Microlaryngoscopy
Endoscopic Cordectomy
Overview
Pre-procedure
Technique
Post-procedure
A myringotomy is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid or to drain pus from the middle ear.
A tympanostomy tube is inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks. Depending on the type of tube used, it is either naturally extruded in 6 to 12 months or removed during a minor procedure.
Those requiring myringotomy usually have an obstructed or dysfunctional Eustachian tube that is unable to perform drainage or ventilation in its usual fashion. Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe acute otitis media (middle ear infection).
There are numerous indications for tympanostomy in the pediatric age group, the most frequent including chronic otitis media with effusion (OME) which is unresponsive to antibiotics, and recurrent otitis media. Adult indications differ somewhat from the pediatric population and include Eustachian tube dysfunction with recurrent signs and symptoms, including fluctuating hearing loss, vertigo, tinnitus, and a severe retraction pocket in the tympanic membrane. Recurrent episodes of barotrauma, especially with flying, diving, or hyperbaric chamber treatment, may merit consideration.
Myringotomy is usually performed as an outpatient procedure. General anesthesia is preferred in children, while local anesthesia suffices for adults. The ear is washed and a small incision made in the eardrum. Any fluid that is present is then aspirated, the tube of choice inserted, and the ear packed with cotton to control any slight bleeding that might occur. This is known as conventional (or cold knife) myringotomy and usually heals in one to two days.
A new variation (called tympanolaserostomy or laser-assisted tympanostomy) uses CO2 laser, and is performed with a computer-driven laser and a video monitor to pinpoint a precise location for the hole. The laser takes one tenth of a second to create the opening, without damaging surrounding skin or other structures. This perforation remains patent for several weeks and provides ventilation of the middle ear without the need for tube placement.
Though laser myringotomies maintain patency slightly longer than cold-knife myringotomies (four weeks for laser and two to three days for cold knife without tube insertion) [9], they have not proven to be more effective in the management of effusion. One randomized controlled study found that laser myringotomies are safe but less effective than ventilation tube in the treatment of chronic OME.[10] Multiple occurrences in children, a strong history of allergies in children, the presence of thick mucoid effusions, and history of tympanostomy tube insertion in adults, make it likely that laser tympanostomy will be ineffective.
Various tympanostomy tubes are available. Traditional metal tubes have been replaced by more popular silicon, titanium, polyethylene, gold, stainless steel, or fluoroplastic tubes. More recent ones are coated with antibiotics and phosphorylcholine.
The placement of tubes is not a panacea. If the middle ear disease has been severe or prolonged enough to justify tube placement, there is a strong possibility that the child will continue to have episodes of middle ear inflammation or fluid collection. There may be continued drainage through the tube (tube otorrhea) in about 15% of patients for the first two weeks after placement, and in 30% beyond that. Otorhea is considered to be secondary to bacterial colonization. The most commonly isolated organism is Pseudomonas aeruginosa, while the most troublesome is Methicillin-resistant Staphylococcus aureus (MRSA). Some practitioners use topical antibiotic drops in the postoperative period, but research shows that this practice does not eradicate the bacterial biofilm.
Evidence suggests that tympanostomy tubes only offer a short-term hearing improvement in children with simple OME who have no other serious medical problems. No effect on speech and language development has yet been shown.
A basic knowledge of the anatomy and physiology of the nose and sinuses is necessary to understand nasal and sinus disorders.
The nose and sinuses are a part of the upper respiratory tract. The three-dimensional anatomy of this area is complex. The function of the nose in addition to smell is to warm, humidify and filter air that passes through it. The external nose consists of a bony and cartilaginous framework. The nostrils, or anterior nares, form the external opening to the nose. The nasal septum is a midline internal structure that separates the left and right nasal cavities. It is composed of cartilage and bone. A deviated nasal septum can cause nasal obstruction.
