Patient selection and consent

Before performing voice surgery, it is essential to be certain that patient selection is appropriate and that the patient understands the limits and potential complications of voice surgery. Appropriate patients for voice surgery not only have voice abnormalities but also want to change their voice quality, effort, or endurance. For example, not all people who have “pathologic” voices are unhappy with them. Sports announcers; female trial attorneys with gruff, masculine voices; and others sometimes consult a physician only because of fear of cancer. If there is no suspicion of malignancy, restoring the voice to “normal” (eg, by evacuating Reinke’s edema) may be a disservice and even jeopardize a career. Similarly, it is essential to distinguish accurately between organic and psychogenic voice disorders before embarking upon laryngeal surgery. Although a breathy voice may be caused by numerous organic conditions, it is also commonly found in people who have psychogenic dysphonia. The differentiation may require a skilled voice team.

Although all reasonable efforts should be made to avoid operative intervention in professional voice users (particularly singers), there are times when surgery is appropriate and necessary. The decision depends on a risk–benefit analysis. If a professional is unable to continue his or her career, and if surgery may restore vocal function, surgery should not be withheld. Making such judgments can be challenging. A rock or pop singer who has a vocal fold mass may have satisfactory voice quality with only minimal technical adjustments. Pop singers perform with amplification, obviating the need to sing loudly and to project the voice in some cases (depending on the artist’s style). Such a patient may be able to “work around” pathology safely for many years. In some classical singers, even minor pathology may be disabling. For example, if a high soprano specializing in Baroque music develops a mild to moderate superior laryngeal nerve paresis, she may experience breathiness and instability. If she gives in to the temptation to compensate by slightly retracting her tongue and lowering her larynx, the breathiness will be controlled because of increased adductory forces, but she will lose the ability to perform rapid, agile runs and trills. Similar problems may occur from compensatory maladjustments in response to other lesions, such as vocal fold cysts. In such instances, the artist may be served better by surgical correction of the underlying problem than by long-term use of hyperfunctional compensation (ie, bad technique) that can cause other performance problems and vocal fold pathology. The patient must understand all of these considerations, including the risks of surgery. The patient needs to acknowledge the risk that any voice surgery may make the voice worse permanently and must consider this risk acceptable in light of ongoing vocal problems.

Even in the best hands, an undesirable scar may develop, resulting in permanent hoarseness. The patient must be aware that there is a possibility that the voice may be worse after surgery. Other complications must also be discussed, including complications of anesthesia, dental fracture, recurrence of laryngeal lesions, airway compromise, and vocal fold webbing. In addition to the hospital’s standard surgical consent, we provide patients with additional written information before surgery. The patient keeps one copy of the “Risks and Complications of Surgery” document, and one signed copy remains in the chart. Specialized informed consent documents are used for other treatments, such as injection of cidofovir, topical application of mitomycin-C, injection of collagen, and injection of botulinum toxin, even though such documents are not required. If medications are used for treatment (rather than research) and are off-label uses of medicines approved by the FDA for other purposes, their use does not require institutional review board approval. We believe it is helpful and prudent to provide patients with as much information as possible and to document that they have been so informed.

It is often helpful for the laryngologist, speech-language pathologist, singing voice specialist, and patient to involve the patient’s singing teacher in the decision-making process. Everyone must understand the risks of surgery and the risk involved in deciding against surgery and relying upon technical maladjustments. In many cases, there is no “good” or “right” choice, and the voice care team must combine expertise with insight into the career and concerns of each individual patient to help the voice professional make the best choice.

Documentation

Preoperative objective voice assessment and documentation are essential in addition to routine documentation of informed consent discussions. A high-quality recording of the patient’s voice must be done before surgery. Auditory memories of physicians and patients are not good in general, and the doctor and postoperative professional voice user are often surprised when they compare postoperative and preoperative recordings. Frequently, the preoperative voice is worse than either person remembers. In addition, such documentation is invaluable for medical–legal purposes. Photographs or videotapes of the larynx obtained during strobovideolaryngoscopy are helpful. Complete objective laboratory voice assessment and evaluation by a voice team should be performed. Proper documentation is essential for assessing outcomes, even for the physician who is not interested in research or publication.

