Anatomy and Physiology of the Larynx 1 J. Pieter Noordzij and Robert H. Ossoff

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1 PHONOSURGERY Preface Gregory A. Grillone xi Anatomy and Physiology of the Larynx 1 J. Pieter Noordzij and Robert H. Ossoff This article discusses histologic and gross laryngeal anatomy and the basic physiology relevant to the clinician who is assessing patients with vocal complaints. Discussion covers the various histologic layers of the vocal folds, including the lamina propria and basement membranes zone, the intrinsic laryngeal musculature and motor and sensory innervation of the larynx, and the basic physiologic parameters of vibratory vocal-fold behavior. Diagnostic and Therapeutic Pitfalls in Phonosurgery 11 Seth Dailey This article provides a practical guide with which surgeons and nonsurgeons can highlight key areas of concern for optimal outcomes in phonomicrosurgery. Factors such as thorough diagnostics, patient history and physical examination, office endoscopy with stroboscopy, and operative examination are essential to avoiding pitfalls and enhancing results. The timing and preparation for surgery and managing expectations allow for mature decisionmaking by the surgeon and patient. Considerations specific to surgical technique must include anesthesia, intubation, exposure of the glottis, lighting, magnification, hemostasis, instrumentation, flap design, and tissue handling. Practical and technologic solutions are offered throughout the text, pointing out future directions for this commonly performed operation. Surgical Management of Sulcus Vocalis and Vocal Fold Scarring 23 Seth H. Dailey and Charles N. Ford Although fibrous tissue is an essential supportive structure in the larynx and vocal fold, disordered fibroplasia can cause contraction VOLUME 39 Æ NUMBER 1 Æ FEBRUARY 2006 v

2 and disturb the viscoelastic properties that are essential for vocal fold function. Sulcus vocalis is a specific example of vocal fold scarring, and it presents the same essential challenge in restoration of function. Vocal fold scar and sulcus vocalis share glottic insufficiency, breathy voice quality, and resistance to tissue alteration as hallmarks. Multiple surgical strategies have been devised to help improve vocal fold closure and pliability. The approaches are open and endoscopic, conceptually direct or indirect, and may or may not involve direct tissue implantation to the vocal fold cover. Specific commentary is provided regarding these different surgical techniques. Future treatment pathways are explored. Injection Laryngoplasty 43 Miriam A. O Leary and Gregory A. Grillone Injection laryngoplasty has developed from decades of experience by otolaryngologists, yet continues to offer exciting opportunities and breakthroughs. Indications for this treatment have expanded widely, and now including a large variety of voice disorders. Likewise, new materials are emerging continually in the field to accommodate these increasing indications. As innovative techniques are developed, more and more patients will benefit from injection laryngoplasty in the future. This article discusses available and investigational materials, indications, and techniques for injection laryngoplasty. Practical Applications of Laryngeal Framework Surgery 55 Hans F. Mahieu Laryngeal framework surgery (LFS) procedures enable functionally monitored correction of vocal-fold position as well as vocal-fold tension, without jeopardizing the delicate structure of the vocal folds, producing good results with few and usually minor complications. Modern phonosurgery requires versatile surgeons to adequately comply with the demands of dysphonic patients. The different types of LFS are rewarding but occasionally demanding procedures, which should be part of the armamentarium of the phonosurgeon. Phonosurgery for Pitch Alteration: Feminization and Masculinization of the Voice 77 Jeffrey H. Spiegel Many procedures for pitch alteration have been developed. This chapter reviews current techniques and their possible value in adjusting vocal pitch. Laryngeal Dystonia 87 Gregory A. Grillone and Teresa Chan Laryngeal dystonia (spasmodic dysphonia) is a focal dystonia that affects laryngeal motor control. There are four major types: vi

