Phonosurgery. Principles and Techniques. Tadeus Nawka 1 Werner G. Hosemann 2

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3 Phonosurgery Principles and Techniques Tadeus Nawka 1 Werner G. Hosemann 2 1 Department of Audiology and Phoniatrics Charité University Medicine, Berlin, Germany 2 Department of Otorhinolaryngology, Head and Neck Surgery Ernst-Moritz-Arndt University Hospital, Greifswald, Germany

4 4 Phonosurgery Principles and Techniques Important notes: Medical knowledge is ever changing. As new research and clinical experience broaden our knowledge, changes in treat ment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accept ed at the time of publication. However, in view of the possibili ty of human error by the authors, editors, or publisher, or changes in medical knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this booklet, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. The information contained within this booklet is intended for use by doctors and other health care professionals. This material is not intended for use as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peerreviewed medical literature. Some of the product names, patents, and re gistered designs referred to in this booklet are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. The use of this booklet as well as any implementation of the information contained within explicitly takes place at the reader s own risk. No liability shall be accepted and no guarantee is given for the work neither from the publisher or the editor nor from the author or any other party who has been involved in the preparation of this work. This particularly applies to the content, the timeliness, the correctness, the completeness as well as to the quality. Printing errors and omissions cannot be completely excluded. The publisher as well as the author or other copyright holders of this work disclaim any liability, particularly for any damages arising out of or associated with the use of the medical procedures mentioned within this booklet. Any legal claims or claims for damages are excluded. In case any references are made in this booklet to any 3 rd party publication(s) or links to any 3 rd party websites are mentioned, it is made clear that neither the publisher nor the author or other copyright holders of this booklet endorse in any way the content of said publication(s) and/or web sites referred to or linked from this booklet and do not assume any form of liability for any factual inaccuracies or breaches of law which may occur therein. Thus, no liability shall be accepted for content within the 3 rd party publication(s) or 3 rd party websites and no guarantee is given for any other work or any other websites at all. Phonosurgery Principles and Techniques Tadeus Nawka 1 and Werner G. Hosemann 2 1 Department of Audiology and Phoniatrics Charité University Medicine, Berlin, Germany 2 Department of Otorhinolaryngology, Head and Neck Surgery Ernst-Moritz-Arndt University Hospital Greifswald, Germany Director: Prof. W. Hosemann, M.D. Walther-Rathenau-Strasse 43 45, Greifswald, Germany Correspondence address of the author: Prof. Dr. med. Tadeus Nawka Klinik für Audiologie und Phoniatrie der Charité Universitätsmedizin Berlin Charitéplatz 1, Berlin, Germany Phone: / , Fax: / , tadeus.nawka@charite.de Prof. Dr. med. Werner G. Hosemann Direktor: Klinik und Poliklinik für Hals-Nasen-Ohren-Krankheiten Kopf- und Halschirurgie der Ernst-Moritz-Arndt-Universität Walther-Rathenau-Str. 43/45, Greifswald, Germany Phone: / Fax: / hosemann@uni-greifswald.de All rights reserved. 1 st edition GmbH P.O. Box, Tuttlingen, Germany Phone: +49 (0) 74 61/ Fax: +49 (0) 74 61/ Endopress@t-online.de No part of this publication may be translated, reprinted or reproduced, transmitted in any form or by any means, electronic or mechanical, now known or hereafter invent ed, including photocopying and recording, or utilized in any information storage or retrieval system without the prior written permission of the copyright holder. Editions in languages other than English and German are in preparation. For upto-date information, please contact GmbH at the address shown above. This text is based on the following publication: NAWKA, T, HOSEMANN, W: Chirurgische Verfahren bei gestörter Stimme. Laryngo-Rhino-Otol 2005; 84 Supplement 1: ; accessible on the internet as a pdf file at lro/doi/ /s Design and Composing: GmbH, Germany Printing and Binding: Straub Druck + Medien AG Max-Planck-Straße 17, Schramberg, Germany ISBN

5 Phonosurgery Principles and Techniques 5 Table of Contents 1.0 Introduction Basic Principles Functional Microanatomy and Body-Cover Theory Lesions of the Reinke Space Auditory and Objective Evaluation of Dysphonia Goals of Voice Surgery Removal of Abnormal Tissue Phonomicrosurgery under Local Anaesthesia Phonomicrosurgery by Direct Microlaryngoscopy Technique General Anaesthesia Benign Lesions Papillomatosis Epithelial Dysplasia and Early-Stage Cancer Laser Surgery for Voice Improvement Vocal Fold Mobility Disorders with Abnormal Position and/or Tension of the Vocal Folds Laryngoplasties, Laryngeal Framework Surgery, and ISSHIKI Thyroplasties Indications Symptoms Timing Complications Medialization Thyroplasty Arytenoid Adduction Other Types of Laryngoplasty Surgical Reinnervation of the Vocal Folds Augmentation Injections Materials Disadvantages of the Injection Technique Reconstruction of Glottic Defects after Endolaryngeal Tumor Surgery Bilateral Vocal Fold Paralysis, Glottic Widening, and Voice Function Discussion References Recommended Instrument Set for Endolaryngeal Phonomicrosurgery

6 6 Phonosurgery Principles and Techniques 1.0 Introduction Phonosurgery is a collective term for surgical procedures aimed at restoring or enhancing the voice and improving verbal communication. A specific, function-oriented indication for these procedures has been accepted since the mid- 20 th century. Hans von Leden and Godfrey Arnold coined the term phonosurgery in The International Association of Phonosurgeons (IAP) established a consensus definition for the term in 2000: Phonosurgery refers to functionoriented surgical procedures that are designed to improve, restore, or maintain the voice (and speech). Modern surgical procedures for the treatment of voice disorders are based on recent discoveries in the ultrastructure of the vocal folds and on the growing experience of many surgeons. Phonosurgery must meet criteria that are commensurate with the increased social and professional demands on the voice. Four main types of pro cedures are practiced in modern-day phonosurgery: l Phonomicrosurgery with direct or indirect access to the larynx l Laryngoplasties l Laryngeal injections l Surgical reinnervation of the larynx The impairment of communication or specific artistic voice skills has assumed greater importance in present-day society. 1.1 Basic Principles Functional Microanatomy and Body-Cover Theory The vocal folds are composed of various types of tissue: epithelium, lamina propria, striated muscle, nerves, vessels, and cartilage. The most important lesions from a phonosurgical standpoint are those involving the lamina propria. The membranous portion of the vocal folds is covered by squamous epithelium. The surface is raised into microridges, which apparently help to maintain the mucous coating, moisture, and shape of the vocal folds. The anterior and posterior commissures are lined by ciliated epithelium. Both types of epithelium are cover ed by a mucous blanket composed of two layers: a deeper watery serous layer and a more superficial mucinous layer. The mucinous layer prevents dehydration of the epithelial cells, while the serous layer allows for ciliary motion in the anterior and post erior commissures, permits contact be tween the vocal folds, and keeps the epithelium moist and pliable. Because of this arrangement, phonatory vibrations give rise to an undulating motion along the edges of the vocal folds called mucosal wave propagation. Adjacent epithe lial cells are interconnected by desmosomes and are attached to the lamina propria by the anchoring collagen fibers of the basement membrane. The most important vibratory structure is the epithelium. It gives shape to the vocal folds and enables them to return to their resting position. The vibrations of the vocal folds during phonation can be observed by stroboscopy, kymography 2, 3 and high-speed video recording 4.

7 Phonosurgery Principles and Techniques 7 The lamina propria is divided into a superficial, intermediate, and deep layer. The superficial layer of the lamina propria contains fewer elastin fibers than the other two layers. Elastic fibers are most abundant in the intermediate layer, while collagen fibers predominate in the deep layer. The vocal ligament is formed by the intermediate and deep layers of the lamina propria. The extracellular matrix (ECM) of the lamina propria consists of fibrous proteins, glycosaminoglycans (polysaccharide chains) such as hyaluronic acid, and proteoglycans (proteins with a carbohydrate component) such as decorin, fibromodulin, and versican. The ECM transforms the aerodynamic energy of phonatory respiration into acoustic energy and helps the vibrating vocal folds return to their resting position. The metabolic processes in the ECM are mediated by enzymes, which are produced by fibroblasts 5. The body-cover model is an attempt to classify the connectivetissue structures of the vocal fold into functional units (Tab. 1). It groups the five anatomical tissue layers of the vocal fold into three functional layers: The first layer, called the cover, consists of the epithelium and superficial lamina propria. The second layer, called the transition, is the vocal ligament consisting of the elastic and collagen fibers of the intermediate and deep layers of the lamina propria. The third layer, called the body, consists of the vocalis muscle 6. Lamina propria Superficial layer Intermediate layer Deep layer Epithelium Muscular fibers Muscle fiber bundle Thyroarytenoid muscle Fig. 0.1 Coronal section through the center of the membranous portion of the human vocal fold. The layered structure is described in Tab. 1. Layers of the vocal folds: anatomical tissue layers compared with functional layers in the body-cover model 6 Five tissue layers Epithelium Lamina propria Superficial layer Intermediate layer Deep layer Body-cover model Mucosa Vocal ligament Cover Transition Thyroarytenoid muscle Muscle Body Tab. 1 Layers of the vocal folds: anatomical tissue layers compared with functional layers in the body-cover model 6.

8 8 Phonosurgery Principles and Techniques Lesions of the Reinke Space Vocal nodules, polyps, and Reinke edema result from epithelial changes that most commonly involve the superficial layer of the lamina propria and may also include the intermediate layer. Excessive vibra - tions during vocal abuse disrupt the structure of the basement mem brane and superficial lamina propria. In patients with vocal nodules, the chronic trauma leads to the deposition of type IV collagen and fibronectin on the vocal folds. In patients with Reinke edema, it leads to the formation of edematous lakes in the intercellular substance along with fibrin deposition with smaller amounts of fibro nectin 7. There is no question that fibroblast activity in these pathological conditions is different from that in normal vocal folds, although we still know very little about the details of normal and abnormal cellular function in the vocal folds Auditory and Objective Evaluation of Dysphonia The evaluation of voice quality and performance is a widely debated issue. At present there are no consistently reliable objective or subjective methods of voice evaluation that can be used to select patients for surgery, analyze the results of different treatments, assess the degree of functional impairment, or compare the results achieved by different surgeons or voice therapists working in different institutions and in different countries. The European Laryngological Society (ELS) 8 has established a protocol that brings us one step closer to a generally accepted, valid method of voice evaluation. It consists of a battery of voice tests comprising five dimensions: l Auditory perceptual voice evaluation 9 l 10, 11 Videostroboscopy l Electroacoustic analysis of the voice signal 12 l Aerodynamic measurements of phonation efficiency l Subjective rating by the 16, 17 patient Perceptual voice evaluation should be done by at least three judges to correct for interindividual differences among the listeners. The test is generally based on the voice qualities of roughness, breathiness, hoarseness, asthenia, strain, and instability using a four-point rating scale such as the GRBAS (overall grade, roughness, breathiness, asthenia, strain) or RHB system (roughness, breathiness, hoarseness). Videostroboscopy is used to evaluate glottic closure 18 and vocal fold motion based on the amplitude of the paralyzed vocal fold and the mucosal wave propagation (normal or diminished) 19. Key acoustic parameters are the voice volume during reading aloud, the dynamic range, the pitch range, and an electroacoustic analysis of variations in the fundamental frequency (jitter) and noise components. Clinically evaluable aerodynamic parameters are the maximum phonation time, glottic airflow, and subglottic pressure. Self-rating of the voice is obtained by having the patient complete a questionnaire (e.g., the VHI 17, 20 ). 1.2 Goals of Voice Surgery Voice disorders that are amenable to phonosurgical treatment fall into two etiologic categories: diseases in which abnormal tissue prevents normal vocal fold vibrations, and vocal fold movement disorders characterized by an abnormal position and/or tension of the vocal folds. Generally a phonosurgical procedure should preserve or restore the functional structure of the vocal folds, giving particular attention to the following points: l Respect the layered structure of the vocal folds l Minimize tissue excision l Minimize tearing of the superficial lamina propria l Preserve the epithelium, especially along the freely vibrating edge of the vocal fold

9 Phonosurgery Principles and Techniques Removal of Abnormal Tissue Various pathological tissue chan ges can interfere with vocal fold vibrations: l Epithelial lesions (e.g., papillomas, epithelial dysplasia, chronic laryngitis, carcinoma) l Changes in the lamina propria (e.g., Reinke edema, nodules, polyps) l Cysts (epidermoid cysts, retention cysts, pseudocysts) l Sulcus, scar-tissue bands along the epithelium l Atrophy, scar, defect l Vascular changes (angiectasis, varices, hematomas) l Arytenoid granulations (contact granuloma, intubation granuloma) l Anterior webs (congenital, acquired, microwebs) 2.1 Phonomicrosurgery under Local Anaesthesia The surgery of small epithelial and subepithelial changes in the vocal folds (up to 5 mm in size) can be performed in the conscious patient under local anesthesia The patient is premedicated with morphine and atropine (10 mg morphine and 0.5 mg atropine s.c.), and the throat and larynx are topically anesthetized with tetracaine applied by spray and cotton swab. This permits the safe, painless removal of nodules, polyps, edema, small papillomas, as well as excisional biopsy under stroboscopic and auditory control (Fig. 0.2). Ambulatory procedures can be done using a laryngeal mirror with an operating microscope or by using a rigid 70º or 90º telescope and observing the field directly or on a video monitor. Correct patient selection and technical proficiency will permit the precise removal of tissue abnormalities. With the growing pressure for outpatient day surgery, this technique will continue to be important and should be in the repertoire of every physician who practices phonosurgery. Fig. 0.2 Removal of granulation polyps of the anterior commissure in an outpatient setting. Generally, the patient is premedicated with subcutaneous morphine and atropine. Tetracaine is used for local anesthesia. The surgeon watches a video monitor while operating. The operative site is exposed by videolaryngoscopy. Here, the surgeon is using a one-handed technique with a universal handpiece and cupped microforceps. 2.2 Phonomicrosurgery by Direct Microlaryngoscopy Technique The advantages of direct microlaryngoscopy include a binocular stereoscopic view of the operative site, high magnification, a sharp image with excellent illumination, a relaxed patient, and a setting in which the surgeon can work calmly and with both hands. It is the most widely used approach in phonosurgery. Fig. 0.3 Direct microlaryngoscopy. The larynx is visualized with a laryngoscope in the supine, intubated patient. The laryngoscope is suspended on a chest support, and the surgeon s arms are supported by arm rests. The operating microscope is used with a 400-mm objective lens and adjusted so that the surgeon can work with both hands.

