Microsurgery of the larynx Larynx
LLOYD A. SEYFRIED, D.O., FOCO Detroit, Michigan
This article describes a method of the Yankauer (1910) and the suspension microsurgery that facilitates precise, frames of Killian, Lynch, or Siefert, were delicate endolaryngeal surgery with monocular tubes. The addition of telescopes to monocular laryngoscopes, did not afford depth minimal trauma while viewing the perception or allow the use or manipulation of larynx with binocular vision and instruments while viewing. Lewy s 1 depth per- three-dimensional selected magnification. ception device provided binocular viewing, but The technique utilizes a simple lacked magnification. modification of the operating microscope A method of microsurgery of the larynx was described by Scalco, Shipman, and Tabb 2 in already in use by the otolaryngologist. 1960, using the Zeiss operating microscope The draped surgical microscope is with a 300 mm. objective lens and the Lynch fitted with a 375 or 400 mm. objective suspension laryngoscope. The authors were lens. The eyepiece housing on the pleased with the brilliant three-dimensional left is fitted with a viewing tube so that image, but felt the need of better designed the resident can view the entire instruments, since standard laryngeal instru- ments gave the sensation of "working with procedure. If photographs are to be crowbars." taken, a camera can be attached to the Kleinsasser3 in 1963 developed a binocular eyepiece housing on the right. The laryngoscope for use with the Zeiss operating technique described here can be microscope, fitted with a 400 mm. objective employed in cases of mucosal and lens. Fine, delicate instruments were devel- oped, produced by the Reiner Company. Klein- submucosal changes in the pharynx and sasser4 in 1965 described microsurgical proce- larynx, small or moderate sized lesions dures for vocal cord stripping for Reinke s of the vocal cords, ventricles, edema, laryngeal polyps, leukoplakia, pachy- or ventricular bands, and endolaryngeal derma, singer s nodes, and carcinoma in situ. surgical procedures. Among more extensive procedures performed were endolaryngeal resection of the vocal cord, arytenoidectomy, and the treatment of adhesions and stenosis. Jako5 in 1964 developed a binocular fiber op- tic laryngoscope for microdiagnosis and micro- surgery of the larynx, for use with the Zeiss Microsurgery of the larynx is a method of operating microscope. The Jako laryngoscope performing precise delicate endolaryngeal sur- (produced by George P. Pilling Company) is gical procedures with minimal trauma while attached to the Lewy 6 gear-driven suspension viewing the larynx with binocular vision and arm supported on a Mayo stand, placed a few selective magnification. It is, in fact, the ap- inches above the patient s chest. Jako also de- plication of the surgical principles of middle veloped a microsurgical instrumentarium for ear microsurgery to the larynx. endolaryngeal surgery well adapted to the re- Most laryngoscopes of the past, except for quirements of a precise technique. These in-
246/86 struments are produced by the Stumer Com- passes a No. 26 cuffed endotracheal tube by pany. way of the mouth between the vocal cords in- General anesthesia is a practical necessity to the trachea. in microsurgery of the larynx to provide the The tube has a built-in inflating channel and surgeon with prolonged time for examination is designed for nasotracheal introduction. The and performance of precise microsurgical pro- added length of this tube places the anesthe- cedures. An endotracheal technique employing siologist s connector and valves far enough a 26-gauge cuffed endotracheal tube with gen- from the mouth that they will not interfere eral anesthesia was described by Priest and with the introduction of the laryngoscope or Wesolowski7 in 1959. This method has been the manipulation of instruments. The cuff is found to provide adequately ventilation for inflated and the pilot tube clamped. The small most patients requiring this procedure, in- tube does not interfere with visualization since cluding many patients with pre-existing chron- it lies completely in the interarytenoid space ic pulmonary disease, chronic bronchitis, bron- in the posterior part of the larynx. If it is nec- chiectasis, and emphysema. The recent re- essary to look at the posterior portion of the lease of Innovar provides a safe method of larynx, the tube can be elevated by the laryn- general anesthesia adaptable to microlaryngo- goscope tip to cause it to lie anteriorly. The scopy by an experienced anesthesiologist. cuffed tube prevents bleeding into the trachea and fogging of lenses. Technique When Innovar is used, the anesthetic gas is My own experiences with microlaryngoscopy changed to nitrous oxide and oxygen. In select- and microendolaryngeal surgery have followed ed cases the endotracheal tube may be