Difficulties with: vision, hemosthasia, suture and flaps transposition

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1 Universidade Federal de São Paulo UNIFESP-EPM EPM New surgical technique for the larynx Transventricular Chondroplastic Laryngotomy - TCL Marcos Sarvat, Nédio Steffen, Henrique Olival-Costa, and Paulo Pontes Rio de Janeiro, Brazil Instituto de Laringologia e Voz do Rio de Janeiro - InLaRio Instituto de Ciências Avançadas em Otorrinolaringologia - ICAO - São Paulo San Francisco, USA Transventricular Chondroplastic Laryngotomy - TCL trans-oral / endoscopic approach Surgical approaches to the larynx trans-oral Tucker (1993) external Direct microlaryngoscopy Kleinsasser (1962) Difficulties with: vision, hemosthasia, suture and flaps transposition 1

2 external approach Transventricular Chondroplastic Laryngotomy - TCL The Problem Loré (2005) Difficulties: Trauma of anterior commissure Tracheotomy Thyrotomy or Laryngofissure Buck (1851) Semon (1897 e 1907) Gluck & Sorenson (1930) Tucker (1993) What can we do in cases with very difficult (or no) exposure? Can indirect surgery and/or special or flexible endoscopic procedures solve all these cases? In these cases, what can we do for lesions affecting the anterior third of one vocal fold like initial tumors, major polyps or Reinke s edema, for exemple? Just an external approach! But what kind of external approach? Transventricular Chondroplastic Laryngotomy - TCL The Idea Idea and Intentions This procedure was born from the conviction that a different way of approaching the larynx externally should exist, while not traumatizing the anterior commissure and allowing for easier and more direct access to the endolarynx And it should be possible with the naked eye and/or lenses, microscopes and endoscopes It should be possible to create an access to the endolarynx through the thyroid cartilage, using a large window, directly to the bottom of the laryngeal ventricle. Complete reconstruction of the organ should be achieved, with no functional sequelae. Through this opening it should be possible to touch and operate directly on both vocal and ventricular folds and ventricles, from the anterior commissure to the arytenoid. We call this procedure Transventricular Chondroplastic Laryngotomy (TCL). 2

3 The procedure: TCL Schematic view pig larynx Searching for TCL An Anatomical Review Right lamina of thyroid cartilage 5 6 Gray (1918) 3

4 Searching for TCL An anatomical review Searching for TCL Rouvière (1927) Jackson and Jackson (1959) Relation between ventricle (VM), cartilage (CT), external (1) and internal (2) pericondrium and thyrohyoid muscle (MTH) Andrea (1975) Avascular area between ventricle (VM) and internal pericondrium (1) Searching for TCL Searching for TCL Netter (1989) Silver (1981) 4

5 Searching for TCL Searching for TCL SP Tucker (1993) Andrea and Dias (1995) TCL why not? Thyroplasties Isshiki (1974) TCL why not? Isshiki (1974) Lejeune (1983) Tucker (1993) Tucker (1984) 6 x 12 mm window Thyrotomy or laryngofissure Buck (1851) Semon (1897 e 1907) Gluck and Sorenson (1930) Dedo (1990) 5

6 TCL why not? Testing TCL Image of excised larynx TA Laryngotomy for teflon removal Netterville (1998) Coleman (1999) Gray SD, Bielamowicz SA, Titze IR, Dive H, Ludlow C. Experimental Approaches to Vocal Fold Alteration: Introduction to the Minithyrotomy Ann Otol Rhinol Laryngol. 1999;108(1):1-9 Thome R, Thome DC, De La Cortina RA Lateral Thyrotomy Approach on the Paraglottic Space for Laryngocele Resection Laryngoscope. 2000;110 (3 Pt 1): cm square window V PS Testing TCL Image of TCL on cadaver Testing TCL Image of TCL on cadaver Simultaneous flexible or rigid laryngoscopy Horizontal incision Median dissection Laryngotomy 6

7 Testing TCL Image of TCL on cadaver Testing TCL Image of TCL on cadaver Ventriculotomy Based on Dingman and Love Testing TCL Image of TCL on cadaver 7

8 TCL - Questions Do we still have patients with unsatisfactory results? Yes Do we tend to be too conservative in choosing the approach? As a new external approach to the larynx, TCL could be used in patients with very difficult (or impossible) exposure or if it's necessary to perform a more elaborate reconstruction. Yes TCL Specific Questions What happens to the cartilage after making this window? What happens to the ventricle after being opened and sutured? Is there any dysfunction of the larynx after TCL? Is this situation frequent? Can indirect surgery and/or flexible endoscopic procedures solve all these cases? In these cases, what can we do for lesions affecting the anterior third of vocal fold tumors, major polyps or Reinke s edema? Animal Experiment 3 pigs = opening the window without accessing the larynx 7 pigs = opening the endolarynx through the ventricle, between the superior 1/3 and the inferior 2/3 of TA TCL Steps Instituto de Ciências Avançadas em Otorrinolaringologia (ICAO) Exposing TA Incision between the superior 1/3 and the inferior 2/3 of TA 8

9 The access / The ventriculotomy (right side) window 1/3 VestF V TA muscle Middle line 2/3 VF Inferior edge of the window 2/3 1/3 Vest Fold Ventricle Vocal Fold Spalteholz (1969) Results Answering the questions Discussion What happens to the cartilage after making this window? What happens to the ventricle after being opened and sutured? Is there any dysfunction of the larynx after TCL? OK OK OK We need alternative methods because the current techniques have limitations, for some special patients; Anatomically, accessing the larynx through the cartilage and ventricle was shown to be simple and direct; No structures like nerves or pyriform sinus are on surgical field or in direct risk of damage; So, anatomically speaking, there are no contra-indications for this procedure; 9

10 Discussion Speculations and Expectations about possible future applications TCL can be considered intermediate between microlaryngoscopy and thyrotomy, and, employing microscopes and opticals, these techniques can be replaced in special diseases and patients. Three objectives can be achieved by TCL: precise surgery easy and safe hemosthasia easier reconstruction TCL, as a direct, unilateral or bilateral access to the endolarynx, allowing image magnification and surgery with up to 4 hands, could be used for: treatment of major benign lesions (sulci, bridges, glottal insufficiency); removal of scars and sinechiae (safer suturing); resection of benign and malignant tumors; flap rotation from close regions and more complex reconstructions of vocal folds (from mucosa to TA muscle) grafts and implantation of tissues and materials; treatment of uni or bilateral paralysis; treatment of spasmodic dysphonia (TA partial removal or TA nerve section) Conclusion This new technique called Transventricular Chondroplastic Laryngotomy has been demonstrated to be viable, providing wide exposure of the endolarynx and adequate reconstruction of this organ. Instituto de Laringologia e Voz do Rio de Janeiro - InLaRio Instituto de Ciências Avançadas em Otorrinolaringologia - ICAO Transventricular Chondroplastic Laryngotomy - TCL Vest F V VF sarvat@centroin.com.br Prof. Paulo Pontes Prof. nedio@nediosteffen.com.br Nedio Steffen ppontes@inlar.com.br Marcos Sarvat Nedio Steffen Henrique Olival Costa Paulo Pontes Thank You! 10

11 ENT World Congress IFOS 2009: Brazil June 1 5, 2009 São Paulo / Brazil 11