Учебники / Operative Techniques in Laryngology Rosen 2008

114	Polypoid Corditis

possible, then a conservative approach is advocated, where unilateral surgeries are performed to avoid complications.

Patients should be counseled preoperatively that the pitch of the voice will increase, they will likely have a short period of breathiness, and that voice therapy postoperatively will usually be required.

18.4Surgical Equipment

Standard phonomicrosurgery instrument set (see Chap. 10, Table 10.1), high-powered suction (typically a liposuction device).

18.5Surgical Procedure

1.Intubation with a 5 or 5.5 MLT

Special care must be exercised to avoid vocal fold injury or damage, due to the limited space that is available for tube placement.

2.Expose larynx with suspension laryngoscope.

3.Incision (Fig. 18.3)

a) Use a fresh sickle knife

b) Incision at the superior/lateral aspect of the vocal fold, beginning at the vocal process and extending to within 3 mm of the anterior commissure

18

 

4.Raise the microflap between the epithelium and the polypoid material (Fig. 18.4).

Using a 30° flap elevator, the epithelium is separated from the underlying polypoid tissue, taking great care not to perforate the epithelial flap, which can be quite thin. As the dissection extends inferiorly, it is necessary to put lateral pressure on the flap elevator to get adequate visualization of the flap. In some cases, an extensive flap is required, extending well into the infraglottis, and from “stem-to-stern” of the entire membranous vocal fold.

5.Raise a plane between the vocal ligament and the overlying polypoid material (Fig. 18.5)

Again, using a 30° flap elevator, the vocal ligament is identified at the superior/lateral aspect of the vocal fold, and a plane is developed between the vocal ligament and the diseased polypoid tissue. Once the material has been freed, it is ready for removal. It should be noted that some mild-to- moderate cases of polypoid corditis might not require much flap elevation (as described in this and step 4); in these cases, the material may aspirate more readily without the need for extensive flap elevation.

6.Removal of polypoid material

Much of the polypoid tissue can be removed with suction; however, suction with a strong negative pressure is essential. Routine operating room suction units are frequently inadequate, and the liposuction units are generally employed. The larger suction tubing used in the units can be adapted to the smaller suction tubing using a “Christmas tree” adaptor. In general, a 5- or 7-French microsuction with closed thumb port is used (Fig. 18.6). Care is taken to retract the flap so it is not caught in the suction. One must allow a few seconds for the maximum pressure to be achieved after placing the suction into the polypoid material. Frequently, there are loculations of more fibrous material mixed in with

Fig. 18.2  Planned bilateral incisions in a typical case of polypoid corditis. Note the lack of anterior extension on the left side, which is designed to minimize the chances of anterior glottic web formation postoperatively

Fig. 18.3  Sickle-knife incision running in an anterior-to-posterior direction at the superior/lateral aspect of the vocal fold

 

the gelatinous polypoid material, which cannot be removed by suction. This material must be manually extracted with a straight or up cups forceps (Fig. 18.7). One must resist the temptation to remove all the polypoid material, as some SLP must be left behind to regenerate Reinke’s space, and maintain vibratory properties.

7.Trimming of redundant mucosa

There is usually a certain amount of redundant mucosa, which can be quite extensive in advanced cases of polypoid

Fig. 18.4  A 30° flap elevator is used to separate the polypoid disease from the epithelium

Chapter 18

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corditis. This mucosa should be conservatively trimmed so that the epithelial edges coapt at the end of the case. (Fig. 18.8). It is best to redrape the flap prior to planning the trimming of mucosa. In cases of massive polypoid corditis, it is not infrequent to sacrifice this mucosa with a large excisional removal of polypoid material. In many cases, however, the epithelial removal will be the last portion of the case. It is best to try to trim the mucosa conservatively at first; more mucosa can always be removed later if needed.