Documentation

Preoperative objective voice assessment and documentation are essential in addition to routine documentation of informed consent discussions. A high-quality recording of the patient’s voice must be done before surgery. Auditory memories of physicians and patients are not good in general, and the doctor and postoperative professional voice user are often surprised when they compare postoperative and preoperative recordings. Frequently, the preoperative voice is worse than either person remembers. In addition, such documentation is invaluable for medical–legal purposes. Photographs or videotapes of the larynx obtained during strobovideolaryngoscopy are helpful. Complete objective laboratory voice assessment and evaluation by a voice team should be performed. Proper documentation is essential for assessing outcomes, even for the physician who is not interested in research or publication.

Timing of voice surgery

The time of voice surgery is important and can be challenging in professionals who have demanding voice commitments. Many factors need to be taken into account, including the menstrual cycle, pre- and postoperative voice therapy, concurrent medical conditions, psychologic state, and professional voice commitments.

Hormonal considerations may be important, especially in female patients who have symptomatic laryngopathia premenstrualis. In patients who have obvious vocal fold vascular engorgement or who have a history of premenstrual vocal fold hemorrhages, it may be better to avoid elective surgery during the premenstrual period. Except in patients in whom surgery is intended to treat vessels that have hemorrhaged repeatedly and that are only prominent before menses, it may be best to perform surgery between approximately days 4 and 21 of the menstrual cycle. Although it seems unnecessary to time surgery in this way for all patients, the issue has not been fully studied.

Timing of surgery with regard to voice therapy and performance commitments can be difficult in busy voice professionals. The surgeon must be careful to avoid letting the patient’s professional commitments and pressures dictate inappropriate surgery or surgical timing that is not in the patient’s best interest. For example, some professional voice users push for early surgery for vocal nodules and promise to appear for voice therapy after a busy concert season ends. This is not appropriate because therapy may cure the nodules and avoid surgical risks altogether. Professional commitments often require that appropriate surgery be delayed until a series of concerts or the run of a play is completed. In treating vocal fold cysts, polyps, and other conditions, such delays are often reasonable. They are made safer through ongoing voice therapy and close laryngologic supervision. Sometimes individualized treatments may help temporize. For example, aspiration of a cyst as an office procedure can provide temporary relief from symptoms, although the cyst is likely to return and require definitive surgery.

At least a brief period of preoperative voice therapy is helpful. Even when therapy cannot cure a lesion, it ameliorates the abuses caused by compensatory hyperfunction, and good preoperative therapy is the best postoperative voice therapy. It is also invaluable in educating the patient about vocal function and dysfunction and in making sure that he or she is fully informed about surgery and other options. After surgery, voice therapy is medically necessary for many conditions. It is important to long-term surgical outcome to time surgery so that the patient is able to comply with postoperative voice rest and postoperative rehabilitation.

Many other conditions must be taken into account when deciding upon the timing of voice surgery. Concurrent medical conditions, such as allergies that produce extensive coughing or sneezing (which may injure vocal folds after surgery), a coagulopathy (even temporary coagulopathy from aspirin use), and other physical factors may be important contributors to voice results. Psychologic factors should also be considered. The patient must understand the risks and complications of surgery and be as psychologically prepared as possible to accept them and to commit the therapeutic and rehabilitation process. Sometimes psychologic preparation requires a delay in surgical scheduling to allow time for the patient to work with the voice team. There are few indications for benign voice surgery that contraindicate a delay of several weeks. It is generally worth taking the time to optimize the patient’s comfort and preparedness. Realistic, committed collaboration by the patient is invaluable in achieving consistent, excellent surgical results.

Voice cosmesis: the “voice lift”

In the modern communication age, the voice is critical in projecting image and personality and establishing credibility. Until recently, voice has not received enough attention from the medical profession or from the general public. Most people (doctors and the general public) do not realize that anything can be done to improve a voice that is unsatisfactory or even one that is adequate but not optimal.