10 10 Phonosurgery Principles and Techniques Fig. 0.4a Intubation granulomas visualized with a Kleinsasser laryngoscope, which provides optimum exposure of the glottis. The ventricular folds can be pushed aside, and the upper (anterior) curve of the laryngoscope tube offers space for instrument use even in the anterior commissure. Fig. 0.4b Reinke edema and a polyp exposed with a Lindholm laryngoscope. The operative field is large and well displayed. The tissue sagging into the right anterior part of the field is considered an undesired side effect of this laryngoscope. Fig. 0.4c The same glottis exposed with a triangular Rudert laryngoscope. Although this laryngoscope offers somewhat less working space, the surgeon may appreciate the more limited field as it focuses the exposure on essential structures. There are no general guidelines for instrumentation, and various aut hors have developed their own instrument sets. Many surgeons use the Kleinsasser, Bouchayer, and Sataloff instruments as well as the special Abitbol laser microlaryngeal instruments. Basic surgical techniques are listed below: Fig. 0.5a The glottis cannot always be visualized with the Lindholm laryngoscope. l Grasping abnormal tissues with cupped forceps or flat heart-shaped graspers l Incision with a scalpel l Dissection of the epithelium and basement membrane with dissecting instruments l Sharp division of the epithelium with scissors l Controlled suction of mucus, pseudomyxoma, blood, and tissue residues l Tissue vaporization with the CO 2 laser l Tissue ablation with a shaver l Hemostasis with monopolar cautery when the laser is not used or ineffective l Suture placement with a needle holder, grasping forceps, and knot pusher l The injection of augmentation material through a high-pressure laryngeal syringe (fat) or customtrimmed butterfly catheter (collagen, hyaluronic acid). Fig. 0.5b If the larynx is difficult to expose, a smaller laryngoscope should be used. This view (same patient in Fig. 05a) was obtained with a Kleinsasser 8590 DN laryngoscope. Laryngoscopes are available in various designs. The latest models are particularly effective for exposing the anterior commis sure 26, 27 and the larynx and its surroundings 28. As with any instrument, practical experience with a particular kind of laryngoscope will enable the surgeon to become more profi - cient in its use. Generally it is best to use a laryngoscope with the largest possible diameter. However, if visualization is found to be difficult, the use of a smaller laryngoscope normally facilitates exposure of the larynx (Fig. 0.5b).

11 Phonosurgery Principles and Techniques 11 a b c d e Figs. 1 Principle of the surgical removal of vocal nodules (after 31 ). The nodule (a) is marked by an elevation of the epithelium. It is resected tangentially with a microscissors (b d). The superficial layer of the lamina propria remains intact, and a minimal epithelial defect is formed (e) General Anaesthesia The standard general anesthesia protocol consists of total intravenous anesthesia with propofol and remifentanil (Ultiva ), muscular relaxation with mivacurium chloride (Mivacron ), and endotracheal intubation. Jet ventilation offers no advantages in routine phonosurgic al procedures 29, although it may be an option in patients with cartilaginous lesions of the vocal fold. A transglottic jet catheter allows for optimum exposure while causing minimal passive movement of the glottis Benign Lesions Vocal nodules, polyps, and Reinke edema are primarily changes of the lamina propria that distend the overlying epithelium. Vocal cord nodules are completely removed (Fig. 1).

12 12 Phonosurgery Principles and Techniques Figs. 1.1a e E Vocal nodules (a) are grasped with a cupped miniature forceps (d) triangular-jaws forceps (b) and excised with a microscissors (c). The epithelium does not close completely over the surgical defect (e), but the wound will heal without scarring if the lamina propria has not been damaged. a b c Measuring just 1 3 mm at their base, the nodules can be excised without special measures to preserve the epithelium. Polyps may be pedunculated with a narrow base or may be broadly sessile on the free edge of the vocal fold. Pedunculated polyps, like vocal nodules, are treated by simple excision. Sessile polyps are resected in a way that leaves some epithelium in place for wound coverage (Fig. 2). This method is also called the microflap technique or mini-microflap technique. Only excess epithelium is removed d e

13 Phonosurgery Principles and Techniques 13 a b c d e Figs. 2 Principle of the surgical removal of vocal polyps (after 31 ). Vocal polyps are epithelial protrusions that are sharply demarcated relative to the surrounding vocal fold epithelium (a). The polyp is incised at its superolateral border (b). Excess subepithelial tissue and epithelium are excised (c, d), and the wound is covered with epithelium (e). Figs. 2.1a e E Vocal polyp (a) with a well-delineated border. The microscissors resection is done at the boundary between firm, healthy epi thelium and the stretched, fragile epithel ium of the protruding polyp (b d). Sufficient epithelium is preserved for wound coverage (e). a b c d e

14 14 Phonosurgery Principles and Techniques a b c d e f g F Figs. 3 Principle of the surgical treatment of Reinke edema (after 31 ). The epithelium over the edematous area is not sharply demarcated from the surrounding epithelium (a). An incision or very small excision of epithel ium is made as far laterally as possible on the upper surface of the bulging vocal fold (b, c). The liquid or gelatinous intercellular material is suctioned (d) or extruded (e) from the lamina propria. Finally the redundant, stretched epithelium is resected (f) until the wound margins are smoothly apposed (g). The same principle is followed in the treatment of Reinke edema, which is removed in the subepithelial plane. The overlying epithe - l ium is incised in the upper surface of the vocal fold and is dissected from the lamina propria while remaining largely intact. The edema is removed by suction or extrusion. Only redundant portions of the epithelium are removed (Fig. 3).

15 Phonosurgery Principles and Techniques 15 a b c d e F Figs. 3.1a e Reinke edema is covered by fragile epithel ium and may be associated with a polypoid expansion (a). The resection is performed with a microscissors (b d). The free edge of the vocal fold remains cover ed by epithelium (e). Removing too much epithelium is the most common error in surgical treatment of Reinke edema. It should be noted that the epithel ium is often very thin and tears easily when grasped with a microforceps. Thus, the surgeon should grasp the epithelium only on the upper surface of the vocal fold and place the incisions laterally in the Morgagni sinus where the Reinke edema terminates at the arcuate line. It is extremely important for vocal function that the free edge of the vocal fold retains its epithelial covering. Generally, there is no need to secure the flap with fibrin or an intralaryngeal suture, although such measures are occasionally recommended 33. Dissection of the epithelium should be carried out patiently and with great care. If the lamina propria is undamaged, the wound will heal without scarring. The epithelium will close and heal without loss of compliance or flexibility, and mucosal wave propagation will be restored.

16 16 Phonosurgery Principles and Techniques a b c d e Figs. 4 Principle of the surgical removal of an epidermoid cyst (after 31 ). The epidermoid cyst has its own epithelium, and the cyst margins are clearly visible through the normal overlying epithelium (a). The cyst is incised laterally (b), dissected free (c), and removed with a microforceps (d). The epithelium will close over the enucleation site (e). In doubtful cases it is advisable to leave some of the edema behind. This is because insufficient closure of the membranous part of the glottis may well contribute to the pathogenesis of Reinke edema. The edema can compensate for this by helping to close the glottic gap. While patients may have a deep, harsh voice because of the edema, they should experience no vocal strain. Postoperative regression of edema will usually clear the harshness of the voice while preserving its deep quality. This may be an important prognostic factor in women who want to keep their low timbre. The epithelium over the Reinke edema can easily be removed inadvertently at operation be cause it is very thin, fragile, and is attached to the distended, edematous upper layer of the lamina propria. The epithelium can easily be grasped and elevated with the microforceps, particularly if the edema is already organized and can be mobilized en bloc. Wound healing in this case will leave a smooth vocal fold, but the epithel ium will be fixed to the vocal fold by scar adhesions and cannot vibrate, leading to severe, irreversible dysphonia. Unfortunately, this type of scarring is still relatively common and is extremely difficult to correct by additional surgery 34, 35. The same principle applies in the treatment of vocal fold cysts: it is essential to preserve the epithel ium (Fig. 4). Retention cysts, which arise from obstructed mucous glands, have a thin glandular epithelium that usual ly tears during surgical manipulations. Epidermoid cysts have a thicker epithelium that can withstand microsurgical dissection and enucleation.

17 Phonosurgery Principles and Techniques 17 a b c d Figs. 4.1a h Removal of a retention cyst in the right anterior commissure (a). This cyst developed following the removal of Reinke edema in which too much epithelium was resected, leading to scarring of the right vocal fold and moderately severe dysphonia. The cyst is opened with the microscissors (b, c) and its contents aspirated (d). Isotonic saline solution is injected beneath the scar tissue (e) to elevate the scar from the vocal fold, which bulges toward the midline (f). Corrections can be carried out in the distended tissue (g), allowing complete removal of the cyst and the elimination of redundant epithelium (h). e g f h

18 18 Phonosurgery Principles and Techniques a b c Figs. 4.2a c Papillomas on the free edge of the vocal fold cause dysphonia (a). In cases where malignancy is histologically excluded and there is no dyspnea, papillomas should be treated according to phonosurgical principles because every operation may cause additional epithelial damage. Papillomas are not surgically curable. The subepithelial infusion protects the lamina propria (b) and exposes the papillomas for removal by laser surgery. Postoperative inspection shows poorly defined vocal fold margins, indicating that the lamina propria is still present (c). The CO 2 laser should be used in a way that prevents charring (microspot, 0.01 s exposure, 7 W) Papillomatosis Laryngeal papillomatosis is an epithelial neoplasia caused by human papillomaviruses. Papillomas may cause a life-threatening airway obstruction, especially in children, by their progressive and sometimes rapid growth into the trachea and lungs 36, 37. The most common symptom in adults is hoarseness. Radical removal is not possible because the viral DNA in the basal cells is not expressed at all sites following an infection 38. Infected basal cells are clinically indistinguishable from virus-free cells. While papillomatosis is not curable at present, it may enter long periods of remission 39. Treatment is symptomatic, therefore, and should be geared toward the preservation of function. The lesions can be resected least traumatically with a CO 2 laser using a high power setting (7 W) and very short pulses (0.01 s). This method produces immediate hemostasis while causing minimal thermal injury to the lamina propria. Tissue removal in the true and false vocal folds should extend only to the level of the surrounding healthy epithelium or, with papillomas covering a larger area, should not go below the basement membrane into the deeper layers of the lamina propria. This avoids causing additional harm and helps to preserve vocal function until remission occurs. An alternative to the laser is the shaver (microdebrider) 40. It should be noted, however, that the shaver may also cause scarring with consequent vocal dysfunction. Small exophytic papillomas can be removed under local anesthesia. Adjuvant therapies such as cidofovir (Vistide ) 41, photodynamic therapy, indole-3-carbinol, lithium succinate, cimetidine, imiquimod, and therapeutic vaccines 38 may be used as an alternative or adjunct to surgical treatment. They have not yet provided an effective solution to the problem of papilloma recurrence, however.

19 Phonosurgery Principles and Techniques 19 a b F Figs. 5 Subepithelial injection is done to check for infiltrative growth and protect deeper layers of the lamina propria from thermal injury by the CO 2 laser (after 34 ) Epithelial Dysplasia and Early-Stage Cancer Laryngeal carcinoma is a potent ial ly life-threatening disease. Treatment consists of radical surgical removal. In doubtful cases, the functional outcome is a less important concern than achieving a complete resection. Functional preservation is dependent on tumor size. Nevertheless, due consideration should still be given to functional aspects in the removal of premalignant lesions, carcinoma in situ, and early T1 tumors by applying microsurgical techniques and using the CO 2 laser 32. In the excision of dysplasia, subepithelial fluid injection is useful for protecting the intermediate and deep layers of the lamina propria in order to preserve phonatory function (Fig. 5). a b c Figs. 5.1a c Carcinoma of the right vocal fold (a). Subepithelial infusion (b) is unsuccessful in establishing a plane of dissection; the expected convex bulge does not appear. A crater remains at the center of the tumor (c), signifying invasion of the vocalis muscle. The tumor must be resected according to oncologic principles. Phonosurgical measures may be considered later if the carcinoma does not recur.

