Phonosurgery Techniques

Phonosurgery Techniques: Basics - Voice Box Tune-Up

Surgery to restore/improve voice, preserving sphincter function & airway patency.

• Goals:
  • Improve/restore vocal function
  • Preserve glottic sphincter
  • Maintain airway patency
• Indications:
  • Benign lesions (nodules, polyps, cysts, Reinke's edema)
  • Vocal fold immobility (paralysis/paresis)
  • Vocal fold scar, sulcus vocalis
• Contraindications:
  • Poor general health; unrealistic expectations
  • Acute laryngeal inflammation
  • Non-compliance with post-op care
• Pre-op Evaluation:
  • Voice assessment (perceptual, acoustic, VHI)
  • Laryngoscopy, Stroboscopy (essential for mucosal wave)
  • Patient counselling

⭐ Stroboscopy is crucial for assessing vocal fold mucosal wave, guiding surgical planning in phonosurgery.

Phonosurgery Techniques: Microlaryngeal Surgery - Tiny Tools, Big Impact

• Principles: Endolaryngeal, microscopic visualization for precise lesion removal, preserving vocal fold structure & function. Goal: Restore voice quality.

• Instruments:

  • Operating microscopes.
  • Suspension laryngoscopes (e.g., Kleinsasser).
  • Long, delicate microinstruments: forceps, scissors, knives, suction.

• Techniques:

  • Microflap: For cysts, Reinke's edema. Incision, elevate flap, remove lesion, redrape flap.
  • Excision: Nodules, polyps. Precise removal, minimal tissue damage.
  • Reinke's Edema: Cordotomy, suction of gelatinous material, redrape mucosa. Avoid excessive removal.
  • ⚠️ Vocal fold stripping is avoided due to high risk of scarring & dysphonia.

⭐ High-Yield Fact: The microflap technique is preferred for intracordal lesions like cysts as it preserves the overlying mucosa, crucial for optimal vibratory function and voice outcome.

Phonosurgery Techniques: Framework & Fillers - Sculpting Sound

Alters VF structure/position for voice improvement.

• Laryngeal Framework Surgery (LFS): Modifies cartilages.

  • Thyroplasty (Isshiki Types):
    • Type I: Medialization (VF paralysis/atrophy).
    • Type II: Lateralization/Abduction (airway narrowing).
    • Type III: Shortening/Relaxation (↓ pitch, e.g., puberphonia).
    • Type IV: Lengthening/Tensioning (↑ pitch, e.g., VF bowing).
    • 📌 Mnemonic: MALT - Medialization, Abduction, Lengthening, Tensioning/Shortening.
  • Arytenoid Adduction: For posterior glottic gap.
  • Arytenoid Abduction: Widens glottis (bilateral abductor paralysis).

• Injection Laryngoplasty (IL): VF augmentation.

  • Indications: Glottic insufficiency, VF atrophy, sulcus vocalis, presbylarynx.
  • Materials:
    • Autologous Fat: Long-lasting, variable resorption.
    • Calcium Hydroxylapatite (CaHA): Durable, less resorption.
    • Hyaluronic Acid (HA): Temporary, diagnostic use.

⭐ Type I thyroplasty (medialization) is the most common surgical treatment for symptomatic unilateral vocal fold paralysis.

Phonosurgery Techniques: Post-Op & Pitfalls - Healing Harmonies

• Post-Op Care Essentials:
  • Voice Rest: Absolute for 3-7 days (microsurgery) or up to 2 weeks (framework). Then relative rest.
  • Hydration: Systemic and local (steam).
  • Anti-reflux: PPIs, lifestyle changes to prevent LPR.
• Voice Therapy Role: Indispensable post-op for vocal hygiene, technique optimization, functional recovery.
• Potential Complications:
  • Early: Hematoma, edema, infection.
  • Late: Granulation, anterior glottic web, scar, persistent dysphonia.

  ⭐ Anterior glottic web, a fusion of anterior vocal folds, is a serious complication often needing surgical division and stenting.

High‑Yield Points - ⚡ Biggest Takeaways

• Type 1 Thyroplasty (Medialization): For unilateral vocal cord paralysis, improves glottic closure.
• Arytenoid Adduction: Complements Type 1 for large posterior glottic gaps.
• Botulinum Toxin (Botox): Mainstay for adductor spasmodic dysphonia.
• Microlaryngoscopy: For excising benign vocal fold lesions (polyps, cysts, nodules).
• CO2 Laser: Offers precise dissection and minimal thermal damage in laryngeal surgery.
• Voice Therapy: Vital pre- and post-phonosurgery for optimal functional recovery.
• Injection Laryngoplasty: Augments insufficient vocal folds (e.g., with fat, hyaluronic acid).