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. E.N.T. Surgery :-
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 –
Parotidectomy
©2009. Nova Medical Centers. Strictly private and confidential
laryngoscopy, Sub- Mandibular Excision
Neck Dissections
bronchoscopy Thyroidectomies
oesophagoscopy and Parathyroidectomies
nasopharyngoscopy with
flexible fibreoptic or rigid
scopes.

6. 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.

7. 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 ?

12. ©2009. Nova Medical Centers. Strictly private and confidential
E.N.T. Surgery :- Particularly Laryngeal Surgery

13. 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
©2009. Nova Medical Centers. Strictly private and confidential

14. 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

21. 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

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E.N.T. Surgery :-

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Micro Laryngeal Surgery

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Micro Laryngeal Surgery

25. 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. •

26. 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
©2009. Nova Medical Centers. Strictly private and confidential

27. 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

28. Tube Position
• Anterior Vocal cords 2/3rd :- small ETT
• Posterior Vocal Cords :- Anterior ETT or
» Jet Ventillation or
» Apneic Techniques
©2009. Nova Medical Centers. Strictly private and confidential

29. Other Considerations
• Laser Protected ETT
• Care of Sub Glottis and
• Care of tracheal Stoma
• Difficult Per Oral exposure
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30. Difficult Per Oral exposure
• Short Thick Neck
• Retrognathia
• Trismus
• Restricted Neck Extention
• Lingual Hypertrophy
• Poor Palatal visualisation
©2009. Nova Medical Centers. Strictly private and confidential

31. Long list of requirements
• Largest Bore Laryngoscope + ant. & post. Comm.
• Suspension Systems
• Specialized Instruments
• Mouth/ dental Guard
• Subepithelial Infusion needle
©2009. Nova Medical Centers. Strictly private and confidential
• 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

36. 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

38. 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

40. 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

49. 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.

50. 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

51. 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.

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

53. Neurophonosurgery
• Reinnervating the PCA muscle
• Nerve anastomosis. Phrenic nerve /ansa cervicalis.
• Phrenic nerve implantation.
• Neuromuscular pedicle Transplantation.
• Reinnervating the TA muscle
©2009. Nova Medical Centers. Strictly private and confidential
• Ansa cervicalis to RLN anastomosis
• Infrathyroid - suprathyroid techniques
• Neuromuscular pedicle Transplantation.

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Laryngo Tracheal Trauma

55. Laryngo Tracheal Trauma
• Increasing accidents
• Time to prepare ourselves is NOW
• Minor Ones or Group I need conservative management
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56. Group II
Intact endolarynx + Displaced thyroid #
• Open reduction + internal fixation ORIF
• Method
– Sutures
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– Wires
– Miniplates

57. Group II
Intact endolarynx + Displaced thyroid #
• ORIF
• AIM – preservation of AP diameter
Maintain Normal position of cords
©2009. Nova Medical Centers. Strictly private and confidential
Austin technique

58. 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
©2009. Nova Medical Centers. Strictly private and confidential

59. 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

60. 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

61. 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

62. 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
©2009. Nova Medical Centers. Strictly private and confidential
• Achieve haemostasis

63. 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
©2009. Nova Medical Centers. Strictly private and confidential
– Keep mucosa down by quilting sutures

64. Group III
Large mucosal lacerations
• Situation 2
– Primary closure is not possible
– Rotate flaps from - Epiglottis
- pyriform sinuses
©2009. Nova Medical Centers. Strictly private and confidential
– Skin flaps
– Mucosal grafts

65. Group III
Large mucosal lacerations
• Situation 3
• Arytenoid cartilage dislocated
– Reduce it back
– Repair mucosa
©2009. Nova Medical Centers. Strictly private and confidential

66. 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