------------------------------------------------------------------------------- TITLE: PHONOSURGERY - SURGERY OF THE VOICE SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: April 6, 1994 RESIDENT PHYSICIAN: Eric W. Bridges, M.D. FACULTY: Byron J. Bailey, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Anatomy A. Muscles 1. Extrinsic 2. Instrinsic B. Nerves 1. Superior laryngeal a. Internal branch-sensory b. External branch-motor to cricothyroid muscle II. Physiology A. Respiratory conduit B. Protection C. Phonation 1. Neuromuscular theory-rapid contraction of laryngeal muscles generates fundamental frequency 2. Aerodynamic theory-interaction of inherent tissue properties and pressure-flow phenomena (mucosal wave) III. Etiology A. Adults 1. Surgery-thyroid/parathyroid, radical neck, diverticulectomy, esophagus/thoracic 2. Neoplasms-thyroid, larynx, esophagus, lung 3. Idiopathic 4. Neurologic conditions-polio, pseudobulbar palsy, amyotrophic lateral sclerosis, bulbar palsy 5. Trauma-rare B. Children 1. Neurologic-Arnold-Chiari malformation 2. Birth trauma-C-section (15%) with 47% bilateral abductor paralysis, forceps (20%) with 66% bilateral abductor paralysis 3. Surgery-PDA, congenital heart, T-E fistula repair 4. Congenital IV. Management A. Historical perspective B. Diagnostic evaluation 1. History-surgery, trauma, neurologic condition, aspiration, dysphagia 2. Head and neck examination-other cranial nerves, cord position 3. Laboratory-thyroid function tests, FTA-Abs, chest radiograph, CT (head, chest), MRI (brain, neck, chest), laryngeal EMG C. Modern treatment 1. Medialization laryngoplasty-Isshiki thyroplasty type I, laryngoplastic phonosurgery, Silastic medialization 2. Arytenoid adduction-indicated for extensive posterior glottic chink not addressed by Silastic medialization 3. Nerve/nerve-muscle transfer a. ansa cervicalis to RLN anastomosis-reversible, larynx not altered, does not prevent future Teflon injection or thyroplasty, symmetric mucosal wave b. nerve-muscle pedicle-to PCA muscle for bilateral abductor paralysis, to LCA for unilateral paralysis, may be combined with thyroplasty 4. Vocal cord injection-Teflon, fat, silicone 5. Cricothyroid approximation-lengthening 6. Vocal fold shortening V. Complications 1. Medialization laryngoplasty-airway compromise, extrusion, infection 2. Arytenoid adduction-anterior displacement with bowing of cord, airway compromise 3. Teflon injection-granuloma, migration, stiff cord with loss of mucosal wave ------------------------------------------------------------------------------- BIBLIOGRAPHY 1. Berke GS. Voice disorders and phonosurgery. In Bailey BJ, et al., eds. Head and Neck Surgery-Otolaryngology. Philadelphia: J.B. Lippincott, 1993:644-657. 2. Crumley RL. Repair of the recurrent laryngeal nerve. 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