Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

Chapter 37
Phonomicrosurgery for Benign Vocal Fold Lesions
307
A
A2
B
B2
C
C2
Figure 37-3. Comparisons of preoperative views of the lesion and postoperative views after microfl ap surgery with 0-, 30-, and 70-degree tele-
scopes. A, Preoperative view with a 0-degree scope. A2, Postoperative view with a 0-degree scope. B, Preoperative view with a 30-degree scope.
B2, Postoperative view with a 30-degree scope. C, Preoperative view with a 70-degree scope. C2, Postoperative view with a 70-degree scope.

308
Section 3
Larynx
A
B
Figure 37-4. A, Mucosal incision at the junction of vocal fold
pathology and the superior surface of the vocal fold. B, Cordotomy
at the lateral aspect of the lesion with a sickle knife.
A
B
Figure 37-5. A and B, Developing a plane with a blunt dissector
between the lesion and deeper tissues.
Figure 37-6. Removal of the lesion and redundant mucosa.
restrictions on the following activities: talking, whisper-
ing, whistling, straining, Valsalva maneuvers, coughing,
and sneezing. On completion of strict voice rest, rigid
stroboscopy should be performed to evaluate the level
of healing of the vocal fold surgical site. If there is ade-
quate epithelial coverage, the patient is transitioned to
light voice use (relative voice rest), usually defi ned as 5
to 10 minutes of breathy, “airy” voicing per hour. The
quantity of voice use is then increased over the subse-
quent weeks, often with the help of a speech-language
pathologist.
Patients should continue taking refl ux medications
after surgery to aid in the healing process. Proper hydra-

Chapter 37
Phonomicrosurgery for Benign Vocal Fold Lesions
309
Figure 37-7. Microfl ap redraped over the operative site.
Figure 37-8. Truncation of a vocal fold polyp (dashed line).
tion is strongly recommended. Continued smoking ces-
sation after surgery is important for maximal healing.
COMPLICATIONS
Complications of phonomicrosurgery range from the
actions taken to achieve adequate exposure, to techni-
cal surgical points, to untoward vocal outcomes. The
potential for injury to the teeth increases when the
patient has poor dentition or multiple missing teeth
and when diffi culty is encountered in gaining exposure
of the larynx. Frequently, these patients can be detected
before surgery. If a dental injury does occur, it should
be promptly repaired to the patient’s satisfaction to
minimize negative feelings toward the surgeon and
anesthesiologist. Injury to the lingual nerve (numbness
of the tongue, change in taste sensation) occurs in
approximately 10% to 20% of patients. These symptoms
are transitory and due to pressure from the laryngo-
scope, and they usually resolve within 4 weeks.
There is a 1% to 2% risk of no voice improvement
after phonomicrosurgery, in addition to a 1% to 2% risk
of the voice becoming worse after surgery. This is often
due to poor wound healing with scar formation. If
surgery requires deeper dissection into the vocal liga-
ment, scar formation is likely. There is currently no
cure for vocal fold scarring, so inadvertent disruption
of tissues deep to the superfi cial lamina propria is dis-
couraged unless mandated by the pathology. If the
microfl ap is not appropriately draped over the surgical
wound and therefore does not adhere to the vocal fold,
epithelial ingrowth deep to the microfl ap will occur.
Surgical excision of the microfl ap is then required.
Microfl ap necrosis and fl ap death can occur with exces-
sive edema and trauma.10 Accordingly, the fl ap must
always be treated with great care. If microfl ap necrosis
does occur, the vocal fold will adequately heal on its
own, but it will take longer. Signifi cant postoperative
stiffness (scarring) can be treated with several monthly
submucosal steroid injections in an attempt to modify
the wound-healing process.
PEARLS
• Laryngeal examination with a rigid videostroboscope
provides valuable information about the possible
type and depth of benign vocal fold lesions.
• Preoperative voice care in the form of voice therapy
and counseling for surgery is paramount in
providing the patient with realistic expectations and
to promote proper wound healing.
• Clear understanding of vocal fold anatomy is
needed to perform precise microfl ap surgical
dissection.
• Close collaboration with the anesthesia team,
proper patient positioning, adequate laryngeal
exposure, and proper instrumentation are vital for
success.
• Postoperative voice rest, vocal restrictions, and voice
therapy are important steps in recovery.
PITFALLS
• Imprecise dissection into the deeper layers of the
vocal fold (vocal ligament and muscle) will lead to
scar formation and worse vocal outcomes.
• Phonotrauma immediately after surgery will lead to
scarring.
• Dental injuries do occur, often as a result of poor
dentition or improper placement of the laryngoscope.
• Worsening of voice after surgery or no voice
improvement (1% to 2% of patients for each) is a
real risk and must be discussed frankly
preoperatively.
• Rushing a patient to surgery before thorough
evaluations by a physician and speech therapist is a
disservice to the ultimate care of the patient and
may downgrade the outcome of the procedure.

310
Section 3
Larynx
References
1. Hirano M: Structure and vibratory behavior of the vocal fold. In
Sawashima M, Cooper F (eds): Dynamic Aspects of Speech Pro-
duction. Tokyo, University of Tokyo, 1977, pp 13-30.
2. Verdolini K, Rosen CA, Branski, R: Classifi cation Manual of Voice
Disorders. Mahwah, NJ, Lawrence Erlbaum Associates, 2005, pp
36-56.
3. Belafsky PC, Postma GN, Koufman JA: Validity and reliability of
the refl ux symptom index (RSI). J Voice 16:274-277, 2002.
4. Belafsky PC, Postma GN, Koufman JA: The validity and reliability
of the refl ux fi nding score (RFS). Laryngoscope 111:1313-1317,
2001.
5. Rosen CA, Andrade Filho PA, Scheffel L, Buckmire RA: Oropha-
ryngeal complications of suspension laryngoscopy: A prospective
study. Laryngoscope 115:1681-1684, 2005.
6. Zeitels SM, Hillman RE, Desloge R, et al: Phonomicrosurgery in
singers and performing artists: Treatment outcomes, manage-
ment theories, and future directions. Ann Otol Rhinol Laryngol
Suppl 190:21-40, 2002.
7. Zeitels SM, Vaughan CW: “External counterpressure” and “inter-
nal distention” for optimal laryngoscopic exposure of the ante-
rior glottic commissure. Ann Otol Rhinol Laryngol 103:669-675,
1994.
8. Sataloff RT, Spiegel JR, Heuer RJ, et al: Laryngeal mini-microfl ap:
A new technique and reassessment of the microfl ap saga. J Voice
9:198-204, 1995.
9. Courey MS, Garrett CG, Ossoff RH: Medial microfl ap for excision
of benign vocal fold lesions. Laryngoscope 107:340-344, 1997.
10. Rosen CA, Villagomez VJ: A Unique complication of microfl ap
surgery of the vocal fold. Ear Nose Throat J 80:623-624, 2001.

Chapter 38
Bilateral Vocal Fold Immobility
Libby J. Smith and Clark A. Rosen
Bilateral vocal fold immobility (BVFI) is not a common
condition. Patients usually have symptoms of airway
insuffi ciency, such as stridor and dyspnea, with a normal
or nearly normal voice. This is in contrast to patients
with unilateral vocal fold immobility, who usually com-
plain of a breathy voice and aspiration. BVFI includes
immobility from both neurogenic causes and mechani-
cal fi xation of the cricoarytenoid (CA) joints.
Bilateral vocal fold paralysis (BVFP) may be due to
(1) iatrogenic injury to the recurrent laryngeal nerve
(e.g., thyroidectomy, anterior cervical disc surgery,
carotid endarterectomy, esophageal surgery), (2) pro-
gressive neurologic disorders (e.g., amyotrophic lateral
sclerosis, Shy-Drager syndrome, syringomyelia, Guillain-
Barré syndrome), and (3) idiopathic causes. Mechani-
cal fi xation of the CA joints causing BVFI may be due
to (1) fi xation of the CA joint secondary to radiation
therapy, rheumatoid arthritis and other connective
tissue disorders, and benign infi ltrative disorders such
as amyloidosis, granulomatous diseases, and trauma
and (2) posterior glottic stenosis (PGS).
Correctly identifying the cause of BVFI and BVFP
is critical in guiding treatment and shaping the expecta-
tions of both the patient and surgeon. The aim of treat-
ment is to improve the airway while minimizing adverse
effects on the voice.
PATIENT SELECTION
Patients with BVFI usually demonstrate symptomatic
airway obstruction and often already have a tracheos-
tomy and want to be decannulated. Contraindications
to treating BVFI, other than performing a tracheos-
tomy, are the presence of aspiration or a rapidly pro-
gressive neurologic disorder. Relative contraindications
to treating PGS are compromised pulmonary status,
uncontrolled diabetes, and previous radiation therapy.
Unrealistic expectations on the part of the patient are
a relative contraindication to treating all types of BVFI.
Patients must understand and accept that to improve
their airway, the quality of their voice may be adversely
affected. Patients should also expect to have worse vocal
quality at the expense of an improved airway. Such
counseling needs to be frank and well documented. A
patient who is unwilling to accept any decrease in vocal
function should be considered for tracheostomy and
not glottic enlargement surgery. In addition, the patient
should understand that multiple procedures might be
necessary to optimize the airway with the least potential
impact on the voice. This allows the surgeon to enlarge
the glottic airway in a staged, conservative fashion,
which hopefully will minimize the negative impact on
the voice.
PREOPERATIVE EVALUATION
It is diffi cult to distinguish between BVFP and BVFI by
physical examination alone. A detailed history aids in
narrowing the differential diagnosis, but additional
studies are usually necessary.
Laryngeal electromyography of both the right and
left thyroarytenoid–lateral cricoarytenoid (TA-LCA)
muscle complexes is useful to determine the cause of
BVFI. If BVFP is present, there will be evidence of sig-
nifi cant neurologic injury, with or without partial recov-
ery. If the neurologic pattern shows a new injury with a
chance of recovery, delaying destructive surgery is
prudent.1 The authors advocate that in an attempt to
preserve the voice, surgery should involve the vocal fold
with the worse neurologic status. This may improve
voice outcomes by not altering the vocal fold that has
best neurologic status and thus better muscle tone.
Patients with BVFI and PGS, in contrast to those with
BVFP, will have normal neurologic activity of the TA-
LCA muscle complexes.
Manual palpation of both CA joints, either in the
offi ce2 or in the operating room, can further help detect
the cause of BVFI and assist in guiding surgical plan-
311

312
Section 3
Larynx
ning. When both joints are impaired, palpation can
determine the CA joint with the least range of motion.
This is the optimal side for static, glottic enlargement
surgery.
PREOPERATIVE PLANNING
Imaging studies are important in evaluating a patient
with idiopathic vocal fold immobility. Enhanced com-
puted tomography (CT) or magnetic resonance imaging
(MRI) of the skull base, neck, and upper part of the
chest can help identify the site of a lesion (brain stem,
vagus nerve, or recurrent laryngeal nerves). Enhanced
CT with fi ne cuts through the larynx is used to evaluate
the CA joint for abnormalities or, in the case of PGS,
the extent of stenosis, which may change the type of
surgical intervention. Arytenoid subluxation or disloca-
tion may also be identifi ed. MRI of the brain is needed
when brain or brain stem causes are suspected, such as
stroke or Arnold-Chiari malformation.
Swallowing studies are crucial in patients who com-
plain of dysphagia. Because the incidence of aspiration
is high after many types of surgery to improve the
airway, more conservative surgery or tracheostomy may
be most appropriate for patients with dysphagia or
tenuous swallowing ability.
SURGICAL APPROACHES
Bilateral Vocal Fold Immobility
Surgical treatment of BVFI involves static enlargement
of the glottic airway. A stepwise approach to create an
adequate airway may be prudent. The surgeon must
integrate the patient’s comorbid problems into the sur-
gical decision-making process. In general, patients with
rapidly progressive neurologic disorders or other serious
comorbid conditions tend to be best treated with a tra-
cheostomy. Most other causes of BVFI can be treated
with conservative endoscopic techniques. Transverse
cordotomy and medial arytenoidectomy procedures are
ideal conservative options because the airway is enlarged
with fewer detrimental effects on vocal quality3 than
occur with external and total arytenoidectomy proce-
dures. Total arytenoidectomy creates a larger posterior
airway but is more likely to lead to aspiration and a
substantive decrease in vocal quality. Endoscopic suture
lateralization is useful as a temporary measure when
there is no loss of mucosa in the posterior glottis.
External (open) arytenoidectomy is reserved for patients
in whom endoscopic procedures have failed or are
impossible because of anatomic limitations. Treatment
of PGS may be achieved by endoscopic or open tech-
niques and consists of lysis of the interarytenoid syn-
echiae, creation of a microtrapdoor fl ap, or the
techniques mentioned earlier. If the patient already has
a tracheostomy before arytenoid surgery, it should
remain in place until a proper capping trial for decan-
nulation can be conducted, approximately 6 weeks after
surgery.
Palpation of the Cricoarytenoid Joint
Palpation of the CA joint is performed by placing a
sturdy instrument adjacent to the vocal process and
pushing laterally. An instrument such as an Abrams
cannula can be used if the patient is awake. A blunt
laryngeal elevator or large cup forceps can be used to
palpate the joint while the patient is under general
anesthesia. Both CA joints are evaluated to compare the
degree of effort required to displace the vocal process
and the speed of medial tissue recoil. If one CA joint
displays better movement, surgery is initially performed
on the contralateral (worse) side. If the interarytenoid
region moves during this maneuver, PGS is probably
present.
Securing the Airway
The patient’s airway is secured by intubation with a
laser-safe endotracheal tube (ETT) if appropriate,
placement of a tracheostomy, or jet ventilation. The
method of airway maintenance is determined by the
severity of the patient’s airway restriction, comorbid
conditions, and the surgery to be performed.
Tracheostomy
Tracheostomy is a reasonable option for patients with
BVFI, especially those with dysphagia or rapidly pro-
gressive neurologic disease, as well as for patients who
do not want decreased vocal function (see Chapter
68).
Transverse Cordotomy
Transverse cordotomy (posterior cordectomy) was
described by Dennis and Kashima in 19894 as a more
conservative surgery than total arytenoidectomy. The
patient is intubated with a 5.0 or 5.5 laser-safe ETT if a
preexisting tracheostomy is not present. The laryngo-
scope is suspended and angled toward the operative
side. Usually, the ETT can be placed in the posterior
glottis to allow exposure of the vocal process on the side
to be operated. Alternatively, the ETT can be placed
anterior to the laryngoscope or jet ventilation can be
used. CO2 laser precautions are implemented, includ-
ing placement of a saline-soaked pledget in the subglot-
tis to prevent disruption of the ETT cuff. A typical CO2
laser setting of 4 watts, superpulse, with a small (0.25 to
0.4 µm) spot size minimizes collateral thermal damage.
After confi rming the location of the vocal process, an
incision is made just anterior to it. Care is taken to not
expose the arytenoid cartilage to avoid the formation
of a granuloma. The cordotomy extends across the
entire width of the true vocal fold and completely sepa-
rates the vocal fold from the vocal process. The incision
may also include the medial 3 to 4 mm of the false vocal
fold (Fig. 38-1). Hemostasis is achieved with the laser,
suction cautery, or bipolar cautery. Endoscopic evalua-
tion with a 30-degree telescope should confi rm that the
cordotomy is fl ush with the wall of the subglottis later-
ally. The application of topical mitomycin C (0.5 mg/
mL) to the wound for 5 minutes is an optional adjunc-

Chapter 38
Bilateral Vocal Fold Immobility
313
tive treatment in an attempt to decrease fi broblast for-
mation and scar tissue at the operative site. Four percent
lidocaine spray is used at the end of the procedure to
minimize postoperative laryngospasm.
Medial Arytenoidectomy
In 1993, Crumley and colleagues described a more con-
servative version of total arytenoidectomy.5 The patient
is intubated with a laser-safe 5 or 5.5 endotracheal tube.
Laser safety precautions are implemented. CO2 laser
ablation of the most medial 2 to 3 mm of the body of
the arytenoid cartilage results in enlargement of the
posterior glottic airway. The vocal process and intra-
arytenoid mucosa should not be disturbed (Fig. 38-2).
The amount of arytenoid cartilage obliterated is guided
by the degree of airway compromise and tissue reaction.
Initially, it is prudent to be conservative in resection in
case the patient might require a contralateral medial
arytenoidectomy or airway enlargement surgery in the
future. This must be discussed before surgery. Hemo-
stasis is achieved with the laser or epinephrine-soaked
(1 : 10,000 concentration) pledgets. Application of
mitomycin C is optional. Laryngotracheal anesthesia
with 4% lidocaine is used to minimize postoperative
laryngospasm.
Total Arytenoidectomy
The classic total arytenoidectomy procedure was
described by Ossoff and associates in 1983.6 The same
initial steps are taken as with the medial arytenoidec-
tomy procedure. Continuous CO2 laser ablation of the
entire body of the arytenoid is achieved by removing
cartilage until the defect is fl ush with the wall of the
cricoid ring (posteriorly and laterally) (Fig. 38-3). This
can be verifi ed with a 70-degree telescope. There is no
reason from an airway standpoint to remove more of
the arytenoid than what is within the cricoid ring. The
laser and epinephrine-soaked pledgets (1:10,000 con-
centration) are used to achieve hemostasis, and applica-
tion of mitomycin C is optional. Laryngotracheal
anesthesia with 4% lidocaine is used to minimize post-
operative laryngospasm.
Endoscopic Suture Lateralization
This procedure is based on the technique of Lichten-
berger and Toohill.7 It is used as a temporizing measure
in patients with early symptomatic BVFP who have an
uncertain prognosis for recovery. Endoscopic suture
lateralization should not be carried out if the patient
has suffered recent trauma to the posterior glottis from
an ETT or is currently intubated. Under microscopic or
telescopic visualization, an endoextralaryngeal needle
carrier device is loaded with 2-0 Prolene suture. The
needle is pushed through the skin and larynx, just ante-
rior and below the vocal process of the most medialized
vocal fold. The suture is secured outside the neck. The
Figure 38-1. CO2 laser incision extending laterally to the cricoid
ring for transverse cordotomy.
Figure 38-2. Defect after medial laser arytenoidectomy.
Figure 38-3. Total arytenoidectomy results in the removal of aryte-
noid cartilage (shaded region) within the cricoid ring (asterisk).

314
Section 3
Larynx
proximal end of the same suture is fed through the free
needle designed to be used with the needle carrier.
This needle is then pushed through the larynx slightly
superior to the vocal fold. Traction is placed on these
two sutures to lateralize the vocal fold. The sutures are
tied over a silicone button on the skin. This step is
repeated, with placement of another lateralization
suture 1 to 2 mm anterior to the fi rst suture (Fig. 38-4).
This procedure can be performed in conjunction with
partial arytenoidectomy as part of a permanent
procedure.
Open Arytenoidectomy
An anterior laryngofi ssure (see Chapter 42) or a lateral
approach with resection of the posterior rim of thyroid
cartilage and elevation of the piriform sinus mucosa
may be used to expose and remove the arytenoid carti-
lage. However, with the advances in endoscopic tech-
niques, these approaches are rarely necessary.
Posterior Glottic Stenosis
PGS can cause BVFI. It is typically associated with intu-
bation and extraesophageal refl ux disease. PGS is mani-
fested as progressive airway obstruction, usually 4 to 8
weeks after extubation. Granulation tissue can cover the
arytenoid cartilage and interarytenoid cleft. If this is
observed, prompt débridement is associated with less
scar tissue formation and consequently less airway
stenosis.
Bogdasarian and Olsen developed a classifi cation
system for PGS that is useful for determining the surgery
necessary to adequately address the stenosis.8 The least
severe group of patients are those with interarytenoid
synechiae and a posterior sinus tract. The next group
includes those with a posterior glottic web that limits
movement of the arytenoids, without fi xation of the CA
joints and no posterior sinus tract. The third group
appears similar to the second; however, one CA joint is
fi xed. The most severe group and the most diffi cult to
treat consists of patients with fi xation of both CA joints
(Fig. 38-5).
Palpation of the Cricoarytenoid Joint
Palpation of the CA joint is performed as described
earlier. If the interarytenoid region moves during this
maneuver, PGS is probably present.
Interarytenoid Synechiae
Suspension laryngoscopy with exposure of the posterior
glottis is carried out after the airway is secured. The
mucosal integrity of the posterior glottis is assessed with
the aid of 0-, 30-, and 70-degree angled telescopes. If an
interarytenoid bridge of mucosa is observed, it is excised.
Mitomycin C can be applied to the defect in the mucosa
to reduce the risk of reformation of synechiae. Release
of the bridge should restore passive mobility of the ary-
tenoid. If patients do not achieve long-term improve-
ment with this procedure, injury to the CA joint
(fi xation) is probable. A static glottic enlargement pro-
cedure as described earlier is then necessary.
Posterior Scar—Microtrapdoor Flap
Dedo and Sooy9 and Goldberg10 described an endo-
scopic fl ap technique to treat PGS. A CO2 laser or knife
is used to make an incision over the less mobile aryte-
noid, from the vocal process into the interarytenoid
cleft and extending up to the contralateral CA joint and
for 4 to 5 mm below the vocal folds in the interaryte-
noid cleft. A mucosal and submucosal fl ap is elevated
from the underlying scar. The scar tissue is excised or
vaporized until mobility is restored or the limits of dis-
section are met. The fl ap is repositioned, and sutures
or fi brin glue may be required to secure the fl ap in
proper position. If joint mobility is not regained, addi-
tional glottic enlargement procedures are necessary as
described earlier. Placement of an endolaryngeal stent
may be necessary in patients who require revision
surgery. Epinephrine-soaked pledgets (1:10,000 con-
centration) provide hemostasis, and mitomycin C may
be applied to the exposed CA joint.
POSTOPERATIVE MANAGEMENT
Patients are usually observed for 24 hours postopera-
tively for airway diffi culties. However, patients with an
established tracheostomy are candidates for outpatient
surgery. Voice rest is not necessary. Patients should
receive perioperative refl ux medications, such as a
proton pump inhibitor, to decrease exposure of the
healing surgical site to refl ux contents. Treatment of
refl ux continues until healing is complete. Pain medica-
tions are also prescribed, and antibiotics are used when
deemed necessary by the surgeon.
Patients will experience signifi cant worsening of
their voice in the immediate postoperative period
because of the large posterior glottic defect and possi-
Figure 38-4. Sutures are placed around the vocal fold and sutured
over a button on the skin, thereby lateralizing the vocal fold.

