UCI Otolaryngology Head and Neck Surgery

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UCI Otolaryngology Head and Neck Surgery

• Thursday Morning Conference
• March 23, 2006
• Paul K. Holden, MD

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Patient Conference

• 68 yo female presents with c/o I lost my voice
  and it never came back approximately 3 months
  ago.

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Patient Conference

• Had URI for about a week
• One morning, while having her first coffee, began
  choking and noticed after that her voice was very
  weak
• Noted a painful rash on left cheek, resolved
  after 3 weeks
• No facial asymmetry
• Continues to choke on some foods (mostly liquids)
• Lost 15 lbs in last 3 months
• No odynophagia

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Patient Conference

• PMH Hypothyroid, HTN
• PSH Hysterectomy (1994), Breast Biopsy (2002),
  TA as child
• Meds benazepril, atenolol, levothyroxine,
  hormone supplements
• NKDA
• Soc No T/E/D, widowed, lives with son and his
  family
• FH - noncontributory

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Patient Conference

• PEx
• WDWN, mildly obese
• PERRL, EOMi
• TM c/i/m AU
• Nose clear, MMM
• OC clear, MMM, fair dentition
• Neck supple, nonpalpable thyroid, trach ML, no
  lymphadenopathy
• Sensation decreased on left V2 distribution,
  normal palate elevation, V1, V3 and CN VII intact
• Voice high pitched, strained, diplophonia,
  fatigues into breathy weak voice, max phonation
  time 3-4 secs, sz ratio 2.51

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Patient Conference

• IDL Unable 2/2 brisk gag
• FOL
• Normal BOT, hypopharynx, epiglottis, piriform
  recesses
• Nonmobile left TVC, in paramedian position
  without sig bowing
• No frank pooling or aspiration observed
• Right TVC mobile, normal appearance
• Normal subglottis

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Patient Conference

• Further Workup
• Lab Tests?
• Imaging?
• Ancillary tests?
• Consults?

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Patient Conference

• CT w/ contrast from skull base through aortic
  arch Negative
• Swallow study aspiration of thin liquids
• EMG SLN weak on left but intact, RLN out on
  left
• What Now? What is the DDx?

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PhonosurgeryA COCLIA Production
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Phonosurgery

• 1. Favorite thoracic surgeon ? hoarse pt s/p TAA
  repair, immobile fold on exam, how determine
  etiology?
• Exam which side, palatal elevation, gag, pooling
• EMG (RLN?)
• Imaging CT w/ con from skull base to arch if
  RLN suspected, MRI skull base if vagus out.

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Phonosurgery

• 2. VF injection medialization vs. intrachordal
  injectionwhat diff?
• Medialization is lateral to vocal process to
  medialize the vocal process ligament in the
  paraglottic space, leaves mucosa unaltered
• Intrachordal is usually to fill a defect, bolster
  a bowing/flaccid defect directly into cord, deep
  to SLP. Less reactive substance preferred.

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Phonosurgery

• 3. UVF injection medialization materials?
• Short Term gelfoam (out), Hyaluronic Acid
  (Restylane), collagen (xeno, allo, auto), fascia,
  fat
• Longer Term Calcium Hydroxyapatite CaHA, Teflon
  (out), Silicone

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Phonosurgery

• 4. Management of Teflon Granulomas
• Remove offending material
• Endoscopic less morbid, poor exposure, limited
  removal, some advocate laser and others cold
  steel. Usually pts with more comorbidities and
  shorter life expectancy.
• Open Laryngotomy vs. Thyrotomy improved
  exposure, more morbid, able to remove more,
  Netterville favors lateral laryngotomy, must
  attempt complete removal on first try in young
  pts.

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Phonosurgery

• 5. Percutaneous vs. laryngoscopic injection
  medialization
• Percutaneous (LA) can adjust to pt voice and
  reinject, limited by pt gag/anxiety, real-time
  view of mobility immediately after injection,
  technically more difficult
• Laryngoscopic can do under LA or GA. GA is
  more controlled but no dynamic eval, LA limits
  same as percutaneous.

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Phonosurgery

• 6. Management of over injection during focal fold
  medialization.
• Overlying mucosa should be incised and material
  removed with small suction to avoid airway
  compromise and/or dispersion of material making
  later removal more difficult or impossible.

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Phonosurgery

• 7. Medialization thyroplasty indications,
  advantages.
• Indications
• Paralysis, presbylaryngus, sulcus vocalis, CT
  joint fixation, postop tissue defects
• Advantages
• Local Anesthetic
• May be reversible
• More anatomic Position
• Vocal Fold Integrity Preserved

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Phonosurgery

• 8. Technique of medialization thyroplasty. What
  would you use for implant?
• 5cm sub-platysmal incision on affected side at
  level of glottis over thyroid lamina
• Dissect straps down to perichondrium
• Raise perichondrial flap, open window 5-8mm
  posterolateral to ventral ML in females, 8-10mm
  in males both at level of glottis. Inner
  perichondrium is preserved!
• Elevate inner perichondrium circumferentially,
  place silastic or PTFE material into window, have
  pt phonate and adjust.
• When desired voice attained, shim into place,
  secure w/ sutures or miniplate.
• Irrigate, penrose, close.

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Phonosurgery

• 9. Goal of Arytenoid Adduction. Indications.
• Abducted arytenoid can have persistent posterior
  glottic aperature that can cause dysphagia and
  dysphonia.
• The action of the LCA is mimicked with a suture
  through the muscular process of the arytenoid and
  sutured through the paraglottic space, anteriorly
  to the inferior thyroid ala (pulling the
  arytenoid into adduction) to close posterior gap.

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Phonosurgery

• 10. Would you perform an arytenoid adduction
  without medialization procedure?
• Generally, medializations are attempted first and
  AA is reserved for persistent posterior gaps.
• In cases of severe glottal incompetence, one can
  combine AA with medialization and some also
  include reinnervation.

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Phonosurgery

• 11. How do you do an Arytenoid Adduction?
• SEE NUMBER 9

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Phonosurgery

• 12. Success of reinnervation procedures.
• Primary reanastomosis after acute injury has high
  synkinesis rate.
• Phrenic-RLN unsuccessful
• Nerumuscular Pedicle and Ansa-RLN both report
  high rates of good voice quality and glottic
  competence (85-95)
• Physiologic motion usually not seen
• Hypoglossal-RLN animal model only

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Phonosurgery

• 13. Bilateral vocal fold paralysis in midline
  position. Pt refuses trach, what other options?
• ELMA
• Cordotomy
• Combination

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THANK YOU!