow. The subglottic pressure then pushes the vocal
folds progressively farther apart from the bottom up (Fig.
3.5B) until space develops (Figs 3.5C and D) and air
begins to flow. Bernoulli’s force created by the air passes Figs 3.5A to J: A schematic presentation of the function of the
laryngeal muscles. The left column shows the location of the
between the vocal folds and combines with the mechani-
cartilages and the edge of the vocal folds when the laryngeal
cal properties of the folds to begin closing the lower por- muscles are activated individually. The arrows indicate the
tion of the glottis almost immediately (Figs 3.5E to H), direction of the force exerted. (1) thyroid cartilage; (2) cricoid
even the upper edges are still separating. The principles cartilage; (3) arytenoid cartilage; (4) vocal ligament; (5) posterior
cricoarytenoid ligament. The middle column shows the views from
and mathematics of Bernoulli’s force are complex. It is a
flow effect more easily understood by familiar examples,
above. The right column illustrates countours of frontal sections 13
at the middle of the musculomembranous portion of the vocal
such as the sensation of pull exerted on a vehicle when fold. The dotted line illustrates the vocal fold position when no
passed by a truck at high speed or the inward motion of muscle is activated. CT, cricothyroid; VOC, vocalis; LCA, lateral
cricoarytenoid; IA, interarytenoid; PCA, posterior cricoarytenoid
a shower curtain when the water flows past it.
The upper portion of the vocal folds has strong elastic
properties that tend to make the vocal folds snap back to to open and close before the upper portion. The rippling
the midline. This force becomes more dominant as the displacement of the vocal fold cover produces a mucosal
upper edges are stretched and the opposing force of the wave that can be examined clinically under stroboscopic
air diminishes because of the approximation of the lower light. If this complex motion is impaired, hoarseness or
edges of the vocal folds. The upper portions of the vocal other changes in voice quality may cause the patient to
folds are then returned to the midline (Fig. 3.5I) com- seek medical evaluation.
pleting the glottic cycle. Subglottal pressure then builds The sound produced by the vibrating vocal folds,
again (Fig. 3.5J), and the events repeat. The frequency called the voice source signal, is a complex tone con-
of vibration (number of cycles of openings and closings taining a fundamental frequency and many overtones or
per second) measured in hertz [Hz] is dependent on higher harmonic partials. The amplitude of the partials
the air pressure and on the mechanical properties of the decreases uniformly at approximately 12 dB per octave.
vocal folds, which are regulated in part by the laryngeal Interestingly, the acoustic spectrum of the voice source
muscles.4 is about the same in ordinary speakers as it is in trained
Pitch is the perceptual correlate of frequency. Under singers and speakers.8 Voice quality differences in voice
most circumstances, as the vocal folds are thinned and professionals occur as the voice source signal passes
stretched and air pressure is increased, the frequency of through their supraglottic vocal tract resonance resona-
air pulse emission increases, and pitch goes up. The myoe- tor system.
lastic-aerodynamic mechanism of phonation reveals that
the vocal folds emit pulses of air, rather than vibrating Resonance
like strings, and also that there is a vertical phase differ- The pharynx, the oral cavity and the nasal cavity act as
ence. That is, the lower portion of the vocal folds begins a series of interconnected resonators, which are more
Ch-03.indd 13 9/8/2010 3:02:37 Gopal

Section
singers. This energy peak must be adjusted and managed

to prevent strong voices from standing out in choral set-
ting.
1 Pitch and Loudness Control

The mechanisms that control two vocal characteristics—
fundamental frequency and intensity—are particularly
important. Fundamental frequency, which corresponds to
pitch, can be altered by changing either the air pressure
or the mechanical properties of the vocal folds, although
changing the latter is more efficient under most condi-
tions. When the cricothyroid muscle contracts, it makes
the thyroid cartilage pivot and increases the distance
between the thyroid and arytenoid cartilages, thus stretch-
ing the vocal folds. This increases the surface area exposed
to subglottal pressure and makes the air pressure more
effective in opening the glottis. In addition, stretching the
elastic fibers of the vocal fold makes them more efficient
at snapping back together. As the cycles shorten and
repeat more frequently, the fundamental frequency and
pitch rise. Other muscles, including the thyroarytenoid,
also contribute.1 Raising the pressure of the airstream also
tends to increase fundamental frequency, a phenomenon
Fig. 3.6: Function of the vocal tract as a resonator that converts
14 the voice source signal into formants that determine an individual’s
for which singers must learn to compensate. Otherwise,
their pitch would go up whenever they tried to sing
timbre, vowel intelligibility and audibility over noise
more loudly.
Vocal intensity corresponds to loudness and depends
complex than that in the left trumpet example or other on the degree to which the glottal wave motion excites
single resonators. As with other resonators, some frequen- the air molecules in the vocal tract. Raising the air pres-
cies are attenuated, while others are enhanced (Fig. 3.6). sure creates greater amplitude of vocal fold displacement
Enhanced frequencies are then radiated with higher from the midline and, therefore, increases vocal intensity.
relative amplitudes or intensities. Sundberg has shown However, it is not actually the vibration of the vocal fold,
that the vocal tract has four or five important resonance but rather the sudden cessation of airflow that is respon-
frequencies called formants. The presence of formants sible for initiating sound in the vocal tract and controlling
alters the uniformly sloping voice source spectrum and intensity. This is similar to the mechanism of the acoustic
creates peaks at formant frequencies. These alterations vibration that results from buzzing lips. In the larynx, the
of the voice source spectral envelope are responsible for sharper the cutoff of airflow, the more intense the sound.4
distinguishable sounds of speech and song.7 The singer’s
formant is of special interest. It is a strong acoustical peak Mucosa Assessment
at about 2,400–3,200 Hz, depending on voice classifica- In the evaluation of voice disorders, clinicians assess an
tion. It is responsible for the “ring” that allows a solo individual’s ability to optimize adjustments of air pressure
singer to be heard over the sounds of choirs, orchestras and glottal resistance. When high subglottic pressure is
and environmental noise. Even though it is roughly 3½ combined with high adductory (closing) vocal fold force,
octaves above middle C, it is an essential component of glottal airflow and the amplitude of the voice source fun-
a singer’s sound. If it is filtered out, even a great voice, damental frequency are low. This is called pressed phona-
like Pavarotti’s, will lose its ring and disappear into the tion and can be measured clinically through a technique
surrounding envelope of sound. known as flow glottography.1,7 Flow glottogram wave
While a strong singer’s formant is essential for easy, amplitude indicates the type of phonation used, and the
exciting solo singing, it is not always a blessing in choral slope (closing rate) gives information about the sound
Ch-03.indd 14 9/8/2010 3:02:38 Gopal

Chapter
pressure level or loudness. If adductory forces are so weak They shape sound quality and enhance audibility by cre-
that the vocal folds do not make contact, the glottis ating a singer’s formant. Specific anatomic adjustments
becomes inefficient at resisting air leakage, and the voice control fundamental frequency and intensity and the effi-
source fundamental frequency is also low. This is known ciency of a singer’s or speaker’s control strategies can be
as breathy phonation. Flow phonation is characterized assessed objectively. It is essential for a surgeon to under- 3
by lower subglottic pressure and lower adductory force. stand all components of voice production and to evaluate
These conditions increase the dominance of the funda- the oscillator, resonator and power source preoperatively
mental frequency of the voice source.1,7,8 Sundberg has and postoperatively. An interdisciplinary team optimizing
shown that the amplitude of the fundamental frequency function of all components of the phonatory system and
can be increased by 15 dB or more when the subject eliminating hyperfunction is essential to obtain the best
changes from pressed phonation to flow phonation.7 possible surgical results.
This is a huge increase. If someone in a factory with a
large paper machine producing 90 dB turns on a second REFERENCES
one, the sound increases by only 3 dB. To get a 15 dB
increase, one would need the deafening sound of 32 such 1. Sataloff RT. Clinical anatomy and physiology of the voice.
machines. If a singer habitually uses pressed phonation, In: Sataloff RT. Professional Voice: The Science and Art
considerable effort will be required to achieve loud voic- of Clinical Care, 3rd edition. San Diego, CA: Plural
ing. The muscle patterns and force that the singer uses
2. Letson JA, Tatchell R. Arytenoid movement. In: Sataloff
to compensate for this laryngeal inefficiency may cause
RT. Professional Voice: The Science and Art of Clinical
vocal fatigue and damage. Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.;
2005. pp. 179-94.
CONCLUSION 3. Baken RJ. An overview of laryngeal function for voice pro-
duction. In: Sataloff RT. Professional Voice: The Science
The vocal mechanism includes the larynx, the abdominal
and back musculature, the rib cage, the lungs, and the
and Art of Clinical Care, 3rd edition. San Diego, CA:
Plural Publishing, Inc.; 2005. pp. 237-56.
15
pharynx, oral cavity and nose. Each component performs 4. Scherer RC. Laryngeal function during phonation. In:
an important function in voice production. The physiol- Sataloff RT. Professional Voice: The Science and Art
ogy of voice is extremely complex, involving interaction of Clinical Care, 3rd edition. San Diego, CA: Plural
among brain centers for speech and other areas. Signals Publishing, Inc.; 2005. pp. 257-74.
are transmitted to the motor nuclei in the brainstem 5. Sundberg J. Vocal tract resonance. In: Sataloff RT.
Professional Voice: The Science and Art of Clinical Care,
and spinal cord, coordinating the activity of the larynx,
3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005.
the chest and abdominal musculature and the vocal tract
pp. 275-92.
articulators. Other areas of the nervous system provide 6. Hirano M. Phonosurgery: Basic and clinical investigations.
additional refinement. Phonation requires interaction Otologia (Fukuoka). 1975; 21:239-442.
among the power source, oscillator, and resonator. The 7. Sundberg J. The Science of the Singing Voice. DeKalb, Ill:
sound produced by the vocal folds, called the voice source Northern Illinois University Press; 1987.
signal, is a complex tone containing a fundamental fre- 8. Scherer RS. Physiology of phonation: A review of basic
quency and many overtones. The pharynx, oral cavity and mechanics. In: Ford CN, Bless DM (Eds). Phonosurgery.
nasal cavity act as a series of interconnected resonators. New York, NY: Raven Press; 1991. pp. 77-93.
Ch-03.indd 15 9/8/2010 3:02:38 Gopal

Chapter
Preoperative Voice Evaluation
4 and Care
Proper patient selection and preparation may be the most the vocal folds routinely reveals vibratory margin abnor-
important and challenging aspects of voice surgery. A malities that affect surgical decision making. However,
comprehensive discussion of these topics could easily fill although rigid telescopic strobovideolaryngoscopy or
a book. Hence, readers should recognize that this chapter high-speed imaging provides excellent resolution of the
provides an extremely brief overview and should be sup- vibratory margin, it does not eliminate the need for evalu-
plemented through other sources. ation of laryngeal dynamics using a flexible laryngoscope
and more natural phonatory positions. Flexible laryngos-
THE HISTORY copy commonly reveals unsuspected problems, such as
vocal fold paresis. Such conditions may be responsible for
Voice patients require a comprehensive history that changes in vocal behavior (such as development of muscle
addresses potential problems in all body systems.1 tension dysphonia) that have caused surgical lesions. The
Maladies as remote as a sprained ankle may alter the underlying problems should be addressed prior to surgery
posture, abdominal support and, by undermining the in most cases.
power source of the voice, they may be responsible for The physical examination should also include the
dysphonia. Gastroenterological abnormalities, endocrino- assessment of and comment on the voice. In part, this
logical problems, pulmonary dysfunction and neurologi- may be performed by a speech-language pathologist, sing-
cal impairments are encountered frequently.2 Patient’s ing voice specialist, acting voice specialist or other mem-
complaints commonly provide clues to diagnoses and bers of the voice team. However, the physician/surgeon
direct further assessment and testing. It is essential for should also be consciously aware of the sound of the voice
the surgeon to establish accurate diagnoses and treat cor- and preoperative notes should document the impressions
rectable conditions before determining whether surgery is of phonatory performance.
necessary, the appropriate kind of surgery and ancillary
surgical management. VOICE MEASURES
The “surgical field” needs to be optimized globally.
This means not only treating inflammatory vocal fold Preoperative quantitative documentation of voice function
problems, such as laryngopharyngeal reflux, but also opti- is valuable for several reasons. First, it sometimes provides
mizing the function of the vocal tract. Muscle tension information about vocal behaviors and characteristics
dysphonia should be eliminated preoperatively in order to that have gone undetected during even multidisciplinary
reduce vocal fold contact forces which, if excessive, may team assessment. Second, it provides baseline information
impair wound healing or predispose patients to recurrent that allows the quantitative assessment of outcomes. At
mass lesions. a minimum, voice recordings should be made using a
standardized protocol. Ideally, more sophisticated analysis
PHYSICAL EXAMINATION should be performed.4
Quality of life assessment also provides valuable
Physical examination of the voice includes more than indi- information that can affect surgical decision making and
rect laryngoscopy or even flexible fiberoptic laryngoscopy. needs outcomes assessment.5 Some patients with severe
The entire vocal tract should be examined meticulously.3 dysphonia are not particularly bothered by their voice
Strobovideolaryngoscopy and/or high-speed imaging of problems. Others with apparently mild dysphonia are
Ch-04.indd 16 9/8/2010 3:02:54 Gopal

Preoperative Voice Evaluation and Care
Chapter
extremely bothered. This is particularly true among sing- REFERENCES
ers and other voice professionals. A patient’s reaction to
dysphonia may help determine whether surgery is justi- 1. Sataloff RT, Hawkshaw MJ, Anticaglia J. Patient his-
tory. In: Sataloff RT. Professional Voice: The Science and
fied. It should also be noted that patients who are very
bothered by relatively mild laryngeal difficulties are also Publishing, Inc.; 2005. pp. 323-38. 4
likely to be very sensitive to mild scarring or other adverse 2. Sataloff RT. Common medical diagnoses and treatments
surgical outcomes. in patients with voice disorders: An introduction and over-
view. In: Sataloff RT. Professional Voice: The Science and
INFORMED CONSENT, TIMING OF VOICE
SURGERY AND RELATED CONSIDERATIONS
3. Sataloff RT. Physical examination. In: Sataloff RT.
Informed consent and timing of voice surgery are reviewed Professional Voice: The Science and Art of Clinical Care,
3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005.
in Chapter 2. It is essential that the patient understands
pp. 343-54.
the risks of surgery. Surgery should be performed when
4. Heuer RJ, Hawkshaw MJ, Sataloff RT. The clinical voice
the patient has completed voice therapy and is still suf- laboratory. In: Sataloff RT. Professional Voice: The Science
ficiently dissatisfied with voice performance to be willing and Art of Clinical Care, 3rd edition. San Diego, CA:
to accept the risks of a bad outcome in order to have a Plural Publishing, Inc.; 2005. pp. 355-94.
chance at voice improvement. The patient’s laryngeal and 5. Benninger MS, Gardner GM, Jacobson BH. New dimen-
medical conditions should have been optimized whenever sions in measuring voice treatment outcome and quality of
possible; and the patient should be prepared (psychologi- life. In: Sataloff RT. Professional Voice: The Science and
cally and professionally) to follow voice rest and rehabili- Art of Clinical Care, 3rd edition. San Diego, CA: Plural
tation protocols after surgery. Publishing, Inc.; 2005. pp. 471-8.
17
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Chapter
5 Indirect Laryngoscopy
Indirect laryngoscopic surgery has been performed for Precise control is not as good as that accomplished with
many years and still has value in some circumstances. It microlaryngoscopy under sedation or general anesthesia,
permits gross biopsy of lesions under local anesthesia, intraoperative loss of patient cooperation may result in
removal of selected foreign bodies, and injection of fat, injury, and the ability to handle complications such as
collagen and other substances. In patients with cervical bleeding and edema is limited. Nevertheless, at times the
pathology (cervical arthritis, fracture, fusion) whose neck procedure is invaluable and it should be in the armamen-
will not flex or extend enough to permit rigid direct tarium of the laryngological surgeon.
laryngoscopy, indirect laryngoscopic surgery may provide
a safe alternative to external surgery.
For indirect laryngoscopic surgery, the patient is gen-
erally seated. Topical anesthesia is applied and may be
augmented by regional blocks. The larynx is visualized
either with a laryngeal mirror, laryngeal telescope or
flexible laryngoscope. When surgery is performed solely
for injection (e.g. fat or collagen), either an external or
transoral technique may be used. External injection may
be performed by passing the needle through the crico-
thyroid membrane and into the desired position lateral
to the vocal fold or through the thyroid lamina usually
near the midpoint of the musculomembranous vocal fold, A
about 7–9 mm above the inferior border of the thyroid
cartilage. Transoral injection has been used more com-
monly (Figs 5.1A and B) and the transoral technique is
also suitable for biopsy and other procedures. Assistance
is required. The patient’s tongue is held with gauze, as
for routine indirect laryngoscopy. Cooperative patients
may be asked to hold the tongue themselves. Angled
instruments designed specifically for indirect laryngo-
scopic surgery are passed through the mouth and guided
visually. Only a surgeon who is skilled in the necessary
maneuvers should perform the procedure. The advantages
of this technique include relatively easy access in anyone
whose larynx can be visualized with a mirror, avoidance B
of the need for an operating room procedure, and ready
availability when delays in getting to a hospital and wait- Figs 5.1A and B: (A) After topical anesthesia, the patient firmly
holds his tongue extended while the mirror and indirect needle are
ing for an operating room might cause serious problems
positioned. (B) The patient phonates a falsetto /i/ as the needle
(e.g. a chicken bone perched above the laryngeal inlet). is inserted for injection. Similar positions may be used for biopsy
However, the procedure also has distinct disadvantages. and foreign body removal
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Indirect Laryngoscopy
Chapter
SURGICAL TECHNIQUES vector of the force is into the glottis. All lesions may
be grasped with heart-shaped forceps and dissected with
Step 1 scissors, spatulas or ball-shaped dissectors. They can be
The patient is generally seated. Transnasal flexible laryn- resected very precisely with scissors. This approach is pref-
goscopy is performed to visualize the larynx. The patient’s erable for lesions, such as cysts that require precise resec- 5
tongue is held with gauze, as for routine indirect laryngos- tion and careful protection of pliable underlying mucosa.
copy. Topical anesthesia is applied transorally (Figs 5.2A
to C) using an indirect laryngoscopy needle. The author’s
preference (RTS) is to apply approximately 4 cc of 4%
lidocaine. Regional blocks may augment this. Note, when
placing the transoral instruments, the laryngoscope is first
placed at a level just below the soft palate, high in the
oropharynx. As the instruments are placed into the larynx,
the laryngoscope is advanced for better visualization.
Step 2
Once the anesthetic takes effect, a subepithelial injection
of 1% lidocaine with 1:100,000 epinephrine is given at
the base of the lesion using a needle (Fig. 5.2D). This
allows for vasoconstriction around the granuloma and
has the added benefit better demarcating the boundary
between normal and abnormal tissue.
Step 3
A Sataloff Straight Indirect Laryngeal Microcup Forceps Fig. 5.2B: A transnasal flexible laryngoscopy is performed to
19
is used to grasp the granuloma (Figs 5.2E and F); the expose the larynx. The laryngoscope is placed just beyond the
soft palate, at the level of the oropharynx, to allow for ease of
transoral placement of an indirect laryngoscopy needle
Fig. 5.2A: Rigid strobovideolaryngoscopy reveals a large granuloma

extending along the musculomembranous left true vocal fold. The
granuloma contacts the right true vocal fold and the vibratory
function of the vocal fold, as seen on stroboscopic examination, Fig. 5.2C: Four percent lidocaine is applied topically through the
suggests a second lesion that is hidden from indirect view by the indirect laryngoscopy needle and is placed directly onto the vocal
large, easily visible granuloma folds
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Section
Fig. 5.2D: Once the desired anesthetic effect has been established, Fig. 5.2F: A second, smaller granuloma is removed from the
a subepithelial injection of 1% lidocaine with 1:100,000 epinephrine right true vocal fold. In this case, Sataloff left-angled cup forceps
is injected into the base of the lesion, at the junction of normal provided easy, precise resection of the lesion at its base, without
and abnormal tissue the need for excessive traction and without tearing the surrounding
normal mucosa. This was possible because this was a small,
friable inflammatory lesion. Heart-shaped forceps and scissors are
preferable in some cases
20
Fig. 5.2E: In this case, this inflammatory lesion was removed

easily with straight microcup forceps. However, for more delicate
lesions without pre-existing stiffness at the base, heart-shaped Fig. 5.2G: Using a 25-gauge Sataloff Indirect Laryngeal Needle,
forceps, scissors and delicate dissecting instruments are available steroid (Decadron 40 mg/ml) is injected into the vocal fold at the
and preferable site of the granuloma
course of oral steroid therapy. Strict antireflux therapy,

Step 4
including a minimum of twice daily proton pump inhibi-
Once the lesion has been removed, a steroid is injected tor and nightly H2 blocker should be implemented before
into the surgical site (Fig. 5.2G). The author (RTS) pre- the decision is made for surgical resection and should be
fers Decadron 4 mg/ml. The patient is placed on a short continued postoperatively.
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Chapter
6 Direct Laryngoscopy
Suspension microlaryngoscopy is now the standard tech- the microscope as a light source.7 Since that time, the
nique for endoscopic laryngeal surgery. The concept of use of microscope magnification has become an essential,
direct laryngoscopy was introduced by Horace Green in routine part of laryngeal surgery (Figs 6.3A and B). The
18522 using sunlight and supported later by Brünings.1 microscope provides excellent stereoscopic vision as well
The history of phonomicrosurgery is reviewed in greater as light and magnification that enhance diagnosis and
detail elsewhere.2-4 The most common light source used help in refining surgical technique. It should be used in
later with laryngoscopes was a headlight worn by the nearly all cases. The Holinger and Jackson laryngoscopes
examiner. Light carriers built into laryngoscopes were have such small internal diameters that good stereoscopic
first developed by Chevalier Jackson in 1915.5 He uti- vision cannot be obtained using the microscope. Jako
lized a light carrier with a tiny incandescent light bulb. solved this problem by developing a larger laryngoscope
Jackson’s laryngoscope design included a flat, removable and adding two fiberoptic light bundles to improve illu-
blade that permitted introduction of a bronchoscope. mination, especially for photography.8 Jako’s design was a
A fiberoptic version of this instrument is still in common great improvement, but it was too wide and thick to per-
use (Fig. 6.1). Holinger modified Jackson’s laryngoscope mit good visualization in many patients. Dedo designed a
by eliminating the removable, sliding component and laryngoscope that incorporated many of the advantages of
adding a slight lift near the tip6 (Fig. 6.2). This helped the Jako and of the Holinger laryngoscopes,9 permitting
in lifting the epiglottis, thereby, improving visualization better visualization of the anterior commissure (Fig. 6.4)
of the anterior commissure. Holinger’s design is still in and stereoscopic vision, as long as the surgeon is at least
common use. Kleinsasser popularized the idea of using 61 cm from the patient. Use of an operating microscope
Fig. 6.1: Jackson laryngoscope. Reproduced from Sataloff RT. Fig. 6.2: Holinger laryngoscope. Reproduced from Sataloff RT.
Professional Voice: The Science and Art of Clinical Care, 3rd Professional Voice: The Science and Art of Clinical Care, 3rd
edition. San Diego, CA. Plural Publishing, Inc.; 2005: Fig. 82.2, edition. San Diego, CA. Plural Publishing, Inc.; 2005: Fig. 82.3,
with permission with permission
Ch-06.indd 21 9/8/2010 3:03:27 Gopal

Section
Fig. 6.4: Dedo laryngoscope. Reproduced from Sataloff RT.

Professional Voice: The Science and Art of Clinical Care, 3rd
edition. San Diego, CA. Plural Publishing, Inc.; 2005: Fig. 82.5,
with permission
22 Killian introduced the first laryngoscope suspen-

sion system in 1910.11 Numerous suspension systems
were invented subsequently. The choice is a matter of
personal preference. However, in selecting a suspension
system, one should look for a device that allows for two-
B
handed surgery, that permits the tongue and larynx to
Figs 6.3A and B: Direct microlaryngoscopy. (A) Note the use of be pulled toward the ceiling (with the patient in supine
the operating microscope and the suspension device. A Mayo stand
is placed under the surgeon’s arms for stability, and towels cushion
position) – rather than necessitating a lever action that
the elbows. (B) Laryngoscope suspension permits bimanual surgery. might fracture teeth and that works well with the laryn-
Reproduced from Sataloff RT. Professional Voice: The Science and goscope and head position preferred by the surgeon. It
Art of Clinical Care, 3rd edition. San Diego, CA. Plural Publishing, should be remembered that the suspension system should
Inc.; 2005: Fig. 82.4, with permission
be used as a stabilizing device. That is, the surgeon should
place the laryngoscope in the desired position and use
with a 400 mm objective lens permits these conditions the “suspension” device to keep it there, rather than using
to be met and provides adequate working room for the the suspension system to generate the forces necessary to
long instruments necessary for endolaryngeal surgery. obtain exposure. Adherence to this principle allows safe
Numerous modifications of these laryngoscopes have been use of leverage systems such as the Lewy device, as well
designed since Jako and Dedo introduced their laryngo- as lifting systems such as Killian’s gallows or the Boston
scopes, including the Gould laryngoscope10 and numer- “Window Crank” (Pilling Company, Fort Washington,
ous other thoughtfully designed laryngoscopes, a few of PA, USA) suspension systems. In general, the best view
which are pictured in Figures 6.5A to F. It is important of the vocal folds can be obtained with the patient in
for the surgeon to have a choice of laryngoscopes available “sniffing” position, with the neck flexed and the head
and to select the one best suited to the patient’s anatomy. extended (Fig. 6.6). This is also the position used most
The surgeon must choose an instrument that minimizes commonly by anesthesiologists for intubation. When the
tissue damage while optimizing exposure and facilitating laryngoscope is placed and suspended, the teeth must
the manipulation of instruments. be protected from trauma by the laryngoscope; and it
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Direct Laryngoscopy
Chapter
6
A B
23
C D
E F
Figs 6.5A to F: (A) Lindholm laryngoscope (Storz), which fits in the vallecula, is ideal in combination with a Benjamin light clip and
is particularly good for photography with 10 mm and other Storz telescopes. (B) Kantor/Berci video-laryngoscope (Storz). (C) Weerda
distending operating laryngoscopes (Storz). (D) Sataloff vallecula laryngoscope, which is similar in use to the Lindholm but has slightly
different shape and incorporates light sources. (E) Ossoff-Pilling laryngoscope, lateral view. The tip of this laryngoscope is identical to
the Holinger anterior commissure laryngoscope. However, the proximal end of the larger male and even the smaller female laryngoscope
is just large enough to permit binocular vision and effective laser use. This scope is invaluable for patients who are difficult to visualize
and who ordinarily would have required surgery through the Holinger laryngoscope. (F) The Sataloff laryngoscope (Medtronic-Xomed,
Jacksonville, FL) has a triangular distal end that approximates the shape of the glottis and has enough lift near the tip to permit good
exposure of the anterior commissure. It is available in large, medium (most commonly used) and pediatric sizes, as well as, in a small
adult anterior commissure form for patients who are particularly difficult to visualize. Reproduced from Sataloff RT. Professional Voice:
The Science and Art of Clinical Care, 3rd edition. San Diego, CA. Plural Publishing, Inc.; 2005: Fig. 82.6, with permission
Ch-06.indd 23 9/8/2010 3:03:29 Gopal

Section
visibility (especially anteriorly), it also introduces laxity

in the vocal folds that may slightly distort the relation-
ship between pathology and normal tissue. Hence, an
appropriate compromise must be achieved in each case
1 in order to optimize visibility of the area of interest, with-
out introducing excessive distortion. Readers interested
in additional information regarding counter pressure and
the forces involved in laryngoscopy are advised to consult
other literature.12, 13
REFERENCES
1. Brünings W. Direct laryngoscopy: Criteria determin-
ing the applicability of autoscopy. Direct Laryngoscopy,
Bronchoscopy and Esophagoscopy. London: Bailliere,
Tindall, Cox; 1912. pp. 93-5.
2. Zeitels S. The history and development of phonosurgery.
In: Sataloff RT. Professional Voice: The Science and Art
of Clinical Care, 3rd edition. San Diego, CA: Plural
Fig. 6.6: “Sniffing position”, ideal for visualization during direct
laryngoscopy. Note that the neck is flexed and the head is
3. von Leden H. The evolution of phonosurgery. In: Sataloff
extended. Often the neck must be flexed considerably more than RT. Professional Voice: The Science and Art of Clinical
illustrated. The occiput is approximately 15 cm above the bed, Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.;
supported by a pillow. The arrows indicate correct direction of 2006. pp. 1095-114.
pull during laryngoscopy 4. Sataloff RT. Voice surgery. In: Sataloff RT. Professional
24 Voice: The Science and Art of Clinical Care, 3rd edition.
San Diego, CA: Plural Publishing, Inc.; 2006. pp. 1137-
is essential that the patient’s head be held still. Sudden
214.
motion or biting on the laryngoscope may result in injury 5. Jackson C. Peroral Endoscopy and Laryngeal Surgery. St.
to the patient. Direct laryngoscopy may be performed Louis, MO: Laryngoscope Co; 1915.
using local anesthesia with sedation or general anesthesia. 6. Holinger P. An hour-glass anterior commissure laryngo-
In addition to choosing an appropriate laryngoscope, scope. Laryngoscope. 1960; 70:1570-1.
it is important to understand principles not only of sus- 7. Kleinsassser O. Microlaryngoscopy and endolaryngeal
pension, but also of internal distention and external coun- microsurgery. II: A review of 2500 cases. HNO. 1974;
ter pressure. In most cases, the laryngoscope should not 22(3):69-83.
only provide visualization of the entire vocal fold, but 8. Jako G. Laryngoscope for microscopic observation, surgery
also should distend the false vocal folds and larynx in and photography. Arch Otolaryngol. 1970; 91:196-9.
9. Dedo HH. A fiberoptic anterior commissure laryngo-
a way that optimizes visualization. Rarely, distension of
scope for use with the operating microscope. Trans Sect
the false vocal folds is not desirable and a laryngoscope Otolaryngol Am Acad Ophthalmol Otolaryngol. 1976;
positioned in the vallecula (such as the Lindholm, Karl 82:91-2.
Storz, Culver City, CA) provides an alternative. However, 10. Gould WJ. The Gould laryngoscope. Trans Sect Otolaryngol
this is an exception rather than a rule. In addition to Am Acad Ophthalmol Otolaryngol. 1973; 77:139-41.
internal distention, external counter pressure is impor- 11. Killian G. Suspension laryngoscopy – a modification of
tant. Gentle pressure over the cricoid cartilage often can the direct method. Trans 3rd Internat Laryngol Congr.
produce dramatic improvement in laryngeal visualization Germany. (Part II) Transactions; 1911:12.
through the laryngoscope. Traditionally, a resident, nurse 12. Zeitels SM, Vaughan CW. “External counterpressure”
or anesthetist has been asked to provide the counter pres- and “internal distention” for optimal laryngoscopic expo-
sure. It is better to use 1 inch tape that extends from one sure of the anterior glottal commissure. Ann Otol Rhinol
Laryngol. 1994; 103(9):669-75.
side of the headrest of the bed to the other and holds
13. Hochman II, Zeitels SM, Heaton JT. Analysis of the forces
steady pressure on the larynx, maintaining the desired and position required for direct laryngoscopic exposure of
position. It is also important to realize that there can be the anterior vocal folds. Ann Otol Rhinol Laryngol. 1999;
a disadvantage to counter pressure. Although it improves 108(8):715-24.
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Chapter
7 Anesthesia
LOCAL ANESTHESIA topical anesthetic between the vocal folds if they can be
visualized easily using a metal tongue blade. Although
Local anesthesia with sedation is desirable in some cases this anesthetic procedure can be performed very rapidly,
for endoscopic laryngeal surgery, especially if fine adjust- patients frequently have difficulty managing secretions by
ments of vocal quality are to be made, as during injec- the time the anesthesia has been applied. Suction should
tion for vocal fold paralysis or reduction of a dislocated be available.
arytenoid cartilage. Many techniques of local anesthesia The adequacy of anesthesia application can be tested
are used. They involve a variety of systemic, topical and by placing a metal tongue depressor against the tongue
regional medications. The technique described below has base and lifting it anteriorly and inferiorly, simulat-
proven most effective in the authors’ hands but should be ing laryngoscope pressure and placement, while the
considered only one of many options. In rare instances, hypopharynx is suctioned. If anesthesia is adequate, these
direct laryngoscopy may be performed without operating maneuvers should not disturb the patient. Throughout the
room support and with topical anesthesia alone. application of anesthesia, the physician and anesthesiolo-
Generally, procedures are performed in the operating gist should maintain verbal contact with the patient, care-
room with monitoring and sedation. Intravenous seda- fully control the airway and monitor vital signs including
tion is administered prior to anesthetic application. The blood oxygen saturation. If adequate topical and regional
authors prefer a sedative that produces amnesia such as anesthesia cannot be established, or if adequate sedation
Midazolam. The oral cavity is sprayed with a topical anes- cannot be achieved safely, the procedure either should
thetic. Cetacaine, 4% xylocaine, 0.5% pontocaine, cocaine be discontinued or general anesthesia should be induced.
and others have all given satisfactory results. Topical anes- Both the patient and the anesthesia team should be pre-
thetic is routinely supplemented with regional blocks pared for possible use of general anesthetic in all cases.
and local infiltration. Bilateral superior laryngeal nerve Most laryngeal procedures can be performed safely
blocks are achieved using 1% xylocaine with epinephrine under local anesthesia. This choice provides not only the
1:100,000. Superior laryngeal nerve block is accomplished opportunity to monitor voice during the procedure but
by injecting 1−2 cc of 1% xylocaine with epinephrine also protection from the risks of endotracheal intuba-
1:100,000 into the region where the nerve penetrates tion. However, there are also disadvantages. When max-
the thyrohyoid membrane, anterior to a line between imal precision is necessary, the motion present during
the greater cornu of the thyroid cartilage and the greater local anesthesia may be troublesome. Greater accuracy
cornu of the hyoid bone. Glossopharyngeal nerve blocks is enhanced by general anesthesia with paralysis. The
are placed using 2 cc of 1% xylocaine with epinephrine safety of local anesthesia during some cases of endola-
1:100,000 in the lateral oropharyngeal wall, a few milli- ryngeal surgery is questionable. In addition to mechani-
meters medial to the midportion of the posterior tonsillar cal surgical problems, in some patients with cardiac or
pillar on each side. The tongue base is then infiltrated pulmonary problems, the respiratory suppression caused
with 2−4 cc, using a curved tonsil needle and metal by sedation may be more hazardous than general anesthe-
tongue depressor. Anesthesia is concluded with intratra- sia. In addition, local anesthetics themselves may pro-
cheal topical application of 4 cc of topical 4% xylocaine, duce side effects. These may include mucosal irritation
administered through a midline injection in the crico- and inflammation (contact dermatitis) that may cause
thyroid membrane (after anesthetizing the skin with 1% not only erythema and pruritus but also vesiculation and
of xylocaine with epinephrine 1:100,000 or by spraying oozing; dehydration of mucosal surfaces or an escharotic
Ch-07.indd 25 9/8/2010 3:03:38 Gopal

Section
effect (especially from prolonged contact); hypersensitivity The choice of agents for general anesthesia is beyond
(rash); generalized urticaria (edema); methemoglobinemia the scope of this chapter. However, in general, the regi-
and anaphylaxis. Safety for use during pregnancy has not men includes use of a short-term paralytic agent to avoid
been established for most topical anesthetics used com- patient motion or swallowing. Intubation and extubation
1 monly in laryngology; and they should be utilized only should be accomplished atraumatically, using the small-
under pressing clinical circumstances, if at all, during the est possible endotracheal tube. Most laryngeal endoscopic
first trimester of pregnancy. Methemoglobinemia may be procedures are short in duration, and a 5 mm inner
a particularly frightening complication of local anesthe- diameter endotracheal tube is generally sufficient, even
sia. Methemoglobin is also called ferric protoporphyrin for most moderately obese patients. The laser may be
(IX globulin) and ferrihemoglobin, because the iron in used during many procedures, and it is best to employ
methemoglobin is trivalent (or ferric) instead of diva- a laser-resistant endotracheal tube unless the surgeon is
lent (ferrous). Methemoglobinemia produces cyanosis, absolutely certain that the laser will not be activated.
although skin discoloration is usually the only symp- Antireflux medications are prudent, especially in
tom of acquired methemoglobinemia. Arterial blood gas patients with symptoms and signs of reflux. However,
analysis confirms the presence of methemoglobin. This reflux may occur under anesthesia even in patients who
condition can be induced by any amine-type local anes- do not have significant clinical reflux. The combination
thetic. Prilocaine and benzocaine are the drugs impli- of acid exposure and direct trauma from the endotracheal
cated most commonly.1 Infants may be somewhat more tube can lead to laryngeal mucosal injury. Intravenous
susceptible, but the condition may occur in patients of steroids (e.g. 10 mg of dexamethasone) may be helpful
any age. Methemoglobinemia is actually a misnomer in minimizing inflammation and edema and possibly in
because the pigment is intracellular, and is not found protecting against cellular injury; and intravenous steroids
in the plasma. Methemoglobincythemia would be more should be used at the surgeon’s discretion, if there is no
accurate; but methemoglobinemia is used commonly. contraindication.
26 Methemoglobinemia is treated by intravenous admin-
istration of methylene blue, although the condition is
Endotracheal intubation provides the safest, most
stable ventilation under general anesthesia, and it gener-
not life-threatening and will resolve spontaneously. The ally provides adequate visibility. However, in some cases,
notion that local anesthesia is always preferable to general even a small endotracheal tube may interfere with surgery.
anesthesia should be viewed with skepticism. The choice Alternatives include general anesthesia without intuba-
depends on the patient, the lesion, the surgeon and the tion and with either jet ventilation or intermittent apnea.
anesthesiologist. Laryngeal microsurgery without intubation was reported
first by Urban.2 The technique involves intravenous
GENERAL ANESTHESIA thiopental, 100% oxygen by mask initially and manually
controlled oxygen insufflation. Few anesthesiologists are
Probably the most important consideration in general comfortable with this technique, and the oxygen insuf-
anesthesia for voice patients is the choice of the anesthe- flation can be an inconvenience during surgery.
siologist. Laryngologists performing voice surgery must Venturi jet ventilation can be a useful technique.
insist on the collaboration of an excellent anesthesiolo- Anesthetic and oxygen can be delivered through a
gist who understands vocal fold surgery and the special needle placed in the lumen of the laryngoscope, through
needs of voice patients. Those of us who work in teaching a ventilation channel in specially designed laryngoscope
institutions recognize that medical students and first-year channels, through a catheter just above or below the
anesthesia residents need to practice intubation. However, vocal folds, such as the Hunsicker catheter (Medtronics-
this need should not be met on patients undergoing sur- Xomed, Jacksonville, FL) or through a Carden tube.3
gery for voice improvement, especially professional voice The authors use the Hunsicker catheter because of its
users. When a gentle, skilled, well-informed anesthesiolo- easy placement, security, laser resistance, and the fact that
gist and laryngologist collaborate, the choice of anesthetic the jet ventilation initiates below the vocal folds. This
depends solely on the patient and lesion, and safe effective seems to cause less mechanical interference at the vibra-
surgery can be carried out. Such teamwork benefits the tory margin during surgery. However, the catheter must
laryngologist, anesthesiologist, hospital, and especially the carefully be placed between the vocal folds by an expert
patient; and every effort should be made to establish the anesthesiologist or the laryngologist and removed care-
necessary professional collaboration. fully to avoid intubation and extubation trauma as might
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Anesthesia
Chapter
be caused by placement of any endotracheal tube. During anesthesiologists must temper their tendency to use the
any surgery that employs jet ventilation, it is essential that largest possible tube. There are very few procedures that
the surgeon be a knowledgeable, cooperative part of the cannot be performed safely through a size 6.5 or smaller
anesthesia team. The airway must remain unobstructed for endotracheal tube, and many can be performed with mask
expiration. If the laryngoscope moves or is removed and anesthesia or a Brain laryngeal mask without intubating 7
obstructs the airway without a warning to the anesthesia the larynx at all. When possible, alternatives to general
team, pneumothorax may result. anesthesia should be considered such as spinal blocks,
All the care exercised in gentle intubation may be for regional blocks and acupuncture. Many procedures com-
naught unless similar caution is exercised during extuba- monly done under general anesthesia with intubation can
tion. The most common error during extubation is failure equally be performed well using another technique. After
to fully deflate the endotracheal tube cuff. This may result surgery, postoperative voice assessment by the anesthesi-
in vocal fold trauma or arytenoid cartilage dislocation. ologist, patient and operating surgeon is essential. If voice
The anesthesia team should be aware of these problems. abnormalities are present other than very mild hoarse-
The surgeon should be present and attentive during intu- ness that resolves within 24 hours, prompt laryngological
bation and extubation to help minimize the incidence of examination should be arranged.
such problems.
Anesthesia is also a prime concern for voice patients
REFERENCES
undergoing nonotolaryngologic surgery involving general
surgeons and other surgical subspecialists. Laryngologists 1. Adriani J, Naraghi M. Drug induced methemoglobinemia:
are frequently called on for guidance by professional voice Local anesthetics. Anesthesiology Rev. 1985; 12(1):54-9.
users, surgeons and anesthesiologists. The anesthesiologist 2. Urban GE. Laryngeal microsurgery without intubation.
must appreciate that the patient is a voice professional, South-Med J. 1976; 69:828-30.
and ensure that intubation and extubation are performed 3. Carden E, Becker G, Hamood H. Percutaneous jet ventila-
by the most skilled anesthesiologist available. In addition, tion. Ann Otol Rhinol Laryngol. 1976; 85:652-5.
27
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Chapter
Instrumentation
8
Microlaryngeal surgery utilizes magnification, usually important for surgeons to be familiar with these princi-
provided by an operating microscope, which is used ples to optimize surgical conditions for each specific case
through a rigid direct laryngoscope.1 Many surgeons are and to document surgery accurately.
not familiar with formulas that determine accurately the Magnifying laryngeal telescopes are also invaluable for
amount of magnification used and it is often recorded assessing vocal fold pathology and mapping lesions for
incorrectly in operative reports. It is not unusual for sur- surgery. 4 mm and 10 mm 0º and 70º telescopes (Karl
geons to assume that the number on the indicator on Storz, Culver City, Calif ) and 30º and 120º telescopes
the zoom control correlates with the number of times are useful in some circumstances. Laryngeal telescopes
the image is magnified, but accurate determination is allow the surgeon to visualize lesions in great detail, to
more complex than that. This author (RTS) usually appreciate the limits of lesions in three dimensions bet-
works with a Zeiss operating microscope (Oberkochen, ter than can be accomplished through a microscope and
Germany) and the information in this discussion refers to visualize obscure areas such as the laryngeal ventricle
specifically to Zeiss instruments. However, the principles (Figs 8.1A to C).
are the same for microscopes manufactured by other A technique known as contact endoscopy has been
companies. To determine the amount of magnification, used by gynecologic surgeons for many years. Its value
the focal length of the binocular tube is divided by the in microlaryngeal surgery was recognized by Dr Mario
focal length of the objective lens and then multiplied by Andrea.2 This technique uses a vital staining agent such
the magnification of the eyepieces.1 That number is then as methylene blue. Contact endoscopy permits visuali-
multiplied by the indicator on the magnification (zoom) zation of the cellular nature and integrity of vocal fold
control of the microscope, on a modern microscope. The epithelium at any given point along the vocal fold. Cell
focal length of the binocular tube is usually a number, nuclear characteristics are visible and specific borders
such as, F125 which corresponds to 1.0; 10 corresponds between pathologic, transitional and normal epithelium
to 0.6; 6 corresponds to 0.4. So, for example, if a sur- can be defined, permitting precise surgical intervention.
geon is using an OPMI-1 microscope with 10x eyepieces, Although this technique is relatively new and requires
a 400 mm objective lens and the magnification set at additional study and experience, it appears extremely
40 (maximum), image magnification is 7.8x (125/400 × valuable in selected cases.
25 × 10 = 7.8x), not 40x, as misstated commonly. Delicate microsurgery requires sharp, precise, small
Simply changing the eyepieces from 10x to 12.5x instruments. The few heavy cupped forceps and scissors
increases the magnification from 7.8x to 9.8x and using that constituted a laryngoscopy tray through the early
20x eyepieces increases the magnification to 15.6x. 1980s are no longer sufficient. It is now possible to obtain
Utilizing an objective lens with a shorter focal length also microlaryngeal instruments that look like ear instruments
increases magnification but brings the microscope closer on long handles. Instruments should be long enough to
to the operating field. Although this approach is used be manipulated easily in the laryngoscope, but not so
during ear surgery, it is not suitable for laryngeal surgery long that they bump into the microscope. They should
because the decreased space between the microscope and include scissors (straight up, up-biting, curved left and
direct laryngoscope is not sufficient to permit unimpeded curved right), small grasping cupped forceps (straight, up-
manipulation of long-handled laryngeal instruments. It is biting, right and left), larger cupped forceps (straight and
Instrumentation
A B
C
29
Figs 8.1A to C: (A) Vocal folds visualized through 10 mm 0° telescope (Karl Storz, Culver City, CA) showing a right vocal fold cyst
(arrowhead) and left reactive swelling (curved arrow). (B) Vocal folds visualized through a 70º telescope, allowing better evaluation of
the vertical surface of the vibratory margin. This view shows that the cyst (arrowheads) involves only the superior one-third to one-half
of the vibratory margin. The well (curved arrow). (C) The laryngeal ventricle visualized above the true vocal fold and below the false
vocal fold through a 70º telescope. Reproduced from Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition.
San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 82.10, with permission
up-biting, at least), alligator forceps (straight, right and body has been utilized for many years.3 Acoustic neu-
left), scalpel, retractors, ball dissectors (straight, oblique roma surgeons have used powered instruments such as
and right-angled), mirrors for reflecting lasers and suc- the House-Urban Rotary Dissector (Urban Engineering,
tions (Figs 8.2A to D and 8.3A to Z). Cutting instru- Burbank, CA) for 3 decades, arthroscopic knee surgeons
ments should be sharp at all times. Suctions should be use powered instruments regularly and powered instru-
thumb controlled, of several sizes, and should include ments have been important to functional endoscopic sinus
both open tip and velvet eye designs. A suction/cautery surgery. Their role in laryngeal surgery is not defined
tip may be valuable occasionally and should be available, completely, but powered laryngeal surgery is clearly use-
as should cotton carriers. Nonreflective instruments with ful in the treatment of some conditions such as selected
laser-resistant coating may be advantageous in some situ- papillomas and neoplasms. The most commonly used
ations. powered laryngeal instrument is the Medtronic-Xomed
Powered laryngeal surgery is a relatively new con- XPS Power System ( Jacksonville, FL) with disposable
cept, although powered surgery for other areas of the laryngeal shaver blades. To use powered instruments
A B
30 C D
Figs 8.2A to D: (A) Traditional laryngeal cupped forceps (top), compared with more modern instruments designed by Dr Marc Bouchayer
(Medtronic-Xomed, Jacksonville, FL). (B) Additional delicate Medtronic-Xomed instruments used routinely by this author. (C) Extremely
useful Medtronic-Xomed (Jacksonville, FL) suction cautery instruments designed by J Abitbol. (D) Selected instruments designed by the
author (RT Sataloff), manufactured by Medtronic-Xomed, Jacksonville, FL. Reproduced from Sataloff RT. Professional Voice: The Science
and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 82.12, with permission
safely, it is important to understand the blades and instru- endoscopes available and be comfortable with their use.
ment settings. For example, to debulk a large, exophytic In some cases, difficult anatomy precludes visualization
or fibrous lesion, the tri-cut laryngeal blade is utilized of certain regions of the larynx, especially at and above
at 3,000 rpm with suction set at a medium vacuum set- the anterior commissure with the operating microscope.
ting. To remove papilloma near the vibratory margin or In such cases, the best way to remove pathology may
anterior commissure in a controlled fashion, it is more be through the use of a 70º telescope for visualization
appropriate to use a 3.5 mm laryngeal skimmer blade at and a powered skimmer blade for resection. Delicate
a speed of 500 rpm in the “oscillate” mode with the suc- microdissection is still the most controlled and appro-
tion set at a low vacuum setting. Although some surgeons priate technique for removing most benign lesions such
prefer using powered instruments under endoscopic con- as cysts and polyps from the vibratory margin of the
trol rather than using a microscope, the authors generally vocal fold. However, powered instruments, used properly,
prefer using a microscope to permit binocular vision and allow surprising precision and may be helpful, especially
bimanual manipulation. However, surgeons should have for selected papillomas and neoplasms.
Instrumentation
A B
C D 31
E F
G H
Figs 8.3A to H
I J
32 K L
M N
O P
Figs 8.3I to P
Instrumentation
Q R
S T 33
U V
W X
Figs 8.3Q to X
Y Z
Figs 8.3A to Z: Selected microlaryngeal instruments (A-W are Sataloff instruments, Medtronic-Xomed, Jacksonville, FL). (A) 30 gauge
straight disposable needle (with cleaning stylet in place) for submucosal infusion or collagen injection. (B) 30 gauge right-angled
disposable needle with cleaning stylet in place. (C) Sharp microknife. This and the sickle knife are disposable and screw into a handle.
The vascular knife and selected other sharp instruments are designed similarly. They are intended for single use so the instruments
are optimally sharp for each patient. (D) Sickle knife. (E) Universal scissor handle. All of the straight-handle Sataloff instruments are
designed to fit in the universal scissor handle. This not only allows the instrument tip to be positioned at any angle, but it also permits
case-by-case adjustments of instrument length from the handle to the tip. This allows the tip of the instrument to be on the vocal fold,
while the handle is close enough to the laryngoscope to permit the surgeon’s fingers to be placed against the head or laryngoscope for
stabilization. (F) Straight spatula. (G) Curved spatula. (H) Fine-angled spatula. (I) Straight blunt ball dissector. (J) Oblique blunt ball
dissector. (K) Small right angle blunt ball dissector. (L) Long right-angled blunt ball dissector. (M) Sharp right-angled book. (N) Vascular
knife. This 1 mm instrument is sharp on the point and blunt on the bottom. It is used for dissecting varicose blood vessels off the
vocal fold. It is essential that it not be confused with the mini-microflap knife. (O) The mini-microflap knife is similar to the sharp
right-angled hook, except the mini-microflap knife is sharpened on the bottom, as well as the tip. This allows it to be placed within
a mucosal pocket and to cut tissue sharply through a small access incision. If it is inadvertently confused with the vascular knife and
34 used for vascular dissection, the sharp inferior surface of the microknife can damage the vocal fold. (P) Small heart-shaped grasper
(comes in right and left directions, left only shown). (Q) Left alligator forceps. (R) Down-bitting forceps. (S) Polished mirror for reflecting
and redirecting laser light (small and large mirrors are available). (T) Fine double hook for retracting laryngeal flaps and large lesions.
(U) 3 French velvet eye suction used during microflap dissection. (V) 3 French velvet eye suction with metal surface to retract tissue
and to prevent tissue prolapse into the surgical field. (W) Cotton carrier. (X) Blunt scissors, vertical action, angled down; blunt scissors,
horizontal action, curved blades, open left; sharp scissors, horizontal action, curved blades, open left. (Y) From left to right, sharp
scissors, vertical action, angled down; blunt scissors, vertical action, straight blades; blunt scissors, vertical action, angled up (numerous
other variations are available). (Z) Suctions, 5 French and 7 French diameter. Reproduced from Sataloff RT. Professional Voice: The
Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing Inc.; 2005: Fig. 82.13, with permission
REFERENCES 2. Andrea M, Dias O. Atlas of rigid and contact endoscopy

in microlaryngeal surgery. Philadelphia, PA: Lippincott
1. Hoerenz P. The operating microscope. I. Optical principles, Williams and Wilkins; 1995. pp. 1-112.
illumination systems, and support systems. J Microsurg. 3. Flint PW. Powered surgical instruments for laryngeal sur-
1980; 1(5):364-9. gery. Otolaryngol Head Neck Surg. 2000; 122(2):263-6.
Chapter
Submucosal Infusion and
9 Laryngeal Microsurgery
The concept of laryngeal infusion was introduced in the In some cases, submucosal infusion may be performed
1890s for the purpose of anatomic studies.1 The tech- with a substance other than saline with epinephrine. For
nique has been used intermittently over the years for a example, if the surgeon plans to inject steroid in a patient
variety of purposes, including infusion of steroids to dis- with scar or sulcus, the steroid may be used for infusion
rupt adhesions in vocal fold scar, placement of collagen initially. It is as effective as saline and epinephrine in
along the vibratory margin, and for separating benign and defining the lesion and tissue planes, but it does not pro-
malignant lesions from underlying structures.2 The tech- vide an equally good vasoconstrictive effect. The efficacy
nique has become more popular among clinicians since of steroid injection in the vocal folds is unknown. Some
the 1980s and 1990s.3,4 surgeons use it regularly. Others are concerned that it may
result in muscle atrophy. If used, it is important for the
Submucosal infusion may be appropriate for a variety
surgeon to utilize an aqueous solution, not an oil-based
of vocal fold masses, but it has disadvantages, as well
preparation. Moreover, the author (RTS) recommends
as advantages. Infusion usually is performed utilizing a
against using steroid suspensions, which appear to be
solution made by combining 9 cc of sterile saline with
“milky-colored” preparations, such as Kenalog (Westwood
1 cc of epinephrine 1:10,000 (a 1:10,000 dilution). A Squibb, Buffalo, NY). Occasionally, the white suspended
small amount of this mixture is infused submucosally particles can precipitate and form a plaque that takes
using a 30 gauge needle to increase the fluid content months to resolve.5 Precipitation and the formation of
of the superficial layer of the lamina propria, to sepa- plaques have not been encountered with steroid solutions,
rate the undersurface of the lesion more clearly from the which are typically clear liquids, such as Dexamethasone.
vocal ligament, and to help define the vocal ligament Cidofovir can also be used sparingly as the infusion mate-
more clearly. In lesions such as, sulcus vocalis, vocal fold rial in patients with papilloma.
scar and papilloma, this technique is extremely helpful.
In other lesions, such as small vocal fold cysts, it may REFERENCES
actually obscure the pathology making surgery more dif-
ficult. When utilized in appropriate cases, the epinephrine 1. Hajek M. Anatomische Untersuchungen uber das
Larynxodem. Arch Klin Chir. 1891; 42:46-93.
also causes vasoconstriction and helps minimize bleeding.
2. Pressman J, Dowdy A, Libby R, et al. Further studies upon
When bleeding does occur, it can be controlled in most the submucosal compartments and lymphatics of the larynx
cases with topical application of epinephrine 1:1,000 on a by the injection of dyes and radioisotope. Ann Otol Rhinol
small cottonoid. Rarely, cauterization with a laser or cau- Laryngol. 1956; 65(4):963-80.
tery is required. Infusion of saline and epinephrine does 3. Welsh LW, Welsh JJ, Rizzo TA. Laryngeal spaces and
not have to be limited to the vocal fold itself. Infusion lymphatics: Current anatomic concepts. Ann Otol Rhinol
Laryngol Suppl. 1983; 105:19-31.
also can be performed in the false vocal fold and lateral
4. Kass ES, Hillman RE, Zeitels SM. Vocal fold submu-
to the ventricle. This infusion technique can be successful cosal infusion technique in phonomicrosurgery. Ann Otol
in everting the ventricle into the surgical field, providing Rhinol Laryngol. 1996; 105(5):341-7.
direct access to lesions that involve the deep recesses of 5. Andrade Filho PA, Rosen CA. Vocal fold plaque following
the laryngeal ventricle. triamcinolone injection. ENT J. 2003; 82(12):908-11.
Ch-09.indd 35 9/8/2010 3:04:07 Gopal

Chapter
10 Laryngeal Laser Surgery

Jean Abitbol, Robert T Sataloff
Ever since the laser was first used for laryngeal surgery in of radiant exposure is central. This is the relation of power
the 1960s, controversy and disappointment have accom- density and time of laser use. Power density describes
panied its use. Because of technical advantages over lasers the relationship among the watts of laser energy deliv-
of other wavelengths, the carbon dioxide (CO2) laser ered and the area of tissue to which energy is deliv-
has become standard for laryngeal surgery. Bredemeier’s ered. Equally important is the concept of lateral thermal
invention of a micromanipulator that allowed the delivery energy spread, i.e. heat generated by the laser spreads
of a CO2 laser beam through a microscope1 heralded the from the point of impact. The longer the tissue exposure,
beginning of the current era of laryngeal laser surgery. the greater the lateral thermal energy spread, and the
The initial report by Strong and Jako2 was encouraging. greater the risk of injuring adjacent structures (e.g. the
Since that time, the laser has become a routine instru- vocal ligament). Consequently, the surgeon should select
ment for laryngeal microsurgery. Nevertheless, although single or intermittent pulses, using the shortest time pulse
its usefulness for some laryngeal procedures is universally that will accomplish the surgical task. When a 400 mm
accepted, its efficacy for many common laryngeal applica- focal lens is used on the microscope and a laser spot
tions is still controversial. In all cases, its advantages must size of 0.4 mm is employed, 4–6 watts at 0.1 seconds
be weighed against its potential hazards. are generally sufficient,4 although up to 10 watts may be
Lasers generate heat. Consequently, they introduce the appropriate for some lesions. This spot size is still in use
possibility of heat-related complications. Although such in many operating rooms. However, it is usually prefer-
complications will be seen even among the patients of the able to use a smaller spot size (0.15 mm or smaller) to
best and most experienced laser surgeons, their incidence permit comparable power density and tissue effect with
can be minimized through a thorough understanding of less laser energy and a smaller zone of destruction. When
the principles of laser surgery. desired, the CO2 laser can also be delivered through a
Laser surgery is complex and requires education of the fiber. This method is sometimes preferable for subglottic
anesthesiologist, complete operating room team and espe- and tracheal stenosis and for treating lesions located more
cially the surgeon.3 The anesthesiologist must be aware distally in the airway. However, this chapter will concen-
that a laser will be used. A laser-resistant endotracheal trate primarily on the delivery of a laser beam through a
tube should be selected and high oxygen concentrations microslad attached to a microscope.
should be avoided. In some cases, helium may be used as The surgeon should also understand the difference
a substitute. The operating room nurses need to under- between continuous, superpulse, ultrapulse and chopped
stand laser use and safety. The laser is checked by the modes of laser delivery. Newer lasers allow the surgeon
nursing staff and surgeon for proper function and align- to select the contour and millijoule level of each laser
ment. Appropriate instruments and laser-resistant drapes burst, permitting more precise control over tissue effect.
must be provided, along with safety glasses. An evacua- In addition, if the surgeon places laser bursts immediately
tion system to remove smoke from the airway must also adjacent to each other, there is likely to be an area of ther-
be employed. Both nurse and surgeon must be responsible mal overlap. Therefore, even when creating a continuous
for the utilization of laser safety devices, such as wet cot- incision, laser impact should be spaced slightly apart to
tonoids in the airway and wet towels around the laryn- avoid inadvertent injury to deeper tissues. This is referred
goscope. Failure to observe any of these precautions may to commonly as “skip technique”. The surgeon must also
result in injury to the patient or operating room staff. recognize that the laser beam has width. It cuts not only
In addition, it is essential that the surgeon under- with the center of the beam, but also with the edge; and
stands the principles of CO2 laser function. The concept there is thermal damage beyond the edge. Therefore, the
Ch-10.indd 36 9/8/2010 3:04:17 Gopal

Laryngeal Laser Surgery
Chapter
surgeon must center the laser beam in the lesion, using diminished by the use of laser-resistant endotracheal
the edge of the beam to create the margin of excision. The tubes or high flow jet ventilation.
surgeon must also understand the use of a focused laser Lateral thermal energy spread is a more common
beam (for cutting or vaporization, for example), a defo- cause of laser-related complications in vocal fold sur-
cused laser beam (for coagulation) and the implications of gery. As laser surgery became increasingly common, 10
spot size. Incisions are made most precisely using a very more and more anecdotal reports surfaced describing
small spot size, often with high power. Vaporization is apparent delayed healing and increased scarring fol-
accomplished best in many situations with a larger spot, lowing laser surgery. Confirmation of these impressions
but still with high power. A large spot with low power is was reported by Abitbol5 and Tapia6 in separate stud-
optimal for coagulation. Microspot lasers provide a beam ies in 1984. Histological observations by Durkin and
as small as 0.1 mm in diameter, which appears to allow co-workers supported anecdotal observations that laser
more precise laryngeal microsurgery than 0.8 mm or even surgery could delay healing and increase scar formation.7
0.4 mm spots. However, the surgeon must recognize that, It is now clear that the most significant disadvantage
as spot size decreases, wattage must be adjusted in order of CO2 laryngeal laser surgery is thermal injury to the
to maintain the desired power density. If the surgeon fails intermediate and deep layers of the lamina propria, which
to appreciate these principles and techniques, thermal contain significant numbers of fibroblasts or the vocalis
injury to normal tissues may result. Hydration of tissue muscle. Such injuries may result in scars. When an ady-
is also important. Serious thermal damage may occur if namic segment is created along the vibratory margin of
the tissue is dry. the vocal fold, dysphonia results. This may take the form
The CO2 laser has distinct advantages over traditional of severe hoarseness and breathiness. At the present time,
instruments. It permits better hemostasis, better visibility there is no consistently effective treatment for adynamic
and less tissue manipulation. For varicosities, benign fri- segments and dysphonia in such cases is generally perma-
able lesions on the superior surface of the vocal folds, nent. Therefore, it is most important to avoid such injury
and selected other lesions, these advantages are compel-
ling. However, the laser also has important disadvantages.
whenever possible.
In general, although the laser can be used safely by an
37
These include loss of tissue by vaporization and conse- expert surgeon for nearly any laryngeal lesion, it does not
quences of thermal injury. offer clear advantages in the treatment of most benign
The problem of tissue loss by vaporization should masses of the vibratory margin of the vocal fold, such as
not be underestimated. Although clinical impressions nodules and cysts.8,9 They are usually not particularly fri-
are often accurate in benign laryngeal lesions, especially able, their limits are easily visualized, and they usually can
following strobovideolaryngoscopy, they are no substitute be removed deftly without injuring the underlying tissue.
for histopathological examination. Even lesions that look Laser excision adds little other than the risk of undesir-
like routine nodules and polyps occasionally turn out to able thermal spread to deeper layers, although techniques
be amyloid, rheumatoid nodules, minor salivary gland using a microspot CO2 laser may decrease the incidence
tumors or serious malignancies. Often they are small. of thermal complications.10,11
The lesion should be excised entirely when possible and Lasers are often helpful in coagulating the central
studied microscopically. Laser vaporization deprives the feeding vessel of unilateral polyps. Such vessels usually are
patient of potentially critical histopathologic assessment. found on the superior surface of the vocal fold. However,
Even in laryngeal papillomatosis, a portion of the abnor- polyps based on the vibratory margin can be excised eas-
mal tissue should be sent for evaluation by the patholo- ily and precisely with microlaryngeal scissors following
gist, although most of the disease should be treated by central vessel coagulation. An infusion should be provided
vaporization. With the microspot, thermal damage on the by injection of saline and then “hydrotomy” is performed.
sample usually is no more than 150 microns. Subsequent microsurgery is easier. If polyp can be sepa-
Heat-induced consequences of laser surgery have rated from the vocal ligament by blunt dissection, it can
received considerable attention. The most dramatic is usually be removed safely by a laser beam directed medi-
endotracheal tube fire. This disaster can usually be avoided ally to avoid injury. However, slight motion or misdirec-
by meticulous attention to laser safety precautions and tion can easily result in a vocal ligament burn; and once
accurate delivery, but it is a well-recognized complica- blunt dissection has been accomplished, the laser offers
tion that is always possible. The risk of laser fire is also no significant advantage over traditional instruments for
Ch-10.indd 37 9/8/2010 3:04:18 Gopal

Section
the final removal of the polyp. Similarly, laser has been phonomicrosurgery was first described 30 years ago.2
advocated for making incisions in the superior surface of Absorption by water yields a small penetration of a laser
the vocal fold prior to evacuation of Reinke’s edema. In beam. Living tissue contains a large amount of water;
this case, although the risk of significant vocal fold scar therefore, absorption of CO2 laser emissions is maximal
1 is low, the laser offers no substantial advantage over scis- in the superficial layers of tissue. It causes a surgical defect
sors except that there is no bleeding; and laser surgery for by the evaporation of tissue fluid and subsequent burn-
this condition is also often slower than surgery with cold ing of organic material. A small proportion of laser light
instruments. Its use in such cases is a matter of individual energy penetrates deeper, partly by absorption but mostly
surgeon’s preferences. by conduction. This causes a zone of devitalized cells due
Laser has been advocated for the treatment of various to thermal damage. The depth of this scarring (which
lesions, including vocal fold webs, granulomas, vocal fold appears as black particles) is due to carbonization and is
paralysis, stenosis and carcinoma. So far, no significant proportional to the energy density and temperate of the
advantages or disadvantages have been identified in the tissue. If laser is used on carbonized tissue, which is black,
treatment of web. Topical contact of mitomycin for two the heat effect increases and the scarring process is dis-
minutes may improve results. The laser does not consist- turbed. Energy density depends on the time of exposure
ently obviate the need for a keel or stent, especially in to the laser, the energy delivered, hand speed, the angle
larger lesions. When arytenoidectomy is necessary, endo- of delivery, and overall, the diameter of the impact point.
scopic laser arytenoidectomy has proven convenient and
successful. Potential laser-related disadvantages include TYPES OF LASERS
the risk of endotracheal tube fire, especially if tracheos-
tomy has not been performed, and thermal damage to Argon Laser
the interarytenoid region, which might result in posterior
laryngeal stenosis. These complications are avoidable in The Argon laser, introduced in the 1960s, was the pioneer-
ing instrument in otolaryngologic laser surgery.21-23 It is a
38 most cases. Lasers may be used in the treatment of granu-
lomas, as long as an adequate biopsy has been obtained stable gaseous laser with a continuous wave. Wavelengths
and the underlying perichondrium is not traumatized. range from 488–514.5 nm, are transmitted through clear
Lasers may be used also for carcinoma, although the fluid and structures and emit light in the visible spec-
value of laser surgery in malignant lesions remains uncer- trum of blue-green. It can be used through flexible fibers
tain.12-18 When the laser is used for laryngeal cancer, in endoscopes. Spot size is about 100–200 microns. This
the surgeon must obtain adequate histological specimens laser is used in the treatment of pigmented and vascu-
not only from the tumor, but also from the margins. The lar lesions and is absorbed by hemoglobin, melanin and
impact of laser use upon vocal quality in laryngeal cancer retinal tissue. The average power is 4–6 watts, but it can
patients remains uncertain. be raised to 30 watts. It has coagulation capability and a
At the present time, the CO2 laser is used most widely very low cutting effect.
for laryngeal surgery, although other lasers have been
tried19,20 as discussed below, and pulsed dye and pulsed Nd: YAG Laser
KTP lasers are used often. So far, other wavelengths do The neodymium: yttrium-aluminum-garnet laser
not appear to be efficacious for most laryngeal surgery as (Nd: YAG laser) has a wavelength of 1,060 nm. It is a
the CO2 laser, for various reasons, including the inabil- solid laser that emits continuous, short infrared wave-
ity to use them through a microscope, excessive thermal lengths and is usable through optical quartz fiber light
injury, or the need for contact between the laser-emitting guides. The Nd: YAG laser beam is transmitted through
instrument and the tissue. Additional investigation of clear fluids and delivers 10–120 watts through a fiberoptic
various wavelengths is needed. channel. It produces a high degree of scatter, which results
in a large spot size, small cutting effect and substantial
CHARACTERISTICS OF LASERS REQUIRED FOR charring effect. The thermal effect is significant and it
PHONOMICROSURGERY is capable of coagulating vessels up to 2 mm in size. Its
tissue penetrating ability is 5–7 mm. At low power, it
Lasers can be used to incise, vaporize, coagulate or shrinks the tissue without any vaporization; however, the
penetrate the vocal fold structures. The use of lasers in thermal effect could damage, destroy or boil the lamina
Ch-10.indd 38 9/8/2010 3:04:18 Gopal

Chapter
propria and ruin the voice by noncontact. With a properly consistently achieve appropriate distance of the fiber from
placed contact tip, the cutting effect is good, but tips must the vessel, in order to maximize the vascular effect while
be in contact with the tissue before firing; otherwise heat minimizing adjacent tissue response. The pulsed-KTP
will be too high due to the scattering effect. This laser laser has been advocated for the treatment of vascular
along,24 or combined with the CO2 laser, can be used in lesions, as well as for the treatment of papillomatosis and 10
treating obstructing malignant laryngeal lesions. dysplasia.26
Potassium, Titanyl, Phosphate (KTP) Crystal Laser Dye Laser Photodynamic Therapy
The KTP/532 laser is an Nd: YAG laser. Its potential Argon lasers or tunable dye lasers, activate hematoporphy-
for use in surgery increased by two important improve- rin derivative (HPD), which is concentrated preferentially
ments: doubling of the frequency of the wavelength and in tumor cells.27 Patients receive a photosensitizing agent,
point of contact. Frequency doubling offers a technique which is administered through an intravenous injection
to change the output wavelength from 1,060 nm (infra- 24 hours before laser treatment. Only tumor cells less
red) to 532 nm (green) by means of a special crystal than 3 mm deep are destroyed, which seems an applicable
that combines two infrared photons to one green photon. technique for treating carcinoma in situ (CIS) or T1N0
Contact KTP with a conical sapphire, which, due to its cancer. Moreover, in all cases, endoscopic examination and
shape, reflects laser energy to the tips and heats up the biopsy must be done prior to developing a treatment pro-
several hundred degrees celsius on a much focused spot, tocol. The drugs used in photodynamic therapy can cause
provides almost a pure cutting effect. The KTP laser is photosensitivity. Patients so treated must remain in dark-
transmitted through clear fluids and structures. It does ness for 30 days, beginning 24 hours after an injection, to
not vaporize well and has a 200 nm spot size when deliv- ensure there is fluorescence of malignant cells only as laser
ered through fiberoptic channels in endoscopes (available irradiation destroys the tumor cells. The wavelength of the
fibers range from 0.2–0.6 mm in diameter). It can also argon laser is 632 microns. Light dosimetry is calculated,
be used through the microscope. Perkins developed the
KTP laser for otosclerosis, before it was used in the lar-
based on the body surface. Photodynamic therapy (PDT)
is performed with laryngoscopy and general anesthesia. It
39
ynx.25 Since 1986, KTP/532 has been used commonly in lasts between 20–45 minutes. PDT follow-up appoint-
the treatment of laryngeal pathology. It is a green beam, ments are scheduled every week for two months and
which may pass through the microscope by the flexible should be made for late in the afternoon to avoid sun
fiberoptic channel of an endoscope. The indications are irradiation. On the vocal folds, this technique is debatable
numerous; however, in our hands, the thermal damages particularly in the treatment of vocal fold cancer, which
seem to be more significant than with the CO2 laser. requires a very early diagnosis. Before undergoing treat-
More recently, pulsed-KTP laser has been used for the ment with the dye laser, a biopsy must be done. First,
treatment of vascular lesions of the vocal fold, in a manner a piece of the vocal fold is removed to diagnose cancer.
similar to the pulsed-dye laser (see below). The pulsed- Following dye laser treatment, a biopsy must be repeated
KTP laser has a wavelength of 532 nm. It has been advo- to confirm that the margins are clear. Due to the side
cated by some proponents as superior to the pulsed-dye effects previously described, a minimal cordectomy type
laser because it may be less likely to cause hemorrhage of 1 should be the safer surgical procedure. The dye laser is
the vessels being treated because the 532 nm wavelength potentially helpful in treating lesions of the anterior com-
is more strongly absorbed by oxyhemoglobin than the missure, for avoiding postoperative web formation and in
585 nm wavelength of the pulsed-dye laser. However, its preserving the voice. Tunable dye lasers may prove more
tissue effects are different than the pulsed-dye laser, and valuable in the near future for treating selected vascular
it may be more likely to cause injury and stiffness of tis- lesions of the larynx, papillomas and other conditions.
sues adjacent to the blood vessels being treated. The KTP Because of the pulsed-dye laser, these techniques are used
laser can be used either on an outpatient basis or in the less often today.
operating room. It is delivered through a fiber. Typical
settings are about 525–750 millijoules per pulse, with a Pulsed Dye Laser
2 Hz repetition rate using a 0.4 mm fiber, this results The 585 nm pulsed dye laser (PDL) has been used
in affluence of about 20–80 joules/cm2. Although it is to treat vocal fold disease only recently. It was recog-
a “near touch” laser, experience and skills are required to nized in 1981 that dye lasers could be used to damage
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Section
microvasculature.28 Pulsed dye lasers can be used through spot size was 800–600 microns; currently, it is 150
a flexible laryngoscope in an office setting or in the oper- microns. Hemostatic capability is limited to microcircu-
ating room. Typically, the laser is passed through a 1 mm lation. A coagulating forceps is necessary to coagulate
fiber and delivers a spot size of 1–2 mm. Typical settings large vocal fold blood vessels (0.6 mm or more) when
1 include up to 5 Joules per pulse, with a 450 microsecond encountered during cordectomy. The greatest advantage
pulse width, a 1 Hz repetition rate, and a fluency of 19–76 of CO2 laser is its precision by using the tangential por-
Joules per square centimeter (j/cm2). Treatment is toler- tion of the beam, thus enabling the surgical accuracy of
ated well. In addition to treating abnormal vasculature, less than 100 microns. The time required to perform laser
the pulsed-dye laser has been used for papilloma29,30 and phonomicrosurgery is also shorter than using a conven-
dysplasia.31,32 Experience has shown that the PDL is safe tional technique.33-35
and effective for vascular lesions, and it also appears to The properties of CO2 lasers are particularly well
be useful in the treatment of carefully selected papilloma suited to laryngeal surgery. The CO2 laser produces a
and dysplasia. However, as with any other laser, complica- cone-shaped impact that has three characteristic levels,
tions can occur. Hemorrhage of the vessels being treated including from the center to the outer layer, an area of
is not rare. The prevalence of this complication can be charring, a region of tissue desiccation and an outer layer
minimized by controlling the distance of the fiber from of edema.
the lesion, and by treating vascular abnormalities start- Electromicroscopic studies of soft tissue show that,
ing with peripheral vessels and working toward the more with a spot size of 130 microns, a power of 50 watts and
ecstatic portions of the lesions. However, even with the an exposure of one second, CO2 laser impact creates a
best technique, complications can occur occasionally. The cone-shaped defect approximately 450 microns deep and
PDL is a “no touch” laser and has proven useful both in 230 microns wide with 30 microns for the center area
office and operating room settings. of charring, 100 microns for the intermediate desiccated
tissue layer and 100 microns for the outer layer of the
Diode Laser
40 This is a newer laser technology with a very precise focus
edematous tissue. CO2 laser tissue interaction depends
on the mode of impact being either a continuous mode
point. It can vaporize and cut with a minimal thermal firing or a pulsed mode firing.
effect. It can be guided through a fiber and used through In the continuous type, photons are emitted with
an endoscope to vaporize papillomas and to open recur- a constant and stable delivery of energy and intensity.
rent glottic webs. A constant power source is needed to keep the active
medium in an excited state of stimulate emissions. In a
CO2 Laser pulsed mode, an intermittent power source is used (simi-
The carbon dioxide or CO2 laser is a sealed gaseous laser lar to a flashbulb). It provides sudden bursts of energy to
with a mixture of CO2, nitrogen and helium. CO2 lasers the active medium. A pulsed mode laser delivers higher
have a wavelength of 10,600 nm. It emits in the infra- energy in a very short time. A continuous wave laser
red portion of the light spectrum, which is invisible to delivers easily 25 watts and a pulsed mode laser will
the human eye. It requires a helium-neon light source to deliver up to 2 watts with each pulse. Between the pulses,
direct the CO2 laser beam. It is highly absorbed in water there is almost no energy, which is the reason a pulsed
and produces no backscatter caused by flash-boiling of CO2 laser has a more accurate and deeper cutting effect
the intracellular water and ablation of cells. with less thermal damage than the continuous mode for
By focusing the CO2 laser beam, the highest energy impact spots of the same diameter.
density is expected and the cutting effect is maximized.
In laryngeal surgery, the ability to cut without instrument LIMITATIONS OF SURGERY
contact, up to a distance of 400 mm through the micro-
scope, is an important advantage of this laser. It is an Laser Tissue Interaction: Four Crucial
aseptic technique. The combination of a slight coagulating Considerations for Phonomicrosurgery
effect on small blood vessels without direct contact with
the vocal fold muscle (as is the usual effect by cauteriza- These tissue interactions may occur singularly or in com-
tion) will produce minimal tissue damage and precision. bination.
Spot size has been one of the parameters to decrease 1. Reflection occurs when the laser beam is not absorbed
since 1972.32 In surgery of the larynx, the original CO2 and does not penetrate the tissue; it is reflected as a
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Chapter
beam on a mirror. Reflection of the laser beam can Safe Laser Phonomicrosurgery Considerations
occur of surgical instruments and can result in tissue • The laser tissue interaction is affected by the duration
damage of the patient or surgical team personnel. of impact, the power of the laser, and the hand speed,
2. Transmission occurs when the laser beam is not which yields power density per second. The amount of
absorbed and passes through the glass. This property energy absorbed by a specific area of tissue per second 10
is especially important when treating diseases of the on initial contact (impact) is different than the second
retina, through the cornea. impact.
3. Absorption occurs when a laser beam is absorbed • The first laser impact at a given location will cut but
by the tissue (an effect similar to a sunbeam being also dehydrate the surgical bed. The second laser firing
focused by a magnifier onto a piece of dry wood), on the same spot will impact the dehydrated tissue,
thus causing it to burn. which will lead to a scattering effect and an increased
4. Scatter or dispersion is a result of a laser beam that possibility of thermal injury of the vocal ligament.
is partially absorbed, transmitted and thus scattered • Laser-safe phonomicrosurgical procedures must follow
through and by the tissue. several basic rules: Cool down the lesion with an icy
Each type of laser interacts with tissue in a specific and moist cottonoid for one minute before surgery;
way, producing characteristic patterns of heat conduction, remove the lesion with duration of 1/10 second per
coagulation, ablation and charring. Knowledge of laser impact and avoid suction directly on the tissue, rather
physics and typical tissue interactions allows the surgeon doing it through the icy and wet cottonoid, which will
to select a laser best suited to the task at hand. not traumatize the epithelium or the lesion.
Limitations of Diode Laser Surgery Instruments Specific for Laser Phonomicrosurgery

