MDL - Polyp

• • • • Functional comparison, according to 2005: Surgical procedures for voice restoration

• • Key: The propensity of the superficial lamina propria to regenerate is minimal, therefore, maximally preserve it

  • Technique

    • For Dr. Jiang and Dr. Durr, see the book Operative Techniques in Laryngology (2008) by Rosen and Simpson, Chapter 15 (page 99) 

    • 2000: Phonomicrosurgical management of vocal fold polyps: the subepithelial microflap resection technique (Zeitels)

  • 2007: Vocal outcomes following subepithelial infiltration technique in microflap surgery: a review of 30 cases

Preparation

• • ETT: Smallest armored tube

    • Tape to left lower lip

• Eyes: Paper tape over lids

  • Wet "eye pads" over tape

  • Another long strip of paper tape over both eye pads

• Head: Wrap with 2 blue towels

  • Avoid towel clamp 

• Split drape 

  • Do not remove sticky cover 

• Tooth guard 

• Microscope

  • Balance

  • Place assistant viewfinder on right 

  • Laser (KTP) settings for hemorrhagic polyp

    • 15 watts (blanching effect) up to 30 watts (vaporizing effect)

    • 15 millisecond exposure

    • 2 pulses per second

    • .4 mm fiber

• Check all equipment including light cables and light sources 

• Back table and mayo stand

Procedure

• • Basic DL with either/or 

    • Hollinger (anterior commissure) laryngoscope 

    • Dedo laryngoscope 

• Place the operative laryngoscope in suspension

  • • Dedo laryngoscope 

• • Bouchayer laryngoscope 

  • Zeitels laryngoscope

• Position the head and neck

  • • Start in a neutral position, adjust as needed 

• • Sniffing position (neck flexion with head extension)

    • • Place a small pillow behind the patient’s head, resulting in atlanto-occipital extension and cervical vertebral flexion

• • • Anterior tracheal pressure with tape, as needed 

• Inspect and palpate the VFs, including the medial and inferior surfaces 

  • • Examine the contralateral VF for reactive changes 

• Photograph using both 0 and 30 degree Hopkins rod endoscope 

• Bring in the operative microscope 

• Using the KTP laser, coagulate (blanch) and "feeding vessels" to hemorrhagic lesions 

• Perform the planned polyp excision using phonomicrosurgical technique via one of two approaches 

• • Microflap

    • Expose the lesion, preferably the entire membranous vocal fold

    • Apply topical epinephrine (1:10,000) to the lesion via a Cottonoid; Avoid local infiltration

    • Epithelial cordotomy at the junction of the lateral aspect of the polyp and the normal vocal fold mucosa, along the superior surface of the vocal fold

    • The microflap elevation is performed medial to the incision to expose the subepithelial pathologic contents of the polyp

    • Vocal fold polyp material is removed via either microsuction or direct removal of the abnormal material with small microcup forceps (1 mm)

    • Alternatively, the lesion can be dissected medially with a 30° flap elevator, preserving additional inferior microflap mucosa

    • Redrape the microflap back over the vocal fold and evaluate the nature and status of the microflap mucosa

    • Trim abnormal mucosa that appears to have adherent polyp material, or is extremely thin and atrophic, or is excessive and will not serve as normal mucosa during the postoperative healing 

    • Redrape the remaining microflap mucosa. Once the flap is redraped, use a blunt instrument (curved elevator) to palpate the operative site to ensure there is no remaining pathology under the flap

    • Treat the associated vascular lesion if needed

  • Truncation - usually preferred 

    • Expose the lesion, preferably the entire membranous vocal fold

    • Apply topical epinephrine (1:10,000) to the lesion via a Cottonoid; Avoid local infiltration

    • Grasp the polyp with small triangular forceps in a medial direction

      • Grasp in a location and manner that is perpendicular to the longitudinal axis of the vocal fold.

      • With the non-dissecting hand, careful control and gentle application of tension should be applied to the vocal fold polyp

    • Microscissors that are either slightly curved (away from the vocal fold) or straight up-cutting scissors are then used to incise the vocal fold polyp at the junction of the polyp and the vocal fold

    • After removal of the majority or the entire vocal fold polyp, careful examination and palpation should be performed to see if there is any residual abnormal mucosa at the vocal fold polyp site that should be removed

      • To help with this assessment, an epinephrine-soaked Cottonoid can be placed on the operative site for several minutes.

      • If there is residual abnormal mucosa, then a 1-mm micro can be used to remove this tissue

    • An alternative removal technique involves grasping of the “dogeared” mucosa with a microcup forceps or small triangle forceps and excising the material with a microcurved scissors

• Obtain hemostasis with small pledget soaked with topical 1:1000 Epinephrine 

• Photograph using both 0 and 30 degree Hopkins rod endoscope 

• • Spray the glottis with 3 ml topical 4% Lidocaine

  • Remove the laryngoscope and tooth guard

  • Examine the airway for any unintentional injury 

Post-op

• • Voice rest

    • For Dr. Durr, use the the University of Texas Voice Rest protocol here

      • See the smartphrase by J Gilde: JEGPIVOICERESTPO

  • For Dr. J, the key is deciding a time period for strict voice rest; Many patients are noncompliant with a complicated voice rest schedule 

• Tylenol #3 as needed

• Colace 

• Regular diet

• Light activity for the first week 

  • Avoid straining  

• RTC 2-3 weeks 

High-Yield

Links

• Boston University - Vocal fold exposure for glottic surgery via a rigid scope

  • YouTube (2:43) - Vocal cord polyp surgery filmed live in the operating room by Sunil Verma (UCI)

  • YouTube (9:39) - Laryngology 101: My vocal cord polyp by James Thomas