Nova Medical Centers KAILASH COLONY

New Delhi

©2009. Nova Medical Centers. Strictly private and confidential

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LARYNGEAL SURGERY IS

WELL SUITED TO

AMBULATORY PRACTICE

Dr. Lalit Mohan Parashar

Deptt of Otorhinolaryngology and

Head & Neck Surgery

Dr. Lalit Mohan Parashar Senior Consultant OTORHINOLARYNGOLOGY &

HEAD and NECK SURGERY

(ORL&HNS)

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The Problem

• Laryngeal Surgery involves airway

• And thereby the problems

• Requiring immediate solutions

• Trained staff

• Tracheostomy may be required

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The Problem

• Most of the ENT Surgery involves airway

• And thereby the problems

• Requiring immediate solutions

• Trained staff

• Tracheostomy may be required

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E.N.T. Surgery :-

ENT Surgeries:-

EAR -:

Cochlear Implants - Myringotomy and Grommet insertion- Tympanoplasties- Stapedectomy with piston placement Mastoidectomy- Sac Decompression- Facial Nerve Decompression and repair.

Endoscopies:

laryngoscopy,

bronchoscopy oesophagoscopy and nasopharyngoscopy with flexible fibreoptic or rigid scopes.

Nose -:

Septoplasty- Septorhinoplasty-

Functional Endoscopic Sinus Surgery- polyposis Trans Nasal Neuro Surgeries- including pituitary tumours and skullbase surgery Optic Nerve Decompression- Orbital decompression-

THROAT -:

Tonsillectomy- Adenoidectomy- endoscopic guidance to ensure complete removal Micro-Laryngeal Surgeries- Uvulo – Palatoplasty- treatment of snoring/ OSA Obstructive Sleep Apnoea Pharyngoplasty- Laryngofissure and other voice box surgeries Tracheal Surgeries

Head & Neck Surgeries –

Parotidectomy Sub- Mandibular Excision

Neck Dissections Thyroidectomies

Parathyroidectomies

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ENT Surgeries:-

EAR -:

Cochlear Implants - Myringotomy and Grommet insertion- Tympanoplasties- Stapedectomy with piston placement Mastoidectomy- Sac Decompression- Facial Nerve Decompression and repair.

Endoscopies:

laryngoscopy,

bronchoscopy oesophagoscopy and nasopharyngoscopy with flexible fibreoptic or rigid scopes.

Nose -:

Septoplasty- Septorhinoplasty-

Functional Endoscopic Sinus Surgery- polyposis Trans Nasal Neuro Surgeries- including pituitary tumours and skullbase surgery Optic Nerve Decompression- Orbital decompression-

THROAT -:

Tonsillectomy- Adenoidectomy- endoscopic guidance to ensure complete removal Micro-Laryngeal Surgeries- Uvulo – Palatoplasty- treatment of snoring/ OSA Obstructive Sleep Apnoea Pharyngoplasty- Laryngofissure and other voice box surgeries Tracheal Surgeries

Head & Neck Surgeries –

Parotidectomy Sub- Mandibular Excision

Neck Dissections Thyroidectomies

Parathyroidectomies

E.N.T. Surgery :-

How can the patient go home ?

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E.N.T. Surgery :-

•So What has changed ?

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E.N.T. Surgery :-So What has changed ?

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E.N.T. Surgery :-So What has changed ?

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E.N.T. Surgery :- Particularly Laryngeal Surgery

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E.N.T. Surgery :- Particularly Laryngeal Surgery

• There have been certain advances:- • 1. In Diagnosis • 2. In understanding Disease • 3. In the Technology in Surgery • 4. Others

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Effective Diagnosis

• Begins at OPD • Clinched in Endoscopy Rooms • Confirmed with/ without Stroboscopy &

• Refined in Voice Lab

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THE ENT OPD

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THE ENT OPD

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Endoscopy

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Endoscopy Room

Normal larynx during phonation3.flv

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Video –endoscopy- stroboscopy

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Vocal Cord Growth

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FUNCTIONAL PRINCIPLES

• BLOOD IN CONTACT WITH CARTILAGE LEADS TO RESORPTION • CARTILAGE IN CONTACT WITH SECRETIONS LEADS TO INFLAMMATION

WHICH LEADS TO GRANULATIONS MESSEGE CARTILAGE HAS TO BE COVERED AT ALL COSTS

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E.N.T. Surgery :-

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Micro Laryngeal Surgery

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Micro Laryngeal Surgery

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Extirpation Endolaryngeal Microsurgery conventional microsurgery(MLS)

• Indications: • Congenital Lesions: • Sulcus vocalis & vergeture. Laryngeal web • Epidermoid cysts & laryngoceles. Laryngeal

stenosis • Acquired lesions • Granulomata. :Benign neoplasm • • VF hemorrhage. • Papillomatosis. • • Dysplasia of VF. & Carcinoma in situ. •

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Laryngeal Surgery Kotby's classification

1. Extirpation endolaryngeal microsurgery. 2. Vocal fold augmentation. 3. Vocal fold repositioning. 4. Neurophonosurgery. 5. Glottal reconstruction after partial laryngectomy. 6. Postlaryngectomy surgery. 7. Laryngo Tracheal Trauma

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G.A. considerations

• Oral Intubation with MLS tube ( high volume low pressure Cuff ) or

• Jet Ventilation – Sub –Glottic Ventury or -- Supra Glottic Ventury via

laryngoscope

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Tube Position

• Anterior Vocal cords 2/3rd :- small ETT

• Posterior Vocal Cords :- Anterior ETT or

» Jet Ventillation or

» Apneic Techniques

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Other Considerations

• Laser Protected ETT

• Care of Sub Glottis and • Care of tracheal Stoma

• Difficult Per Oral exposure

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Difficult Per Oral exposure • Short Thick Neck • Retrognathia • Trismus • Restricted Neck Extention • Lingual Hypertrophy • Poor Palatal visualisation

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Long list of requirements

• Largest Bore Laryngoscope + ant. & post. Comm. • Suspension Systems • Specialized Instruments • Mouth/ dental Guard • Subepithelial Infusion needle • Operating Microscope – 400mm lense • Optical Telescope – 4mm x 20 cms • Microdebrider/ laser system

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Microflap Excision

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Microdebrider

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Laser Assisted

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Robotics

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Vocal Fold Augmentation • Indications: • Correction of glottic incompetence due to: • Unilateral vocal fold paralysis. • Sulcui or after surgery or trauma.

