UCI Otolaryngology Head and Neck Surgery - PowerPoint PPT Presentation

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UCI Otolaryngology Head and Neck Surgery

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Had URI for about a week. One morning, while having her first coffee, began ... Noted a painful rash on left cheek, resolved after 3 weeks. No facial asymmetry ... – PowerPoint PPT presentation

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Title: UCI Otolaryngology Head and Neck Surgery


1
UCI Otolaryngology Head and Neck Surgery
  • Thursday Morning Conference
  • March 23, 2006
  • Paul K. Holden, MD

2
Patient Conference
  • 68 yo female presents with c/o I lost my voice
    and it never came back approximately 3 months
    ago.

3
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

4
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

5
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

6
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

7
Patient Conference
  • Further Workup
  • Lab Tests?
  • Imaging?
  • Ancillary tests?
  • Consults?

8
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?

9
PhonosurgeryA COCLIA Production
10
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.

11
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.

12
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

13
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.

14
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.

15
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.

16
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

17
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.

18
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.

19
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.

20
Phonosurgery
  • 11. How do you do an Arytenoid Adduction?
  • SEE NUMBER 9

21
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

22
Phonosurgery
  • 13. Bilateral vocal fold paralysis in midline
    position. Pt refuses trach, what other options?
  • ELMA
  • Cordotomy
  • Combination

23
THANK YOU!
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