Учебники / Operative Techniques in Laryngology Rosen 2008

Chapter 14

Principles of Vocal Fold Augmentation 14

14.1Fundamental and Related Chapters

Please see Chaps. 5, 31, 33, and 34 for further information.

14.2Vocal Fold Augmentation: Advantages, Disadvantages, and Clinical Utility

There are primarily two treatment modalities that are used for the surgical treatment of glottic insufficiency:

1.Vocal fold augmentation (see Chaps. 31, “Vocal Fold Augmentation via Direct Laryngoscopy”; 33, “Peroral Vocal Fold Augmentation in the Clinical Setting”; and 34, “Percutaneous Vocal Fold Augmentation in the Clinic Setting”)

2.Laryngeal framework surgery (medialization laryngoplasty [ML], arytenoid adduction [AA]) (see Chaps. 38, “Silastic

Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis”; 39, “GORE-TEX® Medialization Laryngoplasty”; 40, “Arytenoid Adduction”; and 41, “Cricothyroid Subluxation”)

There is a lack of consensus among laryngologists regarding the role of these two surgical approaches in the treatment of glottal closure problems. The scarcity of comparative studies for these two treatments has resulted in a lack of evidence to clearly support one over the other. Furthermore, not all forms of glottic insufficiency are the same, thus while some patients may be well served with either approach (i. e., mild–moderate gap with mobile vocal folds), other patients are clearly better served with a specific approach (i. e., ML with AA for a lateralized, shortened immobile vocal fold). The choice of procedure is often a reflection of the surgeon’s own preference.

However, in general, vocal fold augmentation is used in the following settings:

1.Temporary correction in cases of unilateral vocal fold paralysis/paresis, when the prognosis for recovery is uncertain

Vocal fold augmentation results in immediate improvement of voice and/or swallowing, while allowing a period for recovery of vocal fold function. After a period of weeks to months, the injected substance is typically resorbed (see Table 14.1).

Also, temporary vocal fold augmentation can be done in cases in which it is not clear that the glottal insufficiency is the main communication deficit and thus, the temporary augmentation is done on a “trial” basis. If the patient re-

sponds to the surgery, then permanent correction can be done.

2.Permanent correction of mild-to-moderate glottic insuf­fi­ ciency

a)Vocal fold atrophy (as seen in presbyphonia)

b)Vocal fold paralysis

c)Vocal fold paresis

d)Adjunctive augmentation of the vocal fold(s) after prior

laryngeal framework surgery (“touch up”)

Patients with minor degrees of glottic insufficiency (<1- mm glottic gap on phonation) are usually better suited for vocal fold augmentation rather than framework surgery. Conversely, severe degrees of glottic incompetence appear to be more difficult to correct with vocal fold augmentation. A glottic gap of 3 mm or greater (during phonation) is generally better suited for a laryngeal framework surgical approach.

3.Glottic insuffiiciency due to loss of soft tissue in the vocal fold

Examples of this clinical situation include sulcus vocalis, and scarring of the vocal fold after partial laser cordect­ omy.

14.3Surgical Indications and Contraindications

■Vocal fold augmentation is not as effective at closing large (3 mm or greater) glottal gaps compared with framework techniques. This especially true in the case of a large posterior glottal gap in some patients with unilateral vocal fold paralysis (UVFP); these cases are best suited for ML and AA.

■Vocal fold augmentation can be less precise than laryngeal framework surgery. Most vocal fold augmentation procedures require some degree over-injection to allow for reabsorption, rendering fine adjustments to vocal fold position somewhat difficult. However, a similar problem is encountered in ML when factoring in perioperative vocal fold edema during the implant placement. The overcorrection of injection issue is especially true with lipoinjection. The vocal outcome is rendered even more uncertain in those patients who require a general anesthetic for injection, and whose voice result cannot be immediately assessed.