20 20 Phonosurgery Principles and Techniques Figs. 6 E Subepithelial cordectomy (after 43 ). The epithelium and uppermost layer of the lamina propria are removed, preserving the vocal ligament and vocalis muscle. a b Figs. 6.1a d E Severe dysplasia of the squamous epithelium of the left vocal fold (a). The subepi-thelial infusion elevates the abnormal tissue (b), confirming an absence of infiltration below the epithelial level. Ultrashort bursts (0.01 s) from the CO 2 laser divide the epithelium at the boundary with healthy tissue (c). The fluid beneath the epithelium protects the vocal ligament and the deeper layers of the lamina propria. Removal of the lesion leaves a defect over still-intact portions of the lamina propria (d). As healing progresses, this will allow a scar with normal vibrational properties to form within 4 6 months. a b Additionally, subepithelial and subligamentous resection techniques are available for use in patients with early-stage cancers (Figs. 6, 7, see p. 21). This makes it possible to preserve uninvolved structures (vocal ligament, vocalis muscle) that are important for phonation while also satisfying oncologic criteria 42, 43. c d

21 Phonosurgery Principles and Techniques 21 a b F Figs. 7 Subligamentous cordotomy (after 43 ). The epithelium and vocal ligament are removed, preserving the vocalis muscle. a b F Figs. 7.1a b Leukoplakia of the left vocal fold and carcinoma of the right vocal fold (a). Subepithelial infusion is followed by subligamentous laser resection of the carcinoma down to the right vocalis muscle and conventional removal of the leukoplakic lesions on the left side (b). The loss of tissue substance on the right side is compensated by scarring. The left vocal fold is still able to vibrate owing to preservation of the lamina propria, enabling postoperative phonation in the glottic plane Laser Surgery for Voice Improvement Laser microsurgery is a major advance in the treatment of laryngeal disorders. Even so, objections have been raised since its introduction. The main arguments against laser use related to thermal injury, charring, delayed wound healing, and greater postoperative scarring 44. These observations were based on lasers with poor focusing properties and a focal spot size more than 1 mm in diameter 45. Since then, impressive advances have been made in laser technology 46, permitting the laser beam to be focused to microspot size with a focal spot of 0.25 mm or less. The CO 2 laser is particularly effective owing to its low penetration depth, since infrared light energy at a wavelength of 10.6 µm is strongly absorbed in water. With modern lasers, the zone of thermal damage can be kept smaller than 50 µm. This can be achieved by using very short exposure times (m 0.01 s, or 10 milliseconds).

22 22 Phonosurgery Principles and Techniques If a deeper cut is needed, the power level is increased. Deliver ing a rapid succession of high-power laser pulses is known as the ultrapulse or superpulse mode. A CO 2 laser operating in the Q-switched mode can emit very high peak power levels (up to 106 W) per picosecond. This mode can signi ficantly reduce charring and therm al necrosis 47. A current system for laser beam guidance is the AcuBlade system, which can rapidly scan the highly focused laser beam along a designated path, resulting in minimal contact time and thermal injury 48. This laser incision is comparable to a conventional scalpel cut in the depth of its effect. Owing to technological refinements, the laser has gained increasing acceptance as a phonosurgical instrument. Prospective randomized studies comparing laser surgery with conventional instrumentation have shown no significant outcome differences in terms of voice quality and healing rates A power output of 2 3 W may be adequate for lesions in the epithel ium and lamina propria given the use of short exposure times. Muscle resections require up to 15 W of laser power. Bleeding is a minor concern in phonosurgery, as the hemostatic properties of lasers at the indicated settings are satisfactory for these procedures. The technical ability to limit the laser incision to the epithelium must be practiced to ensure that the zone of thermal damage does not extend too deeply 52. A surgeon using a laser for phonosurgery must be aware of these hazards in order to avoid functionally unfavorable scarring during reepithelialization. 3.0 Vocal Fold Mobility Disorders with Abnormal Position and/or Tension of the Vocal Folds Surgery may be indicated in cases of vocal fold fixation due to paralysis or paresis or cricoarytenoid joint disease, neurological voice disorders such as tremor and spastic dysphonia, and laryngeal dysfunction that presents clinically with hyperfunction, hypofunction, or a false-vocal-cord voice. Neurogenic paralysis of the larynx may result from a central or peripheral lesion. The causative lesion of central paralysis may involve the first motor neuron, the extrapyramidal system, the cerebellum, cranial nerve nuclei (mainly the nucleus ambiguus), or multiple sites in the brainstem. Peripheral paralysis may result from lesions of the vagus nerve or its branches, the recurrent laryngeal nerve, or the superior laryngeal nerve 53. Dulguerov published the following breakdown of epidemiological data on the causes of laryngeal paralysis: 10% due to central neurologic diseases such as stroke, jugular foramen syndrome (Vernet syndrome), jugular foramen schwannoma 54, and Avellis syndrome 55 ( laryngeal hemiplegia due to peripheral glossopharyngeal and vagus nerve lesions or medulla oblongata infarction); 10% due to strumectomy or thoracomediastinal surgery 56 ; 40% due to tumors (esophagus); 10% posttraumatic; and 30% idiopathic. Ankylosis of the crico-arytenoid joint after vocal fold paralysis is rare 57. Dysphonia due to unilateral vocal fold paralysis is a surgically treatable condition and is amenable to functional rehabilitation. 3.1 Laryngoplasties, Laryngeal Framework Surgery, and ISSHIKI Thyroplasties The Phonosurgery Committee of the European Laryngological Society 58 proposed the collective term laryngeal framework surgery as a synonym for laryngoplasty. These open surgical procedures involving an external approach through the neck are classified into four main types: approximation laryngoplasty, expansion laryngoplasty, relaxation laryngoplasty, and tensioning laryngoplasty.

23 Phonosurgery Principles and Techniques Indications The indication for surgery is based on the goal of enhancing the voice by improving glottic closure. If contact between the vocal folds is lost due to unilateral paralysis, the glottis will be unable to close during phonation. As a result, each of the vocal folds will vibrate at its own frequency, and the voice will have a harsh quality. An undesired falsetto voice may result from tension on the vocal fold due to partial innervation of the vocalis and cricothyroid muscles. Because glottic closure is incomplete, only a tangential airflow impinges on the vocal fold during phonation and energy is trans ferred ineffectually from the air stream to the vocal fold. The pitch of the speaking voice can be normalized by closing the glottic gap. Turbulent sounds, which are perceived as breathiness of the voice or even aphonia, are less common in recurrent laryngeal nerve palsy than laryngoscopic and stroboscopic findings in glottic insufficiency would suggest. Improving glottic closure also reduces the breathiness of the voice Symptoms The cardinal symptom of unilateral paralysis is hoarseness. Dysphonia in a broader sense refers not just to voice quality but also to vocal abilities such as pitch range, intensity range, endurance, vocal strain, and the subjective rating of voice by the patient. Another important functional disorder that may occur in unilateral paralysis is dysphagia Dyspnea is a less significant concern 62, as unilateral paralysis rarely causes dyspnea serious enough to require treatment Timing An acute operation for vocal fold paralysis is performed within two weeks after the causative nerve lesion. An elective operation is performed up to six months after the onset of paralysis. Surgery for chronic paralysis is performed after six months 63. The rule of waiting at least one year is no longer valid 64. The reversibility of the laryngoplasty justifies this policy. Our own observations have shown that even when mobility is restored, residual lateral bowing of the vocal fold is not troublesome and does not require correction. Voice therapy is effective in stabilizing the laryngeal status, and residual innervation or reinnervation can improve the outcome. Medialization will facilitate voice exercises. If the patient is reluctant to consent to an operation, voice exercises should be prescribed to activate residual mobility and compensate for the phonatory impairment. It should be added that surgical intervention can be safely postponed, as it is still effective even years after the onset of paralysis Complications Edema and wound healing prob - lems are rare. Infection can be prevented with perioperative antibiotics, but this is unnecessary as a routine measure. Tracheotomy 63 is necessary in only a small percentage of patients (1%) whose paralysis is caused by a neck tumor or postoperative sequelae. If silicone has been implanted, it may occasionally evoke an allergic reaction that necessitates reoperation 66. While this risk does not contraindicate all silicone injections, the availability of alternative materials does call into question the routine use of silicone. Complications that require surgic al correction in 1 2% of cases are intraluminal extrusion of the implant 67 and displacement of the cartilage shim. Mild compromise of respiratory function 68 may occur after unilateral vocal fold paralysis and also after thyroplasty. This has no clinic al significance as long as the patient avoids strenuous physical exertion. Other authors 69 have been unable to document any respiratory compromise after thyroplasty. Dyspnea in a setting of unilateral vocal fold paralysis is still more of a theoretical than prac tical problem.

24 24 Phonosurgery Principles and Techniques a b c Figs. 8 Principle of medialization thyroplasty. The lower half of the thyroid lamina is windowed as illustrated in Fig Medialization Thyroplasty Fig. 9 Principle of creating the posterior and thyroid cartilage window (after Maragos 93 ). The most widely used method in approximation laryngoplasties is the medialization thyroplasty 70, which is based on the concept of moving the entire paralyzed vocal fold closer to the midline (Fig. 8 and Fig. 9). It is roughly equivalent to an Isshiki type I thyroplasty 71. The medialization was originally accomplished by depressing the thyroid cartilage 71, 72, as Payr first proposed in Variations invol- 74, 75 ved the use of cartilage wedges or autologous cartilage from the upper part of the thyroid cartilage 76. Isshiki later advocated the placement of a silicone implant carved to the necessary size and shape 77. Other medialization materials include ceramic wedges made of hydroxylapatite 78, Gore-Tex sheets 79-84, plastic wed ges from the Montgomery Thyroplasty Implant System 85, and the Friedrich Titanium Implant System 86, 87.

25 Phonosurgery Principles and Techniques 25 a b c d e f g h i k F Figs. 8.1a k Thyroplasty for recurrent laryngeal nerve palsy on the left side. The thyroid cartilage is exposed, and the proposed window is outlined with a scalpel (a). The cartilage is divided with a cutting burr (b). The piece of cartilage is mobilized and pushed medially with a periosteal elevator (c). The inner perichondrium is left intact. The superior border of the thyroid cartilage is freed of perichondrium (d). A cartilage strip is excised with a scissors (e, f) and inserted crosswise into the thyroplasty window (g) to maintain the position of the medialized piece of cartilage (h). The stabilized cartilages can be secured with Histoacryl glue (i), which fills in the window to the level of the thyroid lamina.

26 26 Phonosurgery Principles and Techniques Arytenoid Adduction Arytenoid adduction 63, moves the vocal fold medially by rotation of the arytenoid cartilage (Fig. 10). It is effective in cases with a broad interarytenoid gap and is performed in conjunction with a medialization thyroplasty. Arytenoid adduction lengthens the total operating time by approximately 30 minutes. The muscular process of the arytenoid cartilage is accessible through the thyroid cartilage by resection, incision and disarticulation of the cricoarytenoid joint 91 or through a separate posterior window 92. Fig. 10 Principle of arytenoid adduction as described by Isshiki 91. The arytenoid cartilage is dislocated and the muscular process is pulled forward to rotate the vocal process medially. It is stabilized with a nonabsorbable suture placed in the anterior margin of the thyroplasty window. This permits glottic closure in the membranous portion of the vocal fold Other Types of Laryngoplasty Other types of laryngoplasty are mentioned here only for completeness, as they have few clinical indications. Nevertheless, they should be part of every phonosurgeon s repertoire. Expansion laryngoplasty can be used in the treatment of excessive glottic closure like that occurring in adductor-type spastic dysphonia. Relaxation laryngoplasty reduces tension on the vocal folds in the anteroposterior direction and lowers the voice in patients with a mutational voice disorder or vocal fold stiffness due to scarring. Tensioning laryngoplasty is used to tighten stretched, lax vocal folds or to raise voice pitch in patients with cricothyroid paralysis and in maleto-female transsexuals 58. a b Figs. 10.1a d E The muscular process of the arytenoid cartilage is accessed through a posterior cartilage window, snared with a suture (a), and pulled forward (b). The arytenoid cartilage is connected to the membranous vocal fold by the vocal process (c). The anterior traction rotates the arytenoid cartilage, tightens the vocal fold, and displaces it medially (d). c d

27 Phonosurgery Principles and Techniques Surgical Reinnervation of the Vocal Folds The ansa cervicalis has been anastomosed to the recurrent laryngeal nerve for laryngeal reinnervation in experimental animals 93, 94 Voice improvement in human patients has also been reported with this technique The paralyzed and reinnervated vocal fold remained fixed during respiration, but the authors found that the increased muscular tension did improve postoperative phonation. The operation, which involves exposing the ansa cervicalis and anastomosing it to the anterior branch of the recurrent laryngeal nerve, is complicated and not widely practiced. 3.3 Augmentation Injections The simplest and most frequently used medialization techniques are those in which augmentation material is injected into the vocal fold to decrease the glottic gap. They may be performed under local or general anesthesia. When local anesthesia is used, the patient is awake and seated in front of the surgeon. The larynx is visualized with a rigid endoscope or laryngeal mirror. Local anesthesia is achieved with 1% tetracaine mixed with epinephrine for vasoconstriction and a detergent (Tacholiquin) for better wetting of the mucosa. When general anesthesia is used, the larynx is exposed with the laryngoscope. General anesthesia is preferred in less cooperative patients. The injection is performed with special needles appropriate for the type of material used. A 23-gauge butterfly needle is best for injecting hyaluronic acid, and a 27-gauge needle is best for collagen. Fat can be injected through a needle with a 1.2-mm lumen attached to a Brüning syringe. Jet ventilation with a narrow tracheal catheter makes it easier to observe the effect of the injection. If endotracheal intubation is necessary, the smallest possible tube size should be used. The material is injected directly into the vocal fold. The needle is inserted either into the lateral part of the vocalis muscle or into the space between the thyroid cartilage and vocalis muscle. Material should not be injected into Reinke s space beneath the vocal fold epithelium (Fig. 11), provided the layers are not scarred or absent. The more viscous the material, the closer it can be placed to the free edge of the vocal fold. a b F Figs. 11 Site for injecting augmentation material into the vocal fold. a - Incorrect injection site, b - Correct injection site (after Hirano 77 ).