Fig. 18.5  Elevation is carried out between the vocal ligament and the polypoid disease

Fig. 18.6  Suction removal of polypoid disease

Fig. 18.7  Supplemental cup forceps removal of disease

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Polypoid Corditis

Fig. 18.8  Trimming of redundant epithelium with up-cutting scissors

Fig. 18.9  After epithelial removal with minimal mucosal dehiscence

Long cuts across the mucosa are preferable to short cuts, and these tend to give a jagged contour to the cut edge. The incised edges of the flap should coapt closely, without a significant mucosal dehiscence (Fig. 18.9).

18	18.6	Postoperative Care
		and Complications

Postoperative care should include PPIs, pain medicine, and voice rest for 5–7 days. Smoking should be discontinued or significantly reduced in the postoperative period.

Expected postoperative course:

■The patient will experience a breathy voice postoperatively, primarily due to the preoperative high subglottal pressures that are used to drive the vibration of the polypoid material. In addition, the pitch of the voice will be significantly higher due to the loss of mass after the surgery. In general, recovery and stabilization of voice takes longer than with most other benign lesions, typically 6–8 weeks.

■Complications are generally related to technical errors in the surgical procedure. The most serious complication is anterior glottic web, which can occur when raw surfaces are left at the anterior free edge of both vocal folds. The best way to avoid this complication is to make the incisions on the lateral aspect of the vocal fold, and not to extend the incisions to the anterior most aspect of both vocal folds.

■Scarring of the vocal folds can also occur. A risk factor for unfavorable scarring is the removal of excessive amounts of the SLP/gelatinous material. The result is stiffness/loss of vibratory properties with rough, breathy dysphonia, vocal fatigue, and lack of projection.

Key Points

■Polypoid corditis is a bilateral process characterized by expansion of Reinke’s space with gelatinous inflammatory material throughout the entire vocal fold, and is seen almost exclusively in smokers.

■Surgical indications for polypoid corditis include symptomatic dysphonia despite medical management, airway encroachment/partial obstruction, or concern of malignancy.

■Microflap surgery can be performed bilaterally, but incisions should not extend to the anterior vocal fold to avoid web formation. Alternatively, it is acceptable to operate unilaterally and stage the second procedure.

■Removal of the polypoid material may require a high-vacuum suction device and/or manual extraction of loculated portions of the disease.

■It is critical that some gelatinous material in the SLP should be left behind to reconstitute Reinke’s space and preserve vibratory characteristics.

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Selected Bibliography

1	Lumpkin SM, Bishop SG, Bennett S (1987) Comparison of surgi-	3
	cal techniques in the treatment of laryngeal polypoid degenera-
	tion. Ann Otol Rhinol Laryngol 96:254–257	4
2	Lumpkin SM, Bennett S, Bishop SG (1990) Postsurgical follow-
	up study of patients with severe polypoid degeneration. Laryngo-
	scope 100:399–402

Courey MS, Gardner GM, Stone RE, Ossoff RH (1995) Endoscopic vocal fold microflap: a three-year experience. Ann Otol Rhinol Laryngol 104:267–273

Zeitels SM, Bunting GW, Hillman RE et al (1997) Reinke’s edema: phonatory mechanisms and management strategies. Ann Otol Rhinol Laryngol 106:533–543

Chapter 19

Vocal Fold Granuloma	19

19.1Fundamental and Related Chapters

Please see Chaps. 1, 4, 5, 10, 11, and 12 for further information.

19.2Disease Characteristics and Differential Diagnosis

Vocal fold granuloma is inflammatory tissue arising from the perichondrium near the arytenoid cartilage (Fig. 19.1). The granuloma typically arises in the area where the vocal process adjoins the body of the arytenoid cartilage. Vocal fold granuloma can occur unilaterally or bilaterally. Granulation tissue can form on other locations of the vocal folds; however, these are different clinical entities and are not discussed in this chapter. Vocal fold granulomas are thought to occur from a perichondritis of the arytenoid cartilage. For perichondritis of the arytenoid cartilage to occur, it is thought that there needs to be a two-step process of (1) mucosal injury and (2) subsequent injury to the perichondrium of the arytenoid cartilage.