92	Principles of Vocal Fold Augmentation

■Vocal fold augmentation is a more minimally invasive approach compared to laryngeal framework surgery. Most laryngeal framework surgery requires a trip to the operating room, i.v. sedation, and the risk of reactive airway edema postoperatively. In addition, the patient is usually required to lie supine for an extended period of time during the surgical procedure. Due to these limitations, many patients with acute/subacute UVFP may not be good candidates for laryngeal framework surgery. Often, the patient with an iatrogenic UVFP is unwilling to return to the operating room for another surgery, yet may be perfectly willing to undergo a vocal fold augmentation in a clinic-based setting (see Chaps. 33, “Peroral Vocal Fold Augmentation in the Clinic Setting” and 34, “Percutaneous Vocal Fold Augmentation in the Clinic Setting”)

14.4Characteristics of Vocal Fold Augmentation Materials

14.4.1 Overview

The ideal vocal fold injection material would be readily available, inexpensive, inert, easy to use, and completely biocom- 14 patible. The search for such a material has been ongoing for almost 100 years, and significant advances in vocal fold augmentation material availability and design have occurred in the last 10 years. The original injection material was paraffin, which resulted in a significant foreign body response and rejection. Similar responses have occurred with Silicone injections as well as most recently with Teflon™ vocal fold injections. An additional requirement of all future vocal fold injection materials will be a matching of the biomechanical properties of the material with the biomechanical properties of either the superficial aspect of the vocal fold (superficial layer of the lamina propria) or the deep aspect of the vocal fold (vocalis, thyroary-

tenoid and lateral cricoarytenoid muscle).

14.4.2Categories of Vocal Fold Augmentation Materials

In general, augmentation substances can be divided into temporary and long-lasting (sometimes permanent) materials.

Temporary injection substances include:

■Bovine gelatin (Gelfoam™, Surgifoam™)

■Collagen-based products

(Zyplast™, Cosmoplast™/Cosmoderm™, Cymetra™)

■Carboxymethylcellulose (Radiesse Voice Gel™)

■Hyaluronic acid gel (Restylane™, Hyalaform™)

Long-lasting injection substances include: ■ Autologous fat

 

■Calcium Hydroxylapatite (Radiesse™)

■Teflon

14.4.3Description of Vocal Fold Augmentation Materials Characteristics

General characteristics of the current materials available for vocal fold augmentation are listed in Tables 14.1 and 14.2.

1.Bovine gelatin

Gelfoam and Surgifoam come as a gelatin powder that is derived from a bovine source. A moderate amount of preparation is required prior to injection, as the powder must be mixed with saline to form a paste. This material is quite viscous and thus requires a large bore injection needle (18 or 19 g) and pressurized injection device (e. g., Bruning syringe). Gelfoam has been widely used in the larynx for over 25 years with good success. The disadvantage of these products is the short duration of activity (4–6 weeks) and the inability to inject the substance through a fine-gauge needle.

2.Collagen-based products

Collagen-based products have been used for vocal fold augmentation for over 20 years. The product with the longest track record is the bovine-derived cross-linked form of collagen, Zyplast. Although no serious adverse reactions have been linked to bovine collagen use in the larynx, there is a potential for an allergic response in up to 2% of the population. For this reason, skin testing is recommended prior to the use of Zyplast, which can delay treatment for 2–4 weeks. Zyplast has been found to last as long as 4–6 month. Newer collagen-based products include Cymetra (micronized cadaveric dermal tissue) and Cosmoplast/Cosmoderm (laboratory-engineered human collagen). Neither product carries the risk of allergic response, although Cymetra has the potential for infectious transmission due to the use of cadaveric tissue as the source. Cymetra has been used extensively for vocal fold augmentation, and although it has been reported to last up to 9 months or more, the authors believe 2–3 months is more accurate. Cosmoplast/Cosmoderm are relatively new substances that have not been used in the larynx, but have potential advantages over the other collagen-based substances due to the low likelihood of allergic response or infectious risks.

3.Hyaluronic acid gels (Hyalan gels) (Restylane, Hyalaform—

Allegan-Inamed, Irvine, CA)

Hyaluronic acid is a naturally occurring glycosaminoglycan that is abundant in human tissue extracellular matrix. Injectable preparations of this substance are composed of crosslinked chains of hyaluronic acid that take on a viscous, wa- ter-insoluble form. These substances have been widely used as injectable fillers in rhytid treatment for over 10 years in Europe. Although these substances have been rarely used for vocal fold augmentation in the United States, clinical reports in the European literature support their safety and efficacy in the temporary treatment of glottal insufficiency. These substances are polysaccharide-based, and thus the

 

chance of immunogenicity is eliminated. Rare instances of hypersensitivity (0.6%) are reported, and are related to low levels of protein impurities in the manufacture of the product. The hyalan gels include Hyalaform (manufactured from rooster combs), and Restylane (manufactured by bacterial fermentation). The duration of effect for these substances is comparable to the collagen-based products, generally 4–6 months, although some reports suggests slightly longer effect of up to 9 months (see Table 14.1).

