Учебники / Operative Techniques in Laryngology Rosen 2008

Chapter 48

303

Fig. 48.7  Placement of fat graft into pocket (endoscopic view)

d)Inserting the fat graft

The fat graft is inserted via the minithyrotomy to lie evenly in the area to be augmented. Ideally, only one fat graft per side is used. This is a technically troublesome step, as the fat tends to bunch in the subepithelial plane and adhere to the instruments used to insert it. An alligator is useful to pull the leading edge of the graft (which lies posteriorly on the vocal fold) into place, and a blunt probe is used where necessary to push it into place (Fig. 48.7). The assistant may also use the shaft of a microlaryngoscopic instrument to smooth the medial margin of the vocal fold and help position the graft (Fig. 48.8). An alternative method of graft placement is to use the outside, plastic sheath of an angiocatheter (~ 16 gauge) the fat graft(s) can be placed into a 3rc luer lock syringe and attached to the angiocatheter sheath. The sheath is then passed through the mini thyrotomy and into the pocket previously dissected along the free edge of the vocal fold. After visual confirmation of the angiocatheter position, the fat can be gently “injected” into the vocal fold.

e)Because of the edema that accumulates during dissection, it is difficult to assess the effect of the graft on vocal fold contour, but this should in no way discourage the surgeon into using less fat. Most unsatisfactory outcomes have resulted from using too little fat.

6.Closure

a)The minithyrotomy may be sealed with fibrin glue or bone wax. The perichondrial flap is replaced if possible.

Fig. 48.8  Assistant smoothing medial margin of the vocal fold after fat graft implantation (endoscopic view)

The area is irrigated and checked for hemostasis. If this seems satisfactory, then the wound may be closed without a drain; if not, a rubber band drain may be placed, to be removed the next morning.

48.6Postoperative Care and Complications

Postoperative care entails:

■Overnight, 23-hour observation

■Pain management

■Intravenous steroids at 8-hour intervals (Decadron, 8 mg, then 4 mg)

■Elevation of the head of bed

■A week of voice rest

■A return to clinic is scheduled 2–4 weeks after surgery.

■Prolonged phonatory recovery times are typical (around 1 month).

As this is a relatively new procedure, there are limited data on long-term (>6 months) voice results. Clearly, any improvement in voice quality post-operatively may deteriorate in certain cases after several months, and these late changes have been attributed to poor fat graft survival.

304	The Gray Minithyrotomy

Complications can include:

■Vocal fold epithelial perforation

■In cases of severe scar, it is not difficult to perforate the vocal fold epithelium. Pinhole perforations do not require that the procedure be terminated. Careful fat implantation may proceed, although if the defect is enlarged, it may result in graft extrusion. Small perforations may be patched using a piece of perichondrium from the outside of the thyroid cartilage. In the presence of a large tear, the procedure is probably best abandoned, to be reattempted after healing of the defect.

■Suboptimal results

■Fat implantation via the Gray minithyrotomy does not restore normal voice in most cases. In part, this is because fat is not a perfect rheologic replacement for absent or altered lamina propria tissues. Alternatives and substitutes currently under development may offer superior results via this same surgical approach. Furthermore, as in all clinical applications of autologous fat, graft survival is somewhat unpredictable. This may account for some deterioration over the long term in certain cases. Finally, scar, sulcus, and similar conditions may involve more than just alterations in the superficial lamina propria, and may involve epithelial and deep tissue changes as well, neither of which the Gray minithyrotomy addresses.

 

Key Points

■The Gray minithyrotomy offers access to subepithelial tissues of the vocal folds, without the need for mucosal incision.

■Dissection and fat implantation are performed via a neck incision under endoscopic guidance, which offers advantages over microlaryngoscopic techniques.

■The angle and approach of the minithyrotomy must allow dissection along the longitudinal axis of the vocal fold and not be perpendicular to the thyroid cartilage.

■The Gray minithyrotomy has been especially well suited to rehabilitation of sulcus vocalis and scar, conditions associated with superficial lamina propria disturbance.