Chapter 38
Bilateral Vocal Fold Immobility
315
ble edema of the vocal fold. Voice should improve over
the next 2 to 3 months, at which point it stabilizes. Fre-
quent follow-up examinations will not only warn the
surgeon of granulation tissue formation, which requires
surgical removal, but also serve to reassure the patient.
A small posterior glottic notch is expected when healing
is complete. Decannulation is deferred until healing is
complete and the airway is adequate, usually 6 to 8
weeks after surgery.
A
B
C
D
Figure 38-5. Grading of posterior
glottic stenosis. A, Interarytenoid
synechia with a posterior sinus tract.
B, Posterior glottic web with mobile
arytenoid cartilage. C, Posterior
glottic web with fi xation of one ary-
tenoid cartilage. D, Posterior glottic
web with fi xation of both arytenoid
cartilages. (Adapted from Cotton RT,
Manoukian JJ: Glottic and subglottic
stenosis. In Cummings CW [ed]: Otolar-
yngology–Head & Neck Surgery. St
Louis, CV Mosby, 1986, p 2168.)
• Palpation of the arytenoid, either in the offi ce or in
the operating room, to confi rm passive motion or
immobility is critical information that helps guide
treatment.
• Endoscopic techniques have replaced larger, more
destructive surgery and have resulted in decreased
patient morbidity.
• Granulation tissue formation is minimized by the
use of perioperative refl ux medications and the
application of mitomycin C to any mucosal defects.
PEARLS
• Patients with BVFI secondary to mechanical fi xation
of the cricoarytenoid joints typically have more
severe airway restriction and require more aggressive
surgical enlargement of the posterior glottis than do
patients with BVFP.
• Laryngeal electromyography is crucial in determining
the presence of neurologic injury and may guide the
surgeon in determining the operative side.
PITFALLS
• Only patients with realistic expectations of the
balance between voice and airway improvement
should undergo surgery to enlarge the glottic airway.
• Overly aggressive primary surgery will probably leave
the patient with more severe breathy dysphonia and
dysphagia than was necessary for airway
improvement or decannulation.

316
Section 3
Larynx
3. Bosley B, Rosen C, Simpson CB, et al: Medial arytenoidectomy
versus transverse cordotomy as a treatment for bilateral vocal fold
paralysis. Ann Otol Rhinol Laryngol 114:922-926, 2005.
4. Dennis DP, Kashima H: Carbon dioxide laser posterior cordec-
tomy for treatment of bilateral vocal cord paralysis. Ann Otol
Rhinol Laryngol 98:930-934, 1989.
5. Crumley RL: Endoscopic laser medial arytenoidectomy for airway
management in bilateral laryngeal paralysis. Ann Otol Rhinol
Laryngol 102:81-85, 1993.
6. Ossoff RH, Karlan MS, Sisson GA: Endoscopic laser arytenoidec-
tomy. Lasers Surg Med 2:293-299, 1983.
7. Lichtenberger G, Toohill RJ: Technique of endo-extralaryngeal
suture lateralization for bilateral abductor vocal cord paralysis.
Laryngoscope 107:1281-1283, 1997.
8. Bogdasarian RS, Olson NR: Posterior glottic laryngeal stenosis.
Otolaryngol Head Neck Surg 88:765-772, 1980.
9. Dedo HH, Sooy CD: Endoscopic laser repair of posterior glottic,
subglottic and tracheal stenosis by division or micro-trapdoor
fl ap. Laryngoscope 94:445-450, 1984.
10. Goldberg AN: Endoscopic postcricoid advancement fl ap for pos-
terior glottic stenosis. Laryngoscope 110:482-485, 2000.
• Posterior glottic airway surgery may worsen glottic
protection during swallowing, thereby increasing the
risk of aspiration.
• Bilateral vocal fold paralysis and immobility must be
differentiated from posterior glottic stenosis because
the initial surgical options may be different.
• Exposure of arytenoid cartilage during transverse
cordotomy may lead to the formation of granulation
tissue and the need for surgical débridement.
References
1. Munin MC, Rosen CA, Zullo T: Utility of laryngeal electromyog-
raphy in predicting recovery after vocal fold paralysis. Arch Phys
Med Rehabil 84:1150-1153, 2003.
2. Krishna P, Rosen C: Offi ce-based arytenoid palpation. Ear Nose
Throat J 85:520-522, 2006.

Chapter 39
Vocal Fold Injection via Microlaryngoscopy
Andrew S. Florea and Clark A. Rosen
Vocal fold injection is a tool of paramount importance
in the otolaryngologist’s armamentarium for treating a
variety of voice disorders. The ability to adequately
approximate the vocal folds is critical for glottal
competence, which is necessary for the proper pro-
duction of voice and for swallowing. As such, multiple
components within the larynx are required for phona-
tion. The presence of an intact vibratory vocal fold
cover over functional muscle of adequate bulk that is
properly attached to a mobile and correctly positioned
cricoarytenoid joint is necessary for accomplishing this
task.1
Multiple factors can cause loss of tissue and volume
of the vocal folds or impairment of adequate vocal fold
neuromuscular function and ultimately result in glottal
incompetence. Glottal incompetence or insuffi ciency
produces a variety of symptoms, including dysphonia
(soft, breathy), decreased volume, vocal fatigue, dys-
phagia, associated aspiration, and odynophonia. Resto-
ration of glottal competence is essential not only for
improving voice-related quality of life but also for pre-
venting the development of potentially life-threatening
dysphagia in patients with vocal fold paralysis after
thoracic or esophageal surgery or stroke because
such patients commonly have multiple comorbid
conditions.2
The primary advantage of vocal fold injection over
open laryngeal framework surgery (i.e., thyroplasty) is
the minimally invasive nature of this approach. In addi-
tion, vocal fold injection provides more direct visualiza-
tion of the vocal folds, which not only assists in precise
volume expansion but also allows direct visualization of
the vocal folds (microlaryngoscopy) for identifi cation
of separate vocal fold pathologic processes such as vocal
fold scar or sulcus vocalis.3
PREOPERATIVE PLANNING
Before the actual surgical procedure, it is important to
take several important steps. First, patients who have
undergone voice therapy should be reevaluated in an
outpatient clinic setting. It is important at this post–
voice therapy visit to review the patient’s history and
inquire about any changes in symptoms that may have
occurred as a result of voice therapy. At this visit a physi-
cal examination, including videolaryngoscopy or video-
stroboscopy, should also be repeated and compared
with the initial examination. If the patient has not
improved after voice therapy and is in need of further
treatment or if the clinical decision was made to proceed
to surgical treatment without presurgical voice therapy,
it becomes important to obtain proper consent. The
consent process includes a discussion of the risks, ben-
efi ts, and alternatives of surgery, as well as material
selection choices and selection rationale. At this point,
preoperative laboratory testing and anesthesiology con-
sultation should also be obtained for patients on a case-
by-case basis. On the day of surgery, the patient should
be properly identifi ed in the operating room before
induction of general anesthesia, and the previous exam-
ination fi ndings should be reviewed to ensure that the
correct vocal fold is being injected and the patient is
appropriately marked.
Vocal Fold Injection Locations
Vocal fold injection can be divided into two separate
categories based on the location of the injection within
the vocal fold: superfi cial and deep, each having unique
indications and techniques.
Superfi cial vocal fold injection is used in cases of
vocal fold scar or localized loss of lamina propria.
317

318
Section 3
Larynx
Superfi cial injection under high-power magnifi cation
with a 27- or 30-gauge needle is performed in an attempt
to restore the size and function of the superfi cial portion
of the lamina propria. Optimal materials presently do
not exist for this procedure, and therefore it is not com-
monly performed. In the past, a variety of collagen-
based products were used, with only moderate success.4
Superfi cial injection is not aimed at correcting prob-
lems of glottal incompetence as commonly seen in
patients with vocal fold paralysis, vocal fold atrophy, or
vocal fold paresis.
Deep vocal fold injection, however, is indicated for
correction of glottal incompetence. This chapter focuses
on this important method of correcting glottal incom-
petence, and subsequent references to vocal fold injec-
tion will mean deep vocal fold injection.
PATIENT SELECTION
Obtaining a detailed history plus performing a thor-
ough physical examination is essential in identifying the
cause and associated symptoms of glottal incompetence.
The patient will commonly have complaints that may
include dysphonia, vocal fatigue, decreased volume,
decreased projection, dysphagia, and odynophonia. On
physical examination, including videostroboscopy,
decreased adduction with an increased open phase is
seen in patients with glottal incompetence. In patients
with vocal fold immobility in which no immediate cause
is found or suspected from the history or physical exam-
ination, additional radiologic evaluation is required to
rule out other disease processes (central nervous system,
tumors of the neck, and either benign or malignant
lung cancer) that could be causing paralysis of the
vagus or recurrent laryngeal nerve (or both).
In patients with suspected vocal fold paralysis, laryn-
geal electromyography can also be used to determine
the prognosis for spontaneous recovery; moreover, it
assists the physician in deciding between a temporary
or permanent implant for treatment.5 In patients with
vocal fold immobility or hypomobility who have laryn-
geal electromyographic fi ndings suggesting a good
prognosis for recovery, consideration should be given
to injection with a temporary implant. However, in
patients with dysphagia or a history of aspiration, imme-
diate injection with a temporary implant is indicated. If
there is no evidence of reinnervation on laryngeal elec-
tromyography or no vocal fold motion at 6 months after
onset, a permanent implant should be considered if the
patient remains symptomatic.
The indication for vocal fold injection is sympto-
matic glottal insuffi ciency as a result of vocal fold paraly-
sis or vocal fold paresis. In most cases, it is warranted
for patients to undergo a short course of speech therapy
before deciding whether surgery is indicated for the
patient’s glottal insuffi ciency. If the patient has a large
glottal gap associated with phonation (larger than
approximately 3 mm) or severe lack of bulk or loss of
tonicity of the vocal fold, it is extremely unlikely that
voice therapy alone will be adequate to treat the patient’s
symptoms. For this reason, these patients can be con-
sidered for immediate surgical treatment with vocal
fold injection.
Great care should be taken during the laryngeal
endoscopy procedure to confi rm that the contralateral
vocal fold in patients with vocal fold paralysis has normal
abductory range of motion. For patients with poor con-
tralateral vocal fold abduction, vocal fold injection
should be performed with great caution or not at all,
given that patients with vocal fold injection are going
to be at increased risk for airway embarrassment post-
operatively. It is also important to note that a patient
with a large glottal gap during phonation as a result of
glottal insuffi ciency probably will not be successfully
treated with a single vocal fold injection procedure
because of limitations on the amount of augmentation
material that can be properly placed in the vocal folds
to close a very large glottal gap. For this reason, some
patients may require repeat vocal fold injection or may
be more suited for treatment with a laryngeal frame-
work procedure such as thyroplasty or arytenoid adduc-
tion, or both (see Chapter 41).
Other causes of glottal insuffi ciency include vocal
fold atrophy, vocal fold scar, and sulcus vocalis. Patients
with these conditions who have inadequate improve-
ment after voice therapy can also be aided by deep vocal
fold injection.2
Material Selection
In 1911, Brunings injected paraffi n via indirect laryn-
goscopy to medialize an immobile vocal fold; the
patient’s voice improved, but unfortunately, a paraffi n-
oma subsequently developed. Since that time, ongoing
research continues in an attempt to fi nd the ideal injec-
tion material for vocal fold medialization. The ideal
material should be long lasting, biocompatible, inex-
pensive, easy to use, and readily available, as well as have
matching biomechanical properties of the deep aspect
of the vocal fold. The alloplastic materials used exten-
sively in the past, such as paraffi n, silicone, and polyte-
trafl uoroethylene (Tefl on), are notorious for causing
granulomas (Fig. 39-1) and foreign body reactions, and
Figure 39-1. Left vocal fold Tefl on granuloma.

Chapter 39
Vocal Fold Injection via Microlaryngoscopy
319
therefore a less reactive alternative implant material was
sought.6 The substances currently available for vocal
fold injection can be divided into two categories: autol-
ogous and bioimplantable (Table 39-1). All these mate-
rials are designed solely for deep vocal fold injection
(except the collagen-based products). Bovine collagen
products (Zyplast, Zyderm) require preinjection skin
testing because a localized infl ammatory response can
occur in 3.5% of the general population, with a delayed
hypersensitivity reaction developing in an additional
1.3%.7
Radiesse (calcium hydroxyapatite [CaHA]) is a
water and glycerin gel carrier containing suspended
spherules of CaHA. The gel carrier is eventually reab-
sorbed, and the CaHA remains at the injection site.8,9
The CaHA in most instances remains present for a long
time. Radiesse Voice Gel, which is the isolated gel
carrier, appears to last approximately 2 to 3 months
and thus is a good temporary vocal fold injection
material.10
Gelfoam/Surgifoam is a saline-diluted gelatin
powder that is injected as a paste. This injection mate-
rial has been used for approximately 20 years with con-
sistent success.11 The duration of augmentation,
however, is approximately 4 to 6 weeks, and the mate-
rial may have a negative impact on vocal fold vibration
and requires a large-bore needle (18 or 19 gauge) for
injection.
Hyaluronic acid (HA) is a ubiquitous substance
present in almost all tissues in the human body, includ-
ing the vocal folds, joints, and cornea. It is a high-
molecular-weight glycosaminoglycan and possesses
viscoelastic properties that ultimately regulate soft tissue
hydration properties.12 Multiple different formulations
of HA (Perlane, Restylane, Hylaform) are available for
“off-label” use as a deep vocal fold injection material,
and it is theorized that the different particle size in each
formulation determines the duration of successful aug-
mentation (i.e., Perlane is believed to last longer because
of its relatively larger particle size). Animal studies have
indicated that the implant may last up to 1 year in the
injected tissue.13 In humans, however, studies appear to
indicate that approximately 25% of patients injected
with HA for glottal insuffi ciency will require reinjection
within 24 months.14
Vocal fold lipoinjection is also used to treat glottal
incompetence associated with small to medium-sized
glottal gaps up to 4 mm. Although used for approxi-
mately the last 10 to 15 years, success with lipoinjection
is somewhat variable, because unpredictable reabsorp-
tion of the implanted fat occurs within the fi rst 4 to 6
weeks after injection.15 Consequently, approximately
30% overinjection of the vocal fold is needed to com-
pensate for expected implant loss in the immediate
postoperative period. The overinjection will result in
dysphonia for approximately the fi rst 3 weeks postop-
eratively. After the 6-week resorption process is com-
pleted, the level of resultant augmentation remains
permanent. As such, vocal fold lipoinjection remains an
ideal option for patients with intact contralateral neu-
romuscular vocal fold function (normal abduction)
who desire to avoid open neck surgery and have con-
cerns about the use of a foreign substance as implant
material.16-18
SURGICAL TECHNIQUE
Deep Vocal Fold Injection via
Microlaryngoscopy
Microsuspension laryngoscopy offers excellent visual-
ization and access for vocal fold injection. The main
disadvantage of this procedure is an inability to ade-
quately assess vocal fold augmentation because the
patient is under general anesthesia.
1. After induction of general anesthesia has been
achieved and the preoperative videolaryngoscopy or
videostroboscopy has been reviewed, visualization of
the larynx is achieved with a large-caliber laryngo-
scope suspended in place with a gallows or fulcrum
suspension device.
2. Zero-, 30-, and 70-degree telescopes are used to
achieve optimal visualization of the larynx and allow
in-depth analysis of the precise pathology and defect
requiring correction. The ideal point for deep injec-
tion is at the intersection of two anatomic landmarks:
(1) a line drawn horizontally across the vocal fold at
the level of the vocal process and (2) the superior
arcuate line (junction of the superior surface of the
vocal fold and laryngeal ventricle) (Fig. 39-2). The
augmentation material is injected slowly, approxi-
mately 5 mm deep to the mucosa.
3. Initially, augmentation should be visible at the level
of the infraglottis, which then subsequently spreads
superiorly to the level of the glottis.
4. If necessary, a second injection site may be used at
the midmembranous vocal fold along the superior
arcuate line.
5. If the patient is in poor medical condition and is at
an increased risk for perioperative morbidity or mor-
tality with general anesthesia, topical anesthesia and
intravenous sedation can be used and endoscopic
vocal fold injection can be performed. This approach
involves the use of a small slotted laryngoscope and
a telescope.3
Table 39-1
MATERIALS CURRENTLY USED FOR
VOCAL FOLD INJECTION
Autologous
Bioimplantable
Fat
Calcium hydroxylapatite (CaHA)
(Radiesse)
Fascia
Bovine collagen (Zyderm and Zyplast)
Hyaluronic acid (Hyalaform,
Restylane, Perlane)
Cadaveric collagen (Cymetra,
Cosmoderm, Cosmoplast)
Miscellaneous (Radiesse Voice Gel,
Gelfoam, Surgifoam, Tefl on)

320
Section 3
Larynx
6. Visualization of the injection allows proper determi-
nation of the required amount and location of the
deep injection (Fig. 39-3).
7. Lidocaine is applied to the larynx to prevent postop-
erative laryngospasm.
For lipoinjection of the vocal fold, fat must be
obtained before vocal fold injection. In patients with
adequate subcutaneous fat, a low-pressure liposuction
device is ideal because it allows rapid, minimally inva-
sive harvest of well-preserved fat globules. During lipo-
suction, care must be taken to control the depth of the
cannula and prevent inadvertent penetration of the
underlying peritoneum or overlying skin. Patients
who have minimal subcutaneous abdominal fat usually
require an open harvest technique, generally in the
infraumbilical area or through a preexisting abdominal
scar. Regardless of the method used for harvest, the fat
must be prepared before lipoinjection to prevent the
infl ammatory response associated with attached blood
and free fatty acids, which reduce graft survival.16
Fat Preparation Process before Lipoinjection
1. Fat is placed in a funnel lined with strips of Merocel,
and suction tubing is applied to the funnel while at
least 2 L of saline are used to remove the free fatty
acids and attached blood from the harvested fat
material.
2. The rinsed fat is then soaked with 100 units of regular
insulin for 5 minutes, thereby theoretically improv-
ing fat cell survival.
3. Afterward, the fat is transferred to a dry Merocel-
impregnated sponge and allowed to air-dry for a
short period (3 to 5 minutes) before loading into the
injection device.
Figure 39-2. Diagram of the ideal location of deep vocal fold injec-
tion. Point B represents the second injection site if inadequate medi-
alization is achieved with the fi rst injection (point A).
A
B
Figure 39-3. Preoperative (A) and postoperative (B) photographs
of a patient with right vocal fold paresis who underwent deep vocal
fold injection with Cymetra.
B
A

Chapter 39
Vocal Fold Injection via Microlaryngoscopy
321
A
B
C
Figure 39-4. Different stages of fat harvest and preparation for
lipoinjection. A, Rinsing fatty acids and enzymes from harvested fat.
B, Loading fat into a syringe. C, Fat globule after injection. Note the
relatively large-bore needle.
POSTOPERATIVE MANAGEMENT
After lipoinjection of the vocal folds, 6 days of absolute
voice rest is recommended to avoid implant migration
and extrusion. Additionally, patients who undergo
lipoinjection should receive a short course of oral
corticosteroids. The steroids reduce postoperative
swelling, thereby decreasing the possibility of airway
compromise.
Only 24 to 48 hours of voice rest is recommended
after deep vocal fold injection with the different
implants described earlier. For alloplastic and biocom-
patible implants, a single dose of intravenous antibiotics
is administered intraoperatively.3
COMPLICATIONS
Airway compromise is the most serious complication of
deep vocal fold injection. In patients with a contralat-
eral hypomobile vocal fold, lipoinjection should be
used with caution because a higher potential for airway
compromise exists as a result of the need for overinjec-
tion. Should airway compromise occur, close observa-
tion, humidifi ed oxygen, intravenous steroids, and
intravenous antibiotics can be used for treatment. If
unimproved after these conservative measures, short-
term intubation or even tracheostomy should be con-
sidered to allow time for postoperative edema to
decrease and return of a patent airway. Removing the
implant material should also be considered.
In cases of overinjection without airway compro-
mise, the patient should be observed for up to 6 months
to allow complete healing, resolution of edema, and
reabsorption of the implant (for temporary materials)
before considering removal of the implant. If a decision
to remove the implant is made, the material can be
removed via a lateral cordotomy under suspension
microlaryngoscopy.
In cases of underinjection, in which the patient
remains symptomatic but does not have dysphagia or
aspiration, further injection augmentation can gener-
ally be done as early as 6 weeks postoperatively.
PEARLS
• Vocal fold injection is an excellent tool for the
treatment of glottal insuffi ciency secondary to vocal
fold paralysis, paresis, or atrophy.
• Vocal fold injection augmentation is performed
relatively quickly without the need for an open
surgical procedure.
• For implant placement it is critical that the injection
be placed in a deep plane and not superfi cial within
the vocal fold.
• Careful material selection specifi c to the patient’s
defi cit and clinical situation is essential for
successful augmentation.
• Temporary injection of the vocal fold can be used as
a “trial” to determine whether vocal fold
augmentation is an appropriate treatment method
for the patient.
4. The same technique as described earlier for deep
injection via microsuspension laryngoscopy applies
for lipoinjection. Thirty percent overcorrection of
the vocal fold is required to compensate for the
expected fat loss that occurs during the 6 weeks after
transplantation. Because overcorrection is necessary,
patients with poor abduction of the contralateral
vocal fold should be injected only unilaterally, and
careful attention should be directed to avoiding
airway compromise (Fig. 39-4).