Vocal fold granuloma is classically seen after endotracheal intubation. The intubation or endotracheal tube causes mucosal injury, and subsequent injury to the perichondrium can occur from persistence of the endotracheal tube or LPR. The most common causes of vocal fold granulomas are thought to

be laryngopharyngeal reflux, vocal misuse or hyperfunction, glottal incompetence with severe hyperfunction often associated with vocal fold paresis, vocal fold atrophy, vocal fold paralysis, vocal fold scar, and chronic cough.

Patients with a vocal fold granuloma can experience globus sensation, dysphonia, and/or odynophonia. If the vocal fold granuloma is extremely large, then shortness of breath and dyspnea on exertion and other airway related symptoms can be present. The postintubation granulomas typically occur in females more than in males and are often associated with a comorbid condition of laryngopharyngeal reflux disease. Typically, these lesions can be treated expectantly as long as the LPR is controlled. This patient subgroup will do quite well and often not require surgical excision of the vocal fold granuloma.

Differential diagnosis for vocal fold granuloma include: (It should be noted that all of the below diagnoses almost never present as isolated lesions at the vocal process/arytenoid):

■Squamous cell carcinoma

■Carcinoma in situ

■Dysplasia

■Amyloidosis

■Tuberculosis of the larynx

19.3Surgical Indications and Contraindications

Indications for vocal fold granuloma surgical removal include:

■To rule out malignancy or infectious etiologies (e. g., tuberculosis, Klebsiella)

■Airway obstruction

■Symptoms of persistent disease despite nonsurgical treatment methods

■Growth of lesion despite medical treatment

Contraindication of vocal fold granuloma surgery comprise surgical removal without addressing the possible underlying etiologic conditions preoperatively (LPR, voice misuse and/or glottal insufficiency).

19.4Surgical Equipment

	The surgical equipment required is a standard phonomicrosur-
	gery instrument set (see Chap. 10, Table 10.1), and a posterior-
Fig. 19.1  Vocal fold granuloma	commissure laryngoscope (as needed).

120	Vocal Fold Granuloma

19.5Surgical Procedure

1.Philosophical overview for vocal fold granuloma removal

The overall goal for surgical removal of vocal fold granuloma is to remove the vocal fold granuloma lesion in as an atraumatic fashion as possible. It is important recognize that after vocal fold granuloma removal, success of the operation (no recurrent granuloma disease) is dependent on the race between the underlying inflamed perichondrium and the surrounding normal mucosa. If the mucosa “wins” this race, then the patient will not have a recurrent granuloma; however, if the perichondrial inflammation continues, then a recurrent granuloma is highly likely. With this in mind, it is important that all aspects of the surgical removal of the vocal fold granuloma are aimed at:

a) Maintaining as much normal mucosa surrounding the surgical site as possible

b) Minimizing all possible irritation or trauma to the underlying arytenoid cartilage perichondrium

2.Exposure and preparation for vocal fold granuloma excision

If the vocal fold granuloma is large or the anesthesiologist refuses to use a small endotracheal tube (5.0), then the surgeon should position the endotracheal tube anterior to the laryngoscope during laryngoscope suspension. This will allow an unfettered view of the posterior commissure, which is required for this surgery. The Pilling posterior-commis- sure laryngoscope facilitates the anterior displacement of the endotracheal tube because it has a slight notch to hold the endotracheal tube anterior during laryngoscope suspension. The other method to keep the endotracheal tube in an anterior position is to slightly alter the angle of the endotracheal tube as it goes through the larynx so it lays nonparallel to the longitudinal axis of the laryngoscope, with a

 

net result of keeping the endotracheal tube in an anterior location while the surgeon works in the posterior glottis (Fig. 19.2). The slight angulation of the laryngoscope also keeps the endotracheal tube anterior and provides optimal exposure of the arytenoid and posterior membranous vocal fold. The ideal exposure for vocal fold granuloma surgery is to have exposure and good visualization of the posterior aspect of the midmembranous vocal fold and the entire arytenoid and posterior glottic area on the side of the lesion.