Selected Bibliography

1Gray SD, Bielamowicz SA, Titze IR, Dove H, Ludlow C (1999) Experimental approaches to vocal fold alteration: Introduction to the minithyrotomy. Ann Otol Rhinol Laryngol 108:1–9

2Paniello RC, Sulica L, Khosla SM, Smith ME (2008) Clinical experience with Gray’s minithyrotomy procedure. Ann Otol Rhinol Laryngol 117:437–442

48

Subject Index

A
abductor spasmodic dysphonia		221
Abraham cannula  210, 226
acetylcholine	221
adductor spasmodic dysphonia		221, 225
adenopathy	31
Adson’s forcep  250
air trapping	54
airway

–edema  235

–foreign body  236

–obstruction  235

–vocal fold injection  202 airway anatomy  38

airway management

–equipment  53

airway protection  7 airway stenosis  37, 38 allergic rhinitis  46 amyloidosis  44 anastomosis  297

ANCA. see antinuclear cytoplasmic antibody

angiocatheter	162
anterior commissure		133, 161
– microweb	106
anterior glottic web		113, 116, 124, 159

–endoscopic flap  160

–endoscopic keel placement  161

–keel removal  163

antinuclear cytoplasmic antibody (ANCA)  44 aryepiglottic fold  155

aryepiglotticus muscle  155 arytenoid  4

–cartilage  3, 25

–dislocation  31

–edema  262

–perichondrium  25

–prolapsed  236

arytenoid adduction			231, 235, 237, 257, 263
– suture  270
arytenoid cartilage		169, 175
– perichondritis		119
arytenoidectomy  88, 167, 170, 176
arytenopexy	231
aspiration of liquid		241
autoimmune disorder			44
autologous fat	93

B

Babcock retractor  275 beclomethasone dipropionate  44 Bell’s palsy  30

Bellucci scissor  302

bilateral vocal fold paralysis (BVFP)  167 Björk flap  37

Boston gallow  300 Botox  215, 221

– injection  121

botulinum toxin (BTX)  43, 45, 221

–dilution  223

–injection approach  222

–laryngoscopic guidance  225

–percutaneous EMG-guided injektion  223

–reconstitution  223

–retrolaryngeal approach  225

–supraglottic injection  225

–translaryngeal approach  225

botulinum toxin injection

–laryngeal injection  226

–topical anesthesia  226

–videomonitoring  226 Bouchayer forcep  65 breathiness  9, 12 breathy dysphonia  45

bronchiogenic carcinoma  30 bronchoscopic dilation  184 Broyles’ ligament  5 budesonide  44

BVFP. see bilateral vocal fold paralysis

C

calcium hydroxylapatite (Radiesse)  94, 213 candidiasis  123

carcinoma

– vocal fold  191 carcinoma in situ

– of the vocal fold  22 cardiopulmomary resuscitation (CPR)  22 cartilage collapse  39

cartilage graft  285 cartilaginous collapse  55 cartilaginous trachea  297 Cetacaine spray  210, 226 chemical laryngitis  44 chemodenervation  221

306 Subject Index

chondrosarcoma of the cricoid  181 christmas tree adaptor  114 chromophore  85

chronic obstructive pulmonary disease (COPD)  10

Cidofovir	130, 133, 215
CO laser	67, 85, 86, 133, 136, 152, 153, 169, 192

–thermal injury  137

–vascular lesion  137

–vocal fold carcinoma  191 collagen  92, 198

conazole  44

consensus auditory-perceptual evaluation of voice (CAPE- V)  13

conus elasticus  5

COPD. see chronic obstructive pulmonary disease

cordotomy		101, 111, 153, 167, 202
– extension		169
corniculate		3
corticosteroid  47
Cosmoderm		92
Cosmoplast		92, 205
Cottonoid	89, 100, 137, 138, 156, 169, 246, 270