The diode laser has limitations that make it unsuitable Good positioning of the patient and good exposure
for most laryngeal surgery, including the precision of fiber of the larynx are the main requirements for perform-
arrangement in the endoscope. It is very difficult not to
damage the vocal fold’s free edge when treating small
ing laryngoscopy. Laser phonomicrosurgery requires few
additional surgical instruments. The adapted instruments
41
lesions with a diode laser. The indications for its use in permit good surgical craftsmanship. One author’s ( JA)
the larynx, if it is used at all, are for treating large papil- laryngeal instrument set, consists of 14 microinstruments
lomas and webs. and three laryngoscopes (two for adults and one for pedi-
atric patients). The specificity of these forceps is that both
Limitations of CO2 Laser Surgery suction and cauterization are linked in one instrument,
The CO2 laser also has a few disadvantages in laryngeal which functions for each purpose. Most are manufac-
surgery. First, it cannot be conducted through a fiber- tured by Medtronic Xomed ( Jacksonville, FL). All of the
optic endoscope. It can also cause tissue loss, which may instrument’s surfaces are matted to prevent reflection of
limit biopsy results; and by thermal injury, it can cause the laser beam and light. One author (RTS) has also
biopsy artifact or vocal fold scarring that can result in developed laryngoscopes and instruments manufactured
dysphonia for 3–6 months if the vocal ligament is not by Medtronic Xomed for use in laser phonomicrosur-
touched. The same complication may appear with cold gery, including polished mirrors to redirect laser light.
instruments if the ligament is traumatized. All laryngoscopes have channels for suction and light.
The choice of laryngoscope depends on the physician’s
PHONOMICROSURGICAL PROCEDURES preference, patient’s morphology and the pathology to
be treated:
Laser phonomicrosurgery is functional surgery. It is not • The pediatric laryngoscope is suitable for children, for
surgery for life-threatening diseases. There must not be some women and patients with restricted access to
any medical (cardiac, pulmonary, renal, metabolic, neu- larynx (jaw pathology, retrognathism). A laryngoscope
rologic) conditions that would be a contraindication to with a long spatula (Medtronic Xomed) is used for
operating on these patients or to subjecting them to gen- long-necked patients.
eral anesthesia. Technical problems that limit the abil- • The A-laryngoscope (Abitbol-laryngoscope), used most
ity to perform laryngoscopy include conditions, such as frequently by the author ( JA), includes two lateral
arthrosis or ankylosis of cervical vertebrae, short neck or channels for light and a superior gliding probe for
prognathism. suction. It is used for treating pathologies of the vocal
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Section
folds and the anterior commissure. Once of the chan- distributed on the entire jaw. This avoids dental accidents,
nels for suction can be used to adapt the Hopkins scope such as chipped or fractured teeth. Intubation is per-
to have a closer view for video recording or photogra- formed.
phy. The A-valve-laryngoscope includes a spatula with
1 a lower articulated valve with an adjustable aperture. ANESTHESIA TECHNIQUES, RISKS AND
A tube guide, shaped as a half-ring, is fixed on the COMPLICATIONS
superior surface of the upper valve to facilitate the
placement and adjustment of the endotracheal tube; Anesthesia for laryngeal laser surgery has three major
thus, the tube does not slip laterally and stays fixed goals.
on the anterior commissure. This laryngoscope is used 1. To ensure good ventilation for the patient while mini-
for lesions of the posterior wall or when performing mizing risk, such as file.
arytenoidectomy. 2. To obtain muscle relaxation that prevents any motion
All of these laryngoscopes have a broad and flat sur- of the vocal folds, thus increasing the surgeon’s com-
face, necessary to spread pressure over the upper jaw teeth, fort with an open and immobile glottic area.
which are protected by the dental plate and posterior 3. To choose anesthetic drugs with a rapid reversal that
dental shield if necessary. Distal illumination is provided allows the quick recovery of pharyngeal and laryngeal
by a glass fiber with a 250 watt cold light. The laryngo- reflexes postoperatively.
scope support is easy to install and is fixed to the table.
To straighten the neck, a supple shaft is necessary. Anesthetic Procedures
The Sataloff laryngoscopes (Medtronic Xomed) have Anesthetic procedures for laser surgery will not be dis-
a more triangular design and more lift near the tip; and cussed in detail in this chapter. They may be found in
they include double light carriers and double suction other literature.37 Surgeons must be familiar with anes-
smoke evaluation channels. There are also other excel- thetic options, including laser surgery with or without
42 lent laryngoscopes available, such as those designed by
Jako, Dedo, Fragen, Kleinsasser and others.
sedation, general anesthesia with endotracheal intubation
and general anesthesia with jet ventilation. Transtracheal
The Zeiss or Wild operating microscopes are fitted ventilation and other specialized techniques may have
with a 350 or 400 mm lens. The laser does most of the value in selected cases as well. Familiarity with anesthe-
difficult work to “microcut” the lesion. Most forceps are sia techniques and potential complications is essential to
22 cm long and have suction for smoke removal; and help the surgeon avoid potentially serious complications,
forceps with a unipolar coagulating system are available. such as intraoperative fire.
If arteries are more than about 0.6 mm in diameter, we
use the forceps rather than laser to coagulate bleeding PRINCIPLES OF CO2 LASER
vessels. One author ( JA) does not use scissors and other PHONOMICROSURGERY
cold instruments routinely, including during most cases in
which the laser is also used. These instruments are a new The laryngoscope is put in place and the microscope used
generation – more precise, smaller and perfectly suited to at a working distance of 400 mm. Routinely, 4–6 watts of
the task. delivered CO2 energy is used in laser laryngeal surgery.
The surgeon should examine the entire larynx and then
MICROLARYNGOSCOPY PROCEDURES focus on the lesion, placing wet and icy, moist cottonoid
under the glottic space to protect the tube and the sub-
Good exposure of the larynx is a key to successful pho- glottic area. A checklist is used to confirm that suction,
nomicrosurgery, including laser surgery as discussed else- laser and coagulation are ready to work. A ring controls
where.36 the focus on the laser beam, from 100–500 microns. The
A disposable dental protector is placed after anesthe- surgeon controls the alignment of the helium-neon aim-
sia is induced. Sometimes, when the teeth are very frag- ing beam and the CO2 laser beam: a first spot is fired
ile, a specially designed dental guard is put between the on the gauze or another target to align the impact with
molars on both sides and a dental plate covers the front the red spot (or aiming beam). The laser incision is barely
teeth; thus, the forces that the laryngoscope induces are visible on the vocal fold with no visible thermal effect,
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Chapter
because of the cutting technique. The thermal effect is The total spot size can be reduced further by striking
seen ordinarily only on a lesion less than 150 microns the tissue tangentially. Thus, only a small part of the spot
in size. For angiomatous polyps, e.g. the technique is to falls on the tissue, while the remaining part falls on a swab
isolate the feeding vessels first, to vaporize them and then or cottonoid held in proximity of the target tissue. This
to remove the polyp. For cysts, nodules and micropolyps, technique is extremely useful in the final stages or removal 10
ultrapulse or superpulse mode will provide a tremendous of pathologic tissue from the free edge of the vocal fold.
advantage in performing very precise surgery with con- By using only a part of the spot on the tissue, the effec-
trolled thermal effect, but also with little or no coagulat- tive spot size is thus reduced to fewer than 100 microns.
ing effect. However, because there are a few vessels on When using in the continuous or repeat mode, the
these types of lesions, there is no troublesome bleeding. slower the beam is moved on the surface, the greater
Surrounding tissue trauma is avoided by using higher is the spread of energy within the tissue. Not only will
energy density. Samples for histological documentation the first few hundred microns suffer irreversible thermal
also are more reliable because of limited thermal artifact damage, but the next few hundred microns will also be
and tissue loss. No firing should occur twice on the same desiccated and thus will not absorb the energy, which
spot or on charred tissue, because this increases the ther- will then be conducted to even deeper tissue. To limit
mal effect tremendously. In some cases, hydrotomy may the spread of energy within the tissue, the beam should
be interesting (injection of saline in the vocal fold to be moved rapidly and not dwell at the same spot for any
isolate the lesion from the deep epithelium). length of time when using continuous or repeat modes.
It must be remembered that the CO2 laser is not
always responsible for scar. Vocal fold epithelium is LASER PHONOMICROSURGICAL TECHNIQUES
fragile. For example, traumatic suction of the vocal fold FOR TYPES OF LESIONS
mucosa can also cause scarring and is avoided by suction-
ing it through a moist cottonoid placed over the mucosa. One author ( JA) uses laser routinely for lesions described
Scar also occurs after surgery with cold instruments and
is also often present preoperatively from the lesion itself.
below and the other (RTS) uses laser rarely for most of
these lesions. Surgical techniques with cold instruments
43
The size of the microinstruments used plays an important are described elsewhere in this book. However, when the
role in avoiding these complications. laser is used, both authors utilize similar techniques, as
The rate of temperature rise in tissue should be described below.
achieved as rapidly as possible. The use of superpulse
mode allows high peak power with each pulsed applica- Protruding Lesions
tion over a very brief period of milliseconds. There is Protruding lesions include nodules, cysts, polyps, granu-
thus an immediate temperate rise at the point of impact, loma, papilloma, laryngocele and Reinke’s edema. Some
resulting in instant vaporization without charring of tis- of them will need hydrodissection by hydrotomy.
sue. The power setting is usually 2–3 watts and the expo-
sure time, 0.05–0.1 second. The energy is applied in single How We Do It in Protruding Lesions (Chronological
shots, repeat mode or continuous mode, depending on Order of Procedure)
the nature of operation. Thus, on the one hand, while • Secure the laryngoscope in place.
removing a lesion from the free edge of the vocal fold, • Palpation of the lesion is crucial, as well as palpation
it is appropriate to use single shots to limit the spread of the other side.
of energy to vocal ligament. On the other hand, to make • The surgical bed is examined with the microscope
an incision on the superior surface of the vocal fold to and often with 90º and 70º Storz laryngeal telescopes
evaluate Reinke’s edema, the superpulse can be used in before and after the surgical procedure.
repeat mode and moved rapidly in the line of incision. • Place the green gauze or cottonoid under the vocal
The use of continuous mode is appropriate when dealing fold.
with a malignant lesion of the vocal fold, because the • Focus the microscope.
spread of energy to deeper tissues will, to a limited extent, • With the grasping forceps, which hold a wet icy cot-
help hemostasis and seal off any lymphatics. It will also tonoid, the lesion is palpated.
reduce the operating time.
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Section
• The icy wet cottonoid is left in place for over the Recessed Lesions
surgical site to cool the vocal fold, and then removed. The recessed lesions are sulcus vocalis, bowed vocal folds,
• The forceps holds a new cottonoid. atrophic vocal folds, notches and vocal fold scar. The laser
• Push slowly from outside to inside the glottic space or a sharp knife will be used to open the space between
1 to isolate the protruding lesions. the scarred epithelium and vocal ligament.
• The laser is aimed with a target at the root of the
lesion, with the beam glancing the free edge tangen- How We Do It in Recessed Lesions
tially. The beam is perpendicular to the superior sur- • Hydrodissection is performed in treating sulcus voca-
face of the fold. The laser shoots at an angle of 90º to lis.
the root of the lesion. The impact is performed on a • The scarred epithelium is removed with laser and is
clean mucosa. Any carbonized tissue is removed with followed by injection of collagen, autologous fat or
a wet icy, small cotton ball to avoid increasing the hydroxyapatite.
thermic effect of a subsequent laser strike. • Injection of these substances is also used in the treat-
• The parameters of the laser are: 0.1 second, 4 watts, ment of bowed or atrophied vocal folds.
spot of 120 microns.
• The lesion is removed almost entirely but without Relatively Flat Lesions
creating a divot in the superficial layer of the lamina Flat lesions include laryngitis, leukoplakia, keratosis,
propria. Reinke’s edema, vascular lesions (microvarices, hemor-
• Using specific forceps, e.g. Monopolar Coagulating rhages), anterior and posterior webs, papilloma, stenosis,
Heart-Shaped Grasper with suction, angled right postirradiation edema and submucosal lesions, such as
for a nodule on the right vocal fold, or a Monopolar cysts and fibrosis. This type of lesion may benefit from
Coagulating Alligator Forceps with suction, curved hydrodissection.
left for a polyp of the left vocal fold, the sample is
How We Do It in Relatively Flat Lesions
44 •
removed.
Frozen section is done when appropriate. • Hydrodissection is utilized.
• If necessary, any small epithelial irregularity is vapor- • The laser is used on the superior surface of the vocal
ized. fold.
• The inferior, then the middle and finally the superior • If a cyst is also present, cold instruments may be used
lips of the vocal fold are checked. This is accomplished in combination with laser dissection.
best with a 70º telescope. Caution: For microvarices, if vessels are parallel to the
• Check the opposite side. free edge, excessive removal should be avoided. Excessive
• Leave an icy wet cottonoid for one minute on the removal will affect the lubrication of the fold.
surgical bed and, if necessary, administer a steroid
injection. Pitch Modification Surgery
• Specific modifications will be made for specific cases, One may need to perform surgery on patients with
e.g. an angiomatous lesion may need feeding vessels excessively high or low vocal pitch. Voice therapy, and
coagulated before excision, as noted above. hormonal treatment in some cases, is the first step in
• Lesions from the middle third and the posterior third treatment. Surgery will be performed only for those
of the vocal fold, such as nodules, polyps, granulomas, who did not improve adequately during an adequate
Reinke’s space edema, laryngitis or keratosis can be therapeutic trial. The vocal fold pitch is regulated by
treated during the same procedure. four principal parameters: the static mass, the vibratory
• Bilateral Reinke’s edema involving the anterior com- mass, the length and tension of the vocal folds and the
missure or the anterior third of the vocal fold, and subglottic pressure, all of which can be modified through
bilateral protruding lesions of the anterior third of phonomicrosurgical procedures.
the vocal fold should be treated one side at a time
(staged procedure). Increasing Pitch
• When treating lesions that involve the anterior com- We have developed an endoscopic technique to increase
missure, the epithelium just above the anterior com- vocal pitch in selected cases. An incision is made paral-
missure and just under the anterior commissure must lel to the free edge of the vocal fold with the CO2 laser
be protected.
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Chapter
(microspot, a power of 1.5 watts, discontinuous fire 0.1 histologically, there is rarely an invasion of the vocal fold
sec), and then some fibers of the thyroarytenoid muscle muscles.
are removed from front to back. Only one side is operated
on. An injection of cortisone is performed on both sides SURGICAL CLASSIFICATIONS
(atrophy was observed in one case on the opposite side). If 10
the voice is not satisfactory, a second procedure is carried Three types of cordectomy:
out three months later on the contralateral side. We even- The author ( JA) has developed a personal surgical clas-
tually or alternatively, may create a web to shorten the sification technique of three types of cordectomy:
vocal folds. This web is created by excising the epithelium 1. Type 1: Mucosa and a portion of the superficial layer
of the anterior commissure and suturing both vocal folds are removed (for T1N0).
together. Isshiki’s techniques, and modifications thereof, 2. Type 2: Mucosa, lamina propria and superficial mus-
remain satisfactory procedures if the patient accepts an cle layers are removed; the false vocal fold may be
open laryngeal operation. Our technique is simple, with removed to allow a better view of the floor of the
a fast rate of healing and no significant complications, ventricle (for T1N0).
so far. Fundamental frequency measured before and after 3. Type 3: Mucosa, lamina propria and thyroarytenoid
laser surgery and patient satisfaction will indicate whether muscles are removed up to the perichondrium. The
the second vocal fold must undergo laser surgery, at least false vocal fold is also removed. Coagulation of pos-
three months later. terior arteries is often necessary. The false vocal fold
may hide lesions sheltered in the ventricle, which is
Decreasing Pitch why the false vocal fold may have to be removed.
Collagen injection on one side, to increase the static vocal Inspection with a 70º telescope is helpful in making
mass, has produced acceptable but temporary results. It judgments in this regard.
seems that the best technique remains the Isshiki proce-
dure described in 197737 and more recently by Tucker in
1985.39 Laser surgery has not proven helpful.
Laser techniques are the same for any type of cord-
ectomy:
45
• A hydrodissection is performed first.
Early Malignant Lesions • The laser beam angle from the microscope to the vocal
The treatment of laryngeal cancer is discussed in detail fold is 90º.
elsewhere.40 However, a few basic principles are reviewed • The laser firing starts perpendicular to the free edge,
here to highlight the applications of laser surgery. Because in the horizontal plane from the free border to the
of the necessity to have a margin with no tumor involved, ventricle to start and finish cordectomy.
cordectomy must be done. Abitbol has described three • A straight firing, parallel to the free border, is
types of cordectomy.41 The staging of the carcinoma is performed with the laser from the anterior angle to
related essentially to the invasion of the basement mem- the posterior angle of the vocal fold incision. It starts
brane zone: 2 mm behind the anterior commissure. It ends 2 mm
anterior to the posterior glottic region. A rectangular
Anatomical/Pathological Classification specimen is removed.
Carcinoma in situ or CIS: The basement membrane zone If any area looks suspicious, a second-look laser micro-
is spared; the lesion originating from the epithelium is surgery may be necessary two months later. Close follow-
located in the superficial layer of the lamina propria. up using strobovideolaryngoscopy is needed. Frozen sec-
Microinvasive carcinoma or T1N0 : The basement mem- tions are necessary in many cases to identify appropriate
brane zone is destroyed, the corium is invaded. The lamina margins.
propria is involved, as well as the Reinke’s space with In our experience, carcinomas of the anterior or pos-
or without the entire vocal ligament being involved. The terior larynx are relative contraindications for laser laryn-
muscles are spared. geal surgery, although safe endoscopic resection is possible
Invasive carcinoma or T2N0 : The basement membrane in some cases. A lesion of the anterior commissure or the
zone and the superficial layer of the muscles are involved. posterior larynx may become a T3 or T4 even when small,
Verrucous carcinoma: A challenging case in that, because of the thinness of the tissue of these locations
macroscopically, it looks like an invasive lesion; but in the larynx. Carcinoma in situ, T1N0 and T2N0 of the
Ch-10.indd 45 9/8/2010 3:04:18 Gopal

Section
middle third are good indications for laser endoscopic 2. Dental trauma can occur, but generally is preventable.
cordectomy and have very satisfactory results. A patient suffering from periodontal disease must be
informed that teeth could be accidentally extracted
Impaired Mobility during laryngoscopy. The surgeon and the anesthetist
1 Vocal fold hypomobility or immobility may be due to must always check the patient’s teeth and inform him
laryngeal nerve paresis, paralysis or mechanical causes, or her of the risks.
such as cricoarytenoid joint ankylosis, subluxation or dis- 3. Neurologically, taste disturbance can last from six
location. The laser has little place in the management of weeks to six months after surgery, as well as a partial
hypomobility in which one or both vocal folds is abducted. paralysis (hypesthesia) of the tongue.
Standard techniques for medialization include injection Complications related to uncontrollable patient fac-
laryngoplasty (autologous fat, fascia, collagen and other tors include granulomas and recurrences, both of which
substances), thyroplasty, arytenoid adduction/rotation and are uncommon. Coughing, throat clearing, sneezing and
arytenoidopexy. Voice therapy before and after surgery is reflux laryngitis must be controlled in the postoperative
important for voice improvement in all such cases. The period to minimize the incidence of vocal fold trauma,
use of Teflon for vocal fold injection was abandoned by including tears and granuloma formation. Voice rest is
authors in the 1980s with the advent of better techniques used for about one week following surgery. One author
that are not associated with complications, such as Teflon ( JA) prescribes antibiotics, anti-inflammatory and antire-
granuloma. Teflon granuloma is still encountered from flux drugs for eight days in association with vitamins and
time-to-time. In some cases, it can occur many years magnesium for one month. The other author (RTS) rou-
after Teflon injection. In others, it occurs because a few tinely prescribes only antireflux medications as indicated.
surgeons still utilize Teflon despite its substantial short- Patients generally are taken off voice rest by their speech-
comings and the availability of better alternatives. Laser language pathologist with whom they will continue post-
does play a role in the treatment of Teflon granuloma. operative voice therapy.
46 The laser plays an important role in the management
of bilateral vocal fold paralysis or fixation in the adducted Laser-related Accidents
position. Techniques to address this challenging problem Cutaneous and mucosal membrane burns of the face,
include vocal fold lateralization by suture placement tongue, lips and eyes can be avoided by efficient protec-
through the thyroid cartilage, reinnervation (including tion with moist compresses on the face of the patient
nerve anastomosis and nerve-muscle pedicle techniques), and the use of an appropriate laryngoscope. Protective
laryngeal pacing; cordotomy, external arytenoidectomy eyeglasses must be worn by the entire surgical team.
and laser arytenoidectomy. The laser is particularly advan- The most serious accident is the tracheal burn due to a
tageous for endoscopic arytenoidectomy and is used by mixture of oxygen and nitrous oxide. The use of helium
both authors. helps to avoid this problem. Finally, laryngeal complica-
tions specific to this surgery, such as stenosis or synechiae,
COMPLICATIONS OF LASER can occur.
PHONOMICROSURGERY To avoid these potential hazards, we subject ourselves
to strict protocol control, including use of a checklist
Complications of laryngeal are rare, but they occur in before each procedure. The occurrence of these compli-
three different areas: cations, in our experience, is infrequent and often minor;
1. Pharyngeal tissue: In addition to the general complica- but they can be serious if not remedied immediately.
tions previously described, laryngoscopy can involve Potential hazards are detected by close clinical supervi-
specific injuries. Tonsillar hematoma and lesions of sion and adequate monitoring of the patient.
the tongue base are difficult to prevent, because these
structures cannot be seen during surgery. They are CONCLUSION
caused by laryngoscope pressure, and only a preven-
tive approach, consisting of a gentle introduction of Excellent expertise is needed in laser phonomicrosurgery.
the laryngoscope and perfect positioning, will help In our experience, the 10 commandments for success are:
to avoid these complications. The laryngoscope must 1. Do not operate on the vocal fold if the patient does
gently follow the anesthetist’s tube. not ask for it (except in cancer).
Ch-10.indd 46 9/8/2010 3:04:18 Gopal

Chapter
2. Obtain optimal exposure of the vocal folds and the SURGICAL TECHNIQUES: KTP LASER
anterior commissure.
3. Touch the free edge of the vocal fold as little as pos- Step 1
sible.
4. Impact only on the superior surface of the vocal fold. Preoperative videostroboscopic images are reviewed 10
5. The angle of laser impact on the vocal fold edge must (Fig. 10.1A). A prominent varix with surrounding spider
be 90º. telangiectasias are seen on the superior surface of the
6. Hand speed must be steady. right true vocal fold.
7. Protect the subglottic space with an icy green gauze
or cottonoid, which must be changed if laser surgery Step 2
lasts more than 6–8 minutes or anytime the material General anesthesia is administered via orotracheal intuba-
dries out. tion, followed by suspension laryngoscopy (Fig. 10.1B).
8. Never fire on charred tissue.
9. Use a cottonoid to remove charred tissue.
10. Appropriate voice rest, medical therapy and voice
therapy should be used before and following laser
phonomicrosurgery.
In summary, laryngeal laser microsurgery is a valuable
addition to the laryngologist’s armamentarium. Several
studies have shown similar results with laser and cold
instruments when surgery is performed by an experienced
surgeon.42-45 In our experience, the surgeon’s experience
and skills are critical to produce optimal results with
laser voice surgery. Although it has many advantages, its
potential hazards militate against injudicious use. Laser
47
surgery requires a fully educated operating team so that
precautions are taken routinely to avoid endotracheal tube
fire or injury to adjacent tissues. In general, the laser is Fig. 10.1A: Preoperative rigid stroboscopic examination reveals
a prominent vessel along the superior surface of the right true
best suited for cases that cannot be treated equally well vocal fold
with traditional instruments, and great care must be exer-
cised if it is used on the vibratory margin of the vocal
fold because of the risk of injury to the vocal ligament
and consequent scarring and permanent dysphonia. In
addition, when serious or unusual pathology may be
present, tissue vaporization may be a serious disadvan-
tage. It must be preceded by adequate biopsy for small
lesions, and surgeons must always consider the possibility
that a section of tissue lost to vaporization may be the
portion that contains critical histopathologic information.
Nevertheless, in expert hands, the laser can facilitate pre-
cise surgery while minimizing bleeding and avoiding seri-
ous thermal injury. A skilled laser surgeon must first be
a skilled classical microlaryngeal surgeon capable of per-
forming Phonomicrosurgery with cold instruments; and
he or she must have excellent hand control to maintain Fig. 10.1B: Direct laryngoscopy-distraction of the soft tissues
has caused collapse of a prominent vessel and emphasizes the
precise placement and speed of the laser beam. The sur-
importance of preoperative stroboscopic examination, as well
geon’s experience and skills are crucial to obtain optimal as careful positioning of the laryngoscope to avoid altering the
results with laser voice surgery. appearance of the surgical field
Ch-10.indd 47 9/8/2010 3:04:19 Gopal

Section
Distraction of the larynx has obscured the prominent varix

previously seen in preoperative imaging. Alternatively,
this procedure may be done in the office under topical
anesthesia using indirect laryngoscopy.
1 Step 3
Prominent vessels are vaporized with the laser (Figs
10.1C and D).
Step 4
The KTP laser has an affinity for vascular structures.
The fiber is placed in proximity of the abnormal vari-
cosities and just superficial to any abnormal vasculature
(Figs 10.1E to G) to vaporize the lesions. Blanching is
Fig. 10.1E: The fiber is seen extending out of the laser and is
seen after laser treatment (Fig. 10.1H).
placed just above the intended vaporization site
48
Fig. 10.1C: Laser in position to vaporize a varicosity Fig. 10.1F: Again, vaporization of the vessel shows an immediate
change to the vascular substructure without any extravasation of
blood
Fig. 10.1D: Vaporization of the prominent vessel without any Fig. 10.1G: The fiber can be placed in the vicinity of
extravasation of blood hypervascularity if no discrete vessel is identified
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Chapter
Step 5 SURGICAL TECHNIQUE: CO2 LASER
Decadron is injected into Reinke’s space (See procedure
Description on Superficial Decadron Injection) to minimize Step 1
any potential inflammation and scarring resulting from any
thermal damage caused by the laser and to improve the Preoperative videostroboscopic images are reviewed 10
stiffness noted preoperatively (Fig. 10.1I and J). (Fig. 10.1K). A prominent varix is seen on the superior
surface of the right true vocal fold.
Step 6
A deep extubation is performed. If the vibratory margin Step 2
is not involved, the patient may be placed on a short General anesthesia is administered via orotracheal intu-
duration of voice rest depending on the extent and loca- bation, followed by suspension laryngoscopy to expose
tion of vaporization or voice rest may not be necessary. the larynx.
49
Fig. 10.1H: Blanching is seen in the area of prior Fig. 10.1J: Hydrodissection causing lyses of adhesions in Reinke’s
hypervascularity space in the right vocal fold, once infiltrated with Decadron,
creates a noticeable difference in the appearance of the vocal
fold when compared with the left
Fig. 10.1I: Decadron is injected into the superficial lamina Fig. 10.1K: Preoperative rigid stroboscopic examination reveals
propria where stiffness was noted preoperatively a prominent vessel along the superior surface of the right true
vocal fold
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Section
REFERENCES
1. Bredemeier HC. Laser accessory for surgical applications.
US Patent 3, 659,613, issued 1972.
2. Strong MS, Jako GJ. Laser surgery in the larynx: Early
1 clinical experience with continuous CO2 laser. Annals of
Otology, Rhinology, Laryngology. 1972; 81:791-980.
3. Ossoff RH. Laser surgery in otolaryngology-head and
neck surgery: Anesthetic and educational considerations
for laryngeal surgery. Laryngoscope. 1989; 99(8 Pt 2 Suppl
48):1-26.
4. Ossoff RH, Karlan MS. Instrumentation for CO2 laser
surgery of the larynx and tracheobronchial tree. Surg Clin
of N America. 1984; 64:973-80.
5. Abitbol J. Limitations of the laser in microsurgery of the
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Symposium: Care of the Professional Voice. New York: The
Fig. 10.1L: An ice chip is used to cool the vocal folds and is then Voice Foundation; 1984. pp. 297-301.
left in the glottis. Although there is no evidence-based research to
support this technique, the authors believe that cooling the vocal
6. Tapia RG, Pardo J, Marigil M, et al. Effects of the laser
fold may help limit the spread of heat and minimize thermal injury upon Reinke’s space and the neural system of the vocalis
muscle. In: Lawrence VL (Ed). Transactions of the Twelfth
Symposium: Care of the Professional Voice. New York: The
Voice Foundation; 1984. pp. 289-91.
7. Durkin GE, Duncavage JA, Toohill RJ, et al. Wound heal-
ing of true vocal cord squamous epithelium after CO2 laser
ablation and cup forceps stripping. Otolaryngol Head Neck
50 Surg. 1986; 95(3 Pt 1):273-7.
8. Motta G, Villari G, Ripa G, et al. The CO2 laser in the
laryngeal microsurgery. Acta Otolaryngol Suppl (Stockh).
1986; 433:1-30.
9. Bennett S, Bishop SG, Lumpkin SM. Phonatory char-
acteristics following surgical treatment of severe polypoid
degeneration. Laryngoscope. 1989; 99(5):525-32.
10. Shapshay SM, Wallace RA, Kveton JR, et al. New micro-
spot micromanipulator for carbon dioxide laser surgery in
otolaryngology. Early clinical results. Arch Otolaryngol
Head Neck Surg. 1988; 114(9):1012-5.
11. Shapshay SM, Rebeiz EE, Bohigan RK, et al. Benign lesions
Fig. 10.1M: The prominent varix is cauterized using the CO2 laser of the larynx: Should the laser be used? Laryngoscope.
1990; 100(9):953-7.
12. Krespi YP, Meltzer CJ. Laser surgery for vocal cord carci-
Step 3 noma involving the anterior commissure. Ann Otol Rhinol
Laryngol. 1989; 98(2):105-9.
A wet, icy cottonoid is placed in the subglottis. A small
13. Shapsay SM, Hybels RL, Bohigian RK. Laser excision of
ice chip is used to cool the vocal folds (Fig. 10.1L) and early vocal cord carcinoma: Indications, limitations, and
may be placed in the glottis. precautions. Ann Otol Rhinol Laryngol. 1990; 99(1):46-
50.
Step 4 14. Eckel HE, Thumfart WF. Preliminary results of endo-
A prominent vessel is vaporized with the CO2 laser. The laryngeal laser resections of laryngeal cancers. Vorlaufige
power is set at 1 or 2 watts and the delivery is with single Ergebnisse der endolaryngealen laserresektionen von
pulses of 0.1 ms and 30 mJ (Fig. 10.1M). Kehlkopfkarzinomen. HNO. 1990; 38(5):179-83.
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15. Thumfart WF, Eckel HE. Endolaryngeal laser surgery in 30. Zeitels SM, Franco R, Dailey SH, et al. Office-based
the treatment of laryngeal cancers. The current cologne treatment of glottal dysplasia and papillomatosis with the
concept. Endolaryngeale laserchirurgie zur Behandlung 585 nm pulsed dye laser and local anesthesia. Ann Otol
von Kehlkopfkarzinomen. Das aktuelle Kolner Konzept. Rhinol Laryngol. 2004; 113(4):265-75.
HNO. 1990; 38(5):174-8. 31. Franco RA, Zeitels SM, Farinelli WA, et al. 585 jm pulsed
16. Hofler H, Bigenzahn W. Voice quality following dye laser treatment of glottal dysplasia. Ann Otol Rhinol 10
CO2 laser cordectomy. Die Stimmqualitat nach CO2- Laryngol. 2003; 112(9):751-8.
laserchordektomie. Laryngol Rhinol Otol (Stuttg). 1986; 32. Strong MS, Jako GJ. Laser surgery in the larynx. Early
65(11):655-8. clinical experience with continuous CO2 laser. Ann Otol
17. Ossoff RH, Matar SA. The advantages of laser treatment Rhinol Laryngol. 1972; 81:791-8.
of tumors of the larynx. Oncology (Williston Park). 1988; 33. Mihashi S. The carbon dioxide laser surgery. Nippon
2(9):58-61, 64-5. Jibiinkoka Gakkai Kaiho. 1975; 78:1244-88.
18. Haraf DJ, Weichselbaum RR. Treatment selection in T1 34. Mihashi S, Jako G, Incze J, et al. Laser surgery in otolaryn-
and T2 vocal cord carcinomas. Oncology (Williston Park). gology: Interaction of CO2 laser and soft tissue. Ann N Y
1988; 2(10):41-50. Acad Sci. 1976; 267:263-94.
19. Shapshay SM, Ruah CB, Bohigian RK, et al. Obstructing 35. Hirano M, Mihashi S, Shin T, et al. CO2 laser apparatus
tumors of the subglottic larynx and cervical trachea: Airway for surgery. Nippon Jibiinkoka Gakkai Kaiho. 1979; 82:34-
management and treatment. Ann Otol Rhinol Laryngol. 9.
1988; 97(5 Pt 1):487-92. 36. Zeitels SM. Phonomicrosurgical techniques. In: Sataloff
20. Tate LP, Newman HC, Cullen JM, et al. Neodymium RT. Professional Voice: The Science and Art of Clinical
(Nd): YAG laser surgery in the equine larynx: A pilot Care, 3rd edition. San Diego, California: Plural Publishing,
study. Lasers Surg Med. 1986; 6(5):473-6. Inc.; 2005. pp. 1215-36.
21. Stahle J, Hogberg L. Laser and the labyrinthe. Some pre- 37. Abitbol J, Sataloff RT. Laryngeal laser surgery. In: Sataloff
liminary experiments on pigeons. Acta Otolaryngol. 1965; RT. Professional Voice: The Science and Art of Clinical
60:367-73. Care, 3rd edition. San Diego, California: Plural Publishing,
22. Stahle J, Hogberg L, Engstrom B. The laser as a tool in Inc.; 2005. pp. 1237-54.
inner-ear surgery. Acta Otolaryngol. 1972; 73:27-37. 38. Isshiki N, Tanabe M, Ishizaka K, et al. Clinical signifi- 51
23. Sataloff J. Experimental use of the laser in otosclerotic cance of asymmetrical tension of the vocal cords. Ann Otol
stapes. Arch Otolaryngol. 1967; 85:614-6. Rhinol Laryngol. 1977; 86:58-66.
24. Sultan R, Marinov V, Falo Kh. The role of the laser in 39. Tucker HM. Anterior commissure laryngoplasty for adjust-
gastrointestinal surgery. Khirurgiia (Sofiia). 1989; 42(2): ment of vocal fold tension. Ann Otol Rhinol Laryngol.
15-9. Bulgarian. 1985; 94:498-501.
25. Perkins RC. Laser stapedectomy for otosclerosis. 40. Anderson TD, Sataloff RT. Laryngeal cancer. In: Sataloff
Laryngoscope. 1980; 90:228-40. RT. Professional Voice: The Science and Art of Clinical
26. Zeitels SM, Akst LM, Burns JA, et al. Office-based 532 nm Care, 3rd edition. San Diego, California: Plural Publishing,
pulsed-KTP laser treatment of glottal papillomatosis and Inc.; 2005. pp. 1375-92.
dysplasia. Annals Otol Rhinol Laryngol. 2006; 115(9):679- 41. Abitbol J. Atlas of Laser Voice Surgery. San Diego,
85. California: Singular Publishing Group; 1995. pp. 300-35.
27. Carruth JAS, McKenzie AL. Preliminary report of a pilot 42. Benninger MS. Microdissection on microspot CO2 laser
study of photoradiation therapy for the treatment of super- for limited vocal fold benign lesions: A prospective rand-
ficial malignancies of the skin, head and neck. Eur J Surg omized trial. Laryngoscope. 2000; 110(Suppl 92):1-17.
Oncol. 1985; 11:47-50. 43. Sataloff RT, Spiegel JR, Heurer RJ, et al. Laryngeal mini-
28. Anderson RR, Parrish JA. Microvasculature can be selec- microflaps: A new technique and reassessment of the
tively damaged using dye lasers: A basic theory and experi- microflap saga. J Voice. 1995; 9:198-204.
mental evidence in human skin. Laser Surg Med. 1987; 44. Remacle M, Lawson G, Watelet JB. Carbon dioxide laser
1:263-76. microsurgery of benign vocal fold lesions: Indications
29. Cohen JT, Koufman JA, Postma GN. Pulsed-dye laser in techniques, and results in 251 patients. Ann Otol Rhinol
the treatment of recurrent respiratory papillomatosis of the Laryngol. 1999; 108:156-64.
larynx. ENT J. 2003; 83(8):558. 45. Zeitels SM. Laser versus cold instruments for microlaryn-
goscopic surgery. Laryngoscope. 1996; 106:545-52.
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Chapter
11 Voice Cosmesis: The Voice Lift

In the modern age of communication, the voice is critical to strengthen the power source of the voice. In many
in projecting image and personality and establishing cred- cases, neuromuscular retraining (specific guided exercise)
ibility. Until very recently, voice has not received enough is sufficient to improve vocal strength and quality, elimi-
attention from the medical profession or from the gen- nate effort and restore youthful vocal quality. Doing so
eral public. In fact, most people (doctors and the general is important not only for singers and other voice pro-
public) do not realize anything can be done to improve fessionals (teachers, radio announcers, politicians, clergy,
a voice that is unsatisfactory or even one that is adequate salespeople, receptionists, etc.) but also really for almost
but not optimal. everyone. This is especially true for older persons. It is
Historically, some techniques for voice improvement ironic but true that, as we grow older, our voices get
date back many years. Singers, actors and public speakers softer, and weaker and at the same time our spouses and
have sought out “voice lessons” for centuries. However, friends lose their hearing. This makes professional com-
recently techniques for voice improvement have expanded munication and social interaction difficult, especially in
and improved, and they have become practical for a great noisy surroundings such as cars and restaurants. When
many more people. one has to work too hard to communicate, it is often
Vocal weakness, breathiness, instability, impaired qual- related to vocal deficiencies. Therefore, it is not surpris-
ity and other characteristics can interfere with social and ing that, when exercises and medications alone do not
professional success. Many problems (particularly breathi- provide sufficient improvement, many patients elect voice
ness, softness, instability, tremor and change in habitual surgery in an attempt to strengthen their vocal quality
pitch) are commonly associated with aging. For most and endurance and to improve their quality of life.
people, these vocal characteristics, which lead people to Several different procedures can be used to strengthen
perceive a voice (and its owner) as “old” or “infirm”, can weak or injured voices. The selection of the operation
be improved or eliminated. depends on the individual’s vocal condition as determined
The first step for anyone seeking voice improvement by a voice team evaluation, physical examination includ-
is a comprehensive voice evaluation. Often, voice prob- ing strobovideolaryngoscopy, and consideration of what
lems that one may ascribe to aging, or even to the natu- the person wants. Care must be taken to ensure that
ral genetic makeup, are caused or aggravated by medical patient expectations are realistic. In most cases, surgery
problems. The possibilities are numerous and include such is directed toward bringing the vocal folds closer together
conditions as reflux, hypothyroidism, paresis, diabetes, so that they close more firmly. This eliminates the air leak
tumors and many others. Sometimes, voice deteriora- between the vocal folds that occurs as a consequence of
tion is the first symptoms of a serious medical problem; vocal atrophy from aging (atrophy or wasting of vocal
so comprehensive medical evaluation is essential before nodules or other tissues) or as a result of paresis or paraly-
treating the voice complaints. sis (partial injury to a nerve from a viral infection or
Once medical problems have been ruled out or other causes). In some cases, the operation is done by
treated, the next step for vocal habilitation or restora- injecting a material through the mouth or neck into the
tion is a program of therapy or exercise provided by a tissues adjacent to the vocal folds, to “bulk up” the vocal
multidisciplinary team that incorporates the skills of not tissues and bring the vocal folds closer together. This is
only a laryngologist but also a speech-language patholo- called injection laryngoplasty and is performed usually
gist or phoniatrist, imaging-voice specialist and an acting- using fat, collagen or other materials. This operation is
voice specialist. The training involves aerobic conditioning sometimes done in the operating room under general or
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Voice Cosmesis: The Voice Lift
Chapter
local anesthesia and, in selected patients, in the office “fine tuning” through additional injections or surgical
with only local anesthesia. Alternatively, the problem can adjustment of the implant. However, usually satisfactory
be corrected by performing a thyroplasty. This operation results are achieved the first time.
involves making a small incision in the neck. The skeleton Voice rehabilitation through medical intervention
of the larynx is entered, and the laryngeal tissues are and therapy/exercise training is appropriate for anyone 11
slightly compressed using Gore-Tex, silastic implants or unhappy with his or her vocal quality and/or endurance
other materials. This procedure is generally done under (so-called “voice lift surgery”) and is suitable for almost
local anesthesia with sedation. All of these procedures anyone who does not have major, serious medical
usually are performed on an outpatient basis. problems such as end-stage heart disease and is not on
Recovery usually takes days to weeks (depending on blood thinner medication that cannot be stopped safely
the procedure). Any operation can be associated with for surgery, so long as that person has realistic vocal goals
complications. Rarely, the voice can be made worse. The and expectations. However, “voice lift” surgery should
most likely complications are that voice improvement is be thought of as a comprehensive program stressing
not quite sufficient or that it does not last over time. medical diagnosis and physical rehabilitation, not as sur-
When these problems occur, they can be corrected by gery alone.
53
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Chapter
12 Postoperative Voice Care

VOICE REST STEROIDS
The efficacy of voice rest as therapy is unproven. Its wide There is no convincing evidence that routine postopera-
standard use is based on anecdotal experience, and com- tive treatment with corticosteroids improves outcomes
mon sense, which may or may not turn out to be cor- following voice surgery. Steroid use varies among sur-
rect. Voice rest may be indicated after vocal fold hemor- geons and is anecdotal. We do not routinely use ster-
rhage, mucosal tear and vocal fold surgery, especially if oids following surgery, although intraoperative delivery
the mucosa of the leading edge of the vocal fold has of 10 mg of dexamethasone is utilized often in cases in
been removed or disrupted. The rationale is attractive, which we are concerned about mild postoperative swell-
even though it is unsubstantiated. Microsurgical tech- ing. If there has been extensive tissue manipulation during
niques are designed to minimize scar formation. A scar endoscopic or laryngeal framework procedures, we may
forms when fibroblast proliferation is initiated in the supplement the intraoperative steroids with postoperative
intermediate and deep layers of the lamina propria. If methylprednisolone or prednisone. Most of our surgical
vibratory margin mucosa has been removed, then the patients are already under treatment for reflux; but if that
lamina propria is exposed. Therefore, it seems reason- is not the case, antireflux medications should be given
able to minimize contact trauma to this region through while patients are taking corticosteroids.
voice rest until the mucosal cover is restored (sometimes
within two to three days, rarely more than one week). ANTIREFLUX MEDICATIONS
Although some vocal fold contact will occur inevitably
because of swallowing and coughing, more (avoidable) There are sufficient clinical and research data suggesting
contact occurs during speech. When a patient phonates that acid and pepsin contact with recent surgical inci-
at a pitch of A below middle C, the vocal folds make sions affects wound healing adversely. Consequently, we
contact 220 times per second. This is close to the normal have a “low threshold” for the prescription of proton
fundamental frequency of the female speaking voice. In pump inhibitors (often in combination with a bedtime
addition, these contacts may be abusive if the patient H2 blocker) in patients in whom we have any suspicion
attempts to achieve his or her preoperative voice qual- of laryngopharyngeal reflux. Antireflux medication is used
ity and volume after surgery. Consequently, the authors at least perioperatively in the vast majority of our patients.
recommend voice rest routinely after surgery, unless the
vibratory margin mucosa has been left intact. Absolute VOICE THERAPY
voice rest is maintained until the vocal fold has remu-
cosalized (rarely more than one week). The author’s (RTS) The best postoperative voice therapy is good preopera-
patients’ first utterance is the /i/ in the examining chair tive voice therapy. It is rare for us to take a patient to
approximately one week after the surgery. Patients then the operating room without formal preoperative evalua-
have a short session with the speech-language pathologist tion by a skilled speech-language pathologist; and usu-
to assist in the transition from silence to limited voice ally at least a few sessions of voice therapy are helpful
use. Relative voice rest and good vocal hygiene under regardless of the pathology. Postoperatively, most patients
the supervision of speech-language pathologists are main- are brought off of voice rest under the supervision of a
tained until complete healing has occurred. Preoperative speech-language pathologist. As soon as a patient is per-
voice therapy is extremely helpful in preparing patients mitted to speak, usually within about one week following
for voice rest and voice conservation. surgery in the vibratory margin, voice therapy is resumed,
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Postoperative Voice Care
Chapter
in combination with relative voice rest. Although evi- off now. I promise I will come back and do voice therapy
dence-based data are scarce, we believe that this process at the end of my concert season”. While there are excep-
minimizes phonotrauma, improves healing and probably tions to every rule, in general this course of action should
decreases the likelihood of recurrent phonotraumatic be avoided. It is usually better to delay surgery until the
pathology. patient is willing and able to comply with postoperative 12
voice rest and therapy. Even patients who travel from
INDIVIDUAL CONSIDERATIONS great distances can receive the necessary treatment. While
such patients may not be able to travel to an expert voice
The need for voice performance may be compelling, team weekly, preoperative and postoperative therapy can
especially in professionals whose ability to make a living be delivered daily over the course of a week in an immer-
depends upon phonation. While management is individu- sion program, supported by follow-up by telephone or
alized to optimize treatment for each patient, care must videoconference. Creativity may be required, but there is
be taken to avoid compromising final outcome. For exam- almost always a way to create a treatment plan that will
ple, in a singer who is in the middle of his/her concert allow our surgical patients to receive the attention neces-
season, it is not uncommon to hear “Please take my cysts sary to optimize surgical outcomes.
55
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SECTION 2
Benign Structural Lesions
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Ch-13.indd 58 9/8/2010 3:05:40 Gopal
Chapter
13 Vocal Fold Cysts

Vocal fold cysts are usually unilateral, although they can

cause contact swelling on the contralateral side (Figs 13.1A
and B). They may also be bilateral (Fig. 13.2). They are
frequently misdiagnosed as vocal nodules initially. Cysts
commonly protrude onto the vibratory margin (Fig. 13.3),
increase the mass of the cover layer and, sometimes,
increase stiffness [particularly when they were associated
with hemorrhage initially (Figs 13.4A and B)]. Whether
they are unilateral or bilateral, they may cause bilateral
vibratory interference. Usually, they involve the superficial
layer of the lamina propria, but in some cases they are
attached to the vocal ligament. Cysts may be congenital
or acquired. Congenital cysts are generally epidermoid,
lined with squamous or respiratory epithelium (Fig. 13.5).
A
Acquired cysts may have epithelial linings and can be
glandular, ciliary or oncocytic. Most are probably reten-
tion cysts caused by trauma that blocks a mucous gland
duct. Cysts can be differentiated easily from nodules
when strobovideolaryngoscopic examination reveals a
fluid-filled mass. A cyst should also be suspected when
“nodules” are diagnosed, and only one side resolves after
voice therapy. The persistent lesion frequently turns out
to be a fluid-filled cyst.
Cysts generally require surgery, although the patient
should undergo a trial of voice therapy first. The author
(RTS) generally schedules surgery tentatively to be per-
formed six to eight weeks after the time of diagnosis,
with a preoperative examination following the trial of
voice therapy. Occasionally, the cyst disappears and does
B
not recur; and sometimes the cyst persists, but is asymp-
tomatic. In these cases, surgery is cancelled, but patients Figs 13.1A and B: (A) Videoprint showing right vocal fold fluid-
are observed closely. If stiffness occurs or worsens at the filled cyst (white arrows) and a left reactive nodule in abduction.
(B) Adduction, in a 52-year-old singing teacher and former
contralateral point of contact or at the base of the cyst, Metropolitan Opera lead singer. In adduction, the shape of the
surgery is reconsidered. Although most symptomatic cysts mass is slightly different from that in abduction, due to shifting the
occur on the vocal fold, it should also be recognized fluid within the mass. Both masses required microsurgical removal,
that cysts commonly occur on the ventricular fold and although in some cases the reactive mass will resolve following
voice therapy and excision of the cyst. Reproduced from Sataloff
epiglottis, as well. Cysts in these areas are probably more RT. Professional Voice: The Science and Art of Clinical Care, 3rd
common than appreciated, but they often go unrecog- edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 85.4,
nized because they are asymptomatic. Histologically, they with permission
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Section
Fig. 13.2: This 29-year-old female is a high school mathematics Fig. 13.3: This 47-year-old professional popular singer has a 17-year
teacher, aerobics instructor, sales representative, cheerleader and history of hoarseness. In January 1994, he developed gradually
cheerleading coach. She has a 5-year history of hoarseness. Her worsening hoarseness, raspiness and inability to sing. His vocal
voice worsened following extensive use. She had previously been deterioration plateaued several months before our examination
told that she had vocal nodules. Strobovideolaryngoscopy revealed in August, 1995. The videoprint reveals a left vocal cyst, which
bilateral, slightly asymmetric, fluid-filled masses that deformed did not respond to voice therapy. The patient underwent excision
with contact. However, they were large enough to interfere with of the left vocal fold cyst, which contained milky fluid. The cyst
vibration and prevent glottic closure. The left mass was clearly was removed with overlaying mucosa, but without disturbing any
a cyst or a soft reactive nodule. Voice therapy resulted in no normal surrounding tissues. He recovered well and was able to
significant improvement. The above videoprint was taken at the resume his professional career. Reproduced from Sataloff RT.
time of microlaryngoscopy. At the time of surgery, both masses Professional Voice: The Science and Art of Clinical Care, 3rd
60 were found to be fluid-filled cysts. She healed well after resection edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 85.6,
of both masses and her voice is within normal limits. Reproduced with permission
from Sataloff RT. Professional Voice: The Science and Art of
Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.;
2005: Fig. 85.5, with permission
A B
Figs 13.4A and B: (A) Videoprint showing left posthemorrhagic vocal fold cyst and resolving hemorrhage with minimal contact-induced
swelling of the right vocal fold. Following complete resolution of the hemorrhage, mild stiffness remained persistent anterior and
posterior to the mass, but severe at the base of the mass. However, phonation improved to normal for this patient’s purpose as a
university professor and a lecturer. (B) This figure shows the typical appearance of a right epithelial cyst involving the superior surface
and vibratory margin. Reproduced from Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. San Diego,
CA: Plural Publishing, Inc.; 2005: Fig. 85.7, with permission
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Vocal Fold Cysts
Chapter
13
Fig. 13.5: Typical histological appearance of a vocal fold cyst

(arrow). It involves the superficial layer of the lamina propria and
epithelium, probably extended into deeper layers. They generally
have a squamous epithelial cyst wall. Cysts of epidermoid origin
have caseous contents. Retention cysts are filled with mucoid
material; and posthemorrhagic cysts contain evidence of blood
products. Reproduced from Sataloff RT. Professional Voice: The 61
Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural
Publishing, Inc.; 2005: Fig. 85.8, with permission
are usually similar to acquired vocal fold cysts, although

epiglottic cysts may also contain lymphoid stroma.
Management of vocal fold cysts provides a particu-
larly good window into the evolution of voice surgery.
The changes in approach to surgical management have Fig. 13.6: The structure of the vocal fold. The vocal fold on
resulted largely because of advances in knowledge of the the right shows normal free mobility of the cover over the body
of the vocal folds as air flows (arrows) through the glottis. The
anatomy and physiology of the vocal tract (especially, our
drawing on the left illustrates scarring of the epithelium to the
knowledge of the vocal folds’ layered structure), techno- deeper layers of the lamina propria, resulting in restriction of
logical developments that have improved our ability to the mucosal wave and stiffness, as seen during stroboscopy. When
examine and quantify voice function, and the availability the scarring is severe enough to stop vibration, the nonvibrating
portion is known as an adynamic segment. Minimizing trauma to
of better surgical instruments.1-3
fibroblast-containing layers help avoid this complication (From
Through the mid-1970s (and later in some centers) Hirano M. Clinical Examination of Voice. New York, NY: Springer-
the operation of choice for benign vocal fold pathology Verlag; 1981:5, with permission). Reproduced from Sataloff RT.
was “vocal cord stripping”, an operation now abandoned Professional Voice: The Science and Art of Clinical Care, 3rd
edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 82.15,
except perhaps in the selected cases of laryngeal cancer. with permission
Hirano demonstrated the complex structure of the vocal
fold (Fig. 13.6) and pointed out that fibroblasts capable
of producing scar were numerous, primarily in the inter- the importance of the complex mucosal wave created
mediate and deep layers of the lamina propria and the during phonation.3-9
muscle. Most benign vocal fold pathology is superficial. The microflap technique was proposed first in 1982
Moreover, research from numerous centers highlighted and was published and illustrated in 1986.10 It has been
Ch-13.indd 61 9/8/2010 3:05:41 Gopal

Section
A B
62
C D
Figs 13.7A to D: Microflap procedure, as illustrated by Sataloff in Cummings et al.10 In this technique: (A) a superficial incision is
made in the superior surface of the true vocal fold. (B) Blunt dissection is used to elevate the mucosa from the lesion. (C) Minimizing
trauma to the fibroblast-containing layers of the lamina propria. Only pathologic tissue is excised under direct vision. (D) Mucosa is
reapproximated without violating the leading edge. This technique is no longer recommended by this author
recommended by numerous other authors since that traumatized directly by contact with the contralateral
time.10-15 It was based on the notion that surgery should vocal fold during phonation or swallowing. This contact
be designed to remove pathology without promoting scar trauma was prevented by elevating a microflap, resecting
formation, that is, without stimulating fibroblasts in the submucosal lesions and replacing the mucosa (Figs 13.7A
intermediate layer of the lamina propria or deeper. With to D). The results of microflap surgery were not uni-
this goal in mind, it seemed reasonable to protect the formly satisfactory. Many were excellent (as were the
intermediate layer of lamina propria by preserving mucosa results of some vocal fold strippings years ago), but careful
along the vibratory margin. If mucosa were absent, strobovideolaryngoscopic analysis and voice assessment
then the intermediate layer of lamina propria would be showed too many cases in which the final outcome was
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Vocal Fold Cysts
Chapter
inexplicably not perfect. In fact, despite what appeared for use in supraglottic stenosis18 or with Ossoff and col-
to be technically flawless operations, a small number of league’s larger “serial microtrapdoor flaps” used for sub-
patients had severe, prolonged stiffness for many months glottic stenosis.19-20
after vocal fold surgery, and critical analysis revealed per- Unfortunately, good, prospective scientific data com-
manent stiffness even in some patients who were happy paring vocal fold stripping, and microflap and mini-micro- 13
with their voice results. Moreover, some of this stiffness flap surgery are not available. Initial anecdotal impressions
was located anterior and posterior to the region of the and the data presented on excision of 96 vocal fold masses
mass, in the areas that had been normal preoperatively. in 60 patients (49 of them singers)17 provide convincing
This observation was explained through a new ana- evidence that mini-microflap surgery and limited mass
tomic discovery. Stephen Gray16 demonstrated a complex excision with overlying mucosa (without disturbing any
basement membrane structure between the epithelium adjacent tissue) (Figs 13.9A to C) provide substantially
and the superficial layer of the lamina propria. Moreover, better results than the microflap surgery advocated origi-
he illustrated that the epithelium and basement mem- nally by this author (RTS). There is less extensive and
brane are attached to the superficial layer of the lamina prolonged postoperative stiffness with this procedure than
propria through an intricate series of type VII collagen was encountered after some cases of microflap surgery.
loops. These loops emanate from and return to basement Mini-microflap is currently recommended for excision of
membrane cells. Type III collagen fibers of the superfi- vocal fold submucosal and epithelial cysts, polyps and
cial layer of the lamina propria pass through them. This similar lesions. When a mini-microflap cannot be created,
highly sophisticated architectural arrangement is prob- resection of the mass with the smallest possible amount
ably variable from person-to-person, and perhaps from of overlying mucosa should be performed.
family-to-family. Basement membrane structures and
the integrity of their attachments are probably related to SURGICAL TECHNIQUES (FIGS 13.10A TO J)
numerous vocal fold functions, including wound healing,
if we can extrapolate from basement membrane behavior
elsewhere in the body. Hence, when we elevate microflaps,
Step 1 63
we are not simply manipulating structurally insignificant Preoperative video stroboscopy is performed, as it directs
tissue. Rather, we are ripping apart delicate, functionally the decision for surgical intervention (Fig. 13.10A). A
important anatomic structures. superficial cyst is appreciated on the right true vocal fold
Consequently, in the latter part of 1991, “traditional” with stiffness at the base. There is also reactive stiffness
microflap surgery was abandoned by many surgeons. appreciated on the contralateral vocal fold, at the area
Since that time, many have limited surgery strictly to apposing the cyst.
the region of pathology, without elevating or disturbing
any surrounding tissue. Masses are either excised with Step 2
the smallest possible amount of their overlying mucosa, General anesthesia is administered using orotracheal
or a mini-microflap is directly elevated over the lesion intubation routinely using 5.0 mm endotracheal tube, but
(Figs 13.8A to D).17 In this technique, a small mucosal nothing larger than 5.5 mm. The vocal folds are viewed
incision is made anteriorly, superiorly and posteriorly using suspension microlaryngoscopy (Fig. 13.10B). A 0°
underlying the vocal fold mass. Gentle retraction is and a 70° laryngeal telescope are used to visualize the
accomplished with a small suction on the surface of the lesion better (images not available). This can often give
lesion, and blunt dissection is used to separate the mass valuable information, such as better appreciation for the
from the lamina propria, reflecting it medially. The mass borders of the cyst and the height of the involved surface
is then excised either with all of its overlying mucosa or of the vocal fold.
preferably retaining a small inferiorly based medial flap
of mucosa. This is generally easy to do once the mass has Step 3
been reflected medially, because the mucosa is already A Straight Sataloff Sharp Knife is used to make an
stretched due to the lesion. The micro-miniflap is a small, incision at the base of the lesion (Fig. 13.10C). The
medially based pedicled flap. It should not be confused length of the incision is no longer than the boundaries
with Dedo and Sooy’s much larger “microtrapdoor flap” of the cyst.
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Section
A B
64
C D
Figs 13.8A to D: (A) In elevating a mini-microflap, an incision is made with a straight knife at the junction of the mass and normal
tissue. Small vertical anterior and posterior incisions may be added at the margins of the mass if necessary, usually using a straight
scissors. (B) The mass is separated by blunt dissection, splitting the superficial layer of the lamina propria and preserving it as much as
possible. This dissection can be performed with a spatula, blunt ball dissector (illustrated) or scissors (as illustrated in A). (C) The lesion
is stabilized and a scissors (straight or curved) is used to excise the lesion, preserving as much adjacent mucosa as possible. The lesion
itself acts as a tissue expander and it is often possible to create an inferiorly based mini-microflap. (D) The mini-microflap is replaced
over the surgical defect, establishing primary closure and acting as a biological dressing. Reproduced from Sataloff RT. Professional
Voice: The Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 82.17, with permission
Step 4 Step 5
Microlaryngeal scissors are placed into the incision with Using a Sataloff Heart-shaped Grasper, the cyst is
the tynes closed (Fig. 13.10D). The scissors are pulled grasped and stabilized medially. The epithelium is freed
slightly medially putting gentle pressure on the cyst and at the anterior (Fig. 13.10E) and posterior (Fig. 13.10F)
avoiding pressure on the vocal fold. The tynes are then limits of dissection using a microlaryngeal scissors. This
spread open to define the plane between the cyst wall step prevents accidental “stripping” beyond the intended
and the underlying superficial lamina propria or vocal resection limits. Dissection then continues along the
ligament. Cysts are usually thin walled and easy to rup- plane between the cyst wall and the underlying lamina
ture. It is therefore a challenge to define the border of propria until the cyst is removed (Fig. 13.10G). The large
the cyst and separate it atraumatically from uninvolved epithelial defect should be left as small as possible. In this
underlying tissue.
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Vocal Fold Cysts
Chapter
13
A B
Figs 13.9A to C: (A) An incision is made on the superior surface

of the vocal fold at the junction of the lesion and normal mucosa.
(B) Blunt dissection with the scissors is used to split the superficial
layer of lamina propria. Note that the force of the side of the
scissors is directed toward the base of the lesion and the glottis,
not laterally toward the vocal ligament. (C) The lesion is stabilized
(not retracted) with heart-shaped forceps and excised, without 65
adjacent normal tissue. A small mucosal gap results, but this usually
heals well. Reproduced from Sataloff RT. Professional Voice: The
C Publishing, Inc.; 2005: Fig. 82.18, with permission
A B
Figs 13.10A and B: (A) Preoperative stroboscopic image of a superficial cyst of the right true vocal fold located in the mid-striking
zone. Stiffness at the base of the cyst with reactive stiffness to the left true vocal fold can be appreciated on the dynamic images.
This influences the decision to pursue a surgical resection and the need to consider addressing both vocal folds during the procedure.
(B) Suspension microlaryngoscopy is used to view of the vocal folds
Ch-13.indd 65 9/8/2010 3:05:42 Gopal

Section
C D
66
E F
Figs 13.10C to G: (C) An incision is made at the base of the cyst,

at the junction of normal and abnormal tissue using a Straight
Sataloff Sharp Knife. The length of the incision should not be longer
than the boundaries of the cyst to avoid disturbing uninvolved
tissue. (D) Straight microlaryngeal scissors are used to spread inside
the incision, defining the plane between the cyst and uninvolved
tissue. The pressure of the scissors is against the cyst, and blunt
dissection allows the superficial lamina propria to separate from
the lesion and be preserved. (E) The cyst is gently grasped with
a Sataloff Heart Shaped Grasper while applying minimal medial
traction. A microlaryngeal scissors is used to release the mass
anteriorly. (F) A microlaryngeal scissors is used to make an
incision posteriorly, further releasing the cyst from the surrounding
epithelium. (G) Curved microlaryngeal scissors are used to dissect
G the cyst off the vocal fold
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Vocal Fold Cysts
Chapter
13
H I
67
Figs 13.10H to J: (H) The defect in the epithelium is about the
size of the cyst and because the lesion could not be separated
from overlying mucosa. In some cases, the cyst can be removed
submucosally preserving all epithelium. (I) Due to the stiffness
seen on preoperative videostroboscopy, Decadron is injected
superficially into the surgical site and into the apposing, stiff area
of the contralateral vocal fold. (J) A postoperative view of the
glottis. The cyst has been resected with minimal trauma to the
J surrounding epithelium
case (Fig. 13.10H), the cyst involved nearly the entire REFERENCES
height of the vocal fold.
1. Hirano M. Phonosurgery. Basic and clinical investigations.
Step 6 Otologia Fukuoka. 1975; 21:239-442.
2. Sataloff RT. Professional Voice: The Science and Art
As there was stiffness seen at the base of the cyst on of Clinical Care, 3rd edition. San Diego, CA: Plural
preoperative videostroboscopy, Decadron 4 mg/ml is Publishing, Inc.; 2005.
injected into this location (Fig. 13.10I). The reactive stiff- 3. Gould WJ, Sataloff RT, Spiegel JR (Eds). Voice Surgery.
ness caused in the contralateral vocal fold at the region Chicago, IL: Mosby Year Book; 1993.
apposing the cyst is also injected. There is minimal visible 4. Sataloff RT. The human voice. Sci Am. 1992; 267(6):
trauma or mucosal disruption seen at the conclusion of 108-15.
the case (Fig. 13.10J). A deep extubation is performed, 5. Sundberg J. The Science of the Singing Voice. DeKalb, IL:
and the patient is placed on strict voice rest until re- Northern Illinois University Press; 1987.
examination in approximately seven days.
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Section
6. Titze IR, Strong WJ. Normal modes in vocal cord tissues. 13. Isshiki N. Phonosurgery–Theory and Practice. New York,
J Acoust Soc Am. 1975; 57(3):736-49. NY: Springer-Verlag; 1989.
7. Titze IR, Talkin DT. A theoretical study of the effects of 14. Ford CN, Bless DM. Phonosurgery: Assessment and
various laryngeal configurations on the acoustics of phona- Surgical Management. New York, NY: Raven Press; 1992.
tion. J Acoust Soc Am. 1979; 66(1):60-74. 15. Sataloff RT. Endoscopic microsurgery. In: Gould WJ,
2 8. Titze IR. Comments on the myoelastic-aerodynamic Sataloff RT, Spiegel JR (Eds). Voice Surgery. Chicago, IL:
theory of phonation. J Speech Hear Res. 1980; 23(3): Mosby Year Book; 1993. pp. 227-67.
495-510. 16. Gray S. Basement membrane zone injury in vocal nodules.
9. Titze IR. The physics of small-amplitude oscillation of the In: Gauffin J, Hammarberg B (Eds). Vocal Fold Physiology.
vocal folds. J Acoust Soc Am. 1988; 83(4):1536-52. San Diego, CA: Singular Publishing Group; 1991. pp. 21-8.
10. Sataloff RT. The Professional Voice. In: Cummings CW, 17. Sataloff RT, Spiegel JR, Heuer RJ, et al. Laryngeal mini-
Frederickson JM, Harker LA, et al. (Eds). Otolaryngology– microflap: A new technique and reassessment of the micro-
Head & Neck Surgery. St Louis, MO: CV Mosby; 1986. flap saga. J Voice. 1995; 9(2):198-204.
pp. 2029-56. 18. Dedo HH, Sooy CD. Endoscopic laser repair of poste-
11. Von Leden H. The history of phonosurgery. In: Gould WJ, rior glottic, subglottic, and tracheal stenosis by division of
Sataloff RT, Spiegel JR (Eds). Voice Surgery. Chicago, IL: micro-trap-door flap. Laryngoscope. 1984; 94(4):445-50.
Mosby Year Book; 1993. pp. 65-96. 19. Duncavage JA, Ossoff RH, Toohill RJ. Carbon dioxide
12. Gould WJ, Lawrence VL. Surgical care of voice disorders. laser management of laryngeal stenosis. Ann Otol Rhinol
In: Arnold GE, Winckel F, Wyke BD (Eds). Disorders of Laryngol. 1985; 94(6 Pt 1):565-9.
Human Communication. New York, NY: Springer-Verlag; 20. Werkhaven J, Ossoff RH. Surgery for benign lesions of the
1984. glottis. Otolaryngol Clin North Am. 1991; 24(5):1179-99.
68
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Chapter
14 Vocal Fold Nodules

Vocal fold nodules are ordinarily caused by voice abuse be underestimated. When nodules are present, the patient
during singing or speaking. Normally, they are bilateral, should be informed with the same gentle caution used in
fairly symmetrical, solid benign masses at the junctions telling a patient that he or she has cancer. Voice therapy
of the anterior and middle thirds of the vocal folds should always be tried as the initial therapeutic modal-
(Figs 14.1 to 14.3). Functionally, this is the midpoint of ity and will cure the vast majority of patients, even if
the musculomembranous portion of the vocal fold, the the nodules look firm and have been present for many
area known as the “striking zone”. It is the area of maxi- months or years. Even for those who eventually need sur-
mal excursion and most forceful contact during phona- gical excision of their nodules, preoperative voice therapy
tion. Typically, these whitish masses increase the mass and is essential to help prevent recurrence of the nodules.
stiffness of the vocal fold cover, interfering with vibra- Surgery for vocal fold nodules should be avoided
tion and causing hoarseness and breathiness. They may be whenever possible and should virtually never be per-
fibrotic and thickening or reduplication of the basement formed without an adequate trial of expert voice therapy
membrane is common. Occasionally, laryngoscopy reveals including patient compliance with therapeutic sugges-
asymptomatic vocal fold nodules that do not appear to tions. A minimum of 6-12 weeks of observation should
interfere with voice production. In such cases, the nodules be allowed while the patient is using therapeutically mod-
should not be treated surgically. However, in most cases, ified voice techniques, under the supervision of a speech-
nodules are associated with hoarseness, breathiness, loss language pathologist and ideally a singing voice specialist.
of range and vocal fatigue. Caution must be exercised Proper voice use rather than voice rest (silence) is correct
in diagnosing small nodules in patients who have been therapy. It has been recognized for many years as effec-
singing actively. Many singers develop bilateral, sym- tive in curing vocal nodules.1,2,4,6-19 In our hands, nodules
metrical, soft swellings at the junction of the anterior are cured by therapy alone in more than 90% of cases.
and middle thirds of their vocal folds following heavy However, this success rate depends upon accurate diagno-
voice use. There is no evidence to suggest that singers sis (e.g. differentiating nodules from cysts), which cannot
with such “physiologic swellings” are predisposed toward be accomplished without strobovideolaryngoscopy.20,21
development of vocal nodules. At present, the condi- Recent literature confirms the value of voice therapy in
tion is generally considered to be within normal limits. the treatment of vocal nodules.22-39 Surgical treatment
The physiologic swelling usually disappears with 24-48 involves conservative removal of nodules, preserving nor-
hours of rest from heavy voice use. Care must be taken mal mucosa and remaining superficial to the intermedi-
not to frighten the patient or embarrass the physician ate layer of lamina propria. This is accomplished best by
by misdiagnosing physiologic swellings as vocal nodules. excising the lesion entirely with sharp instruments, rather
Strobovideolaryngoscopy is essential for accurate diag- than by tearing the mucosa using cupped forceps.
nosis of vocal nodules.1-5 Without strobovideolaryngos-
copy, vocal fold cysts and other lesions will routinely be VOCAL FOLD NODULES IN CHILDREN
misdiagnosed as vocal nodules. Because the conditions
respond differently to treatment, accurate differentiation Vocal nodules in children represent a special case. There
is essential. are differing opinions on management and especially on
Nodules carry a great stigma among singers and actors, the efficacy of voice therapy. In the United States, the
and the psychological impact of the diagnosis should not consensus is that nodules should generally not be operated
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Section
A B D
70
C E
Figs 14.1A to E: Miscellaneous disorders of the larynx. Hyperkinesia of the false vocal folds is seen in hyperfunctional voice abuse.
In its more severe form, phonation may actually occur primarily with the false vocal folds. This condition is known as dysphonia plica
ventricularis. Contact ulcers occur in the posterior portion of the vocal folds, generally in the cartilaginous portion. Vocal fold nodules
are smooth, reasonably symmetrical benign masses at the junction of the anterior and middle thirds of the vocal folds. Although
Netter’s classic drawing is labeled “vocal nodules”, the mass on the right appears hemorrhagic in origin. It may be a hemorrhagic
cyst or fibrotic hematoma from hemorrhage of one of the prominent blood vessels on the superior surface. The mass on the left has
the typical appearance of a reactive vocal nodule. The illustration of vocal nodules during phonation shows failure of glottic closure
anterior and posterior to the masses. This is responsible for the breathiness heard in the voices of patients with nodules. Polypoid
degeneration, Reinke’s edema, has a typical floppy “elephant ear” appearance. Juvenile papillomatosis is a viral disease. This disease
and its treatment frequently result in permanent disturbance of the voice (From the larynx. In: Clinical Symposia. Summit, NJ: CIBA
Pharmaceutical Company; 1964; 16(3): Plate VIII. Copyright 1964 Icon Learning Systems, LLC, a subsidiary of MediMedia USA, Inc.
Reprinted with permission from ICON Learning Systems, LLC, illustrated by Frank Netter, MD, All rights reserved). Reproduced from
Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig.
85.1, with permission
on until after puberty. In the author’s (RTS) opinion, of 6 and we have used this diagnostic technique success-
children with vocal nodules should be treated, especially fully on children as young as 6 months. Once it is clear
if they are bothered by their dysphonia. Dysphonia that the masses are nodules rather than cysts, treatment
commonly results in teasing by other children, exclusion should start with voice therapy. Successful therapy gener-
from activities such as plays and choirs and other hard- ally requires treating the whole family, not just the child.
ships, which should not be allowed to mar childhood. Frequently voice abuses are learned behavior. The patient
Treatment begins with accurate diagnosis. Stroboscopy should be instructed to monitor the vocal behavior of
can be performed easily on most children over the age other family members (gold stars for mom when she does
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Vocal Fold Nodules
Chapter
14
Fig. 14.2: Typical appearance of vocal nodules. Reproduced from

