Atlas of Head and Neck Surgery E-Book
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Atlas of Head and Neck Surgery, by Drs. James I. Cohen and Gary L. Clayman, delivers unparalleled visual guidance and insight to help you master the most important and cutting-edge head and neck procedures. Clear, consistent black-and-white drawings and detailed text lead you through each step of all standard operations, while commentary from leading experts presents alternative techniques – complete with explanations about the differences, nuances, pearls, and pitfalls of each approach. Concise yet complete, this easily accessible text captures groundbreaking techniques such as video-assisted thyroid and parathyroid surgeries; transoral laser surgeries; and robotic surgeries. This surgical technique reference is an ideal resource for planning and performing successful head and neck surgery or preparing for the head and neck portion of the Otolaryngology boards.

  • Understand how to proceed thanks to an abundance of explicit illustrations and detailed text that take you from one step to the next.
  • Quickly find the information you need to make confident decisions. Relevant indications/contraindications, pre-operative considerations, and post operative management are presented in an easily accessible format.
  • Discern the nuances and understand the differences between standard operations and alternate techniques. Experts debate each procedure offering insightful explanations, rationale, and tips for avoiding complications.
  • Master new procedures such as video-assisted thyroid and parathyroid surgeries; transoral laser surgeries; and robotic surgeries. Section editor F. Christopher Holsinger, MD, FACS, is at the forefront of many of these techniques, some of which are being illustrated for the first time here.
  • Learn from some of the very best - Experts from the MD Anderson Cancer Center and the Oregon Health & Science University (OHSU) share their innovative approaches to the surgical techniques and complications management most frequently seen in practice.
  • Understand specific variations in anatomy as they apply to each procedure.



Publié par
Date de parution 06 juin 2011
Nombre de lectures 0
EAN13 9781455728473
Langue English
Poids de l'ouvrage 5 Mo

Informations légales : prix de location à la page 0,0846€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.


Atlas of Head & Neck Surgery

James I. Cohen, MD, PhD, FACS
Professor, Department of Otolaryngology/Head and Neck Surgery; Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center; Oregon Health and Science University, Portland, Oregon

Gary L. Clayman, MD, DMD, FACS
Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery; Professor of Surgery and Cancer Biology; Director of Interdisciplinary Program in Head and Neck Oncology; Chief, Section of Head and Neck Endocrine Surgery; Deputy Head Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
Front Matter

Atlas of Head & Neck Surgery
James I. Cohen, MD, PhD, FACS
Professor, Department of Otolaryngology/Head and Neck Surgery
Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center
Oregon Health and Science University
Portland, Oregon
Gary L. Clayman, MD, DMD, FACS
Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery
Professor of Surgery and Cancer Biology
Director of Interdisciplinary Program in Head and Neck Oncology
Chief, Section of Head and Neck Endocrine Surgery
Deputy Head Division of Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas

1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF HEAD & NECK SURGERY ISBN: 978-1-4160-3368-4
Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: .
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Atlas of head & neck surgery / [edited by] James I. Cohen, Gary L. Clayman.—1st ed.
p. ; cm.
Atlas of head and neck surgery
Includes bibliographical references and index.
ISBN 978-1-4160-3368-4 (hardcover : alk. paper) 1.  Head—Surgery—Atlases. 2.  Neck—Surgery—Atlases. I.  Cohen, James I. II.  Clayman, Gary L. III.  Title: Atlas of head and neck surgery.
[DNLM: 1.  Head—surgery—Atlases. 2.  Neck—surgery—Atlases. WE 17]
RD521.A843 2011
Acquisitions Editor: Stefanie Jewell-Thomas
Developmental Editor: Roxanne Halpine Ward
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Designer: Louis Forgione
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to the concept that the wisdom and humility essential to the practice of medicine are best acquired by rejecting dogma and instead exploring the controversy that surrounds much of what we do every day. My lifelong pursuit of this ideal has required constant nurturing. For this, I am forever indebted to my father who instilled it in me at an early age by design and example, to three decades of residents who have helped me learn and teach in this context, and especially to my wife, Sherry, and my children, Alex and Adam, who have always supported me with love and affection.

James I. Cohen
How we develop as individuals is shaped by both our genetics and our environment. I dedicate this book to those who have directly and indirectly shaped my life, and although I am hesitant to make too long of a list, such an opportunity comes too infrequently. My parents provided encouragement, support, and love for which I am forever grateful. I have had the honor to be educated by and to refer to as colleagues, several surgeons who have been icons in the field of head and neck surgery. These men inspired me with their wisdom, surgical art form, and humility and have remained within me throughout my career. They notably include Drs. Helmuth Goepfert, Alando J. Ballantyne, Robert Byers, and Oscar Guillamondegui. Inspiration has also come from the honor and joy of training immensely talented and brilliant residents and fellows during the past 20 years. Finally, my family, including my loving wife, Mikyung, my beautiful children, Beau and Elizabeth, and my brothers, Lawrence and Marty, and my dear friends have provided endless love and care and the smiles, joy, and laughter that give my life meaning.

Gary L. Clayman
Associate Editors

Peter E. Andersen, MD, Professor, Department of Otolaryngology/Head and Neck Surgery Professor, Department of Neurosurgery Director of Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Ehab Hanna, MD, FACS, Professor and Vice Chairman Director of Skull Base Surgery Department of Head and Neck Surgery Medical Director, Head and Neck Center University of Texas MD Anderson Cancer Center Houston, Texas

F. Christopher Holsinger, MD, FACS, Associate Professor, Department of Head and Neck Surgery Director, Program in Minimally Invasive and Endoscopic Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

William M. Lydiatt, MD, FACS, Professor and Vice Chair, Department of Otolaryngology Director of Head and Neck Surgery University of Nebraska Medical Center Professor, Department of Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska

Joshua S. Schindler, MD, Assistant Professor, Department of Otolaryngology Medical Director, OHSU-Northwest Clinic for Voice and Swallowing Oregon Health and Science University Portland, Oregon

Mark K. Wax, MD, FACS, FRCSC, Professor, Otolaryngology/Head and Neck Surgery Professor, Oral and Maxillofacial Surgery Program Director Director, Microvascular Reconstruction Coordinator, Education, AAOHNS(F) Department of Otolaryngology/Head and Neck Surgery Oregon Health Sciences University Portland, Oregon

Peter E. Andersen, MD, Professor, Department of Otolaryngology/Head and Neck Surgery Professor, Department of Neurosurgery Director of Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Mihir K. Bhayani, MD, Fellow, Department of Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Apostolos Christopoulos, MD, MSc, FRCSC, Assistant Professor, Department of Otorhinolaryngology Centre Hospitalier de l’Université de Montréal Montréal, Québec, Canada

Woong Youn Chung, MD, PhD, Associate Professor, Department of Surgery Yonsei University College of Medicine Seoul, Republic of Korea

Gary L. Clayman, MD, DMD, FACS, Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery Professor of Surgery and Cancer Biology Director of Interdisciplinary Program in Head and Neck Oncology Chief, Section of Head and Neck Endocrine Surgery Deputy Head Division of Surgery, University of Texas MD Anderson Cancer Center Houston, Texas

James I. Cohen, MD, PhD, FACS, Professor, Department of Otolaryngology/Head and Neck Surgery Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center Oregon Health and Science University Portland, Oregon

Robert L. Ferris, MD, PhD, FACS, Professor and Vice-Chair of Clinical Operations Departments of Otolaryngology, Radiation Oncology, and Immunology Eye & Ear Institute Pittsburgh, Pennsylvania

Paul W. Gidley, MD, FACS, Associate Professor, Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Neil D. Gross, MD, FACS, Assistant Professor, Otolaryngology/Head and Neck Surgery Oregon Health and Science University Attending Surgeon, Operative Care Division Portland VA Medical Center Portland, Oregon

Ehab Hanna, MD, FACS, Professor and Vice Chairman Director of Skull Base Surgery Department of Head and Neck Surgery Medical Director, Head and Neck Center University of Texas MD Anderson Cancer Center Houston, Texas

F. Christopher Holsinger, MD, FACS, Associate Professor, Department of Head and Neck Surgery Director, Program in Minimally Invasive and Endoscopic Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Kitti Jantharapattana, MD, Postdoctoral Fellow, Head and Neck Surgery MD Anderson Cancer Center Houston, Texas Instructor, Otolaryngology Head and Neck Surgery Prince of Songkla University Songkhla, Thailand

Ollivier Laccourreye, MD, Professor, Department of Otorhinolaryngology–Head and Neck Surgery University Descartes-Paris V Hôpital Européen Georges Pompidou Member, Académie Nationale de Chirurgie Paris, France

Daniel D. Lydiatt, MD, DDS, FACS, Professor and Interim Chair, Otolaryngology/Head and Neck Surgery University of Nebraska Medical Center Medical Director, Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska

William M. Lydiatt, MD, FACS, Professor and Vice Chair, Department of Otolaryngology Director of Head and Neck Surgery University of Nebraska Medical Center Professor, Department of Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska

Henry A. Milczuk, MD, Associate Professor Chief, Pediatric Otolaryngology Department of Otolaryngology–Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Raul Pellini, MD, Attending Surgeon, Department of Otolaryngology–Head and Neck Surgery National Cancer Institute “Regina Elena” Rome, Italy

Greg Reece, MD, Professor of Plastic Surgery Department of Plastic Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Paolo Ruscito, MD, Attending Surgeon, Department of Otolaryngology–Head and Neck Surgery National Cancer Institute “Regina Elena” Rome, Italy

Joshua S. Schindler, MD, Assistant Professor, Department of Otolaryngology Medical Director, OHSU-Northwest Clinic for Voice and Swallowing Oregon Health and Science University Portland, Oregon

Giuseppe Spriano, MD, Chief, Department of Otolaryngology–Head and Neck Surgery Director, Department of Neuroscience National Cancer Institute “Regina Elena” Rome, Italy

Mark K. Wax, MD, FACS, FRCSC, Professor, Otolaryngology/Head and Neck Surgery Professor, Oral and Maxillofacial Surgery Program Director Director, Microvascular Reconstruction Coordinator, Education, AAOHNS(F) Department of Otolaryngology/Head and Neck Surgery Oregon Health Sciences University Portland, Oregon

Gregory S. Weinstein, MD, Professor and Vice Chair, Otorhinolaryngology: Head and Neck Surgery University of Pennsylvania Philadelphia, Pennsylvania

Mark E. Zafereo, MD, Fellow, Head and Neck Surgery MD Anderson Cancer Center Houston, Texas

Peter E. Andersen, MD, Professor, Department of Otolaryngology/Head and Neck Surgery Professor, Department of Neurosurgery Director of Head and Neck Surgery Oregon Health and Science University Portland, Oregon

William B. Armstrong, MD, Professor of Clinical Otolaryngology and Chair, Otolaryngology–Head and Neck Surgery University of California–Irvine Irvine, California

Leon A. Assael, DMD, Professor and Chair of Oral and Maxillofacial Surgery Medical Director, Hospital Dentistry Oregon Health and Science University Portland, Oregon

Stephen W. Bayles, MD, FACS, Deputy Chief of Surgery Section Head-Otolaryngology Director of Head and Neck Oncology Virginia Mason Medical Center Seattle, Washington

Peter C. Belafsky, MD, PhD, Associate Professor and Director, Center for Voice and Swallowing University of California–Davis Sacramento, California

Manuel Bernal-Sprekelsen, MD, PhD, Head of Ear, Nose and Throat Department, Otorhinolaryngology, Hospital Clinic Tenure Professor for Otorhinolaryngology, Department for Surgical Specialties University of Barcelona Barcelona, Spain Privatdozent for ORL Ruhr-University Bochum, Germany

Nasir I. Bhatti, MD, FACS, Associate Professor, Department of Otolaryngology Head and Neck Surgery Johns Hopkins University School of Medicine Baltimore, Maryland

Brian B. Burkey, MD, FACS, Section Head, Head and Neck Surgery and Oncology Head and Neck Institute Cleveland Clinic Foundation Cleveland, Ohio Adjunct Professor, Department of Otolaryngology Vanderbilt University Medical Center Nashville, Tennessee

Bruce H. Campbell, MD, FACS, Professor, Department of Otolaryngology and Communication Sciences Medical College of Wisconsin Milwaukee, Wisconsin

William R. Carroll, MD, Professor and Director of Head and Neck Oncology Department of Surgery University of Alabama–Birmingham Birmingham, Alabama

Salvatore M. Caruana, MD, Assistant Professor, Department of Otolaryngology–Head and Neck Surgery Columbia University New York, New York

Claudio R. Cernea, MD, Associate Professor of Surgery, Department of Head and Neck Surgery University of Sao Paulo Medical School Sao Paulo, Brazil

Francisco J. Civantos, MD, FACS, Associate Professor Co-Director, Division of Head and Neck Surgery Department of Otolaryngology Sylvester Cancer Center/University of Miami Hospital and Clinics Miami, Florida

Gary L. Clayman, MD, DMD, FACS, Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery Professor of Surgery and Cancer Biology Director of Interdisciplinary Program in Head and Neck Oncology Chief, Section of Head and Neck Endocrine Surgery Deputy Head Division of Surgery, University of Texas MD Anderson Cancer Center Houston, Texas

James I. Cohen, MD, PhD, FACS, Professor, Department of Otolaryngology/Head and Neck Surgery Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center Oregon Health and Science University Portland, Oregon

Seth M. Cohen, MD, MPH, Assistant Professor, Duke Voice Care Center Division of Otolaryngology–Head and Neck Surgery Duke University Medical Center Durham, North Carolina

Ted A. Cook, MD, FACS, Professor, Facial Plastic and Reconstructive Surgery Department of Otolaryngology/Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Robin T. Cotton, MD, FACS, FRCSC, Director, Pediatric Otolaryngology–Head and Neck Surgery Director, Aerodigestive and Sleep Center Cincinnati Children’s Hospital Professor, Otolaryngology–Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati, Ohio

Mark S. Courey, MD, Professor, Otolaryngology–Head and Neck Surgery UCSF Medical Center Director, Division of Laryngology University of California–San Francisco San Francisco, California

Bruce J. Davidson, MD, Professor and Chairman, Department of Otolaryngology–Head and Neck Surgery Georgetown University Medical Center Washington, District of Columbia

Terry A. Day, MD, Professor and Clinical Vice Chairman, Department of Otolaryngology–Head and Neck Surgery Medical University of South Carolina Charleston, South Carolina

Daniel G. Deschler, MD, FACS, Director, Division of Head and Neck Surgery Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear Infirmary Associate Professor, Department of Otology and Laryngology Harvard Medical School Boston, Massachusetts

Gianlorenzo Dionigi, MD, FACS, Associate Professor of Surgery, Department of Surgical Sciences University of Insubria Varese, Italy

Paul James Donald, MD, FRCSC, Professor and Vice Chair, Otolaryngology–Head and Neck Surgery University of California, Davis Sacramento, California

David W. Eisele, MD, FACS, Professor and Chairman, Department of Otolaryngology–Head and Neck Surgery Irwin Mark Jacobs and Joan Klein Jacobs Endowed Chair in Head and Neck Cancer UCSF Helen Diller Family Comprehensive Cancer Center University of California–San Francisco San Francisco, California

D. Gregory Farwell, MD, FACS, Associate Professor, Otolaryngology–Head and Neck Surgery University of California–Davis Sacramento, California

Fred G. Fedok, MD, FACS, Professor and Chief, Section of Facial Plastic and Reconstructive Surgery Division of Otolaryngology/Head and Neck Surgery Department of Surgery Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania

Robert L. Ferris, MD, PhD, FACS, Professor and Vice-Chair of Clinical Operations Departments of Otolaryngology, Radiation Oncology, and Immunology Eye & Ear Institute Pittsburgh, Pennsylvania

Paul W. Flint, MD, Professor and Chair, Otolaryngology/Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Jeremy L. Freeman, MD, FRCSC, FACS, Professor, Department of Otolaryngology–Head and Neck Surgery Professor, Department of Surgery University of Toronto Temmy Latner/Dynacare Chair in Head and Neck Oncology Mount Sinai Hospital/University of Toronto Otolaryngologist in Chief, Department of Otolaryngology–Head and Neck Surgery Mount Sinai Hospital Toronto, Ontario, Canada

Paul L. Friedlander, MD, FACS, Chairman, Department of Otolaryngology Tulane Medical Center New Orleans, Louisiana