Some techniques for voice improvement date back centuries. Singers, actors, and public speakers have sought out “voice lessons” for centuries. Recently, techniques for voice improvement have expanded and improved and have become practical for many more people.

Vocal weakness, breathiness, instability, impaired quality, and other characteristics can interfere with social and professional success. Many problems (eg, breathiness, softness, instability, tremor, and change in habitual pitch) are commonly associated with aging. For most people, these vocal characteristics, which lead people to perceive a voice (and its owner) as “old” or “infirm,” can be improved or eliminated.

The first step for anyone seeking voice improvement is a comprehensive voice evaluation. Often, voice problems that one may ascribe to aging or to genetic makeup are caused or aggravated by medical problems. The possibilities include such conditions as reflux, low thyroid function, diabetes, and tumors. Sometimes, voice deterioration is the first symptoms of a serious medical problem, so comprehensive medical evaluation is essential before treating the voice complaints.

Once medical problems have been ruled out or treated, the next step for vocal habilitation or restoration is a program of therapy or exercise provided by a multidisciplinary team that incorporates the skills of a laryngologist, a speech-language pathologist, and an acting-voice specialist. The training involves aerobic conditioning to strengthen the power source of the voice. In many cases, neuromuscular retraining (specific guided exercise) is sufficient to improve vocal strength and quality, eliminate effort, and restore youthful vocal quality. Doing so is important not only for singers and other voice professionals (eg, teachers, radio announcers, politicians, clergy, salespeople, and receptionists) but also for almost everyone. This is especially true for elderly persons. As we age, our voices get softer and weaker, and at the same time our spouses and friends lose their hearing. This makes professional communication and social interaction difficult, especially in noisy surroundings, such as cars and restaurants. When one has to work too hard to communicate, it is often related to vocal deficiencies. When exercises and medications alone do not provide sufficient improvement, many patients elect voice surgery in an attempt to strengthen their vocal quality and endurance and to improve their quality of life.

Several procedures can be used to strengthen weak or injured voices. The selection of the operation depends on the individual’s vocal condition as determined by a voice team evaluation, physical examination including strobovideolaryngoscopy, and consideration of what the person wants. Care must be taken to ensure that patient expectations are realistic. In most cases, surgery is directed toward bringing the vocal folds closer together so that they close more firmly. This eliminates the air leak between the vocal folds that occurs as a consequence of vocal atrophy from aging (atrophy or wasting of vocal nodules or other tissues) or as a result of paresis or paralysis (partial injury to a nerve from a viral infection or other causes). In some cases, the operation is done by injecting a material through the mouth or neck into the tissues adjacent to the vocal folds to “bulk up” the vocal tissues and bring the vocal folds closer together. This is called “injection laryngoplasty” and is performed usually using fat, collagen, or hydroxyapatite. This operation is sometimes done in the operating room under local anesthesia and, in selected patients, in the office with only local anesthesia. Alternatively, the problem can be corrected by performing a thyroplasty. This operation involves making a small incision in the neck. The skeleton of the voice box is entered, and the laryngeal tissues are compressed slightly using Gore-Tex or silastic implants. This procedure is generally done under local anesthesia with sedation. All of these procedures usually are performed on an outpatient basis.

Recovery usually takes days to weeks, depending on the procedure. Any operation can be associated with complications. Rarely, the voice can be made worse. The most likely complication is that voice improvement is not sufficient or that it does not last over time. When this problem occurs, it can be corrected by “fine tuning” through additional injections or surgical adjustment of the implant. Usually, satisfactory results are achieved the first time.

Voice rehabilitation through medical intervention and therapy/exercise training is appropriate for anyone who is unhappy with his or her vocal quality (so-called “voice lift surgery”) and is suitable for almost anyone who does not have major, serious medical problems (eg, end-stage heart disease) and is not on blood thinner medication that cannot be stopped safely for surgery, so long as that person has realistic vocal goals and expectations. “Voice lift” surgery should be thought of as a comprehensive program stressing medical diagnosis and physical rehabilitation, not as surgery alone.