4.Radiesse Voice Gel (carboxymethylcellulose)

Radiesse Voice Gel (Bioform Medical, San Mateo, Calif.) is currently the only temporary injectable substance that is U.S. Food and Drug (FDA) approved for vocal fold augmentation. The principle material in this substance is carboxymethylcellulose, which is the carrier substance in Radiesse, a long-acting injectable. There is an extremely low risk of allergic response to this substance. Radiesse Voice Gel typically lasts 2–3 months, depending on the volume injected. The voice quality and vocal fold vibration after vocal fold augmentation are good.

Table 14.1  Temporary injectable substances

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93

5.Polytetrafluoroethylene (Teflon)

Teflon vocal fold injection has been performed for over 40 years and was initially touted as an excellent vocal fold augmentation material. However, long term follow up of Teflon vocal fold augmentations revealed a significant complication of a foreign-body granulomatous response occurring up to 5–10 years after injection. The foreign-body response is quite intense and often requires surgical removal of the Teflon, resulting in significant destruction of the surrounding vocal fold (see Chaps. 24, “Endoscopic Treatment of Teflon Granuloma” and 42, “Translaryngeal Removal of Teflon Granuloma”). This removal results in vocal fold tissue loss, leaving a severe deficit and morbidity at the vocal fold augmentation site(s). Because of this significant complication of Teflon vocal fold augmentation, this substance presently has very limited utility.

6.Autologous fat

Autologous fat vocal fold augmentation (a.k.a. vocal fold lipoinjection) has been widely used for the last 10–15 years, with varying levels of reported success. Vocal fold lipoinjec-

Material	Length of effect	Advantages	Disadvantages	Needle gauge
Gelfoam	4–6 weeks	Long track record	Short duration	18
Radiesse Voice Gel	2–3 months	FDA approved	Not as long lasting as colla-	27
		No allergy testing	gen/hyaluronic acid gels (?)
Bovine collagen (Zyplast)	3–4 months	20-year track record	Allergy test required	27
			2- to 4-week delay
Human-derived collagen	3–4 months	No allergy testing	New product/limited experience	27
(Cosmoplast/Cosmoderm)
Micronized AlloDerm (Cymetra)	2–3 months	No allergy testing	More preparation time	18–23
			Unpredictable duration	recommended
Hyaluronic acid gels	4–6 months (?)	No allergy testing	Limited experience	27
(Restylane, Hylaform)

Table 14.2  Long-term/permanent injectable substances

Material	Length of effect	Advantages	Disadvantages	Needle
				gauge
Ca Hydroxylapatite	2–5 + years (?)	FDA-approved	New product	25
(Radiesse)		Long lasting	No long-term track record
Teflon	Permanent	Long lasting	Irreversible	18 or 19
			May cause vocal fold stiffness
			Risk of granuloma
Autologous fat	Several years–	Patient’s own tissue used	Time, morbidity from fat harvest	18 or 19
	permanent (?)	“Forgiving” (defect over-cor-	Performed in OR
		rection rarely occurs)	Unpredictable duration

94	Principles of Vocal Fold Augmentation

tion obviously has the advantages of using a material that is autologous and usually readily available. Sustained results in the correction of glottic insufficiency (>1 year) have been demonstrated in patients treated with lipoinjection for glottic insufficiency. In addition, radiographic presence of fat up to 2 years after lipoinjection has been demonstrated in a number of patients. However, the variable survival in the immediate postoperative period (2 months) is disconcerting to many surgeons, resulting in a lack of consensus regarding whether autologous fat is a good long-term or “permanent” correction option for glottic insufficiency. The success of lipoinjection appears to be operator dependent and the reasons for this have not been clearly identified; however, it is likely due to improper harvesting and preparation of the material as well as incorrect injection techniques.

7.Calcium hydroxylapatite (Radiesse)

Calcium hydroxylapatite (CaHA) microspheres represent a new vocal fold injection material that has been extensively tested in laboratory animals and used clinically as an augmentation material in other parts of the body (nonlaryngeal). The clinical efficacy and long-term results are still pending in the larynx, although long-term augmentation has been demonstrated in other organ systems. This material is composed of microspheres of CaHA (25–45 μm in diameter) suspended in a temporary gel carrier (water, glycerin, carboxymethylcellulose), which allows for easy injection through a needle as small as 25 g. Efficacy up to 12 months

14	has been demonstrated in a multi-institutional clinical trial
	at the time. Currently, it is the only FDA-approved poten-

tially long-lasting glottic injectable. In contrast to Teflon, Radiesse is a naturally occurring substance in the human body; therefore, the risk of chronic granulomatous formation is theoretically small. Long-term animal studies and a short-term human study have demonstrated excellent host acceptance of the CaHA material in the larynx.