322
Section 3
Larynx
5. Munin MC, Rosen CA, Zullo T: Utility of laryngeal electromyog-
raphy in predicting recovery after vocal fold paralysis. Arch Phys
Med Rehabil 84:1150-1153, 2003.
6. Nakayama M, Ford CN, Bless DM: Tefl on vocal fold augmenta-
tion: Failures and management in 28 cases. Otolaryngol Head
Neck Surg 109:493-498, 1993.
7. Keefe J, Wauk L, Chu S, DeLustro E: Clinical use of injectable
bovine collagen: A decade of experience. Clin Mater 9:155-162,
1992.
8. Belafsky PC, Postma GN: Vocal fold augmentation with calcium
hydroxylapatite. Otolaryngol Head Neck Surg 131:351-354,
2004.
9. Rosen CA, Thekdi AA: Vocal fold augmentation with injectable
calcium hydroxylapatite: Short-term results. J Voice 18:387-391,
2004.
10. Kwon TK, Rosen CA, Gartner-Schmidt J: Preliminary results of a
new temporary vocal fold injection material. J Voice 19:668-673,
2005.
11. Schramm VL, May M, Lavorato AS: Gelfoam paste injection for
vocal cord paralysis: Temporary rehabilitation of glottic incom-
petence. Laryngoscope 88:1268-1273, 1978.
12. Laurent T: Biochemistry of hyaluronan. Acta Otolaryngol Suppl
(Stockh) 442:7-24, 1987.
13. Hallen L, Johansson C, Laurent: Cross-linked hyaluronan: A new
injectable remedy for treatment of vocal fold insuffi ciency—an
animal study. Acta Otolaryngol (Stockh) 119:107-111, 1999.
14. Hartegard S, Hallen S, Laurent C, et al: Cross-linked hyaluronan
versus collagen for injection treatment of glottal insuffi ciency: 2-
year follow-up. Acta Otolaryngol 124:1208-1214, 2004.
15. Mikus JL, Koutman JA, Kilpatrick SE: Fate of liposuctioned and
purifi ed autologous fat injection in the canine vocal fold. Laryn-
goscope 105:17-22, 1995.
16. Shaw GY, Szewczyk MA, Searle J, Woodroof J: Autologous fat
injection into the vocal folds: Technical considerations and long-
term follow-up. Laryngoscope 107:177-186, 1997.
17. Hsiung MW, Woo P, Minasian A, et al: Fat augmentation for
glottic insuffi ciency. Laryngoscope 110:1026-1033, 2000.
18. Laccourreye O, Papon JF, Kania R, et al: Intracordal injection of
autologous fat in patients with unilateral laryngeal nerve paraly-
sis, long-term results from the patient’s perspective. Laryngo-
scope 113:541-545, 2003.
PITFALLS
• It is important to avoid injection anterior to the
midmembranous portion of the true vocal fold
because a strained vocal quality will probably result.
• Great care must be taken with deep vocal fold
injection in patients with poor abduction of the
contralateral vocal fold because respiratory
compromise may ensue.
• To avoid infl ammation or rapid reabsorption when
performing lipoinjection, great care must be taken
when processing and handling the fat implant
material.
• Planned overinjection should be performed only
when using substances that are known to have an
element of reabsorption.
• Preoperative review of the patient’s
videolaryngoscopy and stroboscopy is important in
confi rming the patient’s defi cit and avoiding wrong-
site surgery.
References
1. Sulica L, Blitzer A (eds): Vocal Fold Paralysis. New York, Springer,
2006, pp 97-102.
2. Rosen CA: Phonosurgical vocal fold injection procedures and
materials. Otolaryngol Clin North Am 33:1087-1096, 2000.
3. Rosen CA: Phonosurgical vocal fold injection: Indications and
techniques. Oper Tech Otolaryngol Head Neck Surg 9:203-209,
1998.
4. Ford CN, Staskowski PA, Bless DM: Autologous collagen vocal
fold injection: A preliminary clinical study. Laryngoscope 105:944-
948, 1995.

Chapter 40
Management of Recurrent Respiratory
Papillomatosis
Andrew S. Florea and Clark A. Rosen
Recurrent respiratory papillomatosis (RRP) of the
upper aerodigestive tract is a viral-induced benign neo-
plastic process. RRP occurs in a relatively small number
of individuals but is a particularly vexing condition to
treat due to its recurrent nature and the negative impact
on voice, swallowing, and respiratory function. Although
RRP can occur on any mucosal surface, it is most
commonly found at mucosal transition zones in the
larynx, specifi cally at the transition between ciliated
pseudostratifi ed (respiratory) epithelium and stratifi ed
squamous epithelium.1 In recent years, signifi cant sci-
entifi c and clinical advances have resulted in an improve-
ment in treatment outcome.
RRP is caused by the human papillomavirus (HPV),
which is a double-stranded DNA, nonenveloped, icosa-
hedral (20-sided) capsid virus. HPV is responsible for
other medical conditions, including cervical condyloma
and skin lesions (warts). Although many different HPV
subtypes can result in clinical manifestations, the most
common subtypes involved in RRP are HPV-6 and HPV-
11. HPV infection typically produces an epithelial
growth that can either be classifi ed as a spreading or
pedunculated pattern. Classically, these lesions have
“fronds” with a central vascular subcomponent within
each frond providing the “speckled” appearance typical
of RRP (Fig. 40-1).2
RRP is a disease process limited to the epithelial
layer. Interestingly, patients infected with HPV can have
normal-appearing epithelial mucosa that contains HPV-
infected cells.3 This is particularly important to realize
from a surgical standpoint wherein more aggressive sur-
gical excision more often than not is detrimental to the
patient and does not provide improved therapeutic
benefi t. In other words, a deeper excision with wide
margins around the lesion will not benefi t the patient,
because the surrounding normal-appearing mucosa is
already likely to be infected.4
PATIENT SELECTION
RRP occurs in a bimodal age distribution—young chil-
dren and young adults—with symptoms and character-
istics unique to each group. Young children typically
present with a history of abnormal cry, chronic cough,
or recurrent croup, or progressive respiratory ob -
struction often manifesting as stridor. Adult patients
with RRP primarily complain of dysphonia at initial
presentation.
Regardless of the age at presentation, a thorough
physical examination of the head and neck, including
both fl exible fi beroptic laryngoscopy/stroboscopy and
rigid stroboscopy, should be performed if possible. It
may not be possible to adequately perform fi beroptic
laryngoscopy in an outpatient setting in young chil-
dren, so these patients may require microlaryngoscopy
under general anesthesia to obtain a tissue biopsy, diag-
nosis, and determination of the extent of the lesions.5
Adults with epithelial lesions suggestive of RRP found
on initial clinical evaluation should also undergo micro-
laryngoscopy with biopsy to rule out malignancy such
as squamous cell carcinoma and to determine the
extent of the disease.
Once a diagnosis of RRP has been established, it is
important to discuss with the patient and family the fact
that RRP is a chronic disease process and to provide
information about all available treatment options. The
patient and family should be informed that usually fre-
quent surgical procedures may be necessary to debulk
or excise the RRP lesions and, as such, the patient’s
quality of the voice may diminish from repeated sur -
gery of the vocal folds. Additionally, patients and their
families can often benefi t from support groups such as
the Recurrent Respiratory Papillomatosis Foundation,
which is composed of both adults with RRP and the
parents of children affl icted with RRP ().
323

324
Section 3
Larynx
The importance of providing the patient and family
with adequate information as well as assisting them to
develop appropriate expectations cannot be overem-
phasized in helping them to cope with the ramifi cations
of the disease process.
PREOPERATIVE PLANNING
Prior to surgery, appropriate informed consent should
be obtained from the patient (or parents if the patient
is a child). This detailed process should include an
explanation of the risks of surgery, which include:
bleeding, infection, recurrence, chipped teeth, altered
taste, numbness or weakness of the tongue, persistent
or worsened dysphonia, and the likely need for addi-
tional surgical procedures. Patients should also be
informed that some papilloma-covered areas of the
larynx will not be removed, so that surgery will be staged
for sites such as the anterior or posterior commissure
to help prevent the formation of an anterior glottic web
or posterior glottic stenosis. If the patient has any con-
comitant laryngeal irritation-producing conditions such
as laryngopharyngeal refl ux or tobacco use, he or she
should be aggressively treated or eliminated. If avail-
able, the patient’s video laryngoscopy examination
should be viewed preoperatively, thereby providing a
review of the locations of the lesions to assist in surgical
planning.
SURGICAL TECHNIQUE
After general anesthesia has been induced, the airway
should be secured by intubation with an endotracheal
tube for adult RRP patients. A smaller tube such as a
size 5.0 is preferable to allow more working space for
excision of the lesions. In patients with extensive bulky
RRP, a Hunsaker tube (Medtronic-Xomed, Jacksonville,
FL) with jet ventilation may be required. For prepubes-
cent pediatric patients, general anesthesia can be
induced and maintained by intravenous infusion with
spontaneous respiration.
Once the airway has been appropriately secured,
the initial endoscopy should include a thorough exami-
nation of the oral cavity, oropharynx, hypopharynx,
endolarynx, subglottis, trachea, and esophagus to accu-
rately stage the sites and extent of the RRP. During
suspension microlaryngoscopy, the largest laryngoscope
possible is preferred for optimal visualization and ease
of excision of the lesion.6 The use of angled telescopes
is an important adjunct that helps visualize the full
extent of and establish the precise locations of the
lesions throughout the supraglottis and endolarynx.7
The undersurface of the vocal fold, as well as the ven-
tricle and the anterior and posterior commissures, are
best visualized with 30- and 70-degree telescopes. The
angled telescopes are also useful for obtaining photo-
documentation at the beginning and end of the proce-
dure. After appropriate visualization of the lesions,
submucosal infi ltration of epinephrine (1:10,000) deep
to the lesion, using a narrow gauge needle, is useful in
elevating the lesions from important underlying struc-
tures such as the vocal ligament.8 Submucosal injection
brings the lesion closer to the center of the laryngo-
scope, easing removal and providing hemostasis.
Historically, RRP has been excised with “cold steel”
surgical instruments or the CO2 laser. More recently,
however, the microdébrider has been growing in popu-
larity for the excision of RRP, because it provides the
surgeon with the ability to rapidly remove bulky RRP
with minimal trauma to the underlying structures.9,10
Cold steel instrumentation allows precise surgical exci-
sion with complete avoidance of thermal injury to
deeper structures (see Chapter 37). The CO2 laser has
the advantage of allowing precise surgical excision of
RRP in anatomic areas that are diffi cult to reach with
hand-held instruments. The primary drawback of the
CO2 laser is the risk of thermal injury to surrounding
tissue. The microdébrider is used to “skim” the surface,
allowing the attached suction of the instrument to draw
the RRP into the rotating head of the instrument. These
different techniques for excision of these lesions can
be optimally applied to the separate laryngeal subsites:
supraglottis, glottis, and subglottis (see below).
Because RRP is a recurrent disease and is rarely
cured by surgery, it is important that surgery be very
conservative, precise, and restricted to the epithelium
during excision of the lesions. As such, regardless of the
method chosen for removal, the surgeon must always
be cognizant of and strive to prevent damage to the
critical structures of the vocal fold, including the lamina
propria, vocal ligament, anterior and posterior commis-
sures, and subglottis.
All efforts should be made to avoid tracheostomy
in patients with RRP. The surgeon will likely fi nd that
disease tends to rapidly grow and recur around the tra-
Figure 40-1. Recurrent respiratory papillomatosis (RRP) of supra-
glottis and true vocal folds. Notice the frondlike appearance of a
typical RRP lesion.

Chapter 40
Management of Recurrent Respiratory Papillomatosis
325
cheostomy sites in these patients, and may potentially
lead to tracheal and pulmonary dissemination of dis-
ease, which is usually fatal.
Supraglottis
In the supraglottic larynx, RRP typically occurs on the
laryngeal surface of the epiglottis and on the superior
surface of the false vocal fold. When RRP is located
in the laryngeal ventricle and the undersurface of the
false vocal fold, excision of the lesion may be quite dif-
fi cult. As such, removal of the medial portion of the
false vocal fold may be required to optimize access to
the ventricle.
Treatment of RRP on the laryngeal surface of the
epiglottis is often challenging due to the anatomic con-
straints of achieving adequate visualization and expo-
sure. Diffi culty in achieving exposure may lead to
prolonged operative times as the surgeon struggles with
constant repositioning of the laryngoscope to provide
optimal visualization. Due to the anatomic constraints,
RRP in the supraglottis is often diffi cult to view and to
ablate with the CO2 laser.
The microdébrider can be quite useful to the
surgeon for resecting lesions in the supraglottis given
that in this area RRP is often bulky and the microdé-
brider can be angled to allow rapid removal.
Treatment of the superior surface of the false vocal
folds is usually determined by the nature of RRP. If the
disease is bulky, a microdébrider is the ideal method
for rapid and controlled removal of the disease. If the
RRP appears to be superfi cial and spreading, the defo-
cused CO2 laser at a low power setting is useful for
vaporizing these lesions.
Angled 30- and 70-degree telescopes are also useful
for providing visualization during excision of the lesion
with a cup forceps.7 Borrowing from phonomicrosur-
gery techniques, submucosal epinephrine injection
into the lateral ventricle may help displace the lesions
medially so that this area can be viewed through the
laryngoscope, thereby improving ease and likelihood of
complete removal.6
True Vocal Folds
This region contains the true vocal folds and anterior
and posterior commissures, and extends to a point
approximately 1 cm below the true vocal folds anteri-
orly. RRP has a predilection for the true vocal folds
(superior and infraglottic surface) as well as the ante-
rior commissure. In this anatomic location, it is valuable
to reemphasize that removal of RRP should be strictly
isolated to the epithelium because RRP is a superfi cial
disease, and deeper resection will likely result in scar
formation and a worse voice without any improvement
in the control of RRP. When excising RRP near or
involving the anterior commissure, it is important to
remove RRP in a staged unilateral fashion to prevent
the formation of a glottic web (Fig. 40-2). This staged
approach means that the patient will need scheduled
surgery at a later date (approximately 30 days) to
remove RRP from the contralateral side. This same
staged approach is required for surgery in the posterior
commissure. Retraction of the nonoperated contralat-
eral vocal fold is also helpful for providing improved
visualization of the anterior commissure.
Cold steel instrumentation is ideal for excision of
RRP lesions involving the true vocal folds. Using instru-
ments and concepts of phonomicrosurgery for removal
of RRP in the glottis can be quite helpful (see Chapter
37). Bulky RRP can be quickly removed with a micro-
débrider from the true vocal folds (Fig. 40-3). Precision
control similar to cold steel instrumentation, however,
is not achieved. Great care is required to avoid injury
to the lamina propria/vocal ligament. As such, the
microdébrider should be considered only for patients
with bulky lesions or who have already developed vocal
fold scarring from repeated prior surgeries.
A
B
Figure 40-2. Staging of recurrent respiratory papilloma (RRP)
removal from the anterior commissure. A, Intraoperative photograph
before RRP removal. Notice bilateral anterior commissure lesions. B,
After right-sided RRP removal. Lesions are intentionally not removed
from the left anterior commissure to prevent formation of an anterior
glottic web.

326
Section 3
Larynx
Posterior Commissure
The endotracheal tube (ETT) poses a challenge to
proper exposure of the posterior commissure during
microlaryngoscopy. For exposure in this area, the laryn-
goscope is positioned to hold the ETT anteriorly, pro-
viding a clear view of the posterior commissure. A
posterior commissure laryngoscope can be quite helpful
in providing appropriate visualization and exposure,
because the laryngoscope has a notch to secure the ETT
in anterior position. As in the rest of the larynx, angled
telescopes can also be quite benefi cial in helping to
determine the extent of the RRP lesions.
A feared complication of operating in the posterior
commissure is the formation of a posterior glottic web,
which is a diffi cult problem to treat (Fig. 40-4). To
prevent glottic web, the same principles of surgery at
the anterior commissure apply to surgery at the poste-
rior commissure, for example, RRP should be excised
from one side at a time using a staged approach for
removal. Cold steel instrumentation is the preferred
method for resecting RRP from the posterior commis-
sure. Resection using a microdébrider can also be per-
formed for bulky RRP in this area.
Subglottis
The subglottic larynx has its superior border at the
inferior border of the glottis and extends inferiorly to
the trachea. As such, removal of RRP from the subglot-
tis can be challenging due to the diffi culty of obtain -
ing access, as well as airway and anatomic limitations.
Optimal removal of RRP is through a two-handed
approach, using an angled telescope in one hand and
using either cold steel instruments such as cup forceps
or a microdébrider in the other hand. When exposure
is diffi cult, the CO2 laser can be used to ablate the
lesions, whereas hand-held instruments can be used for
retraction to provide improved visualization. It is impor-
tant to be very conservative and judicious in the use of
the CO2 laser to prevent damage to surrounding struc-
tures or cause deep tissue thermal injury. To that end,
a laser set at intermittent, low power provides improved
safety and resection ability for lesions in the
subglottis.2
Adjunctive Therapy for RRP
Because patients with RRP frequently require multiple
surgical procedures for control, fi nding adjunctive
treatment options is important. The goals of adjunctive
treatment options is to eradicate the disease, reduce the
number of surgical procedures, increase the symptom-
free interval, increase the average time period between
surgical procedures, and decrease the overall extent
and severity of disease. These additional treatment
options are usually directed toward the viral etiology of
RRP.
Indole-3-carbinol (I3C) is a chemical found in cru-
ciferous vegetables such as caulifl ower, Brussels sprouts,
cabbage, and broccoli. It has been found to be active
in regulating estrogen metabolism and has been studied
for breast and colon cancer prevention. In an in vitro
experiment, I3C was found to suppress growth of RRP
in an animal model. A prospective clinical trial showed
that approximately one third of patients with RRP who
took oral I3C had a signifi cant reduction in new RRP
growth.11 During the last decade, I3C has been used in
clinical practice with moderate success in treating
patients with RRP.12,13
Systemic interferon has been studied and used
extensively in the past with good control of the disease.
However, multiple signifi cant side effects of treatment
as well as rapid rebound of RRP once treatment is
Figure 40-3. Bulky glottic recurrent respiratory papilloma being
removed with a microdébrider.
Figure 40-4. Recurrent respiratory papilloma at the posterior com-
missure. Excision of lesions must be unilateral and staged to avoid
developing posterior glottic stenosis.