3.After the laryngoscope is suspended and adequate exposure of the posterior glottis is achieved, examine the lesion at high-powered magnification, specifically gently retracting the lesion from its attachment from the arytenoid to view, and gain a sense of the size and location of the stalk. This can also be done by passing a small curved alligator between the vocal fold granuloma and the arytenoid cartilage; this will allow the surgeon to identify the exact location and nature of the vocal fold granuloma stalk.

4.For removal of the vocal fold granuloma, it is best to use a curved alligator (curved in the opposite direction of the side that the vocal fold granuloma is on) and gently grab the stalk that runs between the vocal fold granuloma and the arytenoid cartilage. Preferably, the alligator will grasp the stalk on its most medial aspect. The vocal fold granuloma stalk can then be gently retracted towards the midline, and a curved microscissors (curved in the same direction as the curved alligator) is then used to release or cut the stalk immediately lateral to the curved alligator, thus allowing the removal of the vocal fold granuloma (Fig. 19.3).

5.Application of epinephrine-soaked pledgets (1:10,000 dilution) will achieve hemostasis without any difficulty.

19

Fig. 19.2  Nonparallel placement of the laryngoscope and endotracheal tube

Fig. 19.3  Retraction of vocal fold granuloma stalk with curved alligator and cutting of stalk

 

6.Careful examination and palpation of the operative site will reveal if there is any residual granulation tissue or inflammatory tissue. If this tissue is present, it is best to remove it very carefully and conservatively with l-mm cup forceps or the micro-ovoid cup forceps. Great care should be taken at this juncture to fully remove obvious exophytic tissue and not remove any surrounding normal mucosa or to reach deeply into the operative site. This will minimize the risk of traumatizing the underlying arytenoid perichondrium.

7.Adjunctive procedures to vocal fold granuloma surgery

After the successful removal of the vocal fold granuloma, depending on the exact clinical situation, one should fully evaluate the size and nature of the vocal fold to consider if the patient requires vocal fold augmentation. If vocal fold augmentation is warranted, then vocal fold augmentation should be strongly encouraged and performed simultaneously to the vocal fold granuloma excision (see Chap. 31, “Vocal Fold Augmentation via Direct Laryngoscopy”).

Another adjunctive treatment option especially for recurrent vocal fold granuloma surgery is to consider a vocal fold Botox injection to chemically “splint” or put the voice “at rest” after the vocal fold granuloma excision. Botox can be done during microlaryngoscopy by injecting into the TALCA muscle complex—direct the Botox needle lateral and slightly outward from the vocal process on the side of the vocal fold granuloma. However, ideally Botox injection should be done 3 days prior to the surgical excision of the granuloma (see Chap. 35, “Botulinum Toxin Injection”). Thus, the vocal fold is “at rest” at the time of the excision.

19.6Postoperative Care and Complications

Postoperative care typically involves voice rest for a variable number of days (6–10 days). In addition, LPR treatment (despite the clinical history) should be implemented, including behavior modification and PPI therapy. Voice rest is indicated to maximize the chance of successful healing of the operative site and minimize a chance for recurrent vocal fold granuloma formation.

Complications after vocal fold excision surgery include:

■Recurrent lesion

■Severe cartilaginous or membranous vocal fold defects from excessive or overly aggressive surgical excision of the vocal fold granuloma

To address the problem associated with a recurrent vocal fold granuloma, it is important that all different etiologic possibilities are carefully and systematically reviewed prior to proceeding with a repeated surgical procedure. This includes speech–language pathology evaluation and voice therapy, LPR treatment, and assessment and treatment for glottal insufficiency.

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Key Points

■Vocal fold granuloma is a perichondritis of the arytenoid cartilage from various insults (voice misuse, endotracheal intubation, LPR, etc.).

■Surgery should be performed if concern exists regarding a malignancy or infection, or all nonsurgical treatment options have been exhausted.