–epinephrine-soaked  236

–mitomycin c-saturated  184 Coumadin  77, 139

CPR. see cardiopulmomary resuscitation cranial neuritis  30

cricoarytenoid  7 cricoarytenoid (CA) arthritis  44

cricoarytenoid (CA) joint  4, 167

–ankylosis  175

–palpation  168

cricoarytenoid (CA) joint arthritis  32 cricoarytenoid muscle  225

cricoid

– cartilage  3, 4, 264, 268, 289 cricoid fracture  279

–exploration  282

–repair  282 cricoidotomy  285 cricothyroid  7 cricothyroid joint  4

cricothyroid membrane		215, 216, 224
cricothyroid muscle	5, 263, 289
cricothyroid space	217
cricothyroid subluxation		232, 263

cricotracheal anastomosis  291

cricotracheal stenosis			289
cuneiform cartilage		3
cup forcep  70
curved alligator  106, 120, 192
Cymetra	92, 205
cyst
– of left vocal fold		24
D
Danazol	47
Decadron	189, 235, 236, 242, 300
deep brain stimulation			45

deep vocal fold augmentation. see vocal fold augementation

 

difficult airway exposure  56 diplophonia  141

drip catheter  211

dynamic voice assessment  19

–base of tongue  19

–larynx (global)  19

–nasopharynx  19

– vocal fold (focal)  19

dysarthria	45
dysgeusia	81
dysphagia	45, 292
dysphonia	9, 10, 30, 34, 109, 119

–breathy  241

–glottal insufficiency  29

–inhaler-related  44

–postoperative  81, 112, 235

–psychogenic  46

– spasmodic  12, 45, 221, 222

–vocal fold polyp  99 dysplasia  21

–carcinoma in situ  22 dyspnea  222

–with exertion  255

E

ee-sniff maneuver  31, 33 electroglottography  18 electromyography  30 EMG

–interpretation  222

–machine  222

endo-extralarnygeal suture lateralization  170

endo-extralaryngeal needle carrier						171
endolaryngeal bleeding				233
endolaryngeal dissection				302
endolarynx	47, 66, 68, 69, 103
– telescope for visualization					71
endoscopic flap		160
endotracheal intubation				182
endotracheal tube (ETT)				37, 53, 67, 69, 133, 176
– laser protected  54
epiglottis  4, 68, 69
epinephrine	66, 130, 206, 242, 254
epinephrine-soaked pledget					120, 130
epithelial hypertrophy			21
epithelium	6
essential tremor		45	223
essential voice tremor
ETT. see endotracheal tube (ETT)
extra-esophageal reflux disease  175
extralaryngeal dissection				301
extrathoracic airway obstruction						40

F

false vocal fold (FVF)  157 fat flap  270

fat graft  303

–harvest  147

–implantation  145 fat harvest  200

Subject Index

307

FEESST

274

I

fiber optic airway examination

39

IA. see interarytenoid muscle

fibrous mass

iatrogenic nerve injury

29

–

ligamentous

24

inferior cornu

263

–

subepithelial

24

informed consent

51

flap elevation

124

infrahyoid strap muscle

275

flexible endoscope

216

injection augmentation

197

flexible laryngoscope

31, 211, 223, 234, 257

interarytenoid muscle (IA)  5

flexible laryngoscopy

18, 39, 210

interarytenoid synchiae

176

Fogarty catheter

188

intubation granulomas

43

framework surgery

–

monitored anesthesia

58

J

Freer elevator

268, 284

Jamison scissor

268

functional aphonia

46

jet ventilation

54, 67, 171, 183

functional dysphonia

46

K

fungal laryngitis

44

G

keratosis

22

Kerrison rongeur

244, 254, 258, 259, 276, 289

gallows suspension device

70

Kitner

259

gastroesophageal reflux disease (GERD)  10, 43

Kitner dissector

301

Gelfoam

92

KTP laser

130

GERD. see gastroesophageal reflux disease (GERD)

Gimmick elevator

302

L

globus sensation

119

lamina propria

6, 17, 24, 27, 63

glottal

–

benign lesion

50

–

hyperfunction

9

laryngeal

–

incompetence

198

–

amyloidosis

44

–

insufficiency

91, 142, 209, 215

–

cancer

43

glottic

–

edema

235

–

enlargement procedure

51

–

electromyography (LEMG)