Chapter 40
Management of Recurrent Respiratory Papillomatosis
327
stopped limit clinical usefulness.14,15 Photodynamic
therapy has also been extensively studied for the treat-
ment of RRP. However, so far, no clinical study has
conclusively demonstrated a signifi cant improvement
in disease control.16
Cidofovir is a cytosine nucleotide analog antiviral
medication approved by the U.S. Food and Drug
Administration for treatment of cytomegalovirus retini-
tis. This medication is currently being used in an “off-
label” fashion as an adjunctive treatment of RRP. In
vitro studies have demonstrated that cells infected with
HPV type 16 are more uniformly sensitive to cidofovir
than cells infected with HPV type 6.17 Clinically, however,
intralesional injection of cidofovir for the treatment of
RRP has proven to be very promising for controlling
recurrence and severity, and for increasing the time
period between surgical procedures, particularly in
studies on pediatric patients18; however, the response
may be unpredictable between patients.19 There is also
a suspicion that repeated cidofovir use can cause the
development of dysplasia and the possible subsequent
development of carcinoma.20 Additionally, there is clini-
cal suspicion that cidofovir may increase the possibility
of scar formation of the true vocal folds, and thus is
reserved for patients with extensive lesions who require
frequent and multiple surgical procedures for control
of the RRP.21 Intralesional cidofovir can be injected
superfi cially in the area of RRP disease, either during
microlaryngoscopy or under local anesthesia in the
offi ce via either a per-oral approach or using a fl exible
laryngoscope with a working channel.
An HPV vaccine is a future adjunctive treatment
option that may potentially lead to eradication of this
disease. An HPV vaccine has recently been approved by
the U.S. Food and Drug Administration for the preven-
tion of cervical carcinoma, which is also caused by
HPV.22,23 This vaccine, however, will most likely not
work for patients with active HPV infection as it is
designed for the initial prevention of acquiring HPV. It
is hoped that with widespread implementation of the
HPV vaccine, the number of individuals who develop
RRP will be dramatically reduced.
POSTOPERATIVE MANAGEMENT
When RRP is excised from the area of the anterior com-
missure and the patient may be at risk for developing
an anterior glottic web, “sniffi ng” exercises for 1 week
postoperatively should be prescribed. These sniffi ng
exercises may help reduce the formation of the web.
Pain in the immediate postoperative period is usually
well controlled with acetaminophen.
COMPLICATIONS
Because RRP is a chronic disease for which patients may
require multiple surgical procedures, the progressive
deterioration of voice quality can occur. In patients with
limited mouth opening, or in cases with prolonged
operative times, patients may develop numbness of the
tongue from the position of the laryngoscope. This is
usually self-limited and resolves over a period of several
weeks.24
The most feared complication of RRP surgery is the
formation of a glottic web or stenosis in patients with
lesions at the anterior or posterior commissure. These
complications are challenging to treat and may have
a signifi cant impact on the patient’s voice and
breathing.
PEARLS
• It is important for patients and their families to
understand that RRP is a chronic disease.
• Careful, superfi cial dissection using cold steel
instruments for excision of RRP lesions from the
area of the true vocal folds helps minimize vocal
fold scar formation and subsequent dysphonia.
• For RRP involving the anterior or posterior
commissure, excision of lesions should be unilateral
and staged to avoid formation of a glottic web or
stenosis.
• All efforts should be made to avoid tracheostomy.
• Oral indole-3-carbinol and intralesional cidofovir
injection should be considered for patients with
extensive RRP requiring multiple and frequent
surgical procedures for disease control.
PITFALLS
• Failure to review preoperatively the patient’s video
laryngoscopy examination may result in “missing”
diffi cult-to-visualize sites of disease.
• Injudicious or aggressive use of the CO2 laser or
microdébrider can result in damage to vital
surrounding structures.
• It is important to stay superfi cial during surgical
excision in that deeper and more extensive excision
will not prevent RRP recurrence and may cause
scarring.
• Tissue should always be sent for pathologic analysis
to prevent missing a diagnosis of carcinoma.
• Failure to aggressively treat or eliminate concomitant
laryngeal irritation-producing conditions, such as
laryngopharyngeal refl ux and tobacco use, will
adversely impact the patient’s outcome.
References
1. Kashima H, Mounts P, Leventhal B, et al: Sites of predilection in
recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol
102:580-583, 1993.
2. Rosen CA: Recurrent respiratory papillomatosis. Adv Otolaryngol
Head Neck Surg 15:97-107, 2001.
3. Steinberg B, Topp W, Schneider P, et al: Laryngeal papilloma
virus infection during clinical remission. N Engl J Med. 308:1261-
1264. 1983.

328
Section 3
Larynx
4. Erisen L, Fagan JJ, Myers EN: Late recurrences of laryngeal papil-
lomatosis. Arch Otolaryngol Head Neck Surg 122(9):942-944,
1996.
5. Derkay CS, Malis DJ, Zalzal G, et al: A staging system for assessing
severity of disease and response to therapy in recurrent respira-
tory papillomatosis. Laryngoscope 108:935-937, 1998.
6. Hochman IL, Zeitels SM, Heaton JT: Exposure and visualization
of the glottis for phonomicrosurgery. Op Tech Otol 9:192-195,
1998.
7. Andrea M, Dias O. Rigid and contact endoscopy in microlaryn-
geal surgery technique and atlas of clinical cases. Raven Press,
1995, p 9.
8. Kass ES, Hillman RE, Zeitels SM: Vocal fold submucosal infusion
technique in phonomicrosurgery. Ann Otol Rhinol Laryngol
105:341-347, 1996.
9. Pasquale K, et al: Microdebrider vs. CO2 laser removal of recur-
rent respiratory papillomas: A prospective analysis. Laryngoscope
113:139-143, 2003.
10. Patel N, Rowe M, Tunkel D: Treatment of recurrent respiratory
papillomatosis in children with the microdebrider. Ann Otol
Rhinol Laryngol 112:7-10, 2003.
11. Rosen CA, Woodson GE, Thompson JW, et al: Preliminary results
of the use of indole-3-carbinol for recurrent respiratory papillo-
matosis. Otolaryngol Head Neck Surg 118:810-815, 1998.
12. Newfi eld L, Goldsmith A, Bradlow HL, et al: Estrogen metabolism
and human papilloma virus-induced tumors of the larynx: Che-
moprophylaxis with indole-3-carbinol. Anticancer Res 13:337-
341, 1993.
13. Rosen CA, Bryson PC: Indole-3-carbinol for recurrent respiratory
papillomatosis: Long term results. J Voice 18:248-253, 2004.
14. Levanthal B, Kashima H, Mounts P, et al: Long-term response of
recurrent respiratory papillomatosis to treatment with lympho-
blastoid interferon alfa-N1. N Engl J Med 325:613-617, 1991.
15. Healy G, Gelber R, Trowbridge A, et al: Treatment of recurrent
respiratory papillomatosis with human leukocytes interferon. N
Engl J Med. 319:401-407, 1988.
16. Shikowitz MJ, Abramson AL, Freeman K, et al: Effi cacy of DHE
photodynamic therapy for respiratory papillomatosis: Immediate
and long-term results. Laryngoscope 108:962-967, 1998.
17. Donne AJ, Hampson L, He X, et al: Investigation into the effects
of cidofovir on an in vitro model of recurrent respiratory papil-
lomatosis. Clin Otolaryngol 31:245, 2006.
18. Sheahan P, Sexton S, Russell JD: Is intralesional cidofovir worth-
while in juvenile recurrent respiratory papillomatosis? J Laryngol
Otol 120:561-565, 2006.
19. Chung BJ, Akst LM, Koltai PJ: 3.5-Year follow-up of intralesional
cidofovir protocol for pediatric recurrent respiratory papilloma-
tosis. Int J Pediatr Otorhinolaryngol 70:1911-1917, 2006.
20. Wemer RD, Lee JH, Hoffman HT, et al: Case of progressive dys-
plasia concomitant with intralesional cidofovir administration for
recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol
114:836-839, 2005.
21. Lee AS, Rosen CA: Effi cacy of cidofovir injection for the treat-
ment of recurrent respiratory papillomatosis. J Voice 18:551-556,
2004.
22. Freed GL, Derkay CS: Prevention of recurrent respiratory papil-
lomatosis: Role of HPV vaccination. Int J Pediatr Otorhinolaryn-
gol 70:1799-1803, 2006.
23. Wiatrak BJ: Overview of recurrent respiratory papillomatosis.
Curr Opin Otolaryngol Head Neck Surg 11:433-441, 2003.
24. Rosen CA, Andrade-Filho PA, Scheffel L, Buckmire R: Oropha-
ryngeal complications of suspension laryngoscopy: A prospective
study. Laryngoscope 115:1681-1684, 2005.

Chapter 41
Medialization Laryngoplasty and
Arytenoid Adduction
Clark A. Rosen
Medialization laryngoplasty (type I thyroplasty) and ary-
tenoid adduction are excellent surgical options for
rehabilitation of the voice in patients suffering from
glottic insuffi ciency. These represent the current stan-
dard of care for surgical therapy to augment and reposi-
tion the vocal folds to improve vocal fold closure and
thereby improve vocal function.1,2 Glottic insuffi ciency
may be caused by any combination of the following:
vocal fold atrophy (presbylarynges), vocal fold paresis,
or vocal fold paralysis. These procedures can also be
used to address soft tissue defi cits of the vocal folds
following surgery or trauma.3
A variety of different implant materials have been
used to medialize the vocal folds in a medialization
laryngoplasty approach, including silastic, hydroxylapa-
tite, and Gore-Tex. This chapter discusses the general
approach to medialization laryngoplasty and does not
discuss the different implants or the design of the shape
of the implant, given that these are very personal choices
and that medialization laryngoplasty can be done suc-
cessfully with any of the above-mentioned implant
materials.
PATIENT SELECTION
The majority of patients with glottic insuffi ciency do not
require (or desire) operative intervention. Surgical
therapy is indicated for patients with symptoms that
interfere with their quality of life (voice-related) or
whose glottic insuffi ciency leads to pulmonary compro-
mise due to aspiration.1 The decision to perform surgery
is multifactorial with the patient’s vocal requirements
and overall upper aerodigestive hygiene being key vari-
ables. Once a decision is made that surgery for glottic
insuffi ciency is warranted and the patient understands
the risks and benefi ts, a decision must then be made
regarding an open procedure involving a medialization
laryngoplasty and/or arytenoid adduction or an endo-
scopic, minimally invasive approach, such as vocal fold
augmentation/injection. This decision is typically made
based on a combination of factors, including where the
procedure will take place (offi ce versus operating
room), the patient’s general medical condition, and the
nature and position of the weakened or paralyzed vocal
folds. If the patient’s dysphonia and/or dysphagia is
related to a severe posterior glottic insuffi ciency, aryte-
noid adduction should be strongly considered because
it is the only operation that consistently corrects glottic
insuffi ciency in the posterior aspect of the glottis.4-6
Neither vocal fold augmentation nor medialization
laryngoplasty can address clinical issues related to pos-
terior glottic insuffi ciency.
Indications for medialization laryngoplasty and/or
arytenoid adduction include symptomatic glottic insuf-
fi ciency (dysphonia, aspiration), especially if there is
little or no chance of return of vocal fold motion when
vocal fold paralysis or paresis is present. Relative con-
traindications include a previous history of radiation
therapy of the larynx and marginal airway status due to
poor abduction of one (contralateral to an immobile
vocal fold) or both of the vocal folds.
PREOPERATIVE PLANNING
Equipment
There is a limited need for specialized equipment to
perform medialization laryngoplasty and arytenoid
adduction. Standard head and neck soft tissue instru-
ments are required (similar to those for neck dissec-
tion). A fl exible laryngoscope, preferably with a C-mount
camera and video monitor, must be available. The
surgeon’s preferred implant material must also be avail-
able, be it silastic block, Gore-Tex ribbon, or one of the
329

330
Section 3
Larynx
preformed implants made of silastic or hydroxylapatite.
Often a small drill with a 2- to 3-mm cutting burr is
required when the thyroid cartilage is ossifi ed. It is also
helpful to have a small measuring caliper to measure
precisely the location of the thyroplasty window and the
size and dimensions of a silastic block if it is used.
Preoperative Planning
It is helpful to review the patient’s laryngeal examina-
tion before the surgical procedure is undertaken.
Features of the glottal insuffi ciency, mobility of the
contralateral vocal fold, and overall airway status should
be reviewed. The patient should be counseled to stop
taking all anticoagulation agents, such as nonsteroidal
anti-infl ammatory medications, Coumadin, and Plavix.
It is important to have a discussion with the patient
regarding the environment in the operating room,
given that the patient will be awake and only slightly
sedated. It is best to prepare patients psychologically for
having surgery on their neck while they are awake.
Consent for medialization laryngoplasty and/or ary-
tenoid adduction should include a discussion regarding
the scar on the neck, complications of bleeding and
infection, and the possible need for revision of the
procedure in the future. The patient should be told
that there may be a need for a bilateral procedure and
the addition of an arytenoid adduction procedure
pending the intraoperative results of the medialization
laryngoplasty. Often, with experience, surgeons can
determine preoperatively, based on the laryngeal exam-
ination and the patient’s voice quality, whether they will
require a unilateral or bilateral medialization laryngo-
plasty. However, certain situations do occur intraopera-
tively in which voice quality is only marginally improved
with a medialization laryngoplasty and it is determined
that the patient would benefi t signifi cantly from a simul-
taneous arytenoid adduction. Thus, these different pos-
sibilities must be discussed with the patient preoperatively
and should be included on the consent form.
SURGICAL TECHNIQUE
Medialization Laryngoplasty
(Type I Thyroplasty)
Before the patient comes into the operating room,
nebulization of a lidocaine/Pontocaine mixture is often
done to provide topical anesthesia to the upper aerodi-
gestive tract, which facilitates the patient tolerating the
fl exible laryngoscopy during the procedure. In addi-
tion, Robinol should be administered, unless medically
contraindicated, to minimize laryngeal secretions
during the procedure. Once in the operating room, the
patient is placed in a supine position with a conservative
shoulder roll to provide extension of the neck. Care
should be taken to ensure that the patient is comfort-
able. After intravenous sedation, 1% lidocaine with
1:100,000 epinephrine can be injected both super fi cially
and deep in the area of the thyroid ala of the proposed
side or sides of surgery. Topical anesthesia to the nasal
cavity can be achieved with placement of a cotton
pledget with a combination of a decongestant and anes-
thetic on the pledgets.
Incision for the medialization laryngoplasty is done
in a curvilinear fashion in an adjacent deep normal skin
crease near the inferior border of the thyroid ala. The
platysma muscle is then incised and subplatysmal fl aps
are elevated superiorly and inferiorly to approximately
the level of the hyoid bone and the cricoid cartilage,
respectively. Once the strap muscles are identifi ed, they
can be released from superior to inferior in the midline,
and retracted on the side of the proposed surgery. Sub-
perichondrial infusion of lidocaine with epinephrine is
used before incising the perichondrium of the thyroid
cartilage in the midline. Subperichondrial elevation
should then be done widely to expose the thyroid ala
approximately 5 mm posterior to the muscular tubercle
of the thyroid ala. The posterior aspect of the muscular
tubercle of the thyroid ala will identify the true inferior
border of the thyroid cartilage, which determines the
plane of the vocal fold and location of the thyroplasty
implant (Fig. 41-1). A caliper can then be used to
measure approximately 5 to 7 mm posterior to the
midline of the thyroid cartilage and 3 mm above the
inferior border of the thyroid cartilage. This is the area
where the proposed thyroplasty window will be made.
Once this area has been identifi ed, a 25-gauge needle
can be placed through the thyroid cartilage in this area,
confi rming with simultaneous fl exible laryngoscopy,
that the proposed thyroplasty window is appropriately
positioned immediately lateral to the vocal fold and is
not too posterior, anterior, or superior.
If a Gore-Tex medialization laryngoplasty is planned,
then a 3- × 3-mm window at the previously determined
3 mm
Figure 41-1. Location of medialization laryngoplasty window.

Chapter 41
Medialization Laryngoplasty and Arytenoid Adduction
331
optimal site can be made with a drill (if the thyroid
cartilage is ossifi ed) or with a no. 15 scalpel blade.7 For
a silastic medialization laryngoplasty, the thyroplasty
window is typically 6 × 13 mm in dimension and can be
created with either the drill or a scalpel. Once the
thyroid cartilage has been removed from the window,
it is wise to incise the perichondrium superiorly, poste-
riorly, and inferiorly, creating an anteriorly based inner
perichondrium fl ap. The paraglottic space can then be
elevated posteriorly and inferiorly in preparation for
placement of the medialization laryngoplasty implant.
Simultaneous fl exible laryngoscopy and evaluation of
the voice during the elevation of this pocket will deter-
mine the size, location, and nature of the implant and
is extremely important to the success of the operation.
Surgeons should take great care to avoid overmedializa-
tion of the vocal fold anteriorly as well as superiorly.
These are the two most common mistakes made by
inexperienced surgeons doing medialization laryngo-
plasty. The implant is then inserted through the thyro-
plasty window with simultaneous fl exible laryngoscopy
monitoring and assessment of the patient’s voice quality
(Fig. 41-2). Adjustments can then be made to the
implant based on the fi ndings of the voice quality, vocal
fold augmentation, and vocal fold closure pattern seen
using the fl exible laryngoscope.
Once the voice quality and vocal fold position are
optimized, the implant can be secured to the adjacent
thyroid cartilage with a permanent 4.0 Prolene suture.
Hemostasis should be obtained and a small drain placed
in the dependent portion of the wound. The perichon-
drium should be laid back over the thyroplasty window
and the strap muscles should be reapproximated in the
midline. Finally, skin closure should include both
dermal and epidermal closures to maximize the cos-
metic results of the operative site.
Arytenoid Adduction
Arytenoid adduction is almost always done in combina-
tion with medialization laryngoplasty.4-6 The surgical
approach to arytenoid adduction is the same as
described earlier for medialization laryngoplasty. If
during preoperative planning the surgeon is very con-
fi dent that the patient will require arytenoid adduction,
it is often wise to perform the approach to arytenoid
adduction (described next) before making the medial-
ization laryngoplasty window. After elevating the peri-
chondrium off of the anterior two thirds of the thyroid
ala as described for medialization laryngoplasty, this
elevation should be continued back to the posterior
border, specifi cally skeletonizing the inferior cornu of
the thyroid cartilage. Careful dissection around the pos-
terior border of the thyroid ala from the inferior cornu
superiorly up toward the greater cornu is then done,
taking great care to adhere to the thyroid cartilage to
avoid entering the piriform sinus. For the further expo-
sure and rotation of the larynx, a hook can be placed
on the greater cornu to rotate the larynx and expose
its posterior aspect. Bipolar cautery can then be used to
release the upper portion of the cricopharyngeus
muscle as it attaches to the inferior cornu. This allows
exposure of the piriform sinus. The piriform sinus lies
directly over the posterior lamina of the cricoid carti-
lage, which is the location of the posterior cricoaryte-
noid muscle and is the main anatomic landmark for the
surgical dissection. To fully evaluate the location of the
piriform sinus throughout this portion of the dissec-
tion, it is wise to have the patient intermittently “puff
out” their cheeks or hold their breath, which will infl ate
the piriform sinus and outline its boundaries. Dissec-
tion of the piriform sinus off the cricoid cartilage should
then be done in an inferior-lateral to superior-medial
direction until the posterior cricoarytenoid (PCA)
muscle is identifi ed. The PCA muscle can be identifi ed
by the direction of the muscle fi bers running from a
medial-inferior to lateral-superior direction and ending
at the muscular process of the arytenoid cartilage. Fol-
lowing retraction of the inferior portion of the piriform
sinus, the PCA muscle is usually clearly identifi ed and
can be traced up to identify the ridge on the arytenoid
cartilage, which is the muscular process of the arytenoid
cartilage (Fig. 41-3). A small portion of the posterior
border of the thyroid cartilage can be removed with a
rongeur to assist in fi nding and suturing the muscular
process of the arytenoid cartilage (Fig. 41-4). Once the
muscular process of the arytenoid cartilage is identifi ed,
a fi gure-of-eight suture of 4.0 monofi lament is placed
through the arytenoid cartilage. Confi rmation of proper
placement of this suture is done with simultaneous fl ex-
ible laryngoscopy to confi rm that control and manipu-
lation of the arytenoid is now possible via the suture
placed through the muscular process of the arytenoid
cartilage.
If the medialization laryngoplasty window has not
yet been made, the two arms of the suture placed
through the muscular process of the arytenoid cartilage
can be clamped and the larynx can be placed back into
its anatomic location for creation of the medialization
laryngoplasty window as described earlier. Once the
medialization laryngoplasty window is created, lateral
paraglottic dissection posterior to the window can be
Figure 41-2. Placement of Gore-Tex into paraglottic space to medi-
alize the vocal fold.