■Underlying glottal insufficiency is a common cause of recurrent vocal fold granuloma, and patients should be carefully evaluated for the most common causes of glottal insufficiency and treated at the same time as vocal fold granuloma excision if appropriate.

■Careful surgical excision of the vocal fold granuloma with minimal trauma to the underlying perichondrium and surrounding mucosa is essential to successful surgery for vocal fold granuloma.

Selected Bibliography

1Benjamin B, Roche J (1993) Vocal granuloma, including sclerosis of the arytenoid cartilage: radiographic findings. Ann Otol Rhinol Laryngol 102:756–760

2Devaney KO, Rinaldo A, Ferlito A (2005) Vocal process granuloma of the larynx: recognition, differential diagnosis and treatment. Oral Oncology 41:666–669

3Hoffman HT, Overholt E, Karnell M, McCulloch TM (2001) Vocal process granuloma. Head Neck 23:1061–1074

4Leonard R, Kendall K (2005) Effects of voice therapy on vocal process granuloma: a phonoscopic approach. Am J Otol 26:101–107

5Ylitalo R, Hammarberg B (2000) Voice characteristics, effects of voice therapy, and long-term follow-up of contact granuloma patients. J Voice 14:557–566

6Ylitalo R, Lindestad PA (2000) Laryngeal findings in patients with contact granuloma: a long-term follow up study. Acta Otolaryngol 120:655–659

7Ylitalo R, Lindestad PA (1991) A retrospective study of contact granuloma. Laryngoscope 109:433–436

8Ylitalo R, Ramel S (2002) Extraesophageal reflux in patients with contact granuloma: a prospective controlled study. Ann Otol Rhinol Laryngol 111(Pt. 1):441–446

Chapter 20
Vocal Fold Leukoplakia	20
and Hyperkeratosis

20.1Fundamental and Related Chapters

Please see Chaps. 3, 4, 7, 8, and 10 for further information.

20.2Diagnostic Characteristics and Differential Diagnosis

give valuable information regarding the potential for malignant invasion, as noninvasive pathology tends to preserve mucosal wave, whereas invasive disease leads to the loss of vibratory characteristics. Notable exceptions to this rule are the presence of coexisting polypoid corditis and microinvasive carcinoma of the vocal fold. In this example, the mucosal wave may be preserved due to extensive expansion of the SLP.

Vocal fold leukoplakia (Fig. 20.1) and keratosis are clinical disease processes of the vocal fold epithelium. The physical findings consist of a white plaque on the surface of the vocal fold. Histopathologically, leukoplakia can vary from the very benign (hyperkeratosis of the epithelium) to frankly malignant (microinvasive squamous cell carcinoma). The differential diagnosis of leukoplakia includes papillomatosis, fungal infections (especially candidiasis) and occasionally, tenacious mucous.

Patients with vocal fold leukoplakia are typically smokers; however, other inflammatory conditions may contribute to the development of this epithelial change, such as LPR or possibly viral infection. The patient typically presents with a rough or coarse voice, but vocal fold leukoplakia may be found in an “asymptomatic” patient on routine flexible laryngoscopy.

Videostroboscopy is essential in the evaluation of leukoplakia of the membranous vocal folds. Tenacious mucous can easily be distinguished from a leukoplakic plaque by observing the characteristic movement of the mucous during vibratory activity. More importantly, videostroboscopic characteristics

Fig. 20.1  Leukoplakia of the vocal fold

20.3Surgical Indications and Contraindications

Indications include:

■Leukoplakia of the vocal folds, where histopathology has not been established (especially in cases where mucosal wave is reduced or absent at the lesion site)

■Change in the appearance or nature of preexisting leukoplakia

A (relative) contraindication is a patient who is high-level vocal professional (i. e., singer) before attempting conservative management (antifungals, PPIs, etc.).

20.4Surgical Equipment

The surgical equipment required is a standard phonomicrosurgery instrument set (see Chap. 10, Table 10.1).

20.5Surgical Procedure

1.Intubate with 5.0 or 5.5 microlaryngeal endotracheal tube

2.Expose larynx with suspension laryngoscope.