32, 175

–

insufficiency

29, 33, 94, 231

–

examination

19

–

stenosis

38, 289

–

fracture

279

GORE-TEX

253

– initial assessment

280

–

implant

255

–

framework stenosis

159

granuloma

172

–

framework surgery

91, 197, 231

Gray minithyrotomy

142, 143, 299

–

function

7

–

Pinhole perforation

304

–

gargle

210

GRBAS scale

12

–

inflammation

10

Guaifenesin

47

–

injection

221

H

–

nerve

297

–

stenosis

279

hematoma

219

–

stent

281

hemilarynx

275

–

stent removal

282

hemostasis

73

–

trauma

38, 267, 279

herbal remedy

47

–

vestibule

4

histamine type 2

receptor antagonist  43

laryngitis

44

hoarseness

9, 10, 12, 13

laryngocele

273

holmium:YAG (Ho:YAG) laser

86

–

combined

273

Hopkins rod telescope

67

–

internal

273

horizontal belly

5

–

recurrence

277

human papilloma virus

133

–

termination

276

Hunsaker Mon–Jet catheter

55

–

transthyroid excision

274

Hyalaform

93

laryngocutaneous fistula

287

Hyaluronic acid

92

laryngofissure

281, 287, 290

hyperkeratosis

123

–

parasagittal

269

10

hypernasality

12

laryngopathia premenstrualis

hyponasality

12

laryngopharyngeal reflux (LPR)

10, 43, 119

hypopharynx

226

laryngopharyngeal reflux disease

25, 49, 75

hypophonia

45

laryngoplasty

231

hypothyroidism

10

–

window

254

308	Subject Index

laryngoscope

–flexible  210

–optimal position  70

–placement  81

–positioning  81 laryngoscopic guidance  223 laryngoscopy

–flexible  19, 216

–placement  68 laryngospasm  7, 224 laryngotomy  281

–vertical parasagittal  268

laryngotracheal reconstruction with grafting  283

laryngotracheal stenosis	289
laryngovideostroboscopy	50
larynx

–age-related change  34

–allergic disease  46

–difficult exposure  56

–extrinsic muscle  5

–innervation  6

–intrinsic muscle  4

–squamous cell carcinoma  155

–thyrohyoid approach  218

–vasculature  6

–videocart system  210

–videomonitoring  210

–visualization  17

laser

–CO   86

–contraindication  86

–damage  88

–equipment  87

–fire  89

–indication  86

–nonspecific thermal damage  85

–safety  88

–setting  88

–smoke evacuation  88

–surgery  85

–tissue interaction  85

–type  85, 86

–vaporization  88

–wavelength  85

lateral cricoarytenoid muscle (LCA)  4 LCA. see lateral cricoarytenoid muscle

Lee Silverman voice treatment (LSVT)  45 LEMG. see laryngeal electromyography (LEMG) leukoplakia  21, 43, 123

–multiple patch  124

–recurrence  126

Lichtenberger endo-extralaryngeal needle passer  162, 170

lidocaine

38, 199, 218, 242, 254, 268

–nebulization  211 Lindholm laryngoscope  156 lipoinjection  200

–liposuction fat harvest  201

–preparation of fat  201

 

liposuction  200

– cannula  201

LPR. see laryngopharyngeal reflux (LPR)

lung capacity  7
M
malleable retractor  284
mask ventilation  185, 187
maximal phonation time (MPT)			31, 257
Mayo stand  72, 300
medial arytenoidectomy (MA)			167, 169
medialization
–	depth  247
–	implant extrusion	255
–	postoperative care	250
–	window  258
–	zone  249

medialization laryngoplasty (ML)  32, 231, 263, 264

–airway obstruction  235

–complications  235

–edema  236

–GORE-TEX  253

–implant material  232

–patient selection  232

–revision surgery  237

–Silastic  241

–undercorrection  236 medical laser  85

micro-ovoid cup forcep  65, 121

microalligator		111
microalligator forcep			147
microcup forcep  65, 75, 106, 192
microcurved scissor			74
microdebrider		66, 130, 132
microelevator		65, 75
microflap	24, 73, 109, 114, 143, 146