332
Section 3
Larynx
done with a Cottle elevator to develop a tract that
extends from the muscular process of the arytenoid
cartilage to the medialization laryngoplasty window.
Once this path has been created, a middle ear alligator
can be passed from the window posteriorly to the pos-
terior aspect of the larynx and bring both arms of
the arytenoid adduction suture forward through the
window. Once the sutures have been drawn forward,
one suture can be placed anterior and inferior to the
window through the cricothyroid membrane, and the
second suture can be placed immediately anterior
through the medialization laryngoplasty window
through the thyroid cartilage. Gentle tension on this
suture will rotate the arytenoid into an adducted posi-
tion and signifi cantly improve the vocal fold length and
position of the paralyzed vocal fold. With gentle tension
on the arytenoid adduction sutures, and simulated
medialization through the medialization laryngoplasty
window, voice quality and vocal fold position can be
evaluated to determine optimal suture tension and
amount of medialization required (see Fig. 41-4). When
medialization laryngoplasty is done in conjunction with
arytenoid adduction, typically less medialization is
required, and it is very rare that a signifi cant amount of
tension needs to be applied to the arytenoid adduction
suture for optimal phonatory function. After the aryte-
noid adduction suture has been placed, the medializa-
tion laryngoplasty can be completed and the wound can
be closed as described earlier for the medialization
laryngoplasty procedure.
POSTOPERATIVE CARE
Following both medialization laryngoplasty alone or
medialization laryngoplasty in conjunction with aryte-
noid adduction, patients are observed in the hospital
overnight. During this time period, pain management
is done on an as-needed basis, intravenous steroids are
administered, and the drain is typically kept in place
overnight. The morning following surgery, the drain
can usually be removed and the patient can be dis-
charged home. It is wise to have the patient keep the
head of the bed elevated in the immediate postopera-
tive time period. There is no need for strict voice rest
following either of these laryngeal framework proce-
dures. One dose of prophylactic antibiotics should be
administered in the operating room but no further
treatment is required. Follow-up in the offi ce is approxi-
mately 1 month, given that it takes approximately 3 to
4 weeks for the vocal fold and the surrounding tissues
to resolve before needing a repeat laryngeal examina-
tion in the offi ce.
COMPLICATIONS
The most common complication of medialization laryn-
goplasty is malposition of the implant.8 The implant can
be inappropriately located in a variety of dimensions,
although the most common implant malpositions
include (1) too much medialization of the vocal fold by
the implant and (2) too superior positioning of the
implant.5,9 The latter problem causes a ventricular pro-
lapse and medialization of the false vocal fold, which
impairs normal voice production. In addition, as men-
tioned earlier, excessive medialization of the vocal fold
anteriorly can cause a pressed or strained voice quality.
Lastly, undermedialization of the vocal fold due to inad-
equate implant size will result in signifi cant improve-
Figure 41-3. Identifi cation of the muscular process of the arytenoid
cartilage.
Figure 41-4. A small portion of the posterior border of the thyroid
cartilage can be removed with a rongeur to assist in fi nding and sutur-
ing the muscular process of the arytenoid cartilage.

Chapter 41
Medialization Laryngoplasty and Arytenoid Adduction
333
ment of voice quality intraoperatively as well as for a
week or two following surgery; however, this voice
improvement diminishes rapidly around 3 to 4 weeks
following surgery. On follow-up examination in the
offi ce, undermedialization is seen. This is often due to
the surgeon’s not accounting for the intraoperative
edema that occurs within the vocal fold throughout the
surgical procedure. For this reason, the implant should
be designed to induce a very slight amount of stress
within the voice at the end of the procedure, knowing
that a small amount of the strain in the voice is due to
vocal fold edema, and as that edema resolves in the 2
to 3 weeks following surgery, the voice quality will be
excellent.
A rare complication of medialization laryngoplasty
is implant extrusion. Implants can extrude medially
into the airway or laterally out into the skin. The former
complication is severe and can become an airway emer-
gency. This is believed to occur due to an unrecognized
violation of the mucosa, usually of the ventricle, during
placement of the implant.
Specifi c complications associated with arytenoid
adduction include a pharyngeal cutaneous fi stula and/
or over-rotation of the arytenoid cartilage. Both of these
complications are extremely rare. The former can occur
from violation of the piriform sinus during the dissec-
tion to identify the posterior cricoarytenoid muscle. If
violation is identifi ed intraoperatively, careful oversew-
ing of the piriform sinus is warranted. Over-rotation of
the arytenoid cartilage during the arytenoid adduction
procedure can come from excessive tension placed on
the arytenoid adduction suture. This is usually identi-
fi ed during the procedure and thus rarely occurs. It is
important to note that excessive tension is rarely
required for the arytenoid adduction procedure. The
suture placed on the arytenoid cartilage is only to guide
the arytenoid into a more favorable position for phona-
tion and to keep it there; thus, excessive tension on the
suture is usually not required.
References
1. Netterville JL, Billante CR: The immobile vocal fold. In Ossoff RH,
et al (eds): The Larynx. Philadelphia, Lippincott Williams &
Wilkins, 2004, pp 269-305.
2. Wanamaker J, Netterville JL, Ossoff RH: Phonosurgery: Silastic
medialization for unilateral vocal fold paralysis. Operat Tech Oto-
laryngol Head Neck Surg 1993;4:207-217.
3. Zeitels SM, Mauri M, Dailey SH: Medialization laryngoplasty with
Gore-Tex for voice restoration secondary to glottal incompetence:
Indications and observations. Ann Otol Rhinol Laryngol 2003;
112:180-184.
4. McCulloch TM, Hoffman HT, Andrews BT, et al: Arytenoid adduc-
tion combined with Gore-Tex medialization laryngoplasty. Laryn-
goscope 2000;110:1306-1311.
5. Netterville JL, Stone RE, Luken ES, et al: Silastic medialization and
arytenoid adduction: The Vanderbilt experience. A review of 116
phonosurgical procedures. Ann Otol Rhinol Laryngol 1993;102:
413-424.
6. Woodson GE, Picerno R, Yeung D, et al: Arytenoid adduction:
Controlling vertical position. Ann Otol Rhinol Laryngol 2000;
109:360-364.
7. McCulloch TM, Hoffman HT: Medialization laryngoplasty with
expanded polytetrafl uoroethylene. Surgical techniques and pre-
liminary results. Ann Otol Rhinol Laryngol 1998;107: 841-854.
8. Rosen CA: Complications of phonosurgery: Results of a national
survey. Laryngoscope 1998;108(11 Pt 1):1697-1703.
9. Cohen JT, Bates DD, Postma GN: Revision Gore-Tex medialization
laryngoplasty. Otolaryngol Head Neck Surg 2004;131:236-240.
PEARLS
• Medialization laryngoplasty is an excellent
permanent treatment option for dysphonia due to
glottal insuffi ciency.
• Patient selection and preoperative counseling for
medialization laryngoplasty and arytenoid adduction
must include the unique nature of surgery in the
neck with the patient only lightly sedated.
• Implant selection is based on the material with
which the surgeon feels most comfortable.
• Arytenoid adduction is the only surgery that can
lengthen a foreshortened vocal fold and address
posterior glottal incompetence.
• Slight overmedialization should be done during
medialization laryngoplasty to correct for
intraoperative edema of the vocal fold and prevent
undermedialization of the vocal fold postoperatively.
PITFALLS
• Medialization laryngoplasty and arytenoid adduction
should not be done when the preoperative airway is
compromised with poor contralateral vocal fold
abduction.
• Implant position is the key to successful
medialization laryngoplasty and great care should be
taken to ensure that the implant is not placed too
superior or too anterior.
• Great care should be taken not to violate the airway
during implant placement (medialization
laryngoplasty) and during elevation of the piriform
sinus (arytenoid adduction).
• A clear path must be created for the arytenoid
adduction suture from the muscular process of the
arytenoid to the medialization laryngoplasty window
to ensure proper rotation of the arytenoid.
• Excessive tension on the arytenoid adduction suture
can cause over-rotation of the arytenoid and poor
voice outcome.

Chapter 42
Laryngofi ssure
Ryan J. Soose and Ricardo L. Carrau
Laryngofi ssure, or median thyrotomy, is the most versa-
tile of the transcervical approaches to the endolarynx.
It provides ample exposure to the anterior and poste-
rior aspects of laryngeal anatomy and is associated with
minimal morbidity.
The fi rst laryngofi ssure is attributed to Desault, a
French surgeon who used this approach for removal of
a foreign body in 1819.1 During the 1800s, other sur-
geons attempted the approach for removal of benign
and malignant tumors with varying results. In 1862,
McKenzie surveyed 28 cases in the literature and con-
demned the procedure because of its high morbidity.1
Laryngofi ssure fell into disfavor until the 20th century,
when it gained acceptance as advances in anesthesia,
standardization of tracheotomy, a better understanding
of the physiology of healing, and the advent of anti-
biotics reduced the morbidity of the approach. Today,
laryngofi ssure is the most commonly used transcervical
approach to the endolarynx.
PATIENT SELECTION
The most frequent indications for laryngofi ssure include
the surgical management of extensive or recurrent ste-
nosis of the glottis, combined glottic-subglottic stenosis,
and anterior and posterior glottic webs that are not
amenable to transendoscopic resection.2,3 Laryngofi s-
sure may also be used in patients requiring arytenoidec-
tomy and lateralization of the vocal fold for vocal fold
paralysis who cannot be approached endoscopically
because of anatomic limitations.4,5 Furthermore, benign
and malignant tumors of the larynx can be accessed via
laryngofi ssure, provided that sound oncologic princi-
ples are followed.6-10 Many congenital laryngeal anoma-
lies are also amenable to correction through this
approach.11 Finally, laryngofi ssure may be used to
approach and repair traumatic injuries to the larynx.
PREOPERATIVE EVALUATION
Laryngofi ssure and cordectomy were the standard of
care for T1 to T2 cancers of the glottis for many years.
It is essential that the cartilage and posterior and ante-
rior commissures not be involved with tumor. Informa-
tion concerning such involvement may be ascertained
preoperatively with computed tomography of the larynx
and fl exible fi beroptic and direct laryngoscopy. If trans-
glottic involvement is suspected, it may be better defi ned
preoperatively by magnetic resonance imaging. In
general, however, we prefer hemilaryngectomy for the
resection of malignant tumors not amenable to endo-
scopic resection, because in our experience, hemilaryn-
gectomy yields a better voice than laryngofi ssure and
cordectomy do. A possible exception to this principle
is the local resection of verrucous carcinoma, which is
characterized by extension with a “pushing” rather than
an infi ltrative border and subsequently may not require
ablation of the deep tissues of the glottis or thyroid
cartilage.
Benign tumors that are not amenable to a transen-
doscopic approach, either because of extension or
because they are poorly visualized (i.e., a patient with
cervical spine fusion), may be approached through a
laryngofi ssure. An important contraindication to this
approach is active laryngeal papillomatosis. Any attempt
to remove the papillomas transcervically may result in
dissemination of the disease to the deep tissue planes
of the neck with obvious catastrophic results.
Patients with extensive anterior commissure
webbing, especially if the web has a substantial vertical
dimension, may be approached through a laryngofi s-
sure. This technique permits lysis of the entire web and
placement of a keel to allow re-epithelialization of the
glottis and subglottis. Most posterior commissure webs
are the result of prolonged endotracheal intubation.
335

336
Section 3
Larynx
These webs tend to be broad based and leave consider-
able submucosal scarring. The laryngofi ssure approach
allows thorough excision of not only the web but also
its submucosal scar. Use of a local fl ap of pharyngeal
mucosa rotated into the defect produces reliable results
in restoring the airway.
TECHNIQUE
Laryngofi ssure is classifi ed as clean-contaminated
surgery. Prophylactic perioperative antibiotics are rec-
ommended. The antibiotic selected should provide cov-
erage of bacterial fl ora of the upper aerodigestive tract
(e.g., clindamycin or ampicillin-sulbactam). It is admin-
istered before surgery and continued for 24 hours.
General anesthesia is induced only after the airway
is secured. Many patients with signifi cant airway com-
promise as a result of space-occupying lesions, scarring,
or trauma will already have a tracheostomy. If not, a
tracheotomy should be performed under local anesthe-
sia at the beginning of the procedure. Patients without
signifi cant airway compromise may be intubated and
the tracheotomy performed under general anesthesia.
Direct laryngoscopy is performed before laryngofi ssure,
whenever possible, to assess the extent or severity of any
endolaryngeal tumor, stenosis, or trauma.
A horizontal incision is preferred to provide ade-
quate exposure and a good cosmetic appearance. The
incision is placed in a skin crease over the midsection
of the thyroid cartilage (Fig. 42-1) and carried through
subcutaneous tissue and the platysma. Flaps are ele-
vated in a subplatysmal plane to expose the hyoid bone
superiorly and the caudal edge of the cricoid cartilage
inferiorly. This fi eld must be kept isolated from the
tracheostomy wound to prevent contamination of the
wound from the tracheostomy secretions. The strap
muscles are then retracted from the midline to expose
the thyroid and cricoid cartilage. The perichondrium
of the thyroid cartilage is incised in the midline and
elevated laterally to expose the most medial 2 cm of the
thyroid alae.
A preplating technique is completed with a titanium
plate conformed to the shape of the midthyroid alae.
The screw holes are drilled, and the plate is screwed in
Figure 42-1. Placing the incision in the major cervical skin crease
ensures a good cosmetic result. The level of the incision may be
adjusted according to the need for exposure of the larynx or
trachea.
A
B
Figure 42-2. A, The fi xation plate is bent to conform to the shape
of the thyroid cartilage, the holes are drilled, and the screws are
placed. B, The screws are removed, and the median thyrotomy is
performed. After the procedure, the plate and the screws are
replaced.

Chapter 42
Laryngofi ssure
337
place and then removed to perform the laryngofi ssure
(Fig. 42-2).12 This technique facilitates repair of the thy-
rotomy at the end of the procedure. The plate fi xation
preserves the angle of the thyroid alae, which is impor-
tant to prevent lateral splaying of the thyroid alae with
loss of anteroposterior projection.
A median thyrotomy is performed with the belly of
a no. 10 blade for an adult larynx or a no. 64 Beaver
blade for pediatric patients. A sagittal or oscillating saw
is necessary if the cartilage is calcifi ed. The inner peri-
chondrium should be preserved to avoid damage to the
true vocal cords. To visualize the anterior commissure,
a horizontal incision is made at the midsection of the
cricothyroid membrane, and the thyroid alae are
retracted laterally with single- or double-hook retractors
(Fig. 42-3). A horizontal incision through the cricothy-
roid membrane is preferable to a vertical incision
because it allows wider lateral retraction of the thyroid
alae.
The true vocal cords must be transected in the
midline at the anterior commissure. This area may be
identifi ed through direct visualization or by identifying
Montgomery’s aperture, which is a small hole inferior
to the anterior commissure (Fig. 42-3).2 Alternatively,
the anterior commissure may be divided transendo-
scopically during direct laryngoscopy. Transendoscopic
division of the anterior commissure facilitates its iden-
tifi cation during laryngofi ssure and is especially useful
in cases of anterior webbing.
With the endolarynx exposed, the original indica-
tion for surgery can be addressed. T1 glottic carcinoma,
particularly verrucous carcinoma, that does not involve
the anterior commissure or arytenoids can be resected
with a standard cordectomy. A paralyzed vocal fold can
be managed by arytenoid adduction or by arytenoidec-
tomy and lateralization, depending on the needs of the
patient and the goals of surgery. In cases of laryngeal
trauma, the soft tissue laceration or avulsion can be
repaired at this time. If possible, the laryngofi ssure may
be incorporated into one of the fracture lines. Finally,
laryngeal stenosis can be addressed by excision of scar
tissue, lysis of webs, and if applicable, local fl ap cover-
age. When considerable disruption of the laryngeal
mucosa has occurred (e.g., extensive laryngeal trauma
or signifi cant scar or web excision), placement of a keel
or stent may prevent postoperative scarring at the ante-
rior commissure.
After completion of the endolaryngeal aspect of the
operation, the anterior margin of the true vocal cord is
reattached to the anterior edge of the corresponding
thyroid ala via a horizontal mattress suture with perma-
nent monofi lament material (e.g., nylon, Prolene) (Fig.
42-4). This suture will prevent retraction of the vocalis
muscle and the associated shortening of the vocal fold,
as well as minimize the likelihood of anterior glottic
web formation postoperatively.
The thyrotomy is then closed by replacing the pre-
formed titanium plate (Fig. 42-5). The perichondrium
is reapproximated with interrupted absorbable suture
(e.g., Dexon, Vicryl) (Fig. 42-6). The strap muscles are
approximated in the midline with 3-0 chromic suture.
After hemostasis is achieved, a 1/4-inch Penrose drain is
Figure 42-3. The median thyrotomy has been completed, with
preservation of the mucosa of the endolarynx. The anterior edges of
the thyroid alae are retracted laterally. The arrow indicates Montgom-
ery’s aperture, which marks the level of the anterior commissure.
Figure 42-4. Axial view demonstrating repair of the anterior vocal
cords by fi xation of the tendon of the true vocal cord to the thyroid
ala. This technique prevents contraction of the vocal cords and loss
of anteroposterior diameter.

338
Section 3
Larynx
COMPLICATIONS
In general, laryngofi ssure is associated with low morbid-
ity; most of the complications encountered during this
operation are the result of the endolaryngeal surgery
and not the approach itself. The most common com-
plication after thyrotomy is webbing of the anterior
commissure. Signifi cant webbing is usually the result of
faulty technique, such as failure to reapproximate the
cords to the anterior edge of the thyrotomy or bilateral
injury to the mucosa of vocal folds.
Failure of the thyrotomy to heal is rare and most
common in patients with compromised blood supply,
such as those with small-vessel disease (e.g., diabetes
mellitus), those who have previously undergone radia-
tion therapy, and those with disorders associated with
delayed healing (e.g., Cushing’s disease). Other impor-
tant causes of nonhealing are the presence of a foreign
body or residual tumor.
Most cases of nonhealing of a thyrotomy are associ-
ated with a laryngocutaneous fi stula. A laryngocutane-
ous fi stula may be treated with local care and observed
for a reasonable period (2 to 3 weeks). During this time
the patient is maintained on clear liquids, and supple-
mental enteral nutrition is continued via a silicone
nasogastric tube. This therapeutic approach will be suc-
cessful in most patients.
If the problem persists, the endolarynx should be
evaluated by direct laryngoscopy to assess the possibility
of a tumor or foreign body at the thyrotomy site. Stable
plate fi xation may be preserved even in the presence of
a laryngocutaneous fi stula. If the plate is unstable, it
should be removed because it becomes a nidus for bac-
terial growth. The laryngeal cartilage depends on the
perichondrium for its blood supply. Denuded cartilage
exposed to the lumen of the airway behaves as a foreign
body and should be débrided.
Figure 42-5. Intraoperative photograph taken after the thyrotomy
was repaired with plates.
A
B
Figure 42-6. A, The perichon-
drium and strap muscles are
repaired with absorbable stitches.
B, Axial view demonstrating plate
repair with preservation of the
angle of the anterior thyroid carti-
lage to maintain anteroposterior
diameter.
left subplatysmally and brought out at one of the lateral
ends of the wound. The wound is irrigated and the
platysma is reapproximated with a similar technique.
The skin is closed with 6-0 mild chromic or fast-
absorbing gut suture and wound tape. A compressive
dressing is applied.

Chapter 42
Laryngofi ssure
339
Malunion of the thyrotomy may cause glottic insuf-
fi ciency because of healing of the vocal cords at differ-
ent levels. Failure to re-establish the natural angle of
thyroid cartilage results in poor voice. This is unusual
if the cartilage is carefully reapproximated, especially
after using a miniplate fi xation technique with preplat-
ing. This problem is corrected by repeat thyrotomy and
repositioning of the thyroid alae.
References
1. Alberti PW: Panel discussion: The historical development of lar-
yngectomy. II. The evolution of laryngology and laryngectomy in
the mid-19th century. Laryngoscope 85:188-298, 1975.
2. Montgomery W: Laryngeal stenosis. Surgery of the larynx. In
Montgomery W (ed): Surgery of the Upper Respiratory System.
Philadelphia, Lea & Febiger, 1989, pp 677-750.
3. Milczak HA, Smith JD, Everts EC: Congenital laryngeal webs:
Surgical management and clinical embryology. Int J Pediatr
Otorhinolaryngol 52:1-9, 2000.
4. Rinne J: Late results of laterofi xation in the treatment of bilateral
abductor paralysis of the vocal cords: A clinical study with long-
term follow-up. Clin Otolaryngol Allied Sci 16:436-441, 1991.
5. Woodman DG, Pennington CL: Bilateral abductor paralysis: 30
years experience with arytenoidectomy. Ann Otol Rhinol Laryn-
gol 85:437-439, 1976.
6. Montgomery W: Subtotal laryngectomy for carcinoma of the
larynx: Laryngofi ssure and cordectomy. Surgery of the larynx. In
Montgomery W (ed): Surgery of the Upper Respiratory System.
Philadelphia, Lea & Febiger, 1989, pp 521-607.
7. Tucker HM: Malignant tumors. In Tucker HM (ed): The Larynx.
New York, Thieme Medical, 1987, pp 207-306.
8. Cummings CW, Sessions DG, Weymuller EA Jr, et al: Thyrotomy
with keel for acute traumatic injury of anterior glottis. In Cum-
mings CW, Sessions DG, Weymuller EA Jr, Wood P (eds): Atlas
of Laryngeal Surgery. St Louis, CV Mosby, 1984, pp 115-136.
9. Silver CE: Conservation surgery for glottic carcinoma. In Silver
CE (ed): Surgery for Cancer of the Larynx and Related Struc-
tures. New York, Churchill Livingstone, 1981, pp 83-143.
10. de Campora E, Radici M, de Campora L: External versus endo-
scopic approach in the surgical treatment of glottic cancer. Eur
Arch Otorhinolaryngol 258:533-536, 2001.
11. Sichel JY, Dangoor E, Eliashar R, et al: Management of congenital
laryngeal malformations. Am J Otolaryngol 21:22-30, 2000.
12. Woo P, Kellman R: Laryngeal framework reconstruction with
miniplates: Indications and extended indications in 27 cases.
Oper Tech Otolaryngol Head Neck Surg 3:159-164, 1992.
PEARLS
• Laryngofi ssure provides a versatile approach to a
variety of diseases of the endolarynx, including
benign and malignant tumors, vocal fold paralysis,
laryngeal trauma, and laryngeal stenosis or webs.
• Patients with anatomy that is unfavorable for
endoscopic approaches are excellent candidates for
laryngofi ssure.
• Preplating the thyroid alae minimizes the likelihood
of malunion and its associated complications.
• When laryngofi ssure is performed for malignant
tumors, preoperative imaging is essential to rule out
cartilage invasion and other contraindications to
this approach.
• Laryngofi ssure is considered “clean-contaminated”
surgery, and perioperative antibiotics should be
used to prevent wound infection.
PITFALLS
• Failure to perform a tracheostomy before the
laryngofi ssure provides suboptimal exposure of the
endolarynx during surgery and a potentially unstable
airway postoperatively.
• Inadequate resuspension of the anterior margin of
the vocal cords at the anterior commissure may
result in an anterior glottic web, shortening of the
vocal folds, and poor voice quality postoperatively.
• A laryngocutaneous fi stula generally results from
malunion of the thyroid cartilage but often resolves
with conservative therapy.
• Failure of a postoperative laryngocutaneous fi stula
to heal may indicate the presence of residual tumor,
infection, or a foreign body.
• Recurrent respiratory papillomatosis is a
contraindication to laryngofi ssure because it may
result in dissemination of disease in the neck.

