• Microsurgery of the Vocal Cord
  
• Surgery for the Paralyzed Vocal Cord(s)
  
• Vocal Cord Injections and Implants
  
• Laryngeal Cancer and Voice Preservation Surgery
  

Microsurgery of the Vocal Cords 

Surgery of the vocal cords is done under a general anesthetic and is usually an outpatient procedure.  The patient lies on his back on the operating room table and after going to sleep, a rigid scope (tube) is inserted into the mouth to visualize the larynx.  Tooth guards are used to protect the teeth from the scope which can exert significant pressure on the teeth and tongue during the procedure.  Using the high magnification of a microscope, the vocal cords and larynx are examined in detail and the appropriate procedure is performed.

Lesions are removed taking care to only remove diseased tissue while preserving normal tissue.  For most benign lesions, it is important to stay superficial to the vocal cord tendon and muscle as violation of this principle usually causes excess scarring and an impaired result.  This is true for vocal cord nodules, polyps and cysts.  We believe that because the laser causes more inflammation and delayed healing than "cold" knife dissection, in these cases we use a very fine scalpel for excision.

For vocal cord papillomas, granulomas and cancerous lesions, the carbon dioxide laser has proven to be the instrument of choice.  These lesions tend to be more vascular and because the laser seals small blood vessels as it removes tissues, it is very effective in their removal.

No matter what method of excision is used, resting the voice after surgery to allow healing is important to get an optimal result.  As an analogy, consider what happens when a cut on your finger occurs.  For the best healing, protecting that finger from further trauma is important and obviously, repeatedly rubbing that wound will impair its healing.  The same holds true for cuts on the vocal cord.  For that reason, voice rest of 3-5 days after surgery is necessary.  Voice rest means no speaking, no whispering, (this is actually harder on your vocal cords than speaking), and even no throat clearing.  In addition, proper vocal hygiene as discussed in Caring for Your Voice is also crucial to an optimal result.

Surgery for the Paralyzed Vocal Cord(s)

Unilateral (One) Vocal Cord Paralysis

Left Paralyzed Vocal Cord

After the diagnosis of unilateral vocal cord paralysis is made and other possible disorders  have been excluded, we believe a period of waiting 6 months to 1 year is necessary before a permanent treatment is performed.  This allows time for the vocal cord nerve to recover on its own.  After this period of time, the likelihood of recovery ever happening is minimal and thus a permanent solution is warranted.  During this waiting period, injections of absorbable gelfoam into the vocal cord can temporarily lessen symptoms and improve voice.  The gelfoam typically lasts 6-8 weeks and will thus need repeating over the course of the 6 - 12 months time. Collagen and alloderm are other injectable alternatives.

There are 2 main ways of permanently pushing the vocal cord over (or medializing it).  The first is by means of an injection of Teflon paste or other substances in the vocal cord directly, and the second is by placing an implant through a "window" of the thyroid cartilage and thus medializing it from the outside.  This second option can be supplemented by placing a stitch around the arytenoid cartilage and by pulling it over, pulling the paralyzed vocal cord into a more natural position.  There are pros and cons of each method.  The following will describe them.

Teflon injection is a relatively simple and straightforward method of vocal cord medialization.  Under heavy sedation, visualization of the vocal cord is performed with a scope and the teflon is directly injected into the vocal cord until proper medialization is obtained.  This used to be the standard treatment for vocal cord paralysis as it is quick, (takes 10-20 minutes), simple and usually has good results.  The cons of this procedure, however, outweigh these benefits in most cases.  Once the Teflon has been injected, it is irreversible.  Thus a poor result may not be able to be improved upon without extensive, higher risk surgery.  In addition, over time (meaning years), a low but substantial percentage of patients will have a reaction to the Teflon in which a granuloma occurs causing worsening vocal problems and possible breathing problems.  Only more extensive surgery can improve and control this problem.  For that reason, we use Teflon only in those cases in which optimal voice is not necessary and a prolonged life is not expected.

Other injectable substances such as fat and collagen are also options.  They too are relatively simple to inject.  However, these substances resorb in an unpredictable fashion and thus several injections may be needed for an acceptable result.

Vocal cord medialization with implants is done under local anesthesia with mild sedation.  An incision is made in a skin crease midway down the center of the neck.  The thyroid cartilage is exposed and a "window" is made through the cartilage at the level of the vocal cord.  Then the vocal cord is pushed inward while the patient talks and the amount of inward movement necessary to produce the best voice is measured.  A silastic implant is then custom made and placed into the thyroid cartilage window keeping the vocal cord permanently in the position in which the best voice was heard.  The wound is then closed with a small drain that is removed the following day.  Patients are discharged home the following day.  The cons of this procedure are that the procedure does take more time (average of 1.5 - 2hrs.) and it is more technically involved.  However, the advantage of this procedure is that it is completely reversible, it can be altered for improved results, and there is no reaction to the implant.  In some cases, a suture placed on the arytenoid muscular process is done in order to further move the vocal cord over and produce a better voice.  This does add significant technical difficulty and time to the procedure but may be necessary for optimal results.

Lastly, attempts to regain muscle tone of the vocal cords and possibly some movement may be obtained by sewing a nerve from the neck to the vocal cord nerve. This is called laryngeal reinnervation.  Although it is somewhat controversial, it is without significant risk or side-effects and may be of benefit over the long-term in preventing atrophy of the vocal cords.


