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Laryngeal Framework Surgery (Laryngoplastic Phonosurgery)
Steven M. Zeitels
Laryngeal framework surgery is typically performed for aerodynamic glottal incompetence that has resulted in dysphonia. Most commonly, it is done for vocal-fold paralysis or paresis. It may also be done for tissue loss from trauma or cancer resection. Neurological disorders can also be treated by laryngeal framework surgery, as can generalized vocal-fold atrophy.
- During the office evaluation, laryngeal stroboscopy is imperative for an accurate assessment of a variety of factors contributing to the dysphonia. Transoral telescopic stroboscopy is optimal for assessing the details of the anatomy and generalized pattern of glottal closure and vibration. Flexible fiberoptic stroboscopy provides for observing configurations of paralysis-induced compensation of the laryngeal and pharyngeal musculature because the tongue is not extruded.
- The vocal fold with impaired mobility must be assessed for its position in the axial and vertical planes, as well as magnitude of denervation-related flaccidity. Care should also be taken to assess the glottis for mucosal lesions and surface pliability that may be related to routine phonotrauma. It is also very important to assess the range of motion of the contralateral arytenoid, especially with regard to its limits of abduction. This is critical information if one is to consider an arytenoid repositioning procedure.
- A Medrol (methylpredisolone) dose pack is started a day prior to surgery. Administration of steroids is especially helpful in minimizing intraoperative edema, which can alter judgments regarding the shape and size of the implant. It is also important for restricting intraoperative and postoperative airway edema. Typically, the patient will be discharged on the first postoperative day and will complete the Medrol dose pack after discharge.
- When the patient reaches the operating room, the nasal membranes are locally anesthetized with a decongestant using a combination solution or cocaine hydrochloride. A sterile flexible fiberoptic laryngoscope is then used to check the anatomy and the glottal function prior to injecting local anesthesia. During the procedure, it is prudent to employ a nasal cannula with oxygen, especially in elderly patients with cardiopulmonary dysfunction. Although many surgeons separate the field of the nasal chamber and oral cavity from the neck incision, this author found that to be unnecessary and typically places the towels over the eyes but leaves the nose, mouth, and neck exposed together.
- Laryngoplastic phonosurgery is typically performed under local anesthesia with monitored intravenous sedation. In selected circumstances, it is done with general endotracheal anesthesia; however, this approach precludes real-time adjustment of the reconstruction based on feedback in the acoustical quality of the voice.
- Intravenous perioperative antibiotics are used routinely, and 10 to 15 mg of dexamethasone is administered directly after the intravenous line is placed preoperatively.
- A natural neck crease is selected for the incision at the approximate level of the lower edge of the thyroid lamina (Fig. 17-1). Local anesthesia is a critical component to effective laryngoplastic phonosurgery. We employ a solution that comprises equal parts Marcaine (bupivacaine hydrochloride) 0.75% with 1:200,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine. The resultant solution is 0.375% Marcaine, 1% lidocaine, and 1:150,000 epinephrine. A total of 50 cc is usually mixed for potential use during the case. Typically, 25 to 30 cc is used. The dermis is injected along the selected crease. Local anesthesia is also placed in the subplatysmal plane and along the ipsilateral thyroid lamina. If an arytenoid procedure is planned, the needle is advanced along the posterior edge of the thyroid lamina, staying medial to the carotid artery to anesthetize the inferior constrictor region.
- The length of the incision is based on the extent of the surgery that is planned. If an implant medialization laryngoplasty is planned along with an arytenoid procedure, the incision will extend from the contralateral paramidline region through the anterior sternocleidomastoid muscle region. The length of the incision is also determined by the thickness of the soft tissue superficial to the visceral fascia and the extrinsic laryngeal strap musculature.
- The incision is extended to the surface of the extrinsic laryngeal musculature. Subplatysmal flaps are raised from the level of the inferior cricoid to the hyoid bone, and Gelpi retractors are placed to maintain the flaps.
- A needle-tip electrocautery knife is used on cutting mode to separate the strap musculature in the midline until the thyroid and cricoid cartilages are encountered. A narrow double-prong skin hook is placed in the thyroid notch to rotate the thyroid laminae toward the innervated side and thereby better expose the lamina of the paralyzed vocal fold.
- If an arytenoid procedure is to be done, skip to* on page 113.