Chapter 43
Excision of Laryngocele
Eugene N. Myers
Laryngoceles are uncommon disorders of the larynx.
Galen fi rst mentioned the laryngeal ventricle in the
second century ad.1 Morgagni described the laryngeal
ventricle in 1741.2 Napoleon’s surgeon Baron Larrey is
credited with the fi rst clinical observation of a laryngo-
cele in 1829.3 He suspected that it was a form of goiter
that caused “air tumors” in religious cantors and army
drill instructors. In 1837, Hilton detailed the anatomy
of the laryngeal saccule, which is also known as Hilton’s
saccule.4 Virchow fi rst coined the term “laryngocele” in
1863, calling it a tumor-like lesion with an anomalous
air sac communicating with the laryngeal ventricle.5
Abercrombie in 1881 described congenital laryngeal
cysts in infants.6 In 1915, Shambaugh and Lewis
described laryngeal diverticula.7 In 1970, DeSanto,
Devine, and Weiland from the Mayo Clinic published
what is currently considered to be the defi nitive system
for classifying laryngeal cysts.6 They suggested that the
term laryngocele be confi ned to air-fi lled sacs that com-
municate freely with the laryngeal lumen. Saccular cysts
develop from congenitally large saccules, are fi lled with
fl uid, and do not communicate with the laryngeal
lumen. They distinguished three forms of laryngocele
and grouped them by the anatomic area involved into
internal, external, and mixed types. An internal laryn-
gocele is confi ned to the larynx and extends posterosu-
periorly into the false vocal cord and aryepiglottic fold.
In the external type, there is a cystic enlargement in the
neck only that is typically manifested as a mass lateral
to the thyroid ala. The mixed or combined form com-
bines the internal and external types, with a connecting
isthmus passing through the thyrohyoid membrane
(Fig. 43-1).4 Laryngoceles may be unilateral or bilateral
and are classically fi lled with air, but they may also
contain mucus or other inspissated material. A laryngo-
pyocele is defi ned as a secondary infection in an exist-
ing laryngocele.6
The saccule of the laryngeal ventricle is a normal
structure seen as an outpouching of mucous membrane
that contains mucous glands between the true and false
vocal cords at the anterior one third of the ventricle.8
Internal laryngoceles remain inside the larynx and are
located in the laryngeal ventricle beneath the mucosa
of the false vocal cord and the aryepiglottic fold. The
size of the saccule in normal persons varies greatly.9-11
Broyles9 showed that the height of the saccule is less
than 8 mm in 75% of normal larynges, between 10 and
15 mm high in 17%, and greater than 15 mm in 8%.
Laryngoceles are usually air fi lled but may be fi lled
with mucus or pus and form a mucocele or muco-
pyocele, respectively.12 A laryngocele may become symp-
tomatic at any time during the patient’s life. Holinger13
reported on nine children in whom a laryngocele was
diagnosed. Eight were infants younger than 2 months,
and one was 3 years old and had been symptomatic
since birth. Most laryngoceles, however, are said to arise
in the sixth decade of life.6
There is confusion in the literature regarding the
exact nomenclature between an internal laryngocele
and saccular or ductal cysts, which may be clinically and
histologically indistinguishable from each other, par-
ticularly if the laryngocele is fi lled with fl uid. Histologi-
cally, more than one half of cysts are lined by respiratory
epithelium; the remainder have a stratifi ed squamous,
columnar, or cuboidal epithelium or some combina-
tion of these types. Aggregates of lymphoid tissue have
been observed in about one half of the patients. The
presence of lymphoid tissue is not diagnostic of this
lesion and does not support a branchial origin of these
cysts because the larynx develops medial to the visceral
pouches.14 Normally, the secreted mucus is evacuated
through the ventricular opening. However, after laryn-
geal trauma, neoplasm, or chronic infl ammation,
obstructed mucus can stagnate in the laryngocele and
lead to stenosis of the neck of the saccule. The glands
continue to secrete mucus, which causes an increase in
size of the laryngocele.
The presence of a laryngocele/saccular cyst in a
newborn is classifi ed as congenital. Laryngoceles in
adults are thought to be acquired. There are anecdotal
341

342
Section 3
Larynx
descriptions of an increased incidence of laryngoceles
in patients who are glassblowers or who play a wind
instrument, singers, and patients with partial laryngeal
obstruction. This suggests that chronic increases in
intralaryngeal pressure predispose an individual to the
development of a laryngocele. Most patients with a
laryngocele do not have these occupations; therefore,
it would appear that there may have been a congenital
abnormality that did not become apparent until later
in life. Dray and colleagues described a patient with
bilateral internal laryngoceles who used the false vocal
cords for phonation.15 However, careful review of the
case report suggests that the laryngoceles were probably
due to obstruction caused by long-standing recurrent
laryngeal papilloma. Khan and coauthors reported a
previously asymptomatic 14-year-old patient who under-
went reconstructive hand surgery under general anes-
thesia with a laryngeal mask.16 Several minutes after
normal ventilation, bilateral neck swelling was noticed.
During face mask ventilation, the neck swelling
increased with positive pressure and then collapsed. An
endotracheal tube was inserted and the remainder of
the procedure was uneventful, and postoperatively the
patient recovered satisfactorily with no further treat-
ment. Based on the clinical course it was assumed
that the patient had bilateral internal/external
laryngoceles.
Two other interesting aspects about laryngoceles
should be mentioned. One is that these sacs usually
contain mucus and may therefore become secondarily
infected and be manifested as a laryngopyocele. Patients
in this situation may be “septic” and have stridor requir-
ing stabilization of the airway by either tracheotomy or
drainage of the cyst together with antibiotic therapy.
Computed tomography (CT) is helpful in making this
diagnosis and demonstrating uniform low density,
although the density of the cyst may vary with its protein
content.
The second interesting aspect is that a laryngocele
may be related to squamous cell carcinoma of the
larynx. Approximately 70 reports, encompassing 336
patients in whom laryngoceles were found to coexist
with squamous cell carcinoma of the larynx, have been
published in the literature. Studies devoting special
attention to the detection of laryngoceles suggest that
squamous cell carcinoma is associated with occult laryn-
goceles in up to 28% of patients. When the tumor and
the laryngocele are closely associated anatomically,
treatment is less straightforward. Embryologically, the
saccule arises from the roof of the ventricle and is a
supraglottic structure. In theory, a supraglottic tumor,
even when associated with a laryngocele, should be
amenable to supraglottic laryngectomy if the usual
criteria are met.11 Cassano and associates reported
a patient with a decreased laryngeal airway in whom a
laryngopyocele was diagnosed that proved on biopsy to
be squamous cell carcinoma.17 The patient underwent
subtotal reconstructive laryngectomy with bilateral neck
dissection. The authors emphasized that the presence
of a laryngocele is always a precise indication for detailed
inspection of the ventricle in search of cancer. I encoun-
tered a patient recently who had a laryngocele associ-
ated with squamous cell carcinoma of the larynx
(Fig. 43-2).
Symptoms of laryngocele include hoarseness,
dyspnea, dysphagia, and cough. These symptoms are
present to varying degrees, depending on the extent of
the laryngocele. A laryngocele should be considered in
the differential diagnosis when painful swelling of the
neck and fever are present. The authors recommended
excision through a transcervical approach, including
the internal component of the laryngocele. Direct
laryngoscopy is always used to evaluate the interior of
the larynx and to rule out cancer.
Harney and coworkers reported a laryngocele in a
patient with hoarseness and a long history of cigarette
smoking.12 CT demonstrated a large laryngocele with
an adjacent tumor mass involving the supraglottic
larynx that on biopsy revealed squamous cell carci-
noma. The patient was treated with radiation therapy.
A
B
Figure
43-1. A,
Computed
tomography scan demonstrating a
large internal and external laryn-
gocele manifested as a mass in the
neck. B, Diagram of a combined
internal-external laryngocele.

Chapter 43
Excision of Laryngocele
343
Carrat and colleagues reported a patient with squamous
cell carcinoma who was treated by supracricoid laryn-
gectomy and some years later an external laryngocele
developed, presumably secondary to scarring.18
When therapy is being planned, patients with con-
current laryngocele and laryngeal cancer can be catego-
rized into two groups. In the fi rst group, the squamous
cell carcinoma involves the larynx but does not invade
the laryngocele or the ipsilateral ventricle; standard
treatment of the laryngeal tumor would appear logical.
In these cases one may regard the laryngocele as an
incidental fi nding. In the second group, the cancer is
located within the laryngocele and may be the cause of
the laryngocele by obstructing the ventricle. Because
carcinoma within a laryngocele is diffi cult to diagnose
endoscopically, it is advisable to study the larynx radio-
logically in the preoperative period.19
PATIENT SELECTION
A laryngocele may become clinically apparent in several
ways. Symptoms depend on the size and location of the
cyst and the patient’s age. Respiratory distress in infants
as a result of a laryngocele may be aggravated by head
position or feeding. The most frequent symptoms of a
laryngocele/saccular cyst include hoarseness, dyspha-
gia, pain, and progressive airway obstruction. Adults
may have a muffl ed voice, stridor, dysphagia, or a mass
in the neck. Pennings and associates described two
patients with upper airway obstruction.20 One patient
had a giant laryngocele and required urgent tracheot-
omy to stabilize the situation; the other had a giant
saccular cyst. A laryngocele is normally in open com-
munication with the laryngeal lumen and is at least
partially fi lled with air, whereas a saccular cyst does not
communicate with the laryngeal lumen and is generally
fi lled with mucus. Affected patients usually have an
occasional intermittent minor change in their voice,
hoarseness, or a vague unexplained fullness in their
neck. A patient with an infected laryngocele may have
signs of cellulitis or an abscess in the neck with pain,
tenderness, hyperemia, and fullness in the area of the
false vocal cord and aryepiglottic fold on laryngeal
examination. Impending airway distress and sepsis may
be present. In the case of an external laryngocele, a
mass may be palpated in the neck adjacent to the
thyroid cartilage.
The interior of the larynx should be examined in
the offi ce by indirect fl exible laryngoscopy. The classic
fi nding is submucosal swelling of the area of the false
cord and aryepiglottic fold. Visualization of the ipsilat-
eral and sometimes contralateral vocal cord may be
obscured by the mass. This fi nding and the status of the
vocal cord should be confi rmed at direct laryngoscopy.
The neck should be examined for the presence of an
external component. Swelling will often appear in the
neck ipsilateral to the mass in the larynx when a Valsalva
maneuver is performed. If an external component is
noted and compressed, a hissing and gurgling sound
may be produced and is known as Bryce’s sign.21
CT is valuable and may demonstrate an air- or fl uid-
fi lled cystic mass that may be confi ned to the larynx or
have an external component and may be unilateral or
bilateral. These masses appear as hypodense homoge-
neous endolaryngeal or combined endolaryngeal and
extralaryngeal
masses
extending
extralaryngically
through the thyrohyoid membrane. CT has been the
primary imaging study used because of its ability to
provide a defi nitive diagnosis of laryngocele through
cross-sectional imaging and its superior contrast resolu-
tion.22 CT is also useful in mapping the extent of a
laryngocele and aiding in treatment planning.23,24 Mag-
netic resonance imaging (MRI) is superior in its ability
to evaluate soft tissue and can generally distinguish
obstructed mucus and infl ammation from neoplastic
disease. An uncomplicated laryngeal cyst is usually
homogeneously hypodense on non–contrast-enhanced
CT scanning. Laryngopyocele displays peripheral rim
enhancement, whereas mucus or purulent contents
have a CT density similar to that of adjacent soft
tissue.
Harvey and colleages reported a patient who under-
went radiation therapy for squamous cell carcinoma of
the vocal cord.25 The patient was seen later with a 1-
month history of progressive hoarseness. Physical exam-
ination revealed that the right true vocal cord was fi xed.
MRI showed thickening of the right vocal cord consis-
tent with recurrent cancer, as well as an internal laryn-
gocele. MRI accurately depicted the vocal cord lesion
and its extent.
Figure 43-2. Computed tomography scan revealing a laryngocele
associated with squamous cell carcinoma.

344
Section 3
Larynx
Close and coauthors, in their report of 305 patients
undergoing CT scanning of the neck for unrelated cir-
cumstances, discovered 39 cases of laryngocele, 38 of
which were asymptomatic.26
Gallivan and Gallivan reported two brass instru-
mentalists who while playing their instruments noted
remarkable bulging in the anterior triangle of the
neck.1 Flexible laryngoscopy revealed internal and
external laryngoceles that appeared during brass playing
and disappeared spontaneously with cessation of
playing.
SURGICAL TECHNIQUE
An internal laryngocele (Fig. 43-3) or saccular cyst may
be treated by transoral endoscopic CO2 laser excision.
Once the laryngoscope is inserted and suspended, the
cyst may be removed in one of two ways. If a CO2 laser
is available, the entire false vocal cord is removed in an
anterior-to-posterior direction with an interrupted
cutting pulse (Fig. 43-4). Dissection is carried down
to the perichondrium of the ventricle, and the tissue
is removed. The cystic structure that will be revealed
is the epithelial lining of the laryngocele; this is dis-
sected out with the lesion. The procedure can be safely
carried out even with a large internal laryngocele, which
often relieves progressive airway obstruction.27 The
authors correctly point out that endoscopic laser mar-
supialization or laser vestibulectomy have been used for
the treatment of intact laryngocele and symptomatic
saccular cysts. We have encountered several patients
with benign cystadenoma that was thought preopera-
tively to be a laryngocele. The diagnosis was made only
after the lesion was removed for pathologic examina-
tion. During the laser procedure, effort should be made
to protect the underlying vocal cord from injury by the
laser.
If a CO2 laser is not available or the surgeon is not
trained in this technique, the incision in the false vocal
cord can be made as described earlier with upward-
biting microscissors. Via sharp dissection, the false vocal
cord may also be removed piecemeal with large-cup
biting forceps. Once the false vocal cord is removed,
the cystic lesion is revealed and dissected free from the
mucosa or perichondrium of the ventricle without
injuring the vocal cord.
Thyrotomy Approach
The lateral thyrotomy approach to the paraglottic space
through a vertical split of the thyroid lamina just ante-
rior to the superior cornu was fi rst proposed by Lewis
in 1914.28 New and Erich modifi ed this approach by
dividing the thyroid lamina at the junction of the ante-
rior and middle third, splitting it in half, retracting the
halves, resecting the cyst under direct vision, and sutur-
ing the halves of the lamina back into position.29,30
Accessibility to the paraglottic space has also been
achieved by resecting a horizontal portion of the thyroid
lamina through an en bloc31-35 or a biting-forceps surgi-
cal technique.36 Keim and Livingstone removed a trian-
gular segment at the superior thyroid lamina and the
greater cornu of the hyoid bone to enlarge the opera-
tive fi eld for resection of an internal laryngocele that
had previously been irradiated.37 Malis and Seid devel-
oped a lateral thyrotomy technique in which a rectan-
gular, fold-down, lateral thyroplasty (“trapdoor” fl ap)
was used to approach congenital lateral saccular cysts,
and an inferiorly based thyroid cartilage perichondrial
fl ap was raised.38 Netterville and coworkers gained
access to the paraglottic space through a window or a
trapdoor fl ap in the lateral thyroid lamina, which they
Figure 43-3. Endoscopic view of an internal laryngocele. (The
authors gratefully acknowledge the contribution of this photo by Eiji Yanagi-
sawa, MD.)
Figure 43-4. The incision is made with the CO2 laser used for exci-
sion of an internal laryngocele.

Chapter 43
Excision of Laryngocele
345
used for complete removal of Tefl on granuloma.39
Thome and associates used a lateral thyrotomy approach
to the paraglottic space.40 The authors excised a trian-
gle of thyroid cartilage, the base of the triangle being
superior along the posterior aspect of the thyroid
lamina and the apex interior. This technique allows
access to the paraglottic space and provides superb vis-
ibility for resection of a laryngocele of any size under
direct vision, thereby avoiding recurrence, morbidity,
and complications.
The cervical approach is used in patients who have
a combined laryngocele. A rolled-up blanket is placed
under the shoulders for extension, and the patient’s
head is turned away from the side of the lesion. The
patient is prepared and draped in the usual manner for
a cervical approach under endotracheal anesthesia. An
incision is made in a skin crease at the level of the thy-
rohyoid membrane (Fig. 43-5A). Dissection is carried
down through platysma muscle and fascia. The laryngo-
cele can be palpated and will easily be identifi ed in the
neck (Fig. 43-5B). The wall of the sac is grasped gently
and dissected medial to its point of origin in the larynx,
which protrudes through the thyrohyoid membrane
just superior to the thyroid ala. An incision is made in
B
A
C
Figure 43-5. A, An incision is made
in a skin crease at the level of the
thyrohyoid membrane. B, The laryn-
gocele is identifi ed and dissected to
the point of entry into the larynx. C,
An incision is made in the perichon-
drium of the thyroid ala. The soft
tissue attachments of the sac to the
thyroid membrane and the false vocal
cord are dissected free.

