Dedo – Surgery of the LARYNX and TRACHEA

Preface

This surgical atlas is an attempt to describe all the points that I feel are necessary in the selection and preparation of patients for each of the operations covered. In addition, I have included the details of my surgical technique. Through the years, when I have analyzed unsatisfactory results or complications that developed after my surgery, or others’ operations, I have observed that the failure to attend to one tiny detail caused the problem. Therefore, whenever there was an unsatisfactory result or a complication, I tried to go back over what warning sign or change in surgical technique could be utilized to avoid repetition of the problem.

Thus, this book is an attempt to share all these details that I feel are important in obtaining good results for patients. To accomplish this, I have tried with text and drawings to describe all the twists and turns that can help make an operation easier and safer while attaining a good result. I have tried to systematize and impart all the information a seasoned surgeon usually only shares verbally in the operating room with residents and colleagues.

In order to do this, my medical illustrator, Christine Gralapp, came to the operating room with a photographer equipped with a 35-mm camera with a 200-mm lens. The photographer took approximately 125 to 150 color pictures of the surgical field from about 3 to 4 feet away so that it filled the whole picture. The photographer carefully lined up each shot from my point of view at each step in the operation. This made it possible for the photographs and, subsequently, the color drawings, to portray the surgical perspective beside or at the top of the operating table rather than the usual anatomic perspective with the larynx represented vertically on the page. This per- spective will encourage the surgeons who use this book to imprint the images of these surgical fields directly in their minds without having to transpose them 45 to 90 degrees, as is commonly the case.

Color, much less black-and-white, photographs of soft tissue operative fields do not publish well because of factors such as blood staining of tissues. Black-and-white line drawings do not provide the visual information that color drawings do. Therefore the publisher, Brian Decker, agreed to underwrite the enormous cost of creating as many drawings as I wished to illustrate each operation. First, it was decided which points in the text would benefit from an illustration. Then each illustration was executed by Chris in pencil and revised until it looked as “real” as possible. When I approved the pencil sketch, it was painted in full natural color, not stylized color, so that the arteries are ivory, not red, and the nerves are white, not yellow. I never ceased to be amazed at the extra information that became apparent in the color versions, often necessitating the correction of details that I had missed in spite of careful, repeated examinations of the black-and-white pencil sketches. As originally conceived, this atlas was to describe the soft tissue laryngeal and tracheal, and microdirect laryngoscopy, operations that I have personally done. Brian Decker wished to have a single author describe only those operations that gave consistent results. The reception of this soft tissue atlas will determine whether the second volume, on microlaryngeal laser surgery, is attempted.

We would like to acknowledge a number of people. Maxine Calnon typed and retyped the manuscript. Winifred Wong and Sandra Wong, in my office, handled all of the patient scheduling. Brita Saltvol, the operating room otolaryngology head nurse, provided the instrument lists and sources for instruments and supplies. After four years of effort and a liberal expenditure for the color drawings, Brian Decker provided an editorial assistant here, Elizabeth Zima. At B.C. Decker, the project was handled by Dana Dreibelbis and Gina Scala. We are grateful to Dr. Charles Cummings for carefully reading the manuscript and offering several good suggestions, most of which were adopted.

If some surgeons find any point in this atlas useful, appreciation is due Dr. Roger Boles, formes Chairman of Otolaryngology, and Miss Ruth Wakerlin, former Director of Medical Illustration, at the University of California at San Francisco; and Mr. Decker for encouraging me to write it. I would also like to thank my friends Mr. and Mrs. Edward McBride of Fort Myers, Florida, and MI. and Mrs. Paul Putman of Toledo, Ohio, for their generous donations to our San Francisco Foundation of Otology and Laryngology that have been so helpful in completing this and many other projects. I especially appreciate the care provided my patients by my residents and nurses, and the support of my family during this lengthy project. HERBERT H. DEDO, M.D.

Contents

CHAPTER ONE Indirect Laryngoscopy 1
CHAPTER TWO Teflon Injection of the Vocal Cord 13
CHAPTER THREE Recurrent Laryngeal Nerve Section for Spastic Dysphonia 29
CHAPTER FOUR Cricopharyngeal Myotomy 61
CHAPTER FIVE Tracheotomy 81
CHAPTER SIX Laryngofissure for Nonmalignant Disease 111
CHAPTER SEVEN Segmental Resection of the Trachea 141
CHAPTER EIGHT Vertical Hemilaryngectomy 200
CHAPTER NINE Supraglottic Laryngectomy249
CHAPTER TEN Total Laryngectomy 309
CHAPTER ELEVEN Tracheoesophageal Voice Rehabilitation after Total Laryngectomy 349
CHAPTER TWELVE Radical Neck Dissection 373
APPENDICES 42 5
INDEX 433