There are four sets of paired sinuses. The maxillary sinuses are located beneath the cheeks and under the eyes. The frontal sinuses are above the eyes behind the forehead. The ethmoids are honeycomb shaped sinuses located between the eyes and the sphenoid sinuses are located behind the nose and below the brain. Each of these sinuses is an enclosed space that drains through an ostium or opening into the nose. The sinuses are lined by mucosa that is similar to the lining of the nose. These ostia can become blocked by inflammation or swelling of the mucosa as well as by tumors or bony structures.
The lateral nasal wall internally contains the three turbinate bones. These scroll-like structures are covered in a mucous membrane that contains vascular channels which can swell under certain conditions, such as allergy or inflammation. The tear duct or nasolacrimal duct drains tears from the eyes into the nose where it enters beneath the inferior turbinate. Blockage of this duct from injury or disease causes excess tearing of the eye, or epiphora. The middle meatus is a space under the middle turbinate. Within the middle meatus is the osteomeatal complex which is the common pathway for the drainage of the maxillary (cheek) sinus, frontal (forehead) sinus, and anterior ethmoid sinus. Inflammation or swelling of these key areas may cause blockage of the sinuses.
The superior turbinate is a small structure located high in the nose. Behind the superior turbinate is the opening of the sphenoid sinus, located near the back portion of the septum. The pituitary gland is located directly above and behind the sphenoid sinus. Pituitary surgery is performed through the sphenoid sinus.
Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical treatment of sinusitis and nasal polyps, including bacterial, fungal, recurrent acute, and chronic sinus problems. Ample research supports its record of safety and success.
Telescopes with diameters of 4mm (adult use) and 2.7mm (pediatric use) and with a variety of viewing angles (0 degrees to 30, 45, 70, 90, and 120 degrees) provide good illumination of the inside of the nasal cavity and sinuses. High definition cameras, monitors and a host of tiny articulating instruments aid in identifying and restoring the proper drainage and ventilation relationships between the nose and sinus cavities. Cultures (putting abnormal sinus secretions into an incubator to check for bacteria and fungi) and biopsies (examining small bits of tissue under a microscope) can be easily obtained to yield valuable diagnostic information to guide postoperative therapy for optimal long term results.
All the sinuses can be accessed at least to some degree by means of this surgery: The frontal sinuses located in the forehead, the maxillary sinuses in the cheeks, the ethmoid sinuses between the eyes, and the sphenoid sinuses located in the back of the nasal cavity at the base of the skull.
Computed tomography (CT) navigation is a tool that may be used by surgeons to better correlate surgical anatomy with pre-operative CT imaging. A computer is used to identify the 3-dimensional location of a probe tip placed within the patient’s nose or sinuses. Bleeding, disease processes and anatomical variants among individuals can alter a surgeon’s view of landmarks during surgery. Hence, CT-navigational assistance in sinus surgery is used to improve anatomical identification and avoid damage to vital neighboring structures such as the brain and eyes.
Definitive proof that CT navigation improves outcomes and decreases complications is lacking.
Extreme care is required with this surgery due to the proximity of the sinuses to the eyes, optic nerves, brain and internal carotid arteries. However, these possible serious risks are rare occurrences and there are potentially many benefits from a well-performed endoscopic sinus surgery with appropriate indications. While a surgeon must have adequate training and experience to manage the procedure, endoscopic sinus surgery is one of the most common procedures performed day to day by the average ear, nose and throat specialist physician in private practice.
Tonsillectomy is a 3,000-year-old surgical procedure in which, traditionally, each tonsil is removed from a recess in the side of thepharynx called the tonsillar fossa. The procedure is performed in response to repeated occurrence of acute tonsillitis, obstructive sleep apnea, nasal airway obstruction, diphtheria carrier state, snoring, or peritonsillar abscess. For children, the adenoids are removed at the same time, a procedure called adenoidectomy, or tonsilloadenoidectomy, when combined. Adenoidectomy is uncommon in adults in whom the adenoids are usually vestigial.
