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The Rainbow Passage

When the sunlight strikes raindrops in the air, they act as a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is , according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond his reach, his friends say he is looking for the pot of gold at the end of the rainbow. Throughout the centuries people have explained the rainbow in various ways. Some have accepted it as a miracle without physical explanation. To the Hebrews it was a token that there would be no more universal floods. The Greeks used to imagine that it was a sign from the gods to foretell war or heavy rain. The Norsemen considered the rainbow as a bridge over which the gods passed from earth to their home in the sky. Others have tried to explain the phenomenon physically. Aristotle thought that the rainbow was caused by reflection of the sun's rays by the rain. Since then physicists have found that it is not reflection, but refraction by the raindrops which causes the rainbows. Many complicated ideas about the rainbow have been formed. The difference in the rainbow depends considerably upon the size of the drops, and the width of the colored band increases as the size of the drops increases. The actual primary rainbow observed is said to be the effect of super-imposition of a number of bows. If the red of the second bow falls upon the green of the first, the result is to give a bow with an abnormally wide yellow band, since red and green light when mixed form yellow. This is a very common type of bow, one showing mainly red and yellow, with little or no green or blue.


From Fairbanks, G. (1960). Voice and articulation drillbook, 2nd edn. New York: Harper & Row. pp124-139.

Voice Handicap Index [VHI]

Voice Handicap Index PDF [Jacobson, Johnson, Grywalski, et al.]

Injection Thyroplasty: External Laryngeal Landmarks

A preparation of human larynx showing applied anatomy relevant to external approach of injection thyroplasty.   Triangle - infrahyoid approach where the needle introduced at superior thyroid notch of thyroid cartilage and rounded rectangle for infrathyroid approach where the needle introduced into cricothyroid membrane.  Endoscopic view is achieved by transnasal flexible laryngoscopy.  (1 - cricothyroid muscle, 2 - thyroid cartilage, 3 - thyrohyoid muscle, 4 - tracheal cartilage, dot - central point of superiot thyroid notch)

Laryngeal Surface Topical Anaesthesia

Lidocaine 4% drip method delivered by using curved Abraham cannula

for laryngeal surface topical anaesthesia prio to injection thyroplasty

performed as an office procedure.

Injection Thyroplasty as An Office Procedure

      Phonatory gap upon phonation:            Injection of material into vocal fold


  Vocal fold appearance upon breathing   Closure of phonatory gap upon phonation

                    Post-injection                                      Post-injection

Collagen Injection: Cymmetra®

Calcium Hydroxyapatite Injection: Radiesse™-Radiance FN

Vocal Cord Medialization to Treat Vocal Cord Paralysis (HD)

Gelfoam [Absorbable Gelatin Powder] as a Temporary Injectable Material for Medialization Thyroplasty

Injection Thyroplasty Under GA with Hyaluronic Acid


Atrophy of left true vocal fold as compared to the normal contralateral side.

BEFORE Injection

Please note that the morphology of the paralysed vocal fold may be subte as compared to awake state (office procedure).


AFTER Injection

The amount of injection need to be justified based on preoperative

laryngosopy assesment (voice improvement can't be assessed under GA).

Autologous Lipoinjection

             Abdominal fat harvesting.                    Copious saline irrigation.


The fat will be mixed with insulin 100 unit before loaded 

into laryngeal injector or Bruening syringe.



Endoscopic-assisted lipoinjection.


Watch video of lipoinjection @ YouTube


Suggested reference:

Mallur PS, Rosen CA. Vocal fold injection: review of indications, techniques, and materials for augmentation. Clin Exp Otorhinolaryngol. 2010 Dec;3(4):177-82. Epub 2010 Dec 22.

Netterville Thyroplasty Set

Materials Used for Medialization Thyroplasty

                   Silicone Block                         Pre-carved silicone block


Laryngeal Framework Surgery: Anatomical Landmarks

Figure 1


White line (the equator) corresponds to the location of true vocal fold in the interior aspect of thyroid cartilage.  The midpoint between lowermost point of superior thyroid notch (1) and inferior border of thyroid cartilage (2) at midline, and a line drawn posteriorly parallel to the inferior border of thyroid cartilage outline the true vocal fold position.  X - point of the initial drilling site for Gore-Tex thyroplasty window.  Arrow - inferior thyroid tubercle. 3 - superior cornu of thyroid cartilage, 4 - inferior cornu of thyroid cartilage, circle - cricothyroid joint. 

Figure 2


Needle prick between superior thyroid notch (yellow arrow) and inferior border of thyroid cartilage at midline (green arrow) points to the location of vocal folds at anterior commissure internally.  E - epiglottis, C - cricoid cartilage, T - trachea.

Figure 3


Needle seen exactly at the anterior commissure.  Arrows - true vocal folds, E - epiglottis, C - cricoid cartilage.

Drilling of Right Thyroplasty Window Prior to Gore-Tex Insertion

This image shows the initial drilling point of the thyroid cartilage which is about 1 cm posterior from the midline and about 3-4 mm above the inferior border or the thyroid cartilate.  Cutting drill bead size 2 being used and the window widened and deepened until it reaches the innner perichondrium.


Kerrison punch forceps can be use to refine the thyroplasty

window especially on the inner side of the thyroid cartilage.

Inset show the tip of the forceps at rest and on action.

Gore-Tex Thyroplasty


 The use of drill to make thyroplasty window. Thyroid cartilate being rotated

to contralateral side by using skin hook anchored at superior thyroid notch.

R - right, L - left, C - chin, interrupted line - midline

Thyroplasty window with an inferiorly-based perichondrial flap. 

Gore-Tex strip insertion in layers internally with the amount adjusted accordingly 

by asking the patient to phonate (global medial bulge at true cord level). 

Fiberoptic laryngoscopy can be performed simultaneously for the assesment.

Medialization Laryngoplasty

Left Cricoarytenoid Joint Prior to Arytenopexy: Human Larynx Specimen


Image shows the articular surface of the left arytenoid and its opposite cricoid facet prior to arytenopexy.  This procedure is performed to correct significant posterior glottic gap and asymmetric height of the arytenoid as occured in long-standing vocal fold palsy.

Arytenopexy: Intraoperative View

This figure shows the articular facet of the left crycoarytenoid joint before the suture inserted to medially rotate and fixed the arytenoid cartilage complex.  Arytenopexy is indicated for correction of large posterior glottic gap not adequately treated with Type I thyroplasty alone.

[Yellow arrow- exposed cricoarytenoid joint, white arrow- posterior edge of thyroid lamina after inferior constrictor muscles resected, interrupted line- the Maragos window made for adequate exposure, Lahey cottonoid pressing onto left pyriform fossa mucosa.  Larynx being rotated to the right by using skin hook] 

Phono Micro-Surgery 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.


[KL Ear Nose Throat & Voice Centre, Pantai Hospital Cheras, Kuala Lumpur, MY]