Sataloff RT. Professional Voice: The Science and Art of Clinical
Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005:
Fig. 85.2, with permission
not yell) just as other family members help monitor his Fig. 14.3: Typical histological appearance of a vocal fold nodule.
or her vocalization and remind the child about proper The lesion is sessile and involves the epithelium and superficial
voice use and avoidance of abuse. If voice therapy results layer of the lamina propria. The lesion contains collagenous fibers
and edema. Intermediate and deep layers of the lamina propria
in behavioral modification and proper voice use carried
over into daily life and if nodules persist and symptoms
are not involved. Reproduced from Sataloff RT. Professional Voice: 71
The Science and Art of Clinical Care, 3rd edition. San Diego, CA:
remain disturbing, surgical excision is reasonable. If the Plural Publishing, Inc.; 2005: Fig. 85.3, with permission
child is close to puberty and not terribly disturbed by
the phonatory quality, waiting until after voice mutation
is also reasonable and often results in spontaneous voice long standing should be given a chance to resolve without
improvement. It should be noted that there may be at surgery. In some cases, the nodules remain but become
least a theoretical advantage to operating on younger chil- asymptomatic, with normal voice quality. Stroboscopy in
dren, although it has not been tested or even explored these patients usually reveals that the nodules are on the
clinically. The layered structure of the lamina propria is superior surface rather than the leading edge of the vocal
not present in early childhood and not fully developed folds during proper, relaxed phonation (although they
until around the time of puberty.40,41 One might suspect, may be on the contact surface and symptomatic when
then, that the risk of scarring and permanent dysphonia hyperfunctional voice technique is used and the larynx
might be lower if surgery were performed prior to that is forced down).
time. However, this notion must be considered purely
speculative. SURGICAL TECHNIQUES
Permanent destruction of voice quality is not a rare
complication of vocal fold surgery. Even after expert sur-
Step 1
gery, this may be caused by submucosal scarring, resulting
in an adynamic segment along the vibratory margin of Orotracheal intubation is followed by suspension micro-
the vocal fold. This situation results in a hoarse voice laryngoscopy to expose the glottis (Fig. 14.4A).
with vocal folds that appear normal with regular light,
although under stroboscopic light the adynamic segment Step 2
is obvious. There is no reliable cure for this complication. Rigid telescopes, 30° and 70° are used to better determine
Consequently, even large, apparently fibrotic nodules of the borders of the mass (Fig. 14.4B).
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Section
Fig. 14.4A: A prominent fibrous mass can be seen on the edge Fig. 14.4B: The mass is visualized using a 70o endoscope. A second
of the left true vocal fold mass is appreciated on the right vocal fold with a vessel coursing
over it, along the superior surface of the right vocal fold
72
Fig. 14.4C: An incision is made on the superior surface of the Fig. 14.4D: The mass is dissected bluntly with a Sataloff
vocal fold, at the lateral extent of the mass Curved Spatula
Step 3 Step 4
A superficial incision is made at the lateral border of Using a Sataloff Curved Spatula, the mass is bluntly dis-
the fibrous mass using a Straight Sataloff Sharp Knife sected off the overlying mucosa (Fig. 14.4D) and under-
(Fig. 14.4C) to create a minimicroflap. The incision is lying superficial lamina propria and/or vocal ligament
placed at the junction of normal and abnormal tissue, in (Fig. 14.4E). The surrounding epithelium should not be
order to avoid traumatizing any uninvolved portion of disturbed (Fig. 14.4F).
the vocal fold.
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Vocal Fold Nodules
Chapter
14
Fig. 14.4E: Blunt dissection frees the mass from the underlying Fig. 14.4F: The dissection does not disturb the epithelium
attachments surrounding the incision site
73
Fig. 14.4G: Using a fine grasping instrument, the mass is Fig. 14.4H: Curved microscissors are used to free the mass
retracted medially from the underlying lamina propria
Step 5 Step 6
A fine Sataloff Right Heart Shaped Grasper (Fig. 14.4G) The mini-microflap is redraped (Fig. 14.4I). The vocal
is used to grasp the mass and stabilize it with minimal fold may be palpated for any pathologic lesions that may
medial retraction. The mass is freed from attachments to persist. Extubation is performed while the patient is deep.
the underlying residual superficial lamina propria or vocal The patient is placed on absolute voice rest until the time
ligament using blunt dissection with a spatula or straight of postoperative visualization, usually about one week.
scissors (Fig. 14.4H).
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Section
12. Wilson KD. Voice re-education of adults with vocal nod-

ules. Arch Otol Rhinol Laryng. 1962; 76:68-73.
13. Fisher HB, Logemann JA. Objective evaluation of ther-
apy for vocal nodules: A case report. JSHD. 1970; 35(3):
277-85.
2 14. Fisher HB, Logemann JA. Voice diagnostics and therapy.
Otolaryngol Clin North Am. 1970; 3(3):639-63.
15. Brodnitz FS. Vocal Rehabilitation. Rochester, Minn:
American Academy of Ophthalmology and Otolaryngology;
1971.
16. Drudge MK, Philips BJ. Shaping behavior in voice therapy.
JSHD. 1976; 41(3):398-411.
17. Reed CG. Voice therapy: A need for research. JSHD. 1980;
45(2):157-69.
18. Barnes JE. Voice therapy for vocal nodules and vocal pol-
yps. Rev Laryngol Otol Rhinol. 1981; 102(3-4):99-103.
19. Vaughan CW. Current concepts in otolaryngology: Diag-
Fig. 14.4I: The mass is resected. The entire dissection occurs nosis and treatment of organic voice disorders. N Engl J
under a mini-microflap. Preservation of the epithelium of the vocal Med. 1982; 307(14):863-6.
fold is achieved. The vibratory margin has not been disturbed. 20. Sataloff RT, Spiegel JR, Carroll LM, et al. Strobovideo-
There is secretion on the superior surface, not a strip of loose laryngoscopy in professional voice users: Results and clini-
mucosa. The blood on the right vocal fold is from a concurrent cal value. J Voice. 1988; 1:359-64.
procedure
21. Sataloff RT, Spiegel JR, Hawkshaw MJ. Strobovideo-
laryngoscopy: Results and clinical value. Ann Otol Rhinol
Laryngol. 1991; 100(9 Pt 1):725-7.
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1. Curtis HH. The cure of singers’ nodules. NY Med J. 1898;
23. Karkos PD, McCormick M. The etiology of vocal fold
pp. 37-9.
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2. Rubin HJ, Lehrhoff I. Pathogenesis and treatment of vocal
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3. Brodnitz FS. Goals, results and limitations of vocal reha- 24. Dejonckere PH, Kob M. Pathogenesis of vocal fold nod-
bilitation. Arch Otolaryngol. 1963; 77:148-56. ules: New insights from a modelling approach. Folia
4. Deal RE, McClain B, Sudderth JF. Identification, evalua- Phoniatr Logop. 2009; 61(3):171-9.
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in a public school setting. JSHD. 1976; 41(3):390-7. acceleration and impact stress as possible loading factors
5. Lancer JM, Sider D, Jones AS, et al. Vocal cord nodules: in phonation: A computer modeling study. Folia Phoniatr
A review. Cl Otolaryngol. 1988; 13:43-51. Logop. 2009; 61(3):137-45.
6. Knight FI. Singers’ nodes. Trans Am Laryngol Assoc. 26. Tezcaner CZ, Ozgursoy SK, Sati I, et al. Changes after
1894; xvi: pp. 118-23. voice therapy in objective and subjective voice measure-
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Laryngol Rhinol Otolog Soc. 1897; 3:95-101. Otorhinolaryngol. 2009; 266(12):1923-7.
8. Zerffi AC. Voice reeducation. Arch Otolaryngol. 1948; 27. Shah RK, Engel SH, Choi SS. Relationship between voice
48:521-6. quality and vocal nodule size. Otolaryngol Head Neck
9. Brodnitz FS. Keep Your Voice Healthy. New York, NY: Surg. 2008; 139(5):723-6.
Harper & Brothers; 1953. 28. Eckley CA, Swensson J, Duprat Ade C, et al. Incidence
10. Withers BT, Dawson MH. Treatment of vocal nodule of structural vocal fold abnormalities associated with vocal
cases: Psychological aspects. Tex State J Med. 1960; 56: fold polyps. Braz J Otorhinolaryngol. 2008; 74(4):508-11.
43-6. 29. De Biase NG, Pontes PA. Blood vessels of vocal folds:
11. Wilson DK. Voice re-education of children with vocal A videolaryngoscopic study. Arch Otolaryngol Head Neck
nodules. Laryngoscope. 1962; 72:45-53. Surg. 2008; 134(7):720-4.
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30. Merati AL, Keppel K, Braun NM, et al. Pediatric voice- 36. Ruiz DM, Pontes P, Behlau M, et al. Laryngeal microweb
related quality of life: Findings in healthy children and in and vocal nodules. Clinical study in a Brazilian population.
common laryngeal disorders. Ann Otol Rhinol Laryngol. Folia Phoniatr Logop. 2006; 58(6):392-9.
2008; 117(4):259-62. 37. Gomez-Vilda P, Fernandez-Baillo R, Nieto A, et al.
31. Czerwonka L, Jiang JJ, Tao C. Vocal nodules and edema Evolution of vocal fold nodules from childhood to ado-
may be due to vibration-induced rises in capillary pressure. lescence. J Voice. 2007; 21(2):151-6. 14
Laryngoscope. 2008; 118(4):748-52. 38. Roy N, Holt KI, Redmond S, et al. Behavioral character-
32. Altman KW. Vocal fold masses. Otolaryngol Clin North istics of children with vocal fold nodules. J Voice. 2007;
21(2):157-68.
Am. 2007; 40(5):1091-108.
39. Wohl DL. Nonsurgical management of pediatric vocal
33. Franco RA, Andrus JG. Common diagnoses and treat-
fold nodules. Arch Otolaryngol Head Neck Surg. 2005;
ments in professional voice users. Otolaryngol Clin North
131(1):68-70.
Am. 2007; 40(5):1025-61.
40. Hirano M. Surgical Anatomy and physiology of the vocal
34. Aronsson C, Bohman M, Ternstrom S, et al. Loud voice folds. In: Gould WJ, Sataloff RT, Spiegel JR, (Eds). Voice
during environmental noise exposure in patients with vocal Surgery, New York, NY: Mosby-Yearbook, Inc; 1993.
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35. Shah RK, Feldman HA, Nuss RC. A grading scale for 41. Hartnick CJ, Rehbar R, Prasad V. Development and matu-
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75
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Chapter
15 Vocal Fold Polyps

Polyps are usually unilateral, and often have a prominent

feeding blood vessel coursing along the superior surface
of the vocal fold and entering the base of the polyp [Figs
(VF Nodule Chapter 14.1) 15.1 to 15.7)]. The etiology of
vocal fold polyps often remains unknown. Some appear
to be traumatic. Some are clearly preceded by localized
vocal fold hemorrhage. Polyps may be loose, gelatinous
masses, fibrinoid or hyaline. Polyps have also been clas-
sified as angiomatous, mucoid and myxomatous. They
may extremely be small or involve an entire vocal fold.
Larger polyps frequently extend into the subglottic area.
The functional effect of polyps depends on underlying
pathology and on whether they are unilateral or bilateral,
sessile or pedunculated, symmetrical or asymmetrical and
situated on the margin or elsewhere. With edematous
polyps, the mass of the cover layer may function as if it A
were decreased. If polyps contain blood and/or fibrosis,
the mass is increased. Polyps may interfere with vibration
Figs 15.2A and B: These figures were taken intraoperatively and

shows (left) a pedunculated hemorrhagic polyp (white arrow), with
prominent feeding vessel on the vibratory margin of the vocal fold
(straight black arrows). The pedunculated nature of the lesion
Fig. 15.1: Intraoperative videoprint showing typical appearance of can be seen (right) as the lesion is displaced onto the surface
a sessile, unilateral polyp of the right vocal fold. Reproduced from of the vocal fold [From ENT J, 1993; 72(7), with permission].
Sataloff RT. Professional Voice: The Science and Art of Clinical Reproduced from Sataloff RT. Professional Voice: The Science and
Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Art of Clinical Care, 3rd edition. San Diego, CA. Plural Publishing,
Fig. 85.9, with permission Inc.; 2005: Fig. 85.10, with permission
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Vocal Fold Polyps
Chapter
15
A
Fig. 15.3: Intraoperative videoprint showing right posthemorrhagic
vocal fold polyp with a vascular blush in its base anteriorly and
with jagged feeding vessels. There are also varicosities on the
superior surface of the right vocal fold. The left vocal fold shows
a varicosity and large ectasia on the superior surface, and a cyst
on the left vibratory margin (partially obscured by the right polyp).
Reproduced from Sataloff RT. Professional Voice: The Science and
Art of Clinical Care, 3rd edition. San Diego, CA. Plural Publishing,
77
Figs 15.5A and B: (A) Some polyps are clearly associated with
hemorrhage. Residual blood can be seen within the left vocal fold
polyp, in a videoprint taken through a 70º laryngeal telescope. A
feeding vessel along the vibratory margin also is seen clearly. Such
vessels are often difficult to visualize from above, or using a 0º
telescope. (B) Even a broad-based sessile polyp that is inseparable
from overlying epithelium can be excised without extensive mucosal
resection. This intraoperative photograph shows the mucosal edges
that meet spontaneously almost completely, forming a fairly linear
epithelial deficit. The indentation in the area of resection reflects
Fig. 15.4: Left posthemorrhagic vocal fold polyp as seen dissection along the medial aspect of the lesion in an area that
intraoperatively through a 70º telescope. The polyp is located was adynamic preoperatively. No uninvolved tissue was disturbed.
on the vibratory margin. The metal laryngoscope can be seen This approach is useful in many cases, although in some instances
anteriorly, and the laryngeal ventricle is visualized well above the it is better to transect fibrotic tissue and leave a straight vocal
vocal fold. Reproduced from Sataloff RT. Professional Voice: The fold edge. Reproduced from Sataloff RT. Professional Voice: The
Science and Art of Clinical Care, 3rd edition. San Diego, CA. Plural Science and Art of Clinical Care, 3rd edition. San Diego, CA. Plural
Publishing, Inc.; 2005: Fig. 85.12, with permission Publishing, Inc.; 2005: Fig. 85.13, with permission
unilaterally, bilaterally or, in some cases, they may not characteristics generally allow for the differentiation of
interfere with vibration at all (if they are not located on polyps from nodules and cysts (Fig. 15.11). However, it
the vibratory margin; Figs 15.7 and 15.8). Histological must be recognized that not all lesions that look like
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Section
A A
78
B B
Figs 15.6A and B: (A) Although this is a large polyp, it is based on Figs 15.7A and B: This intraoperative videoprint shows a broad-
a relatively small area along the vocal fold. Consequently, excision based left vocal fold polyp partially obscuring a right vocal fold
involves a risk of scarring to only a small area of the vibratory mass in a 42-year-old rabbi with a 1 ½-year history of gradually
margin. This risk is reduced further because of the amount of progressive dysphonia. (A) A 70º laryngeal telescope. (B) Clarifies
redundant mucosa seen anterior to the mass and the relatively the relation between the right mass and the overlying left polyp.
enlarged Reinke’s space. (B) Polyp located on the right false vocal The right contact lesion was much more firm and fibrotic than
fold. When the mass was not in contact with the vocal folds, the the larger left polyp. Both lesions were removed, and the voice
voice was normal. As the mass enlarged slightly, it touched the improved substantially. Reproduced from Sataloff RT. Professional
superior surfaces of the vocal folds intermittently causing irregular Voice: The Science and Art of Clinical Care, 3rd edition. San Diego,
dysphonia. Resecting a polyp from this region of the false vocal fold CA. Plural Publishing, Inc.; 2005: Fig. 85.15, with permission
generally is not associated with a substantial risk of hoarseness.
Reproduced from Sataloff. RT. Professional Voice: The Science and
Art of Clinical Care, 3rd edition. San Diego, CA. Plural Publishing, treated, they may produce contact injury on the contral-
Inc.; 2005: Fig. 85.14, with permission ateral vocal fold. Voice therapy should be used to ensure
good relative voice rest and avoid abusive behaviors before
polyps are simple, benign polyps. Some may be neoplastic and after surgery. Vocal fold polyps should be removed
(Figs 15.9 to 15.11). conservatively, preserving normal mucosa, and remaining
In some cases, even sizable polyps resolve with relative superficial to the intermediate layer of the lamina propria.
voice rest and a few weeks of low-dose steroid therapy This is accomplished best by using the mini-microflap
such as methylprednisolone 4 mg twice a day. However, technique described in the removal of vocal fold cysts.
most of them require surgical removal. If polyps are not The lesion usually is removed in its entirety with sharp
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Vocal Fold Polyps
Chapter
15
Fig. 15.8: Typical histological appearance of a polyp. It involves the Fig. 15.10: This 79-year-old female had a 3-month history of
epithelium and superficial layers of the lamina propria. Evidence hoarseness. She has smoked at least one pack of cigarettes
of bleeding into the tissue is apparent (arrow), and hyaline daily for 70 years. She has no history of throat pain or otalgia,
degeneration, thrombosis, edema, collagen fibrous proliferation and she denied dysphagia. The intraoperative videoprint above
and cellular infiltration are common (Courtesy of Minoru Hirano, reveals a mass that might have been mistaken for a benign polyp
MD). Reproduced from Sataloff RT. Professional Voice: The Science (arrow). Erythema and fullness are present anteriorly. Actually, this
and Art of Clinical Care, 3rd edition. San Diego, CA. Plural “polyp” is the tip of a squamous cell carcinoma extending into
Publishing, Inc.; 2005: Fig. 85.16, with permission the supraglottic and infraglottic regions, with cartilage invasion. It
involves the true and false vocal folds bilaterally. The tumor was
stage T4N0M0. Reproduced from Sataloff RT. Professional Voice:
The Science and Art of Clinical Care, 3rd edition. San Diego, CA. 79
Plural Publishing, Inc.; 2005: Fig. 85.18, with permission
instruments, rather than by using cupped forceps which

can tear the mucosa or laser which can cause thermal
injury.
Many vocal fold polyps are accompanied by an obvious
central blood vessel that extends from the superior surface
of the vocal fold. Often these vessels course along the
vibratory margin or may originate below the vocal fold
edge. We used to believe that prominent feeding vessels
should be cauterized with a carbon dioxide laser (at
1 watt, 0.1 single pulse second, 30 millijoules, defocused)
or resected to help prevent recurrent hemorrhage and
polyp formation (Fig. 15.12). However, recent research
by the author (RTS) and colleagues (unpublished) has
shown the vessels are not feeding vessels but rather drain-
ing vessels. Blood flows away from the vibratory margin
Fig. 15.9: Intraoperative photograph from a 35-year-old male with lesion in virtually all cases. Hence, the wisdom of ablating
a 6-month history of hoarseness. Although the lesion looks like
a hemorrhagic polyp, histological assessment revealed it to be
these vessels has now been called into question. When
a hemangioma. This was suspected intraoperatively, because of there is a need to eliminate the vessels, the author (RTS)
unusually profuse hemorrhage. The possibility of neoplasm should prefers resection using cold instruments in most cases or
always be kept in mind, and biopsy should not be unduly delayed pulsed KTP laser, but the CO2 laser can be used safely
when a lesion fails to respond promptly to noninvasive therapy.
also. The polyp can then be removed from the vibratory
Art of Clinical Care, 3rd edition. San Diego, CA. Plural Publishing, margin with traditional instruments (Figs 15.13A to D)
Inc.; 2005: Fig. 85.17 with permission or laser (Figs 15.14A and B).
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Section
Fig. 15.11: This videoprint shows an irregular, polypoid, right vocal Figs 15.12: The feeding vessel of a hemorrhagic polyp may be
fold mass (arrows). There is also arytenoid erythema associated treated with a 1-watt defocused laser burst of short duration to
with reflux. The arytenoids are not visible in this picture, but cauterize the vessel and prevent recurrent hemorrhage. The polyp
acid-induced erythema extending into the cartilaginous portion of can then be removed from the leading edge with scissors, avoiding
the vocal folds can be seen (curved arrows). This patient had not the risk of laser injury to the vibratory margin
smoked for more than 10 years. This pedunculated mass was T1N0M0
well-differentiated squamous cell carcinoma, which was excised
with adequate margins. The patient is being monitored closely, border between the mass and the underlying superficial
and no further treatment is planned unless the tumor recurs [From lamina propria or vocal ligament. Care should be taken
80 ENT J, 1994; 73(8), with permission]. Reproduced from Sataloff.
RT. Professional Voice: The Science and Art of Clinical Care, 3rd
not to over-inject, in order to avoid distorting the margins
of the lesion.
edition. San Diego, CA. Plural Publishing, Inc.; 2005: Fig. 85.19,
with permission
Step 4
A superficial incision is made at the lateral border of the
polyp using a straight Sataloff Sharp Knife (Fig. 15.15E)
SURGICAL TECHNIQUES
to create a minimicroflap. The incision is placed at the
junction of normal and abnormal tissue, in order to avoid
Step 1
traumatizing any uninvolved portion of the vocal fold.
Orotracheal intubation is followed by suspension
microlaryngoscopy to expose the glottis (Fig. 15.15A). Step 5
Intubation is performed routinely using a 5 mm endotra- Microlaryngeal scissors are placed into the incision with
cheal tube, but nothing larger than 5.5 mm. the tynes closed (Fig. 15.15F). The scissors are pulled
slightly medially putting gentle pressure on the polyp
Step 2 and avoiding pressure on the vocal fold. The tynes are
Zero degree and seventy degree endoscopes are used to then spread open to define the plane between the polyp
better visualize the borders of the polyp (Figs 15.15B and the underlying superficial lamina propria or vocal
and C). ligament.
Step 3 Step 6
Subepithelial infusion with 1% lidocaine and 1:10,000 The epithelium is freed at the anterior (Fig. 15.15G)
epinephrine causes distention of the superficial lamina and posterior (Fig. 15.15H) limits of dissection using
propria and vasoconstriction of its microvasculature a microlaryngeal scissors. This step prevents accidental
(Fig. 15.15D). This also serves to better delineate the “stripping” beyond the intended resection limits. Using a
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Vocal Fold Polyps
Chapter
15
A B
81
C D
Figs 15.13A to D: (A) The old technique of grasping the lesion with a cupped forceps and avulsing the lesion form the vocal fold is
not sufficiently precise. It allows for tearing of the mucosa beyond the necessary area of excision. Instead, the lesion may be grasped
with a delicate forceps, or preferably stabilized with a fine suction. The lesion should not be retracted medially with forceps, as this
will tent the mucosa and often result in excessive excision. (B) The mucosa is cut sharply rather than ripped. (C) Resection is limited
strictly to the area of pathology. Even with small lesions, but especially with larger lesions, it is often helpful to bluntly separate the
lesion from the underlying lamina propria with a blunt dissector or spreading with scissors. (D) This must be done superficially, and any
pressure should be directed medially (toward the portion being resected), taking care not to traumatize the intermediate layer of the
lamina propria. Reinke’s space is not rich in fibroblasts (although it contains some), and utilizing this technique permits resection of
the diseased tissue only, while minimizing the chance of scarring
Sataloff Heart Shaped Grasper, the polyp is grasped and Step 7

stabilized medially. Dissection then continues along the Preoperative strobovideolaryngoscopy demonstrated stiff-
plane between the base of the polyp and the underlying ness at the base of the polyp suggestive of scar formation.
lamina propria until the polyp is removed (Fig. 15.15I). This common finding is verified by gentle palpation of
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Section
A B
Figs 15.14A and B: (A) When a lesion on the vibratory margin is resected with laser, the center of the laser beam must be located
in the body of the mass. Thus, the zone of destruction (rather than center of the laser beam) is approximately even with the vibratory
margin. (B) A cross-section of the vocal fold illustrates the same principle. Arrow B represents the center of the laser beam, and arrow
A represents the outermost region of the zone of destruction around the laser beam. The zone of destruction should be superficial to
the intermediate layer of the lamina propria to help prevent scar formation
82
A B
Figs 15.15A and B: (A) Preoperative rigid videostroboscopic image of a left hemorrhagic polyp. Stiffness is appreciated at the base
of the lesion and is indicative of scar formation at the base of the polyp. (B) The polyp is visualized using a 0º endoscope
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Vocal Fold Polyps
Chapter
15
C D
83
E F
G H
Figs 15.15C to H: (C) A 70º endoscope is used to visualize better the borders of the polyp. (D) A subepithelial infusion with 1%
lidocaine and 1:10,000 epinephrine is performed. (E) An incision is made on the superior surface of the vocal fold using a Sataloff
Straight Knife, at the lateral border of the polyp. (F) Straight microlaryngeal scissors are used to spread inside the incision, defining
the plane between the polyp and uninvolved tissue. The pressure of the scissors is against the polyp, and blunt dissection allows any
remaining superficial lamina propria to separate from the lesion and be preserved. (G) A microlaryngeal scissors is used to release the
polyp anteriorly. (H) The polyp is released posteriorly using microlaryngeal scissors
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Section
I J
84
K L
Figs 15.15I to L: (I) The polyp is gently grasped with a Sataloff Heart-Shaped Grasper while applying minimal medial traction. A curved
microlaryngeal scissors is used to remove the polyp. (J) Curved microlaryngeal scissors are placed underneath the epithelium and spread
gently, releasing adhesions and creating a mobile microflap. (K) A Sataloff Long Right Angle Ball Dissector is placed under the adhesed
mucosa on the superior surface and used to lyse adhesions, freeing mucosa at the upper edge of the incision. (L) Decadron is injected
superficially into the base of the surgical site
the vocal fold, after removal of the polyp. Curved micro- Step 8
laryngeal scissors are used to create to lyse adhesions and
create a microflap (Fig. 15.15J). Releasing the adhesions A deep extubation is performed, and the patient is placed
and mobilizing the mucosa improves the likelihood of on strict voice rest until re-examination in approximately
restoring the mucosal wave (Fig. 15.15K). Decadron seven days.
4 mg/ml is then injected superficially at the surgical site
(Fig. 15.15L).
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Chapter
Varicosities, Ectatic Vessels and
16 Vocal Fold Hemorrhage
Hemorrhage in the vocal folds and mucosal disruption treatment. Usually, this is due to repeated submucosal
(Figs 16.1A and B) are contraindications to singing, act- hemorrhage emanating from an enlarged, weakened blood
ing or speaking. When these are observed, the therapeutic vessel. More rarely, it is due to dysphonia caused by
course initially includes strict voice rest in addition to engorgement of the blood vessels following the exercise
correction of any underlying disease. of voice use (just like the veins, which pump up in the
In patients with very extensive hemorrhage distort- arms following exercise) and which changes the mass of
ing a vocal fold, an incision along the superior surface the vocal fold. This is a proven but uncommon cause of
with evacuation of the hematoma may expedite healing. voice fatigue (Fig. 16.2).
In general, this is not necessary. However, if the bulging In patients with recurrent hemorrhage from a vari-
vocal fold has not flattened satisfactorily through resorp- cose or ectatic vessel or with voice dysfunction result-
tion of the hematoma within a few days after the hem- ing from small vessel enlargement, vaporization of the
orrhage, evacuation may be considered. Surgery involves abnormal vessels was once the treatment of choice and
suction evacuation of the hematoma through a small inci- still may be indicated in some cases. This is performed
sion on the superior surface. Vocal fold hemorrhage is by a carbon dioxide laser, using defocused 1 watt laser
discussed in detail elsewhere.4 bursts interrupted with single pulses at 0.1 second, 30
Ectatic blood vessels and varicosities are usu- millijoules and icing the vocal fold with an ice chip or
ally asymptomatic. However, occasionally, they require cottonoid soaked in ice water. Care should be taken not
A B
Figs 16.1A and B: Videoprint from a 36-year-old professional singer who developed sudden hoarseness while coughing.
Strobovideolaryngoscopy: (A) Revealed an acute right vocal fold tear (white arrow) and new left vocal fold varicosities with a surrounding
blush of resolving mucosal hemorrhage (black arrows) and a small left vibratory margin mass. Re-examination, three months later.
(B) Showed smaller residual bilateral vocal fold masses (white arrows) and a persistent area of raised, ectatic/varicose vessels (black
arrow). There was also mild stiffness in the region where the left vocal fold hemorrhage had occurred. (From ENT J 1994; 73[9], with
permission) Reproduced from Sataloff, RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural
Ch-16.indd 85 9/8/2010 3:06:21 Gopal

Section
are located in the middle of the musculomembranous

vocal fold, usually on the superior surface. This observa-
tion has been reported previously.2, 3 It was noted that
66% of the varices and ectasias occurred in the region
2 of the superior and lateral extent of the mucosal wave.
This is probably the point at which maximum sheering
forces are generated in the superficial layer of the lamina
propria, as the mucosal wave reaches its superior/lateral
endpoint, decelerates quickly and reverses its direction
to begin the closing phase of the oscillatory cycle. We
speculate that this whiplash-like effect and the limitation
of the microvasculature by the basement membrane of
the epithelium are probably responsible for the prepon-
derance of hemorrhages, ectasias and varices that occur
on the superior and lateral surfaces near the middle of
the musculomembranous portion of the vocal fold. The
Fig. 16.2: Videoprint revealed a prominent varicosity on the left middle segment of the musculomembranous portion of
vocal fold. The large black arrow marks the lateral margin of the vocal fold is now referred to as the striking zone.1 It
the varicosity, the smaller arrow marks the medial margin and
the smallest arrows mark the anterior and posterior extent of is believed that chronic mechanical trauma to the micro-
the varicosity. This vein pumped up during the singing exercises vasculature is responsible for the development of varicosi-
in the same manner as veins of extremities become prominent ties and ectasias, and that the direct collision forces are
during other forms of exercise. This added to the mass effect of
responsible for most of the vascular abnormalities that
the left vocal fold causing interruptions in the vibratory pattern,
voice fatigue, and loss of upper range, increased vocal effort and occur on the medial surface of the vocal fold. The fact that
86 slight hoarseness. These symptoms resolved after vaporization of
the vessel. (From Ear Nose Throat J 73(7):445, with permission.)
so many such abnormalities are actually on the superior
surface rather than on the vibratory margin is probably
due to the fact that the maximum sheering stresses during
Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing,
Inc.; 2005: Fig. 82.22, with permission oscillation are on the superior surface. Due to the whip-
lash-like mechanism of injury, superficial vessels are more
likely to be injured than deeper vessels. This is convenient,
to permit heat transfer to the intermediate or deep layers since the superficial nature facilitates surgical manage-
of the lamina propria. Protection may be accomplished ment. In our reported series of 42 patients for whom
by submucosal infusion and by directing the laser beam sufficient preoperative and postoperative data were avail-
tangentially for blood vessels directly on the vibratory able, mucosal vibration remained the same or improved in
margin, so that the direct impact of the laser beam is not all patients who underwent excision of ectasias or varices
aimed at the vibrating surface. In some cases, the mucosa using cold instruments. This had not been the author’s
may gently be retracted using alligator forceps with a cot- (RTS) experience with CO2 laser management of similar
tonoid along the superior surface, stretching blood vessels lesions in earlier years, prior to developing this technique.
toward the superior surface where they may be vaporized Although the author (RTS) prefers resection of vessels in
more safely over the body of the thyroarytenoid muscle. most cases, CO2 laser cauterization should still be con-
If the vessel is positioned over the lamina propria in such sidered an acceptable option, particularly for lesions far
a manner that laser vaporization cannot be performed lateral to the vibratory margin. However, regardless of
safely, delicate resection of the vessel with preservation location, the importance of avoiding trauma to adjacent
of adjacent mucosa has proven successful in the author’s tissues cannot be overstated.
hands1 (Figs 16.3A to C). This approach is similar to More recently, lasers with a specific affinity for blood
that used for symptomatic varicose vessels elsewhere in vessels have offered useful options in selected cases.
the body, and its technique and results were reviewed by Pulsed dye lasers and pulsed KTP lasers were discussed
Hochman, Sataloff, Hillman, et al. in 1999.1 Thirty-four previously (Chapter 10). They may be used in the operat-
of the 42 patients reported were females, 84% of the ing room or through a flexible laryngoscope in the office.
patients with documented hemorrhages were females, and They are appropriate for treatment of varicosities and
39 of 42 patients were singers. Most ectasias and varices ectasias.
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Varicosities, Ectatic Vessels and Vocal Fold Hemorrhage
Chapter
16
A B
Figs 16.3A to C: Ectasia. (A) This figure illustrates the technique

for elevating and resecting a varicose vessel. A superficial incision
is made in the epithelium adjacent to the vessel using the sharp 87
point of the vascular knife or using a microknife (illustrated).
(B) The 1 mm right angle vascular knife is inserted under the
vessel and used to elevate it. It may be necessary to make more
than one epithelial incision in order to dissect the desired length
of the vessel. (C) Once the pathologic vessel has been elevated, it
is retracted gently to provide access to its anterior and posterior
limits. These can be divided sharply with a pair of scissors or
knife (bleeding stops spontaneously) or divided and cauterized with
a laser, as long as there is no thermal injury to adjacent vocal
ligament. Reproduced from Sataloff RT. Professional Voice: The
C Publishing, Inc.;2005: Fig. 82.23, with permission
SURGICAL TECHNIQUES Step 3

A lateral superficial epithelial incision is made using a
Step 1 Sataloff Vascular Knife directly adjacent to the vessel (Fig.
Orotracheal intubation followed by suspension micro- 16.4C).
laryngoscopy is used to expose the glottis. A prominent
varix can be seen on the superior surface of the right vocal Step 4
fold (Fig. 16.4A). Preoperative stroboscopic examination The vascular knife is rotated 90°. The vessel rests on the
should be reviewed, as the soft tissue distraction of the superior surface of the vascular knife. The vessel is iso-
larynx during suspension may distort vascular lesions. lated by piercing the epithelium on the medial side of
the vessel (Fig. 16.4D).
Step 2
A 70° endoscope is used to better appreciate the nature Step 5
of the vessel. In this case, the varix is seen overlying a The isolated vessel rests in the crook of the vascular
fibrous mass (Fig. 16.4B). knife. Using a gentle, steady force, the knife is advanced
Ch-16.indd 87 9/8/2010 3:06:22 Gopal

Section
A B
88
C D
Figs 16.4A to D: (A) A prominent, tortuous varix is seen on the superior surface of the vocal fold. (B) Using a 70° endoscope the
vessel is seen overlying a fibrous mass. (C) The sharp pointed end of the Sataloff Vascular Knife is used to incise the epithelium just
lateral to the vessel. (D) The knife is rotated at 90° and pierced through the epithelium on the medial side of the vessel. The vessel
rests on the blunt, non-cutting surface of the knife. Blanching of the vessel may occur from compression of the varix
posteriorly (Fig. 16.4E). Blanching of the vessel may Step 7

occur.
Any bleeding arising from the microvasculature of the
Step 6 vocal fold supplying the cut epithelium or varix stops
Once the abnormal limit of the vessel is reached, it spontaneously or is controlled by placing a cotton pledget
may be resected. A microscissor is used to cut the ves- with epinephrine on the surgical field and applying gentle
sel at this location posteriorly (Fig. 16.4F). The varix pressure. Alternatively, a brief laser pulse may be used. A
is gently grasped with a Sataloff Alligator Forcep and deep extubation is performed. As the varix rests on the
gently stabilized medially with minimal retraction. It is superior surface of the vocal fold, the patient is placed
then transected using a curved microscissor. The tech- on absolute voice rest for only 1-3 days to minimizing
nique is then repeated at the anterior limit of the varix trauma to the cut vessel while its ends are sealing firmly
(Fig. 16.4G). Alternatively, the anterior limit may be (Figs 16.4H and I).
transected first.
Ch-16.indd 88 9/8/2010 3:06:23 Gopal

Varicosities, Ectatic Vessels and Vocal Fold Hemorrhage
Chapter
16
E F
89
G H
Figs 16.4E to I: (E) Blunt dissection of the vessel continues toward

the posterior glottis. (F) Laryngeal scissors are used to transect
the vessel at the posterior limit of the dissection. (G) The vessel
is gently stabilized with minimal medial retraction to expose the
anterior attachment, which is then transected. (H) The vessel has
been removed. Hemostasis will be achieved by placing a cotton
pledget bathed in epinepherine over the surgical site for 1 to 2
minutes. Alternatively, the laser may be used to seal the anterior
and posterior ends of the vessel. (I) A five-week postoperative rigid
I stroboscopic image shows a well-healed surgical site
Ch-16.indd 89 9/8/2010 3:06:24 Gopal

Section
REFERENCES 3. Feder RJ. Varix of the vocal cord in the professional voice
user. Otolaryngol Head Neck Surg 1983; 91:435-6.
1. Hochman I, Sataloff RT, Hillman, et al. Ectasias and 4. Sataloff RT, Hawkshaw MJ. Vocal fold hemorrhage. In:
varices of the vocal fold: Clearing the striking zone. Ann Sataloff RT. Professional Voice: The Science and Art
Otol Rhinol Laryngol 1999; 108(1):10-16. of Clinical Care, 3rd edition. San Diego, CA: Plural
2 2. Baker DC Jr. Laryngeal problems in singers. Laryngoscope. Publishing, Inc.; 2005. pp 1291-308.
1962; 72:902-8.
90
Ch-16.indd 90 9/8/2010 3:06:25 Gopal

Chapter
17 Reinke’s Edema
Reinke’s edema is characterized by mucoid, gelatinous Reinke’s edema is usually due to vocal paresis, commonly
fluid in the superficial layer of the lamina propria (Reinke’s involving the superior laryngeal nerve. The paresis may be
space), creating a typical floppy “elephant ear”, polypoid on the ipsilateral or contralateral side. Koufman has made
appearance of the vocal fold (Figs 17.1 to 17.5). It is also similar observations ( Jamie A Koufman, MD, Personal
known as polypoid degeneration, polypoid corditis and Communication, 2000) and has termed localized com-
edematous hypertrophy. It was named after Reinke who pensatory Reinke’s edema that develops in response to
described the compartment, now known as the superficial paresis a “paresis podule”.
layer of the lamina propria, while studying membranous If Reinke’s edema does not resolve after smoking has
edema of the larynx.1 Reinke’s space is defined anteriorly been discontinued and all irritants (including voice abuse)
by Broyles’ ligament, posteriorly by the arytenoid cartilage have been removed, it may be treated surgically. Extreme
and is superficial to the vocal ligament. Reinke’s edema care must be taken to be certain as the patient wants
is generally seen in adults. The condition is more com- voice quality restored to normal. Reinke’s edema is found
mon in women than in men.2 It has been associated with commonly in sports announcers, businesswomen, female
increased subglottic driving pressure in aerodynamic stud- trial attorneys and others who may like the low, masculine
ies by Zeitels et al.3 It has been suggested that patients vocal quality associated with this pathology. When this is
with mucosal irritation and muscle tension dysphonia are the case, and the appearance of the vocal folds does not
likely to develop Reinke’s edema due to aerodynamically suggest malignancy, close follow-up rather than surgery
induced unopposed distension of the lamina propria and is reasonable.
overlying epithelium. Although specific etiology is not When surgery is performed for Reinke’s edema, in the
yet proved, the condition is almost always associated with author’s (RTS) opinion, only one vocal fold should be oper-
smoking,4 voice abuse5 and/or other metabolic problems ated during a sitting in most cases, although this practice
such as hypothyroidism. Reinke’s edema is uncommon in remains controversial. The vocal fold may be incised along
classical professional singers, but it is seen more frequently its superior surface and the edematous material removed
among pop singers, radio and sports announcers, attor- with a fine suction (Fig. 17.6). Redundant mucosa may
neys and salespeople. The condition is usually bilateral, be trimmed and should be reapproximated. Care must
involves the entire membranous vocal fold and may be be exercised to avoid resecting too much mucosa. The
asymmetrical. Vibration is impaired bilaterally. The mass second vocal fold may be treated similarly after the first
of the cover is increased, but stiffness is decreased. It vocal fold has healed. However, the voice improvement
causes a low, gruff, husky voice. Unilateral Reinke’s edema that follows unilateral evacuation of Reinke’s edema is
deserves special attention. The laryngologist should always often surprisingly good, and patients frequently choose
seek an underlying cause. This condition has not been to leave the other vocal fold undisturbed. In addition
studied well, but it should be. The author (RTS) has to this, there is one more important reason for staging
seen malignancy present as unilateral Reinke’s edema. surgery for Reinke’s edema. Occasionally, surgical treat-
More commonly, it occurs secondary to other vocal fold ment for this condition results in a stiff, sometimes even
pathology. In some cases, the pathology is obvious, such adynamic, vocal fold even though this complication the-
as a contralateral lesion causing edema in the superfi- oretically should be rare with the technique advocated.
cial layer of lamina propria induced by vocal fold con- Nevertheless, it can occur even when surgery has been
tact. However, even more commonly, the pathology is performed well. If it occurs on one side and there is
more subtle. In the author’s (RTS) experience, unilateral still Reinke’s edema on the other side, the polypoid side
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Section
92
Fig. 17.1: Miscellaneous disorders of the larynx. Hyperkinesia of the false vocal folds is seen in hyperfunctional voice abuse. In its more
severe form, phonation may actually occur primarily with the false vocal folds. This condition is known as dysphonia plica ventricularis.
Contact ulcers occur in the posterior portion of the vocal folds, generally in the cartilaginous portion. Vocal fold nodules are smooth,
reasonably symmetrical benign masses at the junction of the anterior and middle-thirds of the vocal folds. Although Netter’s classic
drawing is labeled “vocal nodules”, the mass on the right appears hemorrhagic in origin. It may be a hemorrhagic cyst or fibrotic hematoma
from hemorrhage of one of the prominent blood vessels on the superior surface. The mass on the left has the typical appearance of a
reactive vocal nodule. The illustration of vocal nodules during phonation shows failure of glottic closure, anterior and posterior to the
masses. This is responsible for the breathiness heard in the voices of the patients with nodules. Polypoid degeneration, Reinke’s edema,
has a typical floppy “elephant ear” appearance. Juvenile papillomatosis is a viral disease. This disease and its treatment frequently
results in permanent disturbance of the voice. (From The larynx. In: Clinical Symposia. Summit, NJ: CIBA Pharmaceutical Company;
1964:16[3]: Plate VIII. Copyright 1964 Icon Learning Systems, LLC, a subsidiary of MediMedia USA, Inc. Reprinted with permission from
ICON Learning Systems, LLC, illustrated by Frank Netter, M.D. All rights reserved.) Reproduced from Sataloff RT. Professional Voice: The
Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 85.1, with permission
usually compensates. Voice quality is generally satisfac- before surgery is performed on the second vocal fold, this
tory and (most importantly) phonation is not effortful. situation can be avoided in nearly all cases.
If stiffness occurs bilaterally, the voice is not only hoarse
but also requires high phonation pressures. Patients are SURGICAL TECHNIQUES (FIGS 17.7A TO G)
unhappy not only with voice quality but also especially
with the fatigue that accompanies the increased effort
Step 1
required to initiate and sustain phonation. Under these
circumstances, they often feel that they are worse than General anesthesia is administered via orotracheal intuba-
they were with untreated Reinke’s edema. If surgery is tion and exposure of the larynx is obtained with suspen-
staged so that healing can be observed on one vocal fold sion microlaryngoscopy (Fig. 17.7B). We prefer to use a
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Reinke’s Edema
Chapter
17
93
Fig. 17.2: Congenital and inflammatory disorders. The erythema, edema and vascular congestion illustrated in the case of acute
laryngitis are typical of a moderate to severe infection. With vocal folds this inflamed, performance could be justified only under
the most extraordinary circumstances. The subglottic inflammation illustrated from a case of croup is similar to that seen in adults
with severe respiratory infections, which are difficult to control in short period of time, although in adult performers a lesser degree
of inflammation, swelling and airway compromise is usually present. The edematous vocal folds seen in chronic laryngitis have fluid
collections in Reinke’s space. Vocal folds with this appearance may be diagnosed as erythematous vocal folds, Reinke’s edema, polypoid
corditis or polypoid degeneration. In some cases the edema reverses when the chronic irritant is removed. The congenital web illustrated
is extensive. Smaller webs may occur congenitally or following trauma (including surgery). The illustration of laryngomalacia shows an
omega shaped epiglottis. This shape is common in normal larynges before puberty and may persist in some adults, making visualization
difficult. Membranous laryngitis is uncommon and severe, necessitating cancellation of performance commitments. (From The larynx.
In: Clinical Symposia. Summit, NJ: CIBA Pharmaceutical Company; 1964:16[3]: Plate VI. Copyright 1964 ICON Learning Systems, LLC,
a subsidiary of MediMedia USA, Inc. Reprinted with permission from ICON Learning Systems, LLC, illustrated by Frank Netter, M.D. All
rights reserved.) Reproduced from Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. San Diego, CA:
Plural Publishing, Inc.; 2005: Fig. 85.28, with permission
5.0 tube and avoid larger endotracheal tubes in virtually (Fig. 17.7C). The incision should be made large enough
all cases. We also frequently use jet ventilation for poste- to insert a 5- or 7- French suction cannula (Fig. 17.7D).
rior lesions, but it does not offer any significant advantage
for most patients with Reinke’s edema. Step 3
A 5- or 7- French suction cannula is placed into the inci-
Step 2 sion to evacuate the polypoid material in Reinke’s space.
Using a straight Sataloff Sharp Knife, an incision is Often, the material is of a thick, gelatinous consistency
made on the superior-lateral surface of the vocal fold not easily removed with suction. A cottonoid may be
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Section
Fig. 17.3: Typical appearance of Reinke’s edema, worse on the

right than on the left. The hypervascularity seen on the superior
surface of the right vocal fold is associated with chronic Reinke’s
edema routinely. This patient was a smoker and had muscle tension
dysphonia. Reproduced from Sataloff RT. Professional Voice: The Fig. 17.5: Typical appearance of Reinke’s edema. There is edema
in the superficial layer of the lamina propria. Note that the
lesion does not display degeneration, hypertrophy or inflammation
(Courtesy of Minoru Hirano, M.D.) Reproduced from Sataloff RT.
Professional Voice: The Science and Art of Clinical Care, 3rd
94 with permission
A B
Figs 17.4A and B: (A) Reinke’s edema can sometimes be severe enough to cause not only dysphonia but also stridor and occasionally
airway obstruction. Surprisingly, the patient whose vocal folds are pictured had a low, masculine voice (she is female), but denied
airway difficulties. (B) This videoprint shows typical, bilateral Reinke’s edema. This condition is most often seen in smokers, but it is
also often associated with reflux, voice abuse and sometimes hypothyroidism. Reproduced from Sataloff RT. Professional Voice: The
Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 85.30, with permission
Ch-17.indd 94 9/8/2010 3:06:36 Gopal

Reinke’s Edema
Chapter
17
A B
Fig. 17.7A: Preoperative rigid stroboscopic examination of the

larynx reveals bilateral Reinke’s edema. This is commonly called
polypoid corditis, although it is not an inflammatory lesion; and the
preferred term is Reinke’s edema. The edema is in the superficial
layer of the lamina propria or Reinke’s space
95
C D
Figs 17.6A to D: (A) Bulky vocal fold showing Reinke’s edema

(small dots) in the superficial layer of the lamina propria. (B)
Incision in the superior surface opens easily into Reinke’s space.
(C) Using fine needle suction, the edema fluid is aspirated (arrows).
(D) The mucosal edges are reapproximated, trimming redundant
mucosa if necessary
grasped with a Sataloff, Bouchayer or Benninger Alligator

Fig. 17.7B: Suspension microlaryngoscopy is performed and the
Forcep and used to apply steady, gentle pressure to the larynx is visualized
medial surface of the vocal fold and directed laterally (Fig.
17.7E). This can deliver the material through the inci-
sion site. At times, it may be necessary to use a cupped necessary, redundant epithelium is resected away from the
microforcep to grasp and remove the polypoid material vibratory margin. It is the author’s preference (RTS) to
(Fig. 17.7F). perform only unilateral surgery. The side with the greater
amount of edema is generally addressed first. The second
Step 4 side can undergo surgery at a later stage, if the patient is
Evacuating the polypoid material from Reinke’s space still symptomatic and if there is no significant stiffness
restores patency to the glottic airway (Fig. 17.7G). If from the first resection. A deep extubation is performed
Ch-17.indd 95 9/8/2010 3:06:36 Gopal

Section
C D
96
E F
Figs 17.7C to G: (C) An incision is made using the straight Sataloff

Sharp Knife on the superior lateral surface of the vocal fold. The
incision goes through the epithelium and into the superficial
lamina propria without disturbing the deeper vocal ligament. (D) A
5- or 7- French suction cannula is placed through the incision
and the contents of Reinke’s space are evacuated. However, the
polypoid material is often a thick, gelatinous consistency and is
not easily removed with suction. (E) The gelatinous material filling
Reinke’s space may be expressed through the incision by grasping
a cottonoid with a Sataloff Alligator Forcep and applying firm but
delicate pressure to the vocal fold. (F) Often, the thick consistency
of the edematous material in the superficial lamina propria may
require removal using a micro-cupped forcep. (G) Significant
glottic patency is achieved once the edematous collection has
been removed from Reinke’s space. Very little epithelium should
G be trimmed from the superior surface, if any
Ch-17.indd 96 9/8/2010 3:06:37 Gopal

Reinke’s Edema
Chapter
and the patient is placed on a short duration of strict 2. Fritzell B, Hertegard S. A retrospective study of treatment
voice rest, usually for three days. of vocal fold edema: A preliminary report. In: Kirchner
JA, (Ed): Vocal Fold Histopathology: A Symposium. San
Diego, CA: College-Hill Press; 1986. pp. 57-64.
REFERENCES 3. Zeitels SM, Hillman RE, Bunting GW, et al. Reinke’s
edema: phonatory mechanisms and management strategies. 17
1. Reinke F. Uber die funktionelle Struktur der menschlichen
Ann Otol Rhinol Laryngol 1997; 106:533-43.
Stimmlippe mit besonderer berucksichtigung des elas-
4. Myerson MC. Smoker’s larynx. A clinical pathological
tischen Gewebes [About the functional structure of the entity. Ann Otol Rhinol Laryngol 1940; 31:925-9.
human vocal cord with special reference to the elastic tis- 5. Putney FJ, Clerf LH. Treatment of chronic hypertrophic
sue]. Anat Hefte 1897; 9:103-17. laryngitis. Arch Otolaryngol 1940; 31:925-9.
97
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Chapter
Granulomas and
18 Vocal Process Ulcers
Granulomas usually occur on the posterior aspect of the insufficient to permit adequate healing, some of these
vocal folds, often in or above the cartilaginous portion uncommon and difficult patient problems can be solved
(Figs 18.1 to 18.8). Granulomas may be unilateral. They by chemical tenotomy using Botulinum toxin. Although
occur commonly on the medial surface of the arytenoids most other laryngologists have injected Botulinum toxin
cartilage mucosa. Histopathological evaluation reveals into the thyroarytenoid (TA) muscle, this author treats
fibroblasts, collagenous fibers, proliferated capillaries, leu- the lateral cricoarytenoid (LCA) muscle in most cases. If
kocysts and, sometimes, ulceration. Thus, they are actually patients with multiple recurrent granulomas are observed
chronic inflammatory tissue, not true granulomas such closely using frame-by-frame analysis of strobovideo-
as those seen in tuberculosis or sarcoidosis. Granulomas laryngoscopic images, or using high-speed video, many
and ulcers in the region of the vocal processes have tra- will make initial contact during adduction near the point
ditionally been associated with trauma, especially intuba- of the vocal process, closing the rest of the posterior glot-
tion injury. However, they are seen also in young, appar- tis slightly later or discussed below. Weakening the LCA
ently healthy professional voice users with no history of with Botulinum toxin prevents this forceful point contact
intubation or obvious laryngeal injury. Previous teachings and allows resolution of the granulomas.
have held that the lesion should be treated surgically, but Prior to surgical excision, causative and contributing
that the incidence of recurrence is high. In fact, the vast factors should be addressed. Reflux should be treated,
majority of granulomas and ulcerations (probably even and voice therapy instituted. If the lesions do not resolve
those from intubation) are aggravated or caused by acid within a few weeks, excision should be considered. The
reflux, and voice abuse and misuse are associated com- laser may be helpful in removing these lesions because
monly. Ylitalo has published an extensive review of granu- they are generally not on the vibratory margin. Therefore,
loma, including its relationship to reflux.1 In our experi- scarring is unlikely to cause hoarseness. In addition, they
ence, when the reflux is controlled and voice therapy is are often friable, and laser excision helps minimize bleed-
begun, the lesions usually resolve within a few weeks. If ing. However, although lasers are convenient in control-
they do not, they should be removed for biopsy to rule ling hemorrhage in vocal fold granuloma surgery, it must
out other possible causes. So long as a good specimen is be remembered that we are treating a nonhealing area.
obtained, the laser may be used in this surgery. However, Like other thermal injury, laser burns cause substantial
the author (RTS) usually uses cold instruments, wishing tissue damage. Any surgeon who has accidentally struck
to avoid the third degree burn caused by the laser in the his or her finger with a laser beam knows that the effect
treatment of this condition. is more traumatic than a sharp cut of similar size with a
Occasionally, patients present with multiply recur- knife. Consequently, to minimize tissue trauma and pro-
rent granulomas which may present even after excel- mote healing, this author prefers to minimize or avoid
lent reflux control (including fundoplication), surgical laser use at the base of these lesions. The underlying
removal including steroid injection into the base of the perichondrium should not be traumatized. In all cases, a
granulomas and voice therapy. Medical causes other than generous specimen should be removed for biopsy to rule
reflux and muscle tension dysphonia must be ruled out, out carcinoma, granular cell tumors and other possible
particularly granulomatous diseases including sarcoido- etiologies.
sis and tuberculosis. When it has been established that In patients with recurrent granulomas, Botulinum
the recurrent lesions are typical granulomas occurring toxin injection may be considered. This can be performed
in the absence of laryngopharyngeal reflux, the cause is as an outpatient or during surgical resection of granulomas
almost always phonatory trauma. When voice therapy is in the operating room. In general, only a small amount
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Granulomas and Vocal Process Ulcers
Chapter
18
99
Fig. 18.1: Miscellaneous disorders of the larynx. An isolated papilloma such as that illustrated in the top left usually has less grave
implications than the papillomatosis illustrated in Figure 17.1. Nevertheless, careful removal with a laser is appropriate. The broad-
based sessile polyp illustrated has typically prominent vascularity at its base and along the superior surface of the vocal fold. The
contact granulomas illustrated are considerably larger than those shown in Figure 17.1. Even granulomas of this size sometimes resolve
with antireflux therapy and low-dose steroids, although more often excision is required. Subglottic lesions such as the polyp illustrated
usually can safely be removed without adverse effect on the voice. Potentially malignant or premaligant lesions are discussed elsewhere
in this book (From The Larynx. In: Clinical Symposia. Summit, NJ: CIBA Pharmaceutical Company; 1964:16[3]: Plate IX. Copyright 1964
Icon Learning Systems, LLC, a subsidiary of MediMedia USA, Inc. Reprinted with permission from ICON Learning Systems, LLC, illustrated
by Frank Netter, MD. All rights reserved.) Reproduced from Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd
edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 85.20, with permission
of Botulinum toxin is required, and it is best to place only 2.5 mouse units of Botox (Allergan, Irvine, CA) or
it in the lateral cricoarytenoid muscle (LCA) for recur- the equivalent, as discussed elsewhere.2
rent granulomas near the vocal process. In these patients,
there appears to be dominance of LCA activity during SURGICAL TECHNIQUES
the adduction process, causing point-contact near the tip
of the vocal process rather than the broader contact that The surgical techniques for the resection of a vocal fold
results from a different balance of activity between the granuloma are described in Figures 18.9A to L.
lateral cricoarytenoid and interarytenoid muscles, as noted
initially by Zeitels (Steven Zeitels, MD, personal com- Step 1
munication, 1997) and confirmed by this author’s (RTS) Orotracheal intubation is followed by suspension micro-
experience. Both LCA muscles are injected usually with laryngoscopy to expose the larynx (Fig. 18.9D). If
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Section
A B
Figs 18.2A and B: (A) This videoprint shows a large right vocal process granuloma (straight arrows), bilateral prenodular swellings
(curved arrows) and marked diffuse erythema of both regions consistent with gastroesophageal reflux laryngitis (From ENT J, 1994; 73[7],
with permission). (B) Typical appearance of a laryngeal granuloma composed primarily of fibroblasts, proliferated capillaries, collagenous
fibers and leukocysts. An epithelial covering may or may not be present. Reproduced from Sataloff RT. Professional Voice: The Science
and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 85.21, with permission
100
A B
Figs 18.3A and B: (A) During gentle inspiration, a large right pyogenic granuloma fills the posterior glottis (solid white arrow) of
this 42-year-old executive. The mass is based on a stalk attached to the base of the right vocal process. There are varicosities on the
superior surfaces of both folds (black arrows), including a vessel that crosses toward the vibratory margin into a small cyst (curved
white arrow) on the right. (B) On expiration, the small cyst (curved white arrow) and its associated vessels are seen more easily. There
are also contact swellings more anteriorly on the right (white arrowhead) and two left vocal fold cysts (black arrowheads). During
exhalation, the large pyogenic granuloma is displaced superiorly out of the posterior glottis. The severe erythema of the posterior
portion of the larynx is due to reflux. The pyogenic granuloma and cysts were excised. The granuloma recurred despite voice therapy
and reflux control. Botulinum toxin was injected at the time of repeat excision, and he had no recurrence in the subsequent 14 years.
Reproduced from Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing,
Ch-18.indd 100 9/8/2010 3:06:53 Gopal

Chapter
18
Fig. 18.4: Videoprint from a 45-year-old male with recurrent Fig. 18.6: Although granulomas typically occur near the vocal
laryngospasm. He had undergone tracheotomy prior to referral process and medial surface of the arytenoid, they may be seen
to the author (RTS). Strobovideolaryngoscopy revealed bilateral elsewhere. This videoprint reveals a granuloma arising from the
laryngeal granulomas (curved arrows). A Montgomery T tube right vocal false vocal fold and ventricle in an area of previous
(white arrow) was visible in the subglottic area. He also had trauma. There is also a varicosity anteriorly along the right vocal
marked erythema of his arytenoids (straight arrows) and posterior fold, as well as a small anterior web. Reproduced from Sataloff.
laryngeal mucosa consistent with reflux laryngitis. The reflux RT. Professional Voice: The Science and Art of Clinical Care, 3rd
was confirmed by a 24-hour pH monitor. Vigorous therapy was edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 85.25,
instituted. The laryngospasm, cough and other reflux symptoms with permission
stopped. The granulomas resolved spontaneously, and the patient
was decannulated. He has had no difficulty in the subsequent 7 101
years (From ENT J, 1995; 74[10], with permission). Reproduced
Fig. 18.7: Granulomas also can occur in the musculomembranous

portion of the vocal fold, although this is relatively uncommon.
Fig. 18.5: Typical appearance of a laryngeal granuloma occurring This large right granuloma occurred following removal of a mass
near the region of the medial surface of the arytenoid above the from the right vocal fold. Excision of the granuloma was required.
level of the glottis. Reproduced from Sataloff RT. Professional Reproduced from Sataloff RT. Professional Voice: The Science and
Voice: The Science and Art of Clinical Care, 3rd edition. San Diego, Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing,
CA: Plural Publishing, Inc.; 2005: Fig. 85.24, with permission Inc.; 2005: Fig. 85.26, with permission
Ch-18.indd 101 9/8/2010 3:06:54 Gopal

Section
Step 3
Subepithelial infusion with a saline and 1:10,000 epine-
phrine mixture causes distention of the subepithe-
lial tissues and vasoconstriction of its microvasculature
2 (Fig. 18.9E). This also serves to better deliniate the border
between the granuloma and the underlying uninvolved
tissue, commonly perichondrium (which should not be
violated, whenever possible). Care should be taken not
to over-inject, in order to avoid distorting the margins
of the lesion.
Step 4
A superficial incision is made at the superior border of
the granuloma using a straight Sataloff Sharp Knife (Fig.
18.9F). The incision is placed at the junction of normal
and abnormal tissue, in order to avoid traumatizing any
Fig. 18.8: Granulomas may be latrogenic. This videoprint shows uninvolved portion of the vocal fold.
a right Teflon granuloma that occurred in a 52-year-old male.
He had right recurrent laryngeal nerve paresis. After reviewing
all surgical options, he elected Teflon injection in 1988. He was
Step 5
the last patient for whom the author (RTS) utilized Teflon. His A Sataloff Right Angle (or oblique) Ball Dissector is
voice improved and stayed satisfactory for 2 years. Thereafter, used to identify and dissect along a plane between the
he developed a Teflon granuloma. It was excised with a CO2 laser
resulting in satisfactory voice. However, he has had recurrent true vocal fold and the granuloma (Fig. 18.9G). Given
Teflon granulomas, requiring surgical re-excision six times over the inflammatory nature and resulting fibrosis that may
102 the ensuing 12 years. Teflon granuloma development even long
after successful injection is one of the problems that led to the
develop in this disease process, a combination of blunt
and sharp dissection with microlaryngeal scissors may be
abandonment of this procedure for vocal fold medialization in the
late 1980s. Reproduced from Sataloff RT. Professional Voice: The necessary.
Publishing, Inc.; 2005: Fig. 85.27 with permission Step 6
The granuloma is stabilized using a Sataloff (or Bauchayer
endotracheal intubation is used, it is performed routinely or Benninger) Heart Shaped Grasper. A microlaryn-
using a 5.0 mm endotracheal tube, but nothing larger geal scissors is used to free the granuloma off the vocal
than 5.5 mm. For posterior lesions such as granulomas, jet fold from any remaining fibrous tissue attachments
ventilation is often preferable. Supraglottic or subglotttic (Fig. 18.9H).
placement of the jet ventilation catheter can be used. We
prefer subglottic placement. In some cases, the catheter Step 7
can be placed prior to positioning the laryngoscope and A small granuloma is resected in a similar manner. After
will stay out of the way posteriorly. In others, even that performing Steps 1 to 4, microlaryngeal scissors are
technique may impair visualization of the lesion. In such placed into the incision with the tynes closed. The scis-
instances, the ventilation catheter can be placed through sors are pulled slightly medially putting gentle pressure
the laryngoscope and intermittent ventilation can be on the granuloma and avoiding pressure on the unin-
used. The catheter is removed intermittently and surgery volved tissue. The tynes are then spread open to define
is performed while the patient is apneic. When oxygen the plane between the granuloma and the underlying
saturation drops, the catheter is replaced. perichondrium.
Step 2 Step 8
0º and 70º endoscopes are used to better visualize the At times, it is necessary to free the epithelium at the
borders of the granuloma (Figs 18.9B and C). anterior and posterior limits of dissection using a
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Chapter
18
A B
103
C D
Figs 18.9A to E: (A) Strobovideolaryngoscopy reveals a large,

sessile granuloma involving the left true vocal fold. The granuloma
is primarily above the left true vocal fold along the medial surface
of mucosa overlying the arytenoid cartilage. It extends onto the
left true vocal fold, however. A smaller granuloma is seen above
the right vocal fold, originating and extending just beyond that
anterior border of the vocal process. (B) An endoscopic view of
the granuloma using a 0° endoscope. (C) A 70o endoscope is used
to visualize the lesion. The anatomy of the lesion allowed for
a better view of the granuloma from the anterior commissure
looking posteriorly. (D) Suspension microlaryngoscopy is used to
visualize the granulomas. (E) A subepithelial infusion with saline
E and 1:10,000 epinepherine is performed
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Section
F G
104
H I
Figs 18.9F to J: (F) An incision is made at the base of the

granuloma, at the junction of normal and abnormal tissue using a
straight Sataloff Sharp Knife. The length of the incision should not
be longer than the boundaries of the granuloma to avoid disturbing
uninvolved tissue. (G) A Sataloff Right Angle Ball Dissector is used
to identify and dissect along a plane between the underlying
uninvolved tissue and perichondrium and the granuloma. The
granuloma extended to the posterior aspect of the true vocal
fold. The dissection was more difficult in this case because of
three previous resections by other surgeons. (H) The granuloma is
stabilized using a Sataloff Heart Shaped Grasper. A curved micro-
laryngeal scissors is used to free the granuloma from the soft tissue
attachments to the vocal fold. (I) A small granuloma above the
right vocal fold is seen better after an apposing, larger granuloma
has been removed. (J) A subepithelial infusion with saline and
J 1:10,000 epinepherine is performed
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Chapter
18
K L
Figs 18.9K and L: (K) A Sataloff Heart Shaped Grasper is used to stabilize the granuloma. A straight scissor was used for blunt and
sharp dissection to separate the lesion from uninvolved deeper tissues (not shown). A curved microlaryngeal scissor is used to transect
the granuloma off the vocal fold. (L) A suspension microlaryngoscopy view of the vocal folds after the removal of bilateral vocal fold
granulomas
Step 9
microlaryngeal scissors. This step prevents accidental A deep extubation is performed and the patient is awak-
“stripping” beyond the intended resection limits. Using
a Sataloff Heart Shaped Grasper, the granuloma is
ened with mask ventilation. The patient is placed on strict
voice rest until re-examination in approximately seven
105
grasped and stabilized medially (Fig. 18.9K). Dissection days.
then continues along the plane between the base of the
granuloma and the underlying uninvolved tissue until it REFERENCES
is removed using a microlaryngeal scissors (Fig. 18.9L).
It is recommended to perform a bilateral botulinum 1. Ylitalo R. Clinical studies of contact granuloma in poste-
toxin injection into the belly of the lateral cricoaryte- rior laryngitis with special regard to esophagopharyngeal
reflux. Stockholm, Sweden: Karolinska Institute; 2000.
noid muscle. It is advisable to perform a corticosteroid
2. Neuenschwander MC, Pribitkin EA, Sataloff RT. Botulinum
injection into the base of the resected granuloma, as this toxin in otolaryngology. In: Sataloff RT. Professional Voice:
may help decrease localized inflammation and granuloma The Science and Art of Clinical Care, 3rd edition. 2005;
recurrence. pp. 933-44.
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Chapter
19 Papilloma
Laryngeal papillomatosis has been recognized as a problem used effectively in recurrent cases, as well7 (Fig. 19.1).
for more than a century. In 1861, papilloma was described An incision is made on the superior surface of the vocal
by Czermak.1 It was also illustrated by Mackenzie, Türck fold with the laser, leaving a small margin of grossly
and Elsberg.2-4 Sixty-seven of Mackenzie’s first hundred normal tissue around the papilloma. A microflap is then
mirror-guided laryngeal procedures were for papillomatous elevated in the superficial layer of the lamina propria
lesions.5 Nevertheless, optimal treatment continues to elude under the papilloma. The flap and papilloma generally
us. Papilloma is discussed in greater detail elsewhere.6 are retracted medially, and anterior and posterior mar-
When papillomas interfere with voice quality or airway gin incisions are made with scissors or a laser. Contact
patency, surgery is the standard treatment. To minimize endoscopy may be helpful in determining the optimal
the risk of seeding the lower airway with virus, intubation incision site. The inferior margin can then be divided
must be accomplished under direct vision, with a small with the laser under direct vision and the mucosa, and
tube that does not traumatize the papillomas as it passes papillomas are resected en bloc. Although elevation of a
through the larynx. In general, the resection of laryngeal microflap does not ensure the preservation of good vocal
papilloma has been performed with a carbon dioxide laser quality (as discussed above), the odds of a good result
and this instrument offers great advantages. However, it are certainly better with this technique than they are
can also cause problems. When used, a smoke evaporator with indiscriminately “cooking” the vocal ligament. This
should be employed to avoid the risks of infecting the technique appears to produce acceptable voice results and
surgeon or other operating room personnel with viruses some apparent cures in patients who have gone five years
in the laser smoke. Only one side of the larynx should or more without recurrent papillomas. More research is
be operated on during a sitting; in many cases, multiple needed, but the author continues to use this approach
procedures are often necessary. and recommends its consideration. In cases of frequently
Early discouraging experience with recurrent juvenile recurrent papilloma in which only debulking is planned,
papillomatosis, and general agreement that laser surgery powered laryngeal instruments can be helpful and provide
is called for in papilloma, have led to a somewhat indeli- surprisingly good control of the limits of tissue removal
cate approach to laser surgery, in the author’s opinion. (Fig. 19.2).
For many surgeons, laser surgery for papilloma means The use of Cidofovir for laryngeal papillomatosis is
directly vaporizing all the areas of papillomatous involve- promising. This antiviral agent can be injected directly
ment on one vocal fold; this invariably means injury to into the papillomatosis lesions, and some patients respond
underlying tissues. This produces permanent dysphonia dramatically. The use of this substance was pioneered by
in many patients. Moreover, recurrences tend to involve Wellens.8 Although Cidofovir is approved by the United
deeper structures (vocal ligament and muscle) that were States Food and Drug Administration (FDA) for other
not involved initially. uses, laryngeal injection is an off-label use. The medica-
Anecdotally, the author (RTS) believes that adult- tion may have serious side effects, but they are not likely
onset laryngeal papilloma may behave differently from to occur in the doses used commonly for laryngeal sur-
the virulent, juvenile papillomatosis many of us are accus- gery. Concentrations recommended most commonly for
tomed to treating. Consequently, a method has been laryngeal use are in the range of 2.5 to 5 mg per ml, but
employed to attempt cure or at least long-term control, higher concentrations in the range of 15 mg per ml have
rather than simply palliation and to preserve underlying been used frequently without apparent adverse effect. In a
structures. The method works best when the papillomas few cases, concentrations as high as 75 mg per ml have
have not been operated on previously, but it has been been used without any adverse consequences; but there
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Papilloma
Chapter
19
A
A
107
Figs 19.2A and B: (A) Papilloma is debulked with a 3.5 or

4.0 mm angle-tip laryngeal blade at 5,000 rpm, (B) Final removal is
performed with limited trauma to the mucosa and underlying tissues
using a 3.5 mm angle-tip laryngeal skimmer blade at 500 rpm.
(Courtesy: Xomed-Medtronic, Jacksonville, FL). Reproduced from
Sataloff RT. Professional Voice: The Science and Art of Clinical
are questions about long-term effect, including onco-

genicity. So, patients need to be informed fully, and this
antiviral material should be used with caution in adults
and children.
C
Figs 19.1A to C: (A) An incision is made around the area of SURGICAL TECHNIQUES (FIGS 19.3A TO Z)
papilloma with a sharp knife, approaching it as one might approach
an area of carcinoma in situ. (B) A microflap is elevated bluntly,
sparing the underlying superficial layer of lamina propria. (C) The Step 1
region of papilloma is resected. (Courtesy: Medtronic-Xomed,
Jacksonville, FL). Reproduced from Sataloff RT. Professional Voice:
General anesthesia is administered through orotracheal
The Science and Art of Clinical Care, 3rd edition. San Diego, CA: intubation using the smallest possible endotracheal tube,
Plural Publishing, Inc.; 2005: Fig. 82.25, with permission but no larger than a 5.0. We prefer to have a tube in
Ch-19.indd 107 9/9/2010 2:35:54 Gopal

Section
place protecting the airway rather than use jet ventilation

for large bulky lesions. We avoid supraglottic jet ventila-
tion in particular to prevent bronchial implantation of
papilloma. Suspension microlaryngoscopy is performed to
2 expose the glottis (Fig. 19.3L).
Step 2
Telescopes may be used to visualize the lesions better
(Figs 19.3A, B, C, M, W and X).
Step 3
Cidofovir, usually 15 mg/ml, is injected in the subepithe-
lial plane. This can help in delivering the lesions at the
edge of the visual field (Figs 19.3D, N and Y). Much
of this Cidofovir is lost during the dissection and int-
A
ralesional injection into residual tissue may be required
at the end of the case. However, it seems possible that
conservative hydrodissection with Cidofovir may provide
extra protection against papilloma implantation, as com-
pared with hydrodissection with saline.
Note: Using Cidofovir for hydrodissection is some-
what controversial. While the hydrodissection could be
performed with saline and adrenaline 1:10,000, it seems
108 possible that Cidofovir may help prevent growth of recur-
rent papilloma at the base of a lesion. In addition, it is
often possible to get better infiltration into the tissue
adjacent to the base of the lesion prior to making an
incision. Some of the Cidofovir volume is lost through
resection.
Step 4
B
There are a variety of methods that can be employed in
resecting papilloma. When the lesions are away from the Figs 19.3A and B: (A) Preoperative stroboscopic image of the
vocal folds in the adducted position. (B) Preoperative stroboscopic
true vocal folds, particularly the vibratory margin, it is safe
image of the vocal folds in the abducted position shows involvement
to use powered microinstruments (Fig. 19.3E). of the anterior and posterior glottis and supraglottis
Step 5
Often times, it may be necessary to reposition the laryn- Step 8
goscope to gain better exposure (Fig. 19.3F). Straight microlaryngeal scissors are placed inside the
incision with the tynes closed. The scissors are pulled
Step 6 gently medially and the tynes gently spread open, creat-
As the resection approaches the true vocal fold, Sataloff ing a plane of dissection between the papilloma and the
Heart-shaped Graspers, Sataloff Curved Alligator Forceps underlying superficial lamina propria or vocal ligament
and microlaryngeal scissors are preferred over powered (Fig. 19.3P), creating a mini microflap.
instrumentation (Figs 19.3G, H, I and K).
Step 9
Step 7 If necessary, the plane of dissection is developed further
For smaller lesions, a straight Sataloff Sharp Knife is used using a Sataloff Oblique Blunt Ball Dissector (Fig. 19.3Z)
to make an incision at the lateral border, at the junction or a Sataloff Spatula (straight or curved). The instru-
between normal and abnormal tissue (Fig. 19.3O). ment is placed into the incision and is used to bluntly
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Papilloma
Chapter
19
C D
109
E F
Figs 19.3C to G: (C) Endoscopic view of the papilloma.