• Autologous and alloplastic materials. • Transoral or percutaneous approaches. • Silicon, Teflon, Gelfoam, Autologous Fat

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Injection Medialisation

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Repositioning of the Vocal Fold

Medialization surgeries (Mediopexy) 1. Surgical augmentation 2. Arytenoid adduction Lateralization (Lateropexy) 1. Arytenoid repositioning. 2. Arytenoidectomy with posterior partial cordectomy. Sharp dissection Laser excision.

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Laser Assisted

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Thyroplasty

(Laryngeal Framework Surgery)

Altering VF position, shape and tension by manipulating the cartilagenous framework. Isshiki’s functional classification: • Type I - Medialization. • Type II - Lateralization. • Type III - Relaxation (shortening). • Type IV - Stretching (lengthening).

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Thyroplasty

(Laryngeal Framework Surgery)

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Medialisation Laryngoplasty

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Type II - Lateralization

Release the tight closure of the glottis. Approaches: • A vertical incision in the thyroid cartilage and

lateralizing the posterior segment over the anterior one.

• Two paramedian vertical incisions and interpose the lateral segments beneath the anterior segment.

Indication: • Spastic dysphonia.

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Type III - Relaxation (shortening)

Aimed at lowering the vocal pitch. The VF is relaxed by A-P shortening of the thyroid ala. Indications: • Males with high pitch voice, resistant to voice therapy. • Stiff VF with high pitched breathy voice. • Spastic dysphonia.

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Type IV - Stretching (lengthening)

CT approximation to elevate pitch. Other Techniques to elevate the pitch: • Inferiorly based anterior cartilage flap. • Superiorly based cartilage flap. • Anterior commissure advancement.

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Laryngeal Surgery Kotby's classification

1. Extirpation endolaryngeal microsurgery. 2. Vocal fold augmentation. 3. Vocal fold repositioning. 4. Neurophonosurgery. 5. Glottal reconstruction after partial laryngectomy. 6. Postlaryngectomy surgery. 7. Laryngo Tracheal Trauma

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Neurophonosurgery • Reinnervating the PCA muscle • Nerve anastomosis. Phrenic nerve /ansa cervicalis. • Phrenic nerve implantation. • Neuromuscular pedicle Transplantation. • Reinnervating the TA muscle • Ansa cervicalis to RLN anastomosis • Infrathyroid - suprathyroid techniques • Neuromuscular pedicle Transplantation.

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Laryngo Tracheal Trauma

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Laryngo Tracheal Trauma

• Increasing accidents • Time to prepare ourselves is NOW

• Minor Ones or Group I need conservative management

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Group II Intact endolarynx + Displaced thyroid #

• Open reduction + internal fixation ORIF

• Method

– Sutures

– Wires

– Miniplates

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Group II Intact endolarynx + Displaced thyroid #

• ORIF • AIM – preservation of AP diameter Maintain Normal position of cords Austin technique

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Group III Large mucosal lacerations

• Or even small Lacerations involving – Anterior commissure – Free margins of TVC – Exposed cartilage – Multiple # – TVC immobility

• Managed by ORIF + Open laryngeal exploration within 24 hours

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Group III Large mucosal lacerations

• AIM – Return all remaining tissue to appropriate location – Cover all cartilage

• FUNCTIONAL PRINCIPLES

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FUNCTIONAL PRINCIPLES

• BLOOD IN CONTACT WITH CARTILAGE LEADS TO RESORPTION • CARTILAGE IN CONTACT WITH SECRETIONS LEADS TO INFLAMMATION

WHICH LEADS TO GRANULATIONS MESSEGE CARTILAGE HAS TO BE COVERED AT ALL COSTS

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Group III Large mucosal lacerations

• MIDLINE THYROTOMY or • Pramedian if vertical # within 3mm of midline

• Steps of MIDLINE THYROTOMY

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MIDLINE THYROTOMY

• Horizontal skin incision at crico-thyriod m. • Sub platysmal flaps • Separate strap muscles & expose thyroid c. • Midline Thyrotomy saw or drill • Retract laminae laterally • Achieve haemostasis

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Group III Large mucosal lacerations

• Situation 1 – Primary closure is generally possible – 5-0 or 6-0 absorbable sutures – Minimal undermining to move mucosa – Dibridement should be kept to minimum – DRAIN BLOOD COLLECTIONS – Keep mucosa down by quilting sutures

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Group III Large mucosal lacerations

• Situation 2 – Primary closure is not possible – Rotate flaps from - Epiglottis - pyriform sinuses – Skin flaps – Mucosal grafts

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Group III Large mucosal lacerations

• Situation 3 • Arytenoid cartilage dislocated

– Reduce it back – Repair mucosa

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Group III Large mucosal lacerations

• Reconstruct anterior commissure – 4-0 absorbable sutures from anterior TVC to outer perichondrium - keel

• Close thyrotomy – Non absorbable sutures – SS wire – Wire tube tech.

• ORIF if required

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Thank You