Most recently, American Academy of Otolaryngology-Head and Neck Surgery Foundation has published clinical practice guidelines.The panel made a strong recommendation for:
The morbidity rate associated with tonsillectomy is 2% to 4% due to post-operative bleeding; the mortality rate is 1 in 15,000, due to bleeding, airway obstruction, or anesthesia complications.
A sore throat will persist approximately two weeks following surgery while pain following the procedure is significant and may necessitate a hospital stay.Recovery can take from 7 to 10 days and proper hydration is very important during this time, since dehydration can increase throat pain, leading to a vicious circle of poor fluid intake.
At some point, most commonly 7–11 days after the surgery (but occasionally as long as two weeks (14 days) after), bleeding can occur when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1%–2%. It is higher in adults, especially males over age 70 and three quarters of bleeding incidents occur on the same day as the surgery.Approximately 3% of adult patients develop significant bleeding at this time which may sometimes require surgical intervention.
Post-operative pain relief is subject to change. Traditionally, pain relief has been provided by relatively mild narcotic analgesics such as Acetaminophen with codeine, for milder pain, and stronger narcotic analgesics for more severe pain. Recently (January 2011), the FDA reduced the recommended total 24 hour dose because of concern about liver toxicity from the Acetominophen component. An alternative is the use of non-steroidal anti-inflammatory agents, themselves giving rise to concerns that their effect on platelets might increase the risk of post-operative bleeding.In turn, this has renewed interest in techniques other than traditional ‘extra-capsular excision’ in the hope that post-operative pain might be reduced.
Tonsillectomy appears to be more painful in adults than children, although there will be individual variations in response.
For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding fascia, a so-called ‘total’ , or extra-capsular tonsillectomy. Problems include pain and bleeding leading to a recent resurgence in interest in sub-total tonsillectomy or ‘tonsillotomy’ which was popular 60-100 years ago, in an effort to reduce these complications.The generally accepted procedure for ‘total’ tonsillectomy uses a scalpel and blunt dissection or electrocautery, although harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation by sutures, and the topical use of thrombin, a protein that induces blood clotting.
It has already been stated that the benefits of tonsillectomy for sore throat are controversial and time limited. Consequently, the main question of importance becomes whether or not the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. It appears that this may be the case although most observers agree that further time and study is required.
The scalpel is the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other techniques and a brief review of each follows:
Dissection and snare method: Removal of the tonsils by use of a forceps and scissors with a wire loop called a ‘snare’ was formerly the most common method practiced byotolaryngologists, but has been largely replaced in favor of other techniques. The procedure requires the patient to undergo general anesthesia; the tonsils are completely removed and the remaining tissue surface is cauterized. The patient will leave with minimal post-operative bleeding.
Electrocautery: Electrocautery uses electrical energy to separate the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400°C) may result in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.
Thermal Welding: A new technology which uses pure thermal energy to seal and divide the tissue. The absence of thermal spread means that the temperature of surrounding tissue is only 2-3 °C higher than normal body temperature. Clinical papers show patients with minimal post-operative pain (no requirement for narcotic pain-killers), zero edema (swelling) plus almost no incidence of bleeding. Hospitals in the US are advertising this procedure as “Painless Tonsillectomy”. Also known as Tissue Welding.
Carbon dioxide laser: Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils. The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in 2-5% of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are averse to outpatient procedures without sedation.
Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device. The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule.
A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.
Tympanoplasty can be performed through the ear canal (trascanal approach), through an incision in the ear (endaural approach) or through an incision behind the ear (postaurciular approach).
A graft may be taken to reconstruct the tympanic membrane. Common graft sites include the temporalis fascia and the tragus.
The surgery takes ½ to 1 hour if done through the ear canal and 2⅓ to 3 hours if an incision is needed. It is done under local or general anesthesia. It is done on an inpatient or day case basis and is successful 85-90% of the time.