14.5General Principles of Vocal Fold Augmentation

1.Local anesthesia is generally preferred in most cases, so that the patient’s voice can be monitored during the procedure. A notable exception to the rule is vocal fold lipoinjection, which is performed under general anesthesia to facilitate fat harvesting and preparation.

2.Injection techniques include: a) Peroral

i.Curved injection device in the clinic setting (Chap. 33, “Peroral Vocal Fold Augmentation in the Clinic Setting”)

ii.Straight injection device via direct laryngoscopy in the operating room (Chap. 31, “Vocal Fold Augmen-

tation via Direct Laryngoscopy”)

b)Percutaneous (Chap. 34, “Percutaneous Vocal Fold Augmentation in the Clinic Setting”)

i.Translaryngeal (through thyroid cartilage)

ii.Cricothyroid membrane puncture

iii.Thyrohyoid membrane puncture

 

3.Vocal fold augmentation is generally directed at the posterior and mid-membranous vocal fold in the treatment of glottic insufficiency. Ideal injection locations are identified at a point where a transverse line from the tip of the vocal process laterally intersects the superior arcuate line. A second injection site is sometimes needed at the mid-membra- nous vocal fold along the superior arcuate line. (Fig. 14.1).

Fig. 14.1  Illustration showing the correct injection site(s) for vocal fold augmentation

Fig. 14.2  Coronal section of the larynx, illustrating the correct depth of needle placement for injection, slightly inferior to the free edge of the vocal fold

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Fig. 14.3  The appropriate amount of overcorrection used for most injectables (15–30%, or an additional 0.1–0.2 ml of material), as depicted in this right vocal fold augmentation

The depth of injection is generally 3–5 mm, slightly inferior or at the level of the inferior lip of the free edge of the vocal fold (Fig. 14.2).

4.Injection into the superficial layer of the lamina propria (Reinke’s space) should be avoided, as this will result in loss of mucosal pliability and poor vocal quality

5.Overinjection in recommended, to compensate for resorption of the water-based component present in commercially manufactured injectables. In general, a 15–30% overcorrection is recommended (exception noted below), which translates to an additional 0.1–0.2 ml of substance for unilateral procedures. The overcorrection usually results in a slightly rounded, convex contour to the injected vocal fold (Fig. 14.3). The exception to this rule is autologous fat injection. Aggressive overcorrection (100%) is recommended in these cases to account for the substantial resorption of fat that generally occurs within the first 6–8 weeks after lipoinjection (Fig. 14.4).

Key Points

■Vocal fold augmentation is a commonly used surgical treatment for glottic insufficiency.

■Key differences between vocal fold augmentation and laryngeal framework surgery:

■Vocal fold augmentation is less effective at closing large (3 mm or greater) glottal gaps, especially in the posterior membranous region of the vocal folds

■Vocal fold augmentation may be less precise than framework surgery

■Vocal fold augmentation is however, a more minimally invasive approach, and can be carried out in a clinic-based setting.

Fig. 14.4  The appropriate amount of overcorrection used for vocal fold lipoinjection, as demonstrated in this left vocal fold

■Vocal fold augmentation is appropriate in a variety of clinical settings, but is commonly used in the following situations:

■Temporary correction for unilateral vocal fold paralysis

■Trial correction for glottal insufficiency (as a diagnostic measure)

■Permanent correction of vocal fold atrophy (as seen in presbyphonia), vocal fold paresis (unilateral and bilateral), unilateral vocal fold paralysis

■Adjunctive vocal fold augmentation after laryngeal framework surgery (“touch up”)

■Glottic insufficiency due to vocal fold scarring/ soft tissue loss

■A variety of injectable substances are available for vocal fold augmentation, and can be categorized into temporary (2–6 months) and long-acting/per- manent (2 years or more).

■Temporary injection substances include:

■Bovine gelatin (Gelfoam, Surgifoam)

■Collagen-based products (Zyplast, Cosmoplast/Cosmoderm, Cymetra)

■Carboxymethylcellulose (Radiesse Voice Gel)

■Hyaluronic acid gel (Restylane, Hyalaform)

■Long-lasting injection substances include:

■Autologous fat

■Calcium hydroxylapatite (Radiesse)

■Teflon

■Local anesthesia is generally preferred with vocal fold augmentation (peroral or percutaneous approach), so that the patient’s voice can be used as a constant source of feedback during the procedure (Chaps. 33 and 34).