28 28 Phonosurgery Principles and Techniques a b c d e f g F Figs. 11.1a g The left vocal fold is fixed and the vocalis muscle is atrophic (b). An elliptical glottic gap is present during phonation (a). Collagen (Zyplast) is injected lateral to the fixed cord behind the vocalis muscle (c). When the procedure is done under local anesthesia as shown here, the surgeon can monitor the effect of the injection by having the patient vocalize (d). Some overcorrection is necessary to allow for absorption of the collagen (e). Glottic closure is still complete following collagen absorption (f). The injection has straightened out the previously bowed edge of the vocal fold (g).

29 Phonosurgery Principles and Techniques Materials Fat : Of the various injectable biomaterials, which differ in their viscosity 104, 105, autologous fat has the most favorable properties. Teflon: Although this material is still mentioned in the literature 106, injectable Teflon has serious disadvantages (see below) and should no longer be used. Collagen : Collagen produced from bovine skin or homologous acellular collagen 116, 117 is convenient to use and provides immediate good results. The absorption rate cannot be determined precisely for any given case, but a good general estimate is a 40 60% volume loss. Hyaluronic acid 105, : Hyaluronic acid is an insoluble compound with good viscoelastic properties. It is still detectable up to 12 months after injection and is permeated by connective tissue ingrowth (collagen, fibroblasts). The injection of hyaluronic acid yields somewhat better results than collagen injection. Fascia lata : Fascia lata can be cut into small pieces and injected into the vocal fold. The autologous material is transformed into connec tive tissue and is tolerated without signs of an inflammatory or foreign-body reaction. Its effect is comparable to that of other implant materials Disadvantages of the Injection Technique The injection may cause damage to the epithelium, vocalis muscle, or lamina propria. Potential problems include tissue induration, abscess formation at the injection site, hypersensitivity reaction to bovine collagen, or the induction of vascular changes 116 resulting in a deterioration of auditory, aerodynamic and endoscopic findings 128. While poor results are not inevitable 129, the mechanical compression of the lamina propria will necessarily impair the vibration properties of the epithelium. This risk should be considered before the intervention. Teflon injection is of purely historic al interest today. It has been largely abandoned because granuloma formation 130, implant displacement, and uncorrectable faulty placement 131, 132 can spoil the intended outcome of voice improvement.

30 30 Phonosurgery Principles and Techniques Reconstruction of Glottic Defects after Endolaryngeal Tumor Surgery The dysphonia following a partial laryngectomy, usually done for malignant disease, is determined by the extent of the resection and the size of the resulting defect. This type of surgery leads to the formation of rigid intralaryngeal scars. In favorable cases the surgery leaves tissue with good vibrational properties on the non-operated side. Glottic closure is incomplete, and the patient develops compensatory vocal habits, usually consisting of speech in the supraglottic plane (false-vocal-fold voice). The indications for phonosurgery are a broad glottic gap, persistent dysphonia despite voice therapy, and subjective patient dissatisfaction. The functional deficits may consist of an aphonic voice, excessive air consumption during speech, strenuous vocal effort, and swallowing difficulties. The basic principle of vocal fold reconstruction is to move the tissue on the operated side toward the midline. This can be done with the methods described above: mediali zation through an extralaryngeal approach or endolaryngeal microsurgery using advancement flaps and augmentation through a laryngoscope. Although these techniques cannot eliminate hoarseness and restore a normal voice, they can achieve significant improvement of dyspho - nia in most patients. Air consumption is reduced, resulting in increased phrase length and subjective voice improvement. Barring pathological findings at the operative site (leukoplakia, inflammation, granulation), reconstructive surgery can be attempted 6 12 months after tumor surgery. This operation will not interfere with oncologic follow-up. a b Figs. 11.2a d E Glottic defect following a laser cordectomy on the left side (a). Phonation occurs in the plane of the ventricular folds (b), resulting in a false-vocal-fold voice. Below the opposing ventricular folds, there is absence of contact between the intact right vocal fold and the scar on the left side. The defect was augmented and reconstructed by thyroplasty, the implanta tion of septal cartilage grafts, and flap advancement (c). This combination of procedures restored phonation to the glottic plane (d). c d

31 Phonosurgery Principles and Techniques 31 a b c d e Figs. 12 Principle of partial arytenoidectomy and posterior cordectomy with intralaryngeal sutures. (b) The intraluminal part of the vocal process of the arytenoid cartilage is resected by laser surgery, and the incision through the conus elasticus is extended laterally to the cricoid cartilage. (c) The posterior part of the vocal fold is opened with a triangular incision, and the under lying vocalis muscle is resected. (d) The inferiorly based flap from the posterior part of the vocal fold is sutured laterally to the ventricular fold. This creates optimum conditions for wound healing (e) with minimal fibrin and granulation tissue form ation. If the anterior part of the vocal fold can still be adducted, it can be utilized for phonation Bilateral Vocal Fold Paralysis, Glottic Widening and Voice Function Bilateral vocal fold paralysis raises the problem of respiratory distress. Widening the glottis to improve breathing will inevitably cause impairment of phonation. Of the variety of methods available (reviewed in 133 ), partial arytenoidectomy and posterior cordectomy with the CO 2 laser have proven most advantageous 72, 134, 135. Only the part of the arytenoid cartilage projecting into the laryngeal lumen is resected. This prevents fluid aspiration without causing additional swallowing difficulties. Since the anterior part of the membranous portion of the vocal fold is preserved, some vibrating tissue is still available for phonation (Fig. 12). Even with meticulous operating technique, it is impossible to predict vocal function after glottic widening surgery. It is clear, however, that the surgery does cause vocal impairment and that voice quality will depend on the compensatory capacities of the individual patient. These include the remaining innervation of the vocalis muscle by the anterior branch of the recurrent laryngeal nerve or ansa galeni and the ability to acquire a false-vocalfold voice. The operating technique can contribute to preserving these residual functions. A complete cordectomy is unfavorable for voice preservation and almost invariably leads to aphonia.

32 32 Phonosurgery Principles and Techniques a b c d e f g h i k F Figs. 12.1a k Bilateral paralysis of the vocal folds in a paramedian position (a). The operation can be performed under general endotracheal anesthesia or jet ventilation. A tracheotomy is not mandatory. The first incision, the cordotomy, is made transverse to the glottis at the vocal process of the arytenoid cartilage (b), dividing the conus elasticus as far as the upper cricoid cartilage. The triangular opening is produced by retraction of the vocalis muscle. The part of the arytenoid cartilage projecting into the lumen is excised with the laser (c). This requires no additional aids since the arytenoid cartilage generally is not ossified. The posterior part of the vocal-fold muscle is resected with the laser (d). This resection is called a partial posterior cordectomy. Inferiorly, the conus elasticus with its mucosal covering remains intact below the membranous part of the vocal fold. This inferiorly based flap is fixed laterally with intralaryngeal sutures using a micro-needle holder and a small grasping forceps (e g). The suture material consists of an absorbable, braided, atraumatic 5 0 suture 75 cm long. The knot is pushed downward with a knot pusher (h) to permit approximation of the wound margins. The number of sutures depends on the length of the resection (i, k).

33 Phonosurgery Principles and Techniques Discussion Voice quality and vocal efficiency after phonosurgical procedures cannot be evaluated based on a direct comparison of absolute values measured by different authors due to variations in measuring conditions at different institutions. Vocal fold lesions that have been operatively treated under microlaryn goscopic control are functionally evaluated based on voice performance. Function is the reason for the operation, and hence the goal of surgery is functional improvement. The patient must be given the choice of whether or not to have the operation, and he should not regret his consent at a later time. For every head and neck surgeon with a sufficiently self-critical attitude, any procedure done for benign lesions without dyspnea or dysphagia that results in a deterioration of voice quality must be considered a failure. Scrupulous patient selection, meticulous technique, and appropriate resections and corrections will help to prevent irreversible damage. By definition, vocal function is the main priority in phonosurgery. If an operation does not yield the desired result, it should be possible to proceed with a second operation to effect further improvement. For the present, we cannot state definitively whether vocal-fold medialization by a thyroplasty or augmenting injection will generally yield the best voice outcome. High success rates of phonosurgical medialization have been reported for the methods described above 19, 64, 136. They depend chiefly on how well the mobile phonatory structures, lamina propria, and epithelium have been preserved and on the quality and completeness of glottic closure. Medialization procedures leave the vocal fold intact. While this represents an advantage over injection techniques, the latter can completely compensate for residual glottic insufficiency 138. Post-strumectomy lesions account for the highest percentage of cases of vocal fold paralysis that require surgical treatment. But prevention is better than treatment. It has been shown that microdissection technique and intraoperative nerve monitoring can reduce the incidence of vocal fold paralysis to less than 1% 137. If this trend continues, there will be less need for the functional rehabilitation of iatrogenic paralysis in the future. The contribution of reinnervation to surgical success rates is uncertain. Even a partial return of nerve function will improve voice quality, either by improved respiratory mobility or by innervation of the intrinsic laryngeal muscles, which do not atrophy and, consistent with the body-cover model, provide a solid foundation for epithelial movements on the lamina propria. Physicians, patients, and third parties generally agree that voice quality is improved after phonosurgery. Thus, a pre- and postoperative comparison of voice quality is useful for determining whether available diagnostic methods can detect significant changes, i.e., whether they are valid. The protocol of the European Laryngological Society 8 can serve as a model in this regard, emphasizing the need to establish a battery of simple but powerful multidimensional tests for evaluating the abnormal voice (see the section on Auditory and Objective Evaluation of Dysphonia). At present, the various tests are usually considered in isolation but actually relate to different, independent aspects of the voice. In this sense they comprise an interrelated network 139. The goal of multidimensional voice testing is the ability to categorize the degree of voice impairment as normal (0 4%), mild (5 24%), moderate (25 49%), severe (50 95%), or complete (96 100%) based on the International Classification of Functioning, Disability and Health (ICF) 140. A uniform diagnostic protocol that collects valid, reliable data is essential for evidence-based studies. It is up to phoniatrists to develop this protocol.

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Annals of Otology, Rhinology & Laryngology2003; 112: FRIEDRICH G, MAUSSER G, NEMETH E: Entwicklung eines Jet-Tracheoskops. Wertigkeit und Einsatzmöglichkeiten der superponierten Hochfrequenz- Jet-Ventilation (SHFJV) in der endoskopischen Chirurgie der Atemwege. HNO 2002; 50: SATALOFF RT, SPIEGEL JR, HEUER RJ, BAROODY MM, EMERICH KA, HAWK-SHAW MJ, ROSEN DC: Laryngeal mini-microflap: a new technique andreassessment of the microflap saga. Journal of Voice 1995; 9: HOCHMAN II, ZEITELS SM: Phonomicrosurgical management of vocalfold polyps: the subepithelial microflap resection technique. Journalof Voice 2000; 14: ZEITELS SM, HILLMAN RE, FRANCO RA, BUNTING GW: Voice and treatmentoutcome from phonosurgical management of early glottic cancer. Annals of Otology, Rhinology & Laryngology Supplement 2002; 190: REMACLE M:. Personal communication BENNINGER MS, ALESSI D, ARCHER S, BASTIAN R, FORD C, KOUFMAN J, SATA-LOFF RT, SPIEGEL JR, WOO P: Vocal fold scarring: current concepts andmanagement. Otolaryngology Head & Neck Surgery 1996; 115: SASAKI CT, LEDER SB, PETCU L, FRIEDMAN CD: Longitudinal voice qualitychanges following Isshiki thyroplasty type I: the Yale experience. Laryngoscope 1990; 100: SNOECK R, WELLENS W, DESLOOVERE C, VAN RANST M, NAESENS L, DECLERCQ E, FEENSTRA L: Treatment of severe laryngeal papillomatosiswith intralesional injections of cidofovir [(S)-1-(3-hydroxy-2-phosphonylmethoxypropyl) cyto sine]. Journal of Medical Virology 1998;54: SILVER RD, RIMELL FL, ADAMS GL, DERKAY CS, HESTER R: Diagnosis andmanagement of pulmonary metastasis from recurrent respiratory pa-pillomatosis. Otolaryngology Head & Neck Surgery 2003; 129: SNOECK R, ANDREI G, DE CLERCQ E: Cidofovir in the treatment of HPV-associated lesions. Verhandelingen Koninklijke Academie voor Geneeskunde van Belgie 2001; 63:

35 Phonosurgery Principles and Techniques NAWKA T, HILDEBRANDT T, JANTSCHAK J, FLÜGEL W: Verlauf der laryngealen Papillomatose Bericht über 104 Fälle. Lasermedizin 1993; 9: PASQUALE K, WIATRAK B, WOOLLEY A, LEWIS L: Micro debrider versus CO 2laser removal of recurrent respiratory papillomas: a prospective analysis. Laryngoscope 2003; 113: DERKAY CS: Recurrent respiratory papillomatosis. Laryngo scope 2001;111: REMACLE M, ECKEL HE, ANTONELLI A, BRASNU D, CHEVALIER D, FRIEDRICH G, OLOFSSON J, RUDERT HH, THUMFART W, DE VINCENTIIS M, WUSTROW TP: Endo scopic cordectomy. A proposal for a classification by the WorkingCommittee, European Laryngological Society. Eur Arch Otorhinolaryngol 2000; 257: DAMM M, SITTEL C, STREPPEL M, ECKEL HE. Transoral CO 2 laser for surgical management of glottic carcinoma in situ. Laryngoscope 2000;110: LEJEUNE FE: Jr. Intralaryngeal surgery Laryngoscope 1977; 87: MEYERS AD, KUZELA DC: Dose response characteristics of the humanlarynx with carbon dioxide laser radiation. Am J Otolaryngol 1980; 1: SHAPSHAY SM, REBEIZ EE, BOHIGIAN RK, HYBELS RL: Benign lesions of the larynx: should the laser be used? Laryngoscope 1990; 100: FITZPATRICK RE, RUIZ-ESPARZA J, GOLDMAN MP: The depth of thermal necrosis using the CO2-Laser: a comparison of the superpulsed mode andconventional mode. J Dermatol Surg Oncol 1991; 17: REMACLE M, HASSAN F, COHEN D, LAWSON G, DELOS M: New computerguided scanner for improving CO( 2)-Laserassisted microincision. EurArch Otorhinolaryngol 2004; online, Springer 49. BENNINGER MS: Microdissection or microspot CO 2-Laser for limited vocal fold benign lesions: a prospective randomized trial. [erratum appears in Laryngoscope 2000 Apr; 110 (4): 696]. Laryngoscope 2000;110: KEILMANN A, BIERMANN G, HÖRMANN K: CO 2-Laser versus konventionelle Mikrolaryngoskopie bei gutartigen Veränderungen der Stimmlippe. Laryngo-Rhino-Otologie 1997; 76: HÖRMANN K, BAKER-SCHREYER A, KEILMANN A, BIERMANN G: Functional results after CO 2 laser surgery compared with conventional phonosurgery. Journal of Laryngology & Otology 1999; 113: NAWKA T, HAAKE K: Laserchirurgische Erfahrungen in der HNO-Heilkunde. Zeitschrift für ärztliche Fortbildung (Jena) 1990; 84: WARD PH, BERCI G, CALCATERRA TC: Superior laryngeal nerve paralysis anoften overlooked entity. Transactions American Academy of Oph-thalmology & Otolaryngology 1977; 84: LEE SK, PARK K, KONG DS, CHO YS, BAEK CH, NAM DH, LEE JI, HONG SC,SHIN HJ, EOH W, KIM JH: Surgical tactics and outcome of treatment injugular foramen schwannomas. Journal of Clinical Neuroscience2001; 8, (Suppl 1): KRASNIANSKI M, NEUDECKER S, SCHLUTER A, ZIERZ S: Avellis-Syndrom beihirnstammischämien. Fortschritte der Neurologie-Psychiatrie 2003;71: LACCOURREYE O, PAPON JF, KANIA R, MENARD M, BRASNU D, HANS S: Paralysies laryngees unilaterales: donnees epidemiologiques et evolutiontherapeutique. Presse Medicale 2003; 32: GACEK M, GACEK RR: Cricoarytenoid joint mobility after chronic vocalcord paralysis. Laryngoscope 1996; 106: FRIEDRICH G, DE JONG FI, MAHIEU HF, BENNINGER MS, ISSHIKI N: Laryngealframework surgery: a proposal for classification and nomenclatureby the Phonosurgery Committee of the European Laryngological Society. Eur Arch Otorhinolaryngol 2001; 258: CARRAU RL, POU A, EIBLING DE, MURRY T, FERGUSON BJ: Laryngeal framework surgery for the management of aspiration. Head & Neck 1999;21: FLINT PW, PURCELL LL, CUMMINGS CW: Pathophysiology and indicationsfor medialization thyroplasty in patients with dysphagia and aspiration. Otolaryngology Head & Neck Surgery 1997; 116: ABDEL-AZIZ MF, EL-HAK NA, CARDING PN: Thyroplasty for functional rehabilitation of the incompetent larynx. Journal of Laryngology & Otology 1998; 112: BEATY MM, HOFFMAN HT: Impact of laryngeal paralysis and its treatment on the glottic aperture and upper airway flow characteristicsduring exercise. Otolaryngology Head & Neck Surgery 1999; 120: ABRAHAM MT, GONEN M, KRAUS DH: Complications of type I thyroplasty and arytenoid adduction. Laryngoscope 2001; 111: FRIEDRICH G: Externe Stimmlippenmedialisation: Funktionelle Ergebnisse. Laryngo-Rhino-Otologie 1998; 77: BILLANTE CR, CLARY J, SULLIVAN C, NETTERVILLE JL: Voice outcome followingthyroplasty in patients with long standing vocal fold immobility. Auris, Nasus, Larynx 2002; 29: HUNSAKER DH, MARTIN PJ: Allergic reaction to solid silicone implant inmedial thyroplasty. Otolaryngology Head & Neck Surgery 1995;113: LACCOURREYE O, HANS S: Endolaryngeal extrusion of expanded polyte-trafluoroethylene implant after medialization thyroplasty. Ann OtolRhinol Laryngol 2003; 112: JANAS JD, WAUGH P, SWENSON ER, HILLEL A: Effect of thyroplasty on laryngeal airflow. Annals of Otology, Rhinology & Laryngology 1999;108: SCHNEIDER B, KNEUSSL M, DENK DM, BIGENZAHN W: Aerodynamic measurements in medialization thyroplasty. Acta Oto-Laryngologica 2003; 123: KLEINSASSER O, SCHROEDER HG, GLANZ H: Medianverlagerung gelähmter Stimmlippen mittels Knorpelspanimplantation und Türflügelthyreoplastik. HNO 1982; 30: ISSHIKI N, MORITA H, OKAMURA H, HIRAMOTO M: Thyroplasty as a newphonosurgical technique. Acta Oto-Laryngologica 1974; 78: WENDLER J, SEIDNER W, NAWKA T: Phonochirurgische Erfahrungen aus der Phoniatrie. Sprache Stimme Gehör 1994; 18: PAYR E: Plastik am Schildknorpel zur Behebung der Folgen einseitiger Stimmbandlähmung. Dtsch Med Wochenschr 1915; 43: ISSHIKI N, OKAMURA H, ISHIKAWA T: Thyroplasty type I (lateral compression) for dysphonia due to vocal cord paralysis or atrophy. Acta Oto-Laryngologica 1975; 80: GUAY ME, MILLER FR, BAUER TW, TUCKER HM: Vocal fold medializationusing autologous cartilage in a canine model: a preliminary study. Laryngoscope 1995; 105: HIRANO M: Surgical and medical management of voice disorders. In: Colton RH, Casper JK (ed). Understanding voice problems. Baltimore:Williams and Wilkins, 1996: ISSHIKI N, TAIRA T, KOJIMA H, SHOJI K: Recent modifications in thyroplasty type I. Annals of Otology, Rhinology & Laryngology 1989; 98: CUMMINGS CW, PURCELL LL, FLINT PW: Hydroxylapatite laryngeal implants for medialization. Preliminary report. Annals of Otology, Rhinology & Laryngology 1993; 102:

36 36 Phonosurgery Principles and Techniques 79. McCULLOCH TM, HOFFMAN HT: Medialization laryngoplasty with expanded polytetrafluoroethylene. Surgical technique and preliminaryresults. Ann-Otol-Rhinol-Laryngol 1998; 107: CASHMAN S, SIMPSON CB, McGUFF HS: Soft tissue response of the rabbitlarynx to Gore-Tex implants. Annals of Otology, Rhinology & Laryngology 2002; 111: KESKIN G, BOYACI Z, USTUNDAG E, KAUR A, ALMAC A: Use of polyethyleneterephthalate and expanded-polytetrafluoroethylene in medialization laryngoplasty. Journal of Laryngology & Otology 2003; 117: McCULLOCH TM, HOFFMAN HT, ANDREWS BT, KARNELL MP: Arytenoid adduction combined with Gore-Tex medialization thyroplasty. Laryngoscope 2000; 110: SELBER J, SATALOFF R, SPIEGEL J, HEMAN-ACKAH Y: Gore-Tex medializationthyroplasty: objective and subjective evaluation. Journal of Voice2003; 17: STASNEY CR, BEAVER ME, RODRIGUEZ M: Minifenestration type I thyroplasty using an expanded polytetrafluoroethylene implant. Journalof Voice 2001; 15: MONTGOMERY WW, MONTGOMERY SK: Montgomery thyro plasty implant system. Annals of Otology, Rhinology, & Laryngology Supplement 1997; 170: SCHNEIDER B, DENK DM, BIGENZAHN W: Functional results after externalvocal fold medialization thyroplasty with the titanium vocal fold medialization implant. Laryngoscope 2003; 113: FRIEDRICH G: Externe Stimmlippenmedialisation: Operative Erfahrungen und Modifikationen. Laryngo-Rhino-Otologie 1998; 77: SLAVIT DH, MARAGOS NE: Physiologic assessment of ary tenoid adduction. Annals of Otology, Rhinology & Laryngology 1992; 101: ISSHIKI N, TANABE M, SAWADA M: Arytenoid adduction for unilateralvocal cord paralysis. Archives of Otolaryngology 1978; 104: MAHIEU HF, SCHUTTE HK: New surgical techniques for voice improvement. Archives of Oto-Rhino-Laryngology 1989; 246: ISSHIKI N: Phonosurgery: theory and practice. Tokyo: Springer-Verlag, MARAGOS NE: The posterior thyroplasty window: anatomical considerations. Laryngoscope 1999; 109: NONOMURA M, KOJIMA H, OMORI K, KANAJI M, HONJO I, NAKAMURA T, SHI-MIZU Y: Remobilization of paralyzed vocal cord by anticus-lateralismuscle suturing. Archives of Otolaryngology Head & Neck Surgery1993; 119: NASRI S, SERCARZ JA, YE M, KREIMAN J, GERRATT BR, BERKE GS: Effects ofarytenoid adduction on laryngeal function following ansa cervicalisnerve transfer for vocal fold paralysis in an in vivo canine model. Laryngoscope 1994; 104: CRUMLEY RL: Teflon versus thyroplasty versus nerve transfer: a comparison. Annals of Otology, Rhinology & Laryngology 1990; 99: CRUMLEY RL: Unilateral recurrent laryngeal nerve paralysis. Journal of Voice 1994; 8: ZHENG H, LI Z, ZHOU S, CUAN Y, WEN W: Update: laryngeal reinnervation for unilateral vocal cord paralysis with the ansa cervicalis. Laryn-goscope 1996; 106: BRANDENBURG JH, KIRKHAM W, KOSCHKEE D: Vocal cord augmentationwith autogenous fat. Laryngoscope 1992; 102: McCULLOCH TM, ANDREWS BT, HOFFMAN HT, GRAHAM SM, KARNELL MP,MINNICK C: Long-term follow-up of fat injection laryngoplasty for unilateral vocal cord paralysis. Laryngoscope 2002; 112: HILL DP, MEYERS AD, HARRIS J: Autologous fat injection for vocal cordmedialization in the canine larynx. Laryngoscope 1991; 101: SHAW GY, SZEWCZYK MA, SEARLE J, WOODROOF J: Autologous fat injectioninto the vocal folds: technical con siderations and long-term follow-up. Laryngoscope 1997; 107: ZARETSKY LS, SHINDO ML, DETAR M, RICE DH: Autologous fat injection forvocal fold paralysis: long-term histologic evaluation. Annals of Otology, Rhinology & Laryngology 1995; 104: TUCKER HM: Direct autogenous fat implantation for augmentation ofthe vocal folds. Journal of Voice 2001; 15: CHAN RW, TITZE IR: Viscosities of implantable biomaterials in vocalfold augmentation surgery. Laryngoscope 1998; 108: DAHLQVIST A, GARSKOG O, LAURENT C, HERTEGARD S, AMBROSIO L, BORZACCHIELLO A: Viscoelasticity of rabbit vocal folds after injection augmentation. Laryngoscope 2004; 114: STRACHAN D, KAMATH B, WENGRAF C: How we do it: use of a venous cannulation needle for endoscopic Teflon injection to the vocal folds. Journal of Laryngology & Otology 1995; 109: FORD CN, MARTIN DW, WARNER TF: Injectable collagen in laryngeal rehabilitation. Laryngoscope 1984; 94: FORD CN, BLESS DM: Clinical experience with injectable collagen forvocal fold augmentation. Laryngoscope 1986; 96: FORD CN, BLESS DM: A preliminary study of injectable collagen in human vocal fold augmentation. Otolaryngology Head & Neck Surgery1986; 94: FORD CN, GILCHRIST KW, BARTELL TE: Persistence of injectable collagen in the human larynx: a histopathologic study. [erratum appears in La-ryngoscope 1987 Sep; 97 (9): 1042]. Laryngoscope 1987; 97: FORD CN, BLESS DM, CAMPBELL D: Studies of injectable soluble collagenfor vocal fold augmentation. Revue de Laryngologie Otologie Rhino-logie 1987; 108: FORD CN, STASKOWSKI PA, BLESS DM: Autologous collagen vocal fold injection: a preliminary clinical study. Laryngoscope 1995; 105: HACKI T, BÖCKLER R, PEREZ ALVAREZ JC: Indikationen zur Stimmlippenaugmentation mit Kollagen. Laryngo-Rhino-Otologie 1999; 78: REMACLE M, MARBAIX E, HAMOIR M, BERTRAND B, VAN DEN EECKHAUT J: Correction of glottic insufficiency by collagen injection. Annals of Otology, Rhinology & Laryngology 1990; 99: STASKOWSKI PA, FORD CN, INAGI K: The histologic fate of autologous collagen injected into the canine vocal fold. Otolaryngology Head &Neck Surgery 1998; 118: KARPENKO AN, DWORKIN JP, MELECA RJ, STACHLER RJ: Cymetra injectionfor unilateral vocal fold paralysis. Ann Otol Rhinol Laryngol 2003;112: LUNDY DS, CASIANO RR, MCCLINTON ME, XUE JW: Early results of transcutaneous injection laryngoplasty with micronized acellular dermisversus type-i thyroplasty for glottic incompetence dysphonia due tounilateral vocal fold paralysis. J Voice 2003; 17: HERTEGARD S, DAHLQVIST A, LAURENT C, BORZACCHIELLO A, AMBROSIO L: Viscoelastic properties of rabbit vocal folds after augmentation. Otolaryngology Head & Neck Surgery 2003; 128: HERTEGARD S, HALLEN L, LAURENT C, LINDSTROM E, OLOFSSON K, TESTAD P,DAHLQVIST A: Cross-linked hyaluronan used as augmentation substance for treatment of glottal insufficiency: safety aspects and vocal fold function. Laryngoscope 2002; 112: HALLEN L, DAHLQVIST A, LAURENT C: Dextranomeres in hyaluronan (Di-HA): a promising substance in treating vocal cord insufficiency. Laryngoscope 1998; 108:

37 Phonosurgery Principles and Techniques HALLEN L, JOHANSSON C, LAURENT C: Cross-linked hyaluronan (Hylan Bgel): a new injectable remedy for treatment of vocal fold insufficiency an animal study. Acta Oto-Laryngologica 1999; 119: DUKE SG, SALMON J, BLALOCK PD, POSTMA GN, KOUFMAN JA: Fascia augmentation of the vocal fold: graft yield in the canine and preliminaryclinical experience. Laryngoscope 2001; 111: REIJONEN P, LEIVO I, NEVALAINEN T, RIHKANEN H: Histology of injectedautologous fascia in the paralyzed canine vocal fold. Laryngoscope2001; 111: RIHKANEN H: Vocal fold augmentation by injection of autologous fascia. Laryngoscope 1998; 108: RIHKANEN H, KALISTE E, LEIVO I: Processing of fascia for vocal fold injection. A study in vitro and in paralyzed canine vocal folds. Annalsof Otology, Rhinology & Laryngology 2003; 112: RODGERS BJ, ABDUL-KARIM FW, STRAUSS M: Histologic al study of injectedautologous fascia in the paralyzed canine vocal fold. Laryngoscope2000; 110: TAMURA E, KITAHARA S, KOHNO N, OGURA M, HIROI S: Use of freeze-driedautologous fascia to augment the vocal fold: an experimental studyin dogs. Acta Oto-Laryngologica 2002; 122: D ANTONIO LL, WIGLEY TL, ZIMMERMAN GJ: Quantitative measures of laryngeal function following Teflon injection or thyroplasty type I. Laryngoscope 1995; 105: DEJONCKERE PH: Teflon injection and thyroplasty: objective and subjective outcomes. Revue de Laryngologie Oto logie Rhinologie 1998;119: WENIG BM, HEFFNER DK, OERTEL YC, JOHNSON FB: Teflonomas of the larynx and neck. [see comment]. Human Pathology 1990; 21: KASPERBAUER JL, SLAVIT DH, MARAGOS NE: Teflon granulomas and overinjection of Teflon: a therapeutic challenge for the otorhinolaryngologist. Annals of Otology, Rhinology & Laryngology 1993; 102: NETTERVILLE JL, COLEMAN JR JR, CHANG S, RAINEY CL, REINISCH L, OSSOFF RH: Lateral laryngotomy for the removal of Teflon granuloma. Annals of Otology, Rhinology & Laryngology 1998; 107: ECKEL HE, SITTEL C: Beidseitige Rekurrenslähmungen. HNO 2001; 49: NAWKA T: Endoskopische Mikrochirurgie des Larynx mit dem CO2-Laser. Habilitationsschrift. Medizinische Fakultät der Humboldt-Universität zu Berlin, NAWKA T: Endoscopic management of bilateral recurrent nerve paralysis with the CO 2-Laser. In: Rudert H, Werner JA (Hrsg). Lasers in Otorhinolaryngology, and in Head and Neck Surgery. Basel: Karger, 1995: ISSHIKI N: Progress in laryngeal framework surgery. Acta Oto-Laryngologica 2000; 120: NEUMANN HJ: Intraoperatives neurophysiologisches Monitoring (IONM) des Nervus recurrens und Mikrodissektion. Operationstechnische Verfahren zur Risikominderung von Recurrensparesen. Laryngo-Rhino-Otologie 2000; 79: HOFFMAN H, McCABE D, McCULLOCH T, JIN SM, KARNELL M: Laryngeal collagen injection as an adjunct to medialization laryngoplasty. Laryngoscope 2002; 112: DEJONCKERE PH, CREVIER-BUCHMAN L, MARIE JP, MOERMAN M, REMACLE M, WOISARD V: Implementation of the European Laryngological Society (ELS) basic protocol for assessing voice treatment effect. Rev Laryngol Otol Rhinol (Bord) 2003; 124: WHA 54.21Resolution: International Classification of Functioning, Disability and Health (ICF) Introduction. 2001,

38 38 Phonosurgery Principles and Techniques Recommended Instrument Set for Endolaryngeal Phonomicrosurgery 8590 A KLEINSASSER Operating Laryngoscope, for adults, extra large, length 17 cm 8590 B Same, large 8590 C Same, medium, length 17 cm (most commonly used model) 8590 DN Same, small, length 18 cm (for particularly difficult anatomical circumstances) 8590 J Same, medium, length 18 cm (for anterior commissure) 8590 JL Same, medium, length 22 cm (for especially long neck) 8590 K Same, for children, small, length 15 cm 8590 L Same, for infants, small, length 13 cm 8589 C RUDERT Anterior Commissure Laryngoscope, medium, universal size, triangular spatula-shaped, with lateral outer channels for Fiber Optic Light Carrier 8574 LF or Suction Tube to remove vapor 8574 LM, length 17 cm (most commonly used model) 8587 A LlNDHOLM Operating Laryngoscope, large, for adults, inner proximal end 39 x 24 mm, distal end width 18 mm, length 15 cm 8587 GF Fiber Optic Light Carrier, for distal illumination, length 7.5 cm, for use with Laryngoscopes 8587 A/AA/KK 8574 LF Fiber Optic Light Carrier, for distal illumination, length 16 cm, for use with Laryngoscopes 8590 AL/BL/C/CL/DL/JA and 8589 B/C 8602 KLEINSASSER Suction Tube, outer diameter 2 mm, working length 23 cm 8591 A KLEINSASSER Forceps, straight, with 2 mm cupped jaws, with cleaning connector, working length 23 cm 8591 C Same, curved to right 8591 D Same, curved to left 8594 A KLEINSASSER Scissors, straight, with cleaning connector, working length 23 cm 8594 C Same, curved to right 8594 D Same, curved to left 8654 B LINDHOLM Distending Forceps, for atraumatic retraction of true vocal cords and false vocal cords, distal end with blunt curved blades, self-retaining, with ratchet, working length 24 cm 8593 B KLEINSASSER Grasping Forceps, without ratchet, serrated, curved to right, with cleaning connector, working length 23 cm 8593 C Same, curved to left 8593 G Same, with triangular jaws, curved upwards to right 8593 H Same, curved upwards to left 8595 C KLEINSASSER Knife, sickle-shaped, curved, pointed, working length 23 cm 8655 A Elevator, slightly curved, working length 23 cm, for use with Handle T KLEINSASSER Knot Tier, working length 23 cm 8597 KLEINSASSER Handle, for use with 8595 A 8596 T, 8655 A K, 8693 A/B 8660 P KLEINSASSER Needle Holder, straight, small model, for phonosurgery and endolaryngeal microsurgery, 1.8 x 3.5 mm jaws with cross serration, without ratchet, sheath reinforced from distal to proximal, with cleaning connector, working length 20 cm 8660 N KLEINSASSER Needle Holder, delicate, straight, serrated jaws, size 1.8 x 3.5 mm, sheath conically reinforced from distal to proximal end, with ratchet, with cleaning connector, working length 23 cm 8657 H Universal Handle, forceps shape, with 2 handle rings, length 9 cm, for use with 3 mm instruments for phonosurgery and endolaryngeal microsurgery 8595 A 8596 T, 8655 A K and 8656 A S 8691 B Suction Tube, handle with cut-off hole, tip with central opening, outer diameter 1.5 mm, working length 20 cm 8593 GM Miniature Grasping Forceps, extra delicate, serrated, with triangular jaws, curved upwards to right, with cleaning connector, working length 23 cm 8593 HM Same, curved upwards to left 8594 CM KLEINSASSER Miniature Scissors, curved to right, with cleaning connector, working length 23 cm 8594 DM Same, curved to left 8656 B Sickle Knife, straight cutting, delicate, 3 to 1 mm tapered shaft, total length 23 cm 8656 L Elevator, slightly curved, blunt, delicate, 3 to 1 mm tapered shaft, total length 23 cm 8656 LS Same, sharp tip 8681 A Micro Forceps, straight, with 1 mm cupped jaws, with cleaning connector, working length 20 cm 8681 C Same, curved to right 8681 D Same, curved to left 8683 G SHAPSHAY-PERETTI Micro Grasping Forceps, curved upwards to right, serrated, with triangular fenestrated jaws, with cleaning connector, working length 20 cm 8683 H Same, curved upwards to left 8683 D Micro Grasping Forceps, curved to left, serrated, with cleaning connector, working length 20 cm 8683 C Same, curved to right 8684 A Micro Scissors, straight, with cleaning connector, working length 20 cm 8684 C Same, curved to right 8684 D Same, curved to left Indirect Laryngeal Forceps, for biopsy, curved upwards, spoon diameter 4 mm, with cleaning connector, working length 17 cm PELTESON Cotton Applicator, working length 27 cm 8659 FR FEHLAND-NAWKA Needle Holder, with crosswise recess for holding the butterfly needle, for indirect injection into the larynx, with ratched, angled 90 to the right, with cleaning connector, working length 23 cm 8659 FL Same, with ratchet, angled 90 to the left

39 Phonosurgery Principles and Techniques 39 Original KLEINSASSER Operating Laryngoscopes Full size illustration: inner diameter in mm proximal and distal A 8590 B x C 8590 J JL 8590 A L 8590 GF HF DN L K 8590 A KLEINSASSER Operating Laryngoscope, for adults, extra large, length 17 cm 8590 B Same, large 8590 C Same, medium (most commonly used model) 8590 DN Same, small, length 18 cm (for particularly difficult anatomical circumstances) 8590 J Same, medium, length 18 cm (for anterior commissure) 8590 JL Same, medium, length 22 cm (for especially long neck) 8590 K Same, for children, small, length 15 cm 8590 L Same, for infants, small, length 13 cm 8590 GF 8590 GF Fiber Optic Light Carrier, for distal illumination, working length 14 cm, for use with Laryngoscopes 8588 BV, 8590 A-JN, 8590 T, 8590 JV/TV and Diverticuloscopes A, A 8590 HF Fiber Optic Light Carrier, for distal illumination, working length 7.5 cm, for use with Laryngoscopes 8590 K L 8590 HF It is recommended to check the suitability of the product for the intended procedure prior to use.

40 40 Phonosurgery Principles and Techniques RUDERT Anterior Commissure Laryngoscope Full size illustration: inner diameter in mm proximal and distal x C 8589 C 8574 LM 8574 LF 8589 C RUDERT Anterior Commissure Laryngoscope, medium, universal size, triangular spatula-shaped, with lateral outer channels for Fiber Optic Light Carrier 8574 LF or Suction Tube to remove vapor 8574 LM, length 17 cm (most commonly used model) 8574 LF Fiber Optic Light Carrier, for distal illumination, length 16 cm, for use with Laryngoscopes 8590 AL/BL/C/CL/DL/JA and 8589 B/C 8574 LF 8574 LM Insertable Suction Tube to remove vapor, for use with laryngoscopes 8590 BL/CL/JA and 8590 C, length 16 cm 8574 LM

41 Phonosurgery Principles and Techniques 41 Original LINDHOLM Operating Laryngoscopes Full size illustration: inner diameter in mm proximal and distal A 8587 A 8587 GF 8587 A LlNDHOLM Operating Laryngoscope, large, for adults, inner proximal end 39 x 24 mm, distal end width 18 mm, length 15 cm 8587 GF Fiber Optic Light Carrier, for distal illumination, length 7.5 cm, for use with Laryngoscopes 8587 A/AA/KK 8587 GF 8587 M Suction Tube to remove vapor, for LASER treatment, length 8.5 cm 8587 M

42 42 Phonosurgery Principles and Techniques Instruments for Large Lesions KLEINSASSER Suction Tube, outer diameter 2 mm, working length 23 cm 8591 A 8591 A KLEINSASSER Forceps, straight, with 2 mm cupped jaws, with cleaning connector, working length 23 cm 8591 C Same, curved to right 8591 D Same, curved to left 8594 A 8594 A KLEINSASSER Scissors, straight, with cleaning connector, working length 23 cm 8594 C Same, curved to right 8594 D Same, curved to left

43 Phonosurgery Principles and Techniques 43 Instruments for Large Lesions 8654 B 8654 B LINDHOLM Distending Forceps, for atraumatic retraction of true vocal cords and false vocal cords, distal end with blunt curved blades, self-retaining, with ratchet, working length 24 cm 8593 A 8593 A KLEINSASSER Grasping Forceps, without ratchet, serrated, straight, with cleaning connector, straight, working length 23 cm 8593 B Same, curved to right 8593 C Same, curved to left 8593 G Same, with triangular jaws, curved upwards to right 8593 H Same, curved upwards to left