A Mastoidectomy is a procedure performed to remove the mastoid air cells. This can be done as part of treatment for mastoiditis, chronic suppurative otitis media or cholesteatoma. In addition, it is sometimes performed as part of other procedures (cochlear implant). There are essentially 5 different types of Mastoidectomy:
Surgical microlaryngoscopy
Information for patients considering a microscopic surgery on their vocal folds
Microlaryngoscopy is a procedure that means the vocal folds are looked at in great detail with magnification. The magnification may be with a microscope, endoscope or by video enlargement. It is often accompanied by some additional procedure such as removal of a mass, swelling or tumor. Long delicate instruments or a laser may be utilized. It is sometimes performed in the office, though more typically it is performed in the operating room.
Before the surgery, a PARQ conference is held with you. This is an acronym for Procedures, Alternatives, Risks and Questions. It means your surgeon has discussed with you in full detail the reasons for going to surgery and that you are satisfied with those reasons. The surgeon generally needs to see you within a week or two prior to surgery since your problem may have changed, especially if there has been a long interval between the exam and a surgery. There is nothing quite like going to sleep, not needing surgery and getting charged a few thousand dollars for that brief sleep – I don’t think you even get a good dream out of it. You can go over any questions during this pre-surgery visit as well as again on the morning before surgery in the pre-surgery waiting area.
The main risks of the procedure are anesthesia, chipping a tooth, a sore or numb tongue, and a less-than-expected beneficial outcome. Other potential risks could be bleeding, infection, or breathing difficulties. If a laser is used, additional risks should be mentioned.
I will ask you to sign an informed consent form before going to surgery.
When microlaryngoscopy is performed in the operating room, it is usually done with the patient asleep. You may hear by phone from your anesthesiologist the night before or you may meet him/her the morning of surgery. You should tell them of any problems you have had in the past or any concerns you have about having anesthesia. In particular, if you have had trouble with nausea or vomiting in the past, your anesthesiologist may be able to adjust your medications to decrease the chance of stomach acid irritating your vocal folds as it comes back up.
In the preanesthesia area, you get to wear that famous “open back” gown. You will be there for about an hour answering many questions for the tenth or perhaps the twentieth time. You learn that you actually lead a very interesting life judging from the thickness of the stack of papers representing you in the medical record. From there, you leave your family and ride on your back, staring at the ceiling, to the operating room.
The operating room table is often pre-chilled (I warned you). You will be put to sleep with medicine through a vein and may have a mask on to breathe some oxygen while falling asleep. After you are asleep, your head is tipped quite far back. The surgeon sits at the head of the table, essentially above your head. An instrument called a laryngoscope is inserted through your mouth so the surgeon can see down your throat past the back of your mouth. The laryngoscope is a hollow metal tube that when placed in the proper position allows a direct view of your voice box. It pushes the teeth and the tongue out of the way. To protect your teeth from chipping, a rubber or plastic tooth guard is placed over your upper teeth. Your neck is extended so that the surgeon has a view straight down your throat from above. It is a bit like sword swallowing. Your eyes are closed and padded for protection.
If the laser is used, wet towels are placed over and cover your face completely to absorb the laser beam if inadvertently fired. The surgery is delicate and a bit tedious but not difficult. It may take about an hour to perform a typical surgery, though this varies a lot. Many types of procedures can be performed during a microlaryngoscopy. Some typical procedures would include using long (about 12 inches) delicate forceps to grasp and hold a nodule. Then microscissors are used to remove the bump.
Sometimes fluid is injected into the vocal fold to push a surface bump away from the underlying structures before it is cut. The laser may be used to vaporize an unwanted blood vessel. A tumor may be cut out with the laser. Scar tissue may be cut with a knife, fat may be implanted, the incision in the vocal fold may be left open, and in uncommon cases, it may be sewn shut. A biopsy or small sample may be taken to find out what disease is present. I cannot personally think of an occasion to strip a vocal fold. Use caution, if you hear that term. That procedure can cause more harm than good.
You wake up rather quickly and find yourself still in the operating room or in the recovery room. You stay in the recovery room until the nurses and anesthesiologist are certain the majority of the anesthetic is gone from your system. You then return to the day surgery area where you started. When you can stand steadily, keep liquids down without nausea or vomiting and can go to the bathroom (essential human activities) you may go home. The whole process takes up a good part of the day.