–injury  73

–vocal fold polyp  101 microforcep  133

microlaryngeal instrumentation  64

microlaryngoscopy			41, 53, 131, 142, 143, 145
– vocal fold cancer			192
microscissor		66, 106, 111, 130
microsuture	147
microtrap-door flap			177
Midazolam	58
midmembranous vocal fold lesion				23
mitomycin C		161, 170, 176, 179, 184, 282
monitored anesthesia care  58
Montgomery stent			281, 282, 285, 286
MPT. see maximal phonation time
MTD. see muscle-tension dysphonia
mucosa
– perforation		236
mucosal cordotomy			110, 143
mucosal flap elevation  176
mucosal wave		8, 17, 33
muscle-tension dysphonia (MTD)				45

Subject Index

309

N

nasogastric (NG) tube  185 nasolaryngoscopy  38 neck mass  274

neodymium-coupled YAG (Nd:YAG) laser  86 neurological disorder  10

neurotoxin	221
nonlaryngeal malignancy			30
nucleus ambiguus  6
O
odynophonia  119
oropharynx	211, 226
Ossoff-Pilling laryngoscope  56, 65
otolaryngology		9
oxyhemoglobin absorption band  86
oxymetazoline		210, 218, 226, 242, 254, 268
P
palatal paralysis		31
papillary ectasia		135
papilloma virus infection			21

paradoxical vocal fold motion disorder (PVFMD)  46 paraffin  197

paralytic dysphonia  4 paralytic falsetto  31 paraplegia  30

Parkinson’s disease (PD)  34, 45 patient

–history  9

–occupational history  11

–social history  11

–speaking voice  11

PCA. see posterior cricoarytenoid muscle

Penrose drain		298
percutaneous vocal fold augmentation				215
perichondrial flap  258, 303
perichondrial inflammation			120
perichondritis of the arytenoid cartilage				119
perichondrium		233, 244, 254, 284, 301
periodicity	18
PGS. see posterior glottic stenosis (PGS)
pharyngocutaneous fistula			262
phonation	7

phonatory glottal closure  231 phonomicrosurgery  49, 63

–anesthesia  67

–anterior glottic web  159

– apneic technique for anesthesia  67

–CO laser  67

–cold-steel  141

–complication  75, 81

–equipment  65, 105

–informed consent  51

–laryngoscope  65

–laryngoscope placement  68

–	leukoplakia of the vocal fold  123
–	medical complication  82

–microflap approach  73

–microscope  67

–patient position  68

–physical complication  82

–polypoid corditis  113

– recurrent respiratory papilloma (RRP)  129

–sulcus vocalis  141

–surgical microscope  72

–timing  49, 77

– total voice rest  78

–vascular lesion  136

–vocal fold cyst  109

– vocal fold fibrous masses  109

–vocal fold granuloma  119

–vocal fold nodule  105

–vocal fold polyp  100

–vocal fold scar  141

–voice therapy  77 phonosurgery  49

–decision-making process  50

–elective  50

phonotrauma  25, 43, 47, 105, 113 photolysis  85

Pilling posterior-commissure laryngoscope  120 Plavix  77

pneumomediastinum  54 pneumothorax  54, 89

polypoid corditis. see also Reinke’s edema

–phonomicrosurgery  113

–polypoid material removal  114

–redundant mucosa  115

–saddle-bag appearance  113 polytetrafluoroethylene (Teflon)  93 Pontocaine  210, 226

posterior commissure  133

posterior cricoarytenoid muscle (PCA)						5, 259
posterior glottic scar				179
posterior glottic stenosis (PGS)  37, 167, 175
posterior transverse cordotomy (PTC)						167, 168, 172
postviral vagal neuropathy					46
potassium–titanyl–phosphate (KTP) laser  86
PPI. see proton pump inhibitor
presbylaryngis		34, 213
presbyphonia		91
primidone	45
propofol  55, 58
propranolol	45
proton pump inhibitor (PPI)  43
pseudosulcus		43
pulmonary function				40
pulsed-KTP laser			138
pulsed dye laser (PDL)  86, 138
– therapy	136
pyriform mucosa			259, 262
Q
quadrangular membrane					5