Neal Futran, MD, DMD, Professor and Chair, Otolaryngology–Head and Neck Surgery University of Washington Seattle, Washington

Markus Gapany, MD, Associate Professor, Otolaryngology–Head and Neck Surgery University of Minnesota Minneapolis, Minnesota

C. Gaelyn Garrett, MD, Professor, Department of Otolaryngology Vanderbilt Medical Center Medical Director, Vanderbilt Voice Center Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences Nashville, Tennessee

Eric M. Genden, MD, FACS, Professor and Chairman, Department of Otolaryngology–Head and Neck Surgery Professor of Neurosurgery Mount Sinai School of Medicine New York, New York

Helmuth Goepfert, MD, Professor Emeritus, Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Andrew N. Goldberg, MD, MSCE, FACS, Professor, Director, Division of Rhinology and Sinus Surgery Department of Otolaryngology–Head and Neck Surgery University of California–San Francisco San Francisco, California

Neil D. Gross, MD, FACS, Assistant Professor, Otolaryngology–Head and Neck Surgery Oregon Health and Science University Attending Surgeon, Operative Care Division Portland VA Medical Center Portland, Oregon

Patrick J. Gullane, MD, CM, FRCSC, FACS, FRACS (Hon), FRCS (Hon), Otolaryngologist-in-Chief, University Health Network Wharton Chair Head and Neck Surgery–Princess Margaret Hospital Professor and Chair, Department of Otolaryngology Head and Neck Surgery University of Toronto Department of Otolaryngology–Head and Neck Surgery University Health Network Toronto, Ontario, Canada

Gady Har-El, MD, FACS, Chairman, Department of Otolaryngology–Head and Neck Surgery Lenox Hill Hospital New York, New York Professor, Departments of Otolaryngology and Neurosurgery State University of New York–Downstate Medical Center Brooklyn, New York Adjunct Professor, Otolaryngology–Head and Neck Surgery New York University New York, New York

Amy C. Hessel, MD, Associate Professor and Surgeon, Department of Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Peter A. Hilger, MD, Professor, Division of Facial Plastic Surgery Department of Otolaryngology University of Minnesota Minneapolis, Minnesota

Frans J.M. Hilgers, MD, PhD, Chairman-Emeritus, Head and Neck Oncology and Surgery The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital Professor, Oncology-Related Voice and Speech Disorders Institute of Phonetic Sciences Amsterdam Center for Language and Communication–University of Amsterdam Consultant, Head and Neck Oncology and Surgery, Otorhinolaryngology Academic Medical Center–University of Amsterdam Amsterdam, The Netherlands

Henry T. Hoffman, MD, FACS, Professor Director, Voice Clinic Department of Otolaryngology University of Iowa Hospitals and Clinics Iowa City, Iowa

F. Christopher Holsinger, MD, FACS, Associate Professor, Department of Head and Neck Surgery Director, Program in Minimally Invasive and Endoscopic Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

David B. Hom, MD, FACS, Professor, Director, Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology–Head and Neck Surgery University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

David Howard, MD, Professor of Head and Neck Oncology Imperial College London Consultant Head and Neck Surgeon Charing Cross Hospital London, United Kingdom

Jonathan Irish, ND, FRCSC, Chief, Department of Surgical Oncology Princess Margaret Hospital University Health Network Toronto, Ontario, Canada

Jonas T. Johnson, MD, Professor and Chairman, Department of Otolaryngology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Larry R. Kaiser, MD, President, The University of Texas Health Science Center at Houston Houston, Texas

Emad Kandil, MD, FACS, Assistant Professor of Surgery, Department of Surgery Tulane University School of Medicine New Orleans, Louisiana

Dennis Kraus, MD, Attending Surgeon, Head and Neck Surgery Service Department of Surgery Memorial Sloan-Kettering Cancer Center Professor, Department of Otorhinolaryngology–Head and Neck Surgery Cornell University Medical Center New York, New York

Ronald B. Kuppersmith, MD, MBA, FACS, Texas Ear, Nose, and Throat and Allergy College Station, Texas

Ollivier Laccourreye, MD, Professor, Department of Otorhinolaryngology–Head and Neck Surgery University Descartes-Paris V Hôpital Européen Georges Pompidou Member, Académie Nationale de Chirurgie Paris, France

Eric S. Lambright, MD, Assistant Professor of Thoracic Surgery Surgical Director of Lung Transplant Vanderbilt Thoracic Surgery Vanderbilt University Medical Center Nashville, Tennessee

Jeffrey E. Lee, MD, Professor of Surgery, Department of Surgical Oncology University of Texas MD Anderson Cancer Center Houston, Texas

John P. Leonetti, MD, Professor and Vice-Chairman, Neurotology, Otology, and Skull Base Surgery Co-Director of the Loyola Center for Cranial Base Surgery Department of Otolaryngology–Head and Neck Surgery Loyola University Medical Center Maywood, Illinois

Celestino Pio Lombardi, MD, Endocrine Surgery Department Università Cattolica Del Sacro Cuore Policlinico Gemelli Rome, Italy

William M. Lydiatt, MD, FACS, Professor and Vice Chair, Department of Otolaryngology Director of Head and Neck Surgery University of Nebraska Medical Center Professor, Department of Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska

Jeffery Scott Magnuson, MD, Associate Professor of Surgery, Residency Program Director, Department of Surgery Division of Otolaryngology University of Alabama at Birmingham Birmingham, Alabama

Robert H. Maisel, MD, FACS, Professor, Department of Otolaryngology–Head and Neck Surgery University of Minnesota Chief, Department of Otolaryngology–Head and Neck Surgery Hennepin County Medical Center Minneapolis, Minnesota

Rosario Marchese-Ragona, MD, Assistant Professor, Department of Medical and Surgical Specialties Section of Otolaryngology Head and Neck Surgery University of Padova Padova, Italy

Robert G. Martindale, MD, PhD, Professor and Chief, Division of General Surgery Department of Surgery Oregon Health and Science University Portland, Oregon

Sam J. Marzo, MD, Professor, Residency Program Director Director, Parmly Hearing Institute Department of Otolaryngology–Head and Neck Surgery Division of Otology, Neurotology, and Skull Base Surgery Loyola University Health System Maywood, Illinois

Timothy M. McCulloch, MD, Professor and Chairman, Division of Otolaryngology Head and Neck Surgery University of Wisconsin Hospital and Clinics Madison, Wisconsin

Andrew J. McWhorter, MD, Director of Voice Center Assistant Professor, Department of Otolaryngology–Head and Neck Surgery Louisiana State University Health Sciences Center New Orleans, Louisiana

Jesus E. Medina, MD, FACS, Paul and Ruth Jonas Professor, Department of Otorhinolaryngology University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Eduardo Méndez, MD, MS, Assistant Professor, Department of Otolaryngology–Head and Neck Surgery University of Washington Assistant Member, Clinical Research Division Fred Hutchinson Cancer Research Center Seattle, Washington

Albert L. Merati, MD, FACS, Associate Professor and Chief, Laryngology Department of Otolaryngology–Head and Neck Surgery University of Washington School of Medicine Adjunct Associate Professor, Department of Speech and Hearing Sciences College of Arts and Sciences University of Washington Seattle, Washington

Tanya K. Meyer, MD, Assistant Professor Department of Otolaryngology University of Washington Seattle, Washington

Paolo Miccoli, MD, Professor of Surgery Head of the Department of Surgery University of Pisa Pisa, Italy

Henry A. Milczuk, MD, Associate Professor Chief, Pediatric Otolaryngology Department of Otolaryngology–Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Oleg Militsakh, MD, FACS, Assistant Professor, Director Head and Neck Reconstructive Surgery Division of Head and Neck Surgery Department of Otolaryngology University of Nebraska Medical Center Assistant Professor, Director Head and Neck Reconstructive Surgery Department of Head and Neck Surgery Nebraska Methodist Hospital–Estabrook Cancer Center Omaha, Nebraska

Eric J. Moore, MD, Consultant, Otorhinolaryngology–Head and Neck Surgery Mayo Clinic Associate Professor of Otolaryngology Mayo College of Medicine Rochester, Minnesota

Meijin Nakayama, MD, Associate Professor, Otorhinolaryngology Kitasato University School of Medicine Sagamihara, Kanagawa, Japan

Roger C. Nuss, MD, FACS, Assistant Professor of Otology and Laryngology Harvard Medical School Children’s Hospital Boston, Massachusetts

Kerry D. Olsen, MD, Professor, Otolaryngology Head and Neck Surgery Mayo Clinic Rochester, Minnesota

Steven M. Olsen, MD, Resident, Otolaryngology Head and Neck Surgery Mayo Clinic Rochester, Minnesota

Lisa A. Orloff, MD, FACS, Robert K. Werbe Distinguished Professor of Head and Neck Cancer Director, Division of Head and Neck and Endocrine Surgery Department of Otolaryngology, Head and Neck Surgery University of California–San Francisco San Francisco, California

Robert H. Ossoff, MD, DMD, Guy M. Maness Professor of Laryngology and Care of the Voice Department of Otolaryngology Assistant Vice-Chancellor, Office of Compliance and Corporate Integrity Vanderbilt Medical Center Nashville, Tennessee

Giorgio Peretti, MD, Associate Professor, Department of Otorhinolaryngology–Head and Neck Surgery University of Brescia Brescia, Italy

Nancy D. Perrier, MD, FACS, Professor of Surgery, Department of Surgical Oncology University of Texas MD Anderson Cancer Center Houston, Texas

Cesare Piazza, MD, Assistant Professor, Department of Otorhinolaryngology–Head and Neck Surgery University of Brescia Brescia, Italy

Joe B. Putnam, Jr., MD, Professor of Surgery and Chairman, Department of Thoracic Surgery Ingram Professor of Cancer Research Vanderbilt Ingram Cancer Center Professor of Biomedical Informatics Vanderbilt University Medical Center Nashville, Tennessee

Gregory W. Randolph, MD, FACS, Director of General, Thyroid, and Parathyroid Surgical Divisions Massachusetts Eye and Ear Infirmary Member, Division of Surgical Oncology and Endocrine Surgical Service Massachusetts General Hospital Boston, Massachusetts Associate Professor of Otology and Laryngology Harvard Medical School Cambridge, Massachusetts

Marc Remacle, MD, PhD, Professor, Associate Head, Otorhinolaryngology–Head and Neck Surgery Louvain University Hospital of Mont-Godinne Mont-Godinne, Belgium

Alan T. Richards, MD, FACS, Associate Professor, Otolaryngology–Head and Neck Surgery University of Nebraska Medical Center Associate Professor, Head and Neck Surgery Nebraska Methodist Hospital Omaha, Nebraska

William J. Richtsmeier, MD, PhD, Director, Clinician Research, Department of Otolaryngology–Head and Neck Surgery Bassett Healthcare Network Cooperstown, New York

John A. Ridge, MD, PhD, Professor, Senior Member, and Chief, Head and Neck Surgery Section Departments of Surgery and Developmental Therapeutics Fox Chase Cancer Center Professor, Departments of Surgery and Otolaryngology–Head and Neck Surgery Temple University Philadelphia, Pennsylvania

Clark A. Rosen, MD, FACS, Professor, Department of Otolaryngology University of Pittsburgh School of Medicine Director, University of Pittsburgh Voice Center University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Eben L. Rosenthal, MD, Julius Hicks Professor of Surgery, Division of Otolaryngology–Head and Neck Surgery University of Alabama at Birmingham Birmingham, Alabama

John R. Saunders, Jr., MD, MBA, Executive Vice-President, Chief Medical Director Medical Director, Milton J. Dance, Jr. Head and Neck Center Greater Baltimore Medical Center Associate Professor, Otolaryngology–Head and Neck Surgery Surgery, Plastic Surgery Johns Hopkins School of Medicine Baltimore, Maryland

Joshua S. Schindler, MD, Assistant Professor, Department of Otolaryngology Medical Director, OHSU-Northwest Clinic for Voice and Swallowing Oregon Health and Science University Portland, Oregon

David E. Schuller, MD, Vice President, Medical Center Expansion and Outreach Otolaryngology–Head and Neck Surgery John W. Wolfe Chair in Cancer Research College of Medicine CEO Emeritus, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute The Ohio State University Columbus, Ohio

Aniel Sewnaik, MD, PhD, Head and Neck Surgeon, Otorhinolaryngology Head and Neck Surgery Erasmus MC-Daniel Den Hoed Cancer Center Rotterdam, The Netherlands

Ashok R. Shaha, MD, FACS, Jatin P. Shah Chair in Head and Neck Surgery Head and Neck Service Department of Surgery Memorial Sloan-Kettering Cancer Center Professor of Surgery, Department of Surgery Weill Cornell Medical College Cornell University New York, New York

Maisie Shindo, MD, FACS, Professor, Otolaryngology Thyroid and Parathyroid Division Oregon Health and Science University Portland, Oregon

William W. Shockley, MD, FACS, W. Paul Biggers Distinguished Professor Chief, Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology/Head and Neck Surgery University of North Carolina School of Medicine Attending Physician, Department of Otolaryngology/Head and Neck Surgery UNC Hospitals Chapel Hill, North Carolina

James Sidman, MD, Director of Cleft and Craniofacial Programs Co-Director of Vascular Anomalies Program Department of Otolaryngology Children’s Hospitals and Clinics of Minnesota Professor of Otolaryngology and Pediatrics University of Minnesota Minneapolis, Minnesota

C. Blake Simpson, MD, Professor, Department of Otolaryngology–Head and Neck Surgery Director, The University of Texas Voice Center University of Texas Health Science Center at San Antonio San Antonio, Texas

Catherine F. Sinclair, MD, FRACS, Instructor/Fellow Head and Neck Surgery Department of Surgery Division of Otolaryngology Head and Neck Surgery University of Alabama at Birmingham Birmingham, Alabama

James D. Smith, MD, Professor Emeritus, Otolaryngology Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Timothy L. Smith, MD, MPH, Professor and Chief, Rhinology and Sinus Surgery Department of Otolaryngology–Head and Neck Surgery Oregon Health and Science University Portland, Oregon

Carl Henry Snyderman, MD, Professor, Department of Otolaryngology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Robert A. Sofferman, MD, Professor of Surgery and Chief Emeritus Department of Surgery Division of Otolaryngology University of Vermont School of Medicine Burlington, Vermont

Jeffrey D. Spiro, MD, Professor of Surgery, Division of Otolaryngology/Head and Neck Surgery University of Connecticut School of Medicine Farmington, Connecticut

Wolfgang Steiner, MD, Professor Emeritus, Department of Otorhinolaryngology–Head and Neck Surgery University of Goettingen Goettingen, Germany

David J. Terris, MD, FACS, Porubsky Professor and Chairman Surgical Director, MCG Thyroid/Parathyroid Center Department of Otolaryngology–Head and Neck Surgery Medical College of Georgia Augusta, Georgia

Ralph P. Tufano, MD, FACS, Associate Professor, Department of Otolaryngology–Head and Neck Surgery Director of the Johns Hopkins Hospital Multidisciplinary Thyroid Tumor Center Director, Thyroid and Parathyroid Surgery Johns Hopkins School of Medicine Baltimore, Maryland

Joseph Valentino, MD, Professor, Department of Surgery Division Of Otolaryngology–Head and Neck Surgery University of Kentucky College of Medicine Chief of Head and Neck Surgery Department of Surgery Lexington Kentucky Veterans Medical Center Lexington, Kentucky

Isabel Vilaseca, MD, PhD, Consultant, Otorhinolaryngology Hospital Clinic Associate Professor of Otorhinolaryngology Department for Surgical Specialties University of Barcelona Barcelona, Spain

Stephen J. Wang, MD, FACS, Associate Professor, Department of Otolaryngology–Head and Neck Surgery University of California–San Francisco San Francisco, California

Mark K. Wax, MD, FACS, FRCSC, Professor, Otolaryngology–Head and Neck Surgery Professor, Oral and Maxillofacial Surgery Program Director Director, Microvascular Reconstruction Coordinator, Education, AAOHNS(F) Department of Otolaryngology–Head and Neck Surgery Oregon Health Sciences University Portland, Oregon

Randal S. Weber, MD, Professor and Chair, Head and Neck Surgery University of Texas MD Anderson Cancer Center Houston, Texas

Richard J. Wong, MD, Associate Attending Surgeon, Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York