Typically there is minimal pain after surgery. Since this varies from person to person and procedure to procedure, I prescribe Vicodin. Vicodin is essentially Tylenol and a narcotic, hydrocodone. For some, this is a less nauseating option than codeine. This may be used for either throat pain or for a throat tickle or cough. Many find that Tylenol is sufficient for the pain. An over the counter option for cough is dextromethorphan. It is the DM in medications such as Robitussin DM. There are extensive options for management of pain.
These are my particular inclinations and I vary them depending on what I am doing on the voice box and what the vocal needs are of the patient. Expect a wide variation in recommendations from myself as well as others.
Cordectomy involves removal of the entire membranous vocal fold with the vocalis muscle. The inner perichondrium of the thyroid cartilage can be included and the arytenoids cartilage can also be removed, either partially or completely.[1]Cordectomy via thyrotomy is the oldest surgical procedure for the treatment of early glottic carcinoma.[2] It remains the standard by which all other surgical treatments of small glottic cancers are measured.[1]
In 1908, Citelli introduced the so called cordectomy externa through thyrofissure.[3, 4] Chevalier Jackson described total cordectomy to treat patient with airway obstruction from bilateral vocal folds inability (1922) but the procedure was hampered by the resultant poor voice quality.[5] In 1932, Hoover published the results with similar approach through laryngofissure.[6]
An important new concept was the submucosal dissection, which later became a standard. The preservation of the overlying mucosal allowed primary wound closure. Surjan further improved the concept of the submucosal approach through laryngeal fissure.[7, 4] Dennis and Kashima described posterior cordectomy for the treatment of bilateral vocal folds inability in 1989.[8, 9]
Images depicting cordectomy can be seen below.
Diagram showing the incision line (blue dotted line) for right posterior cordectomy in cases of bilateral abductor paralysis.
Diagram showing the result of right posterior cordectomy in cases of bilateral abductor paralysis.
Diagram showing the result of right posterior cordectomy in cases of bilateral abductor paralysis.
Vocal cord cordectomy is indicated in the treatment of the following:
Cordectomy is contraindicated in the following cases:
Endoscopic laser surgery is contraindicated if general anesthesia is a threat to the patient’s life, such as in the following cases:
But, an increased risk is justified in patients with suspected malignancy.[10]
Endoscopic laser surgery is not possible in patients with the following conditions:
Cordectomy can be performed by the following 2 methods depending on the indication:
A classification of laryngeal endoscopic cordectomies was first proposed by European laryngology society in 2000.The classification described 8 types of cordectomies, as follows:[11, 12]
This classification did not propose any specific management for the lesions arising from the anterior commissure, which are being included among the indications for type Va cordectomy. To solve this problem, new cordectomy, encompassing the anterior commissure and anterior part of vocal cord, was proposed by European laryngology society working committee on nomenclature. This is classified as type VI.
Type VI is indicated for cancer originating in the anterior commissure involving one or both the vocal cords, without infiltrating the thyroid cartilage.[11]
European Laryngological Society classification allows one to define and clearly distinguish the extent of excision, which facilitates making meaningful comparisons between vocal outcomes after different types of cordectomy.
Atropine is always included in premedication. Anesthesia is induced by intravenous injection of barbiturates or by application of gas mixture via a mask. Relaxation is usually achieved by a bolus of succinyl choline. A long term relaxant is preferred for cordectomy. The anesthetic usually consists of gas mixture such as halothane, nitrous oxide and oxygen.[10] For more information, see general anesthesia.