310							Subject Index
R
RA. see rheumatoid arthritis
Radiesse Voice Gel  93
raspiness		9
re-anastomosis			297
rectus abdominus muscle						284
recurrent respiratory papilloma (RRP)  21, 82, 129
–	Cidofovir laryngeal injection  133
–	glottis	132
–	laser surgery		131
–	microdebrider removal					132
–	microflap removal			130
–	microforcep removal				131
–	phonomicrosurgery				129
–	posterior commissure					133
–	supraglottis		132
–	telescopic surgery			132
reflux symptom index (RSI)							10
Reinke’s edema			25, 43
Reinke’s space			6, 95, 115
residual arytenoid overhang							170
Restylane		93
rheumatoid arthritis (RA)						44
rheumatological disorder						26
rough voice  9

RRP. see recurrent respiratory papilloma (RRP)

RSI. see reflux symptom index

S

saccular cyst

–endoscopic excision  155

–recurrence  157

saline-infusion trial  205, 206

scant gelatinous-appearing material  111

sevoflurane	54
Sewell retractor  260
sickle knife	66, 73, 124, 130
Silastic  253

–block  241, 246

–catheter  211

–medialization  271

–medialization laryngoplasty  241

–T-tube  292

silent cough		78
silicone	197
silk tape	71
singing voice		12
singing voice therapy  78
sinonasal allergic disease  49
SLE. see systemic lupus erythematosus
Sliding Jackson laryngoscope  57

SLN. see superior laryngeal nerve sound production  7

spasmodic dysphonia (SD)	45, 222
speech–language pathologist	78, 138
speech–language pathology	142
spider telangiectasia  135

squamous cell carcinoma of the glottis  191 stenosis

– congenital  283

 

–excision  296

–rigid dilation  184

–subglottic  181, 283

–tracheal  181 sternocleidomastoid muscle  295 steroid inhaler  44

strain  12

stroboscopy  17, 18, 105

–after phonomicrosurgery  78

–preoperative  63 strobovideolaryngoscopy  135 subepithelial dissection  302

subglottic jet ventilation tube  54

subglottic stenosis	38, 54, 55, 181, 283, 289
subplatysmal flap	242, 254, 275, 285, 296

sulcus vocalis  27, 91, 231, 299

–excision with reapproximation  143

–phonomicrosurgery  141

– vocal fold slicing technique			143
superficial vocal fold injection			205
superior laryngeal nerve (SLN)			6
supraglottis stenosis	159
Surgifoam  92
suspension laryngoscope		114, 176
suspension laryngoscopy		136, 171, 185
suspension microlaryngoscopy			199
suture lateralization	178, 179

systemic lupus erythematosus (SLE)  44

T

T-tube  187, 292

–Hood package  189

–occlusion  189

–placement  185

–stenting  185, 189 T-tube stent  42 T-tube stenting  41

TA. see thyroarytenoid muscle (TA) Teflon  93, 197

–granuloma  151, 267

–injection  151, 267

–mass

– laser ablation  152 Teflon injection  32 testosterone  47 thalamotomy  45 throat clearing  78 throat pain  81

thyroarytenoid muscle (TA)  5, 135 thyrohyoid membrane  155, 273 thyroid

–artery  6

–notch  3

thyroid ala  217, 233, 237, 250

thyroid cartilage  3, 4, 155, 160, 161, 242, 243, 250, 263, 275, 301

–fracture  279, 280 thyroid fracture

–exploration  280

–repair  280

Subject Index

311

thyroid lamina  268 thyroid mass  31 thyroplasty  3

–GORE-TEX ribbon  253

–type I  231

–window  6

thyrotracheal anastomosis  289 total arytenoidectomy  170, 172 total voice rest  78

tracheal

–intubation  295

–stenosis  295

–stoma  39

tracheal airway narrowing  182

tracheal stenosis	38, 54, 55, 181, 283
– intrathoracic	55
tracheal stoma	38
tracheobronchoscopy  41, 298
tracheomalacia	39, 40, 181

tracheostomy  37, 55, 185, 285

–placement  38

–T-tube placement  185

–tube  54, 182

tracheotomy	21, 129, 167, 175, 176, 295, 296
Tramadol  47
trans cricothyroid membrane
– placement of injection needle		217
transnasal esophagoscope  86
transthyroid cartilage  215
– placement of injection needle		217
triangular forcep  65, 111, 192
tympanoplasty  299, 302