(D) Submucosal injection of Cidofovir aids in delivering deeper
lesions. (E) A powered laryngeal shaver is used to resect gross
lesions. (F) Readjusting the laryngoscope is often necessary to
obtain the exposure of other laryngeal subsites harboring lesions.
(G) Papillomatous lesions may be grasped gently with a Sataloff
G Heart-shaped Grasper
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Section
H I
110
J K
Figs 19.3H to L: (H) Sharp dissection is an alternative to using

powered instruments. (I) The friability of laryngeal papilloma
necessitates delicate retraction. (J) Cidofovir is injected superficially
in all areas that evidenced papillomatous changes. (K) Removal of
the lesions restores patency of the airway. (L) Endoscopic view of
L another papilloma
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Papilloma
Chapter
19
M N
111
O P
Figs 19.3M to Q: (M) A view using a 70o endoscope allows better

visualization of the dimensions of the papilloma. (N) Submucosal
injection of Cidofovir aids in hydrodissecting the papilloma off the
vocal ligament and in delivering the borders of the lesion. (O) An
incision is made using a straight Sataloff Sharp Knife, at the border
of normal and abnormal epithelium. (P) Straight microscissors
are used to spread inside the incision, developing a plane for a
microflap between the lesion and the underlying vocal ligament.
(Q) A Sataloff Oblique Ball Dissector is used to further define the
Q plane of dissection
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Section
R S
112
T U
Figs 19.3R to V: (R) Straight microlaryngeal scissors are used to

make an incision at the posterior limit of the resection. (S) An
incision is made at the anterior limit of the resection. Only one
tyne of the straight microscissor is placed inside the incision.
(T) The lesion is gently grasped with a Sataloff Heart-shaped
Grasper and sharply dissected using a curved microscissor. (U) The
papilloma is resected. The surrounding uninvolved epithelium and
vocal ligament have not been disturbed. (V) Additional Cidofovir
is injected into the surgical excision site and in a subepithelial
V plane in the sites of prior papilloma involvement
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Papilloma
Chapter
19
W X
113
Y Z
Figs 19.3W to Z: (W) Endoscopic view of laryngeal papillomatosis using a 0o endoscope. (X) A view using a 70o endoscope allows better
visualization of the dimensions of the papilloma, including extension into the laryngeal ventricle. (Y) A submucosal injection of Cidofovir
is performed. In addition to hydrodissecting the papilloma off the vocal ligament, this maneuver is used here to deliver the lateral
extent of the lesion into the surgical field. (Z) The plane of dissection is developed further using a Sataloff Oblique Blunt Ball Dissector
separate the papilloma from the underlying uninvolved normal and abnormal epithelium and defining the inci-
tissue, further developing the plane of dissection of the sion site. To facilitate this step, a fine Sataloff Heart-
microflap (Fig. 19.3Q). shaped Grasper may be used to grasp the mass and sta-
bilize it with minimal medial retraction before making
Step 10 the relaxing anterior and posterior incisions.
The posterior (Fig. 19.3R) and the anterior (Fig. 19.3S)
limits of the resection are incised using a straight micro- Step 11
scissor. One tyne is placed inside the incision; the outer The mass is grasped gently with a Sataloff Heart-shaped
tyne is rotated medially, tethering the boundary between Grasper and stabilized with minimal retraction toward
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Section
the midline. Sharp dissection of the mass with a curved 2. Mackenzie M. The Use of the Laryngoscope in Diseases
microscissor continues from a posterior to anterior direc- of the Throat with an Appendix on Rhinoscopy. London,
tion (Fig. 19.3T). England: J & A Churchill; 1865.
3. Turck L. Atlas zur Klinik der Kehlkopfkrankheiten. Wien,
2 Step 12 Austria: WIllhelm Braumuller; 1860.
4. Elsberg L. Laryngoscopal Surgery Illustrated in the
After the resection of all visible lesions (Fig. 19.3U), a
Treatment of Morbid Growths Within the Larynx.
subepithelial infusion of Cidofovir is performed (Figs Philadelphia, PA: Collins; 1866.
19.3J and V). The injection should be administered at 5. Mackenzie M. Growths in the Larynx. London, England:
all subsites from which papilloma was resected recently, J & A Churchill; 1871.
and in the case of repeat procedures, all sites that have 6. Friedman O, Sataloff RT. Laryngeal Papilloma. In: Sataloff
harbored active disease. RT. Professional Voice: The Science and Art of Clinical
Care, 3rd edition. San Diego, California: Plural Publishing,
Step 13 Inc.; 2005. pp. 835-44.
General anesthesia is reversed and the patient is extu- 7. Zeitels SM, Sataloff RT. Phonomicrosurgical resection of
bated. If lesions were resected from the vibratory margin, glottal papillomatosis. J Voice. 1999; 13:123-7.
strict voice rest is recommended for up to about 7 days. 8. Wellens W, Snoeck R, Desloovere C, et al. Treatment of
severe laryngeal papillomatosis with intralesional injections
of Cidofovir® [(S)-1-(3-Hydroxy-Phosphonylmethoxy-
REFERENCES
propyl) Cytosine, HPMPC Vistide®] Transactions of the
1. Czermak JN. On the laryngoscope and its employment in XVI World Congress of Otorhinolaryngology – Head and
physiology and medicine. N Sydenham Soc. 1861; 11:1-79. Neck Surger. Sydney, Australia; 1997. pp. 2-7.
114
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Chapter
20 Supraglottoplasty
The otolaryngologist is often called upon urgently to diag- airway symptoms resolved after endoscopic laser excision
nose and treat a patient having stridor. The leading cause of the excessive mucosa. As there have been no studies
of stridor in infants is laryngomalacia, accounting for examining the complications of CO2 laser versus cold
approximately 60 to 75% of congenital laryngeal anoma- knife supraglottoplasty, it is the author’s bias (RTS) to
lies.1 Jackson and Jackson first described laryngomalacia use laser vaporization to address redundant supraglottic
in 1942 as a disorder, in which supraglottic tissue collapses tissue. However, if a patient presents acutely with severe
onto the glottis upon inspiration.2 In infants, this may respiratory distress, a tracheotomy may be indicated as
cause acute respiratory distress, apneic events, pulmonary initial treatment.
hypertension and/or failure to thrive.3,4 Collapse of supra-
glottic tissue necessitating supraglottic laryngoplasty has SURGICAL TECHNIQUES
been described primarily in children with laryngomalacia.
In infants, this disorder usually resolves by age of 12 to 24
Step 1
months spontaneously.5 However, surgical intervention is
needed when the patient experiences apneic events, failure Preoperative flexible indirect laryngoscopic examination
to thrive or the development of pulmonary hypertension.6 reveals redundant supraglottic tissue with severe compro-
Adult patients with supraglottic airway collapse may mise of the laryngeal airway (Fig. 20.1A). A tracheotomy
also present with stridor and difficult breathing. Collapse had been performed previously on this adult patient.
of the supraglottic laryngeal structures can be observed by
using transnasal flexible laryngoscopy. Richter noted that
the findings include prolapse of the arytenoid cartilages,
supra-arytenoid mucosa and accessory cartilages during
inspiration.3 The false vocal folds and aryepiglottic folds
also may be involved. In addition, the problem usually
involves mucosa, not the arytenoid cartilages themselves.
Supraglottic airway collapse must be differentiated from
paradoxical vocal fold movement and vocal fold paralysis,
both of which may have the same presenting signs and
symptoms. In addition, any pulmonary disease with peri-
odic noisy breathing, dyspnea and secondary complaints
such as cough should be ruled out.4
Supraglottic mucosal redundancy in conjunction with
adult obstructive sleep apnea/hypopnea syndrome has
been described in very few case reports over the past
15 years.7, 8 For example, Rodriguez8 et al. describes a
case in which a 48-year-old woman with obstructive
sleep apnea and CPAP/Bi-PAP failure was noted to Fig. 20.1A: Flexible indirect examination of the larynx shows
have massive arytenoid mucosal hyperplasia and whose redundant supraglottic tissue causing airway compromise
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Section
B C
116
Figs 20.1B to D: (B) Suspension microlaryngoscopy is used to

expose the glottis. The prolapse of the redundant supraglottic
soft tissue obscures the airway. (C) The laryngoscope is used to
manipulate the soft tissues to reveal a glottic airway. (D) A saline-
soaked cotton pledget is placed into the glottis to protect the true
D vocal folds from injury by the laser
Step 2 a Digital AcuBlade may be used to complete this step

General anesthesia is administered via transtracheal intu- (Fig. 20.1E2) and if desired, proceed with tissue ablation.
bation, through the tracheotomy site. Suspension micro-
laryngoscopy is performed to expose the larynx (Figs Step 5
20.1B and C). The dissection then continues deep into the redundant
soft tissue (Fig. 20.1F). Often it is necessary to grasp the
Step 3 redundant tissue with a Sataloff Heart-shaped Grasper to
A cotton pledget soaked in saline is placed into the glottis retract and assist in debulking (Fig. 20.1G). Both sides
(Fig. 20.1D). This will serve to protect the vocal folds, of the larynx may be addressed (Fig. 20.1H) at the same
subglottis and trachea from any unintended thermal dam- sitting in selected patients.
age from the carbon dioxide laser.
Step 6
Step 4 When an adequate airway is observed, the general
An incision is made in the tissue using the carbon diox- anesthetic agent is reversed. Voice rest is not neces-
ide laser (Fig. 20.1E1). The boundaries of the planned sary, as the true vocal folds were not involved in the
surgical vaporization are first demarcated. Alternatively, procedure.
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Supraglottoplasty
Chapter
20
E1 E2
117
F G
Figs 20.1E and H: (E1) An incision is made using the carbon

dioxide laser on the superior surface of the false vocal fold. The
initial incisions are used to demarcate the planned surgical limits
of vaporization, (E2) A Digital AcuBlade may be used to make the
incision and perform tissue ablation. The multiple incision and
shaped cutting capabilities may be useful in achieving more precise
incisions. (F) Vaporization continues within the demarcated limits,
deep into the soft tissue. (G) A Sataloff Heart-shaped Grasper
is used to grasp the redundant supraglottic tissue and assist in
surgical debulking. (H) When necessary, bilateral tissue debulking
is performed. However, the anterior portions of both sides are
not operated upon simultaneously, in order to prevent supraglottic
H webbing
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Section
be visualized in the subglottis. The true vocal folds have

been preserved, avoiding simultaneous resection of tissue
adjacent to the anterior limit.
2 REFERENCES
1. Ahmad SM. Congenital anomalies of the larynx.
2. Jackson C, Jackson CL. Diseases and Injuries of the
Larynx. New York: Macmillan; 1942. pp. 63-9.
3. Richter SJ. The upper airway: Congenital malformations.
Paediatr Respir Rev. 2006; 7:260-3.
4. Onley DR, Greinwald JH, Smith RJH, et al. Laryngomalacia
and its treatment. Laryngoscope 1999; 109(11):1770-5.
5. Richter GT. The surgical management of laryngomalacia.
6. Christopher KL. Vocal cord dysfunction, paradoxic vocal
Fig. 20.1I: Postoperative flexible examination of the larynx shows fold motion, or laryngomalacia? Our understanding
a patent laryngeal airway. A small segment of a previously placed requires an interdisciplinary approach. Otolaryngol Clin
tracheostomy tube can be visualized in the subglottis North Am. 2010; 43(1):43-66.
7. Purser S, Irving L, Marty D. Redundant supraglot-
tic mucosa in association with obstructive sleep apnea.
Step 7 Laryngoscope. 1994; 104:114-6.
8. Rodriguez AF, Esteban, et al. Massive hyperplasia of the
A flexible indirect laryngeal examination postoperatively arytenoids mucosa with sleep apnea and stridor. Endoscopic
118 shows a patent laryngeal airway (Fig. 20.1I). A small
segment of a previously placed tracheotomy tube can
resection by CO2 laser. Acta Otorrinolaryngol Esp. 1999;
50(8):661-4.
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Chapter
21 Vocal Fold Scar

Vocal fold scar poses great therapeutic challenges especially has obliterated the layered structure and mucosal wave.
in the treatment of voice professionals. Unfortunately, A scar involving the posterior, subglottic and arytenoid
laryngologists are confronted frequently with patients regions may also be troublesome, but this discussion will
who have remained or become dysphonic after laryngeal be limited to scarring involving the membranous portion
surgery. Occasionally, a cause such as arytenoid dislo- of the vocal folds.
cation can be found and treated. More often, however, Reliable, valid, objective voice assessment is essential in
the problem is scar producing an adynamic segment, diagnosing vocal fold scar, as well as in the assessment of
decreased bulk of one vocal fold following “stripping”, other voice disorders. Accurate assessment of vibration is
bowing caused by superior laryngeal nerve paralysis, or critical, and strobovideolaryngoscopy is virtually indispen-
some other serious complication in a mobile vocal fold. sable to proper diagnosis and management of vocal fold
None of the available surgical procedures for these condi- scar.1,2 Integrity of the vibratory margin of the vocal fold
tions is consistently effective. If surgery is considered at all is essential for the complex motion required to produce
in such patients, it should be discussed pessimistically. The good vocal quality. Under continuous light, the vocal folds
patient should be aware that the chances of returning the vibrate approximately 250 times per second while phonat-
voice to normal or professional quality are slight, and that ing at middle C. Naturally, the human eye cannot discern
there is a chance of making it worse. However, advances necessary details during such rapid motion. Assessment
in the management of vocal fold scar have increased our of the vibratory margin may be performed through high-
therapeutic options. speed photography, strobovideolaryngoscopy, electroglot-
Symptomatic vocal fold scarring alters phonation by tography or photoglottography. Strobovideolaryngoscopy
interfering with glottic closure and the mucosal wave. provides the necessary clinical information in a practical
This may be due to the obliteration of the layered struc- fashion. For example, in a patient with a poor voice fol-
ture of the vibratory margin, as seen commonly after vocal lowing laryngeal surgery and a normal looking larynx,
fold stripping or, to a limited extent, after other vocal stroboscopic light reveals adynamic segments (scar) that
fold surgery or trauma. Similar disruption of the layered explains the problem even to an untrained observer (such
structure and mucosal wave function may also occur con- as the patient). In most instances, stroboscopy provides
genitally such as in some cases of sulcus vocalis. Scarring all of the clinical information necessary to assess vibra-
may also cause dysphonia by the mechanical restriction tion. However, objective voice analysis, particularly aero-
of vibration or glottic closure, as seen in some cases of dynamic and acoustic assessment, is extremely valuable
dense vocal fold web or fibrotic masses on the mem- for diagnosis, therapy and evaluation of treatment efficacy.
branous vocal fold, which may result due to vocal fold
hemorrhage. It is also necessary to distinguish raised scar THERAPY FOR VOCAL FOLD SCAR
that causes failure of glottic closure by mass effect from
the more common scar that effectively thins the vocal Therapy for vocal fold scar depends on the size, location
fold edge and causes failure of glottic closure by adher- and severity of the scar; the vocal needs of the individual
ing the epithelium to the vocal ligament or muscle. In patient, the patient’s motivation; and the skill of the voice
the former case, treatment must include resection of the team. In general, once the vibratory margin of the vocal
scar tissue mass in order to re-establish a straight vocal fold has been scarred (the layered structure obliterated),
fold edge. However, most of this chapter will discuss the it is not possible to return the voice to normal. However,
even more challenging problem of vocal fold scar that several options are available to improve the voice.
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Section
Voice therapy is essential for anyone interested in but the results are not consistently excellent. Pontes and
obtaining optimal results. Most patients do not use their Behlau have suggested a unique approach for the treat-
vocal mechanisms optimally. Consequently, even in the ment of sulcus vocalis that essentially involves multiple
presence of vocal fold scar, teaching the individual to releasing incisions.3 The voice results have been surpris-
2 make an effective use of the support and resonator systems ingly been good, considering the limited success achieved
generally improves vocal intensity and ease, and helps by previous procedures for this condition. These principles
diminish fatigue. Nearly, everyone with significant vocal have been applied to iatrogenic vocal fold scar and appear
fold injury develops compensatory behaviors in an effort to have some merit in severe, extensive scarring (P Pontes,
to decrease breathiness and hoarseness. These gestures are personal communication, April, 1995).
usually hyperfunctional, counterproductive and, in some The problem of glottic incompetence is generally
cases, they are dangerous. Such unconscious adjustments addressed through medialization surgery. Most mediali-
are seen even in the most skilled voice professionals after zation procedures in the past have involved injection of
sustaining a vocal fold injury and scar. Expert voice ther- Teflon. Because this substance can itself cause profound
apy eliminates this compensatory muscular tension dys- scarring, many otolaryngologists have abandoned its use
phonia, further decreasing fatigue and allowing a more in most cases since the mid to latter 1980s. At present,
accurate assessment of vibratory margin function. After the medialization techniques of choice are generally thy-
voice technique has been optimized and the vocal fold roplasty, or injection of a substance other than Teflon.
scar has matured (usually about 6–12 months), judgments For extensive failure of glottic closure, the author has
can be made about the acceptability of the final voice found Type I thyroplasty to be most effective. For limited
result. If voice function is not satisfactory to the patient, medialization, lateral injection of autologous fat (in the
then surgery may be considered. However, it is essential same place where Teflon used to be injected) has proven
for the laryngologist to be sure that the patient’s expec- successful.4 Approximately, 30 to 40% overinjection
tations are reasonable. These do not include restoration is necessary to account for resorption. Other injection
materials are discussed elsewhere.5 Techniques to man-
120 to normalcy. However, in some cases, it is possible to
decrease hoarseness and breathiness substantially. age vibratory margin scar are worthy of more complete
discussion.
SURGERY FOR VOCAL FOLD SCAR Collagen injection was investigated most extensively
by Ford and co-workers.6-8 Long-term results from skin
Vocal fold scar causes dysphonia by disrupting or oblit- injections of collagen have shown a reduction of scar
erating the mucosal wave and by interfering with glottic tissue in the treated areas. Collagen is a thin liquid that
closure. Clear understanding of these facts is necessary if can easily be injected in small quantities. Consequently,
one is to design rational surgical intervention. There is no collagen injections are ideally suited for small adynamic
generally accepted highly successful surgical treatment for segments. The ease and accuracy of injection allow for
vocal fold scar at present. However, numerous procedures attempts at augmentation in areas of scar, as well as for
have been tried, and some are useful in selected cases. managing difficult problems such as persistent posterior
Although there is very little information published on glottic incompetence and combined recurrent and supe-
older attempts at surgical procedures to correct vocal fold rior laryngeal nerve paralysis. Former concerns about
scar, anecdotally, many experienced voice surgeons admit the efficacy and safety of this material9 seem to be less
to having attempted surgery in very small numbers of warranted and experience using collagen has been most
patients. Procedures to restore the mucosal wave have encouraging. When used, collagen is injected into the
included injection of steroids into the vibratory margin, region of the vocal ligament and appears particularly
elevation of a microflap to “lyse adhesions”, followed by appropriate for treating limited vocal fold scarring. Such
simply replacing the microflap, elevation of a microflap cases are common, for example, after laser resection of
with the placement of steroids under the flap and other vocal nodules. Recent experience suggests that pulsed-
procedures. Although none of these procedures produces dye laser treatment also may reduce scar (Peak Woo,
consistently excellent results, they may help somewhat. Personal Communication, 2009). The author (RTS) has
Microflap elevation with steroids is sometimes help- had favorable preliminary results with this approach. For
ful and is still used by the author (RTS) and others more extensive scarring as may be seen following strip-
(M Bouchayer, personal communication, April, 1995), ping of an entire vocal fold, collagen appears less effective.
Ch-21.indd 120 9/9/2010 2:36:19 Gopal

Vocal Fold Scar
Chapter
However, since autologous and allogeneic human collagen tunnel with microinstruments has been attempted, but it
has come into use, results appear to have been better is technically difficult to pack the fat tightly and evenly,
than they were with allogeneic collagen, as discussed and this method appears to cause more trauma to the
elsewhere.5 access tunnel, flap and fat than delivering the implant
In 1995, the author (RTS) introduced a technique for through a Brünings syringe. At present, the fat glob- 21
autologous fat implantation into the vibratory margin of ules are loaded into the Brünings syringe, and the larg-
the vocal fold as a treatment for vocal fold scar.10 The est Brünings needle is used to deliver the fat into the
technique involves implantation into the vibratory mar- preformed vibratory margin pocket. Gross examination
gin, not injection. with a microscope indicates that passing the fat through
To recreate a mobile vibratory margin, a mucosal the Brünings syringe certainly elongates the fat globules
pocket is created and filled with fat in order to prevent and must traumatize them to some degree, but they
readherence of the mucosa to the vocal ligament and appear to be largely intact and not too badly traumatized.
vocalis muscle. An incision is made on the superior sur- At present, this seems to be the best available method,
face (Fig. 21.1A), and a small access tunnel is elevated although technical improvements are tested regularly. In
toward the vibratory margin. The superior incision is a recent review, Neuenschwander, Sataloff, Abaza, et al12
placed in a position that will permit angled instruments reported on the first eight patients who had undergone
to be passed through the tunnel to reach the anterior and vocal fold fat implantation for severe scar and dyspho-
posterior limits of the vocal fold scar. Although working nia. Their mean follow-up time was 23 months. Analysis
through a small access tunnel is technically more difficult of strobovideolaryngoscopy revealed statistically signifi-
than elevating a large flap, it is advantageous because it cant improvement in glottic closure, mucosal wave and
closes spontaneously upon removal of instruments and stiffness. In perceptual studies, there was statistically
prevents fat extrusion from the surgically created pocket. significant improvement in all five parameters of the
If a larger incision is made along the superior surface, GRBAS rating scale.13 All eight patients had undergone
sutures should necessarily be in order to prevent fat
extrusion, and even small sutures create additional tissue
more than one surgical procedure, including fat injection
in all eight, thyroplasty in one, scar excision in two, lysis
121
trauma.11 A pocket is created along the medial margin of adhesions in two and steroid injection in two. The
using a right-angle dissector and an angled knife or scis- senior author (RTS) continues to utilize this procedure.
sors, as needed (Fig. 21.1B). The pocket extends to the However, it should still be considered one among various
superior aspect of the vibratory margin and inferiorly for options for the treatment of dysphonia caused by vocal
at least 3-5 mm to encompass the entire medial surface fold scar.14
ordinarily involved in creating the mucosal wave vertical Occasionally, surgeons are faced with extreme cases of
phase difference during phonation. Fat harvested at the vibratory margin scar. These are especially common after
beginning of the surgery is then used to fill the tun- major trauma or extensive cancer surgery. When a non-
nel (Fig. 21.1C). Instruments are then withdrawn, and vibrating scarred vocal fold is lateralized so that glottic
the access tunnel closes and provides sufficient resistance closure is impossible, and when the involved hemilarynx
against fat extrusion (Fig. 21.1D). The procedure is per- is so densely scarred that the vocal fold cannot adequately
formed under general anesthesia. At the conclusion of the be medialized even with thyroplasty, occasionally more
procedure, the patient is asked to phonate briefly and to extensive surgery for vocal fold scar may be appropriate.
cough in order to be certain that the implant is secure. For example, some such cases may be improved through
Although no problems have occurred to date, if extrusion resection of the scarred hemilarynx and creation of a
occurred, fibrin glue would be tried or a suture would be pseudovocal fold using modifications of strap muscle
placed. techniques employed routinely cordectomy or vertical
Previous experience with lipoinjection has provided hemilaryngectomy.15 Certainly, this is an unusual and
convincing evidence that it is important to avoid extensive extreme approach for the treatment of vocal fold scar,
manipulation or trauma to the fat. The fat is harvested but it is an option that should be in the surgeon’s arma-
in large globules either by resecting a small amount of mentarium for the rare, appropriate patient.
fat (usually from the abdomen) with traditional instru- Familiarity with the latest concepts in vocal fold
ments or by harvesting it with the largest available lipo- anatomy and physiology is essential in understanding the
suction cannula. The fat is gently rinsed with saline, but consequences of vocal fold scar and optimizing results
it is not morselized. Packing the fat through the access of treatment.
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Section
A B
122
C D
Figs 21.1A to D: (A) A small incision is made on the superior surface of the scarred vocal fold, and a narrow access tunnel is
excavated to provide access to the medial edge. (B) Through the access tunnel, an angled instrument is used to elevate a pocket.
It is essential that the mucosa along the medial and inferior margins be kept intact. (C) A Brünings syringe with the largest needle
is passed through the tunnel and used to deposit fat in the pocket. (D) When the needle is removed, the small access tunnel closes
spontaneously, preventing extrusion of the fat. Fat should not extrude even when pressure is placed against the medial margin. If fat
extrusion occurs, a suture can be placed
Case 1: Scar Excision and Buccal Graft The scar is palpated to assess its extent and severity.
Placement Angled endoscopes may be used to better visualize the
scar.
Step 1
Exposure is obtained by administering general anesthesia Step 3
via orotracheal intubation followed by suspension laryn- Hydrodissection is performed by a subepithelial infusion
goscopy (Fig. 21.2A). with 1% lidocaine and 1:10,000 epinepherine (Fig. 21.2B).
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Vocal Fold Scar
Chapter
21
A B
123
C D
Figs 21.2A to D: (A) A depressed scar causing a nonvibrating segment of the vocal fold is visualized along the musculomembranous
portion of the right vocal fold. (B) Subepithelial infusion with 1% lidocaine and 1:10,000 epinephrine causes distention of the superficial
lamina propria and vasoconstriction of its microvasculature. The scared area remains adherent to the vocal ligament, and it can now
be seen extending nearly to the anterior commissure. (C) An incision is made at the lateral extent of the depressed scar. (D) Straight
microscissors are used to spread beneath the scar to create a minimicroflap. This releases the scar from the underlying vocal ligament
This allows for better exposure of the scar and has the the scar may involve the entire vocal ligament, and it
added benefit of causing vasoconstriction of the vocal may be necessary to remove a small portion of muscle.
fold microvasculature.
Step 6
Step 4 Using straight microscissors, the epithelium is incised at
A straight Sataloff Sharp Knife is used to make an inci- the anterior and posterior junctions of normal mucosa
sion at the superior-lateral junction of normal and abnor- and scar tissue (Figs 21.2E and F).
mal epithelium (Fig. 21.2C).
Step 7
Step 5 As more of the tissue deep to the scar is exposed, blunt
Straight microscissors are used to further dissect the scar dissection continues using a Sataloff Curved Spatula
from the underlying vocal ligament (Fig. 21.2D). At times (Fig. 21.2G).
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Section
E F
124
G H
Figs 21.2E to H: (E) An anterior mucosal incision is made using a straight microscissor. (F) A posterior mucosal incision is then made.
(G) Blunt dissection is performed with a Sataloff Curved Spatula to further separate the scar from the underlying vocal ligament. (H) The
scar is stabilized and resected using microscissors
Step 8 and epinephrine. An incision is made using a 15 blade

Once the scar has been elevated, it is firmly grasped through the mucosa and underlying fat (Fig. 21.2J). Fat
with a Sataloff Hear-shaped Grasper and stabilized is harvested with the composite graft (Fig. 21.2K) and
with minimal retraction (Fig. 21.2H). The epithelial acts as a replacement for the superficial lamina propria,
attachments to the vocal fold are transected using improving pliability.
microscissors.
Step 11
Step 9 The buccal mucosal graft site is closed primarily in an
The resultant defect is visualized clearly as being larger interrupted fashion using interrupted absorbable 3.0 cat-
than initial examination had revealed (Fig. 21.2I). gut sutures (Fig. 21.2L).
Step 10 Step 12
The buccal mucosa is prepared for harvest of the graft. The buccual mucosal graft is positioned in the larynx
The proposed graft site is infiltrated with xylocaine and is sutured in place with absorbable catgut sutures.
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Vocal Fold Scar
Chapter
21
I J
125
K L
Figs 21.2I to L: (I) The resulting defect in the right vocal fold involves nearly the entire length of the musculomembranous portion.
The anterior commisure is not involved. (J) An incision is made in the buccal mucosa with a scalpel. The incision is carried deep until
submucosal fat is seen. (K) Submucosal fat is harvested with the mucosa to complete the graft. The fat provides a filler to replace the
absent superficial lamina propria and will provide a platform for the overlying buccal mucosa to vibrate, recreating a mucosal wave.
(L) 3.0 chromic sutures are used to close the buccal incision
Case 2: Superficial Decadron Injection

Multiple sutures are used to hold the graft in optimal
position (Figs 21.2M and N). Step 1
Suspension laryngoscopy is used to visualize to the glottis
Step 13 (Fig. 21.2P).
After successful placement of the graft (Fig. 21.2O), the
patient is extubated deep. He is given oral antibiotics Step 2
(although there is no evidence confirming their efficacy) A 27-30 gauge needle is placed just deep to the epithe-
and is placed on strict voice rest for 7 days. lium, into the region of the superficial lamina propria
Ch-21.indd 125 9/9/2010 2:36:22 Gopal

Section
M N
126
O P
Figs 21.2M to P: (M) The buccal mucosal graft is placed into position. It may be removed and its size adjusted until an optimal
configuration is achieved. (N) Multiple sutures are used to hold the graft in place. (O) The graft has been placed successfully. A deep
extubation is performed, and the patient is kept on strict voice rest until seen for a follow-up examination in 7 days. (P) Direct
laryngoscopic view of the vocal folds
(Fig. 21.2Q). The needle is inserted on the superior sur- Step 4

face of the vocal fold, away from the vibratory margin.
However, injection along the vibratory margin can be per- The laryngoscope is removed, and the anesthetic agent is
formed if scar in that area does not elevate with needle reversed. As there has been no damage to the vibratory
placement on the superior surface. Typically, 0.1-0.5 mL margin, voice rest is not indicated routinely.
is injected.
Case 3: Fat Implantation and Lipoinjection
Step 3
Step 1
It is not uncommon to require multiple injection sites
to elevate (hydrodissect) the superficial lamina propria Orotracheal intubation is followed by suspension micro-
(Fig. 21.2R). laryngoscopy to expose the focal folds (Fig. 21.2S).
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Vocal Fold Scar
Chapter
21
Q R
127
S T
Figs 21.2Q to T: (Q) Decadron is injected into the region of the superficial lamina propria or Reinke’s space. (R) Multiple injections
may be required to adequately disperse the Decadron, hydrodissect under the epithelium, and lyse adhesions. (S) Direct laryngoscopic
view of the vocal folds. Preoperative stroboscopic examination revealed an area of scar along the right vibratory margin. Bilateral
bowing of the vocal folds is also appreciated. (T) An incision is made on the superior-lateral surface of the vocal fold to allow for the
creation of a submucosal pocket with minimal disturbance to the vibratory margin
Step 2 margin, deep to the vocal fold scar (Fig. 21.2U). The
A Sataloff Sharp Knife is used to make an incision along pocket extends to the superior aspect of the vibratory
the superior-lateral surface of the vocal fold, approxi- margin (Fig. 21.2V) and inferiorly for at least 3-8 mm to
mately 3 mm in length. The incision is placed near the encompass all of the medial surface ordinarily involved in
midpoint of the superior surface of the vocal fold and is creating the mucosal wave vertical phase difference during
used to create an access tunnel. This region is the only phonation. If scarring is so severe that the medial pocket
area in which mucosa is elevated along the superior sur- cannot be created with a blunt, Sataloff Right Angle or
face. The creation of a limited access tunnel is essential Oblique Ball Dissector, it can be created sharply with
to prevent fat extrusion (Fig. 21.2T). scissors (taking care not to tear the access tunnel), or with
a Sataloff Flap Knife. This instrument is sharpened on
Step 3 the bottom and should not be used accidentally in place
Using a Sataloff Long Right Angle Ball Dissector, a sub- of the Sataloff Vascular Knife when resecting vessels. The
epithelial access pocket is elevated toward the vibratory vascular knife is blunt on its inferior surface. The flap
Ch-21.indd 127 9/9/2010 2:36:23 Gopal

Section
U V
128
W X
Figs 21.2U to X: (U) A Sataloff Long Right Angle Ball Dissector is used to dissect and create an accessory tunnel. (V) Although working
through a small access tunnel is technically more challenging than elevating a large flap, it has the advantage of closing spontaneously
upon removal of instruments and prevents fat extrusion from the surgically created pocket. (W) A Brünings syring is used to deliver the
fat globules into the accessory tunnel. (X) Upon removal of the instruments, no fat should be seen protruding through the incision site
knife can injure a vocal fold if used inadvertently. It is packing directly usually creates an irregular, lumpy medial
designed to cut sharply at 90º from the handle, to create margin, which is avoided through use of the Brunings
a medial mucosal pocket during fat implantation. syringe.
Step 4 Step 5
Fat harvested at the beginning of the surgery is used The instruments are then withdrawn (Fig. 21.2X), and the
to fill the tunnel. The implant is delivered through access tunnel closes spontaneously and provides sufficient
a Brünings syringe (Fig. 21.2W). At present, the fat resistance against fat extrusion.
globules are loaded into the Brünings syringe. The larg-
est Brünings needle (18 gauges) is used to deliver the fat Step 6
into the preformed vibratory margin pocket. The fat can In this patient, a concurrent left vocal fold lipoinjection is
be packed into the pocket with other instruments, but performed (Figs 21.2Y and Z; refer to Chapter 29—Vocal
Ch-21.indd 128 9/9/2010 2:36:27 Gopal

Vocal Fold Scar
Chapter
21
Y Z
Figs 21.2Y to Z: (Y) A lipoinjection augmentation of the left vocal fold is performed by inserting the Breuning’s syringe laterally, at the
superior arcuate line just anterior to the tip of the vocal process. (Z) The difference in color of the vocal folds can be attributed to
the deep placement of fat into the left vocal fold to achieve the best long-term augmentation results, and the superficial placement
of fat implanted into the right vocal fold
Fold Paresis and Paralysis) to address the previously 6. Ford CN, Bless DM, Loftus JM. The role of injectable
diagnosed glottic insufficiency. Lipoinjection medializa- collagen in the treatment of glottic insufficiency: A study
of 119 patients. Ann Otol Rhinol Laryngol. 1973;
tion should not be performed on the same side as fat
implantation, at the same time. 101(3):237-47. 129
7. Ford CN, Bless DM. Collagen injected in the scarred vocal
Step 7 fold. J Voice. 1988; 1:116-8.
8. Ford CN, Bless DM. Selected problems treated by vocal
The laryngoscope is removed and a deep extubation is fold injection of collagen. Am J Otolaryngol. 1993;
performed. The patient is placed on limited strict voice 14(4):257-61.
rest (usually 3 days) to prevent against the extrusion of 9. Spiegel JR, Sataloff RT, Gould WJ. The treatment of
the implanted fat. vocal fold paralysis with injectable collagen. J Voice. 1987;
1:119-21.
10. Sataloff RT, Spiegel JR, Hawkshaw M, et al. Autologous
REFERENCES fat implantation for vocal fold scar: A preliminary report.
1. Sataloff RT, Spiegel JR, Carroll LM, et al. J Voice. 1997; 11(2):238-46.
Strobovideolaryngoscopy in professional voice users: 11. Feldman MD, Sataloff RT, Epstein G, et al. Autologous
fibrin tissue adhesive for peripheral nerve anastomosis.
Results and clinical value. J Voice. 1988; 1:359-64.
Arch Otolaryngol Head Neck Surg. 1987; 113:963-7.
2. Sataloff RT, Spiegel JR, Hawkshaw MJ. Strobovideo-
12. Neuenschwander MC, Sataloff RT, Abaza M, et al.
laryngoscopy: Results and clinical value. Ann Otol Rhinol
Management of fold scar with autologous fat implanta-
Laryngol. 1991; 100:725-57.
tion perceptual results. J Voice. 2001; 15(2):295-304.
3. Pontes P, Behlau M. Treatment of sulcus vocalis: Auditory
13. Hirano M. Clinical Examination of Voice. New York:
perceptual and acoustic analysis of the slicing mucosa sur- Springer Verlag; 1981. pp. 81-4.
gical technique. J Voice. 1993; 7(4):365-76. 14. Benninger MS, Alessi D, Archer S, et al. Vocal fold scar-
4. Mikaelian D, Lowry LD, Sataloff RT. Lipoinjection
ring: Current concepts and management. Otolaryngol
for unilateral vocal cord paralysis. Laryngoscope. 1991;
101:465-8. Head Neck Surg. 1996; 115(5):474-82.
5. Sataloff RT. Voice surgery. In: Sataloff RT. Professional 15. Spiegel JR, Sataloff RT. Surgery for carcinoma of the lar-
Voice: The Science and Art of Clinical Care, 3rd edition. ynx. In: Gould WJ, Sataloff RT, Spiegel JR (Eds). Voice
San Diego, CA: Plural Publishing, Inc. 2005. pp. 1137-214. Surgery. St. Louis, MO: CV Mosby Co; 1993. pp. 307-38.
Ch-21.indd 129 9/9/2010 2:36:29 Gopal

Chapter
22 Sulcus Vocalis
Sulcus vocalis is a groove in the surface of the membra-

nous portion of the vocal fold, usually extending through-
out its length (Figs 22.1 and 22.2). The lesion is usually
bilateral. In sulcus vocalis, the epithelium invaginates
through the superficial layer of the lamina propria and
adheres to the vocal ligament. This results in a groove
running longitudinally along the vocal fold. The apparent
groove is actually a sac lined with stratified squamous epi-
thelium, and hyperkeratosis is common near the deepest
aspects of the sac or pocket. Some authors believe that
this represents an open epidermal cyst. There is a defi-
ciency of capillaries and an increase in collagenous fibers
in the region of the sulcus. The mass of the cover layer
is reduced, and the invaginated cover layer may adhere to
the vocal ligament, causing increased stiffness.
Consequently, sulcus vocalis is often associated with
hoarseness, breathiness and decreased vocal efficiency. Fig. 22.1: Typical appearance of a bilateral sulcus vocalis.
However, it may be asymptomatic, if it occurs below the Reproduced from Sataloff RT. Professional Voice: The Science and
contact edge.
PSEUDOSULCUS VOCALIS AND SULCUS

VERGETURE it may extend beyond the limit of the musculomembra-
nous portion of the vocal fold, involving the cartilaginous
These conditions may occur in patients with dysphonia portion, as well. Commonly, it is associated with chronic
similar to that in sulcus vocalis but often lens severe and inflammation and edema, usually caused by laryngopha-
hence are important close differentials of the condition. ryngeal reflux. Pseudosulcus vocalis is managed by treat-
Sulcus vergeture has a similar appearance, but is caused by ing the underlying reflux and any other related conditions.
atrophic epithelial changes along the medial margin of the
vocal fold. It is also often associated with a bowed appear- TREATMENT OF SULCUS VOCALIS AND
ance. Usually, the superior edge of the groove appears MUCOSAL BRIDGE
quite mobile, but the inferior edge is generally stiff. The
superior layer of the lamina propria is usually deficient Treatment of sulcus vocalis is controversial. A mucosal
and the epithelium may closely be opposed to the vocal bridge involves a longitudinal separation between the
ligament; but it is an atrophic depression of epithelium mucosa covering the vibratory margin and the rest of
rather than an invagination of variable thickness and scat- the vocal fold (Fig. 22.3A). Mucosal bridges usually are
tered hyperkeratosis, as seen in a true sulcus vocalis. The congenital, but they may be post-traumatic. They have
term “pseudosulcus vocalis” is often used interchangeably been associated with sulcus vocalis, as well. Ordinarily
with sulcus vergeture but is actually a different entity. they are thin strips of mucosa (much less dramatic than
Pseudosulcus is a longitudinal groove that may appear the case shown in Figure 22.3B, but they are challenging
similar to sulcus vocalis or sulcus vergeture, except that therapeutically. Removal of the mucosal bridge does not
Ch-22.indd 130 9/13/2010 12:53:09 Gopal

Sulcus Vocalis
Chapter
22
Fig. 22.2: Histologically, sulcus vocalis involves the superficial

layer of the lamina propria. Dense, collagenous fibers with scant
capillaries and thickened epithelium are common. The epithelium
may adhere to the vocal ligament, but otherwise the transitional
layer is uninvolved. (Courtesy: Minoru Hirano, MD). Reproduced
131
always result in improvement in vocal quality. In some
cases, there is atrophy of the epithelial surface of the
remaining vocal fold, which becomes the vibratory margin
after the bridge has been removed. It is often not possible
to predict phonatory outcome, rendering intraoperative
decision-making difficult.
B
Numerous techniques have been used to treat sulcus
vocalis. The mucosa can be dissected from the deeper Figs 22.3A and B: (A) Strobovideolaryngoscopy of this 33-year-old
singer revealed bilateral vocal fold stiffness, evidence of previous
structures to which it is adherent and simply replaced hemorrhage, left sulcus vocalis (small arrows), right vocal fold
in its original position. This technique, however, fails mass (open arrow), ecstatic vessels on the superior surfaces of
frequently. The area of the sulcus can also be resected both vocal folds with a prominent vessel running at 90º to the
and mucosa can be reapproximated. This technique vibratory margin (curved arrow), a small anterior glottic web (not
shown) and muscular tension dysphonia. The importance of a line
seems to work a little better than simple elevation, but on the superior surface of the right vocal fold (white arrowheads)
it also does not produce consistently satisfactory results. was not appreciated preoperatively. It appeared to be simply a
Collagen injection has been used to treat sulcus vocalis,1 light reflex. (B) Intraoperatively, this was found to be the opening
but it, too, has not been consistently successful. Pontes into an unusually large mucosal bridge. The mucosal bridge was
removed and autologous fat was injected laterally to medialize
and Behlau introduced a technique involving multiple the right vocal fold and improve glottic closure. Reproduced from
crossed incisions throughout the length of the sulcus.2 Sataloff RT. Professional Voice: The Science and Art of Clinical
At first glance, this technique looks as if it should cause Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005:
greater scarring; but it is actually a series of multiple Fig. 85.35, with permission
relaxing incisions following established, plastic surgi-

cal principles. Substantial voice improvement has been has not been determined. However, it is now clear that
achieved in a majority of patients undergoing this proce- various surgical interventions provide at least partial voice
dure. Autologous lipoinjection and fat implantation may improvement in many patients. The principles of man-
also be efficacious. At present, the best surgical technique agement are the same as those discussed for scar.3 It is
Ch-22.indd 131 9/13/2010 12:53:10 Gopal

Section
necessary to address compensatory hyperfunction through The techniques for treating vocal fold scar discussed
voice therapy, failure of glottic closure through medializa- in Chapter 21 are appropriate for treatment of sulcus
tion and recreation of a mucosal wave through surgery vocalis.
on the vibratory margin.
2 Developments over the last 15 years suggest that REFERENCES
patients with significant symptoms caused by sulcus
should be offered surgical options, with the clear under- 1. Ford CN, Bless DM, Loftus JM. The role of inject-
standing that surgical recommendations for this condition able collagen in the treatment of glottic insufficiency: A
study of 119 patients. Ann Otol Rhinol Laryngol 1973;
are still evolving, voice quality could be worse following
101(3):237-47.
voice surgery, and that there is certainly no guarantee of 2. Pontes P, Behlau M. Treatment of sulcus vocalis: Auditory
improvement; but the decision on whether the chances perceptual and acoustic analysis of the slicing mucosa sur-
of achieving better voice are worth the risks should be gical technique. J Voice 1993; 7(4):365-76.
made by the patient and physician on an individual basis. 3. Sataloff RT. Vocal Fold Scar. In: Sataloff RT. Professional
Surgical treatment is now good enough that it should not Voice: The Science and Art of Clinical Care, 3rd edi-
be denied to those symptomatic and informed patients tion. San Diego, California: Plural Publishing, Inc.; 2005;
who elect it. 1309-13.
132
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Chapter
23 Laryngeal Webs
Webs connecting the vocal folds may be congenital, or other minimally reactive substances. Commercially manu-
they may follow trauma. They are particularly liable to factured keels can be used. Sutures are passed into the
form when mucosa is disrupted in the anterior one- larynx through 16-gauge needles inserted through the
thirds of both vocal folds simultaneously, especially near cricothyroid membrane and above the thyroid notch (Figs
the anterior commissure. Many webs cause no vocal or 23.1A to D). The keel can be guided into position, and
respiratory problems and should be left undisturbed. the sutures are fixed into the skin. Hospitalization and
Symptomatic webs may present with hoarse voice or res- close observation for airway obstruction are required for
piratory complaints following trauma, surgical or other. the first 24 hours. The rare complications of the proce-
When the voice is hoarse after trauma and a small web is dure include displacement of the keel with aspiration and
present, it is essential to determine preoperatively whether obstruction, and deep neck infection. Nevertheless, the
the web is truly the cause of the dysphonia. Often the procedure is less traumatic than the external approach,
web is asymptomatic and the hoarseness is caused by and frequently effective. Whether the endolaryngeal or
scarring elsewhere in the vocal folds (an adynamic seg- external approach is used, the keel should be left in posi-
ment) that cannot be diagnosed under routine light. It tion for at least 2-3 weeks.
is extremely helpful to make such determinations before In a new technique that was reported by Sataloff and
subjecting the patient to surgery that may not only fail Hawkshaw1 in 1998, an internal laryngeal stent can be
to improve the voice but can also make it worse. placed without external manipulation, even for placement
Before embarking upon surgical repair, the laryn-
gologist should determine whether the web is sympto-
matic, and its longitudinal and vertical extent. Complete
assessment including strobovideolaryngoscopy and high
resolution CT scan is helpful in defining the lesion. The
importance of stroboscopy cannot be overstated. For rela-
tively small, symptomatic webs, surgery may be performed
endoscopically. More extensive external approaches can be
used when necessary.
Endoscopic resection of a laryngeal web may be per-
formed with traditional instruments or laser. In a small
number of cases, it may be possible to treat a web success-
fully endoscopically without placement of a keel. This is
accomplished by dividing one edge near a vocal fold and
allowing the free edge to fold in on its base on the other
side. The edge may be left free, fixed with fibrin glue,
sutured or “laser welded”. This technique is minimally
traumatic, but recurrences appear more frequently than Fig. 23.1A: Videoprint showing a thick anterior web caused by
they do following placement of a keel. In general, it is repeated surgery for papillomas. Webs this thick often require an
open procedure; but sometimes they can be repaired adequately
necessary to place a laryngeal keel to prevent reformation
endoscopically. Reproduced from Sataloff RT. Professional Voice:
of the web. A tracheotomy is rarely necessary. The keel The Science and Art of Clinical Care, 3rd edition. San Diego, CA:
is fashioned individually out of silastic, Teflon, metals or Plural Publishing, Inc.; 2005: Fig. 82.31, with permission
Ch-23.indd 133 9/13/2010 12:53:28 Gopal

Section
B C D
Figs 23.1B to D: (B) Placement of 16-gauge needles above and below the thyroid cartilage in the midline, in preparation for endoscopic
placement of a keel. This procedure would not generally be used in the presence of papillomas, but is useful for webs from other
causes. (C) Individually fashioned Teflon keel is attached to sutures, passed through the 16-gauge needles. (D) The sutures are drawn
through the needles in order to place the keel in final position in the anterior commissure
134
A B
Figs 23.2A and B: (A) Typical appearance of a moderately thick anterior glottic web as viewed by a 70° endoscope. The patient had
a concurrent leukoplakia of the right vocal fold. (B) 0.02 inch silastic was sewn endoscopically through the vocal fold, without sutures
being passed through the thyroid cartilage or externally. Reproduced from Sataloff RT. Professional Voice: The Science and Art of Clinical
Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 82.32, with permission
Ch-23.indd 134 9/13/2010 12:53:28 Gopal

Laryngeal Webs
Chapter
23
C D
Figs 23.2C and D: (C) As originally described, the knots were tied medially as shown. Now, the knots are tied lateral to the silastic
to avoid knot-induced trauma to the contralateral vocal fold. The sutures were left in place until the contralateral vocal fold appeared
to be remucosalized. This took about three and half weeks. (D) Postoperative appearance, which has remained stable during more than
10 years following surgery. Reproduced from Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. San
Diego, CA: Plural Publishing, Inc.; 2005: Fig. 82.32, with permission
of sutures. The original procedure was performed endo-

scopically using a rectangle of 0.02 inch reinforced silastic
a medicine applicator with a slight ball-like enlargement
on the end, used in past years for dripping cocaine onto
135
usually used in middle ear surgery. This procedure was the vocal folds. Topical anesthetic can be applied with this
designed originally for a patient with aggressive, active instrument, after which the instrument is passed between
papillomatosis and a severe web. Due to the aggressiveness the vocal folds and pulled forward to break-up the web.
of the papilloma, the author (RTS) was reluctant to create The procedure can be repeated periodically, if necessary;
even a suture tract from the larynx through the skin to and it is effective in preventing web reformation in some
secure a keel or stent in the usual fashion, because of cases.2
the risk of seeding papilloma. This entirely endoscopic
technique permits web resection without contamination REFERENCES
of tissues outside of the endolarynx (Figs 23.2A to D).
1. Sataloff RT, Hawkshaw MJ. Endoscopic internal stent. A
Postoperative management following resection of
new procedure for laryngeal webs in the presence of papil-
vocal fold webs can be important to ensuring success. If loma. ENT-J 1998; 77(12):949-50.
a web starts to reform early in the postoperative period, it 2. Stasney CR. Laryngeal webs. A new treatment for an old
can be divided easily in the office. Under indirect laryn- problem. Presented at the 22nd Annual Symposium: Care
goscopy or nasal fiberoptic guidance, a curved indirect of the Professional Voice; 1993: The Voice Foundation,
laryngoscopic instrument is used. The ideal instrument is Philadelphia, PA.
Ch-23.indd 135 9/13/2010 12:53:29 Gopal

Chapter
24 Posterior Glottic Stenosis

Joseph R Spiegel, Robert T Sataloff, Farhad Chowdhury, Mary J Hawkshaw
The posterior glottis consists of the posterior one-third of the interarytenoid region. Type III and Type IV stenosis
(cartilaginous portion) of the vocal folds, the posterior are defined by unilateral and bilateral cricoarytenoid joint
portion of the larynx (commonly called the posterior fixation, respectively.
commissure) with its interarytenoid muscle, the cricoid Evaluation of a patient with suspected PGS begins
lamina, the cricoarytenoid joints, the arytenoid cartilages with a detailed history and thorough visualization of
and the overlying mucosa. Although the term posterior the larynx. Strobovideolaryngoscopy is optimal. Flexible
commissure is used frequently to describe the interary- laryngoscopy provides the best assessment of laryngeal
tenoid region, it is arguably a misnomer. A commissure motion and videorecording can be extremely valuable.
is a “coming together”, as occurs anteriorly and there is Some patients can provide only short bursts of phonation
no “posterior commissure”. Other terminology has been or breathing with their tracheotomy occluded and replay
preferred in recent years. of these portions of the examinations is quite helpful
Stenosis of the posterior glottis arises most often as in diagnosis. Stroboscopy is useful specifically in deter-
a result of the trauma of endotracheal intubation. Factors mining the relative vertical height and tension of the
that affect the development of postintubation complica- vocal folds for assessing cricoarytenoid function and in
tions include traumatic intubation, prolonged intubation, evaluating scarring of the vocal folds. Many patients will
repeated intubations, large endotracheal tube size, motion benefit from electromyography (EMG) of the intrinsic
of the endotracheal tube and the presence of reflux or laryngeal muscles. It is critical to establish the potential
local infection. Occasionally, posterior glottic stenosis laryngeal function by EMG before embarking on planned
may result from other traumatic etiologies such as inha- repair to restore cricoarytenoid mobility. In the presence
lation burns, caustic ingestion and surgical misadventure. of severe paresis or paralysis, the entire effort could be
Patients who develop posterior glottic stenosis (PGS) futile. In a case of suspected paralysis, a normal EMG
often fail extubation and subsequently may present with may signal an arytenoid dislocation or ankylosis. A fine
airway distress and/or dysphonia at various intervals dur- cut computed tomography (CT) of the larynx can be
ing their recuperation, some requiring tracheotomy. The helpful to determine arytenoid position. CT of the neck
classification system used most commonly for PGS was and chest can be utilized to examine other levels or air-
published by Bogdasarian and Olson1 (Table 24.1). Type I way stenosis. Pulmonary function testing, specifically a
stenosis is a scar band between the vocal folds that is ante- flow volume loop, can provide objective measurement of
rior to and separate from the posterior laryngeal mucosa. the airway obstruction and objective voice analysis with
Type II stenosis involves the mucosa and/or musculature airflow studies can quantify and document the effect of
PGS on the voice.2
After initial evaluation, all patients in reasonable
Table 24.1: Posterior glottic stenosis grading system
medical condition undergo endoscopic examination under
Type Pathology general anesthesia. Microscopic examination of the glot-
I Interarytenoid scar, posterior larynx normal tic surfaces, palpation of the cricoarytenoid complex and
II Posterior laryngeal scarring posterior glottic region; and examination of the subglottis
III Posterior laryngeal scarring with unilateral cricoarytenoid and trachea complete the assessment. In cases of simple,
fixation Type I stenosis, endoscopic procedures may suffice for
IV Posterior laryngeal scarring with bilateral cricoarytenoid treatment. When endoscopic mucosal resurfacing and
fixation stenting are feasible, even more problems can also be
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Posterior Glottic Stenosis
Chapter
approached without laryngotomy. However, many patients
with advanced stages of PGS will require open laryngeal
procedures to obtain adequate laryngeal function.
ENDOLARYNGEAL PROCEDURES 24
Endoscopic laryngeal procedures are most useful in the
simplest (Type I) and the most severe (Type IV) forms of
PGS. The simplest form of PGS (Type I) is a scar band
that prevents full abduction of the vocal folds but spares
the posterior laryngeal mucosa (Fig. 24.1). The level of
the scar can be determined by passing an instrument
between the band and the posterior larynx. The band can
be excised with cold instruments or a laser. Recurrences
have not been reported.3, 4 Endolaryngeal procedures are
used to reestablish a glottic airway in patients with Type Fig. 24.1: Type I posterior glottic stenosis,
with a typical scar band
IV PGS when mobility of the cricoarytenoid joints can-
not be restored. Some of these patients have failed closed
and open attempts at repair. Perhaps the most important and scar tissue can be excised posteriorly to the level of
prognostic factor in PGS is mobility of the cricoaryten- the cricoid lamina. The flap is red-raped over the resec-
oid joints. When the joints are mobile and severe paresis tion site. Although contraction of the flap prevents total
or paralysis is present bilaterally, direct treatment of the coverage, the flap can resurface small areas well enough
posterior laryngeal scarring is rarely warranted. If disloca- to allow adequate healing9-11 (Figs 24.2A and B). Most
tion of an arytenoid cartilage is encountered, reduction
should be attempted endoscopically. Even if the joint
patients treated with the microflap trapdoor technique
have Type II stenosis, but occasionally patients with uni-
137
remains fixed, the airway may be improved and appro- lateral cricoarytenoid joint fixation can also be treated
priate vocal fold height may be restored. If any vocal fold endoscopically. In the few number of patients with PGS
mobility can be regained, it greatly improves the chances treated endoscopically with mucosal flaps, most achieve
for a successful repair. Arytenoidectomy is utilized pri- decannulation. However, Duncavage et al have noted even
marily in the treatment of bilateral vocal fold paralysis. better results in their patients with subglottic stenosis.9
However, in cases of PGS involving midline fixation of Newer methods of endolaryngeal suturing and laser weld-
both cricoarytenoid joints, endoscopic laser arytenoidec- ing may allow attempts at endoscopic repair of large areas
tomy may be adequate primary treatment to restore the of scarring in the future.12
airway and permit decannulation.5 Posterior transverse In an attempt to reduce scarring after endoscopic repair,
cordotomy has also been utilized successfully to relieve recent reports have demonstrated the safety and efficacy
airway obstruction in a patient with PGS who had failed of topically applied Mitomycin-C.13, 14 Mitomycin-C
a prior endoscopic procedure.6 is an antineoplastic antibiotic that acts as an alkylating
When the posterior mucosa and interarytenoid mus- agent by inhibiting DNA and protein synthesis. It can
cle are scarred, the value of endoscopic techniques is con- inhibit cell division and fibroblast proliferation and may
troversial. Some authors, such as Kleinsasser,7 feel that be helpful in treating PGS.
open methods should be used whenever scarring involves
the muscle. It is clear that any endoscopic method of OPEN LARYNGEAL PROCEDURES
PGS repair must provide adequate mucosal coverage
of the posterior glottic region. The microtrapdoor flap Most patients with advanced stages of PGS involving
technique that was first described by Dedo and Sooy in dense mucosal and deep scarring will require an open
1984, provides a method of mucosal preservation with surgical procedure to achieve decannulation and optimal
scar excision.8 Using the carbon dioxide laser, a trans- airway. An aggressive approach to the treatment of PGS
verse incision is made superiorly in the posterior laryngeal is warranted, as it has been shown to be the most impor-
mucosa. Vertical relaxing incisions are made bilaterally tant site of stenosis resulting in prolonged tracheotomy.15
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Section
from the postcricoid area. A transposition flap from the

aryepiglottic fold can also be utilized. When adequate
local mucosa cannot be mobilized to cover the laryngeal
wound, free graft tissue is utilized. Buccal mucosa, full
2 thickness grafts and perichondrocutaneous grafts (har-
vested from the auricular concha) have been used success-
fully.17 When free mobility of the cricoarytenoid joints
cannot be established, the arytenoids can be held apart
with cartilage. This procedure has been described using
a small window of cartilage from the thyroid ala or a
portion of costal cartilage18 (Fig. 24.3). Stents are used
to hold the arytenoids laterally during initial healing and
to provide soft pressure on any mucosal flaps and grafts.
Stenting is advocated in many procedures for posterior
glottic reconstruction. Both soft and rigid stents can be
utilized depending on the surgeon’s preference.
A
CONCLUSION
Posterior glottic stenosis is a particularly difficult prob-

lem to treat in long-term airway injuries. The outcome
of treatment will determine the patient’s ability to live
without a tracheotomy, the voice quality and the ability
138 to maintain airway protection during swallowing. Simple
scar bands are excised endoscopically. Deeper scars can be
treated using endolaryngeal procedures if mucosal cover-
age is possible, but most patients with PGS involving
cricoarytenoid fixation require an open procedure. Severe
PGS involving cricoarytenoid fixation usually requires an
open procedure. Severe PGS is approached by laryngot-
omy with cartilage interposition between the arytrenoids,
coverage by a local mucosal flap or graft and postoperative
stenting. Arytenoidectomy and cordotomy may be used
to open the airway when laryngeal mobility cannot be
B re-established.
Figs 24.2A and B: (A) Microtrapdoor flap technique illustrating
transverse and vertical incision. (B) Permitting laser vaporization
SURGICAL TECHNIQUES
of the posterior glottic scar
Step 1
Open procedures for PGS often are combined with treat-
ment of subglottic stenosis and should be completed prior As this is a lesion requiring optimal visualization and
to surgically addressing areas of lower tracheal stenosis. working space in the posteior glottis, general anesthesia
Resection and repair of PGS using a laryngofis- is administered via jet-ventilation through a Hunsaker
sure approach have been reported for many years.16 The catheter under direct visualization. The catheter can be
scarred tissue is excised sparing the interarytenoid muscle, placed either by the anesthesia team or the surgeon.
if possible and the capsules of the cricoarytenoid joints. Suspension microlaryngoscopy is performed to expose the
When scarring is limited to the interarytenoid area, posterior glottis (Fig. 24.4A). Communication between
mucosal coverage is obtained with local mucosal flaps. the anesthesiologist and the surgeon is critical, as the
The most useful is a posteriorly based flap advanced Hunsaker catheter is removed and replaced to balance
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Chapter
24
139
Figs 24.4A and B: (A) Suspension microlaryngoscopy shows

redundant soft tissue in the posterior glottis compromising airway
patency. (B) A straight Sataloff Sharp Knife is used to make a
B curvilinear incision posteriorly, slightly off midline
Figs 24.3A and B: Through a laryngofissure, the posterior glottic

region can be widened by dividing the cricoid and holding the
arytenoids apart with cartilage (A), which is then covered with a should be made slightly off the midline and curvilinear
posteriorly based mucosal flap (B) (Fig. 24.4B).
Step 3
adequate ventilation and surgical exposure. If the laser is Blunt and sharp dissection is performed deep to the pro-
used, concentrated oxygen must be avoided. Use of room posed flap (Fig. 24.4C). The flap may be grasped gently
air or Heliox should be considered. and reflected to expose the underlying redundant soft
tissue and fibrosis.
Step 2
Using a straight Sataloff Sharp Knife, an incision is made Step 4
through the mucosa and underlying fibrous adhesions and Once adequate soft tissue resection has occurred, the flap
soft tissues, demarcating the edge of the flap. The incision is rotated anterior-medially (Fig. 24.4D). It is placed so
Ch-24.indd 139 9/8/2010 3:09:02 Gopal

Section
C D
140
E F
Figs 24.4C to F: (C) The mucosa is gently reflected using a Sataloff Heart Shaped Grasper. The underlying fibrous adhesions and
redundant soft tissue is dissected using laryngeal microscissors, creating a mobile mucosal flap. Underlying scar and bulky tissue are
resected to facilitate airway patency and flap rotation. (D) The mucosal flap is mobilized. It is rotated anteroinferiorly and placed
over the defect resulting from tissue removal. (E) Using 4.0 catgut suture, a stitch is placed to hold the flap into position. (F) The
posterior mucosal flap has been placed. Frayed ends of the suture are transected as close to the knot as possible. Patency of the
posterior glottis has been re-established
as to overlie the defect arising from the removal of sub- placed on aggressive antireflux therapy and is re-examined
mucosal tissue. in approximately 7 days.
Step 5
4.0 catgut suture is used to secure the flap to the posterior REFERENCES
glottis (Fig. 24.4E). The ends of the suture are removed 1. Bogdasarian RS, Olson NR. Posterior glottic laryngeal ste-
as close as possible to the knot (Fig. 24.4F), reducing nosis. Otolaryngol Head Neck Surg 1980; 88:765-72.
the risk of irritation that may lead to impaired healing 2. Smith ME, Marsh JH, Cotton RT, et al. Voice prob-
and granuloma formation, and to contralateral contact lems after pediatric laryngotracheal reconstruction:
trauma. A deep extubation is performed, and the patient Videolaryngostroboscopic, acoustic and perceptual assess-
is awakened using gentle mask ventillation. The patient is ment. Int J Pediatr Otorhinolaryngol 1993; 25:173-81.
Ch-24.indd 140 9/8/2010 3:09:02 Gopal

Chapter
3. Strong MS, Healy GB, Vaughan CW, et al. Endoscopic 11. Werkhaven JA, Weed DT, Ossoff RH. Carbon dioxide
management of laryngeal stenosis. Otolaryngol Clin North laser serial microtrapdoor flap excision of subglottic ste-
Am 1979; 12(4):797-805. nosis. Arch Otolaryngol Head Neck Surg 1993; 119:676-9.
4. McCombe AW, Phillips DE, Rogers JH. Inter-arytenoid 12. Shapshay SM, Wang Z, Volk M, et al. Resurfacing of a
glottic bar following intubation. J Laryngol Otol 1990; large laryngeal wound with mucosa grafting: A combined
104:727-9. technique using endoscopic suture and laser soldering. Ann 24
5. Lim RY. Endoscopic CO2 laser arytenoidectomy for Otol Rhinol Laryngol 1995; 104:919-23.
postintubation glottic stenosis. Otolaryngol Head Neck 13. Rahbar R, Valdez TA, Shapshay SM. Preliminary results
Surg 1991; 105:662-6. of intraoperative mitomycin-C in the treatment and pre-
6. Gaboriau H, Laccourreye O, Laccourreye H, et al. CO2 vention of glottic and subglottic stenosis. J Voice 2000;
laser posterior transverse cordotomy for isolated type 14:282-6.
IV posterior glottic stenosis. Am J Otolaryngol 1995; 14. Rahbar R, Shapshay SM, Healy GB. Mitomycin: Effects
16:350-3. on laryngeal and tracheal stenosis, benefits and complica-
7. Kleinsasser O. Microlaryngoscopy and Endolaryngeal tions. Ann Otol Rhinol Laryngol 2001; 110:1-6.
Microsurgery: Technique and Typical Findings. 15. McCaffrey TV. Classification of laryngotracheal stenosis.
Philadelphia, PA: Hanley & Belfus, Inc. 1980. pp. 84. Laryngoscope. 1992; 102:1335-40.
8. Dedo HH, Sooy CD. Endoscopic laser repair of poste- 16. Montgomery WW. Posterior and complete laryngeal (glot-
rior glottic, subglottic and tracheal stenosis by division or tic) stenosis. Arch Otolaryngol 1973; 98:170-5.
microtrapdoor flap. Laryngoscope 1984; 94:445-50. 17. Hoasjoe DK, Franklin SW, Aarstad RF, et al. Posterior
9. Duncavage JA, Piazza LS, Ossoff RH, et al. The micro- glottic stenosis mechanism and surgical management.
trapdoor flap technique for the management of laryngeal Laryngoscope 1997; 107:675-9.
stenosis. Laryngoscope 1987; 97:825-8. 18. Cummings CW, Sessions DG, Weymuller WA, et al.
10. Beste DJ, Toohill RJ. Microtrapdoor flap repair of laryngeal Posterior glottic split cartilage perichondrial graft. In:
and tracheal stenosis. Ann Otol Rhinol Laryngol 1991; Cummings CW. Atlas of Laryngeal Surgery. St Louis,
100:420-3. MO: CV Mosby Co; 1984. pp. 179.
141
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Chapter
25 Subglottic Stenosis
The subglottis is an anatomical subdivision of the larynx. penetrating wounds of the larynx. Both severe laryngeal
The exact borders are somewhat controversial, as some trauma with fracture of the cricoid and thyroid cartilages
describe it as beginning approximately 5–10 mm below with or without displacement and inadequately managed
the free edge of the vocal fold and extending to the infe- early stages of laryngeal trauma may result in chronic
rior margin of the cricoid cartilage,1 while others place acquired laryngeal stenosis.8
the upper border as the inferior arcuate line.2 Stenosis Most cases of internal laryngeal injury occur sec-
of this portion of the upper respiratory tract affects both ondary to prolonged endotracheal intubation, and this
the soft tissue and cartilage of the endolarynx, and it is remains the most common cause of chronic laryngeal
a challenging problem. stenosis.9,10 Endotracheal intubation accounts for nearly
Subglottic stenosis is defined as partial or complete 90% of cases of acquired chronic subglottic stenosis in
cicatricial narrowing of the endolarynx.3 This process may infants and children.10-12 The reported incidence of ste-
be congenital or acquired, with iatrogenic injuries and nosis after intubation ranges from 0.9 to 8.3%.11,13 Other
external neck trauma accounting for most of the docu- recognized causes include uncontrolled laryngopharyn-
mented cases.3,4 Although the management in adults with geal reflux,14,15 chronic infection, chronic inflammatory
chronic laryngeal stenosis differs from management in disease and laryngeal neoplasm.
the pediatric population, the goal of establishing a stable Laryngeal stenosis is diagnosed by a thorough his-
airway while preserving a serviceable voice remains the tory and physical examination, radiologic evaluation and
same. Of all laryngeal stenoses, chronic subglottic stenosis endoscopic examination of the airway and esophagus.4
is the most common and presents the most significant A 24-hour pH impedance monitor examination should
challenges in management.4 be considered to evaluate laryngopharyngeal reflux. It
Congenital subglottic stenosis is a clinical endoscopic is important to recognize eosinophilic esophagitis as a
diagnosis. It occurs secondary to inadequate recanaliza- separate entity from laryngopharyngeal reflux (LPR)
tion of the laryngeal lumen after completion of normal and gastroesophageal reflux disease (GERD) that must
epithelial fusion at the end of the third month of gesta- be controlled.16 In addition, quantitative documentation
tion.5,6 It is the third most common congenital disorder of voice function is valuable for several reasons. First,
of the larynx after laryngomalacia and recurrent laryngeal it sometimes provides information about vocal behaviors
nerve paralysis.7 In the absence of a history of endotra- and characteristics that have gone undetected during even
cheal intubation or other acknowledged causes of steno- multidisciplinary team assessment. Second, it provides
sis, subglottic stenosis is considered to be congenital. The baseline information that allows quantitative assessment
diagnosis may be difficult to confirm and it is unknown of outcomes. At a minimum, voice recordings should
how many intubated premature infants who fail extuba- be made using a standardized protocol before laryngeal
tion have underlying congenital stenosis.7 surgery is performed, whenever possible. Ideally, more
The most common cause of acquired laryngeal steno- sophisticated analysis should be completed.17
sis in both children and adults is trauma,4 which may be The management of subglottic stenosis in children
either external or internal. Often there is an obvious his- differs from that in adults and some operations useful
tory of a laryngeal insult. Causes of external trauma to the in children generally are not applicable to adults.4 The
neck include but are not limited to blunt trauma to the pathologic findings, patient age, degree and consistency
neck sustained during motor vehicle accidents, injuries of stenosis (hard or soft and percentage of stenosis) and
to the larynx during altercations, clothesline injury and general condition of the patient need to be taken into
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Subglottic Stenosis
Chapter
account when determining the plan of treatment.4,18 In If endoscopic procedures are contraindicated or
addition, a four-stage system of grading subglottic steno- deemed unsuccessful, an open surgical procedure may be
sis has been adopted widely and may help in selecting performed. Options include but are not limited to ante-
intervention options.19 In the case of severe congenital rior cricoid split, external expansion surgery and cricoid
subglottic stenosis, the initial and often emergent inter- resection with thyrotracheal anastamosis. Laryngotracheal 25
vention may be in the form of a tracheotomy to secure mucosal grafting may also be of value for some patients.
and maintain an adequate airway. The goals of correcting a subglottic stenosis are to
Traditional treatment of laryngotracheal stenosis has establish an airway and to preserve laryngeal function.
involved tracheal resection and reanastomosis. Over the Historically, vocal quality after surgical intervention has
past century, this has been maintained as an important been disturbed in most patients and has often been unsat-
option. However, even in the most experienced hands, isfactory.24, 25 With advancing surgical techniques and a
significant mortality and morbidity are associated with greater appreciation for the morbidity of an impaired
this approach. Endoscopic management may be appro- voice, a healthy balance between airway preservation and
priate for some patients. The trend toward endoscopic optimal voice remain the goals of treatment.
treatment of subglottic and tracheal stenosis has been
met with resistance as it is viewed by some authors as SURGICAL TECHNIQUES
ineffective and temporary.20 More recently, reports of
successful endoscopic resection of stenotic lesions have
Step 1
emerged, leading to an increase in the use of this method
as first-line treatment.21 Laryngeal dilatation may prove The patient is taken to the operation suite. General
useful in the early stages of soft-tissue stenosis formation. anesthesia is administered through a tracheotomy that
However, if the stenosis is mature or is cartilaginous, the was performed previously. Suspension microlaryngoscopy
value of endoscopic dilatation is limited. Adequate results is used to visualize the larynx. A near complete circum-
in managing early or mild subglottic stenosis with multi-
ple procedures using the CO2 laser have been reported.22
ferential stenosis of the subglottis is seen (Fig. 25.1A).
In some cases, jet ventilation may be used instead of
143
Application of Mitomycin-C, an antineoplastic antibiotic tracheotomy.
that acts as an alkylating agent by inhibiting DNA and
protein synthesis, seems promising.23 Corticosteroids may Step 2
be used locally or systemically, but their value remains A wet cottonoid is placed into the airway, just distal to
uncertain. the stenosis (Fig. 25.1B). If the laryngoscope is positioned
A B
Figs 25.1A and B: (A) A nearly complete circumferential stenosis of the subglottis is observed through the laryngoscope. (B) A wet
cottonoid is placed distal to the stenosis
Ch-25.indd 143 9/8/2010 3:09:14 Gopal

Section
C D
144
E F
Figs 25.1C to F: (C) The laser is used to vaporize the redundant tissue causing the stenosis. Only two quadrants are vaporized fully
during the procedure to help prevent recurrent stenosis. If necessary, the other two quadrants will be treated at another time. (D) With
adequate evacuation of the smoke, the dissection continues. The cottonoid placed into the subglottis beyond the stenotic segment is
now nearly completely seen without any obstruction. (E) A momentary obstruction of the suction ventilation port in the laryngoscope
occludes and visualization is compromised by the plume of smoke generated by the laser. (F) Patency of the airway is achieved and
the cotton pledget is removed. Surgery is stopped immediately until adequate smoke evacuation is re-established
Step 3
distal to the vocal folds, great care must be exercised to A continuous beam is delivered to the redundant tis-
avoid traumatizing the vocal folds. If the laryngoscope is sue (Figs 25.1C and D), vaporizing two quadrants of
positioned proximal to the vocal folds, cottonoids should the stenosis. A suction cannula is kept in the larynx to
also be placed over the true vocal folds to prevent inad- evacuate the smoke. Alternatively, suction tubing may be
vertent entry from the laser. All exposed parts of the connected directly to the Sataloff laryngoscope. If any
patient’s face are covered with wet surgical towels to temporary interruption of suction occurs, a plume of
protect against any beams from the carbon dioxide laser smoke will obscure the surgical field, and surgery should
that might inadvertently reflect off the laryngoscope or be stopped immediately until adequate smoke evacuation
microlaryngeal instruments. is re-established (Fig. 25.1E).
Ch-25.indd 144 9/8/2010 3:09:15 Gopal

Subglottic Stenosis
Chapter
Step 4 14. Satallof RT, Castell DO, Katz PO, et al. Reflux Laryngitis
Vaporization continues until patency of the airway is and Related Disorders, 3rd edition. San Diego, California.
Plural Publishing Inc.; 2006.
achieved (Fig. 25.1F). At this point, the general anesthetic
15. Koufman JA. The otolaryngologic manifestations of gas-
is reversed. The laser-resistant endotracheal tube is then
troesophageal reflux disease (GERD): A clinical inves-
removed from the tracheotomy site and a tracheotomy tigation of 225 patients using ambulatory 24-hour pH 25
tube is inserted. monitoring and an experimental investigation of the role
of acid and pepsin in the development of laryngeal injury.
REFERENCES Laryngoscope. 1991; 101(4 Pt. 2, Suppl 53):1-78.
16. Orenstein SR, Shalaby TM, Di Lorenzo C, et al. The spec-
1. Cummings CW. History, physical examination, and the trum of pediatric eosinophilic esophagitis beyond infancy:
preoperative evaluation. Otolaryngology: Head & Neck A clinical series of 30 children. Am J Gastroenterol. 2000;
Surgery, 4th edition. Philadelphia, PA: Mosby; 2005. 95(6):1422-30.
2. Kutta H, Steven P, Paulsen F. Anatomical definition 17. Heuer RJ, Hawkshaw MJ, Sataloff RT. The clinical voice
of the subglottic region. Cells Tissues Organs. 2006; laboratory. In: Sataloff RT. Professional Voice: The Science
184(3-4):205-14. and Art of Clinical Care, 3rd edition. San Diego, CA:
3. Cotton RT. Management of subglottic stenosis. Otolaryngol
Plural Publishing, Inc.; 2005. pp. 355-94.
Clin North Am. 2000; 33(1):111-30.
18. Cotton RT, Richardson MA, Seid AB. Panel discussion:
4. Cummings CW. Glottic and subglottic stenosis.
The management of advanced laryngotracheal stenosis.
Otolaryngology: Head & Neck Surgery, 4th edition.
Management of combined advanced glottic and subglot-
Philadelphia, PA: Mosby; 2005.
tic stenosis in infancy and childhood. Laryngoscope. 1981;
5. Tucker GF. Histopathology of congenital subglottic steno-
91(2):221-5.
sis. Laryngoscope. 1979; 89(6 Pt. 1):866-77.
6. Smith II, Bain AD. Congenital atresia of the larynx. 19. Myer CM 3rd, O’Connor DM, Cotton RT. Proposed
A report of nine cases. Ann Otol Rhinol Laryngol. 1965; grading system for subglottic stenosis based on endotra-
74:338-49. cheal tube sizes. Ann Otol Rhinol Laryngol. 1994; 103
7. Cotton RT. Pediatric laryngotracheal stenosis. J Pediatr (4 Pt. 1):319-23.
20. Nouraei SA, Ghufoor K, Patel A, et al. Outcome of endo-
145
Surg. 1984; 19(6):699-704.
8. Maran AG, Murray JA, Stell PM, et al. Early management scopic treatment of adult postintubation tracheal stenosis.
of laryngeal injuries. J R Soc Med. 1981; 74(9):656-60. Laryngoscope. 2007; 117(6):1073-9.
9. Cotton RT, Evans JN. Laryngotracheal reconstruction in 21. Chandran SK, Sataloff RT. Idiopathic subglottic stenosis.
children. Five year follow up. Ann Otol Rhinol Laryngol. Ear, Nose, and Throat Journal. 2009;88(4):860-1.
1981; 90(5 Pt. 1):516-20. 22. Strong MS, Healy GB, Vaughan CW, et al. Endoscopic
10. Cooper JD, Grillo HC. The evolution of tracheal injury due management of laryngeal stenosis. Otolaryngol Clin North
to ventilatory assistance through cuffed tubes: A pathologic Am. 1979; 12(4):797-805.
study. Ann Surg. 1969; 169(3):334-48. 23. Rahbar R, Shapshay SM, Healy GB. Mitomycin: Effects
11. Jones R, Bodnar A, Roan Y, et al. Subglottic stenosis in on laryngeal and tracheal stenosis, benefits, and complica-
newborn intensive care unit graduates. Am J Dis Child. tions. Ann Otol Rhinol Laryngol. 2001; 110(1):1-6.
1981; 135(4):367-8. 24. Zalzal GH, Loomis SR, Fischer M. Laryngeal recon-
12. Holinger PH, Kutnick SL, Schild JA, et al. Subglottic ste- struction in children. Assessment of vocal quality. Arch
nosis in infants and children. Ann Otol Rhinol Laryngol. Otolaryngol Head Neck Surg. 1993; 119(5):504-7.
1976; 85(5 Pt. 1):591-9. 25. McArthur CJ, Kearns GH, Healy GB. Voice quality after
13. Whited RE. Posterior commissure stenosis post long-term laryngotracheal reconstruction. Arch Otolaryngol Head
intubation. Laryngoscope. 1983; 93(10):1314-8. Neck Surg. 1994; 120(6):641-7.
Ch-25.indd 145 9/8/2010 3:09:16 Gopal

Chapter
Bowed Vocal Folds and
26 Presbyphonia
BOWED VOCAL FOLDS allogeneic collagen laterally (the same position as Teflon)
may be useful. Type I thyroplasty may also be helpful in
The term bowed vocal folds is applied commonly when the selected cases. If the larynx is not too severely ossified, the
vocal folds appear to be slightly concave and when glot- effects of medialization can be predicted to some extent
tic closure seems incomplete. Sulcus vergeture is present by medial compression of the thyroid cartilage. If there is
commonly, as well. Under stroboscopic light, many such a significant height disparity, superficial collagen injection
cases reveal complete glottic closure but some thinning may be of value in selected cases. Approximately, 0.2 cc is
of the cover. Bowing of this sort often is associated with injected into the region of the lamina propria to increase
advanced age. In the past, many patients with this con- the bulk of the vocal fold. This procedure may cause stiff-
dition have been told either that it is incurable or that ness and hoarseness and should be used with caution if
surgery to increase vocal fold bulk or tension is advisable. used at all. Vocal lengthening procedures designed for
In the author’s (RTS) experience, neither statement is pitch elevation have been used. However, improvements
true for most patients. Unless there is neurological dam- are generally shortlived, and this approach is rarely indi-
age, the breathiness, slight hoarseness and voice fatigue cated. Arytenoid adduction/rotation will help restore a
associated with apparent bowing in these patients can unilaterally bowed vocal fold to appropriate height, and
be corrected with specially designed voice therapy, ide- this procedure is useful in the case of complete vocal fold
ally including both speaking and singing exercises. Such paralysis. However, if the superior laryngeal nerve alone is
measures result in satisfactory improvement in the vast paralyzed and the vocal fold is still mobile, this procedure
majority of cases. is generally not a good choice.
True vocal fold bowing occurs with neurologic injury,
particularly superior laryngeal nerve paralysis. This condi- PRESBYPHONIA
tion, often labeled “senile vocal fold atrophy”, creates a
The principles discussed above for surgical management
deficit in longitudinal tension, causing the vocal fold to
of severely bowed vocal folds may be applied in cases
be at a lower level and to bow laterally with increased
of profound presbyphonic changes. However, appropriate
subglottal pressure. When the condition is unilateral and cases are uncommon. In general, medical management
incomplete, voice therapy is usually helpful but rarely and voice therapy are sufficient to restore acceptable vocal
restores normalcy. When the superior laryngeal nerve is quality. Occasionally, judicious medialization procedures
completely paralyzed, treatment is much more difficult. (fat injection, collagen injection, AlloDerm injection or
Collagen injections have been advocated for this situation, thyroplasty) may be called for. Lengthening procedures
as have autologous fat injection, thyroplasty and other are even more rarely appropriate and are often disap-
procedures. pointing. However, in unusual cases of severe and dis-
If dysphonia from vocal fold bowing is severe and turbing masculinization of a female voice, as may occur
recalcitrant to voice therapy, surgery is reasonable. with advancing age, these procedures may have a place
Injection of Teflon into mobile vocal folds is virtu- in conjunction with voice therapy.
ally never necessary or advisable. The potential com- Surgical approaches for vocal fold bowing are reviewed
plications of Teflon do not justify its use under these in the chapter on Vocal Fold Paresis/Paralysis, Chapter
circumstances. However, injection of autologous fat or 29.
Ch-26.indd 146 9/8/2010 3:09:27 Gopal

SECTION 3
Premalignant and Malignant

Lesions of the Larynx
Ch-27.indd 147 9/8/2010 3:09:36 Gopal

Ch-27.indd 148 9/8/2010 3:09:37 Gopal
Chapter
Premalignant Lesions of
27 the Larynx
Carole M Dean, Robert T Sataloff, Farhad Chowdhury, Mary J Hawkshaw
Accurate diagnosis and management of premalignant

lesions of the larynx can prevent the development of
laryngeal carcinoma or allow control of malignancy at
an early stage. When laryngeal examination reveals an
epithelial abnormality suspicious for malignancy a biopsy
is indicated to provide a histological diagnosis. Irregular
masses and ulcerations of the mucosa are most suspi-
cious, but more subtle surface changes are often the earli-
est manifestations of malignancy. Suspicion of cancerous
change is greatly increased when the patient has a history
of known etiologic risk factors; cigarette smoking, alcohol
use, asbestos exposure and occupational chemical or dust
exposure. After biopsy, the laryngologist must work with
the pathologist to develop a management strategy based
on clinical and histological findings.
Fig. 27.1: Mild leukoplakia of the left vocal fold (arrow).