346
Section 3
Larynx
the perichondrium of the superior aspect of the thyroid
cartilage; a sharp periosteal elevator is used to elevate
the perichondrium of the inner aspect of the thyroid
cartilage while the soft tissue attachments of the laryn-
gocele to the thyrohyoid membrane and false vocal
cord are dissected out (Fig. 43-5C). If further exposure
is necessary, an oscillating saw may be used to resect the
superior one third of the thyroid ala. This technique
does not result in any diffi culties postoperatively.
Further medial dissection leads to the ventricle, where
the remainder of the sac can be identifi ed, dissected
out, and excised. Hemostasis is obtained, the wound is
irrigated and closed in layers over a Hemovac drain,
and a dressing is applied. The interior of the larynx
should be examined by direct laryngoscopy. Usually,
there is more space than there was at the beginning
rather than edema or other problems, and a tracheot-
omy is not usually necessary. Care must be taken to
avoid injury to the superior or recurrent laryngeal
nerves and their branches.
In children, aspiration of the intralaryngeal portion
of the cyst has been reported to provide temporary
relief. However, mucus will again fi ll the cystic space,
and the same symptoms will recur. If the cyst is confi ned
to the ventricle, the procedure described earlier should
be carried out as early after the diagnosis is made as
possible without putting the patient through unneces-
sary minor procedures. If there is an external compo-
nent, the external approach should be carried out.
POSTOPERATIVE MANAGEMENT
Intravenous antibiotics are administered periopera-
tively for excision of an external laryngocele, because
the neck is exposed to the potentially contaminated
secretions of the airway. Patients who are currently or
have previously been infected should also receive anti-
biotics. The Hemovac drain may be removed when
drainage has stopped, after which the patient may be
discharged safely.
COMPLICATIONS
Airway problems are the most frequent complication.
Unless the airway is defi nitely compromised in some
way, a tracheostomy is not usually necessary. Care should
be taken to make certain that there is no communica-
tion between the laryngeal ventricle and the neck to
prevent subcutaneous emphysema and infection. The
internal and external branches of the superior laryn-
geal nerve do not necessarily have to be identifi ed, but
the surgeon must be aware of the proximity of an exter-
nal laryngocele to branches of the superior laryngeal
nerve. Unless a great deal of previous infection has
caused scar tissue, the dissection is simple and straight-
forward and should be done bluntly to avoid injury to
neurovascular structures.
The major pitfall in this procedure is the possibility
of not resecting the entire sac, whether it be internal,
external, or combined, in which case recurrence would
be expected.
PEARLS
• Internal laryngocele/saccular cysts should be
removed by direct suspension microlaryngoscopy
and CO2 laser.
• Internal and external laryngoceles are approached
through a transcervical approach.
• Imaging studies are valuable in determining whether
a pure internal or an internal-external laryngocele is
present.
• Intralaryngeal manipulation must be kept to a
minimum to avoid airway obstruction.
• Patients with airway obstruction as a result of a
giant laryngocele or laryngopyocele may need a
tracheotomy to establish a safe airway.
PITFALLS
• Lack of imaging studies may result in leaving an
external component behind after removal of what
clinically appeared to be a pure internal laryngocele.
• Failure to resect the entire laryngocele may result in
recurrence.
• Subcutaneous emphysema or recurrent infection
may occur if any communication remains between
the larynx and the neck.
• Airway management is a key feature in managing a
giant or infected laryngocele.
• Dissection of the external component of the
laryngocele may be diffi cult in patients who have
had a laryngopyocele. Care should be taken to avoid
injury to the neurovascular bundle.
References
1. Gallivan KH, Gallivan GJ: Bilateral mixed laryngoceles: Simulta-
neous strobovideolaryngoscopy and external video examination.
J Voice 16:258-266, 2002.
2. Holinger LD, Barnes DR, Smid LJ, et al: Laryngocele and saccular
cysts. Ann Otol Rhinol Laryngol 87:675-685, 1978.
3. Canalis RF, Maxwell DS, Hemenway CV: Laryngocele: An updated
review. J Otolaryngol 6:191-199, 1977.
4. DeSanto LW: Laryngocele, laryngeal mucocele, large saccules
and large saccular cysts: A developmental spectrum. Laryngo-
scope 84:1291-1296, 1974.
5. Baker HL, Baker SR, McClatchey KD: Manifestations and man-
agement of laryngoceles. Head Neck Surg 4:450-456, 1982.
6. DeSanto LW, Devine KD, Weiland LH: Cysts of the larynx: Clas-
sifi cation. Laryngoscope 80:145-176, 1970.
7. DeVincentis I, Biserni A: Surgery of the mixed laryngocele. Acta
Otolaryngol 87:142-151, 1979.
8. Benjamin B: Congenital disorders of the larynx. In Cummings
CW, Fredrickson JM, Harker LA, et al (eds): Otolaryngology–
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9. Broyles EN: Anatomical observations concerning the laryngeal
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10. Delahunty JE, Cherry J: The laryngeal saccule. J Laryngol Otol
83:803-815, 1969.
11. Birt D: Observations on the size of the saccule in laryngectomy
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Excision of Laryngocele
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12. Harney M, Path N, Walsh R, et al: Laryngocele and squamous cell
carcinoma of the larynx. J Laryngol Otol 115:590-592, 2001.
13. Holinger PH: Clinical aspects of congenital anomalies of the
larynx, trachea, bronchi, and oesophagus. J Laryngol Otol 75:1-
44, 1961.
14. Lawson W, Biller HF: Congenital lesions of the larynx. In Bailey
BJ, Biller HF (eds): Surgery of the Larynx. Philadelphia, WB
Saunders, 1985, pp 175-186.
15. Dray TG, Waugh PF, Hillel AD: The association of laryngoceles
with ventricular phonation. J Voice 14:278-281, 2000.
16. Khan SA, Siddiqui MMH, Khan RM: Laryngoceles and the laryn-
geal tube. Anesthesia 58:391, 2003.
17. Cassano L, Lombardo P, Marchese Ragona R, Pastore A: Laryn-
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18. Carrat X, Francois JM, Carles D, et al: Laryngomucocele as an
unusual late complication of subtotal laryngectomy. Ann Otol
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19. Celin SE, Johnson J, Curtin H, Barnes EL: The association of
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20. Pennings RJE, van den Hoogen FJA, Marres HAM: Giant laryn-
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23. Griffi n JL, Ramadan HH, Wetmore SJ: Laryngocele: A cause of
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26. Close LG, Merkel M, Burns DK, et al: Asymptomatic laryngocele:
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Laryngoscope 110:447-450, 2000.

Chapter 44
Laryngeal Trauma
Jonas T. Johnson
Trauma to the larynx accounts for less than 1% of all
trauma. This is explained in part by the fact that the
larynx is relatively protected by the mandible, the
sternum, and the fl exion mechanism of the neck. An
alternative perspective is the percentage of patients
with laryngeal injuries who are dead on arrival at the
emergency department. Line and associates1 reported
a series of 171 victims of blunt neck trauma (strangula-
tion), of whom 112 persons (65%) did not survive. It
has been estimated that the emergency departments of
busy trauma centers will treat 1 patient with laryngeal
trauma for every 5000 to 30,000 emergency department
visits.2
A basic knowledge of the laryngeal anatomy and
physiology is fundamental to understanding the prin-
ciples established for the management of laryngeal
trauma. The primary functions of the larynx are to serve
as the airway and to protect the lower respiratory tract.
The production of voice, although extremely important
for socioeconomic development, is of secondary impor-
tance. Respiratory epithelium that is part of the muco-
ciliary clearing system of the respiratory tract lines most
of the larynx. The sensory innervation of the supraglot-
tic larynx is supplied by the paired superior laryngeal
nerves, which are also branches of the vagus nerves. The
superior laryngeal nerves also innervate the cricothy-
roid muscle, which tightens the vocal folds and, accord-
ingly, is responsible for pitch. The larynx depends on a
complex arrangement of intrinsic muscles innervated
by the recurrent laryngeal nerves, which are branches
of the right and left vagus nerves. A framework com-
posed of cartilage and ligaments supports the laryngeal
soft tissue. The cartilaginous framework of the
larynx relies on the blood supply provided by the
perichondrium.
The larynx is classically divided into three anatomic
areas with different functions and characteristics (Fig.
44-1). Thus, the site of injury infl uences the manage-
ment and prognosis of laryngeal trauma. The supraglot-
tis has abundant soft tissue and redundant mucosa and
is less dependent on external support than lower areas
of the larynx. As long as the sensory innervation is pre-
served, most of the supraglottis can be lost without
major functional defi cits. On the other hand, the glottis
depends on cartilaginous support, cricoarytenoid joint
mobility, and perfect neuromuscular coordination to
perform its sphincteric and voice-producing functions.
To compound these factors, the adult airway is narrow-
est at the glottic level; therefore, any decrease in the
cross-sectional area of the airway at the level of the vocal
cords may compromise the airway signifi cantly (propor-
tional to the square of the radius). The subglottis is
supported by the cricoid cartilage, which is the only
circular cartilage of the laryngotracheal complex. This
is the narrowest point of the neonatal and infant
airway.
Trauma to the larynx may manifest in a wide variety
of ways, refl ecting a multitude of uncontrollable vari-
ables. Factors that may signifi cantly affect subsequent
patient care include patient age, mechanism of injury,
velocity of injury, and cutaneous penetration. Accord-
ingly, evaluation and management of the patient with
laryngeal trauma require accurate assessment, a working
understanding of the principles of laryngeal reconstruc-
tion, and an ability to accommodate unexpected fi nd-
ings at exploration in the operating room.
Children rarely suffer direct trauma to the larynx.
This refl ects the morphologic differences between chil-
dren and adults. The larynx, in children, is relatively
protected inasmuch as it is high in the neck and gener-
ally shielded from direct trauma by the mandible. Addi-
tionally, the soft, fl exible cartilaginous structures of the
pediatric laryngotracheal complex are more tolerant of
blunt trauma.
The mechanism of trauma greatly infl uences the
likelihood for associated injury and the need for multi-
disciplinary collaboration. In general, laryngeal trauma
is classifi ed as blunt or penetrating. The most common
349

350
Section 3
Larynx
mechanism of injury is blunt trauma.3 With a patient
injured in a motor vehicle, a broad general assessment
of the patient’s overall well-being is clearly mandated.
The ABCs (airway, breathing, circulation) of trauma
care must be recalled. Even with trauma limited to the
head and neck, the integrity of the cardiovascular
system, potential for intracranial injury, and status of
the cervical spine must always be assessed as an initial
step of management.
Blunt trauma to the cervical region may produce
serious and life-threatening injury, including total ob -
struction of the airway and signifi cant life-threatening
vascular disruption (Fig. 44-2). Cervical spine injuries
occur in a signifi cant percentage of patients and may
be unappreciated initially because of the obvious soft
tissue damage. Injuries to major structures are more
clearly apparent when a sharp instrument or penetrat-
ing missile results in soft tissue wounds. Nevertheless,
injury may be signifi cant even with minimal signs of
external wounds. Any type of blunt trauma may disrupt
the laryngeal soft tissue or its cartilaginous framework,
producing scarring, loss of support, and subsequent
collapse of the airway and stricture. It may also dislocate
the cricoarytenoid joint, leading to fi xation of the vocal
cord, or disrupt the laryngeal innervation, paralyzing
the vocal cords. It is important to realize that signifi cant
laryngeal trauma may be possible in the absence of
signs of external injury.
A peculiar injury is the one produced by strangula-
tion, which is a broad term that includes hanging, gar-
roting (ligature strangulation), throttling (manual
compression), and choke-holds. Strangulation accounts
for 10% of the violent deaths in the United States.
Victims of strangulation most often die at the site of the
incident, accounting for its infrequency as an emer-
gency department visit.4 Strangulation is characterized
by the application of a static force over the laryngeal
framework, which may fracture the cartilage and not
disrupt the mucosa. This latter fact frequently leads the
examiner to the false assumption that the victim has not
suffered a signifi cant injury. The classic injury in stran-
gulation victims is a fracture of the superior thyroid
cornu, which may be accompanied by cordal hemato-
mas, petechiae of the endolaryngeal mucosa, or aryte-
noid dislocation. A history of signifi cant bleeding that
has spontaneously resolved or a hematoma that devel-
oped rapidly suggests a major vascular injury that will
require evaluation. The Isadora Duncan syndrome con-
sists of strangulation with carotid contusion, avulsion,
or occlusion and laryngeal rupture.5
PREOPERATIVE EVALUATION
The larynx may also be involved in penetrating trauma
to the neck. It is important to recognize that approxi-
mately 60% of the patients with penetrating trauma to
the larynx will have other associated injuries, such as
neurologic vascular or esophageal injuries.2 Penetrating
trauma includes a wide range of injuries, ranging from
stab wounds to gunshot wounds. Although stab wounds
usually follow a straight line or predictable path, bullets
or other projectiles tend to follow planes of least resis-
tance (e.g., fascial planes), producing less predictable
injuries. Bullets cause injury both by direct contact as
well as tissue distention caused by the abrupt displace-
ment of the tissues produced by the bullet’s shock wave
(Fig. 44-3). The trauma caused by this shock wave
increases as the square of the velocity, hence high-
velocity weapons such as assault rifl es cause much
greater injury. Therefore, when evaluating patients with
penetrating trauma, it is important to know the circum-
stances of the attack: factors such as angle of penetra-
tion, types of bullet and weapon, and distance of attack
are all important to estimate the degree of trauma.
The integrity of the airway must be initially assessed.
Cyanosis and stridor are indications for immediate
intervention. Intubation of the acutely traumatized
Subglottis
Glottis
Supraglottis
Base of
laryngeal
ventricle
1 cm
Figure 44-1. Sagittal drawing of the larynx depicting the three
anatomic areas. The glottic larynx extends from the free edge of the
true vocal cord inferiorly 1 cm. This approximates the histologic
observation of stratifi ed squamous epithelium on the glottis changing
to respiratory epithelium of the subglottis.
Figure 44-2. Computed tomography demonstrates a displaced car-
tilage fracture. The integrity of the mucosa should be confi rmed
endoscopically. The cartilage requires reduction and fi xation.

Chapter 44
Laryngeal Trauma
351
airway may be dangerous or impossible. Tracheotomy
or, under some circumstances, cricothyrotomy should
be initiated.6
When the status of the cervical spine is either
suspect or uncertain, manipulation of the neck and
positioning of the patient for tracheotomy may be dif-
fi cult and imprudent. Under extreme circumstances,
insertion of a large-bore needle directly through the
cricothyroid membrane or into the trachea with admin-
istration of oxygen may be lifesaving and “buy time” for
defi nitive airway intervention. Patients with laryngeal
trauma almost invariably have primarily inspiratory
obstruction owing to collapsed tissue during inspira-
tion. Accordingly, oxygen delivered directly in the
trachea may be expired through the injured larynx in
most patients. Concurrent intrathoracic injury, includ-
ing pneumothorax, fractured ribs with a fl ail chest, or
a pulmonary contusion, may be the cause of respiratory
distress and must be considered.
When the airway is compromised but stable, it is
possible to carefully observe the airway in the emer-
gency setting while the remainder of the assessment is
completed. An innovative way to temporarily manage
mild airway compromise is to administer a mixture of
helium and oxygen in a ratio of 70 : 30 via a Venturi
system. Helium is less dense than nitrogen and there-
fore produces less friction and better fl ow through the
airway, decreasing the respiratory workload. A mixture
of helium and oxygen may be useful as a temporary
measure until surgical airway is established.
Ruling out cervical spine fracture will facilitate
patient movement and allow improved positioning of
the patient for tracheotomy. At minimum, this requires
anteroposterior, odontoid, and cross-table and clinical
evaluations. Some spinal cord injuries have no associ-
ated fracture; therefore, one may miss some injuries
when relying on radiographs alone. Examination for
cardiopulmonary, neurologic, orthopedic, abdominal,
and other associated injuries allows the resuscitation
team to prioritize interventions appropriately. In most
facilities, a trauma surgeon coordinates the care of the
injured patient.
Dysphonia and hoarseness in the setting of blunt
trauma to the neck must be considered evidence of
severe laryngeal injury until proven otherwise. These
patients should undergo careful clinical and radio-
graphic evaluation before disposition. Similarly, the
fi nding of cervical subcutaneous emphysema warrants
a presumptive diagnosis of a ruptured viscus structure.7
It is incumbent on the emergency team to identify
the injured area and make plans for subsequent
management.
The potential for injury to cranial nerves must be
considered. Neuropathy in the face of a sharp or pene-
trating injury is an indication for nerve exploration and
neurorrhaphy as needed at the time of surgical explora-
tion. The effectiveness of vagal or recurrent laryngeal
nerve repair is controversial. Neurorrhaphy may result
in synkinesis, but some authors have reported useful
return of motion or at least tone.8
The potential for vascular injury must be consid-
ered. An expanding hematoma or continuing hemor-
rhage from an open wound is an indication for
immediate operative exploration. If the patient is stable,
the area of the carotid sheath may be further evaluated
with various vascular imaging techniques. Blunt trauma
to the carotid may indicate occlusion or dissection,
which may not be initially apparent. The presence of a
bruit may be one indication of such an injury. The value
of close collaboration with a vascular surgery team is
apparent. Lacerations of the cervical esophagus or
pharynx may occur, primarily with penetrating injuries,
and need to be ruled out. Failure to recognize and treat
can lead to serious infectious complications. Depend-
ing on the circumstances, evaluation with either con-
trast radiographic studies or endoscopy is appropriate.
PREOPERATIVE ASSESSMENT
Strict guidelines for preoperative evaluation cannot be
employed. Rather, the circumstances surrounding the
trauma, including concurrent injuries, the mechanism
of injury, and the severity of the injury, must be inte-
grated into the diagnostic plan. Patients with impend-
ing airway obstruction must undergo immediate
tracheotomy. Similarly, patients with injury to the great
vessels may require immediate surgery. Severe or life-
threatening injuries to other bodily systems may delay
intervention for stable laryngotracheal trauma.
When circumstances permit, a careful physical
examination followed by directed imaging studies will
facilitate subsequent treatment planning, intervention,
and care. In one study of patients with laryngotracheal
injury, the most prevalent fi ndings on physical examina-
tion were subcutaneous air (53%), hoarseness (47%),
neck tenderness (27%), and stridor (20%).9
Physical examination should include assessment of
the airway and voice. Dysphonia or hoarseness suggests
laryngeal injury. The soft tissues of the neck should
be carefully observed and palpated. The loss of the
Figure 44-3. This open laryngeal injury (gunshot wound) requires
emergent establishment of a tracheotomy and then comprehensive
repair of both mucosa and framework trauma.

352
Section 3
Larynx
prominent contours of the thyroid cartilage and cricoid
ring may be signifi cant observations. Soft tissue abra-
sion and ecchymosis help confi rm the severity and
direction of injury. The presence of a mass often indi-
cates vascular injury. Soft tissue emphysema suggests
perforation of an air-containing viscus.
Examination of the oral cavity and oropharynx
should be supplemented by direct visualization of the
larynx and hypopharynx. This can be undertaken with
either a rigid telescope or fl exible fi beroptic endoscopic
equipment. The observer should note soft tissue dis-
ruption, lacerations, edema, or ecchymosis. Vocal cord
function should be ascertained. Shortening of the
anteroposterior diameter of the glottis is one indication
of thyroid cartilage fracture and subluxation. The ary-
tenoid cartilage may be dislocated. Kennedy and col-
leagues suggest that strobovideolaryngoscopy may
greatly enhance initial evaluation.10 Traumatic separa-
tion of the larynx from the trachea can occur even in
blunt injuries and is frequently associated with bilateral
vocal cord paralysis. Many patients with the injury do
not survive the acute episode, although the author’s
group has encountered a few such individuals who
survive transport to the emergency department. These
patients can survive if initial management is direct and
skillful.
Findings suggestive of trauma to the laryngotra-
cheal complex should, in almost every circumstance,
lead to subsequent imaging. Computed tomography
(CT) is useful in assessing the integrity of the laryngeal
framework as well as the cervical spine (Fig. 44-4). A CT
scan, however, is not necessary in patients presenting
with clear indications for surgery, such as active bleed-
ing, hematoma, escape of air through the external
wound, hemoptysis, need for emergency cricothyroid-
otomy, exposed cartilage, or signifi cant lacerations of
the mucosa. A CT scan is most useful in evaluating
questionable fi ndings, clinically mild injuries, and
victims of strangulation (Fig. 44-5).
It is of utmost importance to secure the airway and
to perform a fl exible laryngoscopy before transferring
the patient to the CT scanner. We prefer the use of
high-resolution CT with contrast. Undisplaced fractures
of the thyroid or cricoid cartilage in the face of normal
physical examination may require no further interven-
tion (Fig. 44-6). Displaced fractures or soft tissue disrup-
tion almost always requires surgical exploration and
repair. With soft tissue disruption, interval tracheotomy
is usually required. Early exploration invariably results
in easier reduction of cartilaginous injury and more
accurate soft tissue repair.8 Delay in the performance
of the procedure leads to scarring, edema, local infec-
tion, and distortion of tissues that may lead to a poor
outcome. We favor exploration within 24 to 48 hours if
the patient’s general condition permits. Perioperative
antibiotics are warranted and should be initiated be -
fore surgery and discontinued within 24 hours
postoperatively.
Figure 44-4. Computed tomography (CT) scan shows diffuse sub-
cutaneous emphysema. Asymmetry of the laryngeal framework sug-
gests laryngeal fracture.
Figure 44-5. This telescoping fracture of the cricoid cartilage was
the result of strangulation.
Figure 44-6. Minimal displacement of the thyroid cartilage dem-
onstrated on computed tomography scan may not require open
reduction, but the mucosa must be carefully evaluated before nonop-
erative intervention can be deemed satisfactory.