U

unilateral vocal fold paralysis (UVFP)  29, 91, 241

–imaging study  32

–screening laboratory test  32

–treatment  32, 33

upper airway stenosis  183

upper respiratory infection (URI)  9 URI. see upper respiratory infection UVFP. see unilateral vocal fold paralysis

V

vagus nerve  29

–herpes simplex infection  30 Valsalva maneuver  236, 262 vascular knife  136

velcro strap  71

ventricular mucosa  250, 255 vertical belly  5

VFP. see vocal fold paralysis

–treatment  32

VHI. see voice handicap index video examination  19 videolaryngoscopy  199 videostroboscopy  29, 109, 199

–leukoplakia  123

–VFP  31

–vocal fold paresis  33

visual analogue scale  12 visualization

– stroboscopic  17 vocal

– fatigue  9, 13, 33, 241

–hygiene  47

–ligament  6, 110

–pathology  9

–professional  11

–testing  12

–tickle  13

–tremor  45 vocal fold  6

–amplitude  18

–atrophy  142, 213

– augmentation  91, 92, 142, 198

–microlaryngoscopy  199

–bamboo lesion  26

–bilateral paralysis (BVFP)  167

–bowing  34, 253

–carcinoma  22, 191

–cookie cutter defect  107

–cyst  23, 74

–phonomicrosurgery  109

–recurrence  112

–edema  237

–endoscopic injection  199

–epithelial perforation  304

–ETT trauma  173

–fat graft reconstruction  145

–fibrous mass  74

–phonomicrosurgery  109

–granuloma  25, 43, 223

–phonomicrosurgery  119

–hemorrhage  47

–immobility  30, 31

–injection  197, 211

–material  92, 197

–keratosis  21

–phonomicrosurgery  123

–knot tying  147

–leukoplakia  21

–phonomicrosurgery  123

– lipoinjection  94, 198, 200, 201

–medialization  231

–midmembranous lesion  23

–mobility testing  39

–mucosa  6

–nodule  23

–phonomicrosurgery  105

–surgery  105

–overmedialization  237

–papillary ectasia  135

–	paralysis	29, 211, 232, 241, 257, 263
–	paresis	11, 31, 33, 213

–pathologic condition  21

–pathology  72, 73, 82

–percutaneous augmentation  216

–peroral augmentation

– in the clinic setting  215

312

Subject Index

–phonotrauma  22

–pinching  147

–placement of sutures  146

–pliability  18

–polyp  24

–microflap approach  100

–phonomicrosurgery  99

–truncation  101

–truncation approach  100

–	prevention of scar formation  82
–	reactive lesion  25
–	scar  27, 159, 205, 299

–phonomicrosurgery  141

–scarring  116, 139

–spider telangiectasia  136

–stiffness after phonomicrosurgery  78

–subepithelial space  63

–superficial injection  205

–swelling  219

–transoral augmentation  209

–trauma  10

–true hemangioma  135

–undermedialization  250

–vascular lesion  26

–phonomicrosurgery  135

–vibration  17

–vibration symmetry  18

vocalis muscle  5 voice

–aesthenic  12

–alteration  287

–disorder  43

–evaluation  17

–quality  49

–rest  107, 138

–vocal fold polyp  103

–therapy  23, 33, 50

–preoperative  49, 63

–prior to phonomicrosurgery  77

–speech–language pathologist  47

–tremor  221, 223

–unloading  30

voice handicap index (VHI)  12

W

Wegener’s granulomatosis  44 Woodson elevator  244, 254, 268

Y

YAG laser  86

Z

Zyplast  92, 205