TERMINOLOGY
Clinical Terms Inc.; 2005: Fig. 92.1, with permission
Leukoplakia describes any white lesion of a mucous mem-

brane (Figs 27.1 to 27.3). According to Wenig,1 it is not
indicative of underlying malignant tumor. Erythroplakia, a
red lesion of a mucous membrane, is more often indica-
tive of an underlying malignant tumor. Erythroleukoplakia2
refers to a mix of red and white changes of the mucous
membrane (Fig. 27.4). Pachydermia describes abnormal
thickening of the mucous membrane with or without
leukoplakia (Fig. 27.5).
Histologic Terms
Hyperplasia is the thickening to the epithelial surface as
a result of an absolute increase in the number of cells.
Pseudoepitheliomatous hyperplasia is an exuberant reactive
or reparative overgrowth of squamous epithelium (hyper-
plasia) displaying no cytologic evidence of malignancy.
This lesion is frequently associated with granular cell
Fig. 27.2: Moderate leukoplakia, worse on the left. Reproduced
tumor and may be mistaken for an invasive carcinoma. from Sataloff RT. Professional Voice: The Science and Art of
Keratosis is the presence of keratin on the epithelial sur- Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.;
face. Parakeratosis refers to the presence of nuclei in the 2005: Fig. 92.2, with permission
Ch-27.indd 149 9/8/2010 3:09:37 Gopal

Premalignant and Malignant Lesions of the Larynx
Section
Fig. 27.3: More severe leukoplakia involving both vocal folds and Fig. 27.5: Pachydermia of the posterior larynx, most commonly
an anterior web (arrow). Reproduced from Sataloff RT. Professional associated with chronic laryngopharyngeal reflux. Reproduced from
Voice: The Science and Art of Clinical Care, 3rd edition. San Diego, Sataloff RT. Professional Voice: The Science and Art of Clinical
CA: Plural Publishing, Inc.; 2005: Fig. 92.3, with permission Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005:
Dysplasia is a qualitative alteration toward malignancy in

the appearance of cells consisting of cellular aberrations
150 and abnormal maturation. Cellular aberrations include:
Nuclear enlargement, irregularity and hyperchromatism;
increased nuclear/cytoplasmic ratios; dyskeratosis; crowd-
ing of cells; loss of polarity and increased mitotic activ-
ity. Dysplasia is graded mild if the changes are within
the inner third of the surface epithelium, moderate if it
involves one-third to two-thirds and severe if it is found
from two-thirds to just short of full thickness. Severe
dysplasia is differentiated from Carcinoma in situ (CIS)
by normal maturation in the most superficial layers of
epithelium and from invasive carcinoma (Fig. 27.6) by
the integrity of the basement membrane.
Many classifications have been used to describe laryn-
geal epithelial changes. Many of them are similar; some
Fig. 27.4: Left prominent leukoplakia with mild erythema. Right
erythroplakia (arrowhead) with adjacent patchy white areas of
are more or less identical. However, none of the proposed
leukoplakia. Reproduced from Sataloff RT. Professional Voice: The classification systems is perfect. Friedman’s classification3
Science and Art of Clinical Care, 3rd edition. San Diego, CA: Plural is modeled on gynecologic pathology for lesions of the
Publishing, Inc.; 2005: Fig. 92.4, with permission uterine cervix. They use the term laryngeal intraepithelial
neoplasm (LIN) to include both dysplasia and CIS. Their
keratin layer and dyskeratosis is abnormal keratinization classification is as follows: LIN-I corresponds to mild
of individual cells. Metaplasia is a change from one his- or minimal dysplasia; LIN-II corresponds to moderate
tological tissue type to another, e.g. squamous metaplasia dysplasia and LIN-III corresponds to severe dysplasia and
which denotes the replacement of respiratory epithelium CIS. Unlike cancer of the uterine cervix, many carcinomas
by stratified squamous epithelium, it generally occurs of the larynx do not go through the stage of CIS and are
as a result of tissue injury or insult. Koilocytosis is cyto- invasive from the start.4 Hellqvist’s classification system
plasmic vacuolization of a squamous cell suggestive of is also divided into three groups.5 Group I is squamous
viral infection such as human papilloma virus (HPV). cell hyperplasia with or without keratosis and/or mild
Ch-27.indd 150 9/8/2010 3:09:38 Gopal

Premalignant Lesions of the Larynx
Chapter
Most studies have shown that smoking cessation reduces
the risk of laryngeal cancer. The importance of lifestyle
modification must be emphasized to patients with either
premalignant or malignant lesions. One study showed
that patients who continued to smoke after the diagnosis 27
of head and neck cancer had a fourfold increase in the
recurrence rate over those who did not smoke and double
of those who stopped smoking.17
Heavy alcohol use is also a factor in the develop-
ment of laryngeal cancer and the relative risk is higher for
supraglottic cancer than glottic cancer.18 There has been
a consistent finding of an interaction between cigarette
smoking and alcohol consumption on laryngeal cancer
risk. Yet, while studies have demonstrated that the joint
effect of both cigarette smoking and alcohol consumption
are greater than the sum of the individual effects, the
Fig. 27.6: Leukoplakia associated with T1 invasive carcinoma of biological basis of this synergistic effect are still not clear.
the left true vocal fold. From gross appearance alone, it is not
distinguishable from benign leukoplakia. Reproduced from Sataloff
It has been reported that alcohol and tobacco account for
RT. Professional Voice: The Science and Art of Clinical Care, 3rd over 80% of the squamous cell carcinoma of the mouth,
edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 92.6, pharynx, larynx and esophagus in the United States.19 The
with permission presence of this kind of interaction stresses the impor-
tance of intervention on at least one factor for subjects
dysplasia; Group II is squamous cell hyperplasia with exposed to both habits.
moderate dysplasia; Group III is squamous cell hyper-
plasia with severe dysplasia or classical CIS with full
There is increasing evidence that reflux laryngitis may
be a carcinogenic cofactor in the development of laryn-
151
thickness atypia.6-12 geal cancer. The association of reflux, Barrett’s esophagus
In Europe, a classification system was designed by and esophageal carcinoma is well established and can be
Kleinsasser and has been widely applied throughout the used as an analogous model for the larynx.20, 21 Reflux of
world. His classification has three groups that include: gastric acid causes acute and chronic inflammation of the
Class I = Simple Squamous Cell Hyperplasia larynx; that inflammation may (as in Barrett’s esophagus)
Class II = Squamous Cell Hyperplasia with Atypia cause malignant transformation. Ward et al reported, 19
Class III = CIS cases of laryngeal carcinoma in lifetime nonsmokers who
had moderate to severe reflux.22 Freije et al23 also pro-
EPIDEMIOLOGY AND ETIOLOGICAL FACTORS posed that laryngopharyngeal reflux (LPR) plays a role
in the development of laryngeal carcinoma in patients
Laryngeal cancer is primarily a disease of middle age without the typical risk factors.
with a peak incidence in the sixth and seventh decades. Diet is being increasingly studied as an etiological
In the United States, in the year 2000, its incidence was factor in the development of laryngeal carcinoma and
much higher in men than in women with a 4:1 ratio. its role in the causal pathway has gained importance. It
However, this ratio was 20:1 just twenty years prior; the has been suggested that high intake of fruit, salads and
trend reflects the changing pattern of tobacco use in soci- dairy products may confer a protective effect relating to
ety. This decrease in the male-to-female ratio has also laryngeal cancer.18 There is also evidence that deficiencies
been observed worldwide.13 The incidence is also higher in vitamins A, C, E, beta-carotene, riboflavin, iron, zinc
among black people when compared to Caucasian.13, 14 and selenium have been associated with an increased risk
The major etiological factor in the development of of laryngeal cancer. The relationship between dietary fac-
laryngeal cancer is tobacco use. Numerous studies have tors and the occurrence of laryngeal cancer continues to
shown dose-dependent relationships between cigarette use be studied, as does an individual’s dietary habits related
and the development of cancer.15, 16 Smoking cigarettes to cancers elsewhere in the body.
has a strong association with cancer of the larynx while Radiation exposure and/or avocational or occupational
smoking cigars and pipes have a weaker association.15, 16 exposure to hazardous materials, such as nickel, mustard
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Section
gas, wood products, wood stove emissions, coal mines, keratosis and 9.5% for keratosis with atypia. Blackwell
insecticides, silica and dry-cleaning chemicals, have been et al31 retrospectively reviewed 65 patients with long-term
implicated as etiological factors as well.24-27 The etiologi- follow-up after laryngeal biopsy and found the following
cal effect of asbestos on laryngeal cancer is still controver- cancer rates: 0% (0/6) for keratosis without atypia, 12%
3 sial, but it appears to be limited to active smokers.16 In (3/26) for mild dysplasia, 33% (5/15) for moderate dys-
a study by Maier et al,18 92% of laryngeal squamous cell plasia, 44% (4/9) for severe dysplasia and 11% (1/9) for
carcinoma patients were labeled as “blue-collar” workers. carcinoma in situ.
The risk ratio for those workers having no specialist train- Although the presence and grade of dysplasia cer-
ing or upper education, compared to those with occupa- tainly has prognostic implications, the presence of kera-
tional training or higher education level, was a 3.8:1 ratio. tosis has almost no predictive value. Frangeuz et al29
This means that subjects with low occupational training reviewed 4,291 cases and reported that surface keratosis
levels have a significantly increased risk of developing was present in simple and atypical hyperplasia in 68.8%
laryngeal cancer (after adjustment for alcohol and tobacco and 85.5% respectively. Follow-up of these patients
consumption). showed malignant transformation to be 0.8% of cases
The role of human papilloma virus and its relation- with simple hyperplasia and 8.6% of those with atypical
ship to the development of laryngeal cancer is discussed hyperplasia. Keratosis can mask epithelial changes and is
in detail later in this chapter. not a predictor of underlying atypia. However, dysderato-
The goal of treatment of premalignant laryngeal lesions sis is an important morphological feature in the process
of the larynx is the prevention of malignant transforma- of carcinogenesis.29 One study revealed a transformation
tion or the early diagnosis and treatment of subsequent rate of 50% (6/12) in patients with dyskeratosis.7
laryngeal cancer. Control of potential etiological factors, Blackwell et al8, 31 identified five histological param-
especially tobacco use, is necessary for this treatment to eters that were found to be significantly different when
be effective and complete. comparing dysplastic lesions that resolved or remained
152 stable to those that progressed to invasive carcinoma.
These were abnormal mitotic figures, mitotic activity,
MALIGNANT TRANSFORMATION
stromal inflammation, maturation level and nuclear pleo-
Inconsistent use of terminology in reporting laryngeal morphism. The five factors were not statistically different
cancer has hampered the collection of data that could be when comparing severe dysplasia and carcinoma in situ.
used to create a prognostic classification system. A clinical Surface morphology, nuclear prominence and koilocytosis
term, such as keratosis, can describe a lesion that has nor- were not significantly different in the two groups.
mal underlying epithelium or it can describe the surface Histological examination remains the basis of diag-
of an invasive carcinoma.28, 29 There is poor consistency nosis in mucosal lesions of the larynx, however, the
in the histological diagnoses as well. Goldman30 studied prognostic value of the morphological criteria is limited.
28 patients retrospectively with epithelial hyperplastic Quantification of histological parameters may become
lesions of the larynx. Fifty-two operative biopsies were an important supplement to the traditional grading of
performed. Evaluation by 11 pathologists in four differ- dysplasia. Proliferation associated changes, such as a
ent laboratories yielded 21 different histological diagnoses count of mitotic figures, Ki67 or PCNA labeling index,
exclusive of invasive cancer. The grading of dysplasia is which give additional hard data which are correlated to
subjective. Blackwell et al31 reported that one pathologist histological grade.9-11 DNA histograms are being uti-
performed a blinded review of 148 laryngeal biopsies and lized as an addition to microscopic evaluation. There
only agreed with the original interpretation in 54% of the is evidence that lesions with abnormal DNA content
cases reviewed. However, the majority of cases differed by are more likely to persist or progress to intraepithelial
only one grade level (i.e. mild vs moderate). or invasive carcinoma. However, it is important to note
Although the rate of malignancy associated with a that the same studies show that the lack of abnormal
pathological diagnosis of dysplasia varies widely, the pat- DNA content does not exclude malignant transforma-
tern of increasing risk of malignancy with a worsening tion and that some cancers have so few chromosomal
dysplasia grade is consistent. Fiorella et al6 reported an abnormalities that they are below the threshold sensitiv-
incidence of 6% malignant transformation in keratosis ity of image analysis or flow cytometry.12 The prognostic
without atypia and 17% when atypia was present. Kambic value of p53 immunohistochemistry is controversial3 and
et al28 reported a rate of malignant change of 0.3% for many studies have not found any significant association
Ch-27.indd 152 9/8/2010 3:09:39 Gopal

Chapter
between p53 immunoreactivity and the evolution of aggressive diagnostic biopsy and mucosal preservation.
carcinoma.3,11,32-34 Contact endoscopy may be helpful in guiding biopsy
All patients found to have dysplastic lesions of the location. Vocal fold stripping is no longer indicated in
laryngeal mucosa need to be followed closely for many the treatment of mucosal lesions of the vocal folds.
years. Progression to invasive carcinoma often is a slow
Carcinoma in Situ (CIS)
27
process allowing for early diagnosis which should yield
improved cure rates. Blackwell et al31 reported that the CIS is defined as cellular dysplasia involving the entire
average interval between the first biopsy and the diag- thickness of the mucosa without compromise of the base-
nosis of invasive carcinoma was 3.9 years, suggesting ment membrane. The dysplasia may extend into adjacent
that a 5 to 10-year follow-up plan is reasonable. Velasco mucous glands and is still considered and in situ lesion,
et al7 also suggested a more strict follow-up of patients as long as the lesion is confined to the duct and does
with dyskeratosis as a result of a 50% (6/12) malignant not extend in the periductal lamina propia.1, 35 In other
transformation rate. Their report was based on a retro- words, it is a malignant epithelial neoplasm which has all
spective study in which all pathologies were reviewed by the characteristics of a true carcinoma except invasiveness
pathologist. The period of follow-up ranged from 12 to and the ability to metastasize.36 It may exist as an isolated
130 months with a mean of 73 months follow-up. Their lesion, but it is frequently associated with an invasive
conclusion was that there is a longer interval between squamous cell carcinoma (SCC), lying either adjacent to
biopsy and malignant changes when you compare with or remote from it.1 Unlike cervical intraepithelial neo-
patients having invasive carcinoma, the majority of whom plasia, laryngeal CIS is not a required precursor to SCC.
will relapse within 2 years. The ability to provide dedi- Pathologically, the difference between CIS and severe
cated long-term care for patients at risk for head and dysplasia may be very difficult to determine with abso-
neck cancer is now limited by the financial constraints of lute certainty and is in many ways subjective, resulting in
managed care30 in addition to all the other factors that wide differences in the reported incidence and prevalence.
have resulted in their delayed diagnosis and treatment.
The value of clinical examination, including strobovideo-
However, in practice, the difference between these two
lesions is not critical, as both indicate a significant risk
153
laryngoscopy, at regular intervals cannot be overstated. for the future development of invasive cancer.
The senior author (RTS) follows his patients every CIS must be evaluated carefully and invasive carci-
1−3 months for cancer surveillance with videostroboscopy noma must be ruled out. This is even more significant in
performed at each office evaluation. Such practice allows the face of CIS of the supraglottis and subglottis than
for early diagnosis of small invasive carcinomas and use of on the vocal folds,1 as those two sites are considered the
surgical options that yield greater laryngeal preservation “silent area” that usually presents at a later stage of dis-
and better voice quality postoperatively. ease. Thus, CIS generally is present in association with an
The strategy of biopsy differs if there is a single area invasive carcinoma.37 If a small biopsy reveals CIS, then
of suspicion versus broad or multifocal lesions. Single, there must be a high suspicion that an adjacent invasive
small lesions should be excised with a small mucosal mar- cancer was missed, as reported by Ferlito et al.36
gin. This will be sufficient treatment for many dysplas- The incidence of CIS ranges from 1 to 15% of laryn-
tic lesions and intraepithelial neoplasms. When excision geal tumors.36 There is a distinct male predominance and
requires the removal of a large area of a true vocal fold, or it is most frequently seen in the sixth and seventh decades
a critical site, such as the anterior commissure or medial of life.1 Although it can occur anywhere in the larynx, it
margin, a small incisional biopsy may be more appropri- most often involves the anterior portion of one or both
ate to allow for treatment planning with optimal voice vocal folds.1, 36, 38 It may appear as leukoplakia, erythro-
preservation. In patients with broad-based or multifocal plakia or hyperkeratosis. CIS is a microscopic diagno-
lesions, accurate microscopic biopsy at multiple sites is sis and its presenting signs, symptoms and appearance
required. While it is always possible for biopsy sampling is indistinguishable from other lesions of dysplasia or
to miss areas of invasive carcinomas, these techniques hyperkeratosis.36
are usually sufficient. However, if invasion is suspected The biological behavior of this tumor is unknown.
clinically and not confirmed pathologically, the surgeon However, the main pathological issue is whether or not
and patient must be prepared to proceed with additional all CIS will eventually develop into invasive carcinoma.
biopsies. The availability of high resolution microscopic Auerbach et al5 present indirect evidence that in some
guidance with suspension laryngoscopy permits both cases laryngeal CIS may be reversible in an autopsy study
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Section
that showed lower rates of CIS in exsmokers than in two explanations for the discrepancies found in the
active smokers. Stenersen et al4 observed 41 patients with published data. First, there may be understaging of CIS
the diagnosis of CIS or severe dysplasia, but who did (false CIS) and second, the total doses of radiation given
not develop invasive carcinoma in the first year follow- where inadequate. Most CIS lesions are treated surgi-
3 ing their initial biopsy. The average observation time was cally because the biopsy itself provides the opportunity
100 months. Forty-six percent (19/41) developed inva- for complete excision in many cases and because of the
sive SCC after a mean interval of 50 months and 54% limitations of primary radiation therapy. Most impor-
(22/41) returned to normal mucosa. In a literature review, tantly, patients with CIS are at increased risk to develop
Bouquot and Gnepp39 found that an average of 29% of epithelial malignancy at other laryngeal and head and/
cases of laryngeal CIS eventually resulted in invasive car- or neck sites, the mucosa field effect. Dedicating a large
cinoma with a range in the different studies of 3.5−90%. portion of the lifetime radiation dose to the treatment
Untreated cases of CIS were associated with higher rates of an early premalignant lesion or superficially malignant
of transformation: 33.3−90%. When considering all of lesion may limit severely future treatment options if an
these data, it appears that some cases of CIS are revers- invasive malignancy arises at another site. Additionally,
ible if the patient controls tobacco use. Yet, despite close radiation therapy requires an extended course of treat-
observation and treatment, many CIS lesions will progress ment41, 42 and its secondary effects on the local mucosa
to invasive carcinoma. can mask recurrent tumors.41 Yet, radiation therapy still
There are some prognostic factors that can be utilized plays a major role in the treatment of CIS and microinva-
to guide treatment of patients with CIS. Myssiorek et al37 sive carcinoma. Radiation therapy is indicated in patients
studied 41 patients with CIS retrospectively and found who are poor risks for general anesthesia, those who have
a much higher rate of transformation in lesions of the recurrent lesions after previous surgical excision, lesions
anterior commissure (92%) (11/12), than lesions on the that cannot be adequately exposed or resected endoscopi-
membranous vocal fold (17%) (5/29). This may reflect cally and patients with recurrent lesions who cannot be
adequately followed.37,40-44
154 understaging caused by inadequate biopsy at the ante-
rior commissure. This study also found no association of
epidermal growth factor receptors (EGFR) in predicting LARYNGEAL PAPILLOMAS
lesions that will progress to invasive cancer. Epidermal
growth factor (EGF) may play a role in the regulation of
Human Papilloma Virus Epidemiology and
the growth of cancer of the larynx. Some in vitro stud- Molecular Biology
ies have shown that cancer cells are stimulated by EGF/
EGFR (immunohistochemical analysis of over expres- Human papilloma virus (HPV) is a small, nonenveloped
sion), while others evaluated if it had any prognostic DNA virus. More than 70 HPV types have been iden-
value in determining which premalignant lesion or CIS tified. Based on studies of cervical cancer, different
would progress to invasive carcinoma. Results concern- HPV16,18,31,33,35 types have been graded as high-risk
ing its usefulness are inconsistent in the literature.3, 32 oncogenic viruses because they are associated with high
In another study, 37% (7/19) of patients with CIS who grade dysplasia or invasive carcinoma. The low-risk HPV
developed invasive carcinoma were found to have had types6,11,13,32,34,40,42-46 are usually associated with benign
the carcinoma arise at a different anatomic site from the lesions such as uterine cervical condylomas. HPV 6 and
original CIS.4 The authors concluded that there should be HPV 11 are commonly associated with genital lesions as
a high clinical suspicion of a lesion that arises separately well as with laryngeal papillomas.45 HPV types 16 and
from the site of known CIS 18 also occur in the larynx.46
Treatment of CIS has included surgery and radia- There is a high correlation of the risk of malignant
tion therapy. A recent review of primary surgical treat- transformation of infected cells in the presence of high-
ment with microscope laser excision showed a local risk virus types. The viral genome of the HPV includes
recurrence rate of 8% and an ultimate control of 100%. the E6 and E7 oncogene that is responsible for the viral
Smalls et al40 review revealed that radiotherapy as the proteins E6 and E7 respectively. The properties of these
primary treatment of CIS yielded an overall recurrence two oncoproteins have been reported extensively. High-
rate of 96%, following salvage treatment. They offered risk types of HPV encode E6 and E7 oncoprotein that
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Chapter
bind the Rb-related proteins and p53 with as much as represents p53 over expression or only stabilized wild
10-fold higher affinity, than the low-risk HPV types.47 type p53 gene product and whether this possible over
For example, the E6 oncoprotein of HPV 16, can complex expression may be a marker of malignant transformation.
with the host cell p53 tumor suppressor protein thereby The staining pattern of the c-erbB-2 oncogene changed
inducing p53 degradation.45, 46 Loss of p53 function leads from membranous to cytoplasmic in cells demonstrating 27
to deregulation of the cell cycle and promotes mutation, atypical hyperplasia. The real impact of this change also
chromosomal instability and carcinogenesis of the host requires further study.
genome. Nevertheless, it has been reported that p53 can Majoros et al48 published a pathological review of
still preserve the tumor suppressor activity in the presence 101 patients with juvenile laryngeal papillomatosis treated
of HPV types 6 and 11, which are the predominant types at the Mayo Clinic between 1914 and 1960 and noted
in laryngeal papillomatosis.46 greater cellular activity from the beginning of the dis-
The relationship between HPV, p53 and other cel- ease process in the 6 patients who underwent malig-
lular control genes in SCC of the head and neck is nant transformation. This may also reflect the difficulty
potentially complex. Molecular epidemiological research in histologically diagnosing malignant transformation in
is needed to evaluate the independent and joint effects benign papillomas.49-51 Majoros48 retrospective study of
of tobacco, HPV and alterations of other genes involved 101 patients with the juvenile form of the disease revealed
in carcinogenesis. no carcinoma in the 58 patients treated only with surgery
Estimates of the prevalence of HPV types in normal and a malignancy rate of 14% (6/43) in the irradiated
tissue, benign papillomas and cancers of the larynx are patients. The interval between the radiation therapy
inconsistent because of the ongoing evolution in typing (XRT) and the diagnosis of carcinoma ranged from 6 to
methods. Polymerase chain reaction (PCR) is a method of 21 years except in one patient with an interval of only
amplifying target sequences from a DNA specimen thus one year.
providing a higher degree of sensitivity than traditional Clinical data regarding the association of laryngeal
hybridization methodologies. A high interlaboratory
agreement has been achieved on sample acquisition
papillomas and carcinoma are variable. The incidence of
cancer is higher in patients with papillomas that have
155
and processing methods, leading to concordant results. received radiation therapy (XRT). Lindeberg et al.52
McKaig et al45 reviewed the literature to determine HPV found that XRT produced a 16-fold increased risk of
prevalence in head and neck cancer. Using PCR, HPV developing subsequent carcinoma compared to non-
was found in 34.5% (416/1205). Forty percent contained irradiated patients. These results support the commonly
HPV 16, 11.9% contained HPV 18 and 7% contained accepted view that cofactors play an important role in
both types. In addition, 3.8% were positive for HPV 6, human papilloma virus (HPV)-related cancer. Rabbett’s53
7.4% for HPV 11 and 10.9% for both HPV 6 and HPV statement that the only cases of juvenile laryngeal papil-
11. Prevalence was also reported by site with 33% of lomatosis at risk for malignancy are those with a history
laryngeal carcinomas found to be positive. Of those, 46% of XRT has been proven wrong in the recent literature.
contained HPV 16 and 15.9% contained HPV 16 and Shapiro et al54 reported a case of cancer in a juvenile
HPV 18. Despite the prevalences reported, no correlation laryngeal papilloma ( JLP) patient without a history of
between virus infection and disease course or prognosis XRT, but with a history of heavy cigarette and alcohol
could be made. use. There were three other similar cases from the lit-
The precise mechanism of malignant transformation erature also described in that review. In 1982, Bewtra
in laryngeal papillomatosis is still unknown. In a ret- et al55 reported one patient with malignant transforma-
rospective study of 24 cases of laryngeal papillomatosis, tion of JLP without any history of XRT, smoking or
Luzar et al46 tried to determine any prognostic markers alcohol use. This report also reviewed four other cases of
that might reflect the biologic behavior of the infected malignant transformation in patients with longstanding
epithelium; they found that 23 of the 24 cases were HPV diffuse papillomatosis involving the trachea and bronchi
positive using PCR. All sections were immunostrained as well as the larynx. Keim51 also reported a single case
for p53 protein and for c-erbB-2 oncogene product. of malignant change in a patient with JLP without any
The authors concluded that further molecular studies history of XRT. Assessing all these reports, it is apparent
are needed to investigate whether increased p53 truly that, while uncommon, it is certainly possible for benign
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Section
laryngeal papillomas to undergo malignant transforma- of etiologic risk factors and careful preparation and
tion without the stimulus of radiation. The possible effects examination of biopsy specimens. Majaros et al.48 stated
of treatment of papillomas (such as repeated laser exci- that as all of their patients had been hoarse from the
sion) on the development of malignancy are unknown, time of their original presentation with papillomas, there
3 but we believe that they warrant study. were no early clinical signs of malignancy. Consequently,
Lie et al56 presented a retrospective study of 102 presenting signs and symptoms are superimposed on
patients with laryngeal papillomas treated between 1950 the underlying papillomatosis and may include airway
and 1979 with follow-up ranging 4−58 years. Eight obstruction, throat pain, referred otalgia and hemoptysis.
patients developed carcinoma (seven laryngeal and one Both Keim51 and Fechner et al49 report patients with
bronchial). The intervals between diagnosis of the benign progressive symptoms of malignancy, but benign histol-
papillomas and diagnosis of cancer were 4−55 years. Three ogy on early biopsies before invasive cancer was diag-
patients had the juvenile form of disease and five had the nosed. When the clinical suspicion is justified, repeated
adult type. The male to female ratio was 1:1. Two patients biopsy, deep biopsy and even laryngectomy may be nec-
had received XRT, four were smokers, and one patient essary to establish an accurate diagnosis. It is essential
had received bleomycin and interferon. The authors con- for the patient to be informed fully in such challenging
cluded that HPV played a role in carcinogenesis, but that clinical circumstances. Singh and Ramsaroop50 reviewed
cofactors may also have played an important role. Klozar 3 of 17 papilloma patients who developed cancer that
et al57 reported a retrospective study of 179 HPV infected revealed yet a different potential problem: Simultaneous
patients with a 1.7% incidence of cancer. These patients presentation of benign and malignant exophytic laryngeal
underwent 668 operations from 1982 to 1995. When he lesions. All 3 cancer patients were diagnosed less than one
separated the patients by their clinical presentation, he year after their diagnosis of papillomas. Singh et al. con-
found the incidence of malignancy to be 3% (3/102) in cluded that clinical indicators for carcinoma in patients
patients with the adult form and 0% (0/77) in those with with papillomas include gross laryngeal edema, airway
156 the juvenile form.
The concept of a possible cofactor in malignant trans-
obstruction, reduced vocal fold mobility, dysphagia, sub-
glottic extension and cervical adenopathy. When malig-
formation was supported by Koufman and Burke.21 They nant transformation of laryngeal papillomas is suspected,
found 21% (14/88) of patients with adult onset papillo- a benign biopsy result may be misleading. Atypia can
matosis developed SCC of the aerodigestive tract either at be found in both adult and juvenile papillomas and is
the site of the known papilloma or at another site after a not predictive of malignant transformation.45 Clinical
10-year follow-up. All the patients who developed cancer suspicion based on presenting signs and symptoms, and
were smokers or had documented gastroesophageal reflux a complete history of risk factors should guide patient
disease (GERD). Franceschi et al47 reviewed HPV and management.
cancer of the upper aerodigestive tract and found that the
association of smoking, drinking and betel nut chewing CONCLUSION
was too pervasive to permit judgment about HPV as a
carcinogenesis factor. It is important for laryngologists to be familiar with the
Rabkin et al58 studied the incidence of second primary board spectrum of benign premalignant and malignant
cancer in over 25,000 women with cervical cancer from disease that may afflict the larynx. Premalignant lesions
reported from 9 US cancer registries. There was a signifi- must be assessed histologically for malignancy and the
cantly increased risk of cancer of the oral cavity (relative entire larynx must be fully evaluated because of the risk of
risk 2.2) and of the larynx (relative risk 3.4). As HPV is multifocal abnormalities. Adequate preoperative exami-
a well-established risk factor for development of cervical nation, meticulous surgical techniques and long-term
cancer, this suggests that the cervical cancer and second surveillance are necessary in every case. Although early
primaries may share HPV as a causal agent. detection of carcinoma must be our primary goal, diag-
Malignant transformation of laryngeal papillomas is nostic and treatment strategies should be individualized
diagnosed as a result of clinical observation, assessment with functional considerations in mind.
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Chapter
27
A B
157
C D
Figs 27.7A to D: (A) An endoscopic view of an exophytic mass on the right true vocal fold. (B) A 70o endoscope is used to determine
more accurately the borders of the mass. (C) Subepithelial infiltration with saline and epinephrine separates the lesion from the underlying
vocal ligament and causes vasoconstriction of the microvasculature. (D) An incision is made at the junction of normal and abnormal tissue

Subepithelial infiltration with saline and 1:10,000 epine-
Step 1 phrine separates the lesion from the underlying vocal
Orotracheal intubation followed by suspension micro- ligament (Fig. 27.7C). In addition, the injection causes
laryngoscopy is used to visualize the lesion (Fig. 27.7A). vasoconstriction of the epithelial microvasculature.
Step 2 Step 4
Using various endoscopes, particulary one at a 70° view- Using a straight Sataloff Sharp Knife, an incision is made
ing angle, a more accurate assessment of the borders of through the epithelium at the lateral border of the lesion
the mass can be made (Fig. 27.7B). (Fig. 27.7D).
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Section
E F
158
G H
Figs 27.7E to H: (E) The mass is grasped and gently retracted medially. The anterior cut is delicately made using endoscopic scissors,
placing one tyne in the incision and one tyne outside the mucosa. (F) A posterior cut is made in a similar fashion. (G) The mass is
stabilized with minimal retraction toward the midline and sharp dissection continues anteriorly. (H) The mass is resected. There is
minimal trauma to the vocal ligament and uninvolved epithelium has been preserved
Step 5 Step 7
A straight microscissor is used to spread on the under- Sharp dissection of the mass with a microscissor continues
surface of the lesion, dissecting it away from the vocal from a posterior to anterior direction (Fig. 27.7G).
ligament.
Step 8
Step 6 The defect created by the excised mass (Fig. 27.7H)
The mass is gently grasped with a Sataloff Heart- shows minimal trauma to the underlying vocal ligament.
shaped Grasper and stabilized with minimal retraction There has been maximal preservation of the surrounding
toward the midline. The anterior (Fig. 27.7E) and pos- uninvolved epithelium. The patient is extubated deep and
terior (Fig. 27.7F) limits of the lesion are incised with is placed on strict voice rest for 7 days.
a microscissor.
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Chapter
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17. Stevens MH, Gardner JW, Parkin JL, et al. Head and neck Immunohistochemical expression of mettallothionein in
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1983; 109(11):746-9.
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larynx: correlation with p53 and proliferative cell nuclear 47. Franceshi S, Munoz N, Bosch XF, et al. Human papil-
antigen. Pathol Res pract. 1999; 195(12):809-14. lomavirus and cancers of the upper aerodigestive tract:
35. Fried MP. The larynx: A Multidisciplinary Approach, 2nd a review of epidemiological and experimental evidence.
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pp. 470-73. 48. Majoros M, Devine KD, Parkhill EM. Malignant trans-
3 36. Ferlito A, Polidoro F, Rossi M. Pathological basis and formation of benign laryngeal papillomas in children after
clinical aspects of treatment policy in carcinoma in situ of radiation therapy. Surg Clin North Am. 1963; 43:1049-61.
the larynx. J Laryngol Otol. 1981; 95(2):141-54. 49. Fechner RE, Goepfert H, Alford BR. Invasive laryngeal
37. Myssiorek D, Vambutas A, Abramson AL. Carcinoma papillomatosis. Arch Otolaryngol. 1974; 99(2):147-51.
in situ of the glottic larynx. Laryngoscope. 1994; 104(4): 50. Singh B, Ramsaroop R. Clinical features of malignant
463-7. transformation in benign laryngeal papillomata. J Laryngol
38. Myers EN, Sven JY. Cancer of the Head and Neck, 3rd edi- Otol. 1994; 108(8):642-8.
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39. Bouquot JE, Gnepp DR. Laryngeal precancer: a review report. Otolaryngol Head Neck Surg. 1980; 88(6):773-7.
of the literature, commentary, and comparison with oral 52. Lindeberg H, Elbrond O. Malignant tumors in patients
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40. Small W Jr, Mittal BB, Brand WN, et al. Role of radia- nificance of irradiation. Clin Otolaryngol Allied Sci. 1991;
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41. Maran AG, Mackenzie IJ, Stanley RE. Carcinoma in situ of irradiation to malignant degeneration in this disease.
of the larynx. Head Neck Surg. 1984; 7(1):28-31. Ann Otol Rhinol Laryngol. 1965; 74(4):1149-63.
42. Nguyen C, Naghibzadeh B, Black MJ, et al. Carcinoma 54. Shapiro RS, Marlowe FI, Butcher J. Malignant degenera-
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43. Rothfield RE, Myers EN, Johnson JT. Carcinoma in situ 55. Bewtra C, Krishnan R, Lee SS. Malignant Changes in
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44. Medini E, Medini I, Lee CK, et al. The role of radio- 56. Lie ES, Engh V, Boysen M, et al. Squamous cell carcinoma
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45. McKaig RG, Baric RS, Olshan AF. Human papillomavirus 57. Klozar J, Taudy M, Betka J, et al. Laryngeal Papilloma—
and head and neck cancer: epidemiology and molecular precancerous condition? Acta Otolaryngol Suppl. 1997;
biology. Head Neck. 1998; 20(3):250-65. 527:100-2.
46. Luzar B, Gale N, Kambic V, et al. Human papillomavi- 58. Rabkin CS, Biggar RJ, Melbye M, et al. Second pri-
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527:120-4. 136(1):54-8.
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Chapter
28 Laryngeal Cancer
Timothy D Anderson, Robert T Sataloff, Farhad Chowdhury
Carcinoma of the larynx represents approximately 1.3% lesions is critical. In early lesions, treatment usually con-
of all new cancer diagnoses and approximately 20% of all sists of either surgery or radiation therapy, with the choice
head and neck cancers. In 2001, the American Cancer based on the individual’s history and tumor characteris-
Society estimated that in the coming years there would tics, as well as the potential effects on laryngeal function.
be approximately 10,000 new cases of laryngeal cancer In advanced lesions, usually both surgery and radiation
with a 4:1 male to female ratio and that there would be therapy are necessary to optimize long-term survival. New
4,000 deaths due to laryngeal cancer.1 Thirty-five years protocols utilizing neoadjuvant or concomitant chemo-
ago the male to female ratio was between 10:1 and 50:1, therapy have offered some patients with advanced lesions,
the change is probably due to increasing use of tobacco the opportunity to be cured without the need for total
and alcohol among woman.2 Although laryngeal cancer laryngectomy.12
is primarily a disease of older age with peak incidence in
the sixth and seventh decades, it does occur in younger SUPRAGLOTTIC TUMORS
patients, including children.3 Younger patients who
present with laryngeal carcinoma most often are non- The supraglottic larynx extends from the tip of the epi-
smokers who do not have other identifiable risk factors glottis to the ventricles. It includes the laryngeal surface
for laryngeal cancer, suggesting a genetic predisposition.3 of the epiglottis, the aryepiglottic folds, the false vocal
Overall, the major etiological factor in laryngeal cancer folds, the laryngeal surface of the arytenoids and the ven-
is exposure to tobacco. Studies have shown an increased tricles (Fig. 28.1). The mucosa of the lingual surface of
incidence of both premalignant and malignant lesions the epiglottis is in the supraglottic larynx, but the mucosa
in smokers and a dose-dependent relationship between of the vallecula is oropharyngeal. The lymphatic drainage
cigarette use and the development of cancer.4-6 Laryngeal of the supraglottis is extensive. It traverses the thyrohy-
cancer in nonsmokers is rare. Heavy alcohol use is also a oid membrane and travels with the superior laryngeal
factor in the development of laryngeal cancer and there vessels to the deep jugular nodes. This lymphatic path-
appears to be a synergistic effect with tobacco, especially way is separate from the inferior drainage of glottic and
in the development of supraglottic tumors.7 Radiation subglottic tumors owing to a difference in embryological
exposure and exposure to occupational pollutants, such as development. Thus, surgical management of supraglottic
nickel, mustard gas, wood products and pesticides, have tumors is a distinct entity.
also been implicated as etiological factors.4,8,9 The etio- Supraglottic cancer spreads in a pattern dependent
logical effect of asbestos on laryngeal cancer is not yet on its site of origin. It can spread over mucosal surfaces
well documented, but it appears to be limited to active to adjacent structures or it can traverse cartilaginous or
smokers.10,11 Laryngopharyngeal reflux and laryngeal fibrous barriers into deeper spaces. The pre-epiglottic space
papillomatosis may causally be related to cancer. anteriorly is a common site for spread of the epiglottic
Due to the larynx’s unique functions of speech, tumors. This area is abundantly supplied with lymphatics
swallowing and airway protection, treatment of laryn- and invasion of the pre-epiglottic space predisposes to
geal cancer has always been complex and controversial. neck metastases and allows unobstructed cancer extension
Carcinoma of the larynx is a potentially curable disease inferiorly to the anterior commissure and subglottis. The
with a 5-year survival rate of over 67%. However, early paraglottic space, lateral to the endolarynx, is an early
detection of smaller lesions offers a much better oppor- site of spread of false vocal fold and ventricular tumors
tunity for both survival and preservation of laryngeal (Fig. 28.2). Paraglottic space involvement provides for
function. Thus, aggressive clinical evaluation of laryngeal rapid transglottic and subglottic extension.13
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Section
Fig. 28.1: Regions of the larynx
Most clinicians utilize the staging system based on

the American Joint Committee (AJC) for Cancer Staging
and End Result Reporting. Its most recent revision
(1988) is seen in Table 28.1.14 There is little emphasis
on tumor size, with extent of mucosal spread determining
162 the tumor’s class. Progression to T3 status is determined
by fixation of the hemilarynx, involvement of postcricoid
and pyriform mucosa or pre-epiglottic extension. Lymph
node staging is standard for all head and neck cancer
(Table 28.2).
Patients with supraglottic cancer can present with sore
throat, voice change such as hoarseness and dysphagia,
otalgia, halitosis, weight loss or neck mass. The voice is
usually muffled, but true hoarseness is usually a sign of a
transglottic tumor, vocal fold fixation or a low false vocal
fold lesion. Symptoms are often subtle and insidious and
Fig. 28.2: Compartments and barriers in the larynx many tumors are quite extensive at presentation. The cli-
nician must be especially suspicious of supraglottic cancer
in patients with persistent complaints of sore throat and
Table 28.1: Staging of primary tumor in laryngeal
otalgia.
cancer
Lymph node metastases occur in 25−50% of patients
Supraglottis with supraglottic cancer; 30−50% are palpable at presen-
T1 — Tumor limited to one subsite of the supraglottic with normal tation and 20−40% are occult in neck with clinically nega-
vocal fold mobility tive findings.15-19 Contralateral disease is common. The
T2 — Tumor invades more than one subsite of supraglottis or
rate of metastasis increases with tumor size but ranges
glottis with normal vocal fold mobility
T3 — Tumor limited to the larynx with vocal fold fixation and/
from 15−40% even in T1 tumors.15-18
or invades postcricoid area, medial wall of pyriform sinus
or pre-epiglottic tissues Treatment Considerations
T4 — Tumor invades through thyroid cartilage and/or extends to Accurate assessment and staging are critical in deter-
other tissues beyond the larynx mining treatment. Computed tomography scanning
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Chapter
with contrast infusion can help in judging the size and Table 28.2: Staging of lymphatic metastasis in
location of the primary tumor and the extent of lymph laryngeal cancer
node involvement.19 Magnetic resonance imaging (MRI) NX — Regional lymph nodes cannot be assessed.
scanning may be useful, but in most cases CT imaging N0 — No regional lymph node metastasis.
of the larynx is sufficient. All patients should undergo N1 — Metastasis in a single ipsilateral lymph node, 3 cm or less 28
operative laryngoscopy to visualize and palpate the extent in greatest dimension
of the cancer. However, flexible laryngoscopy, especially N2 — Metastasis in a single ipsilateral lymph node, more than
with stroboscopy and video documentation, can provide 3 cm, but not more than 6 cm in greatest dimension or
multiple ipsilateral lymph nodes, none more than 6 cm
an excellent overall assessment and allow operative endos-
in greatest dimension, or bilateral or contralateral lymph
copy to be reserved for the time of definitive treatment. nodes none more than 6 cm in greatest dimension.
This is especially helpful in patients with airway compro- N2a — Metastasis in a single ipsilateral lymph node more than
mise or other significant medical conditions. A thorough 3 cm but not more than 6 cm in greatest dimension.
search for a metachronous primary must be completed, as N2b — Metastasis in multiple ipsilateral lymph nodes, none more
the incidence has been reported to be as high as 20−30% than 6 cm in greatest dimension.
with aerodigestive tract tumors.20 N2c — Metastasis in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension.
In stage I lesions, cure rates with surgery and radiation
N3 — Metastasis in a lymph node more than 6 cm in greatest
therapy are equivalent (75−80%).21,22 Radiation therapy, dimension.
at least within the first year, results in less speech and
swallowing morbidity than laryngeal surgery and gener-
ally is well tolerated. Voice results following treatment with a primary lesion T2 or larger and N0 neck are at
(radiation vs surgery) have not been studied convincingly, risk for bilateral occult neck metastasis and should be
and there is at least a possibility that voice results, 5 treated. Radiation therapy and modified neck dissection
and 10 years after treatment may prove superior after are equally effective.17 In smaller tumors that are treated
limited surgery than after irradiation. Surgery is advan-
tageous in patients with limited primary lesions and in
with primary radiotherapy, both sides of the neck should
also be radiated. Patients who are going to undergo
163
younger patients (thus, reserving radiation for those who planned postoperative radiotherapy also can be spared
may develop another primary tumor later in life).21,22 bilateral neck dissections through irradiation of one or
In stages II and III lesions, treatment options are var- both N0 necks. However, there are significant advantages
ied. For treatment of the primary site, neither surgery to treating the primary lesion surgically and performing
nor radiation with surgical salvage has shown a superior simultaneous, bilateral, modified neck dissections.27,29-32
cure rate and the use of combined therapy is not sup- If there are no metastases, postoperative radiation may
ported clearly.23-25 Using primary radiation therapy is an not be warranted. The discovery of occult nodes can guide
attractive alternative to surgery.26,27 However, the cervical the use of postoperative radiation. Ultimately, the deci-
nodes cannot be assessed, and the morbidity of salvage sion will be influenced by the patient’s history and condi-
surgery must be considered. Most patients undergoing tion, the quality of radiation treatment available and the
salvage surgery will require total laryngectomy, although surgeon’s experience performing conservation modified
partial laryngectomies can be performed safely in selected neck dissection. Recognized indications for postopera-
postirradiation patients. Primary supraglottic laryngec- tive radiotherapy include large tumors, bulky neck disease,
tomy can yield local control rates as high as 90% with extracapsular spread of nodal disease and perineural or
low morbidity.27,28 Stage IV lesions can be treated either angiolymphatic invasion.
with combined surgery (usually a total laryngectomy) in A few data support the need for neck dissection fol-
combination with radiation therapy or with combined lowing chemoradiation therapy for supraglottic tumors.
chemotherapy and radiation therapy in selected patients. Certainly, most residual neck masses should be treated
Protocols combining chemotherapy and radiation have by a neck dissection. In addition, patients who had neck
the advantage of laryngeal preservation in up to two- disease larger than 2−3 cm in size prior to chemoradia-
thirds of patients with equivalent survival.12 tion probably should undergo neck dissection following
Treatment of metastatic neck disease is another con- chemoradiation therapy; because there is a higher inci-
troversial area in the care of supraglottic cancer. Patients dence of residual disease in these patients.33, 34 Local and
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Section
regional recurrence rates are higher after primary chemo- and sensation of the remucosalized larynx are excellent.
radiation when compared to surgery and radiation, which Robotic surgery may prove to be a useful alternative
underscores the importance of aggressive surveillance of to the standard endoscopic approach. Neck dissections
the primary site and the need for neck dissections in are performed several days to weeks after the primary
3 patients with poor prognostic features.12 operation. Oncologic results have been reported to be
equal or superior to open supraglottic laryngectomy.36-39
Surgical Procedures Recurrences often can be treated adequately with repeated
Small T1 cancers limited to the epiglottis can be treated transoral laser excision.40
by transoral, subtotal supraglottic laryngectomy. Relative The standard surgical procedure for cancer, isolated
contraindications to this approach are involvement of the above the vocal folds is the horizontal supraglottic laryn-
pre-epiglottic space, the petiole of the epiglottis, the free gectomy. It can be used for any laryngeal tumor supe-
margin of the false vocal fold or the presence of palpable rior to the ventricles including tumors that involve the
neck disease. Additionally, endoscopic visualization is dif- laryngeal surface of the epiglottis, the medial wall of the
ficult without a large or bivalved laryngoscope designed pyriform sinus above the apex and the aryepiglottic folds.
to provide a wide field of view in the supraglottis.35 The It is contraindicated in patients with vocal fold fixation,
procedure is performed under general anesthesia usually thyroid cartilage invasion or if there is involvement of
with the carbon dioxide (CO2) laser. A laser-safe endotra- the arytenoid cartilage, ventricle, apex of the pyriform
cheal tube is used and a tracheotomy is not necessary. The sinus, anterior commissure, intra-arytenoid area, base
pre-epiglottic space is evaluated during the dissection. If of tongue, paraglottic space or soft tissues of the neck.
pre-epiglottic space invasion is noted, the procedure is Additionally, patients must be in good general health. A
converted to an open, supraglottic laryngectomy. When horizontal hemilaryngectomy allows for normal or near-
endoscopic visualization is difficult, external access to the normal deglutition postoperatively due to the sparing of
supraglottic larynx can be obtained through a transverse, the vocal folds, which will continue to perform their role
164 suprahyoid pharyngotomy or a lateral pharyngotomy in
the pyriform sinus.
in airway protection. However, the patient must be able
to learn a new swallowing technique and must be able to
Although not yet widely used, endoscopic transoral sense and cough out any aspirated material. The patient
CO2 laser resection of larger supraglottic tumors has been must be cooperative, motivated and strong enough to tol-
reported in the literature.36-39 This technique is also per- erate prolonged postoperative rehabilitation. Patients with
formed under general anesthesia with a laser-protected inadequate pulmonary function or poor compliance may
endotracheal tube and wide exposure using a bivalved suffer life-threatening aspiration postoperatively and total
laryngoscope. Although various techniques have been laryngectomy is indicated in this patient population.
described,37-39 most begin with dividing the epiglottis in Supraglottic laryngectomy is performed under gen-
half and dissecting the midline pre-epiglottic space until eral anesthesia with a tracheotomy in place. A separate
the superior surface of the thyroid cartilage is identi- horizontal skin incision is performed and subplatysmal
fied. Dissection is then carried along the edge of the flaps are raised (Fig. 28.3). The strap muscles are divided
superior portion of the thyroid cartilage from anterior in the midline and the thyroid cartilage is exposed. The
to posterior, exposing the entire top of the thyroid car- perichondrium is incised along the superior edge of the
tilage. The laser is then used to dissect along the inner cartilage and dissected inferiorly (Fig. 28.4). This dissec-
surface of the thyroid cartilage preferably leaving the peri- tion must be performed with care using fine elevators. The
chondrium in situ unless it is needed as a tumor margin. perichondrial layer is dissected halfway between the supe-
Dissection is carried down to the level of the vallecula. rior and inferior edges of the thyroid cartilage in males
Posterior cuts are made through the false vocal folds into and one-third of the distance from the superior edge
the ventricle distant from the tumor. The tumor is then in females. The cartilage incision is carried superiorly,
removed through the mouth. In addition to the bivalved medial to the superior cornua on the non-dominant side
laryngoscope, especially designed bipolar cautery forceps (Fig. 28.5). The suprahyoid muscles are then transected
and unipolar cautery instruments are needed for control and the entire hyoid bone is dissected free. The superior
of larger blood vessels. Specialized grasping instruments laryngeal vessels are identified and controlled between
are desirable to provide exposure and retraction of the the greater cornu of the hyoid and superior cornu of the
area to be dissected. Healing occurs over the next several thyroid cartilage on each side. The pharyngeal mucosa is
weeks and most reports indicate that swallowing function identified superior to the hyoid bone and the pharynx is
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Laryngeal Cancer
Chapter
28
Fig. 28.3: A separate transverse incision, superior to the Fig. 28.5: Supraglottic laryngectomy. The transverse cartilage cut
tracheotomy site, is suitable for most partial laryngectomies and is made at the presumed level of the glottis (the superior line is
yields the best cosmetic result used for females) and angled superiorly on the unaffected side
165
Fig. 28.4: Supraglottic laryngectomy. After the strap muscles are Fig. 28.6: Supraglottic laryngectomy. The scissors are placed in
divided, the perichondrium is incised along the superior margin of the ventricle internally and the cartilage is cut externally in the
the thyroid cartilage final maneuver to remove the supraglottic larynx
entered through the vallecula. The epiglottis is grasped (Fig. 28.6). The perichondrium is closed to the base of
and retracted anteriorly and incisions are extended with the tongue using 3-0 or 4-0 absorbable sutures. Before
scissors along the lateral borders of the epiglottis. In tying the first layer of closure, the neck is flexed and the
tumors involving the tip of the epiglottis or vallecula, the remaining larynx is suspended superiorly. The most secure
larynx is entered laterally through the pyriform mucosa suspension is accomplished by passing heavy permanent
on the side opposite the tumor. When the epiglottis is suture (prolene or stainless steel) through drilled holes in
retracted anteriorly, the glottis is visualized directly and the thyroid cartilage and through the mandibular sym-
the extent of the tumor is identified. With the medial physis (Fig. 28.7). The sutures can also be fixed to the
blade of the scissors in the ventricle and the lateral blade mandibular periosteum or the digastric tendons bilater-
in the cartilage incision, the supraglottic larynx is excised ally. The larynx must be suspended as far anteriorly and
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Section
nonirradiated patients can maintain adequate nutrition by

an oral diet within 10−14 days after surgery. Irradiated
patients frequently remain partially dependent on tube
feedings for weeks or months following surgery.
3
GLOTTIC TUMORS
Glottic tumors include neoplasms involving the true vocal

folds, the anterior commissure and the posterior larynx
at the level of the true vocal folds. The superior limit
of the glottis is the lateral recess of the ventricles. The
inferior limit extends 10 mm below the free margin of
the vocal folds at the anterior commissure, decreasing to
5 mm below the free margin posteriorly (see Fig. 28.1).
The lymphatic channels of the glottis are quite sparse and
lie in the submucosal space. Glottic tumors usually spread
Fig. 28.7: Supraglottic laryngectomy. The larynx is suspended along the mucosa and small lesions rarely invade deeper
superiorly and anteriorly by wiring to the mandibular symphysis
structures. When deep invasion occurs, violation of the
inner perichondrium of the thyroid cartilage or the conus
superiorly as possible in order to allow it to remain under elasticus into the paralaryngeal space is the most impor-
the tongue base during the oropharyngeal phase of swal- tant consideration in treatment decisions (see Fig. 28.2).42
lowing. A cricopharyngeal myotomy should be performed By far, the most common presenting symptom of
before closure as well. The laryngeal closure sutures are glottic carcinoma is hoarseness. Sore throat, dysphagia,
166 tied and a second layer of suture is placed. The skin is
closed over a small drain.
hemoptysis and airway obstruction are present usually
in patients with advanced tumors. Otalgia or dry cough
The basic supraglottic laryngectomy can be extended occasionally can accompany hoarseness as early symptoms.
to include additional involved structures. When the Almost all patients with glottic cancer have a history of
mucosa over the arytenoid cartilages is involved, the cigarette smoking. There is a 4:1 male predominance with
entire cartilage can be removed. However, any extension a peak incidence in the sixth and seventh decades.
of the resection that affects vocal fold mobility adversely In early glottic carcinoma, accurate diagnosis and
increases the risk of aspiration and the removal of addi- staging are critical. The most important factor in staging
tional cartilage may result in glottic stenosis. is the presence of vocal fold fixation which makes the
The two most important factors in the postoperative tumor at least T3 (Table 28.3). The first step in evalua-
care of a supraglottic laryngectomy patient are the healing tion is adequate laryngeal visualization to determine the
of the laryngeal closure and mastering of the supraglot- indications and plan for endoscopic biopsy. With fiberop-
tic swallowing technique. As in most partial laryngec- tic laryngoscopy, it should be possible to visualize most
tomies, mucosal closure is not possible and thus initial patients. The addition of video improves documentation
healing is by secondary intention. Patients with condi- and the patient’s understanding and acceptance of future
tions that would affect wound healing adversely, such treatment. Stroboscopy can be invaluable in determining
as malnutrition, diabetes mellitus, chronic alcoholism, the need for biopsy and the depth of tumor spread, espe-
uncontrolled reflux laryngitis and prior radiation therapy, cially in a professional voice user. The absence of mucosal
are poorer candidates for this procedure than patients vibration in the region of a suspicious lesion is not diag-
who do not have such conditions. Successful supraglottic nostic for an invasive process, but it generally increases
laryngectomy can be performed in previously irradiated the clinical suspicion of cancer. Patients suspected of hav-
patients, but other factors must be optimal; and there is ing carcinoma should undergo operative endoscopy and
an increased rate of complications.41 Initial swallowing biopsy. Panendoscopy is recommended because, even with
trials are accomplished best after the nasogastric tube has small glottic tumors, the risk of a metachronous primary
been removed, and, if at all possible, after the trache- is 15%.20
otomy has been removed. Patients are taught to swallow The differential diagnosis of a small glottic lesion
slowly, stopping to cough before each inhalation. Most includes hyperkeratosis, dysplasia, carcinoma in situ and
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Chapter
Table 28.3: Staging of primary tumor in laryngeal removed with a generous excisional biopsy. When preop-
cancer erative suspicion of cancer is high and the patient’s larynx
Glottis can be visualized well by suspension laryngoscopy, exci-
T1 — Tumor limited to vocal fold(s) (may involve anterior
sional biopsy can be planned and accomplished safely.
commissure or posterior larynx) with normal mobility.
Endoscopic Surgery
28
T1a — Tumor limited to one vocal fold.
T1b — Tumor involves both vocal folds. The indications for endoscopic excision of a vocal fold
T2 — Tumor extends to supraglottic and/or subglottis and/or with carcinoma include lesions isolated to the membranous
impaired vocal fold mobility. portion of one or both vocal folds, no impairment of vocal
T3 — Tumor limited to larynx with vocal fold fixation. fold mobility and the ability to obtain adequate visualiza-
T4 — Tumor invades through the thyroid cartilage and/or extends tion by suspension laryngoscopy. Difficulty in obtaining
to other tissues beyond the larynx.
adequate visualization can be expected in patients who are
obese, have short necks, short mandibles, large tongues, a
invasive carcinoma. Accuracy in pathologic diagnosis is narrow dental arch with full dentition or cervical spine
critical. All lesions except invasive carcinoma, are treated disease. Tracheotomy is almost never necessary. General
by simple excision without large margins and with close anesthesia is utilized with a laser-safe endotracheal tube.
observation.43 Invasive cancer requires either total surgical A Dedo, Fragen or Sataloff suspension laryngoscope is
excision with free margins or radiation therapy. preferred by the authors, but any large laryngoscope that
For most T1 and T2 glottic tumors, long-term cure provides good visibility is satisfactory. Toluidine blue may
rates are equal after surgery or radiation.44 The treatment be painted on the vocal fold to reveal areas of increased
decision is made by comparing the time, expense and DNA activity and rigid endoscopes are helpful in visu-
morbidity of radiation therapy to the operative risk and alizing the full extent of the lesion. The lesion(s) can
morbidity associated with surgery. It has always been be excised using either cold microscopic technique or a
assumed that radiation therapy will not alter vocal qual-
ity as much as surgical procedures. However, no study
carbon dioxide laser. The laser is advantageous because of
its accuracy and ability to provide ongoing hemostasis.
167
to evaluate this finding objectively has been completed. However, when treating superficial lesions, damage to the
Anecdotally, voice quality appears to be better during underlying lamina propria or muscle with the laser is
the first year following radiation therapy than during possible. Noninvasive lesions are removed including the
the first year after surgery in most cases. However, it is full thickness of mucosa, but the vocalis muscle is not
not certain that postradiation voice quality is better than exposed. Invasive lesions are outlined with a 1 mm mar-
postoperative voice quality after longer periods, as the gin and are resected with underlying muscle (Fig. 28.8).
late effects of radiotherapy become more evident. When Contact endoscopy may be helpful in mapping the
voice is a primary concern, the location of the tumor and
potential depth of the surgery must be taken into account
along with other factors. The patient must be informed
fully about the advantages, disadvantages and uncertain-
ties associated with each treatment modality before the
patient selects a therapeutic plan. Radiation failures can
be salvaged by partial laryngectomy. Operative morbidity
is higher than in non-irradiated patients and the need for
eventual salvage with total laryngectomy may be as high
as 25%.45-47
Surgical Treatment
Excisional Biopsy
A retrospective study of patients who had partial laryn-
gectomy for small glottic cancers revealed no tumor in
the resected specimen in as many as 20%.48 This means Fig. 28.8: Depth of resection for a small invasive cancer of the
that at least this percentage of tumors can adequately be vocal fold
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Section
exposure and provides a good cosmetic result, but a single

vertical incision can be used. A vertical midline thyrotomy
is performed in most cases, but if endoscopic examination
reveals involvement of the anterior commissure, the verti-
3 cal thyrotomy can be made off-center on the uninvolved
side. Once the larynx is opened, the tumor’s margins are
defined, and the involved vocal fold is resected with a
1 to 2 mm mucosal margin. Resection of the underly-
ing vocalis muscle must be generous due to the inability
to obtain reliable margins in muscle fascicles. Thus, even
in cases in which some mucosa can be spared, a large
bulk of the vocal fold is usually resected. Tumors that
involve the inner thyroid perichondrium or abut the thy-
roid cartilage require vertical hemilaryngectomy in most
cases. However, even with bulky disease, the cartilage can
be spared in many patients with early glottic carcinoma.
Fig. 28.9: Cordectomy performed through a laryngofissure Most cases should be approached with the hope of per-
forming a soft tissue resection alone. In rare cases, small
margin. With fine microscopic technique, a separate mar- lesions on both vocal folds can be resected simultaneously
gin can be obtained to ensure adequate resection. Studies by this technique.52 CT and MRI scanning may be help-
have shown endoscopic techniques to be equal to open ful preoperatively, but examination and biopsy at the time
surgery in obtaining long-term, disease-free survival in of open surgery provide the most definitive indications
selected patients with small cancers.48,49 for cartilage resection.
168 Photofrin-radiated photodynamic therapy has shown
some promise in treating early lesions with preservation Endoscopic Laser-assisted Vertical Hemilaryngectomy
of the mucosal wave.50 After administering a photosen- Glottic carcinoma can be resected using a transoral CO2
sitizer, intraoperative laser light activation causes irrevers- laser-assisted approach in patients in whom adequate
ible cellular change to cells that concentrate the photo- exposure can be obtained.36-39 Contraindications to this
sensitizing agent. As cancer cells concentrate porfimer approach include T4 lesions, especially in patients with
sodium, they are preferentially destroyed. Small studies invasion of thyroid cartilage, extension into the subglottis
have had good results,50 but larger, randomized, control- or extensive supraglottic extension, as well as tumors with
led studies have not been done. fixed vocal folds (which implies invasion of the cricoary-
tenoid joint). Patients in whom adequate exposure cannot
Cordectomy be obtained are not candidates for this technique, but they
Cordectomy remains the standard by which all other sur- may be candidates for robotic surgery in which exposure
gical treatments of small glottic cancers are measured.51 techniques are different.
Cordectomy involves removal of the entire musculom- After obtaining adequate exposure with the bivalved
embranous vocal fold with the vocalis muscle (Fig. 28.9). laryngoscope, the false vocal fold is excised as a separate
The inner perichondrium of the thyroid cartilage can also specimen in order to expose fully the lateral tumor extent.
be removed, either partially or completely. Cordectomy is Tumors involving the anterior commissure can be exposed
contraindicated when vocal fold mobility is impaired, when through excision of the petiole of the epiglottis. If the
the thyroid cartilage is invaded by the tumor or when full extent of the tumor cannot be visualized easily after
there is supraglottic or subglottic extension. Cordectomy these maneuvers, endoscopic excision is likely to result in
can be accomplished endoscopically with a carbon dioxide positive margins and generally should not be performed.
laser. However, it may be difficult to assess lateral tumor Once the tumor is visualized completely, superficial mark-
extension in many cases, and the patient should be pre- ing incisions are made to outline the extent of resection.
pared for conversion to an open procedure. Traditionally, The success of this procedure requires meticulous dis-
cordectomy is performed through a laryngofissure. A tra- section and hemostasis usually with the CO2 laser and,
cheotomy is performed and general anesthesia is utilized. occasionally, monopolar or bipolar electrocautery. Forceps
A separate, superior transverse incision is adequate for are used to retract the vocal fold and tumor medially,
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Chapter
providing counter traction, while the laser is used as a
cutting instrument. The area undergoing dissection should
always be under tension to aid cutting and allow iden-
tification of tissue planes and deep cancer extension.
Cancer up to and including the anterior commissure 28
can be resected using this technique, although adequate
removal of the anterior commissure is technically difficult
and the defect resulting from this procedure creates an
extremely breathy voice which requires further surgery to
improve voice quality. Intraoperative frozen sections and
control of margins are essential with this technique to
verify complete extirpation of the tumor.
No primary reconstruction is undertaken during this
procedure. The resected areas generally mucosalize over
the next few weeks. Resection of the false vocal fold
and infrapetiole region has the added advantage of aid-
ing postoperative surveillance for recurrence. Frequent Fig. 28.10: Standard midline thyrotomy approach for
cordectomy or vertical hemilaryngectomy
postoperative surveillance is important as early recur-
rences often can be cured with a second transoral laser
excision.40 Most patients will form a scar band opposing
the contralateral normal vocal fold, allowing phonation.
Patients with breathy voices after this procedure can be
helped by a variety of procedures to increase the bulk and
size of the scar band on the operated side.
169
Vertical Hemilaryngectomy
When glottic carcinoma invades deeply to involve the
perichondrium, removal of the thyroid cartilage is neces-
sary. If the cartilage itself is invaded, which means a stage
IV tumor, most authors recommend total laryngectomy.53
However, when the area of cartilage involvement is small
and the vocal fold is mobile, a partial laryngectomy with
postoperative radiation therapy may be considered.53
A standard hemilaryngectomy is approached in the
same way as a cordectomy (Fig. 28.10). A second carti-
Fig. 28.11: For vertical hemilaryngectomy, the second cartilage
lage cut is made laterally on the involved side leaving a cut (dashed line) is made leaving a 4−5 mm strip of posterior
3−4 mm strip of the posterior thyroid ala, including the thyroid ala
superior and inferior cornua (Fig. 28.11). The cartilage
cuts can be tailored based on the preoperative examina- anterior commissure (anterior vertical laryngectomy).54, 55
tion and intraoperative assessments. The anterior incision It can also be extended to include part or all of the ary-
can be moved off the midline to include the anterior tenoid cartilage. Additionally, a vertical laryngectomy can
commissure or to remove up to two-thirds of the con- be performed with a supraglottic laryngectomy (supra-
tralateral ala. The cartilage resection can also be quite hemilaryngectomy) or even in an extended fashion as a
narrow, involving a strip 8−10 mm wide in selected cases. near-total laryngectomy. However, extension of the pro-
The outer perichondrium is dissected off the cartilage to cedure increases the risks of postoperative glottic stenosis
be resected and is utilized for closure. A standard hemi- and aspiration, and decreases local control rates.56
laryngectomy must be extended to include the anterior Patients should be treated with perioperative pro-
commissure if it is found to be involved (anterolateral phylactic antibiotics and remain non per os (NPO) for
laryngectomy) and can be performed to remove only the 5−10 days postoperatively. Usually, the tracheotomy can
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Section
either situation, healing proceeds by granulation and epi-

