1. Nova Medical Centers
KAILASH COLONY
New Delhi
©2009. Nova Medical Centers. Strictly private and confidential

2. LARYNGEAL SURGERY IS
WELL SUITED TO
AMBULATORY PRACTICE
©2009. Nova Medical Centers. Strictly private and confidential
Dr. Lalit Mohan Parashar
Deptt of Otorhinolaryngology and
Dr. Lalit Mohan Parashar
Senior Consultant OTORHINOLARYNGOLOGY &
Head & Neck SURGERY
HEAD and NECK Surgery
(ORL&HNS)

3. The Problem
• Laryngeal Surgery involves airway
• And thereby the problems
• Requiring immediate solutions
• Trained staff
• Tracheostomy may be required
©2009. Nova Medical Centers. Strictly private and confidential

4. The Problem
• Most of the ENT Surgery involves airway
• And thereby the problems
• Requiring immediate solutions
• Trained staff
• Tracheostomy may be required
©2009. Nova Medical Centers. Strictly private and confidential

5. ENT Surgeries:- THROAT -:
Nose -:
EAR -: Tonsillectomy-
Adenoidectomy- endoscopic
Septoplasty- guidance to ensure complete
Septorhinoplasty- removal
Cochlear Implants - Micro-Laryngeal Surgeries-
Myringotomy and Grommet Uvulo – Palatoplasty-
insertion- Tympanoplasties- Functional Endoscopic Sinus
treatment of snoring/ OSA
Stapedectomy with piston Surgery- polyposis
Obstructive Sleep Apnoea
placement Mastoidectomy- Trans Nasal Neuro
Pharyngoplasty-
Sac Decompression- Facial Surgeries- including pituitary
Laryngofissure and other
Nerve Decompression and tumours and skullbase
voice box surgeries
repair. surgery
Tracheal Surgeries
Optic Nerve Decompression-
Orbital decompression-
Endoscopies: Head & Neck Surgeries –
©2009. Nova Medical Centers. Strictly private and confidential
Parotidectomy
laryngoscopy, Sub- Mandibular Excision
Neck Dissections
bronchoscopy Thyroidectomies
oesophagoscopy and Parathyroidectomies
nasopharyngoscopy with
flexible fibreoptic or rigid
scopes.

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

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

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

12. 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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13. 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

20. FUNCTIONAL PRINCIPLES
• BLOOD IN CONTACT WITH CARTILAGE LEADS TO RESORPTION
• CARTILAGE IN CONTACT WITH SECRETIONS LEADS TO INFLAMMATION
WHICH LEADS TO GRANULATIONS
MESSEGE
©2009. Nova Medical Centers. Strictly private and confidential
CARTILAGE HAS TO BE COVERED AT ALL COSTS

21. Extirpation Endolaryngeal Microsurgery
conventional microsurgery(MLS)
• Indications:
• Congenital Lesions:
• Sulcus vocalis & vergeture. Laryngeal web
• Epidermoid cysts & laryngoceles. Laryngeal
stenosis
©2009. Nova Medical Centers. Strictly private and confidential
• Acquired lesions
• Granulomata. :Benign neoplasm
• • VF hemorrhage. • Papillomatosis.
• • Dysplasia of VF. & Carcinoma in situ. •

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Micro Laryngeal Surgery

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Micro Laryngeal Surgery

24. 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
©2009. Nova Medical Centers. Strictly private and confidential
1. Predictable Post op/ recovery
2. Hypotensive Anaesthesia

25. Long list of requirements
• Largest Bore Laryngoscope + ant. & post. Comm.
• Suspension Systems
• Specialized Instruments
• Mouth/ dental Guard
• Subepithelial Infusion needle
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• 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

30. Laryngeal Surgery is more than that.
Kotby's classification
1. Extirpation endolaryngeal microsurgery.
2. Vocal fold augmentation.
3. Vocal fold repositioning.
4. Neurophonosurgery.
5. Glottal reconstruction after partial laryngectomy.
©2009. Nova Medical Centers. Strictly private and confidential
6. Postlaryngectomy surgery.
7. Laryngo Tracheal Trauma

31. Vocal Fold Augmentation
• Indications:
• Correction of glottic incompetence due to:
• Unilateral vocal fold paralysis.
• Sulcui or after surgery or trauma.
• Autologous and alloplastic materials.
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• Transoral or percutaneous approaches.
• Silicon, Teflon, Gelfoam, Autologous Fat

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Injection Medialisation

33. 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.
©2009. Nova Medical Centers. Strictly private and confidential
Sharp dissection
Laser excision.

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Laser Assisted

35. 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).
©2009. Nova Medical Centers. Strictly private and confidential

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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

44. 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
©2009. Nova Medical Centers. Strictly private and confidential
the lateral segments beneath the anterior segment.
Indication:
• Spastic dysphonia.

45. 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.
©2009. Nova Medical Centers. Strictly private and confidential

46. Type IV - Stretching (lengthening)
CT approximation to elevate pitch.
Other Techniques to elevate the pitch:
• Inferiorly based anterior cartilage flap.
• Superiorly based cartilage flap.
©2009. Nova Medical Centers. Strictly private and confidential
• Anterior commissure advancement.

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Laryngo Tracheal Trauma

48. Laryngo Tracheal Trauma
• Increasing accidents
• Time to prepare ourselves is NOW
• Minor Ones or Group I need conservative management
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49. Group II
Intact endolarynx + Displaced thyroid #
• ORIF
• AIM – preservation of AP diameter
Maintain Normal position of cords
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Austin technique

50. 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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51. Group III
Large mucosal lacerations
• AIM
– Return all remaining tissue to appropriate location
– Cover all cartilage
©2009. Nova Medical Centers. Strictly private and confidential
• FUNCTIONAL PRINCIPLES

52. FUNCTIONAL PRINCIPLES
• BLOOD IN CONTACT WITH CARTILAGE LEADS TO RESORPTION
• CARTILAGE IN CONTACT WITH SECRETIONS LEADS TO INFLAMMATION
WHICH LEADS TO GRANULATIONS
MESSEGE
©2009. Nova Medical Centers. Strictly private and confidential
CARTILAGE HAS TO BE COVERED AT ALL COSTS

53. Group III
Large mucosal lacerations
• MIDLINE THYROTOMY or
• Pramedian if vertical # within 3mm of midline
• Steps of MIDLINE THYROTOMY
©2009. Nova Medical Centers. Strictly private and confidential

54. 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.
©2009. Nova Medical Centers. Strictly private and confidential
• ORIF if required

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Thank You