Bilateral Vocal Cord Paralysis

Bilateral vocal cord paralysis can be a life-threatening disorder.  When neither vocal cord moves and they are both paralyzed near the middle of the airway, there is no room to breathe and suffocation can occur.  Because breathing is the first priority in treating this condition, a tracheotomy should be performed to allow a secure passage to breathe.  Once this has been done, there are two main options for the patient.  One is to live with the tracheotomy, and two is to undergo surgery in hopes of eventual removal of the tracheotomy.

Living with the tracheotomy has its obvious social and functional disadvantages.  However, 1) breathing is secure, 2) voice may be normal when the tracheostomy tube is plugged (and it may be able to be plugged at all times except during sleep) and 3) eating is normal.

Surgery to treat bilateral vocal cord paralysis attempts to create an airway large enough to breathe through, but not too large such that voice is compromised and aspirating (spillage of food or liquid into the lungs) when eating is a problem.  This is accomplished in staged surgeries by microsurgery of the larynx in which the laser is used to cut the back aspect of one vocal cord and arytenoid.  This procedure and its variants are called laser arytenoidectomy or cordotomy.  Future treatments with electrical pacing of the vocal cords (not unlike a heart pacemaker) is on the horizon.

Vocal Cord Injections and Implants

There are a number of injectable material and implants that are used in the vocal cords for a number of reasons.  One of the common reasons is to use such techniques is for paralyzed vocal cords.  This subject and the technique of injections are covered in Surgery for the Paralyzed Vocal Cord(s).  Another common injection is botulinum toxin (Botox) and it is described in Spasmodic Dysphonia and Botox.  A brief discussion of other materials and causes is described below.

As we age, the muscles of the vocal cords atrophy just like the muscles in our arms and legs.  As they do, they become bowed in form.  This causes a gap between the vocal cords when they try to close during the production of sound and thus leads to a breathier, weaker voice.  This is one critical aspect of the aging voice box known as presbylarynges.  Similar vocal cord abnormalities can also be seen in Parkinson's disease. Methods to "bulk" up the vocal cords with various implants and techniques can be successful.  This includes microsurgery of the vocal cords with injections of collagen, fat or fascia (a fibrous tissue that can be taken from under the skin in multiple places of the body).  Or surgery like that performed for unilateral vocal cord paralysis can be performed on both vocal cords.  The procedure of choice depends upon the degree and anatomy of the bowing, the patient's and surgeon's preferences and a myriad of other considerations that are necessarily individualized.

Laryngeal Cancer and Voice Preservation Surgery

The most common type of cancer of the larynx is called squamous cell carcinoma.  The main risk factors for acquiring this type of cancer are cigarette smoking and excessive alcohol use.  Common symptoms suggesting this diagnosis include prolonged hoarseness, throat pain, shortness of breath, problems swallowing, ear pain and enlarged lymph nodes of the neck.  The diagnosis is made by examining the larynx in the office using fiberoptic scopes as is described in the section called Examining the Larynx.

Once the diagnosis is suspected, biopsies (or pieces of the tumor) are most often taken in the operating room as is described in Microsurgery of the Larynx.  A pathologist will then review the material under a microscope to determine the exact diagnosis.  While the patient is in the operating room, the surgeon will map out the exact location and size of the tumor.  It is also common to evaluate the lungs with bronchoscopy and the esophagus with esophagoscopy to make sure no other tumors are present.  A CT scan (computer generated x-ray) is also often obtained to further evaluate the extent of the tumor. 

Partially uninvolved left vocal cord

Advanced laryngeal cancer of the right vocal cord

Once the diagnosis has been made, the tumor mapped out and perhaps a CT scan of the neck has been performed, discussion with the patient regarding the best treatment for him is done.  Surgical options range from endoscopic microsurgical resection, to partial resection of the larynx, to complete removal of the larynx (a total laryngectomy - in which case a permanent tracheotomy is created and alternative methods of speech are used.) 

The other major means of treating cancer of the larynx is with radiation therapy with or without chemotherapy.  In typical radiation therapy programs, doses of radiation are given daily, 5 days a week for a 6 week period.  Again, there are a variety of protocols which one may be eligible for depending upon the health of the patient, the extent and location of the tumor, and the wishes of all involved. 

Often times surgery is combined with radiation and/or chemotherapy in various protocols.  Surgery may also involve removing the lymph nodes of one or both sides of the neck (called a neck dissection) in areas where the cancer is most likely to spread.  Though the incision of such an operation may extend from beneath the ear to the middle of the neck, most often the long-term functional and cosmetic side-effects are few and inconsequential.

As can be appreciated from this brief overview of laryngeal cancer, there are abundant options available and a team of doctors is necessary to coordinate the care involved to achieve the optimal result.  This team involves otolaryngologists/laryngologists, oncologists, radiation oncologists, speech therapists, nutritionists, nurses and dentists.  All factors and options should be discussed with your doctors.  Remember, it takes more than just chemicals, x-rays, and surgery to beat this disease, it takes understanding, patience, hope and will on everyone's part in order to successfully treat this sometimes devastating disease.