thelialization from the remaining mucosa. For this rea-
son, most surgeons have suggested that a history of prior
radiation therapy or the presence of systemic conditions
3 that slow healing (diabetes mellitus, malnutrition, alco-
holism or renal failure) are contraindications to laryngeal
conservation with a partial laryngectomy. However, with
meticulous technique, a cooperative patient, and mucosal
and cartilaginous reconstruction, partial laryngectomy can
be considered in most cases. The simplest forms of recon-
struction utilize advancement and rotation flaps of local
mucosa to cover exposed areas. A posterior mucosal defect
can be closed by advancing postcricoid mucosa and rotat-
ing tissue from the aryepiglottic fold or medial wall of
the pyriform sinus. More generous portions of pyriform
or posterior pharyngeal wall mucosa can be rotated to
Fig. 28.12: Bipedicled sternohyoid muscle flap interposed deep cover almost an entire hemilarynx, but this narrows or
to the perichondrium
closes the pyriform sinus and may increase the risk of
aspiration. Amin and Koufman have described a recon-
structive technique for cases in which an arytenoid is
sacrificed where the ipsilateral cricoid cartilage is resected
and reconstructed with a local muscle flap and stent.57
Many methods have been used successfully to provide
170 bulk to the operated side and thus improve the postop-
erative voice. Probably the most reliable is a bipedicled,
strap muscle flap that is developed from the anterior half
of the muscle and interposed deep to the perichondrium
of the operated side58 (Fig. 28.12). An inferiorly based
sternohyoid flap can be interposed to cover the aryte-
noid cartilage and provide bulk for a neo-vocal fold59
(Fig. 28.13). Portions of thyroid cartilage, especially the
superior cornua, can be rotated into the defect and then
covered with muscle or mucosa to provide a ridge appos-
Fig. 28.13: An inferiorly based sternohyoid muscle flap used to ing the remaining mobile vocal fold.60
reconstruct the arytenoid bed When cartilage support and mucosal coverage are
necessary, an epiglottic flap is usually the first choice
be removed 1−2 weeks after surgery, but it may need to be for reconstruction after hemilaryngectomy or extended
left in place longer in patients who have extended resec- partial laryngectomy procedures.61, 62 The petiole must
tions, delayed healing (due to previous radiation therapy, be uninvolved by tumor. The epiglottis is grasped at the
diabetes, malnutrition and so on) or aspiration. However, petiole and dissection is carried out superiorly along the
most patients swallow much more effectively after decan- lateral margins as the cartilage is retracted inferiorly. The
nulation. Thus, early removal of the tracheotomy tube is mucosa over the laryngeal surface is usually left intact
encouraged. and the cartilage can be released enough to suture to
the cricoid cartilage inferiorly. There is no evidence of an
Reconstruction after Partial Laryngectomy increased risk of aspiration after use of an epiglottic flap
Primary mucosal closure cannot be obtained after almost and results in radiated patients are excellent.63 Composite
all forms of partial laryngectomy. In most cases, the thy- grafts of nasal septum or auricular cartilage and skin also
roid perichondrium is used to close the operative site. can be used, but healing of these free grafts in radiated
In others, the area of mucosal resection is left open. In tissue is unpredictable.
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Supracricoid Hemilaryngectomy pharyngotomy is connected to the cricothyroidotomy on
Select T2 and T3 glottic and supraglottic carcinomas the less involved side using heavy Mayo scissors, sparing as
can be treated using supracricoid hemilaryngectomy much mucosa as is possible. This maneuver provides ade-
with either cricohyoidopexy (CHP) or cricohyoepiglot- quate visualization for mucosal cuts on the tumor-bearing
topexy (CHEP) for reconstruction.64-67 Supracricoid side. If it is necessary for adequate margins, excision of 28
hemilaryngectomy provides equivalent local control to the ipsilateral arytenoid cartilage may be performed. If
total laryngectomy in carefully selected T3 tumors and the arytenoid is to be spared, the incision should be per-
better local control than vertical partial laryngectomy formed just anterior to or through the vocal process of
in most T2 carcinomas.64-67 The technique involves the the arytenoid. More posterior cuts are likely to violate the
removal of the entire thyroid cartilage, both vocal folds, joint capsule and result in an immobile arytenoid. Once
and resection of up to one arytenoid cartilage. Voice and the tumor is released and removed, the mucosa of the
swallowing results are better when both arytenoid carti- upper part of the arytenoid cartilage is closed over the
lages can be preserved. Contraindications to this proce- exposed arytenoid cartilage. No sutures are placed near
dure include lesions originating in the ventricle or the the inferior portion of the arytenoid to preserve mobil-
anterior commissure with pre-epiglottic space invasion, ity. A suture is then used to pull the arytenoid cartilage
arytenoid cartilage fixation (indicating invasion of the cri- anteriorly and attach it to the cricoid cartilage in order
coarytenoid joint) and subglottic extension of more than to prevent posterior rotation of the arytenoids due to
10 mm anteriorly or 5 mm posteriorly. Patients with poor unopposed posterior cricoarytenoid muscle pull. The pri-
preoperative pulmonary function are not candidates as mary closure of the surgical defect is then performed
microaspiration is an expected consequence despite swal- using three submucosal 0-vicryl sutures that are looped
lowing rehabilitation. The swallowing rehabilitation proc- around the cricoid cartilage and passed through either the
ess after supracricoid hemilaryngectomy is very involved remaining epiglottic cartilage and around the hyoid bone
and patients must be able to participate actively in the in a CHEP, or around just the hyoid bone in CHP. A
rehabilitation process.
Supracricoid hemilaryngectomy is performed under
large portion of the tongue base should be included in
each of these sutures. The sutures are then pulled together
171
general anesthesia with orotracheal intubation. A stand- and tied to impact the cricoid cartilage into the hyoid
ard apron flap incision is made with elevation of the skin bone. Prior to tying these sutures, a tracheotomy is per-
flap to at least 1 cm above the hyoid bone and down to formed with the cricoid cartilage and trachea pulled up
the clavicles. Neck dissections are performed if indicated. to their eventual locations.
The sternohyoid and thyrohyoid muscles are transected Postoperative care includes aggressive speech and
along the superior part of the thyroid cartilage; these swallowing therapy. Nutrition is maintained through a
muscles are then mobilized inferiorly to expose the ster- feeding tube until the patient is able to tolerate a full
nothyroid muscle. The sternothyroid muscle is transected diet. In the immediate postoperative period the patient is
at the inferior border of the thyroid cartilage and the pha- instructed to expectorate all secretions forcefully in order
ryngeal constrictor muscles are incised along the lateral to improve tongue mobility and future swallowing ability.
alae of the thyroid cartilage. The thyroid perichondrium is As the patient is able to tolerate his/her own secretions,
incised along the lateral border and the pyriform sinuses the diet is advanced slowly under the close supervision
are dissected free of the thyroid cartilage. The cricothyroid of the speech and swallowing therapists. Tracheotomy
joints are disarticulated carefully to avoid damaging the decannulation and full oral diet are possible in 95% of
recurrent laryngeal nerves. A cricothyroidotomy is per- patients.64,66
formed and the endotracheal tube is removed from the
mouth and placed through the cricothyroid membrane. Total Laryngectomy
For glottic tumors, the thyrohyoid membrane is incised In the opinion of most laryngologists, advanced tumors
just above the thyroid cartilage, entering the pharynx. In that impair vocal fold motion, exhibit transglottic exten-
supraglottic cancer the hyoid bone periosteum is incised sion or deeply invade adjacent tissues are treated best
and stripped from the deep surface of the bone. A tun- by total laryngectomy, usually combined with postopera-
nel is used to traverse the pre-epiglottic space and enter tive radiation therapy. However, Harwood et al.68 have
the pharynx just above the epiglottis. In either case, the shown the efficacy of primary radical radiotherapy with
tumor is visualized through the pharyngotomy and the surgical salvage. The addition of chemotherapy will allow
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Section
presenting with advanced, obstructing tumors often need

airway protection prior to definitive surgery. Although
tracheotomy provides a definitively safe airway, there has
been some concern that performing tracheotomy before
3 total laryngectomy increases the risk of stomal recurrence.
An alternative, temporizing measure to re-establish an
adequate airway is to debulk the obstructing portion of
tumor, often at the time of biopsy for definitive diagnosis.
Debulking can be accomplished through the use of the
CO2 laser or with the use of powered instrumentation
with specially designed laryngeal attachments.
Prior to total laryngectomy, patients should be treated
with prophylactic antibiotics and are prepared for possible
intraoperative transfusion. Many patients require trache-
otomy under local anesthesia for airway support prior to
Fig. 28.14: An apron flap incision as utilized for total laryngectomy. the induction of general anesthesia. If orotracheal intuba-
The lateral extension can be added for simultaneous radical tion is accomplished, the tube can be left in place until
dissection the trachea is incised.
The incision is determined by the extent of the
resection. A wide, superiorly based apron flap, includ-
ing a tracheal stoma, is performed for simple larynge-
ctomies (Fig. 28.14). This can be extended laterally and
an inferior limb can be added when a neck dissection is
172 performed (Fig. 28.15). A full or half “h” incision with
its modifications also can provide excellent exposure. The
skin flaps are elevated deep to the platysma muscle. They
must be handled gently, especially in radiated patients.
The strap muscles are divided inferiorly and the thyroid
gland is exposed. The carotid sheath structures are identi-
fied, isolated from the larynx and retracted laterally with
the sternocleidomastoid muscle. The thyroid isthmus is
divided and the lobe on the uninvolved side is dissected
sharply from the trachea. On the involved side, dissec-
tion proceeds lateral to the thyroid lobe, isolating and
Fig. 28.15: A utility incision is preferred when laryngectomy is controlling the inferior and superior vascular pedicles. The
combined with a neck dissection larynx is rotated and the inferior constrictor muscles are
dissected sharply from the lateral margins of the thyroid
30−50% of patients who are cured to retain their laryn- ala on each side (Fig. 28.16). The suprahyoid muscles are
ges.12 Patients whose tumors recur after non-surgical dissected from the hyoid bone and the greater cornua are
treatment are most often salvaged with total laryngec- freed. Care must be taken to dissect close to the bone
tomy. Standard wide-field laryngectomy includes resec- to prevent hypoglossal nerve injury. Control and ligation
tion of the entire larynx, the hyoid bone, overlying strap of the superior vascular pedicles of the larynx are the
muscles and the upper trachea. The thyroid lobe on the last steps in separating the larynx from external muscular
dominant side of the tumor is usually removed, as well. structures (Fig. 28.17).
The surgery can be extended to include part or all of The larynx is removed by separating its mucosal
the hypopharyngeal mucosa, the entire esophagus and attachments. The trachea is divided below the second
the entire cervical trachea. Unilateral or bilateral modi- ring or one ring below a pre-existing tracheotomy. The
fied or radical neck dissections are performed in com- incision in the tracheal mucosa is carried superiorly on
bination with total laryngectomy, if indicated. Patients the posterior wall to provide extra length for the stoma.
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Chapter
28
Fig. 28.16: Total laryngectomy. The inferior constrictor muscle Fig. 28.18: Total laryngectomy. When the pre-epiglottic space is
is divided from the lateral margin of the thyroid ala involved, the larynx is entered through the contralateral pyriform
sinus, and the larynx is rotated to expose the tumor
173
Fig. 28.17: Total laryngectomy. After division of the strap muscles Fig. 28.19: Total laryngectomy. The final mucosal incisions are
and the inferior constrictors, the larynx is freed from all muscular made with the tumor visualized directly to allow adequate surgical
attachments margins
Once the trachea is divided, it must be sutured to the through the contralateral pyriform sinus (Fig. 28.18). The
inferior skin margin to prevent retraction into the medi- epiglottis is grasped and mucosal incisions are carried
astinum. Scalpel dissection proceeds through the posterior inferiorly to allow the larynx to be opened on the con-
wall incision until the “gray line” between the trachea and tralateral side to visualize the tumor directly (Fig. 28.19).
esophagus is identified. This reveals a plane that can be Mucosal incisions proceed as medially as possible along
opened bluntly to the level of the arytenoid cartilages. the pyriform sinus mucosa leaving at least a 2 cm mucosal
The lateral attachments along this plane are divided. The margin. The incisions are connected inferiorly and the lar-
pharynx is entered superior to the hyoid bone, through ynx is removed. Mucosal closure of the pharynx is usually
the mucosa of the vallecula. If there is tumor extension performed in a “T” fashion (Fig. 28.20). When extensive
into the epiglottis or vallecula, the pharynx is opened pharyngectomy is required, a straight-line closure may
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Section
Fig. 28.20: Total laryngectomy. T-closure of the pharynx

Fig. 28.21: A silk suture is placed through the tracheoesophageal
puncture and brought through the esophagoscope into the oral
be appropriate. The closure is in two layers: a running, cavity. The suture is attached to dilators; and after adequate
inverting Connell (inverting horizontal mattress) suture dilatation, a 16-gauge red rubber catheter is introduced in the
in the mucosa and interrupted imbricating sutures in the distal esophagus and fixed to the skin
muscularis. Absorbable suture is used. A nasogastric tube
is placed under direct visualization prior to closure. prosthesis requires frequent maintenance and sometimes
174 Creation of a stoma begins by resecting a circular
ellipse of skin slightly larger than the tracheal diameter
considerable speech training. Patient selection is based on
intelligence, compliance and manual dexterity. The fistula
and removing subcutaneous fat from the margin. The can be formed at the time of total laryngectomy or any-
stoma is secured with interrupted vertical mattress sutures time after primary healing is completed. When prosthe-
around the distal tracheal cartilage ring. A continuous 4-0 sis fistula creation is considered as a delayed procedure,
or 5-0 absorbable suture may be placed circumferentially the patient is first evaluated with a barium swallow, to
to closely appose the mucosa and the skin. Large suction rule out pharyngeal stenosis, and an air insufflation test
drains are placed and the skin flaps are closed in layers. is used to prove the patient can produce voice. Usually,
the operation is performed under general anesthesia. A
VOICE AND SWALLOWING REHABILITATION rigid esophagoscope is placed at the level of the superior
AFTER TOTAL LARYNGECTOMY margin of the tracheal stoma. A needle is placed 2−3 mm
proximal to the mucocutaneous junction and visualized
Voice rehabilitation can be accomplished with an electro- in the esophageal lumen. A silk suture is pulled through
larynx (oral or neck placement), esophageal speech or by the esophagoscope (Fig. 28.21). The suture is attached
means of a valve prosthesis placed in a tracheoesophageal to progressively enlarging dilators (usually filiform and
conduit. Historically, multiple attempts have been made followers) until a 16-gauge French red rubber catheter
to create a vocal tract surgically using pharyngeal mucosal is pulled through. The internal portion of the catheter is
flaps placed over the tracheal air column. However, most pushed into the distal esophagus and the external por-
of these methods have been abandoned due to the risk tion is sutured to the skin superior to the stoma. Three
of aspiration. Almost all patients use an electrolarynx to five days later, the catheter is removed and the patient
at some point during their rehabilitation, and approxi- is fitted with a prosthesis. Kits are available with some
mately one-third of laryngectomy patients can obtain prostheses that allow placement of the valve at the time
good results with esophageal speech. of tracheoesophageal puncture, although surgical edema
The valve voice prosthesis can provide a controllable, usually prevents adequate voicing for several days after
non-mechanical voice for over 90% of total laryngectomy placement.
patients.69,70 It can be considered even after hypopha- The fistula also can be formed at the time of total
ryngeal or esophageal reconstruction.71,72 However, the laryngectomy. The common tracheal and esophageal walls
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Laryngeal Cancer
Chapter
are grasped with ring forceps and the incision is made Table 28.4: Staging of primary tumor in laryngeal
high on the posterior tracheal wall. A 16-gauge French cancer
red rubber catheter is placed through the incision into Supraglottis
the esophagus directly. The distal catheter is pushed into T1 — Tumor limited to subglottis
the esophagus and used as a feeding tube postoperatively. T2 — Tumor extends to vocal folds with normal or impaired 28
Placement of the prosthesis within a week of laryngec- mobility.
tomy has the advantages of providing early, excellent voice T3 — Tumor limited to the larynx with vocal fold fixation.
rehabilitation. Patients become more involved in their T4 — Tumor invades the cricoid or thyroid cartilage and/or
extends to other tissues beyond the larynx.
postoperative care and return to work sooner. However,
the fistula can be difficult to manage during radiation
therapy and the patient may not have useful voice during mucosal flap coverage.78 Contraindications to vertical
that time. Additionally, the incidence of stomal stenosis hemilaryngectomy with partial cricoid resection include
is somewhat increased and stenting with laryngectomy prior radiation therapy, vocal fold fixation and extensive
tubes may be necessary.73 invasion of the cricoid cartilage. The incidence of occult
Swallowing rehabilitation is easier after total laryn- lymph node metastasis in subglottic tumors is less than
gectomy than after partial laryngectomy due to the total 10%, so elective neck dissection is not indicated.63
separation of the digestive and respiratory passages by
total laryngectomy. Most patients who do not develop CONCLUSION
pharyngocutaneous fistulae can begin oral feedings 5−10
days after surgery. Oral feeding is generally delayed in Laryngeal carcinoma remains a complex clinical chal-
previously-irradiated patients by several weeks due to the lenge. Intimate knowledge of anatomy, patterns of malig-
relatively high incidence of delayed fistulas in this patient nant spread and diverse treatment options is essential.
population. A recent article has demonstrated the safety Treatment decisions often are difficult when attempting
of oral feedings in selected patients 48 hours after total
laryngectomy.74
to balance adequate tumor control and maintenance of
voice and swallowing function. The curability of laryn-
175
geal cancer has improved only minimally over the past
SUBGLOTTIC CANCER few decades. However, functional treatment results have
improved substantially thanks to adjuvant chemotherapy,
The cricothyroid membrane is found about 10 mm infe- radical radiotherapy, and innovative conservation and
rior to the anterior commissure and 5 mm inferior to reconstructive surgical techniques.
the posterior margin of the vocal fold. Tumor extension
to this membrane allows lymphatic spread to the para- SURGICAL TECHNIQUES: ENDOSCOPIC
tracheal lymph nodes and the thyroid gland. Inferiorly, RESECTION OF CANCER INVOLVING
tumor may extend submucosally to involve the cricoid THE TRUE VOCAL FOLD
cartilage. Circumferential involvement and extensive pos-
terior growth into the hypopharynx are not uncommon.75
Step 1
Most subglottic tumors are extensions from glottic
primary lesions. Primary subglottic carcinoma is rare. Preoperative rigid videostroboscopy reveales an exophytic
Patients usually present with airway obstruction and mass on the left true vocal fold (Fig. 28.22A). Orotracheal
hoarseness is common secondary to a greater than 75% intubation is performed in the operating room routinely
incidence of vocal fold fixation.76 Accurate diagnosis and using a 5.0 mm endotracheal tube, but nothing larger
staging are important (Table 28.4). than 5.5 mm. Suspension microlaryngoscopy is then per-
Surgical excision of primary subglottic tumors always formed to expose the vocal folds (Fig. 28.22B).
requires a total laryngectomy since resection of the cricoid
cartilage destroys the protective function of the larynx Step 2
during swallowing. However, some tumors extending from When evaluating a lesion, it is imperative to use a 0°, 30°
glottic cancers can be resected by vertical hemilaryngec- and 70° endoscopes. This allows better mapping of the
tomy with partial cricoid resection.77 Biller and Som have lesion, in particular extention into the anterior commis-
described a technique of rotating the remaining posterior sure (Fig. 28.22C), ventricle (Fig. 28.22D), and subglottis
margin of the thyroid lamina into the cricoid defect with and height of vocal fold involvement (Fig. 28.22C).
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Section
A B
176
C D
Figs 28.22A to D: (A) An exophytic mass on the left true vocal fold was seen on rigid stroboscopic examination of the larynx.
Preoperatively, papilloma was considered the most likely diagnosis. Intraoperatively, the texture and appearance suggested cancer.
Frozen-section and postoperative pathology confirmed that this was a T2 invasive squamous cell carcinoma that contained papilloma
types 16 and 18. (B) Direct visualization of the lesion is achieved by performing suspension microlaryngoscopy with a Sataloff Medium
Female Laryngoscope. The lesion was friable. (C) A 70o endoscope is used to determine better the borders of the lesion. (D) Using a
70° endoscope, the lesion can be seen extending into the laryngeal ventricle
Step 3 using a microscissors. A small cuff of uninvolved mucosa

(approximately 1−2 mm) can be resected along with the
The lesion is gently stabilized using a Sataloff Heart lesion to achieve a tumor-free margin and is confirmed
Shaped Grasper. A microlaryngeal scissors or a cupped by intraoperative frozen-section analysis. Alternatlively,
forcep is used to biopsy the lesion for intraoperative fro- the tumor can be resected without adjacent uninvolved
zen-section analysis. This lesion was determined to be an tissue, if excisional biopsy is to be followed by radiation
invasive squamous cell carcinoma. therapy. Small biopsy followed by radiation is advocated
by some physicians.
Step 4
An en-block resection of the involved vocal fold is per- Step 5
formed (Figs 28.22E and F). The lesion is stabilized using A large defect can be seen extending to the anterior com-
a Sataloff Heart Shaped Grasper and dissected sharply missure of the larynx, involving nearly the entire left true
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Laryngeal Cancer
Chapter
28
E F
177
Figs 28.22E to G: (E) Sharp dissection of the mass is initiated at the
posterior extent of the lesion, slightly distal to the vocal process.
(F) The dissection continues toward the anterior commissure in
a controlled fashion to achieve an en-bloc resection, minimizing
trauma to uninvolved tissues. (G) The musculomembranous left
true vocal fold and part of the left false vocal fold have been
resected en-bloc. Ideally, margins should be free of disease. If
radiation is planned, it may be appropriate to leave microscopic
G disease, if resecting it would affect voice outcome adversely
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glottic cancers. Arch Otolaryngol 1971; 93(3):238-43. 69. Wood BG, Tucker JM, Rusnove MG, et al.
54. Kirchner JA, Som MD. The anterior commissure technique Tracheoesophageal puncture for laryngeal voice restora-
of partial laryngectomy: clinical and laboratory observation. Ann Otol 1981; 90:492-4.
tions.Laryngoscope 1975; 85:1308-17. 70. Singer MI. Tracheoesophageal speech: vocal rehabilitation
55. Sessions DG, Ogura JH, Fried MP. The anterior commissure after total laryngectomy. Laryngoscope 1983; 93(11 Pt
in glottic carcinoma. Laryngoscope 1975; 85(10):1624-32. 1):1454-65.
56. Biller HF, Lawson W. Partial laryngectomy for vocal cord 71. Bleach N, Perry A, Cheesman A. Surgical voice restoration
with the Blom-Singer prosthesis following laryngopharyn-
cancer with marked limitation or fixation of the vocal cord.
goesophagectomy and pharyngogastric anastomosis. Ann
Laryngoscope 1986; 96:61-4.
57. Amin MR, Koufman JA. Hemicricoidectomy for voice
Otol Rhinol Laryngol 1991; 100(2):142-7. 179
72. Kinishi M, Amatsu M, Tahara S, et al. Primary tracheojeju-
rehabilitation following hemilaryngectomy with ipsilat-
nal shunt operation for voice restoration following pharyn-
eral arytenoid removal. Ann Otol Rhinol Laryngol 2001;
golaryngoesophagectomy. Ann Otol Rhinol Laryngol 1991;
110(6):514-8.
100(6):435-8.
58. Bailey BJ. Partial laryngectomy and laryngoplasty: a tech-
73. Ho CM, Wei WI, Lau WF, et al. Tracheostomal ste-
nique and review. Trans Am Acad Ophthalmol Otolaryngol
nosis after immediate tracheoesophageal puncture. Arch
1966; 70(4):559-74.
Otolaryngol Head Neck Surg 1991; 117(6):662-5.
59. Biller HF, Lucente FE. Reconstruction of the larynx fol-
74. Medina JE, Khafif A. Early oral feeding following total
lowing vertical partial laryngectomy. Otolaryngol Clin laryngectomy. Laryngoscope 2001; 111(3):368-72.
North Am 1979; 12(4):761-6. 75. Micheau C, Luboinski B, Sancho H, et al. Modes of
60. Biller HF, Lawson W. Partial laryngectomy for transglot- invasion of cancer of the larynx. A statistical, histologi-
tic cancers. Ann Otol Rhinol Laryngol 1984; 93 (4 Pt 1): cal, and radioclinical analysis of 120 cases. Cancer 1976;
297-300. 38(1):346-60.
61. Schechter GL. Epiglottic reconstruction and subtotal 76. Stell MP. The subglottic space. In: Alberti PW, Bryce
laryngectomy. Laryngoscope 1983; 93(6):729-34. DP (Eds). Workshops from the Centennial Conference
62. Nong HU, Mo W, Huang GW, et al. Epiglottic laryn- on Laryngeal Cancer. New York, NY: Appleton-Century-
goplasty after hemilaryngectomy for glottic cancer. Crofts 1976; pp. 620.
Otolaryngol Head Neck Surg 1991; 104(6):809-13. 77. Sessions DG, Ogura JH, Fried MP. Carcinoma of the sub-
63. Tucker HM, Benninger MS, Roberts JK, et al. Near- glottic area. Laryngoscope 1975; 85(9):1417-23.
total laryngectomy with epiglottic reconstruction. Long- 78. Biller HF, Som ML. Vertical partial laryngectomy for
term results. Arch Otolaryngol Head Neck Surg 1989; glottic carcinoma with posterior subglottic extension. Ann
115:1314-44. Otol Rhinol Laryngol 1977; 86(6 Pt 1):715-8.
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SECTION 4
Neurogenic Disorders
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Chapter
29 Vocal Fold Paresis/Paralysis

Adam D Rubin, Robert T Sataloff, Farhad Chowdhury
The etiology, prevalence and evaluation of vocal fold posterior gap and a foreshortened vocal fold, arytenopexy
paralysis are discussed elsewhere.1 Unilateral vocal fold may yield a more satisfactory result than traditional aryte-
paralysis is common. It may be idiopathic, or it may occur noid reduction/rotation. Structural considerations should
after injury to the recurrent laryngeal nerve during neck be weighed in light of the patient’s vocal needs, his/her
or thoracic surgery, after neurosurgical procedures or even medical condition and the surgeon’s experience, as well
following simple intubation. When the paralyzed fold as other factors such as vibratory function of the vocal
remains in the partially abducted position, the function- fold (presence or absence of scar) and the person’s pho-
ing fold may be unable to cross the midline far enough to natory skill and demands. Surgeons and patients must
permit complete glottic closure. This will result in hoarse- be prepared for changes in the surgical plan if intraop-
ness, breathiness, ineffective cough, and, occasionally, in erative voice changes are not optimal. Staged surgery is
aspiration (especially after neurosurgical procedures if appropriate in some cases (thyroplasty followed by injec-
other cranial nerves have also been injured). tion laryngoplasty, or vice versa); and it is not rare to
In some cases, surgery should not be performed for need to revise laryngoplastic surgery in order to optimize
vocal fold paralysis until voice therapy has been tried. In results. So, patients and surgeons should be prepared for
many cases, strengthening vocal muscles and improving all possibilities.
speaking technique result in good voice quality and sur-
gery is unnecessary. This is true especially if there is some TEFLON INJECTION
recruitment response on EMG, even if the vocal fold is
not mobile. When the paralysis is idiopathic or when Most surgeons inject materials for vocal fold paraly-
the nerve is not known to be cut, approximately 1 year sis endoscopically under local or general anesthesia.
of observation and therapy should usually be completed Transcutaneous and transoral injection with indirect mir-
to allow time for spontaneous return of function before ror, telescopic or flexible fiberoptic laryngoscopic guidance
performing any irreversible operation. Traditionally, most is also possible. The most common treatment used to be
surgical procedures have worked best for unilateral recur- injection of Teflon (Dupont, Wilmington) lateral to the
rent laryngeal nerve paralysis. paralyzed vocal fold. The Teflon paste pushed the para-
Many factors must be considered in selecting a surgi- lyzed vocal fold toward the midline, allowing the nonpar-
cal procedure for vocal fold repositioning (such as medial- alyzed vocal fold to meet it more effectively (Fig. 29.1A
ization). For example, the surgeon must assess the glottal and B). The author (RTS) has used Teflon only once
configuration. It may be normal during soft phonation, since 1987. Teflon has many disadvantages and better
but there may be insufficient lateral resistance to permit techniques are available. When used, however, correct
loud phonation. This scenario is amenable to injection technique involves injecting Teflon lateral to the vocalis
techniques or thyroplasty. If there is a gap in the middle muscle. The quantity of Teflon should be sufficient to
of the musculomembranous vocal fold but good closure move the vocal fold just to the midline. Injecting too
at the vocal process, implantation of a traditional thy- much or injecting too superficially into the vocal fold
roplasty prosthesis with a straight inner edge (such as mucosa often results in worsened voice quality. When
carved silastic block) is often less satisfactory than injec- properly placed, Teflon usually produced a foreign-body
tion or use of a conformable prosthesis such as Gore- reaction locally but little or no reaction in the surround-
Tex. If there is large posterior gap, injection techniques ing cartilage and muscle.2 Teflon is usually surrounded
alone often do not work well, and arytenoid reposition- by a fibrous capsule. However, occasionally a severe for-
ing procedures should be considered. If there is a large eign-body reaction and granuloma formation may occur.
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Section
This material is injected in the same position as Teflon,

but it is temporary, resorbing in 2−8 weeks. In profes-
sional voice users, periodic Gelfoam injections may be
appropriate early in the course of a recurrent laryngeal
4 nerve paralysis, when recovery cannot be predicted, and
injection of permanent materials is not appropriate. For
this technique, 1 g of sterile Gelfoam powder is mixed
with 4 cc of physiologic saline. The saline must be added
slowly and the mixture should be stirred continuously.
This produces 5 cc of thick paste that can be transferred
to a syringe and then into the Brünings syringe. Injection
technique is then identical to that of Teflon. It should
be noted that, although Gelfoam injection has been used
for this purpose for decades, it has never been formally
approved by the FDA for this use. Gelfoam can be
A
injected in the operating room or in the office. Office
injection usually is performed perorally, using a Brünings
syringe with a curved needle. However, like injection of
collagen and AlloDerm (discussed below), it can also
be injected transcutaneously. Anderson and Mirza have
reported success with this technique for immediate treat-
ment of acute vocal fold immobility with aspiration.5
Although Gelfoam is considered temporary, it usually
184 does cause an inflammatory reaction. Scientific studies of
laryngeal Gelfoam injection are presently inadequate and
the assumption that laryngeal anatomy returns to normal
following Gelfoam resorption still remains unproven.
COLLAGEN, ALLODERM AND FASCIA INJECTION

B Several other materials are still being injected to treat
Figs 29.1A and B: (A) Injection of Teflon lateral to the vocalis vocal fold paralysis, especially collagen, fat, AlloDerm
muscle. (B) Seen from above, the collection of Teflon lateral to the (LifeCell Corporation, Branchburg, NJ), fascia and
vocalis muscle displaces the vocal fold medially. Moving the vocal Calcium Hydroxylapatite (Coaptite, BioForm, Inc.,
fold toward the median position allows the mobile vocal fold to
meet it. The depth of the injected Teflon depends on the size of Franksville, Wisconsin). Ford and Bless have advocated
the larynx, but the injection is usually 3−5 mm below the surface. the use of collagen for many conditions including selected
Generally, 0.3−1.0 cc of Teflon paste is required. Each click of the cases of unilateral vocal fold paralysis.6-8 Collagen is in
Brünings syringe delivers approximately 0.2 cc of Teflon paste. (In
liquid form, rather than a thick paste like Teflon. These
the author’s practice, the use of Teflon injection was virtually
abandoned in the mid-1980s) mechanical differences enhance the ease and accuracy
of injection. In addition, collagen may reduce scar for-
Preoperative and postoperative functional evaluation of mation because it stimulates production of collagenase.
the voice was advocated by von Leden et al. in 1967 Before injecting Bovine collagen, safety precautions such
for all voice patients undergoing surgery for vocal fold as skin testing are mandatory. However, human autolo-
paralysis and should now be standard practice.3 gous and allogeneic collagens are available now and
appear superior to Bovine collagen for various reasons.
GELFOAM INJECTION Not only does the use of human material eliminate the
severe reactions encountered occasionally with Bovine
Effects of Teflon injection or other injected materials can collagen (skin testing is no longer necessary), but pre-
be predicted fairly well by prior injection of Gelfoam liminary experience also suggests that human collagen
paste, which was introduced in 1978 by Schramm et al.4 (Dermalogen, Collagenesis, Beverly, MA) may last longer
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Vocal Fold Paresis/Paralysis
Chapter
following injection,9 potentially making it more useful for
lateral injection (medialization) than Bovine collagen.10-13
Unlike other substances, collagen is designed for super-
ficial injection into the vocal fold margin. A special 25,
27 or 30 gauge laryngeal needle is inserted through the 29
mucosa overlying the vibratory margin until the resistance
of the vocal ligament is felt. Usually, a .03−.08 cc injec-
tion of collagen is injected superficially. If the standard
collagen preparation (Dermalogen) is too viscous for a
given clinical situation, less viscous collagen (Demologen-
lite) can be obtained from the manufacturer. However,
viscosity is usually adequate with Dermalogen if it has
been warmed to body temperature. Collagen may also be
injected laterally. A peroral technique is best for superfi-
cial injection, although collagen can be injected superfi-
cially using an external approach through the cricothyroid
membrane, in selected cases. For injection laterally along Fig. 29.2: In most patients, the paraglottic space can be reached
through a posterior approach, passing a needle behind the posterior
the vocal fold, an external approach through the thyroid border of the thyroid lamina and then angling it anteriorly and
lamina usually works well. The thyroid lamina is usually superiorly. Care should be taken to keep the needle close to the
pierced 7−9 mm above its inferior border. The position thyroid cartilage to help avoid injury to the pyriform sinus or
of the needle can be confirmed by observing paraglottic branches of the recurrent laryngeal nerve
soft tissue movement through a fiberoptic flexible laryn-

goscope. If the patient’s gag reflex is too severe to permit
peroral injection of collagen or other substances or if the
laryngeal cartilage is too ossified to allow passage of a
185
needle through the thyroid lamina, it is often possible to
inject the paraglottic space by passing a needle behind the
posterior aspect of the thyroid lamina (Fig. 29.2). Vocal
fold injection also can be performed through the thyro-
hyoid membrane, using flexible nasolaryngoscopic visual
guidance. This technique was developed for Cidofovir
injection. A 25 gauge needle is inserted into the midline
at the superior border of the thyroid notch after applica-
tion of topical anesthesia; and vocal injection can be per-
formed easily (Milan R. Amin, personal communication,
June 2004). Collagen injections appear to be efficacious
in selected patients and are a valuable addition to the
laryngologist’s surgical armamentarium. Collagen is not
Fig. 29.3: Injection of Alloderm, collagen or other substances may
FDA approved specifically for use in the larynx, although be performed by passing a needle through the thyroid lamina. The
its use has become standard practice. point of insertion is usually about halfway between the anterior
Cymetra micronized AlloDerm (LifeCell Corporation, and posterior borders of the thyroid lamina and about 7−9 mm
above the inferior border
Branchburg, NJ) is an acellular human tissue material that
includes collagen, elastin and proteoglycans. Its use in the
larynx was reported by Passalaqua et al.14 They employed peroral indirect technique in the office, or through direct
an external technique in which the thyroid lamina is laryngoscopy in the operating room.
pierced with a 22 or 24 gauge needle. Needle localiza- Autologous fascia has also been advocated for vocal
tion was confirmed using flexible nasolaryngoscopy and fold augmentation. Rihkanen advised cutting fascia
AlloDerm was injected laterally to treat conditions such into small pieces and delivering it through a Brünings
as bowing (Fig. 29.3). Like collagen, AlloDerm can be syringe.15 The author (RTS) has tried this technique and
injected either through this external technique, through a variations of it over the years. We have used fascia alone
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Section
in a manner similar to that described subsequently by summarized the literature on this subject and addressed
Rihkanen, and fascia mixed with fat to try to diminish many of the problems that make the use of fat contro-
the amount of reabsorption of augmentation material. The versial.19 In particular, the final bulk of the graft and
principle problem with fascia is technical. If all of it is fate of the fat are notoriously unpredictable. At present,
4 not cut into tiny pieces, it is very difficult to pass through the preponderance of evidence suggests that transplanted
the injection syringe. In one instance, it obstructed the fat survives and that the relocated adipose tissue remains
Brünings syringe so firmly that an attempt to pass it dynamic. However, observations in soft tissue sites such
further forward resulted in breakage of the metal syringe. as the face and chest may or may not be applicable to
However, if the fascia is prepared properly, it can be a the fate of fat transplanted to the larynx, especially to the
good material. Relatively, little is resorbed and excessive vibratory margin.
overcorrection should be avoided. Wexler, et al. studied the fate of fat implanted surgi-
Calcium hydroxyapatite (Coaptite, BioForm, Inc. cally in the vocal folds of five dogs.20 The fat was intro-
Franksville, Wisconsin) is a slurry of calcium hydroxyapa- duced through a laryngofissure approach, not by injection.
tite (CaHA) particles. It is approved by the FDA for use The fat was retrieved 2 months after the initial surgery
in the larynx, but there has not been enough experience and in 4 of the 5 dogs was found still to be present.
with this substance to comment on its use and potential Moreover, the autograft produced good functional results,
problems, yet. including greater vocal intensity, lower threshold pressures
for phonation and other improvements in the acoustic
AUTOLOGOUS FAT INJECTION output. Hill, Meyers and Harris used microinjection in
canines after recurrent laryngeal nerve section.21 They
The first use of autologous fat in the larynx was reported used an injection technique without laryngofissure and
by Dedo in 1975 for patients with laryngeal cancer.16 studied the experimental animals histologically at 3 weeks.
He described the placement of a free fat graft under a The bulk of the fat was found to persist for at least that
186 mucosal advancement flap for creating a neovocal fold
following vertical hemilaryngectomy. In many ways, the
period of time.
An excellent study was reported by Archer and
concept is analogous to the fat implantation reported Banks.22 They designed their study to evaluate the long-
here. Unfortunately, Dedo did not provide the number term viability of fat introduced submucosally into scarred
of patients, or any form of objective assessment; but he vocal folds, a procedure very similar to the one the author
reported postoperative voices with minimal hoarseness or developed independently for human use, as described in
breathiness in all cases. This technique has not been used this chapter. Archer and Banks studied 15 canine sub-
widely, and there are no recent reports of its continued jects in three groups. The first group underwent mucosal
use. However, in appropriate cases, Dedo still employs excision of one vocal fold. The second group underwent
a modification of this technique and has had continued mucosal excision of both vocal folds, one of which was
good experience with it (personal communication, April, augmented 6 weeks later with autologous fat by submu-
1995). Human autologous fat injection into the larynx cosal injection at three positions along the vocal fold.
was first reported by Mikaelian, Lowry and Sataloff in These two groups were sacrificed at 6 months. The third
199117 and subsequently by Brandenburg, Kirkham and group was treated the same as the second group, but was
Koschkee.18 These and subsequent reports dealt with sacrificed at 12 months. Each animal was used as its own
autologous lipoinjection lateral to the vibratory margin, control. The stripped vocal folds were thin as compared
placing fat in the same position in which Teflon was used. with normal and fat-augmented vocal folds. All of the
The author (RTS) has had continued excellent experience fat-augmented vocal folds revealed viable adipose cells
with fat injection, particularly in patients who need only in the superficial mucosa. The vocal folds in the fat-aug-
minimal medialization. For patients with a wide poste- mented group were statistically thicker when compared
rior glottic gap, thyroplasty, or thyroplasty in combination with the mucosally damaged, nonaugmented groups.
with fat injection and/or arytenoid adduction has been Although the studies cited above are important, their
preferable. application to humans must be questioned, as with all
There has been extensive experience with autolo- canine research. Unfortunately, there is no better nonhu-
gous fat transplantation in various areas of the body. In man alternative since humans are the only species with
a particularly good review in 1989, Billings and May a layered lamina propria and vocal ligament. Since dogs
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Chapter
have no vocal ligament, extrapolations from dog research
to human response must be made with great caution.
Nevertheless, it is encouraging to note that autologous
fat appears to be preserved and efficacious in the animal
research performed so far. This is especially comforting 29
considering the paucity of experience with fat implanta-
tion in human larynges.
The author has had continued good experience with
autologous fat injections since our first report.17 Several
technical considerations are important in achieving suc-
cess. The first is patient selection. The patients who do
best with autologous fat injection are those who have
only a small glottal gap or those who actually close the
glottis during soft phonation but have insufficient resist-
ance on the paralyzed side to permit loud phonation.
Such conditions occur after spontaneous compensation
for laryngeal paralysis or occasionally following Type I Fig. 29.4: Injection in this patient was performed near the middle
thyroplasty, especially when additional thyroarytenoid of the right vocal fold (arrow). This position is more anterior than
usual. This intraoperative photograph shows 30−40% overcorrection,
muscle atrophy occurs. Similar situations may be seen in the desired endpoint. The apparent bowing of the left vocal fold
patients with vocal fold bowing, as discussed elsewhere is an artifact. Reproduced from Sataloff RT. Professional Voice:
in this chapter. Second, the fat should be traumatized as The Science and Art of Clinical Care, 3rd edition. San Diego, CA:
little as possible, maintaining large globules. Third, fat Plural Publishing, Inc.; 2005: Fig. 82.36, with permission
should not be injected much more posteriorly than the
middle third of the membranous portion of the vocal
fold. A properly placed injection at this location pro-
injection (Fig. 29.5). However, this situation represents
the exception; and surgeons tend to error by injecting too
187
vides adequate medial displacement and allows the medi- little. Overcorrection should normally be at least 30−40%
alized vocal fold to pull the arytenoid and vocal process as described above or repeated injections will be needed in
into better position. Injecting too far posteriorly creates many patients. In most cases, initial fat resorption occurs
a mechanical impediment to passive arytenoid motion, fairly quickly. Patients achieve a serviceable voice within
often resulting in persistent vertical height disparity at the 4−12 weeks. Additional changes occur over 6−12 months.
vocal processes and inferior voice results. Fourth, unlike Occasionally, they may occur even later, necessitating rein-
Teflon, fat requires overinjection by approximately 30%. jection. Such delayed changes have been observed most
The vocal fold should be convex at the conclusion of the commonly following substantial weight loss or a severe
procedure to account for expected resorption (Fig. 29.4). upper respiratory infection. However, in general, if glottic
This overinjection causes moderate dysphonia. If the voice closure is satisfactory, the improvement is permanent.
is excellent at the end of the surgical procedure, a good
final result is unlikely. Initially, the author recommended REMOVAL OF TEFLON
performing these procedures under local anesthesia, in a
manner similar to that used for Teflon injection. However, One of the complications of Teflon injection is overin-
because over injection of fat is performed routinely and jection. If Teflon is injected in excessive amounts or too
there is no need to fine-tune the surgical procedure based superficially, the voice will be substantially worse after
on phonatory function, fat injection can be performed surgery than it was before Teflon injection. Treating such
equally well under general anesthesia. complications and restoring satisfactory vocal quality are
Until recently, it has been said that one could not widely (and correctly) regarded as difficult. However, the
inject too much fat. While this is generally true, there are otolaryngologist may be helped greatly by an accurate
rare exceptions. After more than 10 years of utilizing the preoperative assessment of the problem.
technique, the author has encountered one case in which Cross-sectional imaging using Computed Tomography
excess fat had to be resected. Interestingly, histologically (CT) of a larynx after Teflon injection documents the
normal, viable fat was removed one year following the position of deposited Teflon easily, including its amount
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Section
Fig. 29.5: This 78-year-old corporate executive had substantial

dysphonia related to bilateral superior laryngeal nerve paresis.
He had undergone a fat injection 1 year previously. The usual
overcorrection was performed on the right vocal fold and a small
amount of fat was injected at the same time into the left vocal
fold, but without the usual excess to avoid airway obstruction.
Postoperatively, he retained more fat than usual, especially
anteriorly. This resulted in vocal strain and fatigue. An incision
was made laterally, and the excess fat was resected 1 year
188 following injection. The fat appeared normal and healthy grossly
and microscopically, as seen above. Reproduced from Sataloff
RT. Professional Voice: The Science and Art of Clinical Care, 3rd
with permission
and depth (Figs 29.6A and B). Although this high atten-
uation material (216 hounsfield units) is seen easily, the
B
value of radiological assessment in these cases has been
appreciated only in the later 1980s.23 Figs 29.6A and B: (A) Axial and (B) Coronal CT scans of patient
with left Teflon granuloma, illustrating the value of CT imaging in
In general, preoperative evaluation by strobovideo- mapping the position of the Teflon prior to surgery. Reproduced
laryngoscopy, CT and objective voice analysis allows from Sataloff RT. Professional Voice: The Science and Art of
for reasonably accurate definition of the problem. If the Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.;
Teflon has been injected incorrectly submucosally and 2005: Fig. 82.38, with permission
the vibratory margin is adynamic, but fairly straight, the
patient should be advised that further surgical procedures some people do form a granulomatous response or thick
are unlikely to produce improvement, especially if the capsule, thus increasing mass. Consequently, the amount
vocal fold edge is smooth. If there are multiple lumps of of Teflon may have been correct at the time of surgery but
superficial Teflon with failure of glottic closure between became more than was necessary after the tissue response
them, it is usually worthwhile to remove them and smooth occurred. In the author’s opinion, the best way to address
the vibratory margin to improve glottic closure, even if this problem usually is with an incision with laser later-
vibration is not restored. If Teflon has been injected in a ally over the collection of Teflon. The incision should
correct position, but vocal fold convexity exists because of be far from the vibratory margin. When the CO2 laser
excessive Teflon and/or granuloma formation, results are touches the Teflon, a bright white glow is noted. If there
more satisfactory. It should be noted that the excess may is extensive granulomatous reaction around the Teflon,
not be due to faulty technique on the part of the surgeon. it may be necessary to excise the Teflon with the laser.
Although Teflon should not ordinarily cause a reaction, In other cases, exposing a small portion of the Teflon
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Chapter
allows it to be expressed and suctioned. Gentle pressure SURGICAL TECHNIQUES
with the side of suction against the vocal fold edge is
used to milk the desired amount of Teflon out of the Case 1: Lipoinjection (Figs 29.7A to L)
vocal fold and to re-establish a smooth vocal fold mar-
Step 1
gin. Slight over evacuation creating a minimal concavity 29
of the vocal fold edge seems to produce the best results. General anesthesia is administered via orotracheal
Alternatively, Teflon can be excised externally through intubation.
a thyrotomy. Techniques for the external approach to
resection of Teflon granuloma have been published by Step 2
Netterville and co-workers.24, 25 The approach requires An incision measuring approximately 5 mm is made in a
a thyrotomy and the inner perichondrium is incised. In pre-existing abdominal scar. If no such scar is available,
some cases, the Teflon mass can be shelled out easily. an incision is made in the lower-left quadrant, well below
However, if Teflon and inflammatory response involve the the pubic hairline (Fig. 29.7A) so as not to confuse the
vibratory margin, penetration into the airway can occur. scar with that of a prior appendectomy.
If an external approach is used and it appears as if the
Teflon mass has been removed safely, it may be desirable Step 3
to fill part of the resulting cavity, although it is difficult Fat is harvested via liposuction through a large-bore low-
to assess final phonatory outcome during these proce- pressure liposuction system. The author prefers an 8 mm
dures. This is because Teflon often produces vocal fold liposuction cannula (Fig. 29.7B), as this allows for the
stiffness and scar, and the vocal fold may not lateralize harvest of optimal sized fat particles, minimizing trauma
completely in the operating room. However, if there is a to the fat cells that occurs during high pressure extraction
large cavity created by the resection, some lateralization with smaller cannulas. Alternatively, fat may be harvested
is likely to occur during healing. The cavity can be filled in large globules by resecting a small amount of fat (usu-
with a free fat graft or with a strap muscle flap. Recently,
Netterville has modified his procedure ( James Netterville,
ally from the abdomen) with traditional instruments.
189
MD, Personal Communication, 2001). Rather than using Step 4
a lateral cartilage flap, he approaches the paraglottic space After the fat has been harvested, the incision is closed
now through a vertical thyrotomy incision made approxi- with 3.0 absorbable sutures (Fig. 29.7C). The wound
mately 4 mm from the midline of the thyroid cartilage. edges are approximated with octyl-2-cyanoacrylate.
He has also abandoned the inferiorly-based strap mus-
cle flap because of a few cases of fibrosis that produced
inferior-lateral scarring of the vocal fold. Instead, he is
using a platysmal flap with its attached fat. The author
(RTS) has had reasonable success with inferiorly-based
and superiorly-based strap muscle flaps, so long as they
are divided at the point of origin or insertion, not in the
body of the muscle. An excess amount of muscle is placed
and the muscle is sutured into position with stitches
through the thyroid cartilage. If the tissue deep to the
vocal fold is deficient (muscle atrophy or absence), a flap
including fat is used or a free fat graft. It should be noted
that total removal of Teflon is difficult (often impossible)
using either the external or endoscopical approach. Unless
a hemilaryngectomy is performed, small Teflon particles
remain often. In some cases, they may produce recurrent
symptomatic granulomas months or years after successful
treatment. Such problems are the primary reasons why
Fig. 29.7A: An incision is made through the skin and subcutaneous
Teflon was abandoned in the late 1980s in favor of injec- tissue below the pubic hair line. The incision can also be made in
tion of fat or other materials or thyroplasty. the left lower quadrant or in the inferior porter of the umbilicus
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Section
B C
190
D E
Figs 29.7B to E: (B) A large liposuction cannula (8 mm) is used to harvest the fat. Note the incision does not need to be larger than
the width of the liposuction cannula. The fat may be harvested in large globules either by resecting a small amount of fat (usually from
the abdomen) with traditional instruments. (C) The incision is approximated using subcutaneous sutures and N-butyl octyl cyanoacrylate.
(D) Large particles of fat are removed from the liposuction filter. (E) The liposuctioned fat is rinsed gently with saline. It is important
to avoid extensive manipulation or trauma to the fat. We do not centrifuge the fat or use insulin
Step 5 Step 7
The liposuctioned fat is trapped in an inline filter sys- Suspension laryngoscopy exposes the vocal folds
tem. It is then placed into a sterile filtration funnel (Fig. 29.7H). In this patient, bilateral bowing of the vocal
(Fig. 29.7D). It is then rinsed gently with sterile saline folds can be seen.
(Fig. 29.7E), but not morcelized. The back-handle of a
knife blade is used to rinse the fat of blood and fatty acid Step 8
residues (Fig. 29.7F). The harvested fat is injected into the vocal fold (Fig. 29.7I).
A deep and lateral injection is performed by placement
Step 6 of the needle slightly beyond the tip of the vocal process,
The harvested fat is collected, placed in a 10 ml slip tip at the superior arcuate line, angled laterally.
syringe (Fig. 29.7G) and loaded into a Brünings syringe.
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Chapter
29
F G
191
H I
Figs 29.7F to I: (F) Using the back end of a knife handle, the mixture is stirred allowing the saline to exit through the filter. (G) The
fat is placed into a slip tip syringe in preparation for loading into a Brünings syringe. (H) Suspension laryngoscopic view shows bowed
vocal folds bilaterally. (I) A Brünings syringe is used to inject the fat. The needle is placed at the superior arcuate line just anterior
to the tip of the vocal process
Step 9 Step 11
An approximately 40% over correction is performed to Extubation is performed while the patient is still under
account for fat resorbtion (Fig. 29.7J). deep anesthesia. The patient is kept on absolute voice
rest for at least 48 hours to prevent extrusion through
Step 10 the injection site.
Any fat protruding through the injection site is gen-
tly grasped with microlaryngeal forceps and divided as Case 2: Radiesse Explant with Cold Instruments
close to the injection site as possible (Fig. 29.7K). If left
Step 1
protruding through the injection site, there is a potential
for an inflammatory reaction including granuloma forma- General anesthesia is administered via orotracheal intu-
tion. Little or no contralateral fat injection is performed bation. Suspension microlaryngsocopy is performed to
(Fig. 29.7L). expose the glottis (Fig. 29.8A).
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Section
J K
192
Figs 29.7J to L: (J) Approximately 40% over injection of fat

is necessary to account for resorption. (K) To avoid granuloma
formation, any fat protruding through the injection site is excised.
(L) The procedure is staged to allow for over-correction while
L maintaining patency of the airway
Step 2 Step 5
An incision is made on the superior surface of the vocal As the implant is revealed, it is grasped by a Sataloff
fold with a straight Sataloff Sharp Knife (Fig. 29.8B) to Heart-shaped Grasper and retracted medially (Figs 29.8E
create a microflap. and F). Both blunt and sharp dissection may be neces-
sary to free the implant from the vocal ligament and/
Step 3 or muscle.
Blunt dissection with a Sataloff Long Right Angle Ball
Dissector is used to advance the microflap to better Step 6
expose the implant (Fig. 29.8C). The vocal fold is palpated and examined for any implant
that may have been missed (Fig. 29.8G). Superficial and
Step 4 deep Decadron injections are performed (Fig. 29.8H).
Dissection continues in a circumferential fashion around The general anesthetic is reversed and a deep extuba-
the implant (Fig. 29.8D). The inflammatory reaction and tion is performed. Though the vibratory margin has not
tissue integration caused by the implant necessitates the been touched, the patient is placed on relative voice rest
use of steady but delicate force. to avoid unnecessary trauma to the deeper structures
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Chapter
29
A B
193
C D
Figs 29.8A to E: (A) Suspension microlaryngoscopy is performed

to expose the larynx. (B) An incision is made along the superior
surface of the left true vocal fold. (C) A blunt ball dissector is
used to free the Radiesse implant from the surrounding tissue,
minimizing trauma to the contact surface of the vocal fold. (D) The
implant is freed from the surrounding tissue. (E) The implant is
retracted medially. A combination of blunt and sharp dissection is
E used to remove the implant
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Section
F G
194
H I
Figs 29.8F to I: (F) Fine instruments are used to remove remaining fragments of the Radiesse implant. Like Teflon, it is commonly
impossible to remove all of the Radiesse. (G) The incision will close by secondary intention. The vibratory margin of the vocal fold is
left undisturbed. (H) Decadron is injected into the surgical site to reduce inflammation and resulting scar caused by the dissection.
(I) At 6 weeks postoperative, the surgical site is seen to have healed well on rigid stroboscopic examination
of the vocal fold. A 6-week postoperative rigid strobo- Step 2

scopic examination shows a well-healed surgical site and The vocal fold is palpated to confirm the location of the
increased pliability of the vocal fold (Fig. 29.8I). calcified implant. An incision is made with the laser on
the superior surface of the vocal fold, avoiding the vibra-
Case 3: Radiesse Explant with Carbon Dioxide tory margin (Fig. 29.9B).
Laser Explant
Step 3
Step 1 Dissection continues deep into the vocal fold until the
Alternatively, this procedure can be performed using a implant is encountered (Fig. 29.9C). Blunt dissection
carbon dioxide laser. General anesthesia is administered assists in freeing the implant from the surrounding tis-
via orotracheal intubation, and the glottis is exposed with sue (Fig. 29.9D). Dissection can prove difficult as the
suspension microlaryngoscopy (Fig. 29.9A). A wet cotton implant integrates with the surrounding vocal ligament
pledget is placed deep to the surgical site. and muscle (Fig. 29.9E).
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Chapter
29
A B
195
C D
Figs 29.9A to E: (A) When using a laser, good visualization of

the glottis is obtained and a wet cotton pledget is placed into
the subglottis. (B) An incision is made with the laser on the
superior-lateral surface of the right vocal fold. (C) The dissection
is continued deep into the vocal fold until the Radiesse is
encountered. (D) Blunt dissection is used to free the Radiesse from
the surrounding tissue. (E) The Radiesse implant has integrated
E with the surrounding tissue
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Section
F G
196
Figs 29.9F to H: (F) When the laser hits the Radiesse implant, a
flash is given off similar to that seen with Teflon. (G) The vibratory
margin and epithelium surrounding the incision are preserved.
(H) Videostroboscopic examination at postoperative week 6 shows
H the vocal fold has healed well
Step 4 REFERENCES
As the implant is vaporized with the laser, a flash simi-
1. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis.
lar to that seen in the resection of Teflon is observed In: Sataloff RT. Professional Voice: The Science and Art
(Fig. 29.9F). of Clinical Care, 3rd edition. San Diego, California: Plural
Step 5
2. Stone JW, Arnold GE. Human larynx injected with Teflon
The vocal fold is palpated for any remaining implant paste. Histological study of innervation and tissue reaction.
material (Fig. 29.9G). Deep and superficial injections Arch Otolaryngol. 1967; 86(5):550-61.
of Decadron are performed. The general anesthesia is 3. Von Leden H, Yanagihara N, Werner-Kukuk E. Teflon
reversed and the patient is extubated. The patient is in unilateral vocal cord paralysis. Preoperative and post-
placed on relative voice rest to minimize postoperative operative function studies. Arch Otolaryngol. 1967;
vocal fold trauma. An examination on postoperative week 85(6):666-74.
6 shows a well-healed vocal fold with increased pliability 4. Schramm VL, May M, Lavorato AS. Gelfoam paste injec-
(Fig. 29.9H). tion for vocal cord paralysis: temporary rehabilitation of
Ch-29.indd 196 9/8/2010 3:10:20 Gopal

Chapter
glottic incompetence. Laryngoscope. 1978; 88(8 Pt 1): 15. Rihkanen H. Vocal fold augmentation by injection of
1268-73. autologous fascia. Laryngoscope. 1998; 108(1 Pt 1):51-4.
5. Anderson TD, Mirza N. Immediate percutaneous medi- 16. Dedo HH. A technique for vertical hemilaryngectomy
alization for acute vocal fold immobility with aspiration. to prevent stenosis and aspiration. Laryngoscope. 1975;
Laryngoscope. 2001; 111(8):1318-21. 85(6):978-84.
6. Ford CN, Bless DM. Loftus JM. Role of injectable 17. Mikaelian DO, Lowry LD, Sataloff RT. Lipoinjection 29
collagen in the treatment of glottic insufficiency: a study for unilateral vocal cord paralysis. Laryngoscope. 1991;
of 119 patients. Ann Otol Rhinol Laryngol. 1992; 101(3): 101(5):465-8.
237-47. 18. Brandenburg JH, Kirkham W, Koschkee D. Vocal cord
7. Ford CN, Bless DM. Collagen injected in the scarred vocal augmentation with autogenous fat. Laryngoscope. 1992;
fold. J Voice. 1987; 1:116-8. 102(5):495-500.
8. Ford CN, Bless DM. Selected problems treated by vocal 19. Billings E Jr, May JW Jr. Historical review and present sta-
fold injection of collagen. Am J Otolaryngol. 1993; tus of free fat graft autotransplantation in plastic and recon-
14(4):257-61. structive surgery. Plast Reconstr Surg. 1989; 83(2):368-81.
9. Cendron M, DeVore DP, Connolly R, et al. The biological 20. Wexler DB, Jiang J, Gray SD, et al. Phonosurgical studies:
behavior of autologous collagen injected into the rabbit fat-graft reconstruction of injured canine vocal cords. Ann
bladder. J Urol. 1995; 154(2 Pt 2):808-11. Otol Rhinol Laryngol. 1989; 98(9):668-73.
10. Ford CN, Staskowski PA, Bless DM. Autologous col- 21. Hill DP, Meyers AD, Harris J. Autologous fat injec-
lagen vocal fold injection: a preliminary clinical study. tion for vocal cord medialization in the canine larynx.
Laryngoscope. 1995; 105(9 Pt 1):944-8. Laryngoscope. 1991; 101(4 Pt 1):344-8.
11. DeVore DP, Hughes E, Scott JB. Effectiveness of injectable 22. Archer SM, Banks ER. Intracordal injection of autologous
filler materials for smoothing wrinkle lines and depressed fat for augmentation of the mucosally damaged canine
scars. Med Prog Technol. 1994; 20(3-4):243-50. vocal fold: a long-term histological study. Presented at
12. Burstyn DG, Hageman TC. Strategies for viral removal the Second World Congress on Laryngeal Cancer; Sydney,
and inactivation. Dev Biol Stand. 1996; 88:73-9. Australia; 1994.
13. DeVore DP, Kelman C, Fagien S, et al. Autologen: 23. Sataloff RT, Mayer DP, Spiegel JR. Radiologic assessment
autologous, injectable dermal collagen. In: Bosniak S of laryngeal Teflon injection. J Voice. 1988; 2(1):93-5. 197
(Ed). Ophthalmic Plastic and Reconstructive Surgery. 24. Netterville JL, Coleman JR Jr, Chang S, et al. Lateral
Philadelphia, PA: WB Saunders Company; 1996. pp. 670-5. laryngectomy for the removal of teflon granuloma. Ann
14. Passalaqua P, Pearl A, Woo P, et al. Direct transcutane- Otol Rhinol Laryngol. 1998; 107(9 Pt 1):735-44.
ous translaryngeal injection laryngoplasty with AlloDerm. 25. Coleman JR, Miller FR, Netterville JL. Teflon granuloma
Presented at the 30th Annual Symposium: Care of the excision via a lateral laryngectomy. Oper Techn Otolaryngol
Professional Voice; June 16, 2001; Philadelphia, PA. Head Neck Surg. 1999; 10(1):29-35.
Ch-29.indd 197 9/8/2010 3:10:21 Gopal

Chapter
30 Thyroplasty
TYPE I THYROPLASTY placement of a nerve-muscle pedicle. However, the author

has generally abandoned all of these techniques except
Type I thyroplasty is an excellent approach to medi- during revision cases in favor of Gore-Tex (expanded
alization. This procedure was popularized by Isshiki et Polytetrafluoroethylene). The use of Gore-Tex in the lar-
al in 1975,1 although the concept had been introduced ynx was reported initially by Hoffman and McCulloch.7
early in the century by Payr.2 Thyroplasty is performed Since then, numerous reports have documented its effi-
under local anesthesia. Although the author rarely uses cacy.11-13 In our center, the author (RTS) has used Gore-
the original technique anymore, in classical thyroplasty, Tex for primary Type I almost exclusively since 1999.
with the neck extended, a 4−5 cm incision is made hori- The material is easy to place, easy to adjust and can be
zontally at the midpoint between the thyroid notch and contoured to compensate for vocal fold bowing.
the lower rim of the thyroid cartilage. A rectangle of Our preferred technique is slightly different from pro-
thyroid cartilage is cut out on the involved side. It begins cedures published previously. One of the major advan-
approximately 5−7 mm lateral to the midline and is usu- tages of Gore-Tex is that it can be placed through a
ally approximately 3−5 mm by 3−10 mm. The inferior mini-thyrotomy, obviating the need to traumatize or
border is located approximately 3 mm above the inferior transect strap muscles. A small (2 cm) horizontal inci-
margin of the thyroid cartilage. Care must be taken not sion is made centered in the midline, in a skin crease near
to carry the rectangle too far posteriorly or it cannot the lower third of the vertical dimension of the thyroid
be displaced medially. The cartilage is depressed inward, cartilage. The cartilage is exposed in the midline and the
moving the vocal fold toward the midline. The wedge of perichondrium is incised and elevated. A 5 mm diamond
silicone is then fashioned to hold the depressed carti- bur is used to drill a 5 mm mini thyrotomy. Its anterior
lage in proper position (Figs 30.1A to C). Since Isshiki’s border is located approximately 7 mm from the midline
original description, many surgeons have preferred to in females and 9 mm from the midline in males; and its
remove the cartilage. Most preserve the inner perichon- inferior margin is approximately 3−4 mm above the infe-
drium, although techniques that involve incisions through rior border of the thyroid cartilage. The inner perichon-
the inner perichondrium also have been used success- drium is left intact. A fine elevator, such as a Woodson
fully. Surgeons have also used various or other materials elevator (Codman, Raynham MA) or Sataloff Thyroplasty
including autologous cartilage, hydroxylapatite, expanded Elevator (Medtronics Xomed, Jacksonville FL), is used
polytetrafluoroethylene and titanium.3-9 to elevate the perichondrium posteriorly. In the author’s
Various additional technical modifications have been opinion, it is very important that only minimal elevation
proposed as this technique has become more popular be performed. A small pocket, only 2−3 mm in width,
and several varieties of pre-formed thyroplasty implant parallel to the inferior border of the thyroid cartilage is
devices have been introduced commercially. Many of sufficient. This is substantially different from the exten-
these modifications have proven helpful, especially tech- sive elevation performed during traditional thyroplasty.
niques that obviate the need to carve individualized. However, if the perichondrium is elevated excessively, it
Silicone block implants involve a technique that is often is difficult to control the position of the Gore-Tex. Any
challenging for inexperienced thyroplasty surgeons. The additional elevation necessary will be accomplished by
silicone block modifications described by Dr Harvey the Gore-Tex during insertion. Gore-Tex is then layered
Tucker10 are also useful, particularly the technique of through the thyrotomy incision and adjusted to optimize
cutting out a portion of the prosthesis to allow for the phonation (Figs 30.2A to D).
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Thyroplasty
Chapter
30
A B
Figs 30.1A to C: (A) In Type I thyroplasty, cartilage is cut beginning 5−7 mm

lateral to the midline. The window is about 3−5 mm x 3−10 mm. The window
should be no more than 5 mm from the inferior border of the thyroid cartilage.
199
After the cartilage cut has been completed, the inner perichondrium is elevated.
This drawing illustrates correct window placement. (B) A silicone block is used
to depress the cartilage into proper position, displacing the vocal fold medially.
The silicone may be sutured to the cartilage. It is often necessary to taper
the silicone anteriorly. This drawing also illustrates the most common errors
in thyroplasty surgery, placing the window slightly too high and making the
block too thick anteriorly. (C) Appropriate thyroplasty window position and
C tapered prosthesis
This procedure is performed under local anesthesia removed easily when revision surgery is necessary, simply
with sedation and vocal fold position can be monitored by by pulling on the end of the Gore-Tex that extends a few
flexible laryngoscopy during the operation. We do not use millimeters beyond cyanoacrylate. Gore-Tex thyroplasty is
continuous monitoring routinely, but ordinarily we check so expeditious and atraumatic that it can be performed
the final position visually at conclusion of the operation. bilaterally at the same sitting. This is done commonly to
For closure, other surgeons use perichondrial flaps that treat vocal fold bowing from bilateral superior laryngeal
are repositioned and sutured. The author has found this nerve paresis and other causes and to treat presbyphonia
maneuver unnecessary and time consuming. Once Gore- refractory to voice therapy. Bilateral thyroplasties can be
Tex has been positioned optimally, it is cut a few millim- accomplished ordinarily in less than one hour. A small
eters outside the thyrotomy. The thyrotomy is then filled drain usually is placed at the conclusion of the procedure
with a few drops of cyanoacrylate. This glue does not and removed on the first postoperative day. In many cases,
react with the Gore-Tex. However, it forms a customized the procedure is performed as an outpatient, although
button-like seal with a small inner flange of cyanoacr- overnight observation is appropriate if there is vocal fold
ylate, and with a wick of Gore-Tex in the center of the swelling or any concern about airway compromise.
cyanoacrylate block. This prevents extrusion of the Gore- There have been no studies documenting the efficacy
Tex; and the cyanoacrylate “button” and Gore-Tex are of routine use of steroids or antibiotics in thyroplasty
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Section
A B
200
C D
Figs 30.2A to D: (A) A mini-thyrotomy is created using a 4 mm diamond burr. Limited perichondrial elevation is performed. (B) Gore-Tex
(WL Gore and Associates Incorporated, Newark, Del) is layered into the space between the cartilage and perichondrium. The patient
is asked to phonate, and Gore-Tex is adjusted until phonatory output is optimal. (C) Cyanoacrylate is used to seal the Thyrotomy.
(D) A small amount of Gore-Tex is left externally
surgery. Many surgeons use both routinely. The author performed originally using a silastic block or one of the
(RTS) does not use either antibiotics or steroids rou- performed, commercially available implants. During these
tinely. In our practice, we have encountered only one initial operations, a large thyroplasty window has been
infection following thyroplasty in over 20 years, and that created and perichondrium has been elevated. Removing
was believed to be due to contaminated suture recalled by the silastic block and replacing it with Gore-Tex gener-
the manufacturer shortly after that operation. However, ally does not prove satisfactory. Gore-Tex position
since a foreign body is implanted during thyroplasty, cannot be controlled well because of the postsurgical
many surgeons prefer to give antibiotics prophylactically. anatomy. In general, the author prefers to revise such
cases by carving a new silastic block or by modifying
REVISION THYROPLASTY the prosthesis that had been placed originally. If revi-
sion is being performed because of insufficient medi-
Revision thyroplasty is a more complex matter. Most thy- alization, it is sometimes possible to elevate the anterior
roplasties that have required revision, so far, have been aspect of the prosthesis and layer Gore-Tex medial to it.
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Thyroplasty
Chapter
However, such cases are uncommon. More often, it is thyroplasty.15 Hence, although in our experience and most
necessary to incise the fibrotic capsule in the region of other series airway obstruction has not been common, it
the inner perichondrium with an electric cautery (which must be recognized that this complication and the need
often produces momentary discomfort for the patient) for tracheotomy are possible.
and to create a new prosthesis. The most common prob- 30
lems that require revision are undermedialization result- OTHER TYPES OF THYROPLASTY
ing in persistent glottic insufficiency, excessive anterior
medialization resulting in strained voice, excessively high Isshiki also described other thyroplasty techniques16
placement of the original prosthesis and inappropriate (Fig. 30.3). The Type I thyroplasty described above was
patient selection. Undermedialization can be corrected designed to medialize the vocal fold. Type II thyroplasty
by underlaying Gore-Tex or creating a larger prosthe- expands the vocal folds laterally. It is designed for patients
sis as discussed above, or endoscopically by injecting fat with airway insufficiency after laryngeal trauma. The thy-
or collagen. Excessive anterior medialization is corrected roid cartilage is separated anteriorly and held apart with
by reshaping the prosthesis. In such cases, the original cartilage or some other material. This uncommon proce-
implant is usually too thick, and placed too far anteri- dure restores the airway at the expense of the voice. Type
orly. Excessively high placement is often associated with III thyroplasty shortens the vocal folds by incising and
a cartilage window that is considerably higher than the depressing the anterior segment of the thyroid cartilage.
desirable 3−4 mm above the inferior border of the thyroid This may be used to lower vocal pitch. An additional
cartilage. When additional cartilage is removed to place decrease in fundamental frequency may be obtained by
the prosthesis at the desired height, cartilage deficiency combining this procedure with vocal fold injection to
from the original operation often leaves the prosthesis increase vocal fold mass. However, it involves a fairly
unstable. In such cases, the implanted device should be significant risk of dysphonia. Type III thyroplasty also
secured to the thyroid cartilage by sutures. In fact, when has shown at least temporary efficacy in some patients
using an implant other than Gore-Tex for primary or
revision surgery, the author always secures the prosthesis
with spasmodic dysphonia.
Type IV thyroplasty was designed to lengthen the vocal
201
to cartilage with proline or nylon suture to prevent migra- folds and increase their tension, in order to raise vocal
tion or extrusion. pitch. The cricoid and thyroid cartilages are approximated
Another common reason for revision is inappropriate anteriorly with nylon sutures. This procedure has been
patient selection. If there is a large, symptomatic pos- used primarily for patients undergoing male to female
terior glottal gap, thyroplasty alone is often insufficient. sex-change surgery and for elderly women with excessive
Procedures to alter arytenoid cartilage position are neces- vocal masculinization. Unfortunately, the long-term
sary in many such cases. Failure to recognize this need results (beyond 6−12 months) have been disappointing.
and perform the appropriate operation initially may lead Sataloff et al described an alternative procedure that fuses
to a need for revision surgery that includes arytenoid the cricoid and thyroid (Figs 30.4A to C), which has
repositioning procedures. Apart from malposition of the proven more satisfactory.17 The position of the cricoid
implant, Type I thyroplasty is generally uncomplicated. and thyroid cartilage can be held either with sutures
Successful thyroplasty improves vibratory function.14 as illustrated, or with mini-plates. Surprisingly, these
However, if thyroplasty is complicated by hemorrhage patients have maintained approximately a 1-octave fre-
with superficial hematoma along the vibratory margin, quency range despite complete cricothyroid fusion and
or by infection, vocal fold stiffness with permanent dys- fixation.
phonia can result. Hemorrhage and edema also can pro- Pitch can also be raised by shifting the anterior com-
duce airway obstruction. Although the author has never missure forward. The procedure is performed by making
seen a case, Weinman and Maragos15 reported on 630 incisions similar to those used for Type III thyroplasty.
thyroplasty procedures. Seven of their patients required However, the anterior segment is advanced. The advance-
tracheotomy. Five of 143 patients who underwent aryte- ment is maintained by interposing silastic blocks in the
noid cartilage adduction in association with thyroplasty gaps between the cartilage edges and fixing the carti-
required tracheotomy. In the experience of Weinman lage with mini-plates. Care must be taken not to detach
and Maragos, the median interval from surgery to tra- the anterior commissure ligament during this procedure,
cheotomy was nine hours, with five of the seven patients and during cosmetic laryngoplasty used in sex-change
requiring airway surgery within eighteen hours following patients.
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Section
Type I: Lateral compression Type II: Lateral expansion
202
Type III: Shortening
Type IV: Lengthening
Fig. 30.3: Four types of thyroplasty described by Isshiki16
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Thyroplasty
Chapter
30
A B
203
Figs 30.4A to C: (A) In cricothyroid approximation surgery described

by Isshiki. (B) Sutures tied over bolsters are used to narrow the
cricothyroid space, simulating the action of the cricothyroid muscle. In
our modification. (C) The cricoid cartilage is subluxed behind the thyroid
cartilage. It is fixed into position using sutures and bolsters or using
mini-plates. Although the cricothyroid space is obliterated, the ability
C to vary pitch remains surprisingly good
If the anterior commissure tendon is detached, dys- to perform a laryngofissure or to cut a window near the
phonia usually is severe. The vocal folds become flaccid vertical midpoint of the thyroid cartilage. The vocal folds
and habitual pitch drops. The ability to change pitch should be mobilized for a distance of several millimeters
diminishes and pertubation increases. Separation of the bilaterally. Then, the anterior commissure ligament can be
anterior commissure can occur iatrogenically as noted drawn forward and sutured to cartilage (if present); to a
above, or as a consequence of blunt trauma such as piece of cartilage harvested from the lateral aspect thyroid
may occur from steering wheel injuries, or elbow inju- lamina and placed external to the midline of the thyroid
ries during sports. Anterior commissure laryngoplasty is cartilage; or to a miniplate. In particularly difficult cases,
performed through an external approach. The technique other technical modifications may be necessary.
for repair depends upon the nature of the injury and the Occasionally, singers and actors inquire about surgery
presence or absence of cartilage at the point at which for pitch alteration. Laryngeal framework surgery has
the anterior commissure should be attached. If cartilage proven successful in altering pitch in specially selected
is missing following a laryngeal shave procedure or frac- patients, such as those undergoing gender reassignment
ture, it is sometimes possible to identify the retracted (sex-change) surgeries. However, these operations do not
anterior commissure tendon without additional trauma to provide consistently good enough voice quality to be
the cartilage. If this is not possible, it may be necessary performed on a professional voice user for elective pitch
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Section
change. In addition, considerably more than habitual fun-

damental frequency is involved in the perception of voice
classification and important other factors (such as the
center frequency of the singer’s formant) are not modified
4 by laryngeal surgery.
NOMENCLATURE
In an effort to standardize the confusing nomenclature of

laryngoplastic voice surgery (commonly called phonosur-
gery), the Committee on Speech, Voice and Swallowing
Disorders of the American Academy of Otolaryngology—
Head and Neck Surgery developed a nomenclature, which
the author recommends to use.18
A
SURGICAL TECHNIQUES (Figs 30.5A to T)
Step 1
In the preoperative assessment area, the patient is decon-
gested with topical application of oxymetazoline. 10 cc of
intravenous Decadron are administered. Nasal cottonoid
pledgets with 4% lidocaine are placed in the nasal cavities
204 and left in place throughout the procedure (Fig. 30.5D).
Step 2
The planned surgical incision is marked with the patient
lightly sedated and placed in the neutral position
(Fig. 30.5A). If possible, a prominent skin crease close
to the inferior border of the thyroid cartilage is chosen.
The incision extends approximately 2 cm to either side of B
midline to create a symmetric postoperative scar.
Figs 30.5A and B: (A) The proposed horizontal skin incision
is marked extending approximately 2 cm to either side of the
Step 3 midline. (B) Infiltration of the surgical site with local anesthetic
Approximately, 10 cc of 1% lidocaine with 1:10,000 agent and epinephrine
epinepherine are injected into the incision site and deep
tissues, extending superiorly to the thyroid notch, inferi- blunt, sharp and electrocautery dissection (Fig. 30.5G) is
orly to the cricoid cartilage and to the lateral borders of utilized to dissect through the midline raphe and expose
the thyroid alae (Fig. 30.5B). the thyroid cartilage (Fig. 30.5H). The strap muscles
should not be transected.
Step 4
A sterile surgical site is prepared extending from the Step 6
mandible to the clavicles (Fig. 30.5C). The drapes placed The outer thyroid perichondrium is elevated off the thy-
over the patient’s face are suspend from a Mayo stand roid alae laterally to the oblique line (Fig. 30.5I). It is not
(Fig. 30.5D) and not permitted to lie on the patient, and essential to preserve the outer perichondrium.
the instruments are organized (Fig. 30.5E).
Step 7
Step 5 The anterior-inferior extent of the thyroidotomy win-
A horizontal skin incision is made through the skin dow is demarcated on the thyroid alae with a needle-tip
and subcutaneous tissues (Fig. 30.5F). A combination of electrocautery (Fig. 30.5J). This is placed 3 mm cephalad
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Thyroplasty
Chapter
30
C D
205
E F
Figs 30.5C to F: (C) Sterile preparation and draping of the surgical site. (D) Drapes are suspended, not placed down over the patient’s
face. Nasal cottonoid sponges with decongestant and anesthetic agents are left in place. The strings on the cottonoid are taped to the
cheek so they cannot move inadvertently into the patient’s eyes. (E) Surgical instruments are laid out in an organized fashion on the
Mayo stand. (F) Incision is made through the skin and subcutaneous tissues
from the inferior border of the thyroid cartilage, and, for easier delivery of the Gore-Tex implant to the posterior
males, 9 mm posterior from the anterior attachment of glottis. A small diamond burr can be used instead of a
the vocal folds (7 mm for females). The measurement is curette.
made using a Sataloff elevator.
Step 8 Step 10
A 5 mm diamond burr is used to create a thyroidotomy A Sataloff Thyroplasty Elevator is used to create a pocket
window (Fig. 30.5K). The inner perichondrium of the between the inner perichondrium and the thyroid car-
thyroid cartilage is left intact in most cases. tilage for placement of the implant (Fig. 30.5M). The
pocket is raised in a straight line, parallel to the inferior
Step 9 border of the thyroid cartilage in a posterior direction.
Using a small stapes curette (Fig. 30.5L), the thyroi- There should not be any sweeping motion during the
dotomy window is beveled posteriorly. This allows for elevation of the inner perichondrium.
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Section
G H
206
I J
Figs 30.5G to J: (G) A combination of blunt and sharp dissection with electrocautery is performed. (H) The thyroid cartilage and
overlying perichondrium are exposed. (I) Elevation of the outer thyroid perichondrium extends laterally to the oblique line. (J) The
anterior-inferior extend of the thyroidotomy window is marked
Step 11 against the inside of the thyroid cartilage. A skin hook