44 44 Phonosurgery Principles and Techniques Instruments for Large Lesions 8595 A A KLEINSASSER Knife, oval, straight, working length 23 cm 8595 C Same, sickle-shaped, curved, pointed 8655 A Elevator, slightly curved, working length 23 cm, for use with Handle T KLEINSASSER Knot Tier, working length 23 cm 8597 KLEINSASSER Handle, for use with 8595 A 8596 T, 8655 A K, 8693 A/B 8660 P 8660 P KLEINSASSER Needle Holder, straight, small model, for phonosurgery and endolaryngeal microsurgery, 1.8 x 3.5 mm jaws with cross serration, without ratchet, sheath reinforced from distal to proximal, with cleaning connector, working length 20 cm 8660 N 8660 N KLEINSASSER Needle Holder, delicate, straight, serrated jaws, size 1.8 x 3.5 mm, sheath conically reinforced from distal to proximal end, with ratchet, with cleaning connector, working length 23 cm

45 Phonosurgery Principles and Techniques 45 Instruments for Microlesions and Pediatric Phonosurgery 8654 BK 8654 BK Vocal Cord Retractor, for atraumatic retraction of true vocal cords and false vocal cords in pediatrics, distal end with blunt curved blades, self-retaining, with ratchet and cleaning connector, working length 24 cm 8691 B 8691 B Suction Tube, handle with cut-off hole, tip with central opening, outer diameter 1.5 mm, working length 20 cm 8593 GM 8593 GM Miniature Grasping Forceps, extra delicate, serrated, with triangular jaws, curved upwards to right, with cleaning connector, working length 23 cm 8593 HM Same, curved upwards to left

46 46 Phonosurgery Principles and Techniques Instruments for Microlesions and Pediatric Phonosurgery 8594 AM 8594 AM KLEINSASSER Miniature Scissors, straight, with cleaning connector, working length 23 cm 8594 CM Same, curved to right 8594 DM Same, curved to left 8657 H 8657 H Universal Handle, forceps shape, with 2 handle rings, length 9 cm, for use with 3 mm instruments for phonosurgery and endolaryngeal microsurgery 8595 A 8596 T, 8655 A K and 8656 A S 8656 B 8656 B Sickle Knife, straight cutting, delicate, 3 to 1 mm tapered shaft, total length 23 cm 8656 L 8656 L Elevator, slightly curved, blunt, delicate, 3 to 1 mm tapered shaft, total length 23 cm 8656 LS Same, sharp tip

47 Phonosurgery Principles and Techniques 47 Instruments for Microlesions and Pediatric Phonosurgery 8681 A 8681 A Micro Forceps, straight, with 1 mm cupped jaws, with cleaning connector, working length 20 cm 8681 C Same, curved to right 8681 D Same, curved to left 8683 D 8683 G SHAPSHAY-PERETTI Micro Grasping Forceps, curved upwards to right, serrated, with triangular fenestrated jaws, with cleaning connector, working length 20 cm 8683 H Same, curved upwards to left 8683 D Micro Grasping Forceps, curved to left, serrated, with cleaning connector, working length 20 cm 8683 C Same, curved to right 8684 A Micro Scissors, straight, with cleaning connector, working length 20 cm 8684 C Same, curved to right 8684 D Same, curved to left

48 48 Phonosurgery Principles and Techniques Instruments for Phonomicrosurgery Under Local Anesthesia Indirect Laryngeal Forceps, for biopsy, curved upwards, spoon diameter 4 mm, with cleaning connector, working length 17 cm PELTESON Cotton Applicator, working length 27 cm 8659 FR 8659 FR FEHLAND-NAWKA Needle Holder, with crosswise recess for holding the butterfly needle, for indirect injection into the larynx, with ratched, angled 90 to the right, with cleaning connector, working length 23 cm 8659 FL Same, with ratchet, angled 90 to the left

49 Phonosurgery Principles and Techniques 49 HD Imaging with Operating Microscopes Direct Adaption Direct adaption to the VARIO operating microscope from Carl Zeiss Meditec With the operating microscope the surgeon always has a perfect view of the operating field. Assistants, OR nurses and students, however, often experience poor video presentations, especially if FULL HD visualization is not available. KARL STORZ offers a one-stop-shop solution to upgrade any surgical microscope with state-of-the-art FULL HD imaging technology. To achieve optimal results, all components in the video chain from the camera system to the monitor must be of the highest quality. The most straightforward and professional connection between camera and microscope is the so-called direct adaption. Here the H3-M COVIEW microscope camera and the corresponding QUINTUS TV adaptor are directly connected to the microscope via the C-MOUNT connection.

50 50 Phonosurgery Principles and Techniques IMAGE1 S Camera Heads n For use with IMAGE1 S Camera System IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300 and with all IMAGE 1 HUB HD Camera Control Units TH 106 TH 106 IMAGE1 S H3-M COVIEW Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, with C-MOUNT thread for coupling to microscopes, 2 freely programmable camera head buttons, with detachable camera head cable, length 900 cm, for use with IMAGE1 S and IMAGE 1 HUB HD/HD Keypad, for H3-M camera head, for convenient control of the most important H3-M camera functions, with PS/2 connector, cable length 1 m, alternative to a standard keyboard, for use with H3-M or H3-M COVIEW camera heads, only compatible with IMAGE 1 HUB HD, not compatible with IMAGE1 S Specifications: IMAGE1 FULL HD Camera Heads Product code Image sensor Dimensions w x h x d Weight Optical interface Min. sensitivity Grip mechanism Cable Cable length IMAGE1 S H3-M COVIEW TH 106 3x 1 /3" CCD chip 45 x 50 x 60 mm 240 g C-MOUNT connection F 1.9/1.4 Lux C-MOUNT connection detachable 900 cm

51 Phonosurgery Principles and Techniques 51 HD Imaging with Operating Microscope System Components QUINTUS High-Performance TV Adaptor for Operating Microscopes Unleash the full performance of your operating microscope from CARL ZEISS MEDITEC with FULL HD imaging solutions from KARL STORZ. The new QUINTUS TV adaptor is the perfect interface between the operating microscope and the H3-M COVIEW FULL HD microscope camera head from KARL STORZ. The innovative features of QUINTUS are easy to use, making it one of the most flexible TV adaptors on the market. Product Features: l A rotating C-MOUNT connection at the QUINTUS TV adaptor allows immediate adaption of the camera orientation during mounting. l The focus control makes it possible to easily achieve parfocality (perfectly sharp camera and microscope images). l The iris control provides convenient and optimal adjustment of the depth of field. l Pan (X) function enables adjustment of the horizontal position of the camera image. l Tilt (Y) function enables adjustment of the vertical position of the camera image. The pan and tilt functions helps the surgeon to adjust the position of the camera image according to his individual needs. l The QUINTUS ZOOM model also features a variable focal length f = mm. This allows the surgeon greater flexibility in choosing the exact zone required for documentation. Focal length of the QUINTUS TV adaptor: The QUINTUS TV adaptor is available in the fixed focal lengths f = 45 and f = 55 mm or as a zoom model with variable focal length mm. This provides an optimal FULL HD image in 16:9 in conjunction with the H3-M COVIEW HD microscope camera head from KARL STORZ. 45 mm 55 mm mm Focal lengths: H3-M COVIEW camera image detail sing a QUINTUS TV adaptor with the fixed focal lengths of 45 and 55 mm. Variable focal length: Adjustable H3-M COVIEW camera image detail using a QUINTUS zoom adaptor with variable focal length of mm.

52 52 Phonosurgery Principles and Techniques HD Imaging with Operating Microscope System Components QUINTUS TV Adaptor for operating microscopes from CARL ZEISS MEDITEC with fixed focal length QUINTUS Z 45 TV Adaptor, for CARL ZEISS MEDITEC operating microscopes, f = 45 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW camera heads / QUINTUS Z 55 TV Adaptor, for CARL ZEISS MEDITEC operating microscopes, f = 55 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z as well as IMAGE 1 S1 and S3 camera heads QUINTUS Zoom TV Adaptor for operating microscopes from CARL ZEISS MEDITEC with variable focal length Z QUINTUS Zoom TV Adaptor, for CARL ZEISS MEDITEC operating microscopes, with variable focal length f = mm, for use with all KARL STORZ cameras (SD and HD) Z Further accessories for operating microscopes from CARL ZEISS MEDITEC Iris, for ZEISS Pentero, iris as a necessary extension between the QUINTUS TV adaptor and the operating microscope ZEISS Pentero Optical Beamsplitter 50/50, for use with ZEISS operating microscope or colposcope Note: Optical beamsplitters for other operating microscopes (i.e. LEICA or Möller-Wedel) are available directly from the manufacturers.

53 Phonosurgery Principles and Techniques 53 HD Imaging with Operating Microscope System Components QUINTUS TV Adaptor for operating microscopes from LEICA Microsystems with fixed focal length QUINTUS L 45 TV Adaptor, for LEICA Microsystems operating microscopes, f = 45 mm, recommended for H3-M microscope camera head / QUINTUS L 55 TV Adaptor, for LEICA Microsystems operating microscopes, f = 55 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z as well as S1 and S3 camera heads QUINTUS TV Adaptor for operating microscopes from LEICA Microsystems with variable focal length Z QUINTUS Zoom TV Adaptor, for Leica Microsystems operating microscopes, with variable focal length f = mm, for use with all KARL STORZ cameras (SD and HD) Z QUINTUS TV Adaptor for operating microscopes from Möller-Wedel with fixed focal length QUINTUS M 45 TV Adaptor, for Möller-Wedel operating microscopes, f = 45 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW camera heads / QUINTUS M 55 TV Adaptor, for Möller-Wedel operating microscopes, f = 55 mm, recommended for IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z and S1, S3 camera heads Note: Optical beamsplitters for other operating microscopes (i.e. LEICA or Möller-Wedel) are available directly from the manufacturers.

54 54 Phonosurgery Principles and Techniques VITOM Visualization System for Open Surgery with Minimal Access

55 Phonosurgery Principles and Techniques 55 VITOM Visualization System for Open Surgery with Minimal Access The KARL STORZ VITOM system represents a re vo - lu tio nary and innovative way of displaying open surgery with minimal access in a high quality and ergonomic manner. VITOM is based on the renowned HOPKINS rod lens system from KARL STORZ. With the help of a holding system, VITOM is placed at a working distance of cm above the surgical field. This gives the surgeon more room to work. The small size of the VITOM reduces space re quirements in the OR to a minimum. Due to its slim and compact design, the surgical field is not obstructed and even long instruments can be used with ease. The VITOM system provides great depth of field, optimal magni fication, good contrast and excellent color re production, which are the ideal prerequisites for the best possible recording and playback in FULL HD quality. The first-class enhanced imaging can be observed via a FULL HD monitor from a convenient distance by the surgeon, the assistant as well as the entire OR team. The VITOM system has proven to be an excellent alternative to OR illumination cameras, loupes or op erating microscopes in various surgical disciplines. The VITOM is equipped with an integrated fiber optic light transmission that enables the connection of cold light sources used in endoscopy. The system allows the further use of existing units. A FULL HD endoscope imaging solution from KARL STORZ can also be used with the VITOM system. The VITOM system offers: ## Excellent FULL HD image quality ## Great depth of view ## Large working distance ## Ergonomic monitor work ## Compact design requiring minimal space in the OR ## Use of existing KARL STORZ FULL HD endoscopy system possible Use of the VITOM system in ENT surgery. OR photographs courtesy of: Prof. Dr. Gero Strauss, Director of the International Reference and Development Center (IRDC), Leipzig, Germany.

56 56 Phonosurgery Principles and Techniques VITOM System Overview Exoscope Camera System, Monitor and Illumination Mechanical Holding System VITOM System Overview Documentation System Equipment Cart

57 Phonosurgery Principles and Techniques 57 VITOM System Components Exoscope and Illumination 2 nd Generation VITOM Telescopes Length 11 cm 8100 AA 8100 AA VITOM Telescope 0 with Integrated Illuminator, VITOM HOPKINS Straight Forward Telescope 0, working distance cm, length 11 cm, autoclavable, with fiber optic light transmission incorporated and condensor lenses, color code: green Fiber Optic Light Cables 495 TIP or 495 NVC recommended 495 TIP 495 NVC 495 TIP Fiber Optic Light Cable, highly heat resistant, diameter 4.8 mm, length 300 cm 495 NVC Fiber Optic Light Cable, with 90 deflection to the instrument, very narrow radius of curvature, diameter 4.8 mm, length 300 cm

58 58 Phonosurgery Principles and Techniques VITOM System Components Exoscope and Illumination 2 nd Generation VITOM Telescopes Length 11 cm 8100 DA 8100 DA VITOM Telescope 90 with Integrated Illuminator, VITOM HOPKINS telescope 90, working distance cm, length 11 cm, autoclavable, with fiber optic light transmission incorporated and condensor lenses, color code: blue Fiber Optic Light Cable 495 TIP recommended 495 TIP 495 TIP Fiber Optic Light Cable, highly heat resistant, diameter 4.8 mm, length 300 cm

59 Phonosurgery Principles and Techniques 59 VITOM System Components VITOM 25 Distance Rod, length 25 cm A A2 Wire Tray for Cleaning, Sterilization and Storage of two rigid endoscopes and one light guide cable, including holder for light post adaptors, silicone telescope holders and lid, external dimensions (w x d x h): 352 x 125 x 54 mm, for rigid endoscopes up to diameter 10 mm and working length 20 cm

60 60 Phonosurgery Principles and Techniques VITOM Specifications Working distance: cm Depth of view at working distance of: 25 cm 50 cm 75 cm Depth of view: approx. 3.5 cm approx. 7 cm approx. 10 cm Field of view at working distance of: 25 cm 50 cm 75 cm H3-Z camera zoom 1x 5 cm 10 cm 15 cm H3-Z camera zoom 2x 3.5 cm 7 cm 10.5 cm Reproduction scale at working distance of: 25 cm 50 cm 75 cm 26" Monitor: H3-Z camera zoom 1x approx. 8x approx. 4x approx. 3x H3-Z camera zoom 2x approx. 16x approx. 8x approx. 6x 42" Monitor: H3-Z camera zoom 1x approx. 14x approx. 7x approx. 5x H3-Z camera zoom 2x approx. 28x approx. 14x approx. 10.5x 52" Monitor: H3-Z camera zoom 1x approx. 17x approx. 8x approx. 6x H3-Z camera zoom 2x approx. 34x approx. 16x approx. 12x Technical specifications are subject to change.