Thyroplasty

Another excellent approach to medialization is type I thyroplasty. This procedure was popularized by Isshiki and colleagues in 1975, although the concept had been introduced early in the century by Payr . Thyroplasty is performed under local anesthesia. In classical thyroplasty, with the neck extended, a 4- to 5-cm incision is made horizontally at the midpoint between the thyroid notch and the lower rim of the thyroid cartilage. A rectangle of thyroid cartilage is cut out on the involved side. It begins approximately 5 to 7 mm lateral to the midline and is usually approximately 3 to 5 mm by 3 to 10 mm. The inferior border is located approximately 3 mm above the inferior margin of the thyroid cartilage. Care must be taken not to carry the rectangle too far posteriorly, or it cannot be displaced medially. The cartilage is depressed inward, moving the vocal fold toward the midline. The wedge of silicone is then fashioned to hold the depressed cartilage in proper position. Since Isshiki’s original description, many surgeons have preferred to remove the cartilage. Most preserve the inner perichondrium, although techniques that involve incisions through the inner perichondrium have been used successfully. Surgeons have used various other materials, including autologous cartilage, hydroxyapatite, expanded polytetrafluoroethylene, and titanium .

Various additional technical modifications have been proposed as this technique has become more popular, and several varieties of preformed thyroplasty implant devices have been introduced commercially. Many of these modifications have proven helpful, especially techniques that obviate the need to carve individualized silicone block implants, a technique that is often challenging for inexperienced thyroplasty surgeons. The silicone block modifications described by Tucker are also useful, particularly the technique of cutting out a portion of the prosthesis to allow for the placement of a nerve-muscle pedicle. We have generally abandoned all of these techniques except during revision cases in favor of Gore-Tex in the larynx as reported by Hoffman and McCulloch . Since then, several reports have documented its efficacy, and others are in preparation . Gore-Tex is easy to place and adjust and can be contoured to compensate for vocal fold bowing and a variety of irregular laryngeal configurations.

Our preferred technique is slightly different from procedures published previously.

Access Videos on Gore-tex Thyroplasty and on Post-op Thyroplasty One Year in online version of this article at: http://www.Oto.TheClinics.com .

One of the major advantages of Gore-Tex is that it can be placed through a minithyrotomy, obviating the need to traumatize or transect strap muscles. A 2-cm horizontal incision is made centered in the midline in a skin crease near the lower third of the vertical dimension of the thyroid cartilage. The cartilage is exposed in the midline, and the perichondrium is incised and elevated. A 4-mm diamond bur is used to drill a 4-mm minithyrotomy. Its anterior border is located approximately 7 mm from the midline in female patients and 9 mm from the midline in male patients, and its inferior margin is approximately 3 to 4 mm above the inferior border of the thyroid cartilage. The inner perichondrium is left intact. A fine elevator, such as a Woodson elevator or Sataloff Thyroplasty Elevator (Medtronics Xomed, Jacksonville, FL), is used to elevate the perichondrium posteriorly. It is important that minimal elevation be performed. A small pocket, only 2 to 3 mm in width, parallel to the inferior border of the thyroid cartilage is sufficient. This is substantially different from the extensive elevation performed during traditional thyroplasty. If the perichondrium is elevated excessively, it is difficult to control the position of the Gore-Tex. Any additional elevation is accomplished by the Gore-Tex during insertion. Gore-Tex is then layered through the thyrotomy incision and adjusted to optimize phonation. This procedure is performed under local anesthesia with sedation, and vocal fold position can be monitored by flexible laryngoscopy during the operation continuously during medialization or by checking the final position visually at the conclusion of the operation. Once Gore-Tex has been positioned optimally, it is cut a few millimeters outside the thyrotomy. For closure, some surgeons use perichondrial flaps that are repositioned and sutured. Alternatively, the thyrotomy can be filled with a few drops of cyanoacrylate, which forms a customized button-like seal with a small inner flange of cyanoacrylate, and with a wick of Gore-Tex in the center of the cyanoacrylate the cyanoacrylate block. This prevents extrusion of the Gore-Tex, and the cyanoacrylate “button” and Gore-Tex are removed easily when revision surgery is necessary by pulling on the end of the Gore-Tex that extends a few millimeters beyond the cyanoacrylate. Gore-Tex thyroplasty is so expeditious and atraumatic that it can be performed bilaterally at the same sitting. This is done commonly to treat vocal fold bowing from bilateral superior laryngeal nerve paresis and other causes and to treat presbyphonia refractory to voice therapy. Bilateral thyroplasties can be accomplished ordinarily in less than 1 hour. A small drain usually is placed at the conclusion of the procedure and removed on the first postoperative day. In many cases, the procedure is performed as outpatient surgery, although overnight observation is appropriate if there is vocal fold swelling or concern about airway compromise.