Steven M. Zeitels, MD, FACS, Eugene B. Casey Professor of Laryngeal Surgery Department of Surgery Harvard Medical School Director, Center for Laryngeal Surgery Department of Surgery Massachusetts General Hospital Boston, Massachusetts
Learning how to do an operation can be a daunting task, whether as a first-year resident preparing the night before a case never previously encountered or as a surgeon in a busy practice faced with incorporating a new technique or technology into his or her surgical repertoire. This book acknowledges the realities of how this process occurs. Initially, “rote” learning of the steps involved may be all that can be expected. Over time, it is hoped that an increased understanding of the logic behind these steps and their sequence will be acquired, and this is where most surgical atlases stop. We know, however, that different surgeons perform the same operations in different ways, and these different techniques can work equally well. Although this can be confusing and disconcerting to early trainees as they work with different attending staff or preceptors, ultimately, being able to reconcile the success of these different approaches requires a firm grasp of the unifying concepts behind any procedure. Helping the reader reach this level while still supporting the early phases of learning is the goal of this book.
The book is designed to be read in the same way it is assembled. We selected authors with a known expertise in given procedures and asked them to break down the operations into their component steps, much as they would direct an early learner the first time through the procedures in the operating room. We then asked the authors to provide their logic, for both their technique and the sequence of these steps. This information was interposed into the initial “step sequence” in a separately identifiable way. Key references are provided, where needed.
With the chapters assembled with their artwork, each chapter was then sent to two to four surgeons with known expertise in the subject matter. They were asked to interject commentary into the chapter wherever they thought appropriate, whether to provide emphasis, clarification, or alternate strategies. This commentary is provided in essentially unedited form, interposed in the original author’s text, because we thought that this would best simulate a “virtual conversation” taking place around an operation, such as one that would occur at a surgical technique meeting session where a panel is asked to discuss a given operation. We were surprised and gratified to see the enthusiasm with which the commentators approached the task. Finally, at the end of many of the chapters, we have provided summary comments, when applicable, that seek to clarify common themes, reconcile significant conflicts, or emphasize critical issues.
Through the use of different fonts, color schemes, and paragraph structure, the publisher has preserved the concept of the sequence of the writing process. This allows the reader, depending on his or her knowledge base or time constraints, to read (or reread) the operation at the most appropriate level for his or her need at that point in time. We think that it allows a logical sequence of knowledge acquisition, whether it be rudimentary memorization, review of the steps, a more in-depth understanding of the logic of these steps, or an analysis of the guiding principles that underpin the operation as a whole, through the commentary.
We hope the reader enjoys this approach as much as we have enjoyed assembling it. We think that the discipline of the framework it provides is valid not only for the operations outlined here but also for a lifelong learning process that will allow for the newer techniques and technology that we all will and must confront over the course of our professional lives.

James I. Cohen

Gary L. Clayman
Editors in Chief
Table of Contents
Front Matter
Associate Editors
Unit I: Benign Upper Aerodigestive Disease
Section A: Adult Endoscopy
Chapter 1: Clinical Diagnostic Nasopharyngoscopy
Chapter 2: Diagnostic Clinical Pharyngoscopy and Laryngoscopy
Chapter 3: Operative Pharyngoscopy and Laryngoscopy
Chapter 4: Operative Esophagoscopy and Percutaneous Gastrostomy
Chapter 5: Operative Bronchoscopy
Section B: Airway Operations
Chapter 6: Tracheotomy
Chapter 7: Laryngotracheal Reconstruction for Subglottic and Proximal Tracheal Stenosis
Chapter 8: Cricotracheal Resection for Subglottic Stenosis
Chapter 9: Surgery for Unilateral Vocal Fold Paralysis
Chapter 10: Excision of Saccular Cysts and Laryngoceles
Section C: Neck
Chapter 11: Drainage of Deep Space Neck Infections
Chapter 12: Thyroglossal Duct Cyst Excision (Sistrunk Procedure)
Chapter 13: Branchial Cleft Cyst Excision
Section D: Pharyngeal Operations
Chapter 14: Operations on the Cervical Esophagus and Cervical Spine
Chapter 15: Cricopharyngeal Myotomy and Surgical Management of Zenker’s Diverticulum
Chapter 16: Defatting Tracheotomy
Unit II: Neck and Salivary Gland
Section A: Neck Dissection
Chapter 17: Radical Neck Dissection
Chapter 18: Modified Radical Neck Dissection
Chapter 19: Selective Neck Dissection, Levels I-III (Supraomohyoid Neck Dissection)
Chapter 20: Selective Neck Dissection, Levels I-IV and II-IV (Anterolateral and Lateral Neck Dissection)
Chapter 21: Posterolateral Neck Dissection
Chapter 22: Retropharyngeal Lymph Node Dissection
Chapter 23: Sentinel Lymph Node Biopsy
Section B: Salivary Gland Operations
Chapter 24: Superficial Parotidectomy
Chapter 25: Submandibular Gland Excision
Chapter 26: Excision of Ranula
Chapter 27: Parapharyngeal Space Tumor
Chapter 28: Resection of Carotid Body Tumor
Unit III: Oral Cavity and Oropharyngeal Operations
Section A: Transoral
Chapter 29: Transoral Resections
Chapter 30: Extended Approaches to the Oropharynx
Chapter 31: Transoral Robotic Surgery
Section B: Operations on the Mandible and Maxilla
Chapter 32: Composite Resection with Segmental Mandibulectomy
Chapter 33: Transhyoid and Lateral Pharyngotomy
Unit IV: Laryngopharyngeal Operations
Section A: Laryngectomy
Chapter 34: Exam Under Anesthesia for the Patient with Cancer
Chapter 35: Horizontal Supraglottic Laryngectomy
Chapter 36: Supracricoid Partial Laryngectomy with Cricohyoidopexy or Cricohyoidoepiglottopexy
Chapter 37: Total Laryngectomy
Chapter 38: Stomaplasty for Hands-Free Voice with Tracheoesophageal Puncture
Chapter 39: Tracheoesophageal Puncture in the Clinic via Transnasal Esophagoscopy
Section B: Transoral Endoscopic Head and Neck Surgery
Chapter 40: Transoral Laser Microsurgery
Chapter 41: Transoral Laser Resection of Glottic Tumors
Unit V: Skull Base
Section A: Paranasal Sinus Operations
Chapter 42: Transfacial Approaches
Chapter 43: Maxillectomy
Chapter 44: Craniofacial Resection
Chapter 45: Lateral and Subtotal Temporal Bone Resection
Unit VI: Thyroid and Parathyroid
Section A: Thyroid Operations
Chapter 46: Thyroid Lobectomy and Isthmusectomy
Chapter 47: Subtotal and Total Thyroidectomy
Chapter 48: Video-Assisted Thyroidectomy
Chapter 49: Robotic Thyroidectomy
Chapter 50: Paratracheal and Superior Mediastinal Dissection (Transcervical)
Chapter 51: Transcervical Thymectomy and Superior Mediastinal Dissection
Section B: Parathyroid Operations
Chapter 52: Targeted Parathyroidectomy
Chapter 53: Open Parathyroidectomy
Chapter 54: Video-Assisted Parathyroidectomy
Unit VII: Basic Reconstructive Flaps
Section A: Skin Grafts
Chapter 55: Split-Thickness Skin Graft
Section B: Pedicled Flaps
Chapter 56: Cervicofacial Rotation Flap
Chapter 57: Deltopectoral Flap
Chapter 58: Pectoralis Major Myocutaneous Flap
Chapter 59: Trapezius Flap
Chapter 60: Latissimus Dorsi Myocutaneous Flap
Section C: Neural Reconstruction
Chapter 61: Neural Reconstruction
Unit I
Benign Upper Aerodigestive Disease
Section A
Adult Endoscopy
CHAPTER 1 Clinical Diagnostic Nasopharyngoscopy

Author Joshua S. Schindler

Commentary by Andrew N. Goldberg, Timothy L. Smith

The procedure should be performed with the patient in the seated position with the head supported from behind. The chin should be in a neutral position with the chin centered between the shoulders.
Although the procedure can be performed in any position, secretion management is easiest with the head elevated. A headrest prevents withdrawal by the patient during the procedure. A centered chin prevents apparent asymmetries in the nasopharynx from rotation of the cervical spine.

Indirect Nasopharyngoscopy
Nasopharyngoscopy may be performed transorally with a small mirror. The physician gently grasps the tongue and, using a head mirror or headlight, directs focused light to the mirror placed just beneath and behind the soft palate (Figure 1-1) .

FIGURE 1-1 Indirect mirror nasopharyngoscopy.

The patient’s saliva on the buccal mucosa can be used to defog the mirror prior to insertion in the nasopharynx. TLSmith
Although nasopharyngoscopy may be performed this way, mirror nasopharyngoscopy yields a comparatively limited view of the nasopharynx. It is technically challenging and cannot provide an adequate examination in all patients. We therefore defer mirror laryngoscopy for flexible fiberoptic examination in most cases.

In fact, I have not performed indirect nasopharyngoscopy for years given the ready availability and superior visualization of the nasopharyngoscope.   TLSmith

Fiberoptic Nasopharyngoscopy
The nasal cavity is treated with topical nasal decongestant and local anesthetic using an aerosolizer. The physician stands in front of the patient and directs the scope into the nasal cavity (Figure 1-2A) .

FIGURE 1-2 A, Flexible fiberoptic nasopharyngoscopy. B, Fiberoptic view of anterior nasal cavity.

During fiberoptic nasopharyngoscopy, patients often attempt to tilt the head backward to “assist” the entry of the scope into the nose but this generally increases the difficulty of passing the scope through the nasal cavity. The head should be in a neutral position.   TLSmith
Studies have failed to demonstrate a significant patient benefit from topicalization of the nasal cavity. Despite this, we find that the decongestant spray (oxymetazoline or phenylephrine [Neo-Synephrine]) does facilitate placement of the fiberoptic scope. Anesthetic (e.g., lidocaine, tetracaine [Pontocaine], mepivacaine [Carbocaine]) should take effect within 90 seconds and may be mixed with the nasal decongestant; 2% water-soluble lidocaine jelly also may be used and can facilitate fiberoptic scope placement. We typically treat both nasal cavities to allow placement of the fiberoptic scope through either passageway.

For a right-handed examiner, standing in front of and slightly to the patient’s right allows the examiner to stand closer to the patient in a more comfortable position.
Although there is controversy over the utility of topicalization in the nose, use of decongestant and anesthetic is common practice.
Although anesthetics begin to take effect in 90 seconds, anesthesia is optimal between 5 and 10 minutes. Timing your topicalization and examination will increase comfort of the examination.
Warning the patient in advance that application of topical anesthetic may make it feel difficult to swallow or may make the front teeth feel numb allays some patients’ anxiety if these sensations occur. Noting that the effects typically last less than an hour similarly provides information that many patients appreciate.   ANGoldberg
The fiberoptic scope is passed transnasally to the nasopharynx. Continuous visualization is performed to determine the widest and most comfortable transnasal approach (see Figure 1-2B ).
We prefer to use the floor of the nasal cavity to pass the fiberoptic scope because this is the least sensitive to pain and is commonly the widest passage. If the bilateral nasal floors are impassable, we approach the nasopharynx between the middle meatus and septum.

This approach is directly below the middle turbinate and commonly used in my experience.   TLSmith
Diagnostic nasopharyngoscopy examination begins at the choana. A thorough examination includes inspection of the choana, the eustachian tube orifice, the torus tubarius, and the fossa of Rosenmueller on each side. Midline structures including the adenoid pad, the roof of the nasopharynx, Passavant’s ridge and the posterior mucosa of the soft palate should also be inspected. Motion and closure of the soft palate should also be tested by asking the patient to say “cake” or “kitty cat” (Figure 1-3) .

FIGURE 1-3 Nasopharynx view through flexible fiberoptic scope.
In most cases, all of these structures may be visualized through unilateral nasal cavity placement. Other functional testing, such as Mueller’s maneuver to test for pharyngeal airway collapse with inspiration, may be performed with fiberoptic nasopharyngoscopy. The examiner should take note of relatively subtle asymmetries in the nasopharynx because many lesions in this area are submucosal.

Although nasopharyngoscopy begins at the choana, the opportunity to examine the nasal cavity during the same examination should not be missed. Administration of topical anesthetic and decongestant to both sides of the nose and examination of the nasal cavity provides a complete endoscopic examination with minimal additional morbidity.   ANGoldberg

Editorial Comment
Fiberoptic technology has significantly improved the odds of complete examination of the nasopharynx compared with mirror examination alone—the issue is not whether the nasopharynx can be well seen with a mirror but rather that the technique requires considerable experience, and even with this is poorly tolerated in the majority of patients.
As pointed out the use of topical decongestant with or without topical anesthetic is not mandatory but probably preferred by most clinicians. The key if it is used is to wait sufficiently for both decongestion and anesthesia to take effect. Plan your office visit/examination and patient flow in such a way that the necessary time (5 to 10 minutes) is built in without rushing this.    JICohen

Suggested Readings

Burkey BB, Ossoff RH. Endoscopy of nasopharyngeal cancer. Diagn Ther Endosc . 1994;1:63-68.
Ritter CT, Trudo FJ, Goldberg AN, Welch KC, Maislin G, Schwab RJ. Quantitative evaluation of the upper airway during nasopharyngoscopy with the Muller maneuver. Laryngoscope . 1999;109:954-963.
Strauss RA. Flexible endoscopic nasopharyngoscopy. Atlas Oral Maxillofac Surg Clin North Am . 2007;15:111-128.
CHAPTER 2 Diagnostic Clinical Pharyngoscopy and Laryngoscopy

Author Joshua S. Schindler

Comments by Robert H. Maisel, Albert L. Merati

Indirect laryngoscopy and pharyngoscopy should be performed with the patient in the seated position with the back straight and flexed forward about 20 degrees from perpendicular. The chin should be in a “sniffing” position with the chin centered between the shoulders and slightly elevated.
This position may be used for all types of laryngoscopy (mirror, flexible fiberoptic, or rigid). The head flexion and extension may be adjusted to facilitate visualization of laryngeal and pharyngeal structures with different visualization techniques.

Successful endoscopy begins with correct positioning and verbal preparation of the patient. All the endoscopic skill and topical anesthesia in the world can’t overcome a poorly positioned or ill-prepared patient. This cannot be overemphasized.   ALMerati

Mirror Examination
Transoral laryngopharyngoscopy may be performed with a mirror. The physician gently grasps the tongue and, using a head mirror or headlight, directs focused light to the mirror placed onto or just beneath the soft palate. The soft palate is gently elevated and the mirror is angled inferiorly to perform the examination (Figure 2-1) .

FIGURE 2-1 Indirect mirror laryngoscopy.
In contrast to nasopharyngoscopy, mirror laryngoscopy can yield a magnificent view of the larynx and pharynx without topical anesthesia. Procedures such as vocal cord injection and laryngeal or pharyngeal biopsy may be performed with this technique if the patient grasps his or her own tongue to free the physician’s second hand. Warming the mirror to body temperature or applying a detergent-based defogging solution facilitates visualization.

Telescopic Examination
Transoral laryngopharyngoscopy may also be performed with a rigid angled telescope. The physician grasps the patient’s tongue and passes the telescope transorally to the vallecula. The larynx may be visualized by then asking the patient to phonate while adjusting the telescope to see the endolarynx (Figure 2-2) .

FIGURE 2-2 Indirect rigid telescope laryngoscopy.
Rigid, telescopic laryngopharyngoscopy offers one of the best views of the posterior upper aerodigestive tract. The telescopes may be magnified (up to 10×) and provide unparalleled clarity. Most patients will tolerate this procedure without anesthesia, but topical application of local anesthetic (benzocaine/butyl aminobenzoate/tetracaine [Cetacaine]) may be performed to diminish gagging. Relaxation of the jaw and tongue with retraction by the examiner will prevent elevation of the base of tongue that prevents visualization. Asking the patient to smile widely facilitates elevation of the soft palate. Both 70- and 90-degree telescopes are available to achieve optimal visualization in the widest number of patients.

Flexible Examination
Transnasal laryngopharyngoscopy may be performed with a flexible laryngoscope. The procedure is performed as in nasopharyngoscopy (see Chapter 1 ). Once in the nasopharynx, the scope is passed through the velopalatal closure while asking the patient to gently sniff (Figure 2-3) .