EquipmentThe correct position is essential for the optimal introduction of laryngoscope. The patient should preferably lie horizontally flat on operating table, with neither head ring nor sand bag under the shoulders. The dental plate is put in place before the laryngoscope is introduced.[10]
The procedure begins with the orotracheal intubation with a laser-safe endotracheal tube. The patient’s eyes are then taped and padded and a head drape and upper tooth guard is applied.[14] When the patient is fully relaxed and sufficiently anaesthetized, a largest possible laryngoscope is introduced to get a good view of larynx.[10]
Before introducing the laryngoscope, the patient’s head is fully extended, and the laryngoscope is introduced between the endotracheal tube behind and lower jaw in front. Under visualization, laryngoscope is gently pushed forwards following the endotracheal tube between the epiglottis and the tube until the point reaches the petiole of epiglottis. If laryngoscope is passed too deeply into the larynx, both the vestibular fold and vocal folds are displaced laterally, whereas if the scope is not passed deeply enough the vestibular folds obscure the vocal cords. Once the laryngoscope is correct position, the chest holder is put in place to fix the scope in position. After exact adjustment of the scope, both vocal cords can be seen as far as the apex of vocal process. Once the laryngoscope is in the desired position, the light carrier is removed and an operating microscope is used.[10]
The patient’s head and face are protected with moist towels and the operating microscope, which is fitted with a microspot carbon dioxide laser and 400 mm lens is brought into position. To protect the endotracheal tube cuff, a moist cottonoid sponge is placed in the subglottis. Dissection is begun posteriorly and laterally. Medial retraction of the edge of the lesion shows the plane of dissection as the surgeon dissects anteriorly and inferior edge is resected at the end. A curved trajectory that parallels the contour of the normal vocal fold is used, and the depth of the excision is tailored to the lesion.[14]
The 30º or 70º angle telescope introduced through laryngoscope can be used with the advantage of examining the laryngeal surface of epiglottis, lateral wall of larynx, and subglottic space.[10]
A brief description of different types of cordectomies is given below.[11, 12, 13]
Type I: Subepithelial cordectomyThis involves the resection of vocal fold epithelium, passing through the superficial layer of the lamina propria. It is performed for premalignant lesions and lesions that show malignant transformation. Usually entire vocal cord epithelium is resected and in rare cases, clinically normal epithelium may be preserved. Since subepithelial cordectomy ensures histopathological examination of entire vocal cord, the main role of this surgical procedure is diagnostic. This procedure can also be therapeutic if histological results confirm hyperplasia, dysplasia, or carcinoma in situ without signs of microinvasion.
Type II: Subligamental cordectomyThis is indicated for cases of microinvasive carcinoma or severe carcinoma in situ with possible microinvasion. In this procedure vocal cord epithelium, Reinke space, vocal ligament are resected by cutting between the vocal ligament and vocalis muscle. The resection may extend from the vocal process to the anterior commissure and vocalis muscle is preserved as much as possible.
Type III: Transmuscular cordectomyThis procedure is indicated for small superficial lesions of the mobile vocal folds that reaches the vocalis muscle and without deeply infiltrating it. This involves the resection of epithelium, lamina propria and the part of vocalis muscle. The resection may extend from the vocal process to the anterior commissure. In some cases, partial resection of the ventricular fold may be required for adequate visualization of the vocal fold
Type IV: Total or complete cordectomyThis procedure is indicated for T1a lesions infiltrating the vocalis muscle. The resection extends from the vocal process to the anterior commissure and attachment of vocal ligament to the thyroid cartilage should be cut. The depth of the surgical margins reaches the internal perichondrium of the thyroid cartilage and sometimes perichondrium is included with resection.
Type Va: Extended cordectomy encompassing the contralateral vocal foldThis surgical approach was meant to include the anterior commissure and, depending on the extent of tumor, either a segment or the entire contralateral vocal fold. This procedure is now replaced by type VI cordectomy.
Type Vb: Extended cordectomy encompassing the arytenoidsThis procedure is indicated for vocal fold carcinoma involving vocal process or arytenoid cartilage posteriorly. For this type of resection, arytenoid cartilage should be mobile, and the cartilage is partially or fully resected.
Type Vc: Extended cordectomy encompassing the ventricular foldThis procedure is indicated for ventricular cancers or trans glottis cancers that spread from vocal fold to the ventricle. This involves the resection of ventricular fold and Morgani’s ventricle.