There have been no studies documenting the efficacy of the routine use of steroids or antibiotics in thyroplasty surgery. Many surgeons use both routinely. Sixty milligrams of prednisone taken the night before surgery can help to minimize intraoperative edema, improving the accuracy of implant placement and vocal fold medialization, and thus, the final voice outcome. In our practice, we have encountered only one infection after thyroplasty in over 20 years, and that was believed to be due to contaminated sutures recalled by the manufacturer shortly after that operation. Because a foreign body is implanted during thyroplasty, many surgeons prefer to give antibiotics prophylactically.

Revision thyroplasty is a more complex matter. Most thyroplasties that have required revision have been performed originally using a silastic block or one of the preformed, commercially available implants. During these initial operations, a large thyroplasty window was created, and perichondrium was elevated. Removing the silastic block and replacing it with Gore-Tex generally does not prove satisfactory. Gore-Tex position cannot be controlled well because of the postsurgical anatomy. In general, we prefer to revise such cases by carving a new silastic block or by modifying the prosthesis that had been placed originally. If revision is being performed because of insufficient medialization, it is sometimes possible to elevate the anterior aspect of the prosthesis and layer Gore-Tex medial to it. Such cases are uncommon. More often, it is necessary to incise the fibrotic capsule in the region of the inner perichondrium with an electric cautery (which often produces momentary discomfort for the patient) and to create a new prosthesis. The most common problems that require revision are undermedialization, resulting in persistent glottic insufficiency, excessive anterior medialization resulting in strained voice, excessively high placement of the original prosthesis, and inappropriate patient selection. Undermedialization can be corrected by underlaying Gore-Tex or creating a larger prosthesis as discussed previously or endoscopically by injecting fat or collagen. Excessive anterior medialization is corrected by reshaping the prosthesis. In such cases, the original implant is usually too thick and placed too far anteriorly. Excessively high placement is often associated with a cartilage window that is considerably higher than the desirable 3 to 4 mm above the inferior border of the thyroid cartilage. When additional cartilage is removed to place the prosthesis at the desired height, cartilage deficiency from the original operation often leaves the prosthesis unstable. In such cases, the implanted device should be secured to the thyroid cartilage by sutures. In fact, when using an implant other than Gore-Tex for primary or revision surgery, we secure the prosthesis to cartilage with Prolene sutures to prevent migration or extrusion.

Another common reason for revision is inappropriate patient selection. If there is a large, symptomatic posterior glottal gap, thyroplasty alone is often insufficient. Procedures to alter arytenoid cartilage position are necessary in many such cases. Failure to recognize this need and to perform the appropriate operation initially may lead to a need for revision surgery that includes arytenoid repositioning procedures. Apart from malposition of the implant, type I thyroplasty is generally uncomplicated. Successful thyroplasty improves vibratory function .

If thyroplasty is complicated by hemorrhage with superficial hematoma along the vibratory margin or by infection vocal fold stiffness with permanent dysphonia can result. Hemorrhage and edema also can produce airway obstruction. Weinman and Maragos reported on 630 thyroplasty procedures. Seven of their patients required tracheotomy. Five of 143 patients who underwent arytenoid cartilage adduction in association with thyroplasty required tracheotomy. In the experience of Weinman and Maragos, the median interval from surgery to tracheotomy was 9 hours, with five of the seven patients requiring airway surgery within 18 hours after thyroplasty . Although in most series airway obstruction has not been common, this complication and the need for tracheotomy are possible.