The Gore-Tex ribbon is grasped by an otologic alliga- may be used to rotate the larynx to improve visualization
tor forcep and prepared for implantation (Fig. 30.5N). (Fig. 30.5P).
The implant measures 0.6 cm × 20 cm × 0.6 mm, but
the entire length of a Gore-Tex ribbon is not needed in Step 13
most cases. The voice is periodically assessed during placement of the
implant. The implant is adjusted easily as necessary to
Step 12 achieve optimal voice. This part of the procedure should
Using a middle ear alligator forcep and a Sataloff be done with a combination of extreme care and expedi-
Thyroplasty Elevator, the implant is placed posteriorly ence, as manipulation of the endolarynx causes edema of
through the thyroidotomy window in a layered fash- the vocal folds and gives a false impression of changes
ion (Fig. 30.5O). Each successive layer is packed firmly to the voice.
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Thyroplasty
Chapter
30
K L
207
M N
Figs 30.5K to N: (K) A high-speed 5 mm diamond burr is used to create the thyroidotomy window without violating the inner
perichondrium of the thyroid cartilage. (L) A stapes curette is used to bevel the thyroidotomy window allowing for easier posterior
placement of the implant. A 2 or 3 mm diamond burr can be used as an alternative. (M) Elevation of the inner perichondrium through
the thyroidotomy window parallel to the inferior border of the thyroid cartilage. (N) Gore-Tex implant is prepared for placement
Step 14 Step 16
Once the optimal voice has been achieved, indirect laryn- The incision is closed in a layered fashion. 3.0 vicryl
goscopy is performed to assess glottal closure and may sutures are used to approximate the skin and the edges are
reveal potential correctable acute complications (improper held together with octyl-2-cyanoacrylate. A small drain
level of implant placement, implant extrusion, vocal fold for the evacuation of serous exudate or blood is placed
hematoma, etc.). prior to closure (Fig. 30.5S).
Step 15 Step 17
The implant is transected at the superior lip of the thy- A very loose dressing of gauze sponges held in place
roidotomy window (Fig. 30.5Q). Ethyl cyanoacrylate by an ace wrap is placed and secured with 1-inch silk
may be used to secure the proximal end of the implant tape (Fig. 30.5T). The patient is then evaluated within
(Fig. 30.5R). 24 hours. At that time, the dressing and drain are
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Section
O P
208
Q R
Figs 30.5O to S: (O) Placement of the implant is in a layered

fashion. Care is taken to place the first portion of the implant
posteriorly at around the level of the oblique line. Gore-tex is
rarely required as far anteriorly as the posterior aspect of the
thyrotomy. Excessive anterior placement can cause vocal strain.
(P) A skin hook may be used to rotate the larynx to help obtain
a better view. (Q) The implant is transected at the superior lip
of the thyroidotomy window. (R) Ethyl cyanoacrylate is placed
over the thyroidotomy window. (S) The incision is closed leaving
S a small drain in place
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Thyroplasty
Chapter
6. Flint PW, Corio RL, Cummings CW. Comparison of soft
tissue response in rabbits following laryngeal implantation
with hydroxylapatite, silicone rubber, and Teflon. Ann Otol
Rhinol Laryngol. 1997; 106(5):339-407.
7. McCulloch TM, Hoffman HT. Medialization laryngoplasty
with expanded polytetrafluoroethylene. Surgical technique 30
and preliminary results. Ann Otol Rhinol Laryngol. 1998;
107(5 Pt 1):427-32.
8. Friedrich G. Titanium vocal fold medializing implant:
introducing a novel implant system for external vocal
fold medialization. Ann Otol Rhinol Laryngol. 1999;
108(1):79-86.
9. Giovanni A, Vallicioni JM, Gras R, et al. Clinical experience
with Gore-Tex for vocal fold medialization. Laryngoscope.
1999; 109(2 Pt 1):284-88.
10. Tucker HA. External laryngeal surgery for adjustment of
the voice. In: Gould WJ, Sataloff RT, Spiegel JR (Eds).
Fig. 30.5T: Loosely placed ace wrap is secured using 1 inch silk Voice Surgery. St. Louis: CV Mosby Co; 1993. pp. 275-90.
tape 11. Zeitels SM, Jarboe J, Hillman RE. Medialization laryngo-
plasty with Gore-Tex for Voice Restoration Secondary to
Glottal Incompetence, Presented at the Voice Foundation’s
removed. It is unusual to continue antibiotics beyond the
Annual Symposium, Care of the Professional Voice.
72-hour postoperative period. Steroids may be adminis-
Philadelphia, PA: 2000.
tered if significant edema of the vocal folds is noted. The
12. Zeitels SM. New procedures for paralytic dysphonia:
patient is then seen for a second postoperative evaluation adduction arytenopexy, Goretex medialization laryngo-
in approximately 7 days. plasty, and cricothyroid subluxation. Otolaryngol Clin 209
North Am. 2000; 33(4):841-54.
REFERENCES 13. McCulloch TM, Hoffman HT, Andrews BT, et al.
Arytenoid adduction combined with Gore-Tex medializa-
1. Isshiki N, Okamura H, Ishikawa T. Thyroplasty type I tion thyroplasty. Laryngoscope. 2000(8); 110:1306-11.
(lateral compression) for dysphonia due to vocal cord paral-
14. Omori K, Slavit D, Kacker A, et al. Effects of thyro-
ysis or atrophy. Acta Otolaryngol. 1975; 80(5-6):465-73.
plasty type I on vocal fold vibration. Laryngoscope. 2000;
2. Payr E. Plastik am schildknorpel zur Behebung der Folgen
110(7):1086-91.
einseitiger Stimmbandlahmung. Dtsch Med Wochensch.
15. Weinman EC, Maragos NE. Airway compromise in thy-
1915; 43:1265-70.
3. Cummings CW, Purcell LL, Flint PW. Hydroxylapatite roplasty surgery. Laryngoscope. 2000; 110(7):1082-5.
laryngeal implants for medialization. Preliminary report. 16. Isshiki N. Phonosurgery—Theory and Practice. Tokyo:
Ann Otol Rhinol Laryngol. 1993; 102(11):843-51. Springer-Verlag; 1989.
4. Montgomery WW. Montgomery SK, Warren MA. 17. Sataloff RT, Spiegel JR, Carroll LM, et al. Male soprano
Thyroplasty simplified. Operative Tech Otolaryngol Head voice: a rare complication of thyroidectomy. Laryngoscope.
Neck Surg. 1993; 4:223-31. 1992; 102(1):90-3.
5. Montgomery WW. Montgomery SK. Montgomery thyro- 18. Benninger MS, Crumley RL, Ford CN, et al. Evaluation
plasty implant system. Ann Otol Rhinol Laryngol Suppl. and treatment of the unilateral paralyzed vocal fold.
1997; 170:1-16. Otolaryngol Head Neck Surg. 1994; 111(4):497-508.
Ch-30.indd 209 9/8/2010 3:10:40 Gopal

Chapter
Arytenoid Cartilage Adduction/
31 Rotation, Cricothyroid
Subluxation Arytenoidopexy and
Arytenoidectomy
Arytenoid cartilage adduction/rotation1 and cricothyroid In addition, if the joint is divided and not repaired, the
subluxation work fairly well for recurrent laryngeal nerve natural forces of the neck tend to push the inferior cornu
paralysis but not nearly so well if the superior laryngeal posterior to the cricothyroid joint facet, shortening the
nerve is involved or if the arytenoid cartilage is in abnor- vocal fold and aggravating the dysphonia. Traditionally,
mal position for some other reason. Arytenoid adduc- the author has prevented that problem by suturing the
tion/rotation surgery is usually performed under local cricothyroid joint into its normal position, if it has been
anesthesia. The thyropharyngeus muscle is divided and divided. This prevents retrusion, but it does not result in
the posterior margin of the thyroid cartilage is exposed. passive mobility of the joint in most cases.
Subperichondrial elevation is carried onto the inferior An alternate technique called cricothyroid subluxation
surface of the thyroid ala. The cricothyroid joint is dis- has been described by Zeitels.2 This technique also does
located and the pyriform sinus is protected. When the not assure passive mobility, but it has been surprisingly
pyriform sinus has been elevated for arytenoid cartilage successful at improving frequency range and dynamic
adduction rotation or arytenoidopexy (discussed below), range of phonation, at least during short-term follow-
it is advisable to reattach the mucoperichondrial flap up. A suture is tied around the inferior cornu of the
at the conclusion of the procedure. This helps prevent thyroid cartilage and passed through the midline of the
fibrosis and constriction that may interfere with swal- cricoid cartilage (Figs 31.2A to D). The inferior cornu is
lowing. In addition, extensive pyriform sinus edema pulled gently forward and adjusted in accordance with
may sometimes prolapse producing airway obstruction, the patient’s phonatory response. In Zeitels’ illustrations,
especially in the presence of a posterior thyroid cartilage the inferior cornu is pictured as fairly far anterior to the
window. This problem can be avoided by suturing the cricothyroid joint facet. In the author’s experience (RTS),
pyriform sinus mucosa to the thyroid cartilage (Nicholas it is usually unnecessary to distract it so far anteriorly.
E. Maragos, M.D., personal communication, 2003). The Usually, optimal results are achieved when the posterior
muscular process of the arytenoid cartilage is identified aspect of the inferior cornu is fairly close to the anterior
and the joint is opened in the classic approach through aspect of the cricoid joint facet.
a small incision over the cricoarytenoid muscle. However, When arytenoid cartilage adduction is combined with
in many cases, it is not necessary to open the joint; and thyroplasty, it is not always necessary to create a thyro-
it may be even better not to. Two 3-0 permanent sutures plasty window. The author (RTS) has devised a technique
are fixed in soft tissue across the muscular process and in which a silastic block is placed through a posterior
tied in the directions of the lateral cricoarytenoid and approach. The arytenoid cartilage procedure is performed
lateral thyroarytenoid muscles, adjusting vocal fold posi- first (adduction/rotation or arytenoidopexy). The inner
tion (Figs 31.1A to M). perichondrium is then elevated from posterior to anterior
The author (RTS) prefers not to divide the crico- under direct vision. A silastic block is carved and adjusted
thyroid joint in most cases. When it is divided, it heals to the appropriate size and shape. The position of the
with scar. The resulting fixation may impair movement of silastic block is noted, and the block is removed. A suture
the functioning arytenoid on the contralateral side and is is passed through the thyroid cartilage from external to
likely to impair passive movement of the ipsilateral side in internal at approximately the position of the junction of
response to contralateral cricothyroid muscle contraction. the anterior and middle thirds of the final position of the
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Arytenoid Cartilage Adduction/Rotation, Cricothyroid Subluxation Arytenoidopexy
Chapter
31
A B
211
C D
Figs 31.1A to D: (A) In arytenoid adduction/rotation surgery, the thyropharyngeus muscle is separated from the ala of the thyroid
cartilage. (B) Starting at the posterior aspect of the thyroid cartilage, the inner perichondrium is elevated in order to prevent entrance
into the airway. (C) Ordinarily, the procedure can continue simply with anterior retraction of the thyroid cartilage. However, especially
with a large thyroid ala as encountered in some men, it is helpful to transect the thyroid cartilage in one of the patterns illustrated
above by solid lines. (D) Ordinarily, simple anterior retraction of the thyroid cartilage allows the surgeon to divide the cricothyroid
joint with the scissors, exposing the cricothyroid joint surface
silastic block. The needle is then passed through the outer fast and effective. Gore-Tex (Newark, DE) has not been
surface of the junction of the anterior and middle thirds used in this scenario, because the Gore-Tex would prob-
of the silastic block near its upper border and brought ably extrude through the posterior opening unless it were
back through the silastic block from medial to lateral near sutured into position; and, even then, maintaining optimal
its lower border. It is then passed from the inner surface Gore-Tex position would be challenging. When Gore-Tex
of the thyroid lamina through the outer surface, below is preferred in combination with an arytenoid cartilage
the initial suture entry point. The suture is then tied on procedure, it is performed in the usual fashion through
the outside of the thyroid cartilage. As the suture is tight- an anterior mini-thyrotomy.
ened, the silastic block is reinserted and anchored into Zeitels also introduced adduction arytenoidopexy
position. If the position is not completely stable, a second (Figs 31.3A to G) as an alternative to classical arytenoid
suture can be used. This procedure has proven extremely cartilage adduction/rotation.3 This is an interesting and
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Section
E F
212
G H
Figs 31.1E to H: (E) The muscular process of the arytenoid is located at approximately the level of the vocal fold (dotted line). (F) The
distance (arrow) between the upper margin of the cricothyroid joint and the lower margin of the cricoarytenoid joint is ordinarily less
than 1 cm. The position of the muscular process (m) and vocal process (v) also are illustrated. (G) The muscular process often can be
identified by palpation. (H) After elevating the mucosa lining the pyriform sinus in order to avoid entering the airway, the posterior
cricoarytenoid muscle fibers are divided, and the cricoarytenoid joint is entered. Entry into the joint is not necessary in every case
effective procedure, although it can be challenging tech- been divided from the muscular process. The cricothyroid
nically for inexperienced laryngeal framework surgeons. joint is opened during this procedure, a maneuver not
It is often necessary to divide the cricothyroid joint to always necessary in classic arytenoid cartilage adduction/
obtain adequate exposure, so that the procedure is com- rotation. A suture is placed initially through the medial
bined routinely either with suture repair of the joint or aspect (near the midline) of the posterior face of the
cricothyroid subluxation. In adduction arytenopexy, it is cricoid cartilage, and through the medial aspect of the
easiest to expose the cricoid cartilage at the cricothyroid cricoarytenoid joint. The suture is then passed through
joint, follow the cartilage from the joint to the superior the arytenoid cartilage, looped around the lateral aspect
surface of the cricoid and dissect along the superior sur- of the arytenoid, and then brought back through the joint
face of cricoid cartilage. This allows easy identification and posterior face of the cricoid cartilage where it is tied.
of the cricoarytenoid joint, particularly after the lateral This technique pulls the arytenoid cartilage up the cricoid
cricoarytenoid and posterior cricoarytenoid muscles have facet, closing the posterior glottic gap. It also eliminates
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Chapter
31
I J
213
K L (i) (ii)
Figs 31.1I to L: (I) It is important to be familiar with the anatomic structures that may be encountered during this procedure. The
most important ones include the cricothyroid joint (a), cricoarytenoid joint (b), recurrent laryngeal nerve (c-1), one with its abductor
branches (c-2) and adductor branches (c-3); thyroarytenoid muscle (d), laterocricoarytenoid muscle (e), interarytenoid muscle (f) and
posterior cricoarytenoid muscle (g). (J) A 4-0 nylon suture is placed through the muscular process of the arytenoid. The tip of the
needle is visible in the joint space. (K) After the suture is tied to the muscular process, it is passed through the thyroid ala. An
injection needle may be used if the suture cannot be passed easily using suture needles. (L-i) one or two sutures may be used, pulling
the vocal fold in the direction of the lateral cricoarytenoid (a) and the direction of the thyroarytenoid (b). Adjusting tension between
these two sutures permits proper positioning of the vocal fold. Often, only the lateral cricoarytenoid suture is necessary. Each suture
is passed through two holes in the thyroid cartilage (circles) and tied externally on the thyroid cartilage. Suture placement (L-ii) in the
arytenoid is important. If the suture is placed posteriorly (black dot) on the muscular process, more adduction is possible than if the
suture is placed more anteriorly (open circle)
sutures that extend anteriorly and may interfere with examination). The author (RTS) sometimes finds it nec-
thyroplasty in some cases. In addition, this technique essary to place an additional proline suture or two to
tends to pull the vocal process posteriorly, lengthening stabilize the arytenoid cartilage in the positioned desired.
the vocal fold. However, optimizing vocal process height Woodson et al. have also recognized the problem
can be difficult. To facilitate vocal process alignment, the of controlling the vertical position of the vocal process
patient should be asked to phonate at his or her habitual and have proposed a technique to help control this vari-
pitch (not at high pitch, as used commonly during mirror able factor during arytenoid cartilage adduction/rotation
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Section
i ii
Figs 31.1M: (i) Arytenoid adduction rotation can be combined with Type I thyroplasty. Suture is passed first through the region of the
intended window using either a needle, or small holes created with a drill. The suture is left untied. (ii) After the inner perichondrium
is elevated, the cartilage may be depressed medially and the suture can be tied. Alternatively, the suture can be passed through a
silastic block and tied over the prosthesis. The suture is then passed through another implant placed lateral to the window and tied
again to maintain secure position and prevent the internal prosthesis or cartilage from pulling medially away from the inner aspect of
the thyroid lamina
214
A B
Figs 31.2A and B: (A) 2-0 proline suture is tied around the inferior cornu of the thyroid cartilage.
(B) Passed circumferentially around the cricoid arch in the midline
surgery.4 Their technique works better with arytenoid car- laterally. She observed that arytenoid cartilage adduction
tilage adduction/rotation (for which it was designed) than tends to move the vocal process medially and caudally, but
with arytenopexy because of the degree of joint instability that its position often ends up more caudal than normal.
created during arytenopexy and because of the final posi- She hypothesized that this was due to the absence of the
tion of the inferior cornu of the thyroid cartilage when normal action of the posterior cricoid arytenoid muscle
arytenoidopexy is combined with cricothyroid subluxa- and proposed a posterior anchoring suture to replace pos-
tion. However, the principle can be applied during either terior cricoarytenoid support. She used sutures from the
operation. Woodson noted that in flaccid laryngeal paral- arytenoid cartilage to the inferior cornu of the thyroid car-
ysis, the vocal process often is displaced superiorly and tilage or to the posterior midline of the cricoid cartilage.
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Chapter
31
C D
Figs 31.2C and D: The suture is adjusted to pull the inferior cornu forward, lengthening the vocal
fold. The patient is asked to phonate. When frequency and dynamic range are optimal, it is best to
overcorrect slightly (approximately 1 mm) and fix the inferior cornu in that position
215
A B C
Figs 31.3A to C: (A) The larynx is exposed, and the inferior constrictor is divided and separated from the thyroid lamina. (B) The
cricothyroid joint is separated with scissors. (C) Dissection follows the cricoid cartilage from the cricothyroid joint facet to the superior
rim of the cricoid cartilage. The pyriform sinus is dissected gently posteriorly. The cricothyroid muscle is cut during this dissection
Tension on these sutures decreased caudal displacement, Iwamura has described yet another procedure for ary-
but the sutures anchored near the midline widened the tenoid cartilage repositioning called the lateral cricoary-
glottic gap. Consequently, anchoring the sutures to the tenoid muscle pull procedure.5, 6 This operation is per-
inferior cornu of the thyroid cartilage is preferable when formed under local anesthesia through a 10 mm × 8 mm
using this approach. Although classical arytenoid adduc- thyrotomy window. The window is placed immediately in
tion/rotation is substantially easier and provides excellent front of the oblique line, over the lateral cricoarytenoid
results in some cases, adduction arytenoidopexy has clear muscle (Figs 31.4A and B). Sutures are passed through
advantages in selected cases and should be used especially several points along the atrophic Lateral cricoarytenoid
in patients with complete unilateral vocal fold paralysis, (LCA) muscle bundle and tied first around the muscle
when there is a large posterior glottic gap and the ary- and then to the thyroid cartilage. The sutures are adjusted
tenoid cartilage is tipped far laterally. according to intraoperative voice improvement.
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Section
D E
216
F G
Figs 31.3D to G: (D) The lateral cricoarytenoid and posterior cricoarytenoid muscles are divided from the muscular process. (E) After
the cricoarytenoid joint capsule has been divided and the joint has been opened widely, the posterior cricoarytenoid muscle is dissected
off of the posterior aspect of the cricoid cartilage. (F) 4-0 proline suture on a cutting needle is passed through the posterior face of
the cricoid cartilage and through the cricoarytenoid joint. It is then wrapped around the anterolateral aspect of the arytenoid and
brought back through the joint and posterior cricoid plate. (G) Arytenoid position is adjusted by the tension on the suture as it is tied
along the posterior face of the cricoid cartilage. In some cases, additional simple sutures through the arytenoid and cricoid may be
necessary to adjust vocal process position optimally
NERVE ANASTOMOSIS including vagus nerve bypass, split vagus nerve, phrenic
nerve, and other nerves in the region, have been tried.
Re-anastomosing divided or injured recurrent laryngeal Results have been variable.
nerves has not resulted in the restoration of normal However, research on reinnervation suggests that
motion in most of the cases and has traditionally been the technique may be much more valuable than previ-
considered not helpful. Failures may be due to abnormal ously appreciated. In at least some patients with vocal
intermingling of abductor and adductor fibers or to other fold paralysis, there appears to be some degree of vocal
causes. Attempts have been made to improve the results, fold atrophy after long-term denervation. Although some
optimizing abduction by dividing intralaryngeal adduc- vocal folds show return of normal function even after
tor nerve branches.7 However, this technique has lim- complete recurrent laryngeal nerve section, re-establishing
ited applicability. Procedures using various other nerves, neural supply may be important to maintain vocal fold
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Chapter
31
A
Fig. 31.5: Anastomosis between ansa cervicalis and distal recurrent
laryngeal nerve. Primary end-to-end recurrent laryngeal nerve re-
anastomosis may be performed when both portions of the severed
nerve are available
it results in voice quality superior to the operation it

replaced, which was total cordectomy.13 Traditionally,
arytenoidectomy has been performed through an exter-
nal incision. The procedure was introduced initially in
1946 by Woodman. He described removing the aryte-
217
noid cartilage with preservation of the vocal process.14
Endoscopic arytenoidectomy was described two years
later by Thornell.15 Endoscopic arytenoidectomy has been
successful and effective, and has proven to be a particu-
larly satisfactory approach since use of the carbon dioxide
B laser was introduced for this operation.16-19
The procedure is performed using suspension micro-
Figs 31.4A and B: (A) Sutures are placed through the lateral laryngoscopy. A 400 mm objective lens is usually opti-
cricoarytenoid muscle. (B) The tension on the sutures is adjusted
to optimize phonatory output, and they are fixed to the thyroid mal. Lasers with a spot size of 0.4 mm or less generally
cartilage anteriorly and inferiorly are used at 6−10 watts in continuous mode or repeat
mode with 0.1 second pulses. The corniculate cartilage
bulk (hence the effectiveness of medialization surgery), and mucosa over the apex of the arytenoid are vapor-
and to help control vocal fold pitch.8-11 If a recurrent ized, as is the mucoperiosteum of the apex and body of
laryngeal nerve is known to have been cut during surgery, the arytenoid cartilage. The upper portion of the body of
it is worthwhile for the surgeon to suture the cut ends, the arytenoid is ablated using continuous mode. Repeat
even though this is not likely to result in normal abduc- mode is then used to vaporize the mucoperichondrium
tion and adduction (Fig. 31.5). This subject is discussed of the lower body, which is then vaporized from lateral
at greater length elsewhere.12 to medial. The lateral ligament is transected and the cri-
coid cartilage is exposed. The vocal process is vaporized,
ARYTENOIDECTOMY as is the muscular process preserving the attachment
of the arytenoideus muscle (Fig. 31.6). Vaporization is
Arytenoidectomy remains the most reliable technique for continued lateral to the vocalis muscle to create a scar
reestablishing a good airway in patients with bilateral that will assist in lateralization of the vocal fold (Fig.
vocal fold paralysis or arytenoid fixation. Unfortunately, it 31.7). Because of cartilage exposure, antibiotics generally
generally does so at the expense of voice quality. However, are recommended. If there is no tracheotomy in place,
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Section
helps avoid granuloma formation, a troublesome compli-

cation of arytenoidectomy. Arytenoidectomy patients also
should be treated prophylactically for laryngopharyngeal
reflux. This appears to expedite healing and does not
4 appear to interfere with formation of lateralizing scar.
It is also possible to resect only portions of the ary-
tenoid cartilage. Medial arytenoidectomy (preserving a
thin, lateral shell of arytenoid cartilage) often provides an
adequate airway and minimizes collapse of the posterior
laryngeal anatomy. Medial arytenoidectomy was popular-
ized by Crumley.19 This procedure may be advantageous
particularly in patients who are likely to aspirate after
complete arytenoidectomy. Medial arytenoidectomy has
also been used in unusual circumstances, such as bilateral
pseudoparalysis and other conditions.20
Fig. 31.6: (A) Intermittent step during laser arytenoidectomy,
showing exposure of the cricoid cartilage, (B) vocal process of
the arytenoid cartilage and (C) vocalis muscle REFERENCES
1. Isshiki N, Tanabe M, Sawada M. Arytenoid adduction for
unilateral vocal cord paralysis. Arch Otolaryngol. 1978;
104(10):555-8.
2. Zeitels SM. Adduction arytenoidopexy with medializa-
tion laryngoplasty and cricothyroid subluxation: A new
approach to paralytic dysphonia. Operat Tech Otolaryngol
218 Head Neck Surg. 1999; 10(1):9-16.
3. Zeitels SM, Hochman I, Hillman RE. Adduction aryten-
opexy: A new procedure for paralytic dysphonia and the
implications for medialization laryngoplasty. Ann Otol
Rhinol Laryngol. 1998; 107:1-24.
4. Woodson JE, Picernor R, Yeung D, et al. Arytenoid adduc-
tion. Controlling vertical position. Annals Otol Rhinol
Laryngol. 2000; 109:360-4.
5. Iwamura S, Curita N. A newer arytenoid adduction tech-
nique for one-vocal-fold paralysis: A direct pull of the lat-
eral cricoarytenoid muscle. Otolaryngol Head Neck Surg.
1996; 6(1):1-10.
6. Iwwamura S, Murakawa Y. Tomographic assessment of the
Fig. 31.7: Completed arytenoidectomy with remnant of muscular arytenoid body and unilateral vocal fold paralysis before and
process and arytenoideus attachment and laser-induced trauma
lateral to the vocal muscle to help lateralization (arrow)
after lateral cricoarytenoid muscle-pull surgery. J Japanese
Broncoesophagological Society. 1997; 48(4):310-20.
7. Murakami Y, Kirchner JA. Vocal cord abduction by regen-
erated recurrent laryngeal nerve. An experimental study in
intraoperative corticosteroids are also used by many sur-
the dog. Arch Otolaryngol. 1971; 94(1):64-68.
geons. There are no data proving the efficacy of either 8. Tucker HM. Reinnervation of the unilaterally para-
antibiotics or steroids during this procedure. Their use lyzed larynx. Ann Otol Rhinol Laryngol. 1977; 86(6 Pt
at present depends upon the surgeon’s judgment. There 1):789-94.
are various modifications of arytenoidectomy procedures. 9. Tucker HM, Rusnov M. Laryngeal reinnervation for uni-
Many surgeons (including the author) preserve a mucosal lateral vocal cord paralysis: long-term results. Ann Otol
flap, suturing it over the resection site. Closing mucosa Rhinol Laryngol. 1981; 90(5 Pt 1):457-9.
Ch-31.indd 218 9/8/2010 3:10:54 Gopal

Chapter
10. May M, Beery Q. Muscle-nerve pedicle laryngeal rein- 16. Eskew JR, Bailey BJ. Laser arytenoidectomy for bilateral
nervation. Laryngoscope. 1986; 96(11):1196-200. vocal cord paralysis. Otolaryngol Head Neck Surg. 1983;
11. Crumley R. New perspectives in laryngeal reinnervation. 91(3):294-8.
In: Bailey BJ, Biller HF, (Eds). Surgery of the Larynx. 17. Strong MS, Jako GJ, Vaughan CW, et al. The use of
Philadelphia, PA: WB Saunders; 1985:135-47. CO2 laser in otolaryngology: a progress report. Trans Sect
12. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Am Acad Ophthalmol Otolaryngol 1976;
31
In: Sataloff RT (Ed). Professional Voice: The Science and 82(5):595-602.
Art of Clinical Care, 3rd edition. San Diego, CA: Plural 18. Ossoff RH, Duncavage JA, Shapshay SM, et al. Endoscopic
Publications, Inc.; 2005:871-86.
laser arytenoidectomy revisited. Ann Otol Rhinol Laryngol.
13. Lundy DS, Casiano RR, Landy HJ, et al. Effects of vagal
1990; 99(10 Pt 1):764-71.
nerve stimulation on laryngeal function. J Voice. 1993;
19. Crumley RL. Endoscopic laser medial arytenoidectomy for
7(4):359-64.
airway management in bilateral laryngeal paralysis. Ann
14. Woodman D. A modification of the extralaryngeal approach
to arytenoidectomy for bilateral abductor paralysis. Arch Otol Rhinol Laryngol. 1993; 102(2):81-4.
Otolaryngol 1946; 43:63-5. 20. Cantarella G, Neglia CB, Marzano AV, et al. Bilateral
15. Thornell WC. Intralaryngeal approach for arytenoidectomy laryngeal pseudoparalysis in xanthoma disseminatum
in bilateral abductor vocal cord paralysis. Trans Am Acad treated by endoscopic laser medical arytenoidectomy. Ann
Opthalmol Otolaryngol. 1949; 53:631-6. Otol Rhinol Laryngol. 2001; 110(3):263-8.
219
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Chapter
32 Nerve Muscle Pedicle Surgery

Nerve muscle pedicle surgery involves implanting a por- most effective when it is combined with a medialization
tion of the omohyoid or other muscle with its intact procedure, such as Type I thyroplasty, which can be per-
motor branch from the ansa hypoglossi into a paralyzed formed through the same incision (Fig. 32.1E).
laryngeal abductor muscle (Figs 32.1 A to D) or a portion
of the cricothyroid muscle with its motor branch of the OTHER TECHNIQUES
superior laryngeal nerve into a paralyzed adductor mus-
cle. The concept was originally reported by Takenouchi Numerous other techniques have been tried to restore
and Sato in 19681 and was popularized by Tucker voice quality in patients with vocal fold paralysis. They
et al in 19702, and described in numerous publications include switching of intact muscles, implantation of arti-
thereafter. Success rates have varied, and the operation ficial muscles, cartilage implantation and other methods.
certainly has not been universally satisfactory. Probably, None of the techniques available is entirely satisfac-
the small improvement that is often seen results more tory, although interest in laryngeal pacing is particularly
from change in mass or position than from return of encouraging.3,4 It shows promise for the management of
mobility. Avoidance of atrophy also may occur. Failure of both unilateral and bilateral vocal fold paralysis as do
reinnervation after this procedure has been demonstrated other exciting advances undergoing research.
histochemically in some patients. This procedure is often
A B C
Figs 32.1A to C: (A) The ansa hypoglossi is seen entering the omohyoid muscle. (B) The nerve is followed 2−3 cm into the muscle
to the point at which it branches and (C) is included in a muscle block that leaves the nerve-muscle junctions untraumatized
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Nerve Muscle Pedicle Surgery
Chapter
32
D E
Figs 32.1D and E: (D) The nerve-muscle pedicle is sutured to the desired intrinsic laryngeal muscle. (E) Nerve-muscle pedicle using
the ansa hypoglossi branch to the anterior belly of the omohyoid muscle. After using Tucker’s technique of rotating the nerve-muscle
pedicle and suturing it to the exposed thyroarytenoid muscle through a thyroplasty window, the thyroplasty prosthesis must then be
notched in order to prevent injury to the nerve-muscle pedicle
REFERENCES 3. Goldfarb D, Keane WM, Lowry LD. Laryngeal pac-

ing as a treatment for vocal fold paralysis. J Voice. 1994;
1. Takenouchi S, Sato F. Phonatory function of the implanted 8(2):179-85.
larynx. Jpn J Bronchoesophagol. 1968; 19:280-1. 4. Lundy DS, Casiano RR, Landy HJ, et al. Effects of vagal 221
2. Tucker HM, Harvey JE, Ogura JH. Vocal cord remo- nerve stimulation on laryngeal function. J Voice. 1993;
bilization in the canine larynx. Arch Otolaryngol. 1970; 7(4):359-64.
92:530-3.
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Chapter
Other Techniques for Bilateral
33 Vocal Fold Paralysis
Bilateral vocal fold paralysis still places the patient and double-cam, stainless steel/polythene device that is
surgeon in a most difficult position: there is no good treat- attached to the vocal process through a 1 cm window
ment available, yet. Arytenoidopexy is an alternative to in the thyroid cartilage. This screw-like device can be
arytenoidectomy. In this procedure, no tissue is removed; adjusted incrementally to lateralize the vocal fold pre-
but the arytenoid cartilage is sutured into the abducted cisely, establishing an optimal balance between airway
position.1,2 Unfortunately, this procedure is less consist- and voice. This minimally invasive technique was reported
ent than arytenoidectomy in producing a good airway. after studies in sheep; and human efficacy studies are
However, suture lateralization (passing a stitch through pending. However, the technique appears promising.
the skin in the lateral neck, around the vocal fold, and Although arytenoidectomy provides a good airway,
back out through the skin) can be a useful adjunct to as discussed above, it usually results in breathy, some-
arytenoidectomy, helping to lateralize the posterior aspect what hoarse voice. The better the airway is, the worse the
of the vocal fold. In some cases, suture lateralization may voice. However, if the vocal folds are near the midline,
be sufficient by itself. It is especially valuable in patients producing good voice, a tracheotomy is usually required
in whom it is unknown whether the paralysis will be for active individuals. Another technique proposed to
permanent. re-establish adequate airway is posterior cordotomy,
An interesting alternative to the placement of a suture as described by Dennis and Kashima.4 This procedure
or arytenoidectomy was proposed by Cummings et al3 involves the removal of the posterior one-third of the
(Figs 33.1A and B). They developed a double-helix, vocal fold. This may provide a better voice quality than
A B
Figs 33.1A and B: (A) The Cummings device is snapped into a 1 cm hole cut in the thyroid cartilage, which stabilizes the device and
provides access for adjustment. (B) Once the device is attached to the region of the vocal process (right), the outer cam is retracted,
lateralizing the true vocal fold. The double-helix, double-cam, stainless steel/polythene device is attached to the vocal process through
a 1 cm window in the thyroid cartilage. This screw-like device can be adjusted incrementally to lateralize the vocal fold precisely,
establishing an optimal balance between airway and voice
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Other Techniques for Bilateral Vocal Fold Paralysis
Chapter
arytenoidectomy alone.3 Many surgeons combine this the procedure works, there is usually a 4−6 months delay
principle with arytenoidectomy with a lateral, wedge-like between the surgery and active abduction and adduction.
resection of thyroarytenoid muscle anterior to the vocal The author has occasionally used Botulinum toxin for
process (posterior cordotomy). bilateral vocal fold paralysis. Although this seems coun-
If bilateral vocal fold paralysis presents with good terintuitive, it should be remembered that at least a small 33
voice and borderline airway, reinnervation may be worth amount of reinnervation is common following vocal fold
trying; reinnervation may be worthwhile even when the paralysis. When reinnervation occurs, there is synkine-
vocal folds are in the midline. In order to undergo rein- sis. That is, both abductors and adductors are innervated.
nervation of the posterior cricoarytenoid muscles, patients Consequently, if a borderline airway is present, injecting
must have mobile arytenoids and intact cricoarytenoid Botulinum toxin into the adductor muscles may allow
joints. Ascertaining the condition of the cricoarytenoid enough unopposed abductor function to result in an extra
joints may require palpation during direct laryngoscopy millimeter or two of glottic space. If this is sufficient for
with paralysis. It is advisable to palpate the arytenoid car- the patient, it is certainly less traumatic than arytenoid-
tilages routinely on all patients, so that the surgeon knows ectomy; and usually it results in better voice quality.
the degree of pressure required to move a normal aryten-
oid cartilage. Palpation should be accomplished with the REFERENCES
side of suction or with a spatula placed against the medial
or lateral face of the arytenoid cartilage. Pressure directly 1. Ejnell H, Mansson I, Hallen O, et al. A simple opera-
on the vocal process or its junction with the body of the tion for bilateral vocal cord paralysis. Laryngoscope. 1984;
94:954-8.
arytenoid cartilage should be avoided in order to prevent
2. Geterud A, Ejnell H, Stenborg R, et al. Long-term results
fracturing the vocal process off the arytenoid body. with simple surgical treatment of bilateral vocal cord paral-
A nerve-muscle pedicle 2−3 mm square is created ysis. Laryngoscope. 1990; 100:1005-8.
from any of the strap muscles,5,6 although the omohy- 3. Cummings CW, Redd EE, Westra WH, et al. Minimally
oid is used most commonly. The posterior cricoarytenoid
muscle is exposed by retracting the posterior aspects of
invasive device to effect vocal fold lateralization. Ann Otol
Rhinol Laryngol. 1999; 108(9):833-6.
223
the cricoid cartilage and separating the inferior constric- 4. Dennis DP, Kashima H. Carbon dioxide posterior colec-
tor muscle near the base of the inferior cornu of the tomy for treatment of vocal cord paralysis. Ann Otol
thyroid cartilage. Care must be taken to reflect rather Rhinol Laryngol. 1989; 85:930-4.
5. Tucker HM. Human laryngeal reinnervation: Long-
than transgress the pyriform sinus. The posterior cricoary-
term experience with nerve muscle pedicle technique.
tenoid muscles are recognized easily because they run at
Laryngoscope. 1978; 88:598-604.
right angles to the inferior constrictor. The nerve-muscle 6. Tucker HM. The Larynx, 2nd edition. New York: Thieme
pedicle is sutured into the cricoarytenoid muscle. When Medical Publishers; 1993. pp. 255-65.
Ch-33.indd 223 9/8/2010 3:11:16 Gopal

Chapter
34 Thyroarytenoid Neurectomy
Robert T Sataloff
When Dedo introduced recurrent laryngeal nerve section thyroarytenoid muscle. The procedure is actually slightly
as a treatment for spasmodic dysphonia in 1976,1 the more complex, as described below.
procedure was greeted with great enthusiasm. However, Iwamura’s procedure was reintroduced by Berke and
it quickly became clear that there were problems asso- coworkers in 1991. Their initial report described bilateral
ciated with this approach;2,3 and it was abandoned by thyroarytenoid denervation in dogs, with anastomosis of
most surgeons in the 1980s. Disappointment and contro- the ansa cervicalis to the distal, cut end of the thyroary-
versy surrounding recurrent laryngeal nerve section may tenoid nerve, thereby preventing reinnervation from the
be responsible in part for the delay in recognizing the proximal stump of the thyroarytenoid nerve.5 This pro-
value of selective thyroarytenoid neurectomy. This procedure was also believed to limit atrophy and fibrosis of
cedure was developed by Shinobu Iwamura in 1978 and the thyroarytenoid muscle. Since that time, Berke has
introduced to the United States in 1979.4 As described used this approach in humans and continues to advocate
by Iwamura, this procedure involves creating a window anastomosis of the ansa cervicalis with the distal end of
similar to a thyroplasty window but placed more poste- the cut thyroarytenoid nerve, in order to prevent recur-
riorly. The posterior aspect of the window is adjacent to rence of symptoms.6
the oblique line. The window should be approximately Initially, the procedure advocated by Berke seems
8 mm × 10 mm in size. The inner perichondrium is incised superior to Iwamura’s operation because reinnervation
and blunt dissection is used to identify the thyroaryten- should occur in some patients if the thyroarytenoid nerve
oid branch of the recurrent laryngeal nerve (Fig. 34.1). is merely cut, or even if it is cut, avulsed and clipped. The
Iwamura describes dividing the nerve to paralyze the author (RTS) is familiar with cases in which that problem
has occurred. Interestingly, Iwamura reports that he has
not had problems with recurrence of symptoms (Shinobu
Iwamura, MD, personal communication, 2000); but it
was not clear to the author why the discrepancy existed
until Dr. Iwamura visited Philadelphia and we had an
opportunity to discuss his procedure in detail and review
videotapes of the operation. In addition to performing a
thyroarytenoid neurectomy, Iwamura routinely removes a
large amount of thyroarytenoid muscle. The myomectomy
not only helps to assure that all branches of the thyroary-
tenoid nerve are cut but also removes so much muscle
that normal activity cannot occur even if the residual
fibers are reinnervated. In our experience with laryngeal
electromyography (EMG) in patients with adductor spas-
modic dysphonia following Botulinum toxin injection, we
have found that many patients remain fluent with as lit-
tle as 30−40% reduced recruitment in the thyroaryten-
Fig. 34.1: A window approximately 10 mm by 8 mm is created in oid muscle. Having observed the amount of muscle that
the thyroid lamina, just anterior to the oblique line. Usually, the
Dr Iwamura removes, it seems likely that muscle loss and
thyroarytenoid nerve can be exposed easily with blunt dissection,
after opening the inner perichondrium. However, occasionally, it fibrosis would result in substantially diminished thyroary-
may branch prior to this point and may be more difficult to find tenoid muscle function, even if substantial reinnervation
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Thyroarytenoid Neurectomy
Chapter
from the proximal end of the cut nerve were to occur. ply divide the thyroarytenoid nerve without performing
So, ansa anastomosis is unnecessary if the procedure is either simultaneous myomectomy or nerve anastomosis.
performed in this fashion. Dr Iwamura usually operates Although, we are not prepared to describe a new
on one side, proceeding to surgery on the contralateral surgical technique for abductor spasmodic dysphonia in
side if control is insufficient (a minority of cases). The detail, we have developed and performed surgery to divide 34
author (RTS) has utilized Iwamura’s approach and had the posterior cricoarytenoid muscle and section its nerve.
similar results. Although the operation results in some The procedure is based on our anatomic studies of the
dysphonia, in most patients, generally after 3−6 months, it nerve to the posterior cricoarytenoid muscle and its rela-
is minimal and comparable to voice quality noted during tionships to the nerves to the interarytenoid muscle.8
successful treatment with Botulinum toxin injection.
In some patients, the author (RTS) had difficulty REFERENCES
finding the thyroarytenoid branch of the recurrent laryn-
geal nerve. Research uncovered the fact that the anatomy 1. Dedo HH. Recurrent laryngeal nerve section for spastic
of the terminal branches of the recurrent laryngeal nerve dysphonia. Ann Otol Rhinol Laryngol. 1976; 85(4 Pt
1):451-9.
had never been described. We initiated studies to rem- 2. Aronson AE, De Santo LW. Adductor spastic dyspho-
edy this deficiency in the literature. The thyroarytenoid nia: three years after recurrent laryngeal nerve resection.
branch was studied first.7 In this study, we determined Laryngoscope. 1983; 93(1):1-8.
that the median distance from the inferior tubercle of 3. Dedo HH, Izdebski K. Problems with surgical (RLN
the thyroid cartilage to the thyroarytenoid branch of Section) treatment of spastic dysphonia. Laryngoscope.
the recurrent laryngeal nerve was 3.75 mm. Fifty-four 1983; 93(3):268-71.
percent of the nerves traveled in a horizontal direction 4. Iwamura S. Comments in spastic dysphonia: State of the
within the larynx, but vertical and oblique orientations art. Van L. Lawrence (Ed). The Voice Foundation. New
York, NY; 1979. pp. 26-32.
were observed. The thyroarytenoid division of the recur- 5. Sercarz JA, Berke GS, Ming Y, et al. Bilateral thyroaryte-
rent laryngeal nerve branched in approximately 20% of
specimens. From this study we concluded that surgeons
noid denervation: a new treatment for laryngeal hyperad- 225
duction disorders studied in the canine. Otolaryngol Head
performing the thyroarytenoid neurectomy can identify Neck Surg. 1992; 107(5):657-68.
the likely position of the thyroarytenoid nerve by measur- 6. Berke GS, Blackwell KE, Gerratt BR, et al. Selective laryn-
ing approximately 4 mm from the inferior tubercle along geal adductor denervation-reinnervation: a new surgical
a perpendicular line. In most specimens, the nerve was treatment for adductor spasmodic dysphonia. Ann Otol
encountered within 1−4 mm from the inferior tubercle. Rhinol Laryngol. 1999; 108(3):227-31.
7. Scheid SC, Nadeau DP, Friedman O, et al. Anatomy of
The author (RTS) has been pleased with results of the thyroarytenoid branch of the recurrent laryngeal nerve.
thyroarytenoid neurectomy and myomectomy, but both J Voice. 2004; 18(3):279-84.
this procedure and the procedure described by Berke 8. Eller RL, Miller M, Weinstein J, et al. The innervation
(ansa cervicalis anastomosis) are reasonable options. of the posterior cricoarytenoid muscle: exploring clinical
However, in the author’s opinion, it is unwise to sim- possibilities. J Voice. 2009; 23(2):229-34.
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SECTION 5
Laryngeal Trauma
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Ch-35.indd 228 9/8/2010 3:11:36 Gopal
Chapter
35 Laryngotracheal Trauma
Yolanda D Heman-Ackah, Robert T Sataloff
The incidence of laryngotracheal trauma is estimated to voice analysis should be carried out to map and document
be 1 in 14,000 to 30,000 emergency department visits the injury as well as possible. When there is a ques-
yearly in the United States.1,2 Trauma to the laryngotra- tion as to whether vocal fold motion is impaired because
cheal complex can be classified as blunt, penetrating, of paralysis or mechanical causes, laryngeal electromy-
caustic, thermal and iatrogenic injuries. The morbidity ography should be used. High-resolution (1 mm cuts)
associated with these injuries ranges from chronic airway axial and coronal CT scans are often extremely helpful.
obstruction to voice compromise, with complication rates High resolution allows not only an excellent view of the
as high as 15−25%.3-5 Due to their potential for airway larynx, but also clear visualization of the cricoarytenoid
compromise, these injuries can be lethal, with mortality joints.
rates of 2−15%.3,5 Injuries to the larynx and trachea often When major injuries occur, it is advisable to involve
accompany other severe injuries, and the neck can appear a speech-language pathologist in the patient’s care as
to be deceptively normal even in cases of serious laryn- soon as the medical condition permits, preferably prior
gotracheal disruption. to surgery. After surgery, the speech-language pathologist
Laryngotracheal injuries can be caused by external should participate in the patient’s rehabilitation as soon
or internal trauma. External insults include blunt and as the patient is allowed to speak. In a professional voice
penetrating injuries. In the past, most external laryngeal user, early involvement of the patient’s professional voice
trauma was the result of motor vehicle accidents. Studies teacher is also helpful, so long as the singing or acting
have shown that due to improved car safety features teacher is interested in and comfortable with training of
and reduced speed limits, laryngeal trauma is seen less injured voices. Close collaboration among all members
frequently. Many laryngeal injuries still occur, however, of the voice team is particularly important in rehabilita-
in other types of accidents and in sports. In addition, ting such patients. Despite some excellent retrospective
penetrating injuries are becoming more prevalent due reviews and ongoing studies with animal models, many
to increasing urban violence.6-8 The majority of internal points of controversy remain in the surgical treatment
laryngeal injuries are iatrogenic. Intubation and flexible of laryngeal trauma.2,4,7,11-15 This chapter focuses on the
and rigid endoscopy can lead to injuries of the upper state-of-the-art methods for evaluation and surgery that
airway.9,10 Noniatrogenic internal injuries can result from seem to yield the most consistently acceptable results: a
foreign-body aspiration, caustic ingestion and toxin inha- stable airway with good vocal quality.
lation and, occasionally, voice abuse or trauma (includ-
ing phonation, coughing and sneezing). Laryngeal trauma BLUNT INJURY
may result in laryngeal webs, vocal fold hemorrhage or
mucosal tears, either of which may produce permanent This is the most common cause of laryngotracheal trauma
scars. Trauma may also fracture the laryngeal skeleton, and results from motor vehicle collisions in the adult pop-
dislocate the arytenoids or paralyze the laryngeal nerves. ulation and from accidents involving all-terrain vehicles,
A safe airway should be ensured. If intubation is required, bicycles, contact sports and hanging type injuries in the
immediate or early tracheotomy should be considered young adult, adolescent and pediatric populations. Adults
to minimize the risk of iatrogenic trauma to the vocal and children differ not only in the mechanisms of injury
folds. but also in the types of injuries experienced. These differ-
Whenever possible, a complete diagnostic voice eval- ences can be accounted for, at least in part, by differences
uation including strobovideolaryngoscopy and objective in the relative size, position and degree of calcification of
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Laryngeal Trauma
Section
Table 35.1: Signs and symptoms of laryngeal injury

Hoarseness/dysphonia Dyspnea
Stridor Endolaryngeal edema

Endolaryngeal hematoma Subcutaneous emphysema
5 Endolaryngeal laceration Neck pain/point tenderness
Dysphagia Loss of laryngeal landmarks
Odynophagia Impaired vocal fold mobility
Hemoptysis Arytenoid dislocation
Ecchymosis/abrasions of Exposed endolaryngeal cartilage
anterior neck
A B
the larynx and trachea. Signs and symptoms of laryngeal
injury are enumerated in Table 35.1.
Adult Framework Injuries from Blunt Trauma

In the adult, the inferior border of the cricoid cartilage
sits at the level of the 6th and 7th cervical vertebrae.16
Thus, in the normal upright position, the larynx is
relatively protected from trauma by the overhang of the
mandible superiorly, the bony prominence of the clavicles
and sternal manubrium inferiorly, and by the mass of the
sternocleidomastoid muscles laterally. Laryngeal injuries
230 are relatively rare except when there is a direct blow to
the neck. The usual victim of laryngotracheal trauma in a C D
motor vehicle collision is an unbelted front seat passenger
Figs 35.1A to D: Mechanism of blunt laryngeal trauma: (A) Normal
or driver in a vehicle without protective airbags. Upon laryngeal position. (B) Posteriorly directed force crushing thyroid
collision, the front seat passenger or driver is propelled ala against cervical vertebrae, resulting in a midline fracture.
forward with the neck in extension, eliminating the man- (C) Recovery of larynx from force resulting in detachment of the
dible as a protective shield. The laryngotracheal complex vocal ligament on the left, tear in the right thyroarytenoid muscle
and bilateral arytenoid dislocation. (D) Recovery of larynx from
hits the dashboard or steering wheel with a posterior- force resulting in overlapping, displaced thyroid lamina fracture
superiorly based vector of force, and the thyroid and cri- and malposition of the vocal fold (Illustrations courtesy of Sabrina
coid cartilages are crushed against the cervical vertebrae M Heman-Ackah)
(Figs 35.1A to D).17,18 Direct blows to the larynx can also
occur during athletic competition, while falling forward force onto the cricoid cartilage (Fig. 35.3).18 The cricoid
onto a blunt object, or with hanging of the neck from a has a relatively thin anterior arch that blends laterally into
suspended rope or wire. A wide spectrum of predictable rigidly buttressed tubercles. Lower level impacts result
injuries occurs. The thyroid and cricoid cartilages interact in a single median fracture or multiple paramedian ver-
dynamically to protect the airway from blunt injury.18 tical fractures. The airway is maintained by the lateral
Forces to the anterior larynx often are encountered first buttresses (Fig. 35.4). With higher impact forces, second-
by the thyroid prominence, which bends against the cervi- ary lateral arch fractures can occur in the cricoid carti-
cal vertebrae on impact. The thyroid cartilage eventually lage, resulting in airway collapse and possible injury to
reaches a point of maximal flexibility, and a single median the recurrent laryngeal nerve due to impingement at the
or paramedian fracture occurs (Fig. 35.2). The force then level of the cricothyroid joint (Figs 35.5 and 35.6). If the
impacts the cricoid ring, which was shielded previously force is severe or low in the neck, complete laryngotra-
by the anterior projection of the thyroid cartilage. In a cheal separation may occur.19 Separation usually occurs
patient with a marked laryngeal prominence, multiple between the cricoid cartilage and the first tracheal ring,
fractures of the thyroid cartilage in both the vertical and resulting in displacement of the trachea inferiorly and soft
horizontal planes may occur prior to the distribution of tissue collapse into the airway, with consequent airway
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Laryngotracheal Trauma
Chapter
35
Fig. 35.2: Axial CT scan of the thyroid ala. There is a midline Fig. 35.4: Axial CT scan at the level of the thyroid and cricoid
thyroid ala fracture with diastasis of fracture segments. Reproduced cartilages. There is a vertical, displaced posterior cricoid lamina
from Sataloff RT. Professional Voice: The Science and Art of fracture with fusion of the right cricothyroid joint. The airway is
Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; maintained by the lateral buttresses. Reproduced from Sataloff
2005: Fig. 88.2, with permission RT. Professional Voice: The Science and Art of Clinical Care, 3rd
with permission
231
Fig. 35.3: Axial CT scan of the thyroid ala demonstrating an Fig. 35.5: Axial CT scan of the cricoid cartilage. The airway is
anterior comminuted thyroid ala fracture sustained by the narrowed secondary to anterior and posterior vertical, displaced
patient in a motor vehicle collision. Reprduced from Sataloff cricoid lamina fractures. Reproduced from Sataloff RT. Professional
RT. Professional Voice: The Science and Art of Clinical Care, 3rd Voice: The Science and Art of Clinical Care, 3rd edition. San Diego,
edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 88.3, CA: Plural Publishing, Inc.; 2005: Fig. 88.5, with permission
with permission
obstruction.19-22 The strap musculature and surrounding Pediatric Framework Injuries from Blunt Trauma
cervical fascia can serve as a temporary conduit for air Fractures of the thyroid and cricoid cartilage from blunt
until edema and hematoma formation results in obstruc- trauma are uncommon in the pediatric population. The
tion of this temporary airway. pediatric larynx sits higher in the neck than in the adult
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Laryngeal Trauma
Section
The greater elasticity of the pediatric cartilaginous frame-

work makes it more resilient to external stresses and the
mobility of the supporting tissues tends to protect the
laryngotracheal complex more effectively. Children are
5 likely to sustain soft tissue injuries resulting in edema
and hematoma formation.22,23 This is of particular con-
cern in a child because of the relatively smaller diameter
of the pediatric airway. The pediatric patient is more likely
to sustain transection and telescoping injuries than the
adult. An individual who falls onto the handlebar of
a bicycle, may suffer a telescoping injury in which the
cricoid cartilage is dislocated superiorly underneath the
thyroid lamina (Fig. 35.7).22-25 With more forceful blows,
complete laryngotracheal separation may occur. The ado-
lescent and young adult riding a snowmobile or an all-
terrain vehicle may sustain a “clothes-line” type injury to
Fig. 35.6: Axial CT scan at the level of the thyroid and cricoid the neck. Upon collision with the cable or wire, a hori-
cartilages. There are midline and left lateral fractures of the
thyroid ala and comminuted fractures of the posterior cricoid
zontal, linear force is applied low in the neck, compress-
lamina with loss of the airway space. The airway was secured ing the cricotracheal complex against the anterior cervical
below the fracture segments with tracheostomy. Reproduced from vertebrae and resulting in cricotracheal separation.25 The
Sataloff RT. Professional Voice: The Science and Art of Clinical elasticity of the intercartilaginous ligaments contributes to
Fig. 88.6, with permission substernal retraction of the trachea. These are often fatal
injuries, but occasionally there is enough fascial stenting
232 to maintain an adequate airway until an artificial airway
can be established. There may be an associated injury and
possibly transection of both recurrent laryngeal nerves
which are also compressed against the cervical vertebrae
during the injury.22, 25 Young children may accidentally
hang themselves while playing, and adolescents may do so
intentionally in suicide attempts. In these instances, the
fall to hanging position is usually less than 1−2 feet. The
rope around the neck tightens usually in the region of
the thyrohyoid membrane, resulting in airway obstruction
as the epiglottis closes over the glottis. The distinction
between this and the injury that results from intentional
hanging is that in self-inflicted or accidental injuries,
death is not necessarily imminent; and, in those who
survive, there is usually injury, possibly avulsion, at the
level of the thyrohyoid membrane. In homicidal hanging
(professional execution), the victim is usually dropped a
Fig. 35.7: Axial CT scan at the level of the thyroid and cricoid distance of several feet, resulting in death secondary to
cartilages. There is subluxation of the cricoid cartilage under the
thyroid ala after the patient sustained an elbow injury to the neck tracheal transection or spinal cord injury from C1-C2
while playing basketball. Reproduced from Sataloff RT. Professional dislocation.25
Voice: The Science and Art of Clinical Care, 3rd edition. San Diego,
CA: Plural Publishing, Inc.; 2005: Fig. 88.7, with permission Soft Tissue Injuries from Blunt Trauma
Blunt trauma to the larynx may result in soft tissue
and depending upon the age, can lie between the 2nd injuries with or without associated framework injuries.
and 7th cervical vertebrae. The mandible serves more as a Rupture of the thyroepiglottic ligament can be associ-
protective shield in the child than it does in the adult.23 ated with either horizontal or vertical fractures of the
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Chapter
35
A
Fig. 35.8: Axial CT scan of the larynx at the level of the arytenoids
demonstrating anterior dislocation of the right arytenoid cartilage.
thyroid cartilage. Narrowing of the laryngeal lumen can

occur secondary to herniation of pre-epiglottic tissue or
posterior displacement of the epiglottic petiole.17, 21
Vocal fold injuries result from vertical fractures of the
233
thyroid ala (Figs 35.1A to D). As the thyroid cartilage
snaps back from its compression against the cervical
vertebrae, the thyroarytenoid muscle and ligament may
tear, resulting in a separation at any point along its length.
This may be evident as mucosal lacerations or hemor-
rhage of one or both vocal folds. The mucosa on the
B
arytenoids may be denuded or avulsed. Because of the
traction on the arytenoids from this spring-like motion Figs 35.9A and B: (A) Axial CT scan of the subglottic larynx
demonstrating a displaced, paramedian fracture of the left thyroid
of the thyroid cartilage, they may also become displaced ala. The vocal folds (not shown) are malpositioned. (B) Three-
from the cricoarytenoid joint into a more posterior and dimensional CT reconstruction of the left paramedian thyroid
lateral or anterior position (Fig. 35.8). If one segment ala fracture demonstrating overlapping of the fracture segments.
of the thyroid cartilage fails to return back to its nor- Reproduced from Sataloff RT. Professional Voice: The Science and
mal position, an overlapping fracture may occur, result- Inc.; 2005: Fig. 88.9, with permission
ing in malposition of the vocal fold (Figs 35.9A and B
and 35.10). Lacerations of the pyriform sinus and upper
esophagus may occur as the thyroid cartilage rubs against Associated esophageal lacerations and perforations are
the cervical vertebrae.17,21 Soft tissue injuries associated common.
with cricoid, tracheal and cricotracheal separation inju-
ries within the cartilaginous framework usually involve Assessment of Blunt Injuries
crushed or lacerated mucosa. Both recurrent laryngeal Initial evaluation and assessment of the blunt trauma
nerves are frequently injured and can be severed by blunt patient is similar for adults and children. It is important
trauma that results in cricoid fractures and/or cricotra- to obtain an understanding of the mechanism of injury.
cheal separation. The phrenic nerve also can be injured, A high index of suspicion for blunt neck injury should
especially in cases of cricotracheal separation.17,19,21,22,25 be maintained in motor vehicle collisions, even without
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Laryngeal Trauma
Section
obvious external signs. Knowledge of the speed of the

vehicle at the time of collision, the use of seatbelts by
the trauma victim, and the presence and deployment of
airbags also can be helpful in estimating the amount of
5 force involved. In the patient with short stature, the force
of deceleration against a locking “shoulder” strap that is
draped over the neck may also produce significant injury.
Assessment of the patient begins with evaluation and sta-
bilization of the airway, paying particular attention to the
status of the cervical spine. Assessment then proceeds
with evaluation and stabilization of neurological, cervical
spine, cardiovascular and other emergent organ system
injuries. Management of aerodigestive tract injuries var-
ies depending upon the presence of acute airway distress
(Flow chart 35.1).
Fig. 35.10: Axial CT of the supraglottic larynx. There is a displaced

paramedian fracture of the right thyroid ala. Reproduced from EVALUATION OF THE BLUNT TRAUMA PATIENT
Sataloff RT. Professional Voice: The Science and Art of Clinical WITHOUT AIRWAY DISTRESS
Fig. 88.10, with permission In the patient without immediate signs of upper airway
compromise, the evaluation can procede with a complete
Flow chart 35.1: Management of blunt laryngeal trauma

234
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Chapter
examination, including palpation of the neck, assessment neck trauma, in combination with nondisplaced laryngeal
of voice quality and flexible evaluation of the larynx and fractures or as part of a complex laryngeal surgery.
upper airway. Flexible laryngoscopy allows assessment of In the case of severe injury, inspection and palpation
the mobility of the vocal folds, patency of the upper air- of the arytenoid at the time of surgery is necessary to
way and integrity of the mucosa. If there is an adequate determine joint integrity. Anterior dislocations occur most 35
airway, intubation is not necessary. Due to the potential commonly and usually result from blunt external trauma
for the development of worsening laryngeal edema and compressing the larynx against the cervical spine or from
airway compromise, serial examinations of the airway traumatic intubations. Posterior dislocations occur from
should be performed during the first 24−48 hours after prolonged intubation, traumatic intubation and extuba-
injury if intubation is initially deemed unnecessary. tion, and traumatic endoscopy. Arytenoid dislocations
Management is based on the severity of the initial should be reduced as soon as possible. Even when they are
signs and symptoms.7 Patients with any sign of endo- discovered long after the initial injury, reduction should
laryngeal injury (Table 35.1) should undergo radiologi- be attempted as improvement in vocal quality can be
cal imaging to evaluate for possible laryngeal framework obtained in most cases.28
injury7, 24, 26 or fracture instability (Table 35.2). Patients without fractures on CT scanning and those
Fractures that appear to have the potential for instabi- with minimally displaced, stable fractures can be observed
lity should further be evaluated with direct laryngoscopy closely. Soft tissue injuries that consist of isolated mucosal
and open exploration for repair. Patients with minimally lacerations of the supraglottic larynx, superficial lacera-
displaced fractures that are associated with significant tions of the nonvibrating edge of the true vocal fold, small
endolaryngeal injuries also may require direct laryn- hematomas of the true vocal fold and/or mild mucosal
goscopy, open exploration and repair of the soft tissue edema also may be observed.
injuries. Because of the high potential for concomitant
cervical spine injuries, assessment of the cervical spine is EVALUATION OF THE BLUNT TRAUMA PATIENT
always performed prior to operative intervention of the
laryngeal injuries. The presence of a cervical spine injury
WITH AIRWAY DISTRESS 235
may preclude the ability to perform a direct laryngos- Signs of upper airway distress include stridor, sternal
copy, and repair is begun based on findings on CT scan retraction and dyspnea. The patient should be examined
and flexible endoscopic examination (Figs 35.11A to C). for signs of upper aerodigestive tract injury. In the presence
Dislocation of the cricoarytenoid joint is now recognized of immediate post-traumatic airway distress, significant
as a fairly common component of laryngeal trauma.27,28 laryngotracheal injury is likely. The neck is stabilized to
It can be seen as the only significant lesion after blunt prevent worsening of unrecognized cervical spine injuries,
Table 35.2: CT findings that suggest fracture stability

Fracture type Displacement Stable Suggested Management
Single vertical, Nondisplaced Yes Observe, fixate if symptoms or exam worsen

unilateral
Minimally displaced Yes Fixate if immediate or delayed voice changes, otherwise observe
(< 1 cartilage width)
Displaced
(> 1 cartilage width) No Reduce and fixate
Single horizontal, Nondisplaced Yes Observe, fixate if symptoms or exam worsen
unilateral
Minimally displaced Yes Observe, fixate if symptoms or exam worsen
Displaced No Reduce and fixate
Multiple unilateral Nondisplaced No Reduce and fixate
Multiple bilateral Nondisplaced No Reduce and fixate
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Laryngeal Trauma
Section
A B
236
Figs 35.11A to C: (A) Surgical access for repair of laryngeal
trauma is best obtained through a transverse incision superior
to the tracheotomy site. (B) In cases of comminuted thyroid
cartilage fractures, the larynx must be entered through the
thyrohyoid or cricothyroid membranes so the mucosal incision
can be made accurately under direct vision at the anterior
commissure. (C) Mucosal lacerations are meticulously closed using
C fine absorbable sutures
and the airway is secured with a tracheotomy fashioned Operative evaluation of the larynx with direct laryn-
at least 2 rings below the injured segments or through goscopy is performed after securing the airway. If direct
the distal transected segment under local anesthe- laryngoscopy reveals significant endolaryngeal injuries
sia.1,2,15,17,19,22,29-33 Tracheotomy prevents further laryn- (Table 35.3), open exploration and repair are performed.
geal injury and may expose an unnoticed laryngotracheal The presence of palpable laryngeal fractures is also an
separation. Orotracheal and/or nasopharyngeal intubation indication for open exploration and repair. If direct laryn-
in the presence of severe laryngotracheal trauma can lead goscopy does not reveal a need for open exploration, a
to further laryngeal injury and airway compromise. postoperative CT of the larynx is obtained to complete
In the child with upper airway distress, the airway is the evaluation.
secured in the operating room if time permits. General
anesthesia is induced using an inhalational agent that is SURGICAL EVALUATION
unlikely to cause laryngospasm. During spontaneous res-
piration, a rigid bronchoscope is passed gently through Full evaluation and determination of the need for surgical
the injured larynx and trachea to a point distal to the intervention should begin as soon as a laryngeal injury
sites of injury. Tracheotomy is performed over the bron- is suspected. Schaefer and Leopold both have reported
choscope followed by repair of the injuries.20,23 better results when treatment is initiated in the first
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Chapter
Table 35.3: Indications for operative repair after OPEN EXPLORATION AND REPAIR
blunt laryngeal trauma
Open exploration is performed to repair mucosal lacera-
• Laceration of vibrating edge of true vocal fold tions involving the anterior commissure and/or the vibra-
• Laceration of anterior commissure
• Deep laceration of thyroarytenoid muscle
tory edge of the vocal fold; to repair deep lacerations of 35
the thyroarytenoid muscle; to restore mucosal cover over
• Exposed cartilage
exposed cartilage; to reposition the vocal ligament and
• Impaired vocal fold mobility
anterior commissure; to reposition a displaced epiglottis
• Arytenoid dislocation
• Epiglottis displacement
or herniated pre-epiglottic contents; to re-anastomose
• Herniation of pre-epiglottic contents
separated segments; and to reduce and fixate displaced
• Unstable/displaced laryngeal fractures and/or unstable fractures (Flow chart 35.2). If not pre-
• Airway compromise viously done, tracheotomy is performed to allow intra-
• Extensive endolaryngeal edema operative access to the larynx and postoperative airway
management.
24 hours.2,11 Although many patients who suffer mul- Exposure

tiple trauma must have the evaluation delayed, it should For open exploration, a horizontal neck incision is made
still proceed as soon as their general condition allows. and subplatysmal skin flaps are elevated. To expose the
Indications for surgery can be divided into three groups: thyroid and cricoid cartilages, the strap muscles may
the need to restore cartilaginous integrity, the need to be divided in the midline and retracted laterally. When
restore mucosal integrity, and the need to restore normal endolaryngeal repair of soft tissue injuries is necessary,
cricoarytenoid joint function. entry into the larynx is gained through fractures of the
Intraoperative evaluation begins with direct laryn- thyroid cartilage that are median or those that are para-
goscopy to assess the extent of endolaryngeal injury,
esophagoscopy to assess for esophageal lacerations and
median and less than 0.5 cm from the midline. In patients
with lateral or horizontal fractures of the thyroid cartilage,
237
bronchoscopy to assess for subglottic and tracheobron- a midline thyrotomy is performed. A midline cut is then
chial injuries. The arytenoid cartilages are palpated for made through the anterior commissure under direct visu-
possible dislocation. In the patient with isolated cri- alization, with care not to disrupt further the architecture
coarytenoid joint dislocation, reduction usually can be of the vocal fold. Above the level of the glottis, the endo-
accomplished endoscopically, especially if the dislocation laryngeal incision is curved lateral to the epiglottis on one
is noted early. With delays in diagnosis beyond even a side to avoid cutting through its cartilage or mucosa. Care
week, joint ankylosis can begin, making reduction more is taken during the exposure to avoid further injury to
difficult. Nonetheless, an attempt should be made to relo- the recurrent and superior laryngeal nerves.
cate the arytenoid cartilage back to its normal position
on the cricoid regardless of the interval from the time Endolaryngeal Repair
of injury. In cases of posterior dislocation, this can be The functional goal of repair is to realign glottic tissues
accomplished by inserting the anterior lip of an intubat- to their premorbid anteroposterior, horizontal and trans-
ing laryngoscope with a miller-3 blade into the posterior verse planes, beginning posteriorly and proceeding in an
aspect of the cricoarytenoid joint while exerting a lifting anterior direction to maximize exposure. The arytenoid is
motion in an anteromedial direction on the cricoid car- repositioned with meticulous closure of overlying muco-
tilage. Anterior dislocations can be reduced by exerting perichondrial defects. If the arytenoid mucosa is dam-
a posteriorly directed force on the cricoarytenoid joint aged badly, local rotation flaps can be developed from
using the tip of a rigid laryngoscope.30,34 Anterior dis- the pyriform sinus or postcricoid region. Regardless of
locations can be reduced by direct manipulation of the the extent of the injuries, an attempt should be made
arytenoid body. Care must be taken not to fracture the to repair severe unilateral and bilateral arytenoid inju-
vocal process during this maneuver. If no other injuries ries. Arytenoidectomy as a secondary procedure can be
that require repair are noted on CT scan or on direct considered at a later date after healing has occurred and
laryngoscopy, open exploration usually is not necessary. the wounds have matured.17 This approach allows for the
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Laryngeal Trauma
Section
Flow chart 35.2: Open exploration of laryngeal trauma
238
possibility of vocalization and respiration if at least one this is the region most likely to develop a web or stenosis
of the arytenoids retains some function. as a late complication.
Lacerations in the thyroarytenoid muscle or mucosa Mucosal defects on the false vocal fold and epiglottis
may be repaired with fine absorbable suture. Avascular are less likely to pose significant problems with stenosis.
and crushed mucosal injuries are debrided prior to
closure. If primary closure of mucosal disruptions is
difficult, local advancement or rotational flaps should be
performed. Local advancement or rotational flaps from
the pyriform sinus or postcricoid region usually provide
adequate coverage of the arytenoid and its vocal process.
A sternohyoid muscle flap can fill small defect but does
not provide cartilaginous support (Fig. 35.12). Adequate
mucosa for coverage of the anterior commissure region
usually can be obtained from the epiglottis. If an exten-
sive amount of mucosa is needed, the epiglottic mucosa
can be elevated off the laryngeal and lingual surfaces of
the epiglottis with removal of the cartilage to allow for
a large superiorly based epiglottic flap (Figs 35.13A and
B).35 It is important to ensure meticulous closure and Fig. 35.12: An inferiorly based sternohyoid muscle flap is
re-epithelialization of the anterior commissure region, as utilized to cover a posterior mucosal defect
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Chapter
35
Fig. 35.14: Wires sutured over buttons on the external skin hold
a soft stent in place. The wires also restrict vertical laryngeal
motion in the neck
the fracture is paramedian, the suture is brought through

the midline of the cartilage and secured. It is important
to re-establish the appropriate height of the vocal fold
as well as the appropriate midline placement for opti-
mal postoperative voice results. Proper placement of the
239
vocal ligament helps to ensure the proper position of the
remainder of the vocal fold.
Endolaryngeal Stenting
Questions regarding when and how to utilize stents in
acute trauma repair have not yet been answered adequately.
B However, there are some definitive and relative guidelines.
Figs 35.13A and B: (A) The epiglottis is grasped and its anterior Definitive indications for stenting include severely com-
attachments are severed so that it can be advanced inferiorly minuted fractures where direct fixation is inadequate to
into the laryngeal defect. (B) The epiglottic flap is sutured in the
maintain cartilaginous integrity; severe disruption of the
laryngeal defect using interrupted, permanent sutures
anterior commissure; severe endolaryngeal mucosal dis-
ruption; and large mucosal defects that require application
If primary repair or a local flap cannot be accomplished, of skin or mucosal grafts. If bilateral mucosal lacerations
this area can be left open to granulate and mucosalize by produce webbing, or if a web has been resected, a stent
secondary intention. A ruptured thyroepiglottic ligament also may be employed. Although stenting may seem to
should be re-attached anteriorly to reposition the epiglot- promote a more consistent restoration of the laryngeal
tis to its more anatomical position. Herniated contents of airway, it also may be harmful. Stents have been shown
the pre-epiglottic space should be removed or replaced to cause local inflammatory reaction in almost all cases.36
anterior to the epiglottis and the thyroepiglottic ligament. The wires and sutures used to fix the stent to the cervi-
The attachment of the vocal ligament at the anterior cal skin also produce chronic irritation from the shearing
commissure is inspected. If torn, it is repaired by plac- caused by vertical laryngeal motion during swallowing
ing a slow-absorbing monofilament suture through the (Fig. 35.14).
anterior aspect of the ligament and bringing it through Thus, in cases in which the anterior commissure
a midline fracture to secure it to the thyroid cartilage. If is the major problem, a keel that will prevent anterior
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Laryngeal Trauma
Section
Fig. 35.15: A tantalum keel is utilized to reduce scarring at the

anterior commissure
webbing while not having contact with most of the endo-

laryngeal mucosa is preferred. The keel can be formed
of silastic, teflon or tantalum (Fig. 35.15).37,38 Keels can
be placed through an open incision or endoscopically. In
240 cases in which a patient has normal vocal fold motion or
undergoes cricoarytenoid reduction, stents are avoided if
possible. Whenever stents are utilized, they are removed
as soon as possible. Two weeks are adequate for most
patients unless other medical problems that may delay
healing (e.g. diabetes, malnutrition or advanced age)
coexist. Stents are rarely left in place longer than 4 weeks
in trauma patients.12 Both prefabricated molded stents
and soft stents have been used with success. Molded
stents are available in varying sizes and conform to the
Fig. 35.16: Montgomery premolded laryngeal stents come in
endolaryngeal surfaces, presumably reducing frictional male, female and pediatric sizes
trauma (Fig. 35.16). Both Silastic and Gore-Tex varie-
ties are available. Soft stents, usually a latex finger cot
filled with gauze or a rubber sponge, allow for mucosal stabilization has been achieved using stainless steel wire
swelling and may be less traumatic than molded materials. or nonabsorbable suture. However, because these pro-
Mucosal or split-thickness skin grafts can be fixed cir- vide only two-dimensional fixation, there can be some
cumferentially to either type of stent with the epidermis movement of the laryngeal fragments with head turn-
away from the laryngeal mucosa as a biological dressing ing, flexion and swallowing. Stabilization is optimized
(Fig. 35.17). if a figure-of-eight suture technique is used. The recent
availability of titanium and absorbable miniplates has
Laryngeal Fixation allowed more rigid fixation of the laryngeal framework
Reduction and fixation of the cartilaginous framework is in three-dimensional planes (Figs 35.18A and B). This
performed after all mucosal injuries have been addressed. has the advantage over wire or suture fixation in that it
If a stent is deemed necessary, it is placed prior to repair allows for immediate immobility of the fracture segments,
of the framework injuries. The fractures are reduced can be used effectively in most comminuted fractures and
and fixated to ensure a stable reduction. Traditionally, can decrease the need for endolaryngeal stenting.39,40
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Chapter
usual 1.0 mm drill bit. Alternatively, one may use the
1.0-mm drill bit with the wider threaded “emergency”
screws (1.5-mm diameter) from the 1.3 mm plating set
or self-drilling screws.
Laryngotracheal Reanastomosis
35
In patients with cricotracheal separation, initial intuba-
tion is through the distal segment. Any avulsed or badly
bruised mucosa or cartilage is resected prior to reanasto-
mosis to decrease the incidence of granulation tissue for-
mation. Repair is begun with placement of sutures from
the posterior tracheal mucosa to the inner cricoid peri-
chondrium using 3-0 absorbable suture or fine wire. The
repair then proceeds anteriorly, tying all knots extralumi-
nally. The cricoid and tracheal perichondria and cartilages
Fig. 35.17: Mucosal defects can be repaired by placing a skin are then repaired using a 2-0 or 3-0 absorbable suture.17
graft circumferentially around the laryngeal stent with the dermis The use of absorbable suture decreases the incidence of
facing out anastomotic granulation tissue formation and late steno-
sis.42 In the presence of cricoid injury and/or in patients
in whom postoperative edema seems likely, a T-tube may
be placed as a temporary stent. Postoperatively, the neck
is kept in flexion for 7−10 days to prevent traction on
the anastomotic closure.
Recurrent Laryngeal Nerve Repair 241