Type Vd: Extended cordectomy encompassing the subglottisThis procedure can be used for selected cases of T2 carcinoma with limited subglottic extension without cartilage invasion.
Procedure of type VI cordectomyThis procedure is indicated for cancer originating in the anterior commissure involving one or both the vocal cords, without infiltrating the thyroid cartilage. The surgery comprises anterior commissurectomy with bilateral anterior cordectomy. If the tumor is in contact with cartilage, resection can encompass anterior part of thyroid cartilage. Resection of the anterior commissure may include the subglottis mucosa and cricothyroid membrane, because cancers of anterior commissure tend to spread toward the lymphatic vessels of the subglottis.
The pharynx and teeth should be checked for damage before extubating from anesthesia.
Laryngofissure with cordectomyOpen cordectomy has been used in the surgical management of glottis malignancies with good cure rates. It can be used in patients with T1 lesions who are not amenable to laser cordectomy because of inadequate endoscopic visualization. After a preliminary tracheotomy, a horizontal skin crease incision is made at the middle part of the larynx. Subplatysmal flaps are elevated, and strap muscles are separated along the midline and larynx is exposed. Thyroid cartilage is examined for any signs of invasion. The perichondrium of the thyroid cartilage is elevated in the midline and elevated slightly to both side and thyroid cartilage is cut in the midline.[14]
If the anterior commissure is involved, the vertical thyrotomy incision is made off-center on the uninvolved side. After opening the larynx, the tumor is identified and involved cord is resected with a 1-2 mm mucosal margin. In rare cases, small lesions on both vocal cords can be resected simultaneously by this technique.[1]
For cases requiring superficial cordectomy, no reconstruction is required to achieve a good postoperative voice. If the surgical resection extends deeply in to the thyroarytenoid muscle or to the inner perichondrium, false vocal cord tissue may be swung down to fill the defect. The thyrotomy is closed with interrupted 3-0 Vicryl sutures.[14]
Posterior cordectomy for bilateral abductor palsyUsing carbon dioxide laser, 3.5-4 mm C-shaped wedge of posterior vocal cord is excised from the free border of the membranous cord, anterior to the vocal process, extending 4 mm laterally over ventricular band. Excision should be done anterior to the vocal process and cartilage should not be exposed. This surgical resection creates 6-7 mm transverse opening at the posterior larynx.[15]
Some authors recommend simultaneous bilateral posterior cordectomy for the management of bilateral abductor palsy.[16]
Post-ProcedureComplications of endoscopic cordectomies are as follows:[10]
Endoscopy under general anesthesia should be carried out at least every 2 months for first two years after surgery and with decreasing frequency in the subsequent years.
Adjunctive phonosurgical treatment is not required after type I and II cordectomy because postoperative conversational voice obtained after a standard voice therapy protocol and vocal hygiene, including voice rest for at least 2 weeks after surgery. For type III cordectomy, Eckel et al recommends a primary intracordal autologous fat injection at the end of the endoscopic resection.[13] A potential shortcoming of this technique is the variable resorption rate of the injected fat. Some authors prefer to perform phonosurgical voice rehabilitation only following a disease-free interval of at least 6 months to 1 year. In patient with types IV and V cordectomy, a wider glottic gap usually reduces the possibility of good glottic closure, and the fibrotic nature of the neocord prevents any mucosal wave. These patients can be treated after one year by appropriate phonosurgical procedures.[13]
Most important prerequisite for endoscopic management of laryngeal tumors is ensuring adequate patient compliance to a compulsive postoperative follow-up.[13]
Postoperative careOverview
Pre-procedure
Technique
Post-procedure
A myringotomy is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid or to drain pus from the middle ear. A tympanostomy tube is inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks. Depending on the type of tube used, it is either naturally extruded in 6 to 12 months or removed during a minor procedure.
Those requiring myringotomy usually have an obstructed or dysfunctional Eustachian tube that is unable to perform drainage or ventilation in its usual fashion. Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe acute otitis media (middle ear infection).