FIGURE 2-3 Flexible fiberoptic laryngoscopy.
Flexible transnasal laryngopharyngoscopy may be performed in all patients and is generally well tolerated. It affords the most access (including the subglottis and cervical trachea, in some cases) and allows for both structural and functional examination of the larynx, oropharynx and upper portion of the hypopharynx.

Even in very experienced hands, there are patients in whom flexible fiberoptic laryngoscopy is difficult, nearly impossible, and even impossible. This is usually the result of a combination of the following: (1) patient physical sensitivities such as an extreme gag reflex; (2) poor preparation of the patient, that is, talking through the examination, informing the patient about the process, positioning, and anesthesia; (3) patient psychologic preparation. Although they may intrinsically be limited in their capacity to tolerate this simple examination, many patients have become “unexaminable” following a previous traumatic examination. This latter situation is best handled by addressing it directly, and doing so prior to any attempt to examine the patient.   ALMerati
Comprehensive flexible fiberoptic laryngoscopic examination should include examination of the base of tongue, vallecula, epiglottis, aryepiglottic folds, glossoepiglottic fold, superior hypopharynx, posterior pharyngeal wall, arytenoids, false vocal folds, true vocal folds, and immediate subglottis. Functional examination should include true vocal fold abduction and adduction (Figure 2-4) .

FIGURE 2-4 View of larynx through flexible fiberoptic laryngoscope.
With the flexible endoscope in place, a number of techniques can be used to facilitate visualization. Protrusion of the patient’s tongue will often demonstrate the vallecula and may show the lingual surface of the epiglottis. Insufflation of the cheeks may be used to open the pharynx in some patients and allow visualization of the hypopharynx. Alternatively, left and right head turn usually allows inspection of the contralateral piriform sinus—sometimes to the apex.

Flexible scopes are available to the operator in several different sizes by diameter of tip cross section, allowing more patient comfort, pediatric examination, and suction or biopsy channel. The pediatric scope is 1.5 mm, the adult flexible scopes are 3.6 mm, and the channeled scope is 6.1 mm in diameter. The video scope with “chip in tip” is 3.9 mm, and other scopes have a tip diameter of 3.2 mm. Decision on which scopes fit the internal anatomy is achieved actively during the procedure.   RHMaisel
The glottis is generally quite easy to see in relaxed voicing and respiration. Sniff can be used to demonstrate maximal vocal fold abduction and is useful in patients with laryngeal stenosis and true vocal fold motion impairment. Some patients have pressed, hyperfunctional voicing with closure of their false vocal folds during phonation, known as plica ventricularis. Visualization of the true vocal folds and glottic closure may be obtained in such patients by asking them to phonate on inspiration.
Functional examinations, such as videostroboscopy and functional endoscopic evaluation of swallowing, may also be performed using basic laryngopharyngoscopy techniques.

Video and still photo capture is possible for patient education during a consultation and can be archived to compare with the direct laryngoscopic view and subsequent office examination to permit objective observation of the effects of the medication or speech therapy.   RHMaisel

Editorial Comment
The odds of success in office-based comprehensive examination of the upper aerodigestive tract have been greatly enhanced by fiberoptic technologies so that now not only is visualization improved but a more complete assessment of function is possible. However, for the reasons mentioned, mirror examination and rigid fiberoptic telescopes still have a place and can provide views not achievable with the smaller flexible telescopes. All techniques require practice, a cooperative and well-prepared patient, and a structured approach to ensure that all necessary information is specifically sought out.
A planned examination under anesthesia in no way should be seen as a substitute for what can be seen in the office but rather should be viewed as complementary to what is already known from the office visit. In most circumstances with modern technology the majority of information is gleaned from the office examination; the clinician should make a specific “checklist” of the unique additional information still needed and achievable by examination under anesthesia before a decision to go forward with this is made.   JICohen

Suggested Readings

Hiss SG, Postma GN. Fiberoptic endoscopic evaluation of swallowing. Laryngoscope . 2003;113:1386-1393.
Rosen CA, Amin MR, Sulica L, Simpson CB, Merati AL, Courey MS, et al. Advances in office-based diagnosis and treatment in laryngology. Laryngoscope . 2009;119:S185-S212.
Verikas A, Uloza V, Bacauskiene M, Gelzinis A, Kelertas E. Advances in laryngeal imaging. Eur Arch Otorhinolaryngol . 2009;266:1509-1520.
CHAPTER 3 Operative Pharyngoscopy and Laryngoscopy

Author Joshua S. Schindler

Commentary by Robert H. Ossoff, Clark A. Rosen, Steven M. Zeitels

General Considerations
Direct laryngoscopy and pharyngoscopy are procedures fundamental to the practice of otolaryngology and essential components of a complete head and neck examination. The ability to obtain direct line-of-sight visualization of the entire upper aerodigestive tract is as critical as it is challenging. Although flexible examination provides a tremendous amount of information and may obtain tissue for biopsy, direct examination allows the surgeon to palpate the tissue, to assess characteristics of lesions such as depth and adherence to deeper tissues, and visualize regions of the upper aerodigestive tract that cannot be seen in the office (e.g., lateral extent of the ventricle, the undersurface of the vocal folds, the piriform sinuses).
Laryngoscopy and pharyngoscopy are somewhat unique among head and neck procedures in that they are both diagnostic and therapeutic. As such, it is not uncommon for the surgeon to identify unexpected pathology or to find that the pathology is different than that anticipated by previous clinical and radiographic examinations. This uncertainty mandates that the surgeon have broad experience in techniques and a wide array of instruments to manage whatever he or she finds at the time of the procedure.
Of particular importance in the performance of laryngoscopy is the ability of the surgeon to manage and maintain an adequate airway before, during, and after the procedure. All laryngoscopy procedures should be considered airway procedures. Before proceeding to the operative suite, the surgeon should have the requisite skill, support, and equipment necessary to manage the most difficult airway safely. Emergencies do happen and advance preparation is the only defense against catastrophe. This preparation includes a careful preoperative assessment of the patient’s airway anatomy and respiratory requirements, an honest assessment of the surgeon’s skill, thorough discussion and close communication with supporting anesthesia and nursing staff, inspection of the operative equipment for completeness and proper function, and multiple plans for managing a difficult airway.

The role of preoperative communication and planning with the anesthesia and nursing teams cannot be overemphasized. This should include not only initial airway management strategies but also several backup options. This sequence of airway “management options” should be determined preoperatively. Similarly, an intraoperative and postoperative airway plan should be discussed and agreed on by the anesthesia, nursing, and surgical teams. This discussion typically focuses on issues such as endotracheal tube size and placement, use of jet ventilation, placement of tracheotomy, and use of apneic technique. This type of discussion should also ensure that emergency airway equipment, jet ventilation equipment, heliox, and a Combitube are available and agreed on by all members of the operative team.   CARosen

I am in complete agreement with the points raised by Dr. Schindler and elaborated on by Dr. Rosen regarding preoperative and intraoperative communication. There is no such thing as an easy “airway” case.   RHOssoff
In most situations the lesions of greatest concern to the otolaryngologist are malignancies of the larynx, oropharynx, and hypopharynx, and evaluation for such lesions should be performed during all direct laryngoscopy procedures. That said, there are many reasons to perform direct laryngoscopy including evaluation and removal of masses, acquiring and maintaining an airway, removal of foreign bodies, improvement in glottic competence, assessment and management of scar tissue and stenosis, and improving swallowing function. Although many of these aims require different techniques and instrumentation, the basic procedures of laryngoscopy and pharyngoscopy should be performed in the same fashion, order, and method in all patients to ensure that the surgeon performs an adequate examination and does not overlook any unexpected pathology.

The usual and customary sequence of performing laryngoscopy and pharyngoscopy also allows the perioperative team to better support the surgeon.   RHOssoff

Equipment for Laryngoscopy and Pharyngoscopy

Considerations on Scopes
Adequate instrumentation is essential to ensure a safe, complete, and effective laryngoscopy procedure. Instruments can be divided into two basic groups: (1) those aimed at evaluation and exposure of the patient’s anatomy and (2) those needed to perform the expected procedure. Although it is important to plan ahead for laryngoscopy and have the equipment needed to perform the expected procedure, it is not uncommon to find unexpected pathology and require additional equipment for the evaluation and management of whatever the surgeon finds. In addition, having instruments available for alternate methods of both examination and treatment is essential to prevent the added risk of future procedures.
We maintain all of the necessary equipment in a standardized location. Although a surgical tray or two may be used to hold the equipment while not in use, we strongly recommend a surgical cart with multiple drawers that can be brought to the surgical suite. This affords the surgeon immediate access to all of the equipment that might be needed to perform the expected procedure as well as any additional procedures that may be required without contaminating multiple sets of instruments. In addition, the cart allows organization of the instruments in order to quickly determine if all of the necessary equipment is available and ensure rapid delivery of the necessary instruments to the surgeon if necessary.

Access to an adequate and appropriate endoscopic armamentarium cannot be overemphasized. Lack of availability of proper instrumentation can lead to all sorts of misadventures in the upper aerodigestive tract including less-than-favorable outcomes.   RHOssoff
Diagnostic laryngoscopy and pharyngoscopy in their purest form require only a scope, a suction, a light source, and a tooth protector. Although this may seem simple, the options for all of these items are vast. There is significant debate over the most useful laryngoscopes and technique, and preferences vary from institution to institution. Simply put, any technique and scope that provides adequate exposure in a safe fashion is useful.
The surgeon should have familiarity with many options in order to obtain a successful result in a wide variety of patients. Laryngoscopes and pharyngoscopes come in many shapes and sizes designed to obtain different views of the laryngeal anatomy in different patients. Although a comprehensive discussion of laryngoscope design and options is well beyond the scope of this chapter, a brief description of some of the more common scopes is warranted to allow familiarity and a frame of reference for the reader.
After becoming familiar with the laryngoscopes available at their institution, the reader is encouraged to learn about other brands and models by inspecting laryngoscopes at vendor stands at meetings and obtaining catalogs from several of the manufacturers. It is important to remember that no single laryngoscope is optimal for all patients and all procedures.
Probably the two most commonly encountered laryngoscopes in the United States for adult procedures are the Holinger anterior commissure (AC) scope (Figure 3-1) and the Dedo microlaryngoscope (Figure 3-2) . Although many surgeons are facile with these two models and can perform diagnostic procedures in nearly all patients, both scopes have limitations that make them unsuitable in some situations.

FIGURE 3-1 The Holinger anterior commissure (AC) hourglass laryngoscope.

FIGURE 3-2 The Dedo microlaryngoscope.
Although they are commonly requested and described by name, each of these laryngoscopes actually comes in several different forms and may be available from more than one manufacturer. Despite subtle differences, the basic features are preserved.
The Holinger AC scope has a very narrow shaft and a flared distal end to allow maximal exposure of the anterior commissure. These features allow a monocular view of the anterior-most surfaces of the larynx and subglottis in even the most difficult to expose patients. As such, this is an excellent scope to have available for both diagnostic examinations and obtaining an airway in patients whose larynx is difficult to visualize. Unfortunately, its advantages come at the cost of a very limited field of view and inability to afford binocular vision for microlaryngoscopy procedures or bimanual instrumentation.

It is important to note that the Holinger AC scope is not appropriate for most operative procedures of the pharynx and larynx other than for viewing only. In most situations this laryngoscope should not be suspended and used for biopsy, given a lack of binocular vision, increased ability to be disoriented, and poor exposure at the operative site in case of bleeding.   CARosen

The Holinger laryngoscope 1 was introduced in 1960 in an era when the assistant functioned as the head holder to alter the position of the line-of-sight vector for the laryngoscopist. 1 This allowed for distal viewing despite the narrow central hourglass waist. The narrow central region was designed to accommodate the common restriction of large scope placement by the posterior floor of mouth along with the insertion of the palatoglossus and palatopharygeus muscles with the tongue. The Holinger laryngoscope was designed for performing visual examination and one-handed surgery without magnification as it was introduced prior to the era of microlaryngoscopy.   SMZeitels

The Holinger AC laryngoscope can be suspended and used with telescopes and microlaryngeal instruments in otherwise difficult to expose individuals.   RHOssoff
The Dedo laryngoscope was designed in an effort to allow binocular visualization and bimanual instrument use following introduction of the operating microscope in direct microlaryngoscopy. The shaft is much wider and tapers only gently toward the tip. There is little anterior flare. Some models have bilateral light carriers and suction ports for aspirating smoke plumes in laser-assisted laryngoscopy. Although this laryngoscope is tremendously useful because it yields wide laryngeal exposure, it may not be suitable for patients with an anteriorly positioned or high larynx.

The Dedo laryngoscope expanded the caliber of the Holinger design to accommodate the surgical microscope and the 400-mm front lens; however, the hourglass shape continued to partially restrict binocular stereoscopic microlaryngoscopic viewing. For this reason we introduced the Universal Modular Glottiscope, 2 which was designed specifically to examine and perform glottic surgery. It provides a full binocular glottal field, and the distal lumen is conformed as a lancet arch to accommodate the inner contours of the thyroid laminae, which is especially valuable for treating glottic cancer. This feature distracts the vestibular folds to provide enhanced viewing of the superior vocal fold region, a concept initially introduced by Jackson 3 in the 1920s as laryngostasis. Killian 4 and Jackson 3 both recognized decades ago that an “inverted V” distal contour optimally exposed the glottis given its intrinsic shape.   SMZeitels
Although a thorough discussion of all available laryngoscopes is not possible, it is useful to know that there is an instrument designed to overcome almost all exposure problems in laryngoscopy and allow optimal performance of different procedures. Procedure-specific laryngoscopes are designed for visualization of the supraglottis, posterior commissure, anterior commissure, and subglottis.

A primary advantage of bivalve laryngoscopes is that the surgeon has substantially greater degrees of freedom while angulating hand instruments.   SMZeitels
Other scopes are designed for evaluation of the oropharynx and hypopharynx. Laryngoscopes have numerous features such as multiple light carriers, suction ports, jet ventilation ports, and telescopic video ports. Some laryngoscopes have sliding channels to allow placement of an endotracheal tube and greater range of motion for instruments, distending distal and proximal tips to allow optimal exposure of the larynx and greater instrument access, and removable handles to facilitate placement and suspension.

I agree that the Holinger AC scope is a good “starting” laryngoscope and can be important from a diagnostic perspective, and the Dedo laryngoscope is often a “workhorse” for simple pharyngoscopy and laryngoscopy procedures. However, it is important to note that neither of these laryngoscopes is appropriate for high-quality detailed microlaryngoscopy procedures if a larger laryngoscope can be used. Multiple manufacturers make laryngoscopes larger than the Dedo laryngoscope, and these laryngoscopes can be suspended above the area of interest and provide significantly greater exposure and operative ease, thus increasing surgeon precision and improving operative outcome. The take-home point must be emphasized that the largest possible laryngoscope that can be safely inserted and suspended above the operative site in question should be used, as opposed to a surgeon settling for the view obtained from the Holinger AC scope or a Dedo laryngoscope.   CARosen

True laryngeal suspension 4 - 7 requires a gallows that suspends the patient with the primary force being exerted at the tongue base, supraglottis, and mandible. This is in contradistinction of what most surgeons use, which are chest-support laryngoscope holders/stabilizers that exert force on the maxilla. True suspension force on the mandible as demonstrated by Kirstein (written communication, 1897), Killian, 4 and Jackson 9 allows for the largest-caliber speculum to be positioned. This is a key strategic goal because optimizing laryngoscopic exposure frequently influences the precision of a surgical procedure.   SMZeitels

Having a selection of operative microlaryngoscopes is essential. At this point in my career, I have drifted back to a more centrist position regarding scope selection as it specifically relates to size of the scope. By that I mean that I will choose a microlaryngoscope that adequately exposes the surgical field but typically not the largest scope. To me the key is adequate and good exposure, and the largest possible laryngoscope is not always required to achieve that.   RHOssoff

Direct Laryngoscopy and Pharyngoscopy with or Without Biopsy

Preoperative Considerations
The indications for direct laryngoscopy and pharyngoscopy are myriad and generally include abnormality or mass, noted or suspected, in the oropharynx, supraglottis, glottis, subglottis, or hypopharynx; trauma or burn to upper aerodigestive tract structures; stridor; dysphagia with symptoms or findings suspicious for lesion or stricture of the upper aerodigestive tract; throat pain without obvious source; need to obtain an adequate airway; evaluation for second primary lesion with known upper aerodigestive tract malignancy; and obtaining and maintaining a stable airway for endoscopic tracheobronchial procedures.
There are few contraindications to laryngoscopy and pharyngoscopy, but strict contraindications should include cardiopulmonary instability with a stable airway, neck instability (e.g., fracture), and immobility of the mandible precluding adequate jaw excursion.
Although operative endoscopy may be performed under sedative/local anesthesia, optimal control, precision, and evaluation are attained under general anesthesia. Judicious use of intermediate-length nondepolarizing paralytic agents can facilitate exposure and maintain an immobile field.
Endotracheal intubation with as small a tube as can be used for adequate ventilation (usually 5 to 6 Fr) will facilitate the procedure if it can be performed safely and without significantly disturbing the pathology of interest.