Laryngotracheal separation injuries may be accompanied
by bilateral recurrent laryngeal nerve injuries. An attempt
should be made to locate the nerves if the vocal folds
exhibit evidence of immobility preoperatively. Crushed or
otherwise damaged but intact nerves should be left alone
to regenerate on their own. If a severed nerve is found,
A B the severed ends should be freshened, and an attempt
should be made to reanastomose the epineurium using
Figs 35.18A and B: Miniplate fixation of a vertical thyroid lamina
fracture (Illustrations courtesy of Sabrina M Heman-Ackah) a fine monofilament suture under tension-free closure. If
a tension-free closure is unable to be obtained, or if the
proximal end is unable to be located and the opposite
The miniplates can be bent to conform to the geom- nerve is intact, unilateral ansa cervicalis to recurrent
etry of the laryngeal framework, thus preserving the laryngeal nerve transfer is an option. Recurrent laryngeal
anteroposterior and transverse dimensions of the larynx. nerve repair is unlikely to restore full abductor or adductor
Usually, low profile plates in the 1.2−1.4 mm size range function to the vocal fold, but it may provide enough tone
provide adequate fixation of the laryngeal framework and to the thyroarytenoid muscle for long-term vocalization
are less prominent than larger profile systems. In patients purposes.43,44 If soft-tissue injury in the neck is extensive
without significant ossification of the thyroid cartilage, and ansa cervicalis to recurrent laryngeal nerve transfer
it is often necessary to use drill bits that are two sizes cannot be performed, hypoglossal to recurrent laryngeal
smaller than the screw in order to prevent problems nerve transfer or cable grafting using a greater auricular
with over drilling of the soft cartilage.39-41 For example, or sural nerve graft are other possibilities for nerve repair.
if one were to use a 1.3 mm plating system, the hole In general, better results are obtained with nerve transfer
would be drilled with a 0.8-mm drill bit instead of the than with cable grafting procedures.
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Laryngeal Trauma
Section
PENETRATING INJURIES CAUSTIC AND THERMAL INJURIES
Penetrating injuries are the second most common cause Caustic and thermal injuries to the larynx can cause signi-
of laryngotracheal injuries in the adult and the most com- ficant acute and chronic airway compromise as well as
5 mon cause in the pediatric population.1,4,22 These inju- late vocal complications. Caustic injuries occur in both
ries result from accidental or deliberate stab wounds and the adult and pediatric populations. Caustic injuries can
from gun shot wounds. It is important to understand result from ingestion of bases, acids or bleaches. The
the mechanism of the injury, the direction of the force, most severe injuries are caused by bases, which produce
as well as the instrument used to create the injury. If the a liquefaction necrosis of muscle, collagen and lipids with
path has traversed the midline, an injury to the upper progressively worsening injury over time. Acids cause a
aerodigestive tract is likely. As in the blunt trauma patient, coagulation necrosis that occurs more rapidly and tends
victims of penetrating injuries to the larynx and trachea to damage superficial structures only. In children under
can appear to be comfortable; however, complications age 5, these tend to be accidental ingestions. Adolescent
from airway compromise, vascular injuries and esopha- and adult ingestions usually are suicide attempts and tend
geal perforations can result in mortality rates as high as to produce the most severe injuries.47, 48
19%.5,45,46 Therefore, a high index of suspicion coupled Thermal laryngeal injuries usually are encountered in
with a thorough physical examination is necessary. patients who have experienced significant burn injuries
from closed-space fires.49 The laryngeal injuries most
Assessment of Penetrating Injuries often result from thermal insult to the supraglottic and
The initial concerns in evaluating and treating patients glottic larynx.50 Because inhalational injuries may affect
with penetrating injuries are the assessment and esta- the larynx, tracheobronchial tree or the lung paren-
blishment of a patent airway and the evaluation and chyma, all patients experiencing significant inhalational
control of vascular and cervical spine injuries, as these injuries should undergo at least flexible laryngoscopy and
242 are often major contributing factors to early morbidity
and mortality in penetrating neck injuries.45 In patients
bronchoscopy.
The primary concern is protection of the airway. The
who require emergent airway control, the decision to per- decision to perform tracheotomy versus orotracheal intu-
form orotracheal intubation versus tracheotomy must be bation is controversial. Orotracheal and nasotracheal intu-
individualized. The patient with a minor injury is less bation carry the risk of causing further mucosal injury.
likely to have an occult laryngotracheal separation, mak- There have been several studies to suggest that tracheo-
ing attempts at intubation less problematic.45 tomy in the burn patient places the patient at increased
Patients who are noted to have signs and symptoms risk of long-term sequelae such as tracheal stenosis and
of a significant aerodigestive tract injury (see Table 35.3) sepsis.50-52 In general, tracheotomy is recommended in
should undergo rigid direct laryngoscopy with consi- patients who cannot be intubated endotracheally due
deration for possible open neck exploration and repair.45 to significant laryngeal injury, those who fail extubation
Since associated esophageal injuries have been reported in and/or those in whom prolonged respiratory support will
as many as 20−50% of the patients with laryngeal injuries, be necessary.49, 52, 53
esophagoscopy should also be performed at the time of Late complications associated with thermal and caustic
rigid endoscopy.5,45 injuries include stenosis and webbing. Scar formation may
continue for several months following the initial insult.49
Repair of Penetrating Injuries Thus, the larynx and trachea should be evaluated serially
Repair of penetrating laryngeal injuries and postoperative over the course of several months. Repair is delayed until
management is accomplished in a similar fashion as would scar formation has stabilized. This helps to minimize the
be done with the blunt trauma patient. In patients with incidence of recurrent scar formation and enhances the
combined esophageal and posterior tracheal wall injuries, chances for successful repair.49,53
consideration should be given to placing a muscle inter-
position flap between the trachea and the esophagus to IATROGENIC INJURIES
prevent the formation of a tracheoesophageal fistula. This
can be accomplished with the use of a nearby pedicled Iatrogenic injuries to the larynx include radiation injuries
strap or sternocleidomastoid muscle flap. and injuries that result from intubation or thermal trauma
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Chapter
(such as laser fire). Doses of radiation used to treat head
and neck cancer (6000–7000 cGy) can result in injury to
the mucosa and cartilaginous framework of the larynx if
it is included in the radiation field.
The most common iatrogenic injury to the larynx 35
results from intubation trauma.54 Since children are
more often subjected to prolonged intubation as prema-
ture infants and neonates in the intensive care unit, they
are more likely to experience complications as a result of
being intubated.55
In neonates, prolonged intubation often leads to
circumferential granulation tissue, scarring and even-
tual stenosis of the subglottis. This region is most often
affected because the cricoid is the narrowest portion of
the airway in the neonate and is, thus, most traumatized
A
by the endotracheal tube. The posterior tilt of the cricoid
cartilage in neonates likely helps to prevent damage to
the interarytenoid region, which is the most common site
of injury in the adult.
Subglottic stenosis in the infant from intubation
injury can be managed similarly to congenital subglottic
stenosis. For stenoses that are less than 50% obstructing,
management can consist of observation, dilatation or CO2
laser excision. If CO2 laser is used for a circumferential
stenosis, it is done serially with no more than 30% of
243
the circumference resected during any one procedure to
prevent restenosis. If the stenosis is 50−70% obstruct-
ing, one may consider either endoscopic procedures or
open procedures, depending on the location and potential
ease of an endoscopic procedure. Stenotic regions that are B
more than 70% obstructing are managed best using open Figs 35.19A and B: (A) After resection of posterior glottic stenosis,
techniques. Lesions isolated to the subglottic region may a superiorly based mucosal flap is elevated. (B) The mucosal flap is
advanced into the defect and fixed with fine, absorbable sutures
be treated with an anterior cricoid split procedure. Longer
stenotic regions may be treated with either cartilage graft-
ing or resection with end-to-end anastomosis. Completely advancement flap from the interarytenoid notch or from
stenotic regions require resection and reanastomosis.56 an aryepiglottic fold or a similar endoscopic procedure
Scarring of the posterior glottis uncommonly causes can be performed (Figs 35.19A and B).59 The value
problems with airway compromise. Attempts to release of adjunctive treatment with topical mitomycin-C to
posterior glottic scar bands usually should be avoided to prevent restenosis is being studied currently, but prelimi-
prevent worsening stenosis unless substantial symptoms nary results are encouraging.60
justify the risks. In cases of significant airway compromise
and minimal posterior scarring, treatment with micro- CONCLUSION
scopic direct laryngoscopy and carbon dioxide laser divi-
sion of the scar band is usually successful.57 Care should Injury to the laryngotracheal complex can result from
be taken during these divisions to protect the normal blunt, penetrating, caustic, thermal and iatrogenic insults.
mucosa of the interarytenoid region.58 Occasionally, The primary concern in the initial management of these
repeat microscopic direct laryngoscopy with repeat laser injuries is the establishment and maintenance of an
division is needed. In cases with moderate to severe adequate airway. Treatment can then address the recon-
interarytenoid scarring, a laryngofissure with a mucosal struction of the normal anatomical relationships of the
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Laryngeal Trauma
Section
larynx and trachea in an attempt to restore the normal 18. Travis LW, Olson NR, Melvin JW, et al. Static and
phonatory, respiratory and protective functions of the dynamic impact trauma of the human larynx. Trans Sect
Otolaryngol Am Acad Ophthalmol Otolaryngol. 1975;
larynx.
80(4 Pt 1):382-90.
19. Ashbaugh DG, Gordon JH. Traumatic avulsion of the tra-
5 REFERENCES chea associated with cricoid fracture. J Thorac Cardiovasc
Surg. 1975; 69(5):800-3.
1. Bent JP 3rd, Silver JR, Porubsky ES. Acute laryngeal 20. Gold SM, Gerber ME, Shott SR, et al. Blunt laryngotra-
trauma: A review of 77 patients. Otolaryngol Head Neck cheal trauma in children. Arch Otolaryngol Head Neck
Surg. 1993; 109(3 Pt 1):441-9. Surg. 1997; 123(1):83-7.
2. Schaefer SD. The treatment of acute external laryngeal 21. Bryce DP. Current management of laryngotracheal injury.
injuries. ‘State of the art’ Arch Otolaryngol Head Neck Adv Otorhinolaryngol. 1983; 29:27-38.
Surg. 1991; 117(1):35-9. 22. Ford HR, Gardner MJ, Lynch JM. Laryngotracheal dis-
3. Jewett BS, Shockley WW, Rutledge R. External laryngeal ruption from blunt pediatric neck injuries: Impact of early
trauma analysis of 392 patients. Arch Otolaryngol Head recognition and intervention on outcome. J Pediatr Surg.
Neck Surg. 1999; 125(8):877-80. 1995; 30(2):331-4.
4. Gussack GS, Jurkovich GJ, Luterman A. Laryngotracheal 23. Myer CM 3rd, Orobello P, Cotton RT, et al. Blunt laryn-
trauma: A protocol approach to a rare injury. Laryngoscope. geal trauma in children. Laryngoscope. 1987; 97(9):1043-8.
1986; 96(6):660-5. 24. Offiah CJ, Endres D. Isolated laryngotracheal separation
5. Minard G, Kudsk KA, Croce MA, et al. Laryngotracheal following blunt trauma to the neck. J Laryngol Otol. 1997;
trauma. Am Surg. 1992; 58(3):181-7. 111(11):1079-81.
6. Angood PB, Attia EL, Brown RA, et al. Extrinsic civil- 25. Alonso WA, Caruso VG, Roncace EA. Minibikes,
ian trauma to the larynx and cervical trachea—Important a new factor in laryngotracheal trauma. Ann Otol Rhinol
predictors of long-term morbidity. J Trauma. 1986; Laryngol. 1973; 82(6):800-4.
26(10):869-73. 26. Schild JA, Denneny EC. Evaluation and treatment of acute
7. Schaefer SD, Close LG. Acute management of laryn- laryngeal fractures. Head Neck. 1989; 11(6):491-6.
244 geal trauma. Update. Ann Otol Rhinol Laryngol. 1989;
98(2):98-104.
27. Hoffman HT, Brunberg JA, Wintr P, et al. Arytenoid
subluxation: Diagnosis and treatment. Ann Otol Rhinol
8. Komisar A, Blaugrund SM, Camins M. Head and neck Laryngol. 1991; 100(1):1-9.
trauma in taxicabs. A growing urban problem. Arch 28. Sataloff RT, Feldman M, Darby KS, et al. Arytenoid dis-
Otolaryngol Head Neck Surg. 1991; 117(4):442-5. location. J Voice. 1988; 1:368-77.
9. Blanc VF, Tremblay NA. The complications of tracheal 29. Reece CP, Shatney CH. Blunt injuries to the cervical
intubation: A new classification with a review of the lit- trachea: A review of 51 patients. South Med J. 1988;
erature. Anesth Analg. 1974; 53(2):202-13. 81:1542-7.
10. Whited RE. A prospective study of laryngotracheal 30. Chodosh PL. Cricoid fracture with tracheal avulsion. Arch
sequelae in long-term intubation. Laryngoscope. 1984; Otolaryngol. 1968; 87(5):461-7.
94(3):367-77. 31. Harris HH. Management of injuries to the larynx and
11. Leopold DA. Laryngeal trauma: A historical com- trachea. Laryngoscope. 1972; 82(10):1924-9.
parison of treatment methods. Arch Otolaryngol. 1983; 32. Ogura J. Management of traumatic injuries of the larynx
109(2):106-12. and trachea including stenosis. J Laryngol Otol. 1971;
12. Cohn AM, Larson DL. Laryngeal injury: A critical review. 85(12):1259-61.
Arch Otolaryngol. 1976; 102(3):166-70. 33. Fuhrman GM, Stieg FH 3rd, Buerk CA. Blunt laryngeal
13. Olson NR. Surgical treatment of acute blunt laryngeal inju- trauma: Classification and management protocol. J Trauma.
ries. Ann Otol Rhinol Laryngol. 1978; 87(5 Pt 1):716-21. 1990; 30(1):87-92.
14. Potter LR, Sessions DG, Ogura JM. Blunt laryngotracheal 34. Sataloff RT, Bough ID Jr, Spiegel JR. Arytenoid disloca-
trauma. Otolaryngol. 1978; 86:906-23. tion: Diagnosis and treatment. Laryngoscope. 1994; 104(11
15. Trone TH, Schaefer SD, Carder HM. Blunt and penetrat- Pt 1):1353-61.
ing laryngeal trauma: A 13-year review. Otolaryngol Head 35. Olson NR. Laryngeal suspension and epiglottic flap in
Neck Surg. 1980; 88(3):257-61. laryngopharyngeal trauma. Ann Otol Rhinol Laryngol.
16. Holinger PH, Schild JA. Pharyngeal, laryngeal, and tra- 1976; 85(4 Pt 1):533-7.
cheal injuries in the pediatric age group. Ann Otol Rhinol 36. Thomas GK, Stevens MH. Stenting in experimental laryn-
Laryngol. 1972; 81(4):538-45. geal injuries. Arch Otolaryngol. 1975; 101(4):217-21.
17. Pennington CL. External trauma of the larynx and trachea. 37. Dedo HH. Endoscopic teflon keel for anterior glottic web.
Immediate treatment and management. Ann Otol Rhinol Ann Otol Rhinol Laryngol. 1979; 88(4 Pt 1):467-73.
Laryngol. 1972; 81(4):546-54.
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38. McNaught RC. Surgical correction of anterior web of 50. Moylan JA. Smoke inhalation and burn injury. Surg Clin
the larynx. Trans Am Laryngol Rhinol Otol Soc. 1950; North Am. 1980; 60(6):1533-40.
pp 232-42. 51. Lund T, Goodwin CW, McManus WF, et al. Upper airway
39. Woo P, Kellman R. Laryngeal framework reconstruction sequelae in burn patients requiring endotracheal intubation
with miniplates: indications and extended indications in or tracheostomy. Ann Surg. 1985; 201(3):374-82.
27 cases. Operative Techniques Otolaryngol Head Neck 52. Eckhauser FE, Billote J, Burke JF, et al. Tracheostomy 35
Surg. 1972; 3:159-64. complicating massive burn injury. A plea for conservatism.
40. Woo P. Laryngeal framework reconstruction with mini- Am J Surg. 1974; 127(4):418-23.
plates. Ann Otol Rhinol Laryngol. 1990; 99(10 Pt 1):772-7. 53. Miller RP, Gray SD, Cotton RT. et al. Airway recon-
41. Pou AM, Shoemaker DL, Carrau RL, et al. Repair of struction following laryngotracheal thermal trauma.
laryngeal fractures using adaptation plates. Head Neck. Laryngoscope. 1988; 98(8 Pt 1):826-9.
1998; 20(8):707-13. 54. Richardson MA. Laryngeal anatomy and mechanisms of
42. Grillo HC, Donahue DM, Mathisen DJ, et al. trauma. Ear Nose Throat J. 1981; 60(8):346-51.
Postintubation tracheal stenosis. Treatment and results. 55. Cotton RT, Seid AB. Management of the extubation prob-
J Thorac Cardiovasc Surg. 1995; 109(3):486-93. lem in the premature child. Anterior cricoid split as an
43. Crumley RL. Teflon versus thyroplasty versus nerve trans- alternative to tracheotomy. Ann Otol Rhinol Laryngol.
fer: A comparison. Ann Otol Rhinol Laryngol. 1990; 99(10
1980; 89(6 Pt 1):508-11.
Pt 1):759-63.
56. Lusk RP, Wooley AL, Holinger LD. Laryngotracheal sten-
44. Crumley RL. Update: Ansa cervicalis to recurrent laryn-
osis. In: Holinger LD, Lusk RP, Green CG (Eds). Pediatric
geal nerve anastomosis for unilateral laryngeal paralysis.
Laryngology and Bronchoesophagology. Philadelphia, PA:
Laryngoscope. 1991; 101(4 Pt 1):384-8.
Lippincott-Raven Publishers; 1997. pp. 172-84.
45. Grewal H, Rao PM, Mukerji S, et al. Management of
57. Dedo HH, Rowe LD. Laryngeal reconstruction in acute
penetrating laryngotracheal injuries. Head Neck. 1995;
and chronic injuries. Otolaryngol Clin North Am. 1983;
17(6):494-502.
46. Feliciano DV, Bitondo CG, Mattox KL, et al. Combined 16(2):373-89.
tracheoesophageal injuries. Am J Surg. 1985; 150(6):710-5. 58. Dedo HH, Sooy CD. Endoscopic laser repair of poste-
47. Hawkins DB, Demeter MJ, Barnett TE. Caustic inges- rior glottic, subglottic and tracheal stenosis by division or
microtrapdoor flap. Laryngoscope. 1984; 94(4):445-50.
245
tion: Controversies in management. A review of 214 cases.
Laryngoscope. 1980(1); 90:98-109. 59. Dedo HH, Sooy FA. Surgical repair of late glottic stenosis.
48. Schild JA. Caustic ingestion in adult patients. Laryngoscope. Ann Otol Rhinol Laryngol. 1968; 77(3):435-41.
1985; 95(10):1199-201. 60. Correa AJ, Reinisch L, Sanders DL, et al. Inhibition
49. Jones JE, Rosenberg D. Management of laryngotracheal of subglottic stenosis with mitomycin-C in the canine
thermal trauma in children. Laryngoscope. 1995; 105(5 Pt model. Ann Otol Rhinol Laryngol. 1999; 108(11 Pt 1):
1):540-2. 1053-60.
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Chapter
36 Vocal Process Avulsion

Vocal process avulsion may occur with internal or external with the contralateral vocal process, mobility of the vocal
laryngeal trauma. Examination findings may be subtle. process independent from the body of the arytenoid car-
Highly magnified strobovideolaryngoscopic evaluation tilage, and foreshortening and decreased stretch of the
is helpful. Endoscopic evaluation with palpation under vocal fold during glissando.
general anesthesia may be necessary. Voice therapy should Treatment of the vocal process avulsion must be geared
be administered initially. Surgical options include the toward the severity of the injury and the expectations of
use of injectable materials for closed reduction, chemical the patient. A trial of voice therapy usually is warranted,
tenotomy with botulinum toxin, endoscopic open reduc- as this may provide a satisfactory voice for some patients.
tion of the fracture via a cordotomy approach, or open If one proceeds with surgery, several options are available.
reduction using a laryngofissure. Endoscopic open reduction of the fracture is our preferred
Vocal process avulsion can result from intubation or approach.
from external trauma to the larynx. These are also the
most common etiologies of arytenoid dislocation, which SURGICAL TECHNIQUES (Figs 36.1A to I)
should be included in the differential of dysphonia after
such events. Discrepancy in the heights of the vocal pro-
Step 1
cesses may be seen with either vocal process avulsion or
arytenoid dislocation. Close examination of movement of General anesthesia is administered via jet ventilation
the body of the arytenoid cartilage in relation to the vocal through a Hunsaker catheter. Suspension microlaryngo-
process may help distinguish between the two. Of note, scopy is performed to visualize the larynx (Fig. 36.1A).
when reducing an anterior arytenoid cartilage dislocation,
one should take care not to place an instrument under Step 2
the vocal process or insert the laryngoscope too deeply Palpation of the vocal fold confirms the presence and
into the larynx so as to place the vocal process at risk location of the avulsed vocal process (Fig. 36.1B).
for avulsion. External laryngeal trauma is potentially life-
threatening. Dysphonia is an ominous sign and should Step 3
alert the physician to a possible laryngeal fracture or vocal An incision is made on the superior surface of the vocal
fold injury. fold avoiding the vibratory margin (Fig. 36.1C). Blunt
In the author’s (RTS) experience, patients with vocal dissection, often with a straight scissor, may be used to
process avulsion have presented with persistent dysphonia gain exposure of the vocal process (Figs 36.1D, E and F).
weeks to months after the initial insult.1-3 Some struc-
tural injury was suspected from examination and EMG Step 4
results. Other symptoms in the acute setting may include Using the smallest available needle, a 4.0 diameter
pain and dysphagia. Findings of a vocal process avulsion catgut suture is placed through the body of the aryten-
can illusive, and close examination of the larynx with both oid (Fig. 36.1G). Then, the suture is placed through the
flexible laryngoscopy and rigid videostroboscopy is critical proximal end of the vocal process (Fig. 36.1H). A “figure
in the evaluation of these injuries. Signs of avulsion may of 8” suture is positioned, approximating the avulsed
include an apparent separation of the vocal process from vocal process to the body of the arytenoid. The knot is
the arytenoid body, abnormal angle or position of the secured and can be seen protruding through the incision
vocal process, overlapping of the avulsed vocal process (Fig. 36.1I). The frayed ends of the suture are removed
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Vocal Process Avulsion
Chapter
36
A B
247
C D
Figs 36.1A to E: (A) Visualization of the glottis is obtained through

microlaryngoscopy. General anesthesia is administered via jet
ventilation using a Hunsaker cather. (B) Palpation of the vocal fold
confirms the presence of a vocal process avulsion. (C) An incision
is made on the super surface of the vocal fold overlying the area
of the avulsed vocal process. (D) Straight laryngeal microscissors
may be used to bluntly dissect the surrounding tissue. (E) The
E ‘floating’ detached vocal process is seen
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Laryngeal Trauma
Section
F G
248
H I
Figs 36.1F to I: (F) The proximal end of the vocal process is exposed. (G) A “figure of 8” suture is placed using the smallest available
needle and Catgut suture. The first pass is made through the body of the arytenoid. (H) A suture has been placed through the body of
the arytenoid. It will then be placed through the proximal portion of the detached vocal process. (I) A knot is seen protruding through
the incision site. The ends of the suture are kept small, as this will avoid causing unnecessary trauma to the vocal fold and possible
granuloma formation
to prevent unnecessary trauma and resulting granuloma the operating room. A deep extubation is performed and
formation on the vocal fold. The surrounding epithelium the patient is kept on strict voice rest until a follow-up
has not been disturbed. examination is performed, usually after 7 days.
Step 5
The vector of the force generated by contraction of the REFERENCES
thyroarytenoid muscle could conceivably overcome the 1. Rubin AD, Hawkshaw MJ, Sataloff RT. Vocal process
strength of the newly placed suture and redetach the avulsion. J Voice. 2005; 19(4):702-6.
vocal process. It is the practice of the author (RTS) to 2. Sataloff RT, Heuer RJ, Hawkshaw MJ, et al. Vocal fold
inject botulinum toxin into the thyroarytenoid muscle avulsion. Ear Nose Throat J. 1995; 74(4):230.
of the involved vocal fold, usually at approximately 1−2 3. Abraham R, Shapshay S, Galati L. Botulinum-assisted
weeks before surgery. If not done preoperatively, botuli- endoscopic repair of traumatic vocal fold avulsion. Ear
num toxin is injected into the thyroarytenoid muscle in Nose Throat J. In press.
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Chapter Cricoarytenoid and Cricothyroid
37 Joint Injury: Evaluation and
Treatment
CRICOARYTENOID JOINT INJURY eminence and becomes the primitive laryngeal aditus.
The aditus lies between the sixth branchial arches. The
Vocal fold hypomobility or immobility may occur fol- laryngotracheal groove fuses in a caudocranial direction
lowing internal or external neck trauma. The impaired at about the fourth week. The ventral ends of the sixth
mobility may be due to vocal fold paresis or paralysis, branchial arches grow and form the arytenoid eminences.
cricoarytenoid joint fixation or arytenoid dislocation or During the seventh week, a fissure appears on each ary-
subluxation. Dislocation is the displacement of a struc- tenoid eminence extending into the primitive vestibule.
ture, particularly a disarrangement of the normal relation This is the laryngeal ventricle. The last portion of laryn-
of bones or cartilages forming of a joint. Dislocation and gotracheal groove to be obliterated is the intra-arytenoid
luxation are not synonymous. Subluxation is an incomplete sulcus at about 11 weeks.
dislocation, such that there is still contact between joint Laryngeal hyaline cartilages develop from branchial
surfaces, although the relationship is altered. Subluxation arch mesoderm, and elastic cartilages are derived from
is synonymous with semiluxation, and it constitutes a mesoderm of the floor of the pharynx.4 Most of the aryte-
specific form of dislocation. Most arytenoid dislocations noid is composed of hyaline cartilage. However, the vocal
are actually subluxations; but the term dislocation encom- processes are developed separately in association with the
passes partial and complete malposition and will be used vocal folds and consist of elastic cartilage. “Arytenoid”
throughout this chapter. Arytenoid dislocation is misdi- comes from the Greek work arytainoeides, meaning ladle-
agnosed commonly as vocal fold paralysis. When accurate shaped. The cartilages are pyramidal, consisting of an
diagnosis is delayed, surgical repair becomes more dif- apex, base and two processes. The base articulates with
ficult, although not impossible as previously thought.1,2 the cricoid cartilage. The apex attaches to the corniculate
Many laryngologists were taught that arytenoid reduc- cartilage of Santorini and to the aryepiglottic fold. The
tion was impossible or inappropriate beyond the first or vocal process projects anteriorly to connect with the vocal
second week following injury. Our experience suggests ligament and the muscular process is the point of inser-
that reasonably good results are common so long as the tion for most of the muscles that move the arytenoid.5
arytenoid is reduced within about 10 weeks.2 Although The cricoarytenoid facets are well defined, smooth and
reduction can be performed even many years following symmetrical. Each arytenoid articulates with an elliptical
arytenoid dislocation, late reductions usually result in cor- facet on the posterior superior margin of the cricoid ring.
rection of the vertical height disparity without restoration The cricoid facet is about 6 mm long and is cylindrical.6
of joint motion. Traditional teaching holds that the cricoarytenoid joint
motion includes rotating, gliding and rocking. Most of
EMBRYOLOGY AND ANATOMY the cricoarytenoid motion is rocking. However, along the
long axis of the cricoid facet, gliding also occurs.7 Limited
Understanding the complicated embryology and anatomy rotary pivoting is permitted as well. More recent studies
of the arytenoid cartilages is helpful in clarifying surgical suggest that these traditional descriptions are not fully
principles and avoiding complications. The primordium of accurate and that complex revolution may more succinctly
the larynx, trachea, bronchi and lungs arises as an out- describe arytenoid behavior.8 The arytenoid cartilages
growth of the pharynx during the third week of embryo- and the cricoarytenoid facets are extremely symmetric
nic life, forming a laryngotracheal groove.3 This anterior and consistent.9 The cricoarytenoid joint is an arthrodial
groove lies immediately posterior to the hypobranchial join, supported by a capsule lined with synovium. The
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Laryngeal Trauma
Section
capsule is strengthened posteriorly by the cricoarytenoid

ligament.9 This ligament is strong and ordinarily prevents
anterior subluxation. The axis of the joint is at an angle of
about 45° from the sagittal plane and 40° from the hori-
5 zontal plane. The cricoarytenoid joint controls abduction
and adduction of the true vocal folds, thereby facilitating
respiration, protection of the airway and phonation.
Arytenoid motion is controlled directly by intrinsic
laryngeal muscles, including the posterior cricoarytenoid,
lateral cricoarytenoid, interarytenoid and thyroarytenoid.
It is also affected by the cricothyroid muscle, which
increases longitudinal tension of the vocal fold (which
attaches to the vocal process of the arytenoid), and to a
lesser degree by the thyroepiglottic muscle, which tenses
the aryepiglottic fold.
Fig. 37.1: Typical appearance of a posterior arytenoid dislocation.

ARYTENOID DISLOCATION: DIAGNOSIS The dislocated left arytenoid lifts the vocal process (arrowhead),
so the abnormal side overlaps the mobile vocal fold. Reproduced
Traditionally, arytenoid dislocation has been suspected from Sataloff RT. Professional Voice: The Science and Art of
on the basis of history and absence of the jostle phe- Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.;
nomenon present in many cases of unilateral vocal fold 2005: Fig. 89.1, with permission
paralysis.10 Often it is not diagnosed until direct laryn-

goscopy reveals impaired passive mobility of the vocal
250 fold. Preoperative differentiation between vocal fold
paralysis and arytenoid dislocation should be possible
in virtually all cases. However, if not considered specifi-
cally, it will often be missed. Disparity in height between
the vocal fold processes is much easier to see in slow
motion under stroboscopic light at various pitches then
with continuous light. In posterior dislocations, the vocal
process and vocal fold are usually higher on the dislocated
side11 (Fig. 37.1). In anterior dislocations, generally they
are lower on the abnormal side12 (Fig. 37.2). In either
case, the injured vocal fold may move sluggishly or be
immobile. Rarely, abduction and adduction may appear
almost normal under continuous light. Video documenta-
tion of the preoperative and postoperative appearance can
prove particularly helpful in cases of arytenoid dislocation
not only diagnostically, but also because many of these Fig. 37.2: Typical appearance of a severe anterior dislocation.
patients are involved in litigation related to their injuries. The left arytenoid is tilted forward and the vocal process pulls
the vocal fold to a lower level (arrow), so the mobile right vocal
The most valuable tests are the stroboscopic examina- fold overlaps the abnormal side during adduction. Reproduced from
tion to visualize differences in vocal process height; CT Sataloff RT. Professional Voice: The Science and Art of Clinical
scan of the larynx, which should image the arytenoid Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.; 2005:
dislocation and reveal clouding or obliteration of the Fig. 89.2, with permission
cricoarytenoid joint space; and laryngeal electromyog-
raphy (EMG) to differentiate an immobile dislocated to assess other vocal fold injuries. Stiffness and scar of
arytenoid joint from vocal fold paralysis. Airflow analy- the musculomembranous portion of the vocal folds are
sis is also helpful in documenting changes before and found commonly in association with arytenoid disloca-
after therapy. Strobovideolaryngoscopy is also important tion. The trauma causing dislocation frequently involves
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Cricoarytenoid and Cricothyroid Joint Injury: Evaluation and Treatment
Chapter
37
A B
251
Figs 37.3A to C: (A) A normal larynx can be visualized from
the back. The cricoarytenoid ligament is seen on both sides.
The interarytenoid muscle has been removed. The posterior
cricoarytenoid muscle is preserved on the right. In posterior
arytenoid dislocation. (B) The posterior cricoarytenoid ligament
is generally made more lax and it is not torn. In an anterior
dislocation. (C) The posterior cricoarytenoid ligament is generally
torn (as illustrated) or avulsed from its insertion into the cricoid
C or arytenoid cartilage
considerable force that results in vocal fold hemorrhage. dislocation is most commonly caused by intubation. The
It is important to recognize the presence of vocal fold laryngoscope engages the posterior lip of the arytenoid,
scar prior to reducing an arytenoid dislocation, in order tearing the posterior cricoarytenoid ligament and tip-
to inform the patient about reasonable expectations for ping the arytenoid anteromedially (Figs 37.3A to C). The
surgical outcome. vocal process ordinarily is lower than normal in such cases.
When the author reported his series of 26 cases in Complex arytenoid dislocations also occur and can be par-
1994, only 31 additional cases had been reported in the ticularly challenging. In our more recent (unreported) cases,
literature.2 Since that time, additional cases have been direct anterior dislocation has been seen in two patients.
documented.10-22 Although anterior and posterior dislo- In these cases, the arytenoid is displaced anteriorly, but
cations are described most commonly, it has been noted the vocal process is high. This injury requires considerable
previously that the arytenoid can be dislocated in any trauma, with disruption of cartilage. Both cases have fol-
direction.2 Complex dislocations have been observed in lowed intubation. With injury of this severity, endoscopic
some of the cases cared for by the author.2 reduction has been less satisfactory than with more typical
Posterior dislocation is commonly an extubation anterior or posterior dislocations. In rare instances, even
injury. The arytenoid is displaced posterolaterally, and the more complicated situations can be encountered, including
vocal process is high and laterally positioned. Anterior bilateral arytenoid dislocation (Fig. 37.4).
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Laryngeal Trauma
Section
Fig. 37.4: This 62-year-old artist and teacher awoke from abdominal
surgery with severe hoarseness, breathiness and sore throat, ten
months prior to our evaluation. Both vocal folds were immobile
and laryngeal electromyography was normal. Note the very unusual
position of the arytenoids. They are at different heights. The B
right arytenoid (curved arrow) is dislocated posteriorly. The left
arytenoid has suffered a complex anterior arytenoid dislocation Figs 37.5A and B: Straight Miller-3 laryngoscope blade (A) used by
(straight arrow) with the vocal process displaced straight forward anesthesiologists. (B) The curved tip with a slight lip (arrow) has
and high. Note the bowing and laxity of the left vocal fold. proven ideal for the reduction of posterior arytenoid dislocation.
252 Reproduced from Sataloff RT. Professional Voice: The Science and
Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing, Art of Clinical Care, 3rd edition. San Diego, CA: Plural Publishing,
Inc.; 2005: Fig. 89.4, with permission Inc.; 2005: Fig. 89.5, with permission
TECHNIQUES FOR SURGICAL REDUCTION OF rolled lip. The instrument is placed in the pyriform sinus
ARYTENOID DISLOCATION with the rolled tip of the laryngoscope against the infe-
rolateral edge of the dislocated cartilage (Figs 37.6A to
Although early spontaneous reduction of arytenoid dis- D). The surgeon’s other hand is placed on the opposite
location has been reported,2 surgical reduction generally side of the larynx externally to apply counter pressure.
is required. Voice therapy for at least a brief period may The arytenoid is distracted cranially then manipulated
be helpful in some cases and preoperative evaluation anteromedially to pop the arytenoid back into position.
by a speech-language pathologist is generally recom- Substantial force is often necessary, sometimes the full
mended. Surgeons also should be aware that nonsurgical strength of the author’s right arm.
approaches have been suggested. For example, Rontal and A Holinger laryngoscope is usually used to reduce
Rontal have introduced the concept of chemical tenotomy anterior dislocations. More delicate instruments, such
using Botulinum toxin to enhance spontaneous reduc- as cupped forceps, are not strong enough and are more
tions.23 In some cases, adjunct procedures performed at likely to lacerate the mucosa and expose cartilage to the
the time of arytenoid reduction also may be advisable, as risk of infection. No instrument should be placed under
discussed below. the vocal process because of the risk of fracture at the
embryological fusion plane between the vocal process
Closed Reduction for Posterior Arytenoid and body of the arytenoid. The Holinger laryngoscope is
Dislocation rotated so that its supralateral surface makes broad con-
The author (RTS) has found the anesthesiologist’s old- tact with the anteromedial face of the arytenoid. The sur-
fashioned, straight, Miller-3 laryngoscope blade to be the geon’s other hand is placed against the larynx externally
most useful instrument for posterior arytenoid dislocation and posteriorly for manipulation and counter pressure
(Figs 37.5A and B). Newer models do not have the distal (Figs 37.7A to D).
Ch-37.indd 252 9/8/2010 3:12:04 Gopal

Chapter
A
37
B C D
Figs 37.6A to D: To reduce a posterior arytenoid dislocation, the tip of a Miller-3 blade is placed in the pyriform sinus (A). To reduce a
left posterior dislocation, the laryngoscope is rotated medially (B) so that the lip on the laryngoscope engages the dislocated arytenoid
as the laryngoscope is drawn superiorly out of the pyriform sinus. Digital external counterpressure (A) is required; and the right hand
ordinarily needs to be placed more anteriorly than illustrated in this figure. If illustrated in proper position, the hand would block
visualization of the tip of the laryngoscope. Once the arytenoid has been hooked by the lip of the laryngoscope (C), considerable force
is necessary to distract the arytenoid in a cephalad direction, and then to rotate it anteromedially, hence reducing it (D)
253
B C D
Figs 37.7A to D: To reduce an anterior dislocation, a Holinger laryngoscope is positioned (A). To reduce a right arytenoid dislocation,
the laryngoscope is rotated about 130º (B) so that the upper surface of the laryngoscope makes broad contact with the medial surface of
the dislocated arytenoid (C). The surgeon’s contralateral hand is placed externally, posteriorly on the larynx (A), so that the arytenoid is
manipulated between the laryngoscope tip and the fingers of the surgeon’s right hand, to reduce this right arytenoid anterior dislocation.
Considerable force is required to reduce the arytenoid (D); and care must be taken not to injure or avulse the vocal process
For complex dislocations, a combination of these arytenoid posteriorly. Then, a combination of the Holinger
techniques is used. It may be necessary to refracture the laryngoscope and Miller-3 laryngoscope is used to return
cartilage and/or separate the joint in order to manipulate the arytenoid to optimal position.
the arytenoid. For example, in lateral and anterolateral When endoscopic closed reduction is not successful
dislocations, it has been helpful to use the Holinger laryn- or is so unstable that dislocation recurs, open reduc-
goscope to disrupt the cartilage and fibrosis, bringing the tion and fixation should be considered. The procedure is
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Laryngeal Trauma
Section
A B C
Figs 37.8A to C: Digital reduction can be accomplished occasionally, especially for patients who are edentulous and who have had
recent posterior dislocation or redislocation following recent arytenoid reduction. The patient’s tongue is retracted by the patient or
an assistant, leaving the surgeon’s other hand free for external counterpressure (A). The surgeon’s index or middle finger is placed in
the pyriform sinus, engaging the dislocated arytenoid (B). The surgeon’s other hand applies external counterpressure and the arytenoid
is reduced digitally (C)
performed using a standard arytenoid adduction/rotation was placed in her pyriform sinus, and her posterior ary-
approach. Usually, the joint is entered. If the joint has tenoid dislocation was manually reduced. It maintained
254 been obliterated by scar, a “joint” is created sharply, usually
using an iris scissors. The arytenoid is moved to optimize
good position and mobility returned. This technique has
been used on two other patients whose arytenoids redis-
vocal process position. The surgery is performed with the located within 48 hours following surgical reduction.
patient awake, and it is important to adjust vocal process Most recently, another new technique was utilized.
position while the patient is phonating at his/her habitual The author (RTS) was called to see a patient who had
frequency, rather than using a high pitch. If the aryten- awakened with a hoarse, weak, breathy voice and inef-
oid is unstable or hypermobile, it is sometimes possible fective cough following anterior cervical fusion. Posterior
to stabilize it with 3−6 fine sutures placed through the arytenoid dislocation was diagnosed easily, and good vocal
soft tissue attached to the cricoid and arytenoid carti- fold innervation was confirmed by electromyography.
lages. This approach has not been discussed by previous However, the patient had a short, thick neck and was
authors; but the author has found it useful to stabilize flexed in a halo, and on full-dose Coumadin. In the oper-
a hypermobile cartilage in selected cases, particularly if ating room, the arytenoid was reduced indirectly under
the arytenoid is tending to fall anteriorly. Essentially, the nasal fiberoptic laryngoscopic control. A right angle bayo-
sutures replace the posterior cricoarytenoid ligament. net forceps was used. This is the instrument that used to
Special situations and challenging clinical conditions be utilized routinely for holding cocainized cotton in the
sometimes demand other solutions to the problems of pyriform sinuses to provide local anesthesia to the larynx.
arytenoid dislocation. On three occasions, the author has The tip of the forceps was covered with a red rubber cath-
used digital reduction (Figs 37.8A to C). The first was eter. The instrument was placed in the pyriform sinus, and
on an edentulous patient in an intensive care unit who the arytenoid was lifted cranially, anteriorly and medially;
had extubated herself repeatedly. Her physicians were and it popped back into position easily (Figs 37.9A to D).
concerned even about the risk of transporting her to the It is worthwhile attempting endoscopic reduction
operating room, let alone sedating her. Yet, she had res- even long after the injury.1,2,22 In 1998, the author suc-
piratory problems, and it was important to restore the cessfully reduced an anterior arytenoid dislocation that
efficiency of her cough. Her tongue was held with gauze had occurred 38 years previously, restoring vertical sym-
in the manner of indirect laryngoscopy, at the bedside. An metry of the vocal process and fold, although thyroplasty
assistant helped stabilize her larynx externally. A finger was necessary to provide adequate medialization.
Ch-37.indd 254 9/8/2010 3:12:05 Gopal

Chapter
37
B C D
Figs 37.9A to D: This previously underscribed procedure can be used for patients with posterior arytenoid dislocation and difficult
anatomical constraints, such as this patient in a halo. (A) A flexible laryngoscope is placed in the nostril to observe the larynx. A right
angle instrument, such as a laryngeal bayonet forceps, is covered with a shortened red rubber catheter. The hole in the red rubber
catheter (B) assists in making stable contact with the dislocated arytenoid. The posterior aspect of the dislocated arytenoid is engaged
(C) and drawn superiorly, and anteromedially, to reduce the dislocated cartilage (D)
ADJUNCTIVE MEASURES CRICOTHYROID JOINT INJURY
Several adjunctive measures should be considered when

performing arytenoid reduction. For a long-standing pos-
Although injuries to the cricoarytenoid joint have been
discussed in considerable detail as noted above, dyspho-
255
terior dislocation, especially when the reduction seems nia related to injury of the cricothyroid joint has been
unstable, simultaneous medialization should be consid- reported only rarely.24,25 Otolaryngologists should be
ered. Thyroplasty or injection of autologous fat or collagen aware that injury to this structure can occur, causing
not only helps medialize the vocal fold, but it also tends severe voice dysfunction. The cricothyroid joint is a syno-
to pull the vocal process forward. This helps maintain the vial articulation between the inferior cornu of the thyroid
desired arytenoid position. cartilage and the side of the cricoid cartilage. In 1978,
Following anterior dislocation, Rontal and Rontal Schultz-Coulon described a 44-year-old professional
have suggested Botulinum toxin injection into adductor singer who suffered a severe laryngeal contusion following
muscles that tend to pull the arytenoid forward.23 In fact, a sports accident.24 He recovered from the acute injury
they have suggested that Botulinum toxin alone may result but complained of persistent loss of his falsetto voice.
in “spontaneous” reduction without the need for surgical Left unilateral subluxation of the cricothyroid joint was
intervention. In the author’s opinion, while this may be diagnosed by xeroradiography. At lower pitches, his voice
true in rare cases, it is not likely to occur once the joint reportedly returned to normal, but he failed to recover
has been fibrosed. More investigation of this novel con- his falsetto despite over twelve months of intensive voice
cept is certainly warranted. However, the author (RTS) therapy. The author attributed this permanent impairment
has used Botulinum toxin intraoperatively on many occa- to disturbance of the tilting mechanism between the cri-
sions when arytenoid reductions have appeared some- coid and the thyroid cartilages.
what unstable. If a posterior dislocation can be reduced In 1998, Sataloff et al. reported two patients with
but tends to redislocate posteriorly when the patient is cricothyroid joint dysfunction.25 Case 1 was a 38-year-
asked to cough in the operating room, Botulinum toxin old retired professional basketball player. He had been
can be injected into the posterior cricoarytenoid muscle. struck in the anterior neck 12 times during his career.
This permits unopposed pull from the adductor muscle,5 The last injury had resulted in immediate and persis-
which tends to move the arytenoid in the desired direc- tent breathiness, decreased volume, hoarseness, very low
tion. When combined with autologous fat injection, this pitch and inability to project his voice. His cricothyroid
technique has proven to be very effective. joint was fused and ossified (Figs 37.10A to C); and
Ch-37.indd 255 9/8/2010 3:12:05 Gopal

Laryngeal Trauma
Section
A B
256
Figs 37.10A to C: (A) Anterior oblique CT scan of larynx showing
normal left cricothyroid joint (arrow). (B) Anterior oblique 3D CT
scan showing fusion of cricoid and thyroid in region of obliterated
cricothyroid joint (arrow). (C) Posterior-anterior 3D CT scan
showing the left cricothyroid joint intact (open arrows) and fusion
with new cartilage formation in the right cricothyroid joint region
(straight arrow). Reproduced from Sataloff RT. Professional Voice:
The Science and Art of Clinical Care, 3rd edition. San Diego, CA:
C Plural Publishing, Inc.; 2005: Fig. 89.10, with permission
his cricothyroid space was widened, fixing his voice in CONCLUSION

vocal fry. Case 2 was a 36-year-old male who had been
involved in an altercation. He complained of dysphagia, Arytenoid dislocation is not rare, although it is often
mild vocal weakness and laryngeal pain that was most misdiagnosed as vocal fold paralysis. Although the goal of
pronounced during sneezing and coughing. His left crico- treatment is restoration of normal position and function,
thyroid joint was separated (Fig. 37.11). Both patients this cannot always be achieved. However, even correcting
had significant dysphonia due to impairment of the tilting the vertical height abnormality is worthwhile. Essentially,
mechanism between the cricoid and thyroid cartilages. In this simplifies the problem, converting it to one that can
Case 1, motion between the cricoid and thyroid cartilages be managed easily by standard medialization surgery. It is
was eradicated completely. Voice therapy alone was not essential for the surgeon to understand the anatomy and
adequate, and surgery was necessary to restore mobility. surgical principles involved, because visualization during
In Case 2, motion was impaired but still present. Voice surgical manipulation is extremely limited and considerable
therapy permitted restoration of vocal quality and endu- force is required. In virtually all cases, the patient’s voice
rance adequate for the patient’s purposes. If the patient can be improved, and airway problems and other signifi-
had greater professional voice demands, surgery to realign cant complications have not been encountered so far.
the cricoid and thyroid cartilages (reduction of the joint Injury to the cricothyroid joint has been reported
separation) would have been offered. rarely, although it is certain that it has occurred more
Ch-37.indd 256 9/8/2010 3:12:05 Gopal

Chapter
8. Letson JA Jr, Tatchell R. Arytenoid movement. In: Sataloff
RT (Ed). Professional Voice: Science and Art of Clinical
Care, 3rd edition. San Diego, CA: Plural Publishing, Inc.;
2005. pp. 179-94.
9. Pennington CL. External trauma of the larynx and trachea.
Immediate treatment and management. Ann Otol Rhinol 37
Laryngol. 1972; 81(4):546-54.
10. Jackson C, Jackson CL. Disease and Injuries of the Larynx.
New York, NY: Macmillian; 1942. pp. 321.
11. Sataloff RT, McCarter AA, Hawkshaw M. Posterior ary-
tenoid dislocation. Ear Nose Throat J. 1998; 77(1):12.
12. Sataloff RT, Spiegel JR, Heuer RJ, et al. Pediatric anterior
arytenoid dislocation. Ear Nose Throat J. 1995; 74(7):454-6.
13. Szigeti CL, Baeuerle JJ, Mongan PD. Arytenoid disloca-
tion with lighted stylet intubation: case report and retro-
spective review. Anesth Analg. 1994; 78(1):185-6.
14. Alexander AE Jr, Lyons GD, Fazekas-May MA, et al.
Utility of helical computed tomography in the study of
Fig. 37.11: Axial CT scan showing normal right cricothyroid joint
arytenoid dislocation and arytenoid subluxation. Ann Otol
(curved arrow) and separated left cricothyroid joint (straight
arrow). This appearance was consistent throughout the CT Rhinol Laryngol. 1997; 160(12):1020-3.
scans and is not due to rotation. Reproduced from Sataloff RT. 15. Gauss A, Treiber HS, Haehnel J, et al. Spontaneous reposi-
Professional Voice: The Science and Art of Clinical Care, 3rd tion of a dislocated arytenoid cartilage. Br J Anaesth. 1993;
edition. San Diego, CA: Plural Publishing, Inc.; 2005: Fig. 89.11, 70(5):591-2.
with permission 16. Hsu CS, Huang CT, So EC, et al. Arytenoid subluxa-
tion following endotracheal intubation—a case report. Acta
Anaesthesiol Sin. 1995; 33(1):45-52.
frequently, but has not been recognized that often.
Laryngologists should be familiar with the nature and
17. Rieger A, Hass I, Gross M, et al. Intubation trauma of 257
the larynx—a literature review with special reference to
the importance of the cricothyroid joint and the poten- arytenoid cartilage dislocation. Anasthesiol Intensivmed
tial for symptomatic injury of this structure. Additional Notfallmed Schmerzther. 1996; 31(5):281-7.
experience is needed to determine optimal treatment. 18. Friedberg J. Giberson W. Failed tracheotomy decannula-
tion in children. J Otolaryngol. 1992; 21(6):404-8.
19. Talmi YP, Wolf M, Bar-Ziv J, et al. Postintubation ary-
REFERENCES
tenoid subluxation. Ann Otol Rhinol Laryngol. 1996;
1. Sataloff RT, Feldman M, Darby KS, et al. Arytenoid dis- 105(5):384-90.
location. J Voice. 1987; 1(4):368-77. 20. Stack BC Jr, Ridley MB. Arytenoid subluxation from blunt
2. Sataloff RT, Bough ID Jr, Spiegel JR. Arytenoid disloca- laryngeal trauma. Am J Otolaryngol. 1994; 15(1):68-73.
tion: diagnosis and treatment. Laryngoscope. 1994; 104(11 21. Hiong YT, Fung CF, Sudhaman DA. Arytenoid subluxa-
Pt 1):1353-61. tion: implications for the anaesthetist. Anaesth Intensive
3. Lee GJ. Essential Otolaryngology, 3rd edition. New York: Care. 1996; 24(5):609-10.
Medical Examination Publishing; 1983. pp. 306-10. 22. Sataloff RT. Arytenoid dislocation. Operative Techniques
4. Langman J. Medical Embryology, 3rd edition. Baltimore: Otolaryngol Head Neck Surg. 1998; 9(4):196-202.
Williams and Wilkins; 1975. pp. 269-72. 23. Rontal E, Rontal M. Laryngeal rebalancing for the treat-
5. Hollinshead WH. Anatomy for Surgeons, 3rd edition. New ment of arytenoid dislocation. J Voice. 1998; 12(3):383-8.
York: Harper and Row; 1982. pp. 423-7. 24. Schultz-Coulon HJ, Brase A. Clinical and roentgenological
6. Maue WM, Dickson DR. Cartilages and ligaments of the manifestations of unilateral subluxation of the cricothyroid
adult human larynx. Arch Otolaryngol. 1971; 94(5):432-9. joint. HNO. 1978; 26(2):68-72.
7. von Leden, Moore P. The mechanics of the cricoarytenoid 25. Sataloff RT, Rao MV, Hawkshaw M, et al. Crycothyroid
joint. Arch Otolaryngol. 1961; 73:541-50. joint injury. J Voice. 1998; 12(1):112-6.
Ch-37.indd 257 9/8/2010 3:12:06 Gopal

Index
A Axial CT of supraglottic larynx 234 Closed reduction for posterior arytenoid

Abdominal Axial CT scan of dislocation 252
muscle 8 cricoid cartilage 231 CO2 laser 49
support 16 subglottic larynx 233 Coagulopathy 6
Abduction 8 thyroid ala 231 Cocaine 25
Absorbable sutures 243 Arytenoid cartilage 8 Collagenous fibers 98
Absorption 41 Collapse of supraglottic tissue 115
Action of intrinsic muscles 11 B Compartments and barriers in larynx 162
Actually chronic inflammatory tissue 98 Baroque music 5 Completed arytenoidectomy 218
Acute right vocal fold tear 85 Basement membrane structures 63 Complications of laser phonomicrosurgery
Adam’s apple 8 Benjamin light clip 23 46
Adduction 8 Benninger alligator forcep 95 Computed tomography 136
Adult framework injuries from blunt Benzocaine 26 Congenital
trauma 230 Bernoulli’s force 13 and inflammatory disorders 93
Allergies 6 Bilateral cysts 59
Alloderm 184 cricoarytenoid fixation 136 Contact
American Joint Committee (AJC) for superior laryngeal nerve blocks 25 dermatitis 25
Cancer Staging and End Result Bipedicled sternohyoid muscle flap 170 endoscopy 28
Reporting 162 Blunt Contralateral pyriform sinus 173
Anaphylaxis 26 dissection 65, 124 Cordectomy 45, 168
Anatomy of voice 8 injury 229 Coronal CT scans 188
Anesthesia 25 laryngeal trauma 237 Cricoarytenoid 249
Anterior Body of joint 212, 213
comminuted thyroid ala fracture 231 arytenoids 248 ankylosis 46
mucosal incision 124 vocal folds 8 injury 249
web 150 Borders of ligament 251
Anterolateral laryngectomy 169 mass 157 Cricohyoepiglottopexy 171
Antireflux medication 54 polyp 83 Cricohyoidopexy 171
Apron Botulinum toxin 5, 98 Cricoid
flap incision 172 Boundaries of granuloma 104 arch 214
laser 38 Bowed vocal folds 146 cartilage 8, 203, 215
Arterial blood gas analysis 26 Brain laryngeal mask 27 Cricothyroid
Arytenoid Bredemeier’s invention 36 joint 212, 213, 215, 256
adduction 211 Broyles’ ligament 91 facet 215
rotation 214 Brünings syringe 121, 128, 190, 191 injury 249, 255
cartilage 11, 14, 103 Bulky vocal fold 95 membrane 18
aduction/rotation 210 muscle 8, 203
dislocation 250 C contracts 14
erythema 80 Carbon dioxide laser 117 space 203
motion 11 Carden tube 26 subluxation arytenoidopexy 210
Arytenoidectomy 210 Cartilages of larynx 9 Crystal laser 39
Aspirin 7 Catgut suture 248 Curved microlaryngeal scissors 84, 105
Assessment of Caustic and thermal injuries 242 Cysts 43
blunt injuries 233 Cervical arthritis 18
penetrating injuries 242 Cetacaine 25 D
Autologous fat 46 Chronic laryngopharyngeal reflux 150 Decadron 49, 204
injection 186 Cidofovir 5, 35, 106, 109, 113 Dedo laryngoscope 22
Index.indd 259 9/9/2010 2:34:40 Gopal

Dental trauma 46 Flexible Inferior cornu of thyroid cartilage 214

Dexamethasone 26, 35 fiberoptic laryngoscopy 16 Infraglottic
Diamond burr 200 fibers 38 air pressure 13
Diode laser 40 laryngoscope 18, 40, 255 vocal tract 11
Direct Flow Injection laryngoplasty 52
laryngoscopy 24, 47 glottogram 14 Injection of
microlaryngoscopy 22 glottography 14 alloderm 185
Displaced cricoid lamina fractures 231 Four crucial considerations for Teflon lateral to vocalis muscle 184
Dye laser photodynamic therapy 39 phonomicrosurgery 40 Inner perichondrium of thyroid cartilage
Dyskeratosis 150 Fracture 18 207
Dysplasia 150 Friability of laryngeal papilloma 110 Instruments specific for laser
Function of laryngeal muscles 13 phonomicrosurgery 41
E Fusion of cricoid 256 Interarytenoid
Ecstatic vessels 131 muscle 251
Ectasia 87 G scar 136
Ectatic vessels 85 Gastroenterological abnormalities 16 Intra-abdominal pressure 12
Edema 26 Gastroesophageal reflux Intravenous
Electromyography 136, 224 disease 142, 156 steroids 26
Endolaryngeal laryngitis 100 thiopental 26
repair 237 Gelatinous fluid 91 Intrinsic muscles 8
stenting 239 Gelfoam injection 184 Invasive carcinoma 45, 150
Endoscopes 38, 83 Glossopharyngeal nerve blocks 25 Iron 26
Endoscopic Glottic tumors 166 Isshiki procedure 45
laryngeal surgery 25 Glottis 8, 13, 19, 50
laser-assisted vertical hemilaryngec- Gould laryngoscope 22 K
tomy 168 Granuloma 19, 43, 98, 103-105 Keratosis 44, 149
resection of cancer involving true and vocal process ulcers 98 Killian’s gallows 22
vocal fold 175 formation 192 Koilocytosis 150
surgery 167 KTP laser 47
Endotracheal tube 26, 27, 37 H
Epidermal growth factor 154 Head and neck cancer 162 L
Epiglottic flap 239 Heart-shaped forceps 20 Lamina propria 37, 45, 72, 131
Epinephrine 19, 20, 25, 35, 83, 123 Hellqvist’s classification system 150 Laryngeal
Epithelium 11, 72 Hematoporphyrin derivative 39 cancer 161
Erythema 25, 93 Hemilarynx 162 fixation 240
Erythroleukoplakia 149 Hemorrhages 6, 77 granulomas 101
Erythroplakia 149 Holinger laryngoscope 253 intraepithelial neoplasm 150
Excisional biopsy 167 House-urban rotary dissector 29 laser surgery 36
Exophytic mass 157 Human papilloma virus 154 mirror 18
Exposure of cricoid cartilage 218 related cancer 155 mucosal injury 26
Extensive coughing 6 Hunsicker catheter 26 muscles 13
External injection 18 Hydrodissection 44, 49 papillomas 154
Extravasation of blood 48 Hydrotomy 37, 43 papillomatosis 37, 106, 113
Extrinsic Hydroxyapatite 44 telescope 18, 28, 63, 77, 78
laryngeal muscles 8 Hyoid bone 25 trauma 227
muscles 8 Hyperkinesia of false vocal folds 70, 92 webs 133
Hyperplasia 149 Laryngectomy 8
F Hypesthesia 46 Laryngitis 44
False vocal folds 8, 117 Laryngocele 43
Fascia 46 I Laryngomalacia 115
Fat implantation and lipoinjection 126 Iatrogenic injuries 242 Laryngopathia 6
Ferric protoporphyrin 26 Indirect laryngoscopy 16, 18 Laryngopharyngeal reflux 6, 16, 54
Ferrihemoglobin 26 needle 19 Laryngoplasty 46
260
Index.indd 260 9/9/2010 2:34:41 Gopal

Index
Laryngoscope 22 Miniplate fixation of vertical thyroid Perichondrium 200, 206, 224

suspension system 22 lamina fracture 241 Pharyngeal tissue 46
Laryngoscopy 47 Mini-thyrotomy 200 Pharynx 8
Laryngotracheal Miscellaneous disorders of larynx 70, 92, Phonation 12
reanastomosis 241 99 Phonatory cycle 13
trauma 229 Mitomycin-C 5, 137 Phonomicrosurgery 4
Larynx 8, 39 Monopolar coagulating Photodynamic therapy 39
Laser alligator forceps 44 Physiology of voice 12
arytenoidectomy 218 heart-shaped grasper 44 Pitch
phonomicrosurgical techniques for Montgomery and loudness control 14
types of lesions 43 premolded laryngeal stents 240 modification surgery 44
related accidents 46 T tube 101 Pneumothorax 27
resistant endotracheal tubes 37 Mucosa 8 Polypoid corditis 95
tissue interaction 40 assessment 14 Polyps 43
Lateral cricoarytenoid muscle 98, 99 Mucosal flap 243 Pontocaine 25
Left Muscle tension dysphonia 16 Posterior
prominent leukoplakia 150 Muscular process of arytenoid 212 arytenoid dislocation 250, 251, 255
sulcus vocalis 131 Musculomembranous vocal fold 18, 86 cricoarytenoid muscle 251
true vocal fold 72, 103 glottic stenosis 136, 137, 243
vocal fold 86, 187 N grading system 136
Leukocysts 98 Nasal cottonoid sponges 205 laryngeal scarring 136
Leukoplakia 44, 149, 150 Neodymium: yttrium-aluminum-garnet larynx normal 136
Level of oropharynx 19 laser 38 mucosal
Lewy device 22 Nerve muscle pedicle surgery 220
defect 238
Lidocaine 19, 20, 83, 123 Neurological impairments 16
incision 124
Limitations of Nodules 43, 59
Postoperative voice care 54
CO2 laser surgery 41 Noise maker 8
Potassium 39
diode laser surgery 41 Normal
Premalignant
surgery 40 laryngeal position 230
and malignant lesions of larynx 147
Lindholm laryngoscope 23 larynx 251
lesions of larynx 149
Lipoinjection 189 left cricothyroid joint 256
Premenstrual period 6
Liposuction cannula 190
Lungs 8 O Preoperative voice evaluation and care 16
Presbyphonia 146
Lymph node metastases 162 Oblique ball dissector 127
Open Prilocaine 26
M exploration Principles of CO2 laser phonomicrosur-
Malignant transformation 152 and repair 237 gery 42
Management of blunt laryngeal of laryngeal trauma 238 Proliferated capillaries 98
trauma 234 laryngeal procedures 137 Proline suture 214
Mayo stand 22 Oral cavity 8 Prominent varix 50
Mechanism of blunt laryngeal Orotracheal intubation 47, 99, 107, 189 Protruding lesions 43
trauma 230 Outer thyroid perichondrium 206 Pruritus 25
Melanin 38 Oxymetazoline 204 Pseudoepitheliomatous hyperplasia 149
Menstrual cycle 6 Pseudosulcus vocalis 130
Metaplasia 150 P Pubic hair line 189
Methemoglobin 26 Pachydermia 149, 150 Pulmonary
Methemoglobincythemia 26 Papilloma 35, 39, 43, 106, 109, 133 dysfunction 16
Methemoglobinemia 26 Paraglottic space 185 hypertension 115
Methylene blue 26 Parakeratosis 149 Pulsed-dye laser 39
Microinvasive carcinoma 45 Part of thyroarytenoid muscle 8 Pyogenic granuloma 100
Microlaryngoscopy 92 Partial Pyriform sinus 253
Microtrapdoor flap technique 138 injury 52
Midazolam 25 laryngectomies 165 R
Mild paralysis of tongue 46 Radiesse implant 194
erythema 150 Parts of laryngeal skeleton 8 Reconstruction after partial
leukoplakia of left vocal fold 149 Penetrating injuries 242 laryngectomy 170
261
Index.indd 261 9/9/2010 2:34:41 Gopal

Recurrent Signs and symptoms of laryngeal Superior

laryngeal nerve 213 injury 230 laryngeal nerve block 25
repair 241 Silk suture 174 surface of vocal fold 72
laryngospasm 101 Simple squamous cell hyperplasia 151 Supine position 22
Reflection 40 Skeleton 8 Supracricoid hemilaryngectomy 170
Regions of larynx 162 Skin discoloration 26 Supraglottic
Reinke’s Skip technique 36 laryngectomy 165, 166
edema 5, 38, 43, 44, 91, 94, 95 Sneezing 6 larynx 165
space 10, 45, 49, 95 Sniffing 22 tissue 115
Removal of Teflon 187 Sound production 12 tumors 161
Repair of penetrating injuries 242 Squamous vocal tract 11
Revision thyroplasty 200 cell Supraglottoplasty 115
Rib cage 8 carcinoma 153 Suprahemilaryngectomy 169
Right hyperplasia 151 Surgery for vocal fold scar 120
erythroplakia 150 epithelial cyst wall 61
true vocal fold 47, 49, 157 epithelium lines 10 T
vocal fold 123, 188 Staging of Techniques for
mass 80, 131 lymphatic metastasis in laryngeal bilateral vocal fold paralysis 222
Rotation surgery 211 cancer 163 surgical reduction of arytenoid
primary tumor in laryngeal cancer dislocation 252
S 162, 167, 175 Teflon
Safe laser phonomicrosurgery Sternohyoid muscle flap 170, 238 granuloma 46, 102, 188
considerations 41 Steroids 54 injection 46, 102, 183
Sarcoidosis 98 Storz Temporary coagulopathy 6
Sataloff laryngeal telescopes 43 Therapy for vocal fold scar 119
alligator forcep 88 telescopes 23 Thyroarytenoid 14
curved spatula 72, 124 Straight muscle 98
flap knife 127 microlaryngeal scissors 112 nerve 224
heart shaped grasper 81, 84, 102, Miller-3 laryngoscope blade 252 neurectomy 224
105, 140 Sataloff sharp knife 66, 72, 104, 139 Thyrohyoid membrane 25
indirect laryngeal needle 20 Striking zone 69 Thyroid 14
left-angled cup forceps 20 Strobovideolaryngoscopy 6, 16, 85, 101, cartilage 8, 14, 18, 25, 206
long right angle ball dissector 127, 103, 131 lamina 18, 185, 215, 224
192 Structure of vocal fold 61 Thyroidotomy window 207
oblique blunt ball dissector 108 Subcutaneous tissue 189 Thyropharyngeus muscle 211
right Subepithelial Thyroplasty 198, 214
angle 127 infiltration 157 Timing of voice surgery 6
heart shaped grasper 73 infusion 83, 123 Titanyl 39
sharp knife 80, 102, 108, 139 injection 19, 20 Topical anesthesia 18
straight Subglottal pressure 13 Tortuous varix 88
indirect laryngeal microcup Subglottic Total laryngectomy 171-174
forceps 19 cancer 175 Trachea 3
knife 83 pressure 14 Tracheotomy 165
vascular knife 87, 88, 127 stenosis 142 Transmission 41
Scar Submucosal infusion 35 Transnasal flexible laryngoscopy 19
excision and buccal graft placement and laryngeal microsurgery 35 Transoral
122 Sulcus vocalis 130, 131 injection 18
formation 10 Superficial technique 18
Senile vocal fold atrophy 146 decadron injection 49 Treatment of sulcus vocalis and
Sense of feeling 12 lamina 123 mucosal bridge 130
Sessile granuloma 103 layer of lamina propria 61, 65, 79, Tuberculosis 98
Sharp dissection 114 95 Tucker’s technique 221
262
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Index
Types of Vocal Voice

lasers 38 cord stripping 61 cosmesis 52
thyroplasty 201 fold 8, 13, 14, 65, 83, 88, 108, 212 lift surgery 53
cysts 59, 61 measures 16
U hemorrhage 85 therapy 54
Ulcers 98 nodules 69, 71
Unilateral cricoarytenoid 136 nodules in children 69 X
fixation 136 paresis 16, 183 Xylocaine 25
scar 119
V ligament 36, 124 Z
Vallecula 23 nodules 71 Zeiss
Verrucous carcinoma 45 process of arytenoid cartilage 218 instruments 28
Vertical hemilaryngectomy 169 tract 8 microscope 4
Vibratory margin 82 Vocalis muscle 8, 11, 218 operating microscope 28
263
Index.indd 263 9/9/2010 2:34:41 Gopal

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Atlas of

Prelims.indd i 9/8/2010 3:12:28 Gopal

Robert T Sataloff MD DMA FACS

Shruti Joglekar MBBS MD DORL

Mary J Hawkshaw BSN RN CORLN

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Prelims.indd iii 9/8/2010 3:12:29 Gopal

© 2011, Jaypee Brothers Medical Publishers

First Edition: 2011

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Jean Abitbol MD Yolanda D Heman-Ackah MD

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Prelims.indd ix 9/8/2010 3:12:30 Gopal

Section 1 Basic Principles and Procedures

1. Introduction: The History, Evolution and

3. Anatomy and Physiology of the Voice: A Brief Overview 8

4. Preoperative Voice Evaluation and Care 16

Prelims.indd xi 9/8/2010 3:12:30 Gopal

9. Submucosal Infusion and Laryngeal Microsurgery 35

10. Laryngeal Laser Surgery 36

11. Voice Cosmesis: The Voice Lift 52

Section 2 Benign Structural Lesions

13. Vocal Fold Cysts 59

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15. Vocal Fold Polyps 76

16. Varicosities, Ectatic Vessels and Vocal Fold Hemorrhage 85

17. ReinkeÊs Edema 91

18. Granulomas and Vocal Process Ulcers 98

20. Supraglottoplasty 115

22. Sulcus Vocalis 130

23. Laryngeal Webs 133

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25. Subglottic Stenosis 142

Section 3 Premalignant and Malignant Lesions of the Larynx

27. Premalignant Lesions of the Larynx 149

28. Laryngeal Cancer 161

Section 4 Neurogenic Disorders

29. Vocal Fold Paresis/Paralysis 183

30. Thyroplasty 198

31. Arytenoid Cartilage Adduction/Rotation, Cricothyroid Subluxation

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32. Nerve Muscle Pedicle Surgery 220

33. Other Techniques for Bilateral Vocal Fold Paralysis 222

34. Throarytenoid Neurectomy 224

Section 5 Laryngeal Trauma

35. Laryngotracheal Trauma 229

36. Vocal Process Avulsion 246

37. Cricoarytenoid and Cricothyroid Joint Injury: Evaluation and

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Basic Principles and

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INTRODUCTION muscle), extends on each side from the arytenoid carti-