61 Phonosurgery Principles and Techniques 61 VITOM System Components Cold Light Fountain XENON 300 SCB Special Features: ## Extremely high light intensity due to 300 Watt Xenon lamp ## Built-in antifog pump ## With integrated KARL STORZ Communication Bus (KARL STORZ-SCB) Cold Light Fountain XENON 300 SCB power supply / VAC, 50/60 Hz including: Mains Cord Silicone Tubing Set, length 250 cm SCB Connecting Cable, length 100 cm Specifications: Lamp type Color temperature Light outlets Light intensity adjustment XENON 15 V, 300 Watt 6000 K 1 continuously adjustable via a membrane keyboard or KARL STORZ Communication Bus Signal Dimensions w x h x d Weight Certified to: 305 x 165 x 335 mm 7.96 kg IEC and UL 544, protection class 1/CF

62 62 Phonosurgery Principles and Techniques IMAGE1 S Camera System n Economical and future-proof ## Modular concept for flexible, rigid and 3D endoscopy as well as new technologies ## Forward and backward compatibility with video endoscopes and FULL HD camera heads ## Sustainable investment ## Compatible with all light sources Innovative Design ## Dashboard: Complete overview with intuitive menu guidance ## Live menu: User-friendly and customizable ## Intelligent icons: Graphic representation changes when settings of connected devices or the entire system are adjusted ## Automatic light source control ## Side-by-side view: Parallel display of standard image and the Visualization mode ## Multiple source control: IMAGE1 S allows the simultaneous display, processing and documentation of image information from two connected image sources, e.g., for hybrid operations Dashboard Live menu Intelligent icons Side-by-side view: Parallel display of standard image and Visualization mode

63 Phonosurgery Principles and Techniques 63 IMAGE1 S Camera System n Brillant Imaging ## Clear and razor-sharp endoscopic images in FULL HD ## Natural color rendition ## Reflection is minimized ## Multiple IMAGE1 S technologies for homogeneous illumination, contrast enhancement and color shifting FULL HD image CLARA FULL HD image CHROMA FULL HD image SPECTRA A * FULL HD image SPECTRA B ** * SPECTRA A : Not for sale in the U.S. ** SPECTRA B : Not for sale in the U.S.

64 64 Phonosurgery Principles and Techniques IMAGE1 S Camera System n TC 200EN TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to 3 link modules, resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB and digital Image Processing Module, power supply VAC/ VAC, 50/60 Hz including: Mains Cord, length 300 cm DVI-D Connecting Cable, length 300 cm SCB Connecting Cable, length 100 cm USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US * Available in the following languages: DE, ES, FR, IT, PT, RU Specifications: HD video outputs Format signal outputs LINK video inputs USB interface SCB interface - 2x DVI-D - 1x 3G-SDI 1920 x 1080p, 50/60 Hz 3x 4x USB, (2x front, 2x rear) 2x 6-pin mini-din Power supply Power frequency Protection class Dimensions w x h x d Weight VAC/ VAC 50/60 Hz I, CF-Defib 305 x 54 x 320 mm 2.1 kg For use with IMAGE1 S IMAGE1 S CONNECT Module TC 200EN TC 300 TC 300 IMAGE1 S H3-LINK, link module, for use with IMAGE1 FULL HD three-chip camera heads, power supply VAC/ VAC, 50/60 Hz, for use with IMAGE1 S CONNECT TC 200EN including: Mains Cord, length 300 cm Link Cable, length 20 cm Specifications: Camera System Supported camera heads/video endoscopes LINK video outputs Power supply Power frequency Protection class Dimensions w x h x d Weight TC 300 (H3-Link) TH 100, TH 101, TH 102, TH 103, TH 104, TH 106 (fully compatible with IMAGE1 S) , , , , , , (compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*) 1x VAC/ VAC 50/60 Hz I, CF-Defib 305 x 54 x 320 mm 1.86 kg * SPECTRA A : Not for sale in the U.S. ** SPECTRA B : Not for sale in the U.S.

65 Phonosurgery Principles and Techniques 65 IMAGE1 S Camera Heads n For use with IMAGE1 S Camera System IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300 and with all IMAGE 1 HUB HD Camera Control Units TH 100 TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB HD/HD Specifications: IMAGE1 FULL HD Camera Heads Product no. Image sensor Dimensions w x h x d Weight Optical interface Min. sensitivity Grip mechanism Cable Cable length IMAGE1 S H3-Z TH 100 3x 1 /3" CCD chip 39 x 49 x 114 mm 270 g integrated Parfocal Zoom Lens, f = mm (2x) F 1.4/1.17 Lux standard eyepiece adaptor non-detachable 300 cm TH 104 TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, autoclavable, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB HD/HD Specifications: IMAGE1 FULL HD Camera Heads Product no. Image sensor Dimensions w x h x d Weight Optical interface Min. sensitivity Grip mechanism Cable Cable length IMAGE1 S H3-ZA TH 104 3x 1 /3" CCD chip 39 x 49 x 100 mm 299 g integrated Parfocal Zoom Lens, f = mm (2x) F 1.4/1.17 Lux standard eyepiece adaptor non-detachable 300 cm

66 66 Phonosurgery Principles and Techniques Monitors 9619 NB 19" HD Monitor, color systems PAL/NTSC, max. screen resolution 1280 x 1024, image format 4:3, power supply VAC, 50/60 Hz, wall-mounted with VESA 100 adaption, including: External 24 VDC Power Supply Mains Cord 9619 NB 9826 NB 26" FULL HD Monitor, wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1080, image fomat 16:9, power supply VAC, 50/60 Hz including: External 24 VDC Power Supply Mains Cord 9826 NB

67 Phonosurgery Principles and Techniques 67 Monitors KARL STORZ HD and FULL HD Monitors Wall-mounted with VESA 100 adaption Inputs: DVI-D Fibre Optic 3G-SDI RGBS (VGA) S-Video Composite/FBAS Outputs: DVI-D S-Video Composite/FBAS RGBS (VGA) 3G-SDI Signal Format Display: 4:3 5:4 16:9 Picture-in-Picture PAL/NTSC compatible 19" 9619 NB l l l l l l l l l l l l l 26" 9826 NB l l l l l l l l l l l l l Optional accessories: 9826 SF Pedestal, for monitor 9826 NB 9626 SF Pedestal, for monitor 9619 NB Specifications: KARL STORZ HD and FULL HD Monitors Desktop with pedestal Product no. Brightness Max. viewing angle Pixel distance Reaction time Contrast ratio Mount Weight Rated power Operating conditions Storage Rel. humidity Dimensions w x h x d Power supply Certified to 19" optional 9619 NB 200 cd/m 2 (typ) 178 vertical 0.29 mm 5 ms 700:1 100 mm VESA 7.6 kg 28 W 0 40 C C max. 85% x 416 x 75.5 mm VAC EN , protection class IPX0 26" optional 9826 NB 500 cd/m 2 (typ) 178 vertical 0.3 mm 8 ms 1400:1 100 mm VESA 7.7 kg 72 W 5 35 C C max. 85% 643 x 396 x 87 mm VAC EN , UL , MDD93/42/EEC, protection class IPX2

68 68 Phonosurgery Principles and Techniques VITOM n System Components Mechanical Holding System UGN UGK HC HR HM HC Articulated Stand, L-shaped, long, reinforced version, only, especially large swivel range, with one mechanical central clamp for all five joint functions, height 48 cm, swivel range 66 cm, with quick release coupling KSLOCK (female) HR Rotation Socket, to clamp to the operating table, with one mounted Butterfly Nut HRS, for European and US standard rails, with lateral clamp for height and angle adjustment of the articulated stand HM Extension Rod, 50 cm, with lateral clamp for height adjustment of the articulated stand, for use with articulated stands HA, HB or HC and socket HK or HR UGN Clamping Jaw, metal, clamping range 16.5 up to 23 mm, with quick release coupling KSLOCK (male), for use with all square-headed KARL STORZ HOPKINS telescopes UGK Clamping Jaw, with ball joint, large, clamping range 16.5 to 23 mm, with quick release coupling KSLOCK (male), for use with all square-headed KARL STORZ HOPKINS telescopes CN Clamping Cylinder, folding, for flexible mounting of 10 mm telescopes on the telescope sheath, autoclavable. The clamping cylinder allows vertical movement and rotation of the telescope.

69 Phonosurgery Principles and Techniques 69 VITOM n System Components Data Management and Documentation KARL STORZ AIDA Exceptional documentation The name AIDA stands for the comprehensive implementation of all documentation requirements arising in surgical procedures: A tailored solution that flexibly adapts to the needs of every specialty and thereby allows for the greatest degree of customization. This customization is achieved in accordance with existing clinical standards to guarantee a reliable and safe solution. Proven functionalities merge with the latest trends and developments in medicine to create a fully new documentation experience AIDA. AIDA seamlessly integrates into existing infrastructures and exchanges data with other systems using common standard interfaces. WD 200-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, power supply VAC, 50/60 Hz including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm WD 250-XX* AIDA Documentation System, for recording still images and videos, dual channel up to FULL HD, 2D/3D, including SMARTSCREEN (touch screen), power supply VAC, 50/60 Hz including: USB Silicone Keyboard, with touchpad ACC Connecting Cable DVI Connecting Cable, length 200 cm HDMI-DVI Cable, length 200 cm Mains Cord, length 300 cm *XX Please indicate the relevant country code (DE, EN, ES, FR, IT, PT, RU) when placing your order.

70 70 Phonosurgery Principles and Techniques VITOM n System Components Workflow-oriented use Patient Entering patient data has never been this easy. AIDA seamlessly integrates into the existing infrastructure such as HIS and PACS. Data can be entered manually or via a DICOM worklist. ll important patient information is just a click away. Checklist Central administration and documentation of time-out. The checklist simplifies the documentation of all critical steps in accordance with clinical standards. All checklists can be adapted to individual needs for sustainably increasing patient safety. Record High-quality documentation, with still images and videos being recorded in FULL HD and 3D. The Dual Capture function allows for the parallel (synchronous or independent) recording of two sources. All recorded media can be marked for further processing with just one click. Edit With the Edit module, simple adjustments to recorded still images and videos can be very rapidly completed. Recordings can be quickly optimized and then directly placed in the report. In addition, freeze frames can be cut out of videos and edited and saved. Existing markings from the Record module can be used for quick selection. Complete Completing a procedure has never been easier. AIDA offers a large selection of storage locations. The data exported to each storage location can be defined. The Intelligent Export Manager (IEM) then carries out the export in the background. To prevent data loss, the system keeps the data until they have been successfully exported. Reference All important patient information is always available and easy to access. Completed procedures including all information, still images, videos, and the checklist report can be easily retrieved from the Reference module.

71 Phonosurgery Principles and Techniques 71 VITOM n System Components Documentation System " KARL STORZ Touch Screen, 24V, wall mounting, RS 232, VGA, resolution max x 1024 (SXGA mode), including RS 232 cable, SVGA cable, mains cord and external power supply 24 VDC, power supply VAC, 50/60 Hz * * Sterile Cover, for 19 KARL STORZ touch screen MSK Monitor Holding Arm, height and side adjustable, tilting, can be mounted either on the left or on the right side, swivel range 190, reach 300 mm, loading capacity max. 15 kg, with monitor holder VESA 75/100, for Equipment Carts xx Equipment Cart UG 220 UG 220 Equipment Cart wide, high, rides on 4 antistatic dual wheels equipped with locking brakes 3 shelves, mains switch on top cover, central beam with integrated electrical subdistributors with 12 sockets, holder for power supplies, potential earth connectors and cable winding on the outside, Dimensions: Equipment cart: 830 x 1474 x 730 mm (w x h x d), shelf: 630 x 510 mm (w x d), caster diameter: 150 mm inluding: Base module equipment cart, wide Cover equipment, equipment cart wide Beam package equipment, equipment cart high 3x Shelf, wide Drawer unit with lock, wide 2x Equipment rail, long Camera holder

72 72 Phonosurgery Principles and Techniques Recommended Accessories for Equipment Cart UG 540 Monitor Swifel Arm, height and side adjustable, can be turned to the left or the right side, swivel range 180, overhang 780 mm, overhang from centre 1170 mm, load capacity max. 15 kg, with monitor fixation VESA 5/100, for usage with equipment carts UG xxx UG 540 UG 310 Isolation Transformer, 200 V 240 V; 2000 VA with 3 special mains socket, expulsion fuses, 3 grounding plugs, dimensions: 330 x 90 x 495 mm (w x h x d), for usage with equipment carts UG xxx UG 310 UG 410 Earth Leakage Monitor, 200 V 240 V, for mounting at equipment cart, control panel dimensions: 44 x 80 x 29 mm (w x h x d), for usage with isolation transformer UG 310 UG 410 UG 510 Monitor Holding Arm, height adjustable, inclinable, mountable on left or right, turning radius approx. 320, overhang 530 mm, load capacity max. 15 kg, monitor fixation VESA 75/100, for usage with equipment carts UG xxx UG 510

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