The surgeon should habitually be present during endotracheal intubation to observe as the anesthesia team places the endotracheal tube, noting the blade size and ease or difficulty with the exposure for intubation. This ensures that the otolaryngologist is present at the time of airway establishment and may predict the ease of placement of the operating laryngoscope.   CARosen

A Hunsaker jet-ventilation catheter can be valuable with laryngeal stenosis patients or when working in the periarytenoid and interarytenoid regions.   SMZeitels

The surgeon should be ready to take over the intubation if he or she senses any difficulty by the anesthesia team. Traumatic intubation needs to be minimized to prevent trauma to the delicate tissues of the larynx.   RHOssoff
Close communication with anesthesia staff and preparation for alternative means of ventilation are essential to safe induction and intubation. Imaging studies should be available during the procedure and reviewed with the anesthesia staff prior to induction. It is the surgeon’s responsibility to confirm availability and proper function of all laryngoscopy equipment prior to induction.

Before starting direct operative pharyngoscopy and laryngoscopy, the surgeon should confirm total muscle paralysis with the anesthesia staff. No twitches on peripheral nerve monitoring ensures optimal relaxation prior to laryngoscope insertion and minimizes the chance of injury to surrounding structures during the procedure.   CARosen
The surgical suite is often small and, depending on the procedure planned, may contain numerous pieces of bulky, unwieldy equipment. Preoperative consideration of the location of this equipment and its order of use is essential to efficient use of operating room time. Although many configurations work well, a simple set of principles may allow the surgeon to configure any available room rapidly (Figure 3-3) .

FIGURE 3-3 Room configuration.
First, the anesthesiologist must have immediate access to intravenous lines and ventilating circuits. Typically the patient should not be turned more than 90 degrees away from the anesthesiologist and one arm should be available for blood pressure, oxygen saturation, and emergency intravenous access. Multiple light sources should be available and may be positioned in a number of places around the surgeon with attention paid to cables and obstruction. If a video cart is to be used, it is often most convenient to place this at the patient’s feet. The instrument cart should be placed in the room for rapid access to additional instruments by a noncontaminated circulating assistant.

In my practice, the assistant is on the right-hand side of the surgeon, given that most surgeons are right-handed.   CARosen

Operative Steps
STEP 1. Position the patient with the head as close as possible to the head of the bed.
STEP 2. Induce general anesthesia as per management plan with anesthesia staff.
In most cases induction of general anesthesia and endotracheal intubation may be performed by qualified anesthesia staff prior to performing upper airway endoscopy. Once intubated, the tube is taped to the left lower lip and corner of mouth (for a right-handed surgeon).

After the anesthesia team has successfully intubated the patient, the surgeon should ensure that the endotracheal tube is placed to the left side of the base of the tongue prior to taping the endotracheal tube at the left corner of the mouth. Given that most intubations are done with the right hand, this naturally places the endotracheal tube on the right side of the base of the tongue, and for the right-handed surgeon, this places the endotracheal tube in a “competing” position for direct pharyngoscopy and laryngoscopy. The most effective way to reposition the endotracheal tube to the left base of the tongue is not to use a tongue blade, but instead to use a gloved index finger, manually placing the endotracheal tube to the left aspect of the patient’s base of tongue prior to securing the tube.   CARosen

When performing laser-assisted operative microlaryngoscopy, the tube should not be taped so that it can be rapidly removed should an airway fire occur.   RHOssoff
STEP 3. Turn the head of the bed toward the surgeon and drape the operative field.
The eyes are carefully taped closed and protected to prevent corneal abrasions or other injuries. Plastic eye shields are available, but gauze eye pads are generally sufficient. Typically these are soaked in water prior to application to maintain safety in the event the laser is later used.
The arm opposite the anesthesiologist is padded and tucked and the patient is draped in a clean fashion such that the ventilator circuit can be seen and monitored by the anesthesiologist.
STEP 4. Perform a careful bimanual examination while the patient is under general anesthesia ( Figure 3-4 ).

FIGURE 3-4 Bimanual examination.
With wet gloves to facilitate examination, digital palpation of the lips, gingivolabial and gingivobuccal sulci, floor of mouth, anterior tongue, and retromolar trigones should be performed.
Deeper palpation of the soft palate, tonsils, posterior pharyngeal wall, base of tongue, and vallecula should be performed to assess for submucosal lesions not appreciated during office examination. The lingual and palatine tonsils are often involved in cases of occult malignancy, and palpation is surprisingly sensitive in identifying such lesions if performed carefully. In cases of laryngeal cancer, the preepiglottic space and base of tongue can often be palpated for signs of invasion.
The long finger should be used to palpate the palatoglossal folds and piriform sinuses to the level of the hyoid bone if possible. Also, any discrete suspicious masses should be biopsied with cup forceps either through the laryngoscope or by direct visualization.
Once oropharyngeal examination is completed, the neck may be carefully palpated with the patient under general anesthesia to feel for lymphadenopathy, particularly deep to the sternocleidomastoid muscles.

It is very important to perform digital and bimanual palpation of the structures of the oral cavity, oropharynx, and hypopharynx.   RHOssoff
STEP 5. Prepare the patient’s head and oral cavity for direct laryngoscopy and pharyngoscopy.
Preparation for direct laryngoscopy and pharyngoscopy begins with dental protection and head positioning. Standard positioning for unassisted laryngoscopy places the patient’s neck flexed and atlanto-occipital joint extended (Figure 3-5) .

FIGURE 3-5 Patient positioning for laryngoscopy and pharyngoscopy.
If the patient has maxillary dentition, a Silastic or rubber tooth protector is applied. If the maxillary dentition is absent, a saline-soaked gauze or towel may be used. In cases in which the maxillary dentition is poor or loose, extreme caution must be used. Dental impression putty may be placed in the tooth protector to help maintain support if some of the dentition is absent or suspect.

Saline-soaked gauze can often cause significant mucosal trauma to the edentulous alveolar ridge. A superior alternative is to use a small piece of high-density foam such as is found in otologic or neurosurgical head rests. A strip of high-density foam (approximately 1-2 cm × 3-4 cm × 0.5 cm) can be placed inside a small plastic bag and then placed between the laryngoscope and the alveolar ridge.   CARosen

Rolling a wet surgical sponge and placing it between the maxillary alveolus and labial surface of the upper lip as well as using another to protect the maxillary alveolar ridge will usually protect the patient’s tissues in edentulous patients, in my experience.   RHOssoff
Contrary to popular anesthesia and otolaryngology teaching, substantial pressure may be applied to the maxillary dentition so long as the pressure is applied gradually and directly into the maxilla over stable teeth. Any rapid acceleration in the anteroposterior dimension can lead to dental injury or loss.
With a simple set of basic precautions, the skilled surgeon can obtain excellent direct visualization of nearly all regions of the oropharynx, larynx, and hypopharynx. Of greatest concern is injury to the teeth. Although the tooth protector helps reduce the likelihood of injury, damage to the dentition can still occur through carelessness.
Most commonly, injuries occur when the surgeon attempts to inspect anterior structures and the wrist flexes to reduce the angle between the line of the scope and the floor. This places the proximal end of the laryngoscope against the teeth and uses them as a fulcrum to raise the distal tip of the laryngoscope into the base of tongue. Proper technique applies anterior pressure against the base of tongue with the laryngoscope, without using it or the teeth as a fulcrum, and keeps the proximal end of the laryngoscope off of the teeth. One usually knows that the technique is correct when the patient’s head comes off the table.

One method to reduce the risk of dental injury during laryngoscopy is to ensure the use of proper upward force by monitoring the surgeon’s arm muscle use or activation. Inappropriate “fulcrum” use of the laryngoscope involves bicep muscle use and suggests that the surgeon is not providing the appropriate forces on the laryngoscope to achieve exposure. In contrast, to achieve the appropriate upward and forward force on the laryngoscope during pharyngoscopy and laryngoscopy, significant tricep and deltoid muscle activation should be used. This is especially helpful when training and monitoring students of laryngoscopy.   CARosen
Proper head positioning for direct laryngoscopy is famously controversial and hotly debated among laryngologists. In general, head position is largely dependent on the patient’s anatomy and the region the surgeon wishes to inspect. If an operative table with adjustable head position is used, a shoulder roll is generally not required.
The examination may begin in the “sniffing” position with the atlanto-occipital joint extended and the neck gently flexed. This position is suitable for careful inspection of the oropharynx and hypopharynx. Often the larynx may also be exposed adequately in this position.
Greatest anterior exposure of the larynx with little or no dental pressure can be obtained with the neck flexed and the atlanto-occipital joint flexed (Figure 3-6) . Raising the head of the operating table facilitates this positioning. Although this view is excellent for diagnostic examinations, it is often cumbersome for the surgeon because the laryngoscope is pointed near vertically and the patient cannot be placed in suspension in this position easily.

FIGURE 3-6 Greatest anterior exposure of the larynx with little or no dental pressure can be obtained with the neck flexed and the atlanto-occipital joint flexed.

To optimize exposure of the pharynx and larynx for direct examination, the basic principle of neck flexion and head extension is not controversial and is an essential tenet for pharyngoscopy and laryngoscopy. Neck flexion is easily achieved using an elevated head pillow, with or without upward rotation of an articulated head of the operating table. Head extension can be achieved during laryngoscopy (especially during suspension of the laryngoscope). Any unfavorable angle of the suspended laryngoscope for microlaryngoscopy can be overcome easily by placing the operating room table in Trendelenburg position or using articulated eyepieces of the microscope.   CARosen
In contrast, the distal hypopharynx and cervical esophagus can be visualized most easily with both the atlanto-occipital joint and neck extended (Figure 3-7) . This position is often used for rigid esophagoscopy and is readily obtained by lowering the head of the bed.

FIGURE 3-7 The distal hypopharynx and cervical esophagus can be visualized most easily with both the atlanto-occipital joint and neck extended.

Remarkably, the sniffing position is widely espoused as the optimal position for exposure of the glottis and therefore intubation. In fact, flexion of the neck and atlanto-occipital joint (see Figure 3-6 ) provides optimal viewing in a difficult laryngoscopic exposure, which was recognized by Johnson 10 a century ago. 11, 12 Endotracheal intubation 13, 14 was done approximately 15 years after the conventional introduction of direct laryngoscopy, and anesthesiologists copied the surgeons’ sniffing position using similar viewing vectors from the head of the bed. However, surgeons required this viewing vector to perform substantial instrumentation of soft tissues while anesthesiologists could easily intubate patients in flexion-flexion position (see Figure 3-6 ).   SMZeitels
The surgeon may need to adjust his or her body and head position to obtain direct line of sight down the laryngoscope. Additional extension of the atlanto-occipital joint and neck is improper and may lead to dental injury as the laryngoscope contacts the teeth.

Reverse Trendelenburg position adjustments typically allow for more comfortable head and neck position of the surgeon.   SMZeitels

The surgeon must be aware of his or her body, head and neck alignment. Great care should be exercised to avoid sticking one’s chin out too far or extending one’s neck too much. Careful positioning by the surgeon is essential to avoid acquiring long-term cervical spine degenerative changes. Do not be afraid to ask your assistant, nurse, or other member of the operative team if your “head is situated over your shoulders.”   RHOssoff
Injuries to the pharyngeal mucosa and tongue can occur through aggressive manipulation of the laryngoscope. The best means to avoid these injuries is to know the location of and maintain precise control over the distal tip of the laryngoscope. It is not uncommon for the surgeon to be inspecting mucosa, but not be entirely certain where the mucosa is within the oropharynx or hypopharynx. The natural reaction is to start looking side to side and deeper to see if more landmarks come into view to allow orientation. This tendency must be avoided and the surgeon should gently withdraw the laryngoscope until known anatomic structures come into view. Once reoriented to the position of the distal tip of the laryngoscope, the surgeon may then advance the scope carefully and attempt to identify the next landmark. Useful landmarks include the uvula, the epiglottis, the arytenoids, and the endotracheal tube itself. Poorly oriented attempts to perform laryngoscopy will lead to mucosal injury and bleeding, which only compounds the difficulty of the examination.
The importance of orientation should contribute to the surgeon’s decision on which laryngoscope to use because small scopes allow only a limited view of critical landmarks. In general, the surgeon should choose the largest laryngoscope that can be used to evaluate all portions of the anatomy.
STEP 6. Perform oropharyngeal examination.
Endoscopic evaluation typically begins with examination of the oropharynx (Figure 3-8) . For a right-handed surgeon, pharyngoscopy and laryngoscopy begin with a scissoring motion of the left thumb and forefinger to open the jaw. The structures that should be identified discretely and carefully inspected include the soft palate, the tonsils, the palatoglossal folds, the base of tongue and vallecula, the lingual surface of the epiglottis, the lateral pharyngeal walls, the posterior pharyngeal walls, the walls and apex of the piriform sinuses, the postcricoid mucosa, the esophageal introitus, the laryngeal surface of the epiglottis, the aryepiglottic folds, the arytenoids, the interarytenoid space, the false vocal folds, the ventricles, the true vocal folds, and the immediate subglottis.

FIGURE 3-8 Examination of the oropharynx.
The surgeon should develop his or her own methodical system that evaluates all of the anatomy and is repeated in the same order and manner with every examination to ensure that all areas of the anatomy are inspected thoroughly. The following is one method for inspecting all of these structures.
The scope is inserted with the right hand and the surgeon immediately begins the process of orientation. The surgeon should pay careful attention to the lower lip and corner of mouth as he or she passes the laryngoscope because it easy to pinch between the teeth and the scope. Insertion in the midline rapidly yields a view of the uvula and soft palate (Figure 3-9) . The posterior pharyngeal wall may be visualized at this point. In returning the laryngoscope to the uvula, the surgeon may trace the soft palate laterally to the right tonsillar fossa. At the inferior pole of the tonsil, the surgeon may proceed to the palatoglossal fold and base of tongue. As the surgeon draws the tip of the scope medially, the vallecula and lingual surface of the epiglottis come into view and may be inspected (Figure 3-10) . The same structures on the left may be visualized as the surgeon draws the scope to the left palatoglossal fold and inferior tonsil pole. As the surgeon draws the scope up the left tonsillar fossa and, palate the uvula again comes into view.

FIGURE 3-9 View of the uvula and soft palate, as well as the posterior pharyngeal wall.

FIGURE 3-10 The vallecula and lingual surface of the epiglottis come into view.
Some patients release copious saliva following induction of anesthesia. If this causes any difficulty with visualization, the surgeon or anesthesia staff may administer a small dose of glycopyrrolate (Robinul). Typically 0.2 mg is effective. Glycopyrrolate can cause significant urinary retention, particularly in older men.

There is a substantive time delay (about 20 minutes) between the administration of glycopyrrolate and decreased salivation; therefore, this medicine should be given preoperatively for patients undergoing direct pharyngoscopy and/or laryngoscopy, unless there is a medical contraindication.   CARosen
STEP 7. Perform hypopharyngeal examination.
With the uvula in view, the distal tip of the laryngoscope is pressed into the tongue and tongue base. This should bring the tip of the epiglottis into view with little or no rotation of the laryngoscope. Careful direction of the laryngoscope laterally will demonstrate the palatoglossal fold. Keep the proximal end of the laryngoscope off the teeth; the scope may be gently passed into the superior aspect of the piriform sinus.
To facilitate the examination the surgeon may direct the shaft of the laryngoscope into the lingual sulcus, thus displacing the tongue away from the side being inspected. This usually allows continued anterior passage of the laryngoscope without rotation of the laryngoscope. As the piriform sinus is entered, the surgeon will note that there are no landmarks in this cone of mucosa leading to the apex. This is an easy region to lose orientation.