Example of a chapter is shown below

CHAPTER SEVEN

Segmental Resection of the Trachea With Laryngeal Release, Mediastinal Mobilization, and Primary Anastomosis for Tracheal Stenosis

Causes and Prevention of Laryngeal Technique and Tracheal Stenosis

Endotracheal Tube Injuries in the Larynx
Complete or Partial Tracheal Stenosis
Tracheotomy Tube Type
Tracheotomy Technique Skin Flap Elevation
Treatment of Tracheal Stenosis
Techniques That Do Not Work
No Tracheotomy Expected To Be Necessary Postoperativeb
Tracheotomy Postoperatively-Intracricoid Stenosis
Tracheotomy Already in Place
Draping
Tracheal Ident@cation
Freeing the Lower and Middle Cervical Trachea
Locating the Stenotic Segment
Freeing the Cricoid and Upper Tracheal Rings
Mobilization of the Mediastinal Trachea
Ident@cation of the Stenotic Segment
Resection Limits-Length and Upper Limits
Removal of the Stenotic Segment
Sternotomy and Resection of a Low Stenosis
High Stenosis Extending within the Cricoid
Establishment of the Airway
Placement of Sutures
Wound Closure
With Tracheotomy
With Endotracheal Tube via Larynx

Complications

Tracheal Stenosis
Diagnosis and Preoperative Eva
Skin Prep Area
Equipment and Supplies Laryngeal Release
Instruments
Sutures, Needles, and Blades
For Sternotomy

Closure

Segmental Resection of the Trachea

ENT Minor Set

On Clamp and Scissors Stringer

Clamps
Mosquito (4) Straight Kelly (2)
Providence (12) Curved Kelly (12)
Miscellaneous
Lahey scissor (1)
Mayo scissors (2; 1 straight,
1 curved)
Allis forceps (2)
Diamond needle holders (2)
Plastic needle holders (2)
Large towel clips (2)

In White Towel

Lahey scissors (1)
Curved Mayo scissors (1)
Straight Mayo scissors ( 1)
Forceps
Adson (2)
Tissue (2)

In Tray

Bovie clip ( 1)
Retractors
Senn (2)
Vein (2)
Suction Tubes
Andrews (1)
Frazier No. 10 (1)
1 percent lidocaine with
epinephrine 1:100,000 (2)
Labels for solutions
No. 3 Bard-Parker knife handles (2)
No. 7 Bard-Parker knife handle
Smooth tissue (2)

Examples of surgical drawings are shown below

Example of a text is shown below

Endotracheal Tube Injuries in the Larynx

As mentioned earlier, in addition to the possibility of injury to the false and true vocal cords on insertion of the endotracheal tube, the mucosa and the perichondrium of the arytenoid cartilages can be necrosed by an endotracheal tube that is too large or by letting the patient cough or “buck” on the tube. As the body tries to heal the ulcers on the arytenoids and seal off and heal the underlying chondritis, granulation tissue forms on the medial surfaces of the arytenoids. This produces two possible results. Granulomas can occur on the arytenoids that may heal spontaneously or that may require repeated laser removals every few months via direct laryngoscopy until the arytenoids epithelialize and heal; or the granulomas can fuse and through scar formation cause the arytenoids to grow together.’ If endotracheal tube pressure causes the necrosis to extend into the cricoarytenoid joints, they will become frozen, so that even if the posterior commissure stenosis is repaired, the vocal cords will not be able to adduct (open) to provide an adequate airway.’

Posterior glottic stenosis gives the appearance of bilateral recurrent nerve paralysis during indirect laryngo~copy.’.~.’~

The diagnosis of posterior glottic stenosis has been missed in some patients because direct laryngoscopy has not been routinely done in patients with apparent bilateral recurrent laryngeal nerve paralysis after endotracheal tube intubation.’ It is important to recognize posterior commissure stenosis when it is present because it can now be treated successfully, often endoscopically, with KTP532 laser* submucosal scar resection, creation of micro-trapdoor mucosal flaps andlor Teflon keels.’.’ If necessary, laryngofissure with mucosal flap advancement can be done (see Chapter 6, Laryngofissure) so that the tracheotomy tube can be removed.

