|
|
|
Articles
back
Special Considerations In
Laryngoplasty
When the End larynx or Piriform Sinus is
Inadvertently Entered
Among laryngoplasty
surgeons, there is no consensus as to what is to be done
if the larynx is inadvertently entered during ML. This may occur when the
cartilage window is made, and then some surgeons abort the procedure, while
others treat the patient with perioperative parenteral antibiotics, and
complete the operation. There are not sufficient data to show which is the best
course of action, but if the "rupture" is small and the silastic implant does
not abut the tear, then it appears that completing the procedure is probably
appropriate and that complications are unlikely. If the tear is large and there
is a chance that the silastic implant may be exposed internally, then the
procedure should be aborted.
The piriform sinus is always at risk during the performance of AA. After the
arytenoid sutures have been placed in the muscular process, the surgeon should
place double skin hooks on the wound edges, thereby creating a "basin" of the
entire surgical field, which should be filled with saline, and the patients
should be asked to phonate, to perform a valsalva maneuver, and to "blow out a
candle." If there is a "leak" in the piriform sinus, these maneuvers will yield
a steady stream of air bubbles. When a laceration of the periform sinus occurs,
the surgeon should find and repair the defect, drain the wound, and administer
antibiotics. Wound infection and pharyngocutaneous fistula are serious
potential complications of unrecognized piriform sinus injury.
Timing of Surgery After Skull-Base
Resection
Patients undergoing skull-base surgery for
resection of skull-base tumors develop irreversible ipsilateral vocal cord
paralysis, and usually have a wide-open posterior commissar resulting in
aphonic and aspiration. The combined ML/AA procedure is an excellent procedure
to employ in this group of patients, and results in a return to normal feeding
and restoration of the voice in most cases. (Obviously, in cases where there
are neurological deficits of multiple cranial nerves, this may not be the
case).
Routinely, following skull-base resection, a feeding tube, but no tracheotomy,
should be placed, and as soon as the patient is able to tolerate a
local/standby laryngoplasty procedure, a ML/AA procedure should be performed.
Usually, these procedures can be performed within 1-3 weeks after the oncology
resection. This staged approach allows the laryngoplasty
procedure to be
performed without an end tracheal tube in place, and appears to obviate
tracheotomy.
A Special Precaution -- End tracheal Intubations After Laryngoplasty
In the author's experience, one case of airway obstruction, requiring a
tracheotomy occurred in a patient who was intubated for a general surgical
procedure four days after ML. The Intubations was traumatic, and a hematoma
developed. Since that time, it is recommended that end tracheal intubations
,
particularly for elective surgery, be avoided for a minimum of 3-6 months after
laryngoplasty.
Pitch-Altering Laryngoplasty
Procedures
Laryngoplasty procedures to alter (increase
or decrease) the pitch of the voice have been reported by Isshiki6-9 and
others.12-14 Unfortunately, these procedures are often ineffective, and in some
cases, can lead to worsening of the voice. In the mid-1980s, I performed a
number of these procedures and found that: (1) procedures to lower the pitch of
the voice were effective, but caused the voice to be rather pitch-locked" and
dysphonic (hoarse); and (2) procedures to lower the pitch of the voice were
only transiently effective, and in most cases the pitch of the voice returned
to its per operative baseline within six months.2 I concluded that these
pitch-altering procedures were unsatisfactory, being at best, unpredictable,
and at worst, ineffective and sometimes detrimental. As of this writing, no
substantive published data (with any surgical method) have convincingly shown
that any of these procedures are effective.
Conclusions
laryngoplasty and the arytenoid adduction procedures have added a
new dimension to the surgical management of vocal cord paralysis, and currently
enable the surgeon to restore laryngeal function to near-normal in most cases.
Laryngoplasty procedures to increase or decrease the pitch of the voice should
still be considered experimental, since no data have been yet reported that
substantiate the efficacy of such procedures. � J.A. Koufman, M.D.
|
|
back
|
|
|