The hyoid bone laterally and the pharyngoepiglottic fold anteriorly demarcate the oropharynx from the hypopharynx, which can be helpful in defining and mapping the geography of cancer in this region. The pharyngoepiglottic fold is the surface mucosal structure overlying the hyoepiglottic ligament.   SMZeitels
Gentle passage of the scope should continue to yield a potential space that ends in a blind pouch (Figure 3-11) . This is the apex of the piriform sinus and may be confirmed by gentle palpation of the distal tip of the scope medially against the cricoid cartilage. The esophageal introitus should be viewed with slight medial observation and confirms orientation. As the scope is drawn medially, the postcricoid mucosa and posterior hypopharyngeal wall may be inspected. Once the examination is completed, the laryngoscope may be withdrawn to the uvula and the sequence may be repeated on the opposite side.

FIGURE 3-11 The apex of the piriform sinus.
STEP 8. Perform laryngeal examination.
From the uvula, the laryngoscope is again pressed into the tongue to visualize the tip of the epiglottis. Rotation of the tip of the laryngoscope superiorly and gentle advancement allows passage of the tip posterior and superior to the tip of the epiglottis. This allows inspection of the aryepiglottic folds and some of the laryngeal surface of the epiglottis. The surgeon should note that the laryngeal surface of the epiglottis is parallel to the tip of the laryngoscope and complete inspection of this region often requires an angled telescope.
The aryepiglottic folds should be followed on both sides to the arytenoid cartilages. These may be gently palpated with a suction or blunt probe to confirm mobility, if indicated.

If arytenoid joint fixation and the subsequent diagnosis of arytenoid ankylosis and/or dislocation is a preoperative clinical concern, then during the direct laryngoscopy, it is best to perform palpation of the arytenoids and subsequent cricoarytenoid joints either as an awake, in-office procedure, or before the endotracheal tube is in place and/or the laryngoscope is suspended. Optimal visualization of the posterior glottis and the arytenoids should be achieved prior to an endotracheal tube being inserted. Each arytenoid should be independently palpated just anterior to the vocal process of the arytenoid cartilage. One should be looking for decreased motion or “stiffness” of the cricoarytenoid joint during lateral traction applied to the arytenoid. In addition, careful examination of the posterior commissure should be done during this maneuver to fully evaluate the possibility of posterior glottic stenosis (a common cause of bilateral vocal fold motion impairment).   CARosen
The interarytenoid space should be inspected. If the endotracheal tube is taped to the patient’s left lower lip, the surgeon should inspect the interarytenoid space from the right arytenoid cartilage. With this cartilage in view, the scope tip should be directed posteriorly and placed behind the endotracheal tube. The tip may then be advanced inferiorly and the interarytenoid space will come into view as the endotracheal tube is moved gently into the anterior glottis (Figure 3-12) . The immediate posterior subglottis, often to the level of the first or second tracheal ring, may also be viewed from this position.

FIGURE 3-12 The interarytenoid space comes into view.

This is the technique that I use to visualize the posterior commissure, arytenoids and vocal process area.   RHOssoff
Withdraw the scope to the epiglottis, maintaining the tip of the scope inferior to the tip of the epiglottis. Applying pressure into the base of tongue with the shaft of the laryngoscope will gently lift the patient’s head from the operating table. The false vocal folds should come into view. These may be inspected and the vocal processes should also be seen.
Continued gentle application of pressure into the base of tongue should yield a view of the vocal folds and anterior commissure. If this region is difficult to expose, the surgeon may try elevating the head of the operating table 4 to 7 cm, applying gentle posterior pressure to the cricoid cartilage, or switching to a smaller laryngoscope. Sometimes the surgeon must make all of these changes in order to obtain an adequate view. One of the most common mistakes is to pass the laryngoscope tip too deep, which prevents full view of the anterior commissure. As a rule, if visualization is poor, the surgeon should first attempt to improve the exposure by gently withdrawing the laryngoscope before advancing it.

To further improve anterior exposure during direct laryngoscopy, the clinician should ensure that the patient’s head and neck are positioned in neck flexion and head extension. Also consider applying gentle anterior neck downward pressure in the area of the upper trachea and/or cricoid to maximize anterior commissure visualization during laryngoscopy and microlaryngoscopy.   CARosen
With the anterior commissure in view, the ventricles may be carefully inspected by pressing the false folds laterally with the tip of the laryngoscope (Figure 3-13) .

FIGURE 3-13 False versus true vocal folds.

The distal aperture of most tubular laryngoscopes (through 1960) is round posteriorly to expose the interarytenoid region (see Figure 3-12 ) because they were designed before the era of endotracheal tube placement during surgical laryngoscopy. Laryngoscopes such as the Jako, 15 Kleinsasser, 16 and Dedo 17 unnecessarily adopted that feature from earlier designs. Davis and associates 18 clearly demonstrated that glottic cancer resections often failed in the anterior commissure and posterolateral paraglottic region due to limitations in laryngoscopic exposure from the circular-oval laryngoscope speculum. However, the optimal shape of a distal laryngoscope lumen to expose the neoplasm in Figures 3-12 and 3-13 is triangular. 2 SMZeitels
Complete examination of the ventricular mucosa requires a sharply angled telescope (usually 70 degrees).

Use of telescopes (5 mm diameter, 30 cm in length) during direct laryngoscopy and microlaryngoscopy is essential and should be a routine part of all pharyngoscopy and laryngoscopy procedures, most notably after the laryngoscope has been suspended. Zero-, 30-, and 70-degree telescopes provide a “three-dimensional” view of many areas of the larynx and pharynx that are difficult to visualize with direct laryngoscopy and binocular microlaryngoscopy. These areas include the posterior commissure, the infraglottis, subglottis, anterior commissure, and the laryngeal ventricles. The use of angled telescopes through a suspended laryngoscope provides the surgeon important staging and “mapping” information that complements and supplements the information obtained from binocular, high-powered microlaryngoscopy.   CARosen

I completely agree that today telescopic evaluation using 0-, 30-, and 70-degree telescopes is an integral part of diagnostic and therapeutic microlaryngoscopy. I also routinely use these same telescopes to monitor operative progress as needed and to evaluate my results following completion of the case.   RHOssoff
Inspection of the immediate subglottis may be performed through the vocal folds or the laryngoscope may be gently passed through the vocal folds for improved visualization. Again, angled telescopes may be very useful to view the entire mucosa of the subglottis.
STEP 9. Biopsy suspicious pharyngeal and laryngeal lesions ( Figure 3-14 ).

FIGURE 3-14 Biopsy.
If any lesions are encountered during the examination, they should be noted and, after the entire examination is completed, the lesion(s) should be viewed again for consideration of biopsy.

An operative diagram of the larynx should be used in the operating room to document lesions seen during pharyngoscopy and laryngoscopy and location of biopsies. Preferably this is a standardized diagram that is placed in the medical record.   CARosen
If biopsy is indicated, the lesion and surrounding mucosa should be treated with topical 1 : 10,000 epinephrine for 2 to 3 minutes. Once vasoconstriction is initiated, the surgeon may proceed with biopsy.
Most of the lesions of the oropharynx, larynx, and hypopharynx that require biopsy for diagnostic purposes are mucosal and are amenable to simple biopsy with cup forceps between 2 and 4 mm in diameter. Biopsy involves pressing the open forceps into the lesion, closing the jaws, and rapidly withdrawing the forceps with a tearing action (see Figure 3-14 ). In most cases several biopsies should be obtained to ensure adequate tissue for diagnosis.
If the lesion appears to be submucosal, additional biopsies of the submucosa may be taken following initial removal of the overlying mucosa.
If the lesion is noted within the palatine tonsil, strong consideration should be made to unilateral tonsillectomy in order to ensure adequate tissue for biopsy and adequate postprocedure hemostasis. Although unilateral tonsillectomy results in oropharyngeal wall asymmetry which is annoying in subsequent surveillance for malignancy, routine removal of the opposite tonsil is unnecessary and increases postoperative pain and risk of bleeding.
Although biopsy in most regions is safe, special attention should be paid to lesions of the membranous vocal fold. Superficial lesions of the true vocal fold that are worrisome for malignancy should be biopsied.
Because limited lesions may be treated with microsurgery or radiation therapy for definitive management, the surgeon should pay very careful attention to biopsy technique to avoid biopsy of any normal tissues. Although bulky tumors may be biopsied with large-cup forceps without magnification, proper evaluation and biopsy of small lesions of the vocal folds is best performed with an operating microscope and microlaryngeal instruments to minimize the chance of permanent dysphonia following definitive management.
Excessively deep biopsies may violate the vocal ligament, leading to sulcus formation. Indiscriminant vocal fold “stripping” should be condemned because it can lead to excessive loss of the lamina propria and profound dysphonia. Biopsy or stripping near the anterior commissure can also lead to anterior glottic web formation and should be performed with adequate magnification and great care.

It is also important to note that there is often a role for a microflap approach for removal of vocal fold lesions that allows for optimal and maximal precision of tissue removal and orientation of the specimen.   CARosen

Today proper care and respect for the tissues of the vocal folds represents the standard of care. Use of the operating microscope with mid to high magnification similar to otologic microsurgery of the middle ear is the expectation. The microflap approach can be used with good confidence and is ideal to manage premalignant and superficial malignant lesions of the vocal folds. Vocal fold stripping is of historical significance only and should not be used as a technique for mucosal removal.   RHOssoff
STEP 10. At the conclusion of laryngoscopy, treat the larynx with topical anesthetic to reduce the chance of laryngospasm.
This can be easily accomplished with several milliliters of 4% lidocaine solution sprayed onto the vocal folds.
STEP 11. Remove the laryngoscope and the dental protector.
STEP 12. Suction the patient’s oral cavity and oropharynx clear of blood and secretions.
STEP 13. Return the patient to the anesthesia staff for extubation.
In order to prevent laryngospasm, extubation should be delayed until the patient is awake and following commands.

Suggested Readings

Benjamin B, Lindholm CE. Systematic direct laryngoscopy: the Lindholm laryngoscopes. Ann Otol Rhinol Laryngol . 2003;112(9 Pt 1):787-797.
Friedrich G, Kiesler K, Gugatschka M. Curved rigid laryngoscope: missing link between direct suspension laryngoscopy and indirect techniques? Eur Arch Otorhinolaryngol . 2009;266(10):1583-1588.
Hochman II, Zeitels SM, Heaton JT. Analysis of the forces and position required for direct laryngoscopic exposure of the anterior vocal folds. Ann Otol Rhinol Laryngol . 1999;108(8):715-724.
Zeitels SM. Atlas of phonomicrosurgery and other endolaryngeal procedures for benign and malignant disease . San Diego: Singular; 2001. pp 23-36

Suggested References of Historical Interest Provided by Dr. Zeitels

1 Holinger PH. An hour-glass anterior commissure laryngoscope. Laryngoscope . 1960;70:1570-1571.
2 Zeitels SM. A universal modular glottiscope system: the evolution of a century of design and technique for direct laryngoscopy. Ann Otol Rhinol Laryngol . 1999;108(Suppl 179):1-24.
3 Jackson C, Tucker G, Clerf LH. Laryngostasis and the laryngostat. Arch Otolaryngol . 1925;1:167-169.
4 Killian G. Die Schwebelaryngoskopie und ihre praktische Verwertung . Vienna: Urban & Schwarzenberg; 1920.
5 Grundfast KM, Vaughan CW, Strong MS, De Vos P. Suspension microlaryngoscopy in the Boyce position with a new suspension gallows. Ann Otol Rhinol Laryngol . 1978;87:560-566.
6 Killian G. Die Schwebelaryngoskopie. Archr Laryngol Rhinol . 1912;26:277-317.
7 Zeitels SM, Burns JA, Dailey SH. Suspension laryngoscopy revisited. Ann Otol Rhinol Laryngol . 2004;113:16-22.
8 Reference deleted in proofs.
9 Jackson C. Position of the patient for peroral endoscopy, in peroral endoscopy and laryngeal surgery . St. Louis: Laryngoscope Co; 1915. pp 77-88
10 Johnston RH. Some original endoscopic methods. Laryngoscope . 1913;23:607-617.
11 Hochman II, Zeitels SM, Heaton JT. An analysis of the forces and position required for direct laryngoscopic exposure of the anterior vocal folds. Ann Otol Rhinolaryngol . 1998;108:715-724.
12 Hochman II, Zeitels SM. Exposure and visualization of the glottis for phonomicrosurgery. Op Tech Otolaryngol Head Neck Surg . 1998;9:192-195.
13 Elsberg CA. Clinical experiences with intratracheal insufflation meltzer, with remarks upon the value of the method for thoracic surgery. Ann Surg . 1910;LII:23-29.
14 Jackson C. Anesthesia for Peroral Endoscopy. Peroral Endoscopy and Laryngeal Surgery . St. Louis: Laryngoscope Co; 1915. 54-72
15 Jako GJ. Laryngoscope for microscopic observation, surgery, and photography. Arch Otolaryngol . 1970;91:196-199.
16 Kleinsasser O. Microlaryngoscopy and endolaryngeal microsurgery . Philadelphia: Saunders; 1968.
17 Dedo HH. A fiberoptic anterior commissure laryngoscope for use with the operating microscope. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol . 1976;82:ORL91-92.
18 Davis RK, Jako GJ, Hyams VJ, Shapshay SM. The anatomic limitations of CO 2 laser cordectomy. Laryngoscope . 1982;92:980-984.
CHAPTER 4 Operative Esophagoscopy and Percutaneous Gastrostomy

Author Joshua S. Schindler

Commentary by Nasir I. Bhatti, Robert G. Martindale, John R. Saunders, Jr.

Transnasal Esophagoscopy
STEP 1. Unsedated, thin-caliber esophagoscopy is performed under local anesthesia alone. The nasal cavity is prepared with topical nasal decongestant (e.g., oxymetazoline, phenylephrine) and local anesthetic (e.g., lidocaine, tetracaine [Pontocaine]) as in flexible laryngoscopy; 2% lidocaine water-based lubricant is then applied liberally to the nasal cavity on a cotton-tipped applicator.
It is preferable if the patient fasts before the procedure for a brief period, although I have not encountered problems if the patient has not done this. The surgeon is performing esophagoscopy, not gastroscopy, and the esophagus should be devoid of food that could obstruct visualization.

I instruct the patient not to eat solid food for at least 4 to 6 hours before the procedure.   NIBhatti

The application of the lidocaine in this manner allows the operator to assess which nares will be most optimal to pass the endoscope.   JRSaunders
STEP 2. The patient is positioned in a chair with the head comfortably supported. A 60- or 100-cm flexible esophagoscope is passed transnasally along the floor of the nose (Figure 4-1).

FIGURE 4-1 Transnasal esophagoscopy.
As a right-handed individual, I prefer to hold the scope in my right hand and advance the scope with my left. If bony obstruction prevents passage along the floor, the “middle road” just medial to the middle meatus entrance may be used. The scope is passed to the nasopharynx and then to the oropharynx.

Because most transnasal scopes are designed for right-handed operators, they function better by holding the endoscope with the left hand to manipulate the flexion or retroflexion dial with the left thumb, freeing the right hand to rotate and direct the scope.   JRSaunders
STEP 3. With the scope positioned just over the piriform sinus, the patient is asked to swallow forcefully. The scope is gently passed into the cervical esophagus through the upper esophageal sphincter (UES).
Gagging is expected and typically modest.

As in all passages of endoscopes this should be done under direct vision particularly because the passage through the lower esophageal sphincter (LES) can be somewhat tortuous.   JRSaunders

Pharyngeal anesthesia may make the patient very uncomfortable and may give a false but alarming sensation of not being able to breathe!   NIBhatti
STEP 4. Once in the cervical esophagus, the scope is gently passed to the stomach.
STEP 5. The stomach is gently inflated and inspected to a limited degree unless the 100-cm scope is used. Retroflexion of the scope allows visualization of the diaphragmatic hiatus and Z-line.
Patients tolerate unsedated, transnasal esophagoscopy extremely well. Although nasal anesthesia is essential to the procedure, pharyngeal and hypopharyngeal anesthesia often complicates the procedure because patients find it difficult to manage their own secretions. In some circumstances, pharyngeal application of benzocaine/butyl aminobenzoate/tetracaine (Cetacaine) may be used to diminish a strong gag reflex.
Patients should be warned and prepared for the gagging that occurs with passage of the scope through the UES. With a gentle touch this is limited or absent and, once the scope is in the cervical esophagus, usually extinguishes quickly.