Occasionally, singers and actors inquire about surgery for pitch alteration. Laryngeal framework surgery has proven successful in altering pitch in specially selected patients, such as those undergoing gender reassignment surgery. These operations do not provide consistently good enough voice quality to be performed on a professional voice user for elective pitch change. In addition, considerably more than habitual fundamental frequency is involved in the perception of voice classification, and other important factors (such as the center frequency of the singer’s formant) are not modified by laryngeal surgery.

Indirect laryngoscopic surgery

Laryngoscopic surgery is generally performed through direct laryngoscopy. Indirect laryngoscopic surgery has been performed for many years and has value in some circumstances. It permits gross biopsy of lesions under local anesthesia; removal of selected foreign bodies; and injection of fat, collagen, and other substances. In patients who have cervical pathology whose neck does not flex or extend enough to permit rigid direct laryngoscopy, indirect laryngoscopic surgery may provide a safe alternative to external surgery.

For indirect laryngoscopic surgery, the patient is generally seated. Topical anesthesia is applied and may be augmented by regional blocks. The larynx is visualized with a laryngeal mirror, a laryngeal telescope, or a flexible fiberoptic laryngoscope. When surgery is performed solely for injection (eg, fat or collagen), an external or transoral technique may be used. External injection may be performed by passing the needle through the cricothyroid 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, about 7 to 9 mm above the inferior border of the thyroid cartilage. Transoral injection has been used more commonly ( Fig. 1 ), 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 laryngoscopic 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 of the need for an operating room procedure, and ready availability when delays in getting to a hospital and waiting for an operating room might cause serious problems. The procedure also has disadvantages. Precise control is not as good as that accomplished with microlaryngoscopy under sedation or general anesthesia, intraoperative loss of patient cooperation may result in injury, and the ability to handle complications such as bleeding and edema is limited. Nevertheless, at times the procedure is invaluable, and it should be in the armamentarium of the laryngologic surgeon.

( Left ) After topical anesthesia, the patient firmly holds his tongue extended while the mirror and indirect needle are positioned. ( Right ) The patient phonates a falsetto /i/as the needle is inserted for injection. Similar positions may be used for biopsy and foreign body removal. ( From Sataloff RT. Professional voice: the science and art of clinical care. 3rd edition. San Diego (CA): Plural Publishing, Inc.; 2006; with permission.)

Direct laryngoscopy

Suspension microlaryngoscopy is the standard technique for endoscopic laryngeal surgery. The concept of direct laryngoscopy was introduced by Green in 1852 using sunlight and supported later by Brünings . The history of phonomicrosurgery is reviewed in greater detail elsewhere . Many laryngoscopes are available. An instrument should be selected for each patient that provides excellent exposure of the vocal folds, internal laryngeal distension, and minimal distortion of the area of surgical interest.

In addition to choosing an appropriate laryngoscope, it is important to understand principles of suspension and of internal distention and external counterpressure. In most cases, the laryngoscope should provide visualization of only the entire vocal fold and should distend the false vocal folds and larynx in a way that optimizes visualization. Rarely, distension of the false vocal folds is not desirable, and a laryngoscope positioned in the vallecula (eg, the Lindholm; Karl Storz, Culver City, CA) provides an alternative. This is the exception rather than the rule. In addition to internal distention, external counterpressure is important. Gentle pressure over the cricoid cartilage often can produce dramatic improvement in laryngeal visualization through the laryngoscope. Traditionally, a resident, nurse, or anesthetist has been asked to provide the counterpressure. It is better to use 1 inch tape that extends from one side of the headrest of the bed to the other and holds steady pressure on the larynx, maintaining the desired position.

There can be a disadvantage to counterpressure. Although it improves visibility (especially anteriorly), it introduces laxity in the vocal folds that may distort slightly the relationships between pathology and normal tissue. Hence, an appropriate compromise must be achieved in each case to optimize visibility of the area of interest without introducing excessive distortion. Readers interested in additional information regarding counterpressure and the forces involved in laryngoscopy are advised to consult other literature .

Anesthesia