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Phono-Microsurgery Instruments

A- dissector ball end, B- hook, C- angled elevator,

D- curved elevator, E- needle sharp pick,

F- curette oval spoon, G- lancet knife, H- sickle knife, I- round knife.

Laryngeal Injection Needles

Sataloff Laryngeal Injection Needles set by Medtronic Xomed.  These fine tip needles can be used for intralesional therapeutic injection such as triamcinolone for scar, subepithelial saline infusion with or without adrenaline in benign laryngeal pathology, and cidofovir injection for recurrent respiratory papillomatosis.

Anterior Commissure Laryngoscope: An Ideal Laryngoscope for Phonomicrosurgery

Nicely exposed operating field which allows an excellent microscopic view and unrestricted bimanual instrumentations.

Poorly exposed operating field with hidden anterior commissure.  The polyp (+) has a broad base attached to right vocal fold free border.  Repositioning of the laryngoscope tip, the use of vocal fold retractor device, and external cricoid pressure would give the exposure required.

Endoscopic Laryngeal Assessment

Endoscopic examination has becomes more routinely done and complementary to laryngeal assessment using microscope.  It is performed once the laryngoscope properly set in place.  Rigid endoscope offers superior clarity image, depth perception, and capable of viewing at extreme angle not usually achievable by using operating microscope.  Different scope tip angle being used; usually 0 degree, 30 degree, and 70 degree - rarely 120 degree.  Thus, it has superseded the use of microlaryngeal mirror commonly used in the older days!
View using 0 degree endoscope. 
 
View by using 70 degree endoscope. 
 
Figures depict still images during rigid endoscopic assessment under general anaesthesia in a patient having right vocal fold cyst.  (R - right, L - left, (+) - cyst, arrow - reactionary lesion at medial edge of the opposite vocal fold) 

Microflap Excision of Vocal Fold Polyp

Endolaryngeal Microsurgery of Benign Vocal Fold Polyp

   Benign left vocal fold polyp before and after endolaryngeal microsurgery.

Endolaryngeal Microsurgery of Benign Vocal Fold Polyp (Bilateral)

 Before surgery.

 

.

After surgery. 

Phono-Microsurgery of Vocal Vold Polyp: The Sequential Intraoperative Views

                        Figure A                                            Figure B

                        Figure C                                               Figure D

                        Figure E                                                Figure F

                         Figure G                                          Figure H

 

Figure A: Good exposure obtained preferably by using an anterior commissure laryngoscope with adequate internal diameter to allow bimanual instrumentation without crowding the operative view.  Vocal fold retractor may need to be used and cricoid pressure applied if necessary.

 

Figure B: Firm grasp of polyp with soft medial traction to enable the base of the polyp to be seen clearly.

 

Figure C: Excising the polyp by using a suitable microlaryngeal scissors, curve-to-right for this left-sided polyp.

 

Figure D: Transient bleeding is to be expected as shown.

 

Figure E: Topical application of adrenaline for homeostasis.  This may be repeated few times.

 

Figure F: Remains of polyp can be seen if any and need further removal.  Do not over-excised and know when to stop!

 

Figure G: View just before the vocal fold retractor removed.

 

Figure H: View at completion of surgery before the patient extubated.

 

Immediate voice improvement is rewarding for the patient and wait for the official histopathological report before concluding the diagnosis.

 

[Pantai ENT Laser & Voice Centre, Pantai Hospital Cheras, Kuala Lumpur, MY] 

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