■Augmentation is directed at the posterior and midmembranous vocal fold, along the lateral vocal fold (superior arcuate line), and at a depth of 3–5 mm.

96	Principles of Vocal Fold Augmentation

■Injection into the superficial lamina propria (Reinke’s space) is to be avoided.

■Overinjection (15–30%) is recommended to compensate for resorption of the water-based component present in most injectable substances. The exception to this rule is autologous lipoinjection, which requires substantial overcorrection.

Selected Bibliography

1Brandenburg JH (1992) Vocal cord augmentation with autogen­ ous fat. Laryngoscope 102:495–500

2Ford CN, Martin DW, Warner TF (1984) Injectable collagen in laryngeal rehabilitation. Laryngoscope 94:513–518

3Ford CN, Bless DM (1986) Clinical experience with injectable collagen for vocal fold augmentation. Laryngoscope 96:863–869

 

4Hertegar S, Hallen L, Laurent C et al (2004) Cross-linked hyaluronan versus collagen for injection treatment of glottal insufficiency: 2-year follow-up. Acta Otolaryngol 124:1208–1214

5Remacle M, Marbaix E, Bertrand B, Hamoir M, van den Eeckhaut J (1990) Correction of glottic insufficiency by collagen injection. Ann Otol Rhinol Laryngol 99:438–444

6Rosen CA (2000) Phonosurgical vocal fold augmentation: procedures and materials. Otol Clinics North Am 33:1087–1096

7Rosen C, Gartner-Schmidt J, Casiano R et al (2007) Vocal fold augmentation with calcium hydroxylapatite (CaHA). Otolaryngol Head Neck Surg 136:198–204

8Schramm VL, May M, Lavorato AS (1978) Gelfoam paste injection for vocal cord paralysis: temporary rehabilitation of glottic incompetence. Laryngoscope 88:1268–1273

9Simpson CB, Amin MR (2004) Office-based procedures for the voice. Ear Nose Throat J 83(Suppl.):6–9

10Watterson T, McFarlane SC, Menicucci AL (1990) Vibratory characteristics of Teflon-injected and noninjected paralyzed vocal folds. J Speech Hear Disord 55:61–66

14

Part B Phonomicrosurgery

for Benign Laryngeal

Pathology

IIPhonomicrosurgical Voice Procedures

Chapter 15

Vocal Fold Polyp	15

15.1Fundamental and Related Chapters

Please see Chaps. 4, 8, 10, 11, and 12 for further information.

15.2Disease Characteristics and Differential Diagnosis

A vocal fold polyp can have a variety of different features and presentation characteristics, and typical features involve an exophytic lesion with quite-thin mucosa (Fig. 15.1). The lesion is typically unilateral but can be bilateral. Often, there will be a hemorrhagic nature to the polyp, giving it a maroon or bloodcolored appearance. If the vocal fold polyp is not hemorrhagic, then it will be clear and may even have a translucent nature to it. The stroboscopic features of a vocal fold polyp include minimal dampening of the overall mucosal wave and an hourglass closure pattern.

Physically, at the time of surgery, a disorganized gelatinous material is found within the subepithelial space in patients with a vocal fold polyp. The vocal fold polyp can be associated with

increased vascularity around the lesion, often noted as a varix feeding the lesion (see Chap. 22, “Vocal Fold Varix”). Typically, a vocal fold polyp is associated with misuse or heavy use of the voice, such as in a variety of phonotraumatic behaviors. These behaviors can result in a vocal fold polyp in a gradual/progressive fashion or in a sudden fashion often associated with an acute vocal fold hemorrhage.

Differential diagnosis associated with vocal fold polyp includes:

■Reinke’s edema

■Vocal fold cyst

■Pseudocyst

■Vocal fold fibrous mass

■Localized edema of the vocal fold (temporary)

■Vocal nodules

15.3Surgical Indications and Contraindications

Indications for surgery for vocal fold polyp include:

■A combination of dysphonia and lack of significant response to nonsurgical treatment methods (voice therapy, medical management)

■A vocal fold polyp that is associated with a significant vocal fold varix that is at risk for vocal fold hemorrhage

Contraindications for surgery comprise:

■Patients medically unable to tolerate general anesthesia

■Inability to obtain proper visualization of vocal folds during microlaryngoscopy

