Laryngeal framework surgery topic presentation.pptx
- 1. Laryngeal Framework Surgery Dr Darpanarayan Satapathy JR, Dept of ENT & HNS SCBMCH, Cuttack
- 2. Introduction • Voice – identity of a person. Production of voice • Pulmonary reserve. • Resonance created in the nose , PNS, oral cavity and pharynx. • Movement of cord, shape , size and structural integrity of cord.
- 3. History • 1911- Brunnings , made the 1st attempt to medialize vocal fold by injecting paraffin. • 1915- Payr – pedicle flap of cartilage. • 1974- Isshiki –proposed different type of thyroplasty for different dysphonia. http://www.entandaudiologynews.com/
- 4. Definition (ELS 2001) • Open surgical external approach procedures performed on the laryngeal skeleton and the insertion of muscles to correct vocal fold positioning and tension. • Objective: improve the voice without directly intervening in the vocal folds.
- 5. Laryngeal framework • Cartilages • Ligaments • Membranes • Muscles
- 6. Cartilages
- 7. Thyroid cartilage • Most prominent cartilage • Two laminae • Thyroid notch • Superior and inferior cornua • Vocal fold lies closer to the inferior border of the thyroid cartilage
- 8. Muscles • The intrinsic muscles- • 1. adductors • 2.abductors • 3. tensor • Adductors – lateral cricoarytenoid, thyroarytenoid, interarytenoid. • Abductor – posterior cricoarytenoid • Tensor – cricothyroid
- 14. Approximation laryngoplasty Indications: - Symptomatic glottic insufficiency (dysphonia, aspiration). U/L vocal fold paralysis. Vocal fold atrophy, including age related atrophy. Vocal fold bowing due to ageing and cricothyroid joint fixation. Sulcus vocalis - Soft tissue defect resulting from excision of pathological masses. Contraindications: -Malignant disease overlying laryngotracheal complex. -Poor abduction of C/L vocal fold. -h/o radiation therapy to larynx.
- 17. Treatment options for unilateral VFP • Observation • Voice therapy • Surgical intervention • Injection augmentation • Laryngeal framework surgery • Re-innervation
- 18. Procedure Positioning Anasthesia- LA preferred Thyroid cartilage is palpated Midline is also marked on the chin, neck and sternal notch. Incision -horizontal with about 3-4 cm Thyroid cartilage widely exposed
- 20. Type 1 thyroplasty window
- 22. Implants
- 24. Cont.. Textbook of Laryngology – N K Narukar, A Roychoudhury
- 25. Complication • Penetration of endo-laryngeal mucosa - assess air leak before placement of implant in window. • Wound infection – Chondritis. • Airway obstruction – overnight monitoring is required. • Implant extrusion-Can become displaced and even extrude into the airway.
- 26. Limitation • Mechanical nature of the procedure. • Imparts only static change to laryngeal framework with no effect on dynamic function. • No effect on vocal fold muscle mass, innervation and mobility. • Closure of posterior glottis limited. • No effect on vocal fold level in vertical plane.
- 27. Adduction of arytenoid • Lower the vocal process • Stabilize and medialize the vocal process • Suture mimics TA-LCA muscle complex . Textbook of Laryngology – N K Narukar, A Roychoudhury
- 28. Indication of arytenoid adduction • Breathy voice, large glottic chink,fixed lateral paralysed high cord. • Disadvantage- Time consuming, difficult to locate muscular process of arytenoid, ineffective in bowing of cord.
- 34. Expansion laryngoplasty Indication - adductor spasmodic dysphonia( involuntary muscle spasms in the intrinsic muscles of larynx). Treatment options – botulinum toxin injection , recurrent nerve sectioning and expansion laryngoplasty
- 35. Type 2 thyroplasty – lateral approach • purpose of this procedure is to increase the transverse diameter of the thyroid cartilage, extending the glottic space.
- 36. Type 2 Thyroplasty – medial approach • Thyroid cartilage is split in the midline. • Split ala kept apart with the help of 3 mm sialastic shims or titanium miniplate. Catani GSA, Catani MEC, Kinasz LRS, et al. Laryngeal framework surgery. J Otolaryngol ENT Res. 2020;12(5):151 154 ‒
- 37. • Thyroarytenoid myomectomy- Transoral or open approach • Vocal cord abduction by suture method • Partial arytenoidectomy
- 38. Selective sectioning of adductor nerve branches
- 40. Woodman’s procedure • Technique similar to arytenoid adduction • Two holes drilled in posterior ala, suture threaded and phonatory attempt used to control extent of lateralisation.
- 41. Advantage and disadvantage of type 2 thyroplasty Advantages: Optimal glottal closure can be adjusted and readjusted - No damage of physiologic function - Reversible Disadvantages: Technically difficult Shim displacement Does not relieve cause of Spasmodic Dysphonia.
- 42. Relaxation laryngoplasty • Tension of the vocal folds reduced by antero-posterior shortening of thyroid ala. • Lowers the pitch.
- 43. Relaxation laryngoplasty (TYPE 3) • Indication – 1.Males with high pitch voice resistant to voice therapy.( Puberophonia/ Mutational falsetto) 2. Stiff VF with high pitched breathy voice. 3. Spastic dysphonia
- 45. Cont … Lateral approach : ( Type III) Thyroid ala is incised at about junction of anterior and middle one third, and 2-5 mm cartilage strip is excised.
- 47. Cont… • Medial approach: ( Anterior commissure retrusion) - Retrusion of the middle portion of the thyroid cartilage and leads to reduction in the length of vocal folds. • - Vertical incision was made either side of the midline of the thyroid cartilage.
- 48. Type 4 thyroplasty • Increases the vocal pitch. • It increases the distance between the vocal fold attachments and thus raise the tension of vocal fold. • Indications: Androphonia -Abnormally low pitched voice in female. • -Male to female trans-sexualism - Abnormallly lax or bowed vocal folds (presbyphonia)
- 49. Cricothyroid approximation • Cricothyroid Approximation : - increases vocal pitch by simulating the contraction of cricothyroid muscle with sutures. • The cricoid and thyroid cartilage is approximated as closely as possible. • Non absorbable monophilic sutures are placed to draw the cricoid and thyroid cartilages together.
- 52. A-P Lengthening of thyroid ala
- 54. Thank You