omit- rather closely the methods of Kleinsasser and ted completely. of Jako. I would anticipate many changes and The Jako laryngoscope illuminated with refinements in the future, as occurred in the twin fiber optic light bundles is introduced in- development of microsurgery of the middle to the pharynx. The instrument is held in the ear. Consequently, a high degree of adaptabil- left hand, the tip engages the epiglottis, which ity to these expected developments should be is lifted, and the laryngoscope is advanced to maintained. expose the vocal cords. The teeth are protect- The technique I employ is as follows: The ed with a rubber gump. In the edentulous pa- patient s larynx is sprayed topically with Ce- tient, a pad of gauze moistened in saline or tacaine aerosol spray and the larynx is view- Tissu-Sol, protects the alveolar ridge. A stur- ed with a mirror by the resident, who drops 2 dy Mayo stand is positioned a few inches cc. of 4% Xylocaine between the vocal cords above the patient s chest and firmly tightened with a laryngeal syringe. The patient then lies to sustain the pressure exerted by the Lewy on his back on the surgical table and the an- frame. With the right hand, the Lewy frame esthesiologist starts an intravenous infusion of is fastened to the handle of the laryngoscope 5% dextrose, and succinylcholine is added to and the support arm of the frame lowered to obtain muscle relaxation. Fluothane anesthe- contact the Mayo stand; the gear of the frame sia is then induced. When the patient is suffi- is then tightened sufficiently to expose the ciently relaxed, the anesthesiologist exposes larynx, including the anterior commissure, to the larynx with a McIntosh laryngoscope and full view (Fig. 1).
Journal AOA/vol. 68, November 1968 247/87 Fig. 1. Jako laryngoscope with Lewy suspension arm in use with Zeiss microscope arranged for horizontal viewing. mirror, properly adjusted for angulation. With small fine suction tips, the surface can be kept clean and bloodless (Fig. 2). Palpation of vocal cords with the probe or suction tip will detect induration and submucosal changes, found in carcinoma in situ and early carcinoma. Changes in the vascular pattern are also noted. Kleinsasser8 has classified vascular patterns found in hyperkeratosis and precancerous and cancerous lesions. Normal capillary branching Fig. 2. Stiimer microsurgical laryngeal instruments. is broken in precancerous and carcinomat- ous laryngeal mucosa. Capillaries thus take on wormlike and U-shaped patterns, instead of At this point both hands are free. The the twig-branch appearance of the normal draped surgical microscope, adjusted for hori- capillary tree. zontal viewing and fitted with a 375 or 400 The brilliant three-dimensional visualiza- mm. objective lens, is wheeled into position so tion with which one can see the tiniest lesion that the operator, seated at a comfortable is remarkable. Removal is accomplished with height, can obtain a full, three-dimensional, small knives, forceps, scissors, and snares de- unobstructed view of the larynx. Straight signed for this procedure. With them, one can viewing tubes are necessary to obtain a com- work as precisely and accurately as in middle fortable viewing and operating position. The ear surgery. Only tissue that is clearly patho- eyepiece housing on the left is fitted with a logic is removed. This can be accomplished House-Urban viewing tube so that the resi- with greatly decreased trauma and with a dent will be able to view the entire procedure. subsequent reduced period of healing (Figs. The right side of the microscope is unob- 3-8). structed to permit passage, manipulation, and withdrawal of instruments. If photographs are Indications to be taken, the House-Urban Robot camera The following are indications for microlaryn- is attached to the right eyepiece housing and goscopy and endolaryngeal microsurgery as will not interfere greatly with the passage or presently developed: manipulation of instruments. Pilling Com- 1.Mucosal and submucosal changes in the pany makes a photographic attachment devel- pharynx and larynx. Kleinsasser° states that oped by Jako for photography of the larynx, the laryngomicroscope is as valuable to the if the microscope has not been adapted for laryngologist as the culdoscope is to the gyne- House-Urban equipment. cologist in the differential diagnosis of muco- The magnification for diagnosis and surgery sal changes, especially the early diagnosis of is selected; usually this is from 16x to 25x. carcinoma. The ventricles are inspected by opening them 2. Small or moderate sized lesions of the with a small blunt hook to retract the ven- vocal cords, ventricles, or ventricular bands; tricular bands. The undersurface of the vocal these include polyps, nodules, cysts, leukopla- cords can be seen with the aid of a small Jako kia, hyperkeratosis, and carcinoma in situ.
248/88 Fig. 3 (left). Polyp of right vocal cord (X16). Fig. 4 (right). Immediate postoperative view; polyp removed (X16).
3. Endolaryngeal surgical procedures such as Teflon paste injection of the vocal cord for flaccid adductor paralysis; cordectomy or ary- tenoidectomy for bilateral abductor paralysis.
Contraindications Fig. 5 (left). Large irregular vocal nodules (X10). Microlaryngoscopy and endolaryngeal micro- Fig. 6 (right). Immediate postoperative view; nodules surgery are contraindicated in the following removed (X10). patients: 1. Patients with advanced or invasive car- cinoma. Passage of an endotracheal tube through an area of known malignancy is not indicated, because of fragmentation of the tu- mor and the possibility of implanting tumor cells. 2. Infants and small children. Present equipment is not practical for the infantile larynx, which is best examined with the in- Fig. 7 (left). Granuloma of left ventricle (X16). Fig. 8 fant laryngoscope and mummying. (right). Immediate postoperative view; granuloma 3. Ankylosis of the temporomandibular removed (X16). joints, arthritis, diseases of the cervical spine, or other anatomic problems which would pre- vent straight line viewing from the front 1. Lewy, R. B.: Depth perception in laryngoscopy. Report of an instrument used to accomplish binocular vision through a tube. teeth to the larynx. The Broyles anterior corn- AMA Arch Otolaryng 72:383-4, Sep 60 missure laryngoscope is best adapted to view- 2. Scalco, A. N., Shipman, W. F., and Tabb, H. G.: Microscopic suspension laryngoscopy. Ann Otol 69:1134-8, Dec 60 ing the difficult larynx. 3. Kleinsasser, 0.: Mikrochirurgie im Kehlkopf. Arch Ohr Nas Kehlkopfheilk 183:928-33, 26 Nov 64 4. Kleinsasser, 0.: Weitere Technische Entwicklung und erste Summary Ergebnisse der "endolaryngealen Mikrochirurgie." Z Laryng Microsurgery of the larynx is a method of per- Rhinol Otol 44:711-27, Nov 66 5. Jako, G. J. and Kleinsasser, 0.: Endolaryngeal micro-diagno- forming precise, delicate endolaryngeal sur- sis and microsurgery. Scientific Exhibit, American Medical As- gical procedures with minimal trauma while sociation 115th Annual Convention, Chicago, June 26-30, 1966 and Exhibit, American Academy of Ophthalmology and Otolaryngology viewing the larynx with binocular vision and meeting, Chicago, October 29-November 3, 1967 6. Lewy, R. B.: Suspension fixation gear power laryngoscopy three-dimensional selective magnification, and (with motion pictures). Laryngoscope 69:693-5, Aug 54 the method utilizes a simple modification of 7. Priest, R. E., and Wesolowski. S.: Direct laryngoscopy under general anesthesia. Trans Amer Arad Ophthal Otolaryng 64:639- the operating microscope already in use by the 48, Sep-Oct 60 otolaryngologist. The technique of microlaryn- 8. Kleinsasser, 0.: Die Laryngomikroskopie (Lupenlaryngoskopie) und ihre Bedeutung fur die Erkennung der Vorerkrankungen und geal diagnosis and microlaryngeal surgery is Friihformen des Stimmlippencarcinoms. Arch Ohr Nas Kehl- described and the indications and contraindi- kopfheilk 180:724-7, 1962 9. Kleinsasser, 0.: Ein Laryngomikroskop zur Friihdiagnose und cations are discussed. Microsurgery expands Differential-diagnose von Krebsen in Kehlkopf, Rachen und Mund- the existing horizons of laryngology and pro- hiihle. Z Laryng Rhinol Otol 40:276-9, Apr 61 vides additional help in the early diagnosis of carcinoma. Dr. Seyfried, 211 Glendale Avenue, Suite 300, Detroit, 48203,
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