3.Infiltrate into the submucosal space—superficial lamina propria or Reinke’s space—using a 27-g needle (Fig. 20.2).

a) The mucosa will be distended, and generally, noninvasive leukoplakia will be noted to lift up from the underlying vocal ligament. Invasive areas of mucosa can sometimes be noted to remain adherent to the underlying vocal ligament, creating a depression, or “divot” (Fig. 20.3).

b) The infiltration should be done slowly; generally, 0.1– 0.3 ml is all that is necessary.

c) Ensure that the needle is primed, so that air is not infiltrated under the flap.

124	Vocal Fold Leukoplakia and Hyperkeratosis

Fig. 20.2  Submucosal infusion of 1:10,000 epinephrine in vocal fold

4.Incision (Fig. 20.4)

a)Use a fresh sickle knife.

b)Make the initial incision just lateral to the area of leukoplakia, in a posterior-to-anterior direction.

iNote that if a diagnosis of malignancy has not been established, no “margins” are required.

iiKeep the incision superficial by maintaining a slight pull on the knife superiorly (toward you), which “tents up” the mucosa, protecting the deeper layers.

5.Undermine the diseased epithelial layer from the underlying structures (Fig. 20.5).

a)Use the 30° flap elevator to develop a plane in the sub-

20	epithelial space, taking care to be as superficial as pos-
	sible.

b)Very early in the dissection, one must identify the vocal ligament. It is relatively easy to place the flap elevator into of the fibers of the vocal ligament, and begin the plane too deep. This is especially true in cases of re-excision for recurrent leukoplakia and inflammatory leukoplakic processes.

c)Caution must be exercised when extending the dissection inferiorly, as the surgical plane does not continue in the same direction, but instead extends laterally. Because of this, it is easy to perforate the epithelial flap, if one is not careful. To avoid this tendency, one must push the back end of the flap elevator against the vocal ligament laterally, which improves exposure for inferior flap elevation (Fig. 20.6a, b)

d)Ensure that the entire extent of the leukoplakia is undermined freely prior to proceeding. This is done by visualizing the flap elevator through the flap as the dissection proceeds.

 

Fig. 20.3  Invasion of epithelial lesion into the vocal ligament, creating a focal depression or “divot” within the otherwise distended SLP after submucosal infiltration

6.Make posterior, then anterior epithelial incisions (Fig. 20.7)

a)Using an up-cutting scissors held sideways in one hand and a flap elevator in the other, the leukoplakic flap is lifted up and the posterior boundary of epithelium is incised, followed by the anterior.

7.Complete the excision by making the inferior epithelial cut.

a)It is often helpful to check that the microflap incision encompasses the entire diseased epithelium by periodically redraping the flap (Fig. 20.8) and rechecking the incisional line.

b)The epithelial lesion is retracted with a microflap using a triangular forceps, while an up-cutting scissor is used to excise the lesion in a posterior to anterior direction. (Fig. 20.9)

Special consideration should be given to:

■Pinning and orienting the specimen for the pathologist can be very helpful in guiding future therapy. This can be accomplished by placing the epithelial specimen on a tongue blade, indicating the medial/lateral and anterior/ posterior orientation (Fig. 20.10). It is recommended that the surgeon review the histopathology personally with the pathologist, taking note of any anatomic regions that are severely dysplastic/and or invasive. Using this information, future endoscopic treatment can be directed to the specific region of the vocal fold that is involved.

■Multiple patches of leukoplakia can be addressed in the same setting; however, one must be cautious to avoid bilateral anterior epithelial removal, which may result in anterior glottic web formation.

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Fig. 20.4  Sickle knife incision immediately lateral to leukoplakia

Fig. 20.5  Flap elevation (undermining) of leukoplakic lesion

Fig. 20.6  Coronal section of vocal fold depicting lateral pressure on	Fig. 20.7  Anterior flap incision is made after the posterior incision
the flap elevator to improve visualization of infraglottic flap