Complete or Partial Tracheal Stenosis

Complete or partial subglottic and tracheal stenosis following prolonged intubation is usually 2 to 3 cm in length and is due to overinflation of the balloon cuff, which causes pressure necrosis of the mucosa. The mechanism of injury is interference with the blood supply of the mucosa and tracheal rings by exceeding the perfusion pressure of the vessels in the mucosa that are trapped between the balloon and tracheal rings.5,” It used to be thought that by using low-pressure, high-compliance cuffs this risk could be eliminated. Low-pressure, high-compliance cuffs have more of a safety margin *Laserscope. 3052 Orchard Dr., San Jose. CA 95134

Surgical Checklist

1. Risks and alternatives are explained to the patient and documented in the chart.
2. Operative permit is signed.
3. Blood is typed and cross-matched if it is anticipated that the patient will lose more than 1 unit of blood during the operation.
4. Laboratory data are checked to make sure they are within normal limits.
5. Physical examination is in chart.
6. Nasogastric tube is installed (if it will be needed after the operation).
7. Room temperature is set at
70-72°F (adult)
72-74°F (child)
74-76°F (infant)
8. Review of the surgical instruments with the circulating nurse.
9. Review of the special anesthesia requirements (e.g., tube size; wrapped in foil
tape for laser surgery), oral, nasal, or via tracheotomy, with the anesthesiologist.
10. Give IV antibiotics during all operations in which the pharyngeal mucosa is open, which will cause saliva contamination of the neck and trachea.
11. Position the patient properly on the operating room table, with the top of the patient’s head flush with the head end of the operating room table.
12. Adjust the surgical lights over the surgical field after the patient is asleep so that the light will not be in his or her eyes before anesthetization. Do this before scrubbing.
13. Check the Bovie electrocautery to see that it is plugged in and working.
14. Check the suction trap, bottle, and hose to see whether all are functioning properly.
15. Place IV poles at the corners of the head of the table if the anesthesiologist is to be situated at the patient’s head. In all operations with a tracheotomy (except free-standing tracheotomy), the anesthesiologist is at the left hip of the patient, and the IV poles should be placed 18 inches from the left shoulder and adjacent to the left ankle.
16. Confirm with the nurse or surgical assistant the skin area to be shaved and sterilized.

Index Example is shown below

equipment and supplies, 20
history, 14-15
incorrect sites of injection, 25, 25, 26
indications, 16-19
work-up, 17
indirect laryngoscopy in, 18
overinjeaion. 25-26,26
principles, 15, 16
seroma or granuloma reaction, treatment of,
technique, 21-27
26-27
anesthetization, 21
injection, 22-27,22-24
timing of procedures, 18-19
vs. collagen, 16, 26
Teflon underinjection, of vocal cord, after
recurrent laryngeal nerve section, for
spastic dysphonia, 55
Total laryngectomy, 309-347
draping, 3 16
equipment and supplies, 3 15
incision, of skin, 317-318.317
indications and contraindications, 3 10-3 14,
Lines of resection, 312
postoperative care, 346-347
preoperative care and work-up, 314
prepping and draping, 316,316
skin incision, 317-318, 317
skin prep area, 315
technique, cancer, side of involvement,
312
dissecfion of, 330,331
space between, 323,323
carotid sheath and larynx, creation of air
closure, of pharyngeal mucosa, 338, 338-339
cricnpharyngeal muscle, 340,340-341
of pharyngeal muscle, with loose
of skin, 344, 345
cricopharyngeal and constrictor muscles,
dissection of, and preservation of thyroid
lobe, 326, 326-327
dissection of involved side, freeing of thyroid
lobe, 330, 331
hyoid bone, greater cornu of, freeing of, 328, 329
release of, and flap elevation, 322, 322-323
larynx, separation of, from trachea, 332, 333
larynx and carotid sheath, creation of air
pharyngeal entry, 334, 335
pharyngeal mucosa, closure of, 338,338-339
pharyngeal muscle, closure of, with loose
cricopharyngeal muscle, 340, 340-341
space between, 323, 323
pharyngoepiglottic fold and pharyngeal wall,
separation of larynx and trachea, 332, 333
skin closure, 344,345
specimen, removal of, 336,337
sternohyoid and sternothyroid muscles,
strap muscles, division of, 324, 324-325, 326
superior laryngeal nerve, artery, and vein,
thyroid lobe, preservation of, and dissection
resection of, 336, 337
division of, 324, 324-325, 326
division of, 328, 329
of cricopharyngeal and constrictor
muscles, 326, 326-327
trachea, separation of, from larynx, 332, 333
tracheostoma, creation of, with “pie crust‘’
technique, 342,343, 344,345
tracheostomy, 318, 319, 320,321
total laryngectomy, 349-372
Tracheoesophageal voice rAhabilitation after
background, 350
Blom-Singer valve installation, complications,
granulation tissue blocking side port, 368,
leakage around valve, 368
leakage through valve. 367
macrostoma, 369-370, 369, 370
microstoma, 369
failure of fistula to close, 371, 371368
equipment and supplies, 354