Fig. 9.1
Endoscopic tools: (a) Telepack X LED (Storz®). (b) operating laryngoscope (HAVAS Operating Laryngoscope Storz® with light carrier) and one straightforward telescope 0° (Hopkins II® – Storz®). (c) three laryngeal forceps (LaryngoFIT HAVAS® – Storz®)
Fig. 9.2
Endoscopic tools: (a) laryngeal scissor (LaryngoFIT HAVAS® – Storz®). (b) triangular fluted straight. (c) one with bite spoon. (d) one fluted straight
9.2 Arytenoidectomy
Arytenoidectomy is a permanent and irreversible surgical procedure where the laryngeal inlet is widened in its transverse axis. The aim is to enlarge the glottic airway size to improve symptoms, with minimal adverse effect on voice and swallowing [3].
Arytenoidectomy is usually performed in cases of bilateral vocal fold immobility caused by either paralysis of the vocal cords or their fixation [4, 5]. It may be divided into a conservative procedure (transverse cordotomy and medial arytenoidectomy) and a radical procedure (total arytenoidectomy) [6]. Ossoff et al. described the total (complete) arytenoidectomy procedure in 1983 [4]. Dennis and Kashima first described the procedure of transverse cordotomy or posterior cordectomy in 1989 [7]. Medial arytenoidectomy (partial arytenoidectomy) was described in 1993 by Crumley [8].
Arytenoidectomy can be performed endoscopically by conventional cold steel microsurgery or with the use of laser; currently, the latter is the more popular approach [5, 9, 10]. Endoscopic partial arytenoidectomy and posterior/transverse cordotomy have become more popular recently, because it was claimed that total arytenoidectomy led to aspiration problems postoperatively and disturbed voice significantly [11].
Arytenoidectomy can also be done by an external or open method if laser is not available, if previous endoscopic or microsurgical procedures have failed, or in cases for which access to the area is limited by anatomical distortions (Fig. 9.3).
Fig. 9.3
Different degrees of arytenoid removal (medial, total) compared with transverse cordotomy: Area n.1: transverse cordotomy; Area n.2: laser ablation of the medial arytenoid for medial arytenoidectomy; Area n.3: laser ablation of total arytenoidectomy
Different degrees of arytenoid removal (medial, total) compared with transverse cordotomy:
Area n.1: transverse cordotomy
Area n.2: laser ablation of the medial arytenoid for medial arytenoidectomy
Area n.3: laser ablation of total arytenoidectomy
9.2.1 Arytenoidectomy with Laser [12]
Step 1
Exposition of glottic area, especially its posterior portion (Fig. 9.4).
Fig. 9.4
Ar arytenoid, VF vocal fold
Fig. 9.5
Ar arytenoid
Fig. 9.6
Ar arytenoid
Fig. 9.7
Ar arytenoid
Step 2
Submucosal dissection of the cartilage is performed using CO2 laser.
Arytenoid cartilage is dissected off the surrounding tissues using also microscissor. The junction of arytenoid with cricoid is identified, and that is the posterior wall of the joint capsule. The joint is opened. The arytenoid is removed from the cricoid cartilage by the use of laser CO2 (Figs. 9.8, 9.9, 9.10 and 9.11)
Fig. 9.8
Ar ca arytenoid cartilage
Fig. 9.9
Ar ca arytenoid cartilage
Fig. 9.10
Ar ca arytenoid cartilage
Fig. 9.11
Ar ca arytenoid cartilage, Cr ca cricoid cartilage
Step 3
In order to avoid stenosis and granuloma formation, the area which corresponds to arytenoidectomy is recovered by repositioning of mucosal flap with Vicryl 4.0 suture and fibrin adhesive.
The medially based advancement flap is sutured posterolaterally endoscopically between the anterior edge of the mucosal flap and the surgical bed (H) around the previous place of the muscular process of arytenoid (Figs. 9.12 and 9.13).
Fig. 9.12
fl mucosal flap, Cr ca cricoid cartilage
Fig. 9.13
The area which corresponds to arytenoidectomy is recovered by repositioning of mucosal flap with Vicryl 4.0 suture and fibrin adhesive
9.2.1.1 Arytenoidectomy with Cold Instruments
Step 1
Fig. 9.14
Ep epiglottis, Ar ca arytenoid cartilage, Ar mu arytenoid mucosa
Fig. 9.15
Ar mu arytenoid mucosa
Fig. 9.16
Ar ca arytenoid cartilage, Ar mu arytenoid mucosa
Fig. 9.17
Ar ca arytenoid cartilage, Ar mu arytenoid mucosa
Step 2
Arytenoid cartilage is dissected off the surrounding tissues. The muscular process of arytenoid is sharply dissected off its muscular attachments (Figs. 9.18 and 9.19).
The junction of arytenoid with cricoid is identified, and that is the posterior wall of the joint capsule. The joint is opened. The arytenoid is removed from the cricoid cartilage by cutting other connective tissue components of the joint (Fig. 9.20).
Fig. 9.18
Ar ca arytenoid
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