Patients should be encouraged to belch any excess air that is insufflated during the procedure.   JRSaunders
STEP 6. After briefly examining the stomach, the stomach is suctioned free of air and the scope is withdrawn through the diaphragmatic hiatus to view the gastroesophageal junction. Biopsies for lesions or Barrett’s esophagus may be taken through the working channel.
Several passes are often necessary to adequately visualize the entire gastroesophageal junction, or Z-line. Biopsies of the esophagus in the absence of sedation are challenging because of the constant peristalsis, and the surgeon must ensure adequacy of the specimen. Often, grasping the tissue with the forceps and pulling back and forth under direct visualization will allow determination if the area to be biopsied has been captured in the forceps. Lesions in the cervical esophagus are even more challenging because this region is more sensitive to pain than is the distal esophagus.

I haven’t found this to be a problem. The main problem is the extremely small sample that can be biopsied with each pass of the biopsy forceps.   JRSaunders
STEP 7. The scope is gently withdrawn through the remainder of the esophagus, noting structural and mucosal abnormalities. Once withdrawn into the hypopharynx, the scope may be withdrawn completely.
The mucosa of the UES and lower hypopharynx cannot adequately be assessed with a flexible endoscope, and thus if a lesion is suspected in this area, sedated rigid laryngoscopy and esophagoscopy are indicated to adequately view this region.

Operative Flexible Esophagoscopy
STEP 1. Under general anesthesia flexible esophagoscopy is performed by grasping the patient’s jaw and lifting anteriorly. The scope is then placed transorally with a gentle inferior curve. With the scope draped over the surgeon’s shoulder, the surgeon gently passes the flexible esophagoscope gently into the hypopharynx and through the UES. This is done blindly by palpation (Figure 4-2).

FIGURE 4-2 Transoral flexible esophagoscopy, with the patient under general anesthesia.
Operative flexible esophagoscopy can be performed with either sedative or general anesthesia. For the head and neck surgeon, this is usually performed under general anesthesia because of lesions in the oropharynx, hypopharynx, larynx, or esophagus and the difficulties in assessing these areas adequately with flexible techniques.
If the surgeon encounters resistance to passage, the scope is withdrawn 1 to 2 cm, rotated 5 degrees in either direction, and repassed.
Entering the cervical esophagus with a flexible scope under general anesthesia is one of the initial challenges of esophagoscopy. With practice it becomes very easy to place the scope by this method and it is very fast. Many head and neck cancer patients have strictures and altered anatomy in this region. This can complicate passage of the scope and may prove to be impossible without visualization. In such cases, a Miller or Macintosh laryngoscope from the anesthesia department can facilitate opening the hypopharynx and passing the scope under direct visualization into the cervical esophagus. In some cases, dilation is necessary before the scope can be placed.

In our resident training program we have the attending staff pass the scope as the resident steers the endoscope. It seems that about half the time the scope can be easily passed as previously described; other times the opening through the UES should be visualized before the scope is passed through.   JRSaunders

If the surgeon/operator has performed direct operative laryngoscopy and has used a shoulder roll, it should be removed to facilitate entry into the upper esophageal sphincter. Dilation in the case of previous radiation can be risky, and extreme caution and significant experience in esophageal endoscopy are warranted. Pulling the mandible forward as depicted in Figure 4-2 is often necessary.   NIBhatti
STEP 2. The surgeon passes the scope to the stomach and gently inflates it.
STEP 3. Once the scope is well into the midportion of the stomach lumen, retroflexion of the scope allows visualization of the diaphragmatic hiatus and Z-line.
STEP 4. The stomach is inspected as required and on completion suctioned to remove excess insufflated gas.
STEP 5. Visualization of the esophagus is done while withdrawing the scope.
Finger controls help keep the scope centered in the esophagus and allow visualization of all mucosal surfaces.
Biopsies may be taken though the 2.3-mm working port. Once passed through the UES into the hypopharynx, the scope is withdrawn.

Rigid Esophagoscopy
STEP 1. Rigid esophagoscopy is performed transorally under general anesthesia with the patient completely relaxed. A tooth protector is placed on the maxillary dentition and the neck is extended to bring the esophagus in line with the oral cavity (Figure 4-3).

FIGURE 4-3 Positioning for rigid esophagoscopy.
STEP 2. The scope is passed into the hypopharynx and then into the cervical esophagus.
STEP 3. With gentle elevation of the tip of the scope and protection of the maxilla with the thumb or forefinger, the scope is gently passed through the cervical esophagus (Figure 4-4).

FIGURE 4-4 Initiating rigid esophagoscopy.
The surgeon must keep a lumen in view while advancing the scope (Figure 4-5) .

FIGURE 4-5 Advancing rigid esophagoscope.
Rigid esophagoscopy is tremendously valuable for evaluation of lesions in the hypopharynx and their extension into the cervical esophagus. It is a particularly dangerous technique in inexperienced hands, however. It is very easy to pass the scope through a stricture, neoplasm, or Zenker’s diverticulum into the mediastinum. Unrecognized, such injuries can be fatal. Prompt management of such complications with cessation of oral intake, enteral bypass (feeding tube) placement, and mediastinal drainage is critical. Proper positioning and depth of anesthesia are also important to help prevent serious complications.

The rigid esophagoscope should ideally be advanced by traction using the thumb on the undersurface of the scope. Rotating the patient’s head from side to side can facilitate visualization of the lumen.   JRSaunders

As otolaryngologists become more and more familiar with flexible esophagoscopy, experience with rigid esophagoscopy is diminishing. Extreme caution is therefore advised to avoid passing a rigid esophagoscope into the mid- and especially lower esophagus. Asking the anesthesiologist to help with muscle relaxation is always helpful.   NIBhatti
STEP 4. The scope is advanced only to the mid- or upper portion of the distal third of the esophagus.
It becomes increasingly difficult (and dangerous) to pass it to the distal esophagus. Biopsies may be taken directly or with the use of an operating telescope.
STEP 5. The rigid esophagoscope is gently withdrawn under direct visualization.

Percutaneous Gastrostomy
STEP 1. Begin percutaneous gastrostomy tube placement by performing flexible esophagogastroduodenoscopy.
Percutaneous gastrostomy placement is a valuable skill for a head-and-neck surgeon. With proper patient selection and attention to technique, it is extremely safe.
Prior to placement of a percutaneous gastrostomy, the surgeon should inspect the entire upper gastrointestinal (GI) tract to at least the first portion of the duodenum. This is important to exclude pathology in these sites and to understand the position and geometry of the pylorus and lesser curvature of the stomach.
Percutaneous procedures should be considered with extreme caution in patients with previous abdominal surgery and obesity. Relative contraindications include ascites and the presence of malignant lesions of the esophagus, stomach, or duodenum.
During gastrostomy placement the greatest danger is malposition of the tube with placement into or through the colon, small bowel, or liver edge. Thus patients with previous intraabdominal surgery should be considered for referral for possible open gastrostomy placement.

Patients with prior surgery for ventral hernia repairs with synthetic mesh are especially at risk. Passing the gastrostomy tube through synthetic mesh will have a disastrous result of abdominal wall infection and fasciitis.   RGMartindale

A single dose of a broad-spectrum antibiotic is given prior to the procedure (see Jafri et al, 2007).   JRSaunders
STEP 2. The scope is passed to the stomach and through the pylorus to exclude malignant or dangerous pathology (e.g., advanced duodenal ulcer) that might require additional treatment or be a contraindication to gastrostomy placement.

In addition to the malignant lesions noted, patients with portal gastropathy will have large venous structures noted in the submucosa.   RGMartindale
STEP 3. With the stomach inflated, an assistant palpates the epigastrum just inferior to the costal margin with a single finger (Figure 4-6).

FIGURE 4-6 Palpating for suitable position for gastrostomy.
This palpation should be seen endoscopically as a discrete projection into the anterior stomach wall. Transillumination of the skin around the depression may be performed in a darkened room. Placement of the gastrostomy tube too close to the pylorus can allow natural passage of the balloon or bolster into the duodenum and lead to gastric outlet obstruction.The procedure may be aborted in favor of open gastrostomy tube placement if visualization of stomach anatomy is not perfect.

We like to start from lateral to medial until the area of maximum indentation is found. For questionable sites, the Ponsky technique of passing a needle with an attached saline-filled syringe through the puncture site until it is visualized in the stomach, without other air entering the syringe, signifying entry through another gas-filled viscus, can be helpful (see Ponsky, 1998). Patients who have had prior gastric resection may have gastric remnants that are too small to be insufflated to the abdominal wall. They may have a retro-colic anastomosis, making the Ponsky syringe technique an important addition.   JRSaunders

Using a single finger to palpate the epigastrium cannot be overstated. If a large portion of the anterior wall of the stomach depresses with the finger palpation, the surgeon should continue to search the anterior abdominal wall for a point where the stomach is easily noted to see projection onto the stomach wall with even mild pressure. This will minimize the potential of passing a needle through the liver edge or colon.   RGMartindale

Otolaryngologists with limited experience should ensure seeing transillumination of the abdominal wall. This will reduce the risk of misplacement of the tube into the colon.   NIBhatti
STEP 4. While keeping the stomach inflated, the assistant chooses a site two fingerbreadths below the costal margin between the xiphoid process and the anterior axillary line on the left (Figure 4-7).

FIGURE 4-7 Site selection for percutaneous gastrostomy.
Endoscopically, the point should be lateral to the lesser curvature so as to prevent migration of the gastrostomy tube through the pylorus.

If a combination tube of gastrostomy and jejunostomy may be needed, the tube should be placed near the antrum to allow easy placement of the jejunostomy portion of the combination tubes.   RGMartindale
STEP 5. The abdomen is prepped and draped in sterile fashion. A 1-cm vertical incision is made at the site on the anterior abdominal wall.

The size of the incision is much more important than the orientation.   JRSaunders
STEP 6. With the stomach fully inflated, a needle catheter is passed into the stomach.

An additional method to “test” for appropriate approximation of the anterior abdominal wall and stomach is to place a 1.5-inch 21- or 23-gauge needle through the anterior abdominal wall and evaluate the location and angle of entry of needle into the stomach. After this is confirmed, the larger 12- or 14-gauge needle catheter is placed.   RGMartindale
STEP 7. A wire is passed through the catheter and grasped with a snare through the gastroscope.
The surgeon should be aware that there are different kits and methods to gastrostomy tube placement (availability may vary substantially from institution to institution). The Ponsky pull technique is described, but push techniques are common as well. It is the surgeon’s obligation to full understand what kits are available and how these tubes are placed.

Other commercially available choices for gastrostomy tube placement kits include the technique of T-fasteners used to pexy the stomach to the anterior abdominal wall. The Seldinger technique is then used to place the gastrostomy tube by first passing a needle, followed by a guidewire. Dilators are then passed over the wire, followed by the tube, with a balloon to secure it in the stomach.   NIBhatti
STEP 8. The scope, snare, and wire are brought out through the mouth and a gastrostomy pull-type tube secured to the wire (Figure 4-8).

FIGURE 4-8 Passing guidewire for percutaneous gastrostomy.
During the procedure, gentle insufflation of the stomach with complete effacement of the normal rugae helps ensure that the stomach “floats” up to the anterior abdominal wall and displaces other organs that may be between it and the peritoneum.
Good visualization and control of the wire during the procedure are also critical to prevent injury to the stomach.

Too much air insufflation can push air into the jejunum and interfere with gastric apposition to the abdominal wall.   JRSaunders
STEP 9. The wire is then withdrawn from the abdomen side, pulling the gastrostomy tube through the mouth and through the esophagus (Figure 4-9).

FIGURE 4-9 Pulling gastrostomy into stomach wall.
STEP 10. The gastrostomy tube is secured at the abdominal wall between 2 and 4 cm from the skin depending on the girth of the patient (Figure 4-10).

FIGURE 4-10 Securing gastrostomy tube to abdominal wall.
The tube should be secured snugly, but not tightly against the skin to prevent necrosis and “buried bumper syndrome.”

We don’t secure the tube in any way and prefer it to have some play rather than to be snug.   JRSaunders

Keeping the tube exiting the abdomen at a 90-degree angle will help prevent mucosal and skin necrosis. When the tube is allowed to hang to one side or the other, the internal bolster places excessive pressure on the mucosa and causes pressure necrosis, leading to leakage and increased risk of infection. The tube can be easily kept at a 90-degree angle by placing a Kerlix or small face towel placed at the base of the tube.   RGMartindale
STEP 11. The tube is attached to a straight drainage bag and the gastroscope removed.
Although feeding may begin immediately after placement, we find that many patients do not tolerate feeding shortly following the procedure and we prefer to “rest” the stomach and GI tract by connecting the new gastrostomy tube to a straight drainage bag for 24 hours before feeding.

We allow administration of enteral medication in small volumes (<50 mL) immediately after tube placement.   NIBhatti

We generally wait for the return of normal bowel sounds at 1 to 24 hours before initiating feeding.   JRSaunders

Postoperative Considerations for Percutaneous Gastrostomy
Late complications are rare following percutaneous gastrostomy placement. Subdiaphragmatic air following the procedure is common on chest x-ray and should not cause alarm.

The air can be noted under the diaphragm for approximately 4 to 5 days, and if present over 5 days, concern of gastric leakage should increase.   RGMartindale
Rebound tenderness, fever, bowel obstruction, and vomiting should be evaluated very carefully following the procedure for perforation of the large or small bowel. Leakage around the gastrostomy after resuming feeding is typically the result of gastric stasis rather than breakdown of the gastrostomy site. Stimulation of the stomach motility prokinetic agents may be helpful.

We recommend that patients rotate their tubes 360 degrees daily. This helps ensure that the mushroom end of the tube has remained in the stomach rather than being extruded into the tract. If there is a question regarding this, the bumper can be withdrawn, and the tube should easily move back and forth into the stomach. Gastrografin tube studies can be misleading for tubes that are partially extruded but still in communication with the gastric lumen. Extruded tubes are generally easily removed using topical lidocaine gel and replaced with a balloon gastrostomy tube in an office setting.   JRSaunders

Pain at the gastrostomy site should be evaluated carefully. Buried bumper is a common etiology. The occurrence is most common when the gastrostomy tube is pulled too tightly to the abdominal wall.   RGMartindale
Erythema and local skin excoriation around the gastrostomy site is common and often best treated with gentle loosening of the skin flange. Antibiotics with activity against gram-positive cocci (e.g., cephalexin) may be useful for erythema consistent with cellulitis around the site. Yeast organisms are also a common cause of erythema under the skin flange, particularly in patients who have regular leakage of tube feed around the flange. Skin barriers and antifungal creams may be helpful in managing such problems.

The routine cleaning of the peritube site with mild soap and warm water will prevent most gastrostomy tube site irritations and skin problems.   RGMartindale
Seeding of the gastrostomy tube site with upper aerodigestive tract cancer has been reported, but is incredibly rare. Although direct contact and transfer of tumor cells has been suggested as a mechanism, other data suggest that hematogenous spread of malignancy with subsequent seeding of the gastrostomy wound may play a greater role. We do not consider the presence of upper aerodigestive tract malignancy a contraindication to gastrostomy tube placement or the use of “pull-type” tubes, such as those described in the technique described earlier.

