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Common head and neck viva topics
Published in Joseph Manjaly, Peter Kullar, Advanced ENT Training, 2019
Other surgical options: Arytenoid adduction: Technically challengingNon-selective laryngeal reinnervation: Ansa cervicalis to recurrent laryngeal nerve
Phonosurgery
Published in John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford, Head & Neck Surgery Plastic Surgery, 2018
Isshiki23 described an arytenoid adduction procedure for patients where there is a large posterior gap and the paralysed cord is at a different vertical level. Good results have been reported, both initially for a competent larynx and long term for voice production.24 A modification of this technique is the arytenoid fixation and cricothyroid subluxation as described by Zeitels.25 With an extended incision, the arytenoid cartilage is exposed, its attached muscles divided and the arytenoid cartilage is fixed in a midline position. Tension of the paralyzed cord is obtained by a suture between the inferior horn of the thyroid cartilage and the cricoid cartilage anteriorly (Figure 67.12). This is usually combined with a medialization thyroplasty and allows correct positioning of the arytenoid cartilage and gives tension and bulk to the paralyzed vocal cord. Although technically challenging, it is the author’s personal choice for patients with a large posterior glottic chink.
Laryngeal trauma
Published in Declan Costello, Guri Sandhu, Practical Laryngology, 2015
Guri Sandhu, S. A. Reza Nouraei
The neck is inspected for evidence of injury such as skin abrasions, bruising and entry and exit wounds in penetrating trauma, and is palpated for crepitations, laryngeal tenderness and any obvious changes in laryngeal anatomy such as loss of the prominence. Open wounds should not be explored at this stage as instrumentation may restart haemorrhage. Flexible nasendoscopy is then performed, and the oropharynx and hypopharynx are examined for injuries. The laryngeal mucosa is examined for lacerations and haematomas, and particular care is taken to assess the vibratory edge of the vocal cords and the anterior commissure. Arytenoid adduction is examined during phonation; abduction is assessed by asking the patient to say ‘eee’ followed by a sniff. Impairment of arytenoid mobility may be secondary to structural damage or due to recurrent laryngeal nerve injury. Note is taken of any exposed or protruded cartilage or submucosal distortion of the framework. A sign of cartilaginous injury is failure of the vocal cords to meet in the same horizontal plane.
Study of arytenoid adduction performed under general anesthesia
Published in Acta Oto-Laryngologica Case Reports, 2019
Yu Saito, Ryoji Tokashiki, Kiyoaki Tsukahara
For unilateral vocal fold paralysis, we consider arytenoid adduction (AA) surgery under local anesthesia the procedure of choice. In general, position of paralyzed vocal fold divided into paramedian or intermedian. It is also said paralyzed vocal fold having large posterior glottal chink tend to have severe level difference during phonation. However according to our research over 10 years, passive movement of the paralyzed vocal fold, with displacement outward and upward, is present in all cases of unilateral vocal fold paralysis on phonation [1–3], and AA is essential for achieving a good voice [3,4]. During surgery, simulation is carried out while listening to the patient’s voice and concurrently performing type 1 or 4 thyroplasty. We have conducted AA surgery under local anesthesia for almost 300 patients at Tokyo Medical University Hospital and associated hospitals. The result has been 100% improvement in the voice of most patients, with a maximum phonation time (MPT) of 10 s or greater and mean air flow rate (MFR) of 200 ml or less [4,5]. Voice improvement does not depend on the severity of preoperative phonetic impairment (e.g. MPT will improve to 30 s or more even in patients with an MPT of 1 s). In addition, ∼60% of patients have said that they were able to sing after the operation [6]. To our knowledge, this is one of the best reported outcomes for vocal cord paralysis surgery. The results reflect the fact that AA, a procedure to restore physiological adduction of the vocal cords, and type 1 thyroplasty, a procedure to restore the volume of the paralyzed thyroarytenoid muscle, are performed under local anesthesia while listening to the patient’s voice. However, for various reasons, AA is occasionally performed under general anesthesia. If AA was performed under general anesthesia, it would not be possible to make adjustments while listening to the patient’s voice, making a satisfactory surgical outcome unlikely. The inability to perform voice monitoring means that post-operative vocal improvements may be moderate. The aim of this report is to evaluate effect and limitation of AA surgery under general anesthesia.