Chapter 44
Laryngeal Trauma
353
OPERATIVE TECHNIQUE
The fi rst initiative in the management of patients who
have trauma to the laryngotracheal complex is to estab-
lish a secure and safe airway. Under many circum-
stances, this is the most challenging and dangerous
aspect of the entire procedure. The most experienced
members of both the surgical and the anesthetic teams
must be present at this juncture. Delegation of this
aspect of the case to the junior members of the team is
a serious error in judgment. When preoperative assess-
ment has indicated signifi cant disruption of laryngo-
tracheal anatomy, an airway must be secured with
tracheotomy. When time permits, we prefer tracheot-
omy between the second and third or third and fourth
tracheal cartilage rather than cricothyrotomy. If crico-
thyrotomy is performed, it should be revised to a tra-
cheotomy if it will be needed for more than 7 days. The
presence of cervical spine fracture must be ruled out
before any airway or endoscopic procedure in which
the head is moved. If it cannot be ruled out, the safest
route is tracheotomy without neck extension.
Following establishment of a secure airway, diag-
nostic endoscopy is almost always indicated. Once again,
the cervical spine must be “cleared” before endoscopic
manipulation. The cervical esophagus as well as the
larynx should be examined. Cartilage displacement
without signifi cant mucosal disruption may be success-
fully managed without formally entering the airway.
Conversely, signifi cant injury to the laryngeal skeleton
with soft tissue disruption requires a direct approach
that allows soft tissue repair and reduction of the laryn-
geal fracture.
The choice of incision must consider the need for
exploration and repair of concurrent injuries as well as
the position of coexistent lacerations. When a proce-
dure is to be limited to the laryngotracheal complex, a
transverse incision may be suffi cient. Under many cir-
cumstances, a superiorly based apron fl ap is appropri-
ate. The inferior aspect of the apron will be the site of
the tracheotomy. The strap muscles are separated,
allowing direct observation of the site of injury. Frac-
tures may be reduced by employing small elevators and
hooks, taking care to avoid further damage to the car-
tilaginous structures and underlying mucosa.
When exploration of the mucosal surfaces is
required, efforts should be made to place the cartilage
incision directly through the midline at the level of the
glottis. This is facilitated by horizontally incising the
mucosa at the cricothyroid membrane, then cutting
superiorly under direct visualization. Entering the ante-
rior commissure from either side is a serious technical
error that will adversely affect the outcome of the repair.
Mucosal repair then is undertaken using fi ne absorb-
able sutures. Attachment of the true vocal cord to the
anterior commissure must be ensured (Fig. 44-7). When
in doubt, we employ a fi ne nonabsorbable suture to fi x
the anterior-most portion of the vocal cord to the ante-
rior commissure. Soft tissue avulsion injuries are
unusual, so that repair is similar to assembling a puzzle.
Lacerations and fl aps can be repaired and anatomy
restored. Rarely, denuding injuries are close to one
another, especially with penetrating injuries; these may
result in scar contracture and subsequent stenosis, so
replacement of lost mucosa with mucosal grafts or fl aps
and stenting may be required.
Stents may be either hard or soft and require stabi-
lization with nonresorbable sutures passed through
buttons. Wire tends to break and should be avoided.
The use of stents in the lumen is controversial. Clearly,
the presence of a foreign body carries with it the poten-
tial for further trauma to the mucosal surfaces of the
laryngotracheal complex. This potential disadvantage
must be weighed against the need to support cartilagi-
nous and soft tissue repairs. It is important to clearly
distinguish the functional difference between a stent
and a keel. A stent is designed to support 360 degrees
of the airway, thereby providing support to the cartilagi-
nous framework and mucosa. Theoretically, epithelial
migration can progress, circumferentially if needed,
and contracture or adhesion may be prevented. Unfor-
tunately, experience has taught that scar contracture
may progress after stent removal, and soft tissue injury
induced by stent motion or a poorly fi tting stent may
contribute to subsequent stenosis.
A keel, in contrast, is designed to keep the oppos-
ing surfaces of the two vocal cords from contracting,
thereby allowing the surface to fully mucosalize to
prevent web formation (Fig. 44-8). The presence of the
keel inserted through a laryngofi ssure may lengthen
the anteroposterior dimension of the larynx. The need
for a keel to prevent webbing at the anterior commis-
sure in patients with signifi cant injury to the true vocal
cord is far less controversial. Insertion of a keel allows
Figure 44-7. When laryngofi ssure is used to expose the larynx, the
surgeon must ensure that the anterior commissure is fi xed at the
completion of the case. This is best done by employing fi ne nonre-
sorbable suture.

354
Section 3
Larynx
migration of mucosa anteriorly and prevents adhesions
and synechiae.
Cartilage repair must be meticulous and may be
undertaken with nonresorbable suture, wire, or mini-
plating systems (Figs. 44-9 through 44-12). We and
others11,12 have successfully employed small plates to
repair injuries to the thyroid and cricoid cartilages.
Resorbable miniplates are now available.13 The surgeon
must be certain that the screws are properly sized such
that they do not penetrate the mucosal surfaces. Sup-
porting the framework in an anatomic position often
requires overcorrection of the thyroid cartilage, because
the natural vector of force tends to spread the alae,
thereby shortening the anteroposterior dimension of
the larynx.
Cricoid fractures can be elevated and wired to
either a microplate or an arch bar. Soft tissues are
returned to the anatomic position, and the wound is
closed in layers. A passive drain (e.g., Penrose) should
be employed because a watertight mucosal closure is
rarely possible. Accordingly, use of a suction drain is
imprudent in that it will aspirate mucus into the wound.
If the skin incision incorporates the tracheotomy, efforts
must be made to seal the tracheotomy wound from the
rest of the wound by approximating the subcutaneous
tissues of the fl ap to the strap muscles. Use of a com-
pressive dressing may be ill-advised, especially in the
face of cartilage injury. The administration of periop-
erative prophylactic antibiotics that are effective against
oral fl ora is indicated.
POSTOPERATIVE MANAGEMENT
Patients undergoing surgery for laryngeal trauma
should be observed postoperatively in an acute care
setting. Routine use of oximetry is advisable. Nothing is
given by mouth in the acute period. In the face of injury
to the hypopharynx or esophagus, the patient may be
fed through a nasogastric tube until edema and pain
have resolved enough to permit oral feeding. Patients
with injuries limited to the laryngotracheal complex
can frequently be fed by the third or fourth postopera-
tive day.
Routine tracheotomy care includes the use of
humidifi ed air delivered to the tracheotomy with a tra-
cheotomy mask. A T tube connector should be avoided
because it may torque the tracheotomy, producing
unnecessary damage. The nursing service should begin
regular tracheotomy care with suctioning and cleansing
of the inner cannula.
Figure 44-8. The use of a keel is intended to allow the injured
surface of the vocal cord to reepithelialize to the anterior limit of the
keel, thereby avoiding development of a side-to-side web.
Figure 44-9. This schematic demonstrates how miniplates can be
employed to repair thyroid or cricoid cartilage injuries.
Figure 44-10. Miniplates, with appropriate length screws, are
ideally suited to repair and stabilize cartilage fractures.

Chapter 44
Laryngeal Trauma
355
The tracheotomy tube can be removed when the
airway is stable and the glottis is competent to prevent
aspiration. We test for glottic competency by defl ating
the tracheotomy tube cuff. Aspiration is an indication
that the glottis is incompetent, and continued use of a
cuffed tracheotomy tube is necessary. Continued cough
may be a more subtle indication of aspiration.
The adequacy of the airway can be ascertained
through direct visualization with fi beroptic equipment.
The airway can be functionally assessed for integrity by
changing the tracheotomy to a smaller uncuffed trache-
otomy tube. The tube is then plugged and the patient
observed for respiratory distress. Patients who tolerate
the use of a plugged tracheotomy tube during a 24-hour
day may be safely decannulated. The tracheotomy site
is allowed to heal by secondary intention.
It may be advisable to prepare patients with signifi -
cant laryngotracheal trauma for home tracheotomy
care and to discharge them for subsequent follow-up
and decannulation as an outpatient. Minimal follow-up
of severe laryngotracheal injury in which stenosis may
result from scar contracture must be measured in
months.
Accidental decannulation may be life-threatening
in the case of acute repair of a laryngotracheal injury.
This is especially true in patients in whom a stent has
been inserted. Prevention is the fi rst principle in the
management of this complication. The tracheotomy
tube should be sutured to the cervical skin. Ties around
the neck are used as reinforcement. Recovery room and
intensive care personnel must be advised of the nature
of the injury. If intubation is not possible, these person-
nel, especially, must be briefed on the management of
accidental tube displacement. Tube reinsertion can be
facilitated by replacement of traction sutures through
the tracheal ring above and below the tracheotomy site.
These sutures are taped to the skin during the postop-
erative period. Replacement of a fresh tracheotomy
tube is facilitated if the patient can be placed in a head-
extended position. Direct visualization of the tracheot-
omy site facilitates proper placement of the tube. Blind
insertion of the tube into the tracheotomy site may lead
to placement in the peritracheal soft tissue anterior to
the trachea, with subsequent efforts at ventilation asso-
ciated with a high resistance and the development of
subcutaneous air or pneumothorax. This disastrous
circumstance can be prevented only by placing the
tube in the tracheal lumen. Immediate access to prop -
er lighting, retraction instruments, and small-caliber
replacement tubes may facilitate management under
emergent situations.
Mucus or saliva coming from the drain is an indica-
tion of wound dehiscence and a fi stula. The drain
should be maintained until soft tissues have had an
opportunity to seal. This usually takes 7 to 10 days, fol-
lowing which the drain can be advanced and the fi stula
tract will close. Antibiotics may be administered to
prevent the development of systemic sepsis. Premature
removal of the drain may result in a subcutaneous col-
lection with subsequent elevation of the cervical skin
fl ap. Collections require opening of the wound and
reinsertion of a drain.
The most signifi cant long-term complication of
laryngotracheal repair is stenosis. All healing tissue goes
through a period of wound contracture. Circular
wounds are the most likely to lead to stenosis. The
medical literature is replete with a menu of secondary
reconstructive techniques (see Chapter 45). Prevention
of stenosis through gentle handling of tissue, accurate
reapproximation of injured tissue, and judicious use of
stents, keels, and other lumen-keepers seems to be the
most reliable tactic.
Long-term stenting may succeed in maintaining a
lumen, but it will not prevent stenosis due to scar con-
tracture. Eventual open exploration with adequate
grafting may be necessary to create a permanent
lumen.
Figure 44-11. Complex fractures may require more than one plate
for fi xation.
Figure 44-12. Shattered laryngeal cartilage is supported by mesh
framework. A Montgomery stent is fi xed with translaryngeal-
transcutaneous sutures.

356
Section 3
Larynx
References
1. Line WS Jr, Stanley RB, Choi JH: Strangulation: A full spectrum
of blunt neck trauma. Ann Otol Rhinol Laryngol 4:542-546,
1989.
2. Schaefer SD, Close LG: Acute management of laryngeal trauma:
Update. Ann Otol Rhinol Laryngol 98:98-104, 1989.
3. Kleinsasser NH, Priemer FG, Schulze W, Kleinsasser OF: External
trauma to the larynx: Classifi cation, diagnosis, therapy. Eur Arch
Otorhinolaryngol 257:439-444, 2000.
4. Borowski DW, Mehrotra P, Tennant D, et al: Unusual presenta-
tion of blunt laryngeal injury with cricotracheal disruption by
attempted hanging: A case report. Am J Otolaryngol 25:195-198,
2004.
5. Gowens PA, Davenport RJ, Kerr J, et al: Survival from accidental
strangulation from a scarf resulting in laryngeal rupture and
carotid artery stenosis: The “Isadora Duncan syndrome.” A case
report and review of literature. Emerg Med J 20:391-393, 2003.
6. Kleinsasser NH, Priemer FG, Schulze W, Kleinsasser OF: External
trauma to the larynx: Classifi cation, diagnosis, therapy. Eur Arch
Otorhinolaryngol 257:439-444, 2000.
7. Goudy SL, Miller FB, Bumpous JM: Neck crepitance: Evaluation
and management of suspected upper aerodigestive tract injury.
Laryngoscope 112:791-795, 2002.
8. Green DC, Ward PH: The management of the divided recurrent
laryngeal nerve. Laryngoscope 100:779-782, 1990.
9. Stassen NA, Hoth JJ, Scott MJ, et al: Laryngotracheal injuries:
Does injury mechanism matter? Am Surg 70:522-525, 2004.
10. Kennedy TL, Gilroy PA, Millman B, et al: Strobovideolaryngos-
copy in the management of acute laryngeal trauma. J Voice
18:130-137, 2004.
11. De Mello-Filho FV, Carrau RL: The management of laryngeal
fractures using internal fi xation. Laryngoscope 110:2143-2146,
2000.
12. Sasaki CT, Marotta JC, Lowlicht RA, et al: Effi cacy of resorbable
plates for reduction and stabilization of laryngeal fractures. Ann
Otol Rhinol Laryngol 112(9 pt 1):745-750, 2003.
13. Bhanot S, Alex JC, Lowlicht RA, et al: The effi cacy of resorbable
plates in head and neck reconstruction. Laryngoscope 112:890-
898, 2002.
PEARLS
• Penetrating laryngeal trauma requires endoscopic
evaluation and repair of disrupted epithelium and
cartilage.
• Voice change following blunt cervical trauma
mandates evaluation of laryngeal anatomy.
• All patients with signifi cant laryngeal trauma should
be considered at risk for cervical spine injury.
• Penetrating airway trauma may be associated with
signifi cant neurovascular injury.
• Tracheotomy (or cricothyrotomy) may be required
when laryngeal trauma results in stridor or cyanosis.
• Displaced thyroid and cricoid cartilage fractures
require early reduction to improve long-term results.
• Keels and stents may facilitate epithelial regrowth
and prevent scarring following major disruption.
• Tracheotomy tubes must be secured in the presence
of severe laryngeal trauma.
PITFALLS
• Failure to reduce a signifi cant laryngeal fracture may
result in permanent dysphonia.
• Failure to establish normal contour of the thyroid
cartilage will result in poor voice and often requires
rigid fi xation.
• Failure to observe and document post-traumatic
injuries may lead to patient dissatisfaction.
• Poorly secured tracheotomy tubes may lead to
airway obstruction.
• Laryngeal stents and keels may obstruct if poorly
secured.

Chapter 45
Acquired Laryngeal Stenosis
Ryan J. Soose and Ricardo L. Carrau
The basic functions of the larynx include being the
conduit for air, protecting the airway from aspiration,
phonating, coughing, fi xing the chest for straining
activities, and maintaining positive end-expiratory pres-
sure. All these functions are impaired in patients with
stenosis.1-4
Acquired laryngeal stenosis is a rare condition. Stell
and colleagues estimated that the average otolaryngolo-
gist can expect to see fi ve cases during an entire career.4
Laryngeal stenosis may arise from a variety of causes,
and the degree of laryngeal dysfunction ranges widely.
The diversity of treatment methods reported in the lit-
erature is matched only by the imagination of the sur-
geons dealing with the problem.
ANATOMIC CONSIDERATIONS
The larynx is protected by the mandible, the sternum,
and the fl exion mechanism of the neck. Nevertheless,
it can be injured by external or iatrogenic trauma. Sys-
temic diseases, infections, and neoplasms may also
cause stenosis.
Injury to the laryngeal soft tissue or its cartilaginous
framework can lead to scarring and loss of support, with
subsequent collapse of the airway and stenosis. The
laryngeal cartilaginous framework depends on the peri-
chondrium for blood supply. Cartilage deprived of its
blood supply necroses rapidly and acts as a foreign body
that induces an infl ammatory reaction and causes
further tissue destruction and scarring. After injury, the
soft tissue planes of the larynx are disrupted and fi lled
with blood, which may develop into an organized hema-
toma and further fi brosis.
The site of injury also infl uences the development
of stenosis. Different areas of the larynx have intrinsic
characteristics that protect or predispose to various
injuries. The supraglottis has more soft tissue and more
redundant mucosa and is less dependent on external
support than the glottis or subglottis is. Supraglottic
structures such as the hyoid and epiglottis can be sacri-
fi ced without signifi cant loss of laryngeal function.
Injuries to the supraglottis are therefore associated with
a better prognosis.
The glottis represents the narrowest area in the
adult airway. The soft tissue of the glottis depends on
cartilaginous support, cricoarytenoid joint mobility,
and perfect neuromuscular coordination for normal
function. The recurrent laryngeal nerve has preferen-
tial innervation of the adductor muscles, which predis-
poses the glottis to abductor paralysis with injury.
The subglottic area is supported by the cricoid ring,
the only circular cartilage in the laryngotracheal
complex and the narrowest part of the airway in neo-
nates. The subglottis is lined with respiratory epithe-
lium over a submucosa composed of loose areolar
tissue. Respiratory epithelium is not well suited to toler-
ate trauma and is easily disrupted, thereby leading to
healing by secondary intention and scarring. These
factors make the subglottis more susceptible to stenosis
than any other region of the larynx.
ETIOLOGY
External Trauma
Increased civilian violence and motor vehicle accidents
have led to an increase in the incidence of post-
traumatic laryngeal stenosis. Even when adequate and
immediate repair is accomplished, severe disruption of
supporting structures or laryngotracheal separation is
usually accompanied by some degree of airway narrow-
357

358
Section 3
Larynx
ing.5-7 The incidence of laryngeal stenosis after external
trauma varies from 0% to 59%.
Intubation
The incidence of laryngeal stenosis after prolonged or
repeated intubation has been estimated to range from
3% to 8% in both adults and children.8-11 Figures as
high as 44% have been cited for low-birthweight neo-
nates and those with respiratory distress syndrome.8-12
Earlier endoscopy and tracheotomy in low-birthweight
infants and other high-risk groups may reduce the fre-
quency of intubation-related laryngotracheal stenosis in
these patients.12
Causes of laryngeal stenosis after intubation are
multifactorial. Mechanisms of laryngeal injury most
commonly associated with laryngotracheal intubation
include time of intubation, size of the tube, pressure
and rubbing of the shaft against the larynx, repeated
intubation, foreign body reaction to the tube, release
of toxic substances used for sterilization, use of a stylet,
route of intubation, nursing care, and anatomic differ-
ences between the genders.
Animal and clinical studies have correlated differ-
ent intubation methods with clinical and histologic
injury patterns. Nordin and Linholm,13 in a rabbit
model, correlated the degree of damage with time of
intubation and cuff characteristics. They concluded
that the pressure of the cuff over the tracheal surface
is more important than the length of intubation.
Because the microcirculation of the laryngeal mucosa
stops at a pressure of 30 mm Hg, low-volume, high-
pressure cuffs are more likely to cause ischemic injury
than high-volume, low-pressure cuffs are.
Whited,14 in a dog model, studied how the biome-
chanics of endotracheal tubes produces ulceration of
the posterior glottis and circumferential injury to the
subglottis and trachea. He demonstrated that the
infl ammatory reaction progresses even after the tube is
removed. Whited15 confi rmed the fi ndings of his animal
study in a clinical prospective study in which the degree
of injury was correlated with patterns and length of
intubation. He found that patients intubated for 2 to
5 days had a 0% to 2% incidence of chronic stenosis,
those intubated for 5 to 10 days had a 4% to 5% inci-
dence, and those with an indwelling tube for more than
10 days had a 12% to 14% incidence. He suggested that
a tracheotomy may prevent laryngotracheal stenosis in
patients who need endotracheal intubation for more
than 10 days.
Bryce16 also correlated the time of intubation with
laryngeal injuries. Lesions caused by repeated intuba-
tion were the most severe. This study suggested that
perichondritis is the most signifi cant factor for the
development of stenosis.
Age is another important factor infl uencing the site
and degree of stenosis. Neonates show a predisposition
for subglottic involvement,9 whereas adults are more
prone to posterior commissure lesions.8,11 Nevertheless,
combined stenosis accounts for about one third of all
cases of laryngeal stenosis at any age.
Tracheotomy
A high tracheotomy may be associated with glottic and
subglottic injury. The type of incision and biomechani-
cal factors related to the tube contribute to the devel-
opment of stenosis.17 Ideally, a tracheotomy should be
performed through the third or fourth tracheal ring. A
high tracheotomy through the fi rst tracheal ring or the
cricoid cartilage may lead to cricoid chondronecrosis
with resultant fi brosis and stenosis.
Similarly, cricothyroidotomy has been associated
with a higher incidence of laryngeal stenosis than tra-
cheotomy has. The cricothyroid membrane ranges from
8 to 13 mm (average of 9 mm) in adults.18 Damage to
the cricoid as a result of the introduction of microor-
ganisms or direct trauma to the cartilage may lead to
chondronecrosis. Tracheotomy tubes are poorly suited
to intubate the subglottic larynx because of the lack of
overlying soft tissue. In addition, the outer diameter of
a no. 6 Shiley tracheotomy tube is 10 mm, which is
larger than the height of the cricothyroid membrane in
a signifi cant proportion of the population.
Endoscopy
The effects of endoscopic instruments on the laryngeal
airway refl ect the care and skill of the operator. Rough
handling of tissue, excessive biopsy of tissue, inadver-
tent or inaccurate laser ablation, and oversized instru-
ments all promote tissue fi brosis and stenosis.
Caustic Burns
The sphincteric action of the supraglottis often impedes
contact of an ingested caustic agent with the glottis.
Consequently, severe caustic burns of the supraglottis
usually occur without any involvement of the glottis.
The pharyngeal walls, however, are commonly injured
as the chemical passes into the cervical esophagus.
Caustic burns are characterized by extensive destruc-
tion of mucosa, submucosa, and muscles. The subse-
quent wound contracture and fi brosis may result in
dysfunction.
Nasogastric Intubation
Nasogastric tubes are an often overlooked source of
trauma. Nasogastric intubation produces infl ammation
secondary to a foreign body reaction to the tube, swal-
lowing impairment with pooling of secretions, pressure
necrosis, and gastropharyngeal refl ux. All these factors
play a role in the development of postcricoid ulceration
with resultant perichondritis. Healing leads to fi brosis
and contracture. The trauma associated with the naso-
gastric tube may be synergistic with the trauma induced
by an endotracheal tube.
Infectious and Granulomatous Diseases
Tuberculosis, histoplasmosis, blastomycosis, leprosy,
and syphilis are endemic in several areas of the world.
They share a common phase of erythema and edema
that progresses to chondritis, necrosis, and scarring.19