■A patient without vocal functional limitations

15.4Surgical Equipment

1.Standard phonomicrosurgical equipment (see Chap. 10, Table 10.1)

2.Bipolar or laser equipment for the treatment of associated vocal fold varix as needed (see Chaps. 13, “Principles of Laser Microlaryngoscopy” and 22, “Surgical Management of Vocal Fold Vascular Lesions”)

Fig. 15.1  Vocal fold polyp

100		Vocal Fold Polyp
			on which approach to select is based on the amount of healthy
	15.5	Surgical Procedures
			mucosa associated with the polyp.
			1. Microflap approach for vocal fold polyp removal
	Vocal fold polyp is best surgically removed via a phonomicro-			a) Exposure of lesion, preferably the entire membranous
	surgical approach (see Chap. 10, “Principles of Phonomicro-			vocal fold
	surgery”). There are two main methodological approaches to			i. Application of topical epinephrine (1:10,000) to the
	the surgical removal of a vocal fold polyp. First, using a micro-			vocal fold lesion via a Cottonoid
	flap approach and second, a truncation approach. The decision			ii. Subepithelial infusion for vocal fold polyp is contra-

15

Fig. 15.2  Cordotomy at junction of polyp and vocal fold

Fig. 15.3  Microflap elevation

Fig. 15.4  Removal of polyp contents	Fig. 15.5  Dissection of polypoid material medially, preserving infra-
	glottic mucosa

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101

indicated, given that this could blur the demarcation of the junction between the vocal fold polyp and the normal vocal fold tissue.

iii.Epithelial cordotomy is planned and made through the epithelium at the junction of the lateral aspect of the vocal fold polyp and the normal vocal fold mucosa, along the superior surface of the vocal fold (Fig. 15.2).

iv.The microflap elevation is performed medial to the incision to expose the subepithelial pathologic contents of the vocal fold polyp (Fig. 15.3).

v.Vocal fold polyp material is removed via either microsuction or direct removal of the abnormal material with small microcup forceps (1 mm) (Fig. 15.4). Alternatively, the lesion can be dissected medially with a 30° flap elevator, preserving additional inferior microflap mucosa (Fig. 15.5).

vi.Redrape the microflap back over the vocal fold and evaluate the nature and status of the microflap mucosa (Fig. 15.6).

vii.Trim abnormal mucosa that appears to have adherent polyp material, or is extremely thin and atrophic, or is excessive and will not serve as normal mucosa during the postoperative healing (Fig. 15.7).

viii.Redrape the remaining microflap mucosa. Once the flap is redraped, use a blunt instrument (curved elevator) to palpate the operative site to ensure there is no remaining pathology under the flap (Fig. 15.8).

ix.Treat the associated vascular lesion if needed (see Chap. 22, “Surgical Management of Vocal Fold Vascular Lesions”).

x.4% Lidocaine is sprayed onto the larynx (commonly referred to as a LTA [laryngotracheal anesthesia])

2.Truncation of the vocal fold polyp

a)Application of topical epinephrine to the vocal fold lesion

b)Subepithelial infusion for vocal fold polyp is contraindicated, given that this could blur the demarcation of the junction between the vocal fold polyp and the normal vocal fold tissue.

c)Grasp the vocal fold polyp with small triangular forceps in a medial direction (Fig. 15.9).

The nature and approach to grasping the vocal fold polyp is extremely important and is a key determinant of the success of the procedure. The vocal fold lesion should be grasped in a location and manner that is perpendicular to the longitudinal axis of the vocal fold. With the nondissecting hand, careful control and gentle application of tension should be applied to the vocal fold polyp.

d)Microscissors that are either slightly curved (away from the vocal fold) or straight up-cutting scissors are then used to incise the vocal fold polyp at the junction of the polyp and the vocal fold (Fig. 15.9).

e)After removal of the majority or the entire vocal fold polyp, careful examination and palpation should be performed to see if there is any residual abnormal mucosa at the vocal fold polyp site that should be removed. To help with this assessment, an epinephrine-soaked Cottonoid can be placed on the operative site for several minutes. If there is residual abnormal mucosa, then a 1-mm microcup forceps can be used to remove this tissue. An alternative removal technique involves grasping of the “dogeared” mucosa with a microcup forceps or small triangle forceps and excising the material with a microcurved scissors (Fig. 15.10).

Fig. 15.6  Redrape and evaluate viability of microflap mucosa

Fig. 15.7  Trim abnormal microflap mucosa