3 adductor, abductor, mixed type, and adductor laryngeal breathing dystonia. Over the past 20 years, major advances have been made in the diagnosis, evaluation, and treatment of spasmodic dysphonia. The genetic and neurologic origins of spasmodic dysphonia and other dystonias are being sought actively, and will lead to further advances in treatment. Botulinum toxin remains the most safe and effective treatment of symptoms of adductor and abductor spasmodic dysphonia. Treatment of Adductor Spasmodic Dysphonia with Selective Laryngeal Adductor Denervation and Reinnervation Surgery 101 Dinesh K. Chhetri and Gerald S. Berke Spasmodic dysphonia (SD) is a voice disorder characterized by abnormal intermittent spasms of intralaryngeal muscles, resulting in voice breaks during speech. Patients who have SD typically have no other associated chronic medical problems or handicaps and are highly functioning individuals, but they perceive their voice significantly limits them functionally, physically, and emotionally. One main hurdle toward achieving a cure for SD is that the cause and pathophysiology of SD remain unclear; there are no animal models for this disorder. What is known from laryngoscopic and electromyographic examinations is that voice breaks in SD are associated with abnormal electrical activity of the laryngeal nerves, resulting in increased muscle movements. This article focuses on the surgical management of the adductor variant of spasmodic dysphonia by selective laryngeal adductor denervation and reinnervation. Office-Based Laryngeal Procedures 111 Peak Woo This article outlines the procedures that are amenable to being performed under local anesthesia in the general otolaryngologist s office. These procedures can be performed without a lot of expensive equipment and can be done with existing diagnostic equipment that is supplemented by a few simple instruments. This article gives details about the technique of office anesthesia, and the necessary office equipment and instruments. Contemporary Management of Laryngeal Papilloma in Adults and Children 135 Jennifer G. Andrus and Stanley M. Shapshay Occurring in children and adults, recurrent respiratory papillomatosis (RRP) is the most common neoplasm in humans. Although benign, malignant transformation of these human papillomavirus-associated lesions is well documented, but rare. More commonly, RRP can be life threatening because of airway obstruction from growth and proliferation of the papilloma lesions. Successful long-term eradication of RRP lesions is unreliable; however, there vii

4 has been some improvement in reducing the number and frequency of procedures that require general anesthesia through the use of adjuvant treatments and in-office procedures. Laser Applications in Laryngology: Past, Present, and Future 159 Steven M. Zeitels and James A. Burns Since their introduction in laryngology over 30 years ago, lasers have facilitated critically important innovations. These advances accommodated well to otolaryngology, which has led in minimally invasive surgical approaches since mirror-guided interventions in the nineteenth century. The lasers discussed in this article will provide new platform technologies that will likely lead to enhanced treatment of a number of benign and malignant laryngeal disorders. There is an expanding group of centers in which fiber-based technologies have already caused many procedures to be performed by means of local anesthesia in the clinic or office, especially for chronic diseases such as papillomatosis and dysplasia. This approach is likely to expand significantly because of the diminished patient morbidity along with socioeconomic pressures of health care delivery. Endoscopic Treatment for Early Glottic Cancer: Indications and Oncologic Outcome 173 Giorgio Peretti, Cesare Piazza, and Andrea Bolzoni The authors treatment approach for the comprehensive management of early glottic cancer can be divided into two basic therapeutic scenarios. Tis and T1a lesions of the midcord are treated preferably by an excisional biopsy, which, after appropriate preand intraoperative diagnostic work-up, allows precise diagnosis and definitive treatment of these lesions. This approach is associated with minimal morbidity, short hospitalization time, and a high cost-effectiveness ratio. Moreover, the postoperative voice has been shown to be comparable to that of controls because most of the vocalis muscle is preserved. On the other hand, T1b and T2 tumors deserve special attention because comparable oncologic outcomes may be seen with other therapeutic modalities. Therefore, appropriate preoperative counseling, including other voicesparing options (eg, radiation or chemoradiation therapy) should always be part of the informed consent discussion. Reconstruction of Glottic Defects after Endoscopic Cordectomy: Voice Outcome 191 Marc Remacle, Georges Lawson, Dominique Morsomme, and Jacques Jamart Although there is no linear correlation between the amount of tissue removed and vocal outcome, a significant glottic gap that viii

5 persists after endoscopic cordectomy may lead to poor voice quality. Development of thick and sometimes partially stenosing synechia at the anterior commissure also is a major factor that leads to poor voice result after extended cordectomy. Medialization thyroplasty for correction of glottic gap, transoral placement of a keel after laser-assisted section, and topical application of mitomycin- C for anterior glottic synechiae are effective procedures for managing glottic abnormalities after endoscopic cordectomy. This article focuses on our experience with the management of glottic gaps and anterior commissure synechiae, including patient selection, surgical technique, and outcome. Eosinophilic Esophagitis: Its Role in Aerodigestive Tract Disorders 205 Dana M. Thompson, Amindra S. Arora, Yvonne Romero, and Eileen H. Dauer Eosinophilic esophagitis (EE) is a unique clinicopathologic entity that has slowly gained attention over the past decade but has not been well recognized in the field of otolaryngology. The precise cause of the disease is not known but is likely associated with food and environmental allergic antigens. Otolaryngologists should be familiar with the presentation because many patients experience concomitant pharyngolaryngeal and airway symptoms. As the otolaryngologist s role in the evaluation and management of esophageal disease continues to expand, it will be imperative to consider EE as a potential diagnosis among young children with feeding disorders and adolescents and adults with dysphagia. Esophagoscopy, with biopsies of the proximal, mid, and distal esophagus are essential tests for diagnosing EE, and food allergy testing may be helpful in identifying possible causative agents that should be restricted or eliminated. Index 223 ix