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This paper records our experience in dealing with 432 patients where phonosurgery was done. The cadaver study of the larynx confirms the basic principles on which the techniques are based. Our experience with Type 1 thyroplasty is that it gives better results than Teflon paste injection. Use of the microscope during laryngeal surgery has given us greater precision in dealing with mucosal and submucosal pathology. The results of surgery are excellent but require to be followed up with vocal rest, hygiene and rehabilitation to prevent recurrence and get good long-term results of voice improvement.
The voice plays a very important role in human communication. It is but natural that any disturbance of voice, i.e. hoarseness, breathiness or hypernasality causes serious concern to the patient. Very often the voice changes may be due to a specific lesion, for example carcinoma of the larynx. In such cases the primary concern is to treat the cancer, but in other patients voice disturbance may be due to a benign lesion. The aesthetic surgery for voice improvement in these patients is called phonosurgery. Removal of vocal nodules, polyps, cysts, and other benign lesions, has been done for a long time . Our experience with newer techniques of voice improvement started in the mid-seventies at the All India Institute of Medical Sciences with the availability of microlaryngoscopy and special syringes for Teflon paste injection in unilateral paralyzed vocal cords.
Our experience with laryngeal framework surgery or thyroplasties are of more recent origin, i.e. last 5 years. As we have gathered more experience in this field our confidence in dealing with voice problems has gradually gown and these techniques are gaining acceptance in our country.
A large number of patients present with voice problems and are treated as outpatients or by day care surgery. The following data summarizes our experience at the Department of Otorhinolaryngology at the All India Institute of Medical Sciences and at Batra Hospital, New Delhi. The material consisted of vocal nodules, cysts, polyps, Reinke's oedema, dysphonia plica ventricularis, vocal cord paralysis, neolarynx and rhinolalia aperta. The numbers of various lesions cannot be interpreted as true prevalence as some of the data in respect of outpatients may not be complete.
When a patient presents with voice problems he is managed as follows:-
The voice problems may be caused by mucosal lesions, muscular lesions and defective anatomical structure (Table 1). It is seen that a majority of voice problems are due to pathology in mucosa and submucosa. In majority of these cases it is possible to restore voice to normal by microlaryngeal surgery. We prefer to do cutting by scissors and knife as opposed to the use of laser. The laser is more cumbersome to set up and may cause deeper injuries. Among the muscular problems the most common lesion requiring surgery is unilateral non-compensated vocal cord paralysis following thyroid surgery. In such cases Teflon paste injection under microscope and Type 1 thyroplasty with silastic implant offer good results. However, in our experience voice improvement with thyroplasty gave better and long lasting results. We need a larger number of cases to arrive at statistically valid results (Table 2).
We have had experience in eight patients (5F + 3M) of Type 1 thyroplasty with silastic implants. Six patients had left-sided thyroplasty and 2 patients had right-sided thyroplasty. No patient developed any obstruction to breathing. Most patients were satisfied with voice quality, with improvement in pitch, loudness, duration and reduction in breathiness. No patient had silastic extrusion or operative site infection. Fifty per cent patients showed evidence of submucosal haemorrhage after surgery on the operated side. No drain was used in any patient to reduce chances of infection and corticosteroids were given to reduce postoperative oedema.
The patients with neolarynx after surgery for cancer larynx have the major problem of cancer-free survival. As most of our patients come in the advanced stages our survival figures reflect on the long-term results of neolarynx surgery. The patients with hyper-rhinophony or rhinolalia aperta are usually due to congenital abnormality of palate and there is significant improvement of voice in such patients. They and their relatives may not always be satisfied with the results due to high expectations (Table 2).
Saito et al demonstrated experimentally that it is primarily the mucosal vibration that produces sound . The intracordal muscles can actively change the tension and configuration of the cord and take part in changing the shape of the vibrating cord but it is the mucosal fold which is passively oscillating to produce sound. Thus majority of cases with benign mucosal disorder have voice change as the primary complaint.
Majority of patients with voice problem due to organic abnormalities are candidates for phonosurgery if they do not respond to conservative treatment. In all such patients a detailed pre-operative session should be held to give a realistic picture of end results and to explain the nature of the voice problem and post-operative management. We have found this to be very important in order to have a satisfied patient.
The surgery for voice improvement has a long history. Table 3 shows the various techniques used, their originator or advocate and the year in which they were reported for the first time. Surgeons have often reported on more than one technique and sometimes changed their recommendation. This is because phonosurgery has been rapidly evolving in the last 3 decades.
The results of surgery for mucosal lesions has given good results in almost all cases. It is however imperative to impress on the patient that the primary cause of mucosal lesion, i.e. vocal abuse causing vocal nodule will recur unless the primary cause is removed. We have prefered cold surgery rather than laser surgery. Rehabilitation advice is important in the post-operative period. Before starting on the laryngeal framework surgery a cadaver study should be done to avoid making the common mistakes which can cause complications. We have studied the anatomy of the human larynx and dissected specimens as advised by Isshike .
Asai laryngoplasty , and its modifications were used in patients requiring total laryngectomy. A wide variety of palatopharyngoplasty procedures have been done for hyperrhinophony or hypernasality , but are not a subject of study of this paper. Teflon paste injection has been done with good results in 10 out of 12 cases. Over the course of time some of the patients again developed weakness of voice and 2 patients required re-injection of Teflon paste. One of the patients developed respiratory difficult which subsided with corticosteroids and antibiotic treatment. Since we have been injecting under general anaesthesia voice improvement was checked only after patient recovered from anaesthesia. In Type 1 thyroplasty done under local anaesthesia the silastic implantation can be adjusted for maximum improvement of voice quality.
In conclusion, the Isshiki laryngeal framework surgery  as a part of phonosurgery has been rapidly evolving in India. In our experience laryngeal framework surgery for paralytic lesions of vocal cords gives better results than Teflon paste injections and is the method of choice.