Laryngochondroplasty

Considerations

• 1997: Aesthetic reductive thyroid chondroplasty

• 2003: Endoscopically facilitated reduction laryngochondroplasty

  • 2008: Chondrolaryngoplasty under general anesthesia using a flexible fiberoptic laryngoscope and laryngeal mask airway - Dr. Spiegel

  • Minimize the risk of destabilizing the anterior commissure tendon, a potentially disastrous and irreversible injury to a patient's voice, by placing a 22-gauge needle through the laryngeal cartilage to identify the level of the anterior commissure

  • This injury is especially devastating for transgendered women, for whom lowering of the voice is a particularly difficult handicap to overcome

• 2008: Aspects of transgender laryngeal surgery

Preparation

• • Mark

    • ~ 2 cm horizontal linear incision in skin crease above the level of the thyroid notch or in the crease of the cervicomental angle 

    • V at the thyroid notch

    • X at the cricoid 

  • Local anesthesia 

    • 3 ml 1% Lidocine with 1:100,000 Epinphrine infitlration 

  • Prep

    • Iodine-based sterilization 

Procedure

• • 15 blade to complete skin incision

  • Bovie to incise subcutaneous fat to the level of the strap muscles 

• Retract inferiorly to the area of the thyroid cartilage

• Blunt dissection between the strap muscles exposes the overlying perichondrium of the thyroid cartilage

• Bovie to incise through the perichondrium along the anterior angle of the thyroid cartilage, extending to the left and right superiorly along the superior edge of the cartilage

• Freer for subperichondrial dissection to expose the cartilage

• Curved hook is placed on the posterior surface of the thyroid cartilage in the midline at the base of the notch, and superior-to-anterior retraction is performed

  • At this point, the anesthesiologist advances the fiberoptic endoscope through the LMA until the anterior commissure of the larynx is visible

    • This can be challenging because retraction on the cartilage can move the laryngeal inlet to a position more anterior than normal. Not all styles of LMA are created equal. In our institution, we have discovered that the reusable, sterilizable LMA functions better for endoscopy than the disposable, single-use LMA

• Once a good view of the commissure is obtained, the surgeon takes a 22-gauge needle and inserts it in the midline

• The needle is inserted at a point above which the surgeon would like to remove all cartilage for maximal cosmetic result

  • Owing to ossification of the cartilage with age, the needle may need to be placed with a twisting, drilling motion. Although this can require patience, there have been no patients in whom a gentle drilling motion with a 22-gauge needle failed to pass through the cartilage. We have tried this procedure with a thinner needle but find that 22-gauge needles are the smallest that reliably can be passed through the often ossified thyroid cartilage

• Once the needle is passed through the midline, its position is visible on the video screen

• The surgeon chooses to leave at least 2 mm of cartilage and tissue above the superior surface of the true vocal cords to provide a high certainty of adequate support

  • If the needle is too low, it is withdrawn and passed again more superiorly. The safety of placing small holes through the laryngeal cartilage has been established by prior reports

• Occasionally there is anteriorly projecting cartilage inferior to the level of the anterior commissure

  • When this occurs, it is necessary to accept a less-than-ideal cosmetic result rather than to risk lowering the voice

• On occasion, it may be possible to shave part of the projecting cartilage (less than full thickness), although this procedure subjects the patient's voice to increased risk and is not recommended for the surgeon who only occasionally performs chondrolaryngoplasty

  • Once a safe level has been identified, this level is marked on the cartilage, and the needle and endoscope may be withdrawn. Visible or palpable anteriorly projecting cartilage superior to the mark is then removed to, but not including, the inner perichondrium. Bleeding is carefully controlled with a bipolar cautery, then the strap muscles are reapproximated in the midline, and the wound is closed in layers. No drains have been necessary

Sample operative report

Findings:

Prominent laryngeal prominence ("Adam's apple")

Performed laryngochondroplasty;

Rongeur used to remove small fragments of cartilage at the the thyroid notch

Fiberoptic flexible laryngoscope used to visualize level of false cords using a 22G needle and removal of cartilage done superior to this level

Procedure in Detail:

The patient was transported to the operating room and positioned supine on the operating room table. The safety check was completed. Anesthesia was administered by the anesthesiology staff.

The planned incision was marked; It consisted of a horizontal incision in a natural skin crease superior to the thyroid notch. *** mL of local anesthetic was infiltrated. The patient was then prepped in the usual sterile fashion.

The 15 blade was used to carry the incision through the skin. Bovie cautery was used to carry the incision vertically down to the level of the fascia overlying the strap muscles. These were divided vertically and retracted laterally to expose the thyroid cartilage. The fascia overlying the cartilage was incised with the use of Bovie. A Cottle elevator was used to lift the perichondrium off the cartilage. Fiberoptic flexible laryngoscopy was performed by the anesthesia staff while a 22 gauge needle was inserted into the cartilage to mark the location of the vocal cords. The needle was found to be just superior to the false vocal cords. The thyroid cartilage superior to this point was then reduced superficially in layers by the use of a 15 blade and rongeur to achieve the desired aesthetic outcome. Hemostasis was achieved with the use of pressure or electrical cautery as needed. The perichondrial and strap muscle flaps were then reapproximated in the midline together with the use of interrupted 4-0 Polysorb suture. The platysma and superficial fascia were also closed with interrupted 4-0 Polysorb suture. The skin was closed with a running subcuticular 5-0 Biosyn suture. Steri-strips were applied on the skin.

The case concluded. There were no complications. All counts were correct. The patient was transported to the recovery room without issue.

Post-op

• • Complications 

    • Anterior commissure destabilization 

    • Laryngospasm

    • Hematoma

Pearls & Pitfalls

High-Yield

Links

• YouTube (9:54) - Pitch elevation with reduction of laryngeal prominence

• Dr. Spiegel - Tracheal Shave