Editorial Comment
Changes in technology (thin caliber esophagoscopes that can be passed transnasally) and procedures (percutaneous versus open gastrostomy) have greatly expanded the head-and-neck surgeon’s role and capability in the field of esophagology. A familiarity with each of the techniques is important, and they should be seen as complementary rather than competitive with respect to the more traditional rigid esophagoscopy and open gastrostomy, which still have a role. Most of the serious problems that arise from these procedures can be traced to trying to push a given approach beyond its safe limitations rather than choosing an alternate one.   JICohen

Suggested Readings

Ghogomu NT, Kallogjeri D, Nussenbaum B, Piccirillo JF. Iatrogenic esophageal perforation in patients with head and neck cancer: evaluation of the SEER-Medicare database. J Otolaryngol Head Neck Surg . 2010;142:728-734.
Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther . 2007;25:647-656.
Ponsky JL. Transilluminating percutaneous endoscopic gastrostomy. Endoscopy . 1998;30:656.
Postma GN. Transnasal esophagoscopy. Curr Opin Otolaryngol Head Neck Surg . 2006;14:156-158.
Schrag SP, Sharma R, Jaik NP, Seamon MJ, Lukaszczyk JJ, Martin ND, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis . 2007;16:407-418.
CHAPTER 5 Operative Bronchoscopy

Author Joshua S. Schindler

Commentary by Seth M. Cohen, Paul W. Flint, Tanya K. Meyer

General Preoperative Considerations
For either flexible or rigid bronchoscopy, the surgeon should have all available information in the room prior to starting the procedure. In common cases, such as upper aerodigestive tract tumors and airway stenosis, computed tomography (CT) scans of the area of concern can be critically important in assessing the extent of a given lesion.
Unlike pulmonologists, otolaryngologists must perform bronchoscopy at times when most indications mandate general anesthesia. This means that management of the airway throughout the procedure is of paramount importance and the primary responsibility of the otolaryngologist. Preoperative assessment of the patient’s oral, pharyngeal, laryngeal, and tracheobronchial anatomy through physical examination, indirect laryngoscopy, and radiographic imaging is critical to safely maintaining ventilation during the procedure.
The surgeon must consider the relative pulmonary health of each patient to understand how that patient will tolerate periods of inadequate ventilation. In many cases the pathology may not allow intubation or even adequate bag-mask ventilation, and the surgeon must be prepared for multiple contingencies. Although a careful appraisal of the surgeon’s comfort, skill, and available equipment for direct laryngoscopy (see Chapter 3 ) is essential, bronchoscopy can add additional challenges to ventilation that must be considered prior to inducing general anesthesia.
It is vitally important that the surgeon meet with the anesthesiologist prior to induction to review the plan for managing the airway. Although this management should be considered the responsibility of the surgeon, there are a number of airway measures with which the anesthesiologist is more familiar that can be life-saving in emergencies.

One of the most important steps in operative airway management is preoperative planning including discussions with anesthesia and having multiple plans for airway management.   SMCohen

In an average adult patient, assuming adequate preoxygenation, after cessation of respiration there is approximately 3 minutes until desaturation, 6 minutes until asystole, and 11 minutes until brain death (this varies by the age of the patient and comorbidities). Thus it is critical to be prepared for contingency plans in case of failure of the primary airway plan before the patient enters the operating room (OR). If the contingency plan for securing the airway is a fiberoptic intubation, that fiberoptic scope should be in the OR, and the optics, light source, and suction should be tested before the patient arrives. If the contingency plan is a tracheotomy, the tracheotomy tray needs to be open with the appropriate blade loaded on the scalpel. There is no time to search for equipment when the operative team is moving from the primary to the contingency airway plan.
It is important to ensure proper positioning of the patient on the OR table prior to the start of anesthesia. Make sure that the head of the bed can flex superior and inferior to facilitate placing the patient in the proper “sniffing” position for optimal laryngeal exposure. Also make sure that the patient is positioned at the very head of the table so that the surgeon or anesthesiologist does not have to reach an additional distance to manipulate the airway.   TKMeyer
In some cases, stabilization of the airway with an awake tracheotomy under local anesthesia prior to induction of general anesthesia is the safest way to proceed with airway evaluation.

It is useful to calculate the maximal dose and volume allowed for lidocaine for each patient. During flexible bronchoscopy in a sensitive patient, it is possible to get near the toxic lidocaine dose, especially if the 4% topical lidocaine is used. It may be safer to use 1% or 2% plain lidocaine preparations in these cases.   TKMeyer

Flexible Bronchoscopy Preoperative Considerations
Otolaryngologists most commonly perform flexible bronchoscopy with the patient intubated because the procedure is usually part of a comprehensive panendoscopy of the upper aerodigestive tract. Because of this it is important to discuss the intubation with the anesthesiologist prior to induction. The necessary diameter of the endotracheal tube depends on the bronchoscope used and the intent of the procedure. Most diagnostic procedures can be done with a 5.1-mm bronchoscope and 2-mm cup forceps for biopsies. These will easily fit down a 7-mm endotracheal tube and even a 6.5-mm tube. Therapeutic procedures, such as those performed for removal of large mucous plugs, dilation, or stent placement, require a 7-mm bronchoscope with a 2.8-mm working channel. These tubes fit best down a 7.5- to 8-mm endotracheal tube. Coordinating intubation with the anesthesiologist is helpful to avoid delays for tube changes.

It is useful to “test” the sizing by making sure the chosen bronchoscope fits through the endotracheal tube or laryngeal mask airway. Make sure that you have enough room for ventilation around the bronchoscope.   TKMeyer

Rigid Bronchoscopy Preoperative Considerations
Rigid bronchoscopy is substantially different from flexible bronchoscopy and is almost never performed in the absence of general anesthesia. In order to perform rigid bronchoscopy, the surgeon must obtain direct line-of-sight access to the lower airway. Although this is often easy in children because of their anatomy and particularly pliable tissues, obtaining line-of-sight access in adults can be difficult. As such, the surgeon may consider a variety of methods to view and manipulate the lower airway, some of which do not even require a rigid bronchoscope. Regardless of what method the surgeon uses, having a full complement of equipment used for direct laryngoscopy is often useful.

It is essential to make sure that all equipment that may be needed is available and working. Lighting for scopes and suction need to be checked prior to the patient entering the OR.   SMCohen

Flexible Bronchoscopy
STEP 1. Attach the swivel adaptor to the endotracheal tube ( Table 5-1 ).
TABLE 5-1 Equipment for Flexible Bronchoscopy
• Bronchoscope
• Swivel adapter (Bodi connector)
• Silicone lubricant
• Anti-fog solution
• Biopsy forceps
STEP 2. Pass the bronchoscope through the endotracheal tube to the distal tip ( Figure 5-1 ).

FIGURE 5-1 Flexible fiberoptic bronchoscopy through an endotracheal tube.
It is helpful to suction the endotracheal tube prior to advancing the bronchoscope to avoid collecting mucus at the tip. If the scope becomes fogged or covered with mucus, simply wipe the scope tip gently across the carina to clear the tip. Lavage of 2 to 3 mL of respiratory-grade sterile saline may also help.
For most diagnostic procedures the surgeon should avoid the urge to suction patches of mucus. These can clog smaller scopes and simply prolong the procedure.
STEP 3. Pass the scope to the carina and into the right mainstem bronchus. View the visible portions of the lower airway.
Use a combination of finger and wrist action for directional control of the distal tip of the scope. The surgeon should stand tall and keep the scope as extended and straight as possible. This allows the surgeon to “dance” using wrist rotation of the bronchoscope. Doing so is critical to add the third degree of freedom at the tip of the scope and allow atraumatic advancement into all air passages. If the scope is not extended, rotation of the body of the scope will only result in coiling of the cable rather than movement of the tip.

To further maintain visual orientation, it is helpful for the surgeon to turn slightly and face the side being examined.   PWFlint
Comprehensive bronchoscopy will inspect the mid and distal trachea, the carina, and bronchi including the right upper lobe, right bronchus intermedius, right middle lobe, right lower lobe, left upper lobe, left lingua, and left lower lobe. To enable the scope to pass, each segment should be noted and inspected for lesions. The proximal trachea is better visualized by direct laryngoscopy/tracheoscopy without an endotracheal tube in place using a rigid telescope (see Chapter 3 ).

During the examination, apply frequent suction in all areas inspected to assess for tracheomalacia. Collapse of anterior and lateral walls identifies segments with loss of cartilaginous support.   PWFlint

Having a standard evaluation algorithm can help ensure that all areas are inspected.   SMCohen
STEP 4. Biopsy suspicious lesions by passing the forceps through the working channel of the scope.
Most lesions in the lower airway can be biopsied. Although there can be a concern about creating a bronchopleural fistula or pneumothorax, these problems are rare with intraluminal lesions. The surgeon should exercise caution biopsying lesions that appear to be outside of or through the cartilaginous lumen as well as particularly vascular lesions.

Flexible bronchoscopy can also be easily performed under general anesthesia using a laryngeal mask airway (LMA) and spontaneous ventilation. The patient is induced and the LMA is placed by the anesthesia team. The swivel adapter is placed. The bronchoscope is introduced through the LMA. At the glottis, topical lidocaine can be given to prevent laryngospasm and coughing. Additional topical lidocaine can be given in the trachea—be careful to monitor total dose given. With this technique, vocal fold motion, the status of the subglottis, the dynamic stability of the trachea with respiration and cough (tracheomalacia), and the lower airways can all be assessed and manipulated.   TKMeyer

Equipment for Rigid Bronchoscopy ( Table 5-2 )
Bronchoscopes come in different sizes and lengths. In most situations a 40-cm bronchoscope is the appropriate length. A normal adult male airway will usually accommodate a 9-mm-diameter scope easily. Smaller patients, airway stenosis, and unusual anatomy may necessitate the use of smaller scopes.
TABLE 5-2 Equipment for Rigid Bronchoscopy
• Rigid bronchoscope
• Light source
• Suction
• Anesthesia circuit adapter (Jolly tube)
• 45-cm Hopkins rod telescope
• Macintosh (or other) laryngoscope (if needed)
In many cases a rigid bronchoscope is not necessary or desirable. In such cases the surgeon can establish the airway with a laryngoscope and suspension apparatus. Ventilation may be performed with intermittent removal and replacement of an endotracheal tube through the laryngoscope (intermittent apneic technique) or via jet ventilation. The jet ventilator is often the most efficient because it allows the surgeon to work with no endotracheal tube in the way and maintain ventilation. Again, a rigid 45-cm Hopkins rod telescope is useful for visualizing the airway.

Rigid Bronchoscopy
STEP 1. Place the bronchoscope in the oropharynx with the longer end of the beveled tip directed anteriorly.
STEP 2. Pass the scope behind the epiglottis and identify the glottis ( Figure 5-2A ).

FIGURE 5-2 A, Rigid bronchoscope insertion to larynx.
The bronchoscope has a tiny distal aperture given its length, and it can often be challenging to identify the glottis.
If secretions are a problem—which are cumbersome to suction from a 40-cm bronchoscope—the anesthetist may administer glycopyrrolate (Robinul) to reduce these.
A sturdy tooth protector is often helpful to prevent dental injury.
If the glottis cannot be easily identified, the surgeon may use a Macintosh or similar laryngoscope to expose the glottic aperture and place the rigid bronchoscope (see Figure 5-2B ).
A small amount of water-based lubricant on the outside of the bronchoscope can facilitate passage through the lower airways.
STEP 3. Rotate the bronchoscope 180 degrees to advance the scope into the cervical trachea ( Figure 5-3 ).

FIGURE 5-3 Rotate rigid bronchoscope to pass through glottis.
The beveled end of the scope facilitates exposure throughout the procedure. Like a laryngoscope, the longer end is adjacent to the epiglottis when exposing the larynx. Before passing through the glottic aperture the bevel is rotated to better view the airway as the surgeon passes the scope through the glottis.

Rotating the bevel is helpful to atraumatically lateralize one vocal fold to facilitate passage through the glottis.   SMCohen
Head position may change during this part of the procedure. It is often easiest to see the glottis with the neck slightly flexed, as in direct laryngoscopy. Once the glottis is exposed, the airway will angle more anteriorly and the surgeon may need to extend the neck substantially to safely advance the bronchoscope. A shoulder roll is rarely necessary if the head of the bed can be lowered to flex the neck.
STEP 4. Attach the proximal glass, ventilator adapter, and the anesthesia circuit to initiate ventilation.
Most rigid bronchoscopes have side holes that extend about 5 cm up from the tip. Because of this the surgeon cannot effectively ventilate with positive pressure from the anesthesia circuit until the scope tip is about 5 to 6 cm below the glottis.
Be aware that small-diameter bronchoscopes may leak substantially through glottic apertures of normal caliber. Effective ventilation is not possible unless the scope is closely sized to the airway lumen.
STEP 5. Carefully advance the bronchoscope to the carina.
With the bronchoscope in the cervical trachea, the surgeon “threads” the airway onto the bronchoscope by gently advancing the scope through the open lumen.
The rigid bronchoscope can be extremely dangerous if it is not carefully advanced through the airway. The junction of the membranous tracheal wall with the cartilaginous rings of the tracheal is particularly easy to separate and cause a bronchopleural fistula. The surgeon must always see an open lumen before advancing the scope and may need to rotate the scope slightly in order to take advantage of the beveled end.

The left hand is used to advance the scope (see Figures 5-2A and 5-3 ) in controlled increments while guiding with the right hand, thus minimizing the risk of injury.   PWFlint
STEP 6. Rotate the patient’s head to gain access to the bronchi ( Figure 5-4 ).

FIGURE 5-4 Turn patient’s head to the contralateral side to obtain straight line access to the bronchus.
Turning the head allows the surgeon to angle the scope into the right and left airways, using the glottis as the pivot point. To view the right mainstem bronchus, the surgeon should turn the patient’s head to the left and vice versa.
STEP 7. Biopsy suspicious lesions using a 2- to 4-mm cup forceps.

Bronchoscopy Without a Rigid Bronchoscope
STEP 1. Perform suspension laryngoscopy and expose the glottic aperture.
This is often the most useful way to perform airway evaluation and intervention. It affords the surgeon unencumbered access to the entire lower airway from the vocal folds to the lower lobe takeoffs. Without an endotracheal tube or rigid bronchoscope, the surgeon has much more room to manipulate instruments and work in several areas of the lower airway without adjusting the airway. The surgeon should use the largest laryngoscope that will allow visualization of the glottis and jet ventilation. I prefer the Lindholm laryngoscope when possible, but the Dedo laryngoscope will also work effectively.

In select patients, total intravenous anesthesia (TIVA) can be used to allow spontaneous ventilation. This works better in younger, thin patients without pulmonary disease.   TKMeyer
STEP 2. Establish jet ventilation.
Establishing jet ventilation can be tricky to those unfamiliar with the technique. Many laryngoscopes have a side channel to allow attachment of a jet ventilator and direct the air to the tip of the scope. Some laryngoscopes require small attachments for this. The “Hunsaker” needle may also be used.

Keep in mind that the procedure may also be performed under brief apneic conditions without the use of jet ventilation.   PWFlint
The surgeon should monitor for chest rise and fall to assure adequate ventilation and not simply oxygenation. Usually 20 to 30 mm Hg pressure is adequate for effective ventilation. In obese patients, reverse Trendelenburg position may be helpful to improve ventilation.
A suspension table (Mustard, Mayo, etc.) should always be used for jet ventilation because using the patient’s chest as the suspension surface may prevent adequate ventilation.
For this procedure, 100% oxygen may be used, and as long as nothing that can burn is placed in the airway, there is no risk of laser or electrical fire.
At no time should the proximal end of the laryngoscope be substantially obstructed, to avoid the risk of barotrauma.
The surgeon should wear eye protection during jet ventilation.
STEP 3. Perform bronchoscopy with a 45-cm by 5-mm 0- or 30-degree Hopkins rod telescope ( Figure 5-5 ).

FIGURE 5-5 Rigid telescope through laryngoscope for airway inspection.

A 70-degree telescope may also be useful.   SMCohen
The surgeon may need to adjust the patient’s head position and laryngoscope position to attain line-of-sight access through the trachea and bronchi. Use of a 30-degree endoscope may preclude the need to take the patient out of suspension and turn the head for visualization of the bronchi.
STEP 4. Biopsy suspicious lesions under close visualization using the telescope and 2- to 4-mm cup forceps.
When the procedure is completed, the surgeon may place a No. 6 endotracheal tube through the laryngoscope, withdraw the scope over the tube, and emerge the patient from general anesthesia at the discretion of the anesthesiologist with a secure airway.

Interventional Bronchoscopy with Tracheal Balloon Dilation
STEP 1. The surgeon should perform suspension laryngoscopy and bronchoscopy with jet ventilation and a 45-cm Hopkins rod telescope as described previously.
Rigid bronchoscopy can also be performed, but ventilation and visualization are both compromised as a result of the bronchoscope.
Jet ventilation can be used effectively with even the smallest airways (3 to 4 mm) and allows the greatest flexibility with instrumentation.
The stenosis should be inspected for position relative to the vocal folds and length (both in cm). It may also be palpated for rigidity. Tracheal stenoses come in many varieties. Cartilaginous collapse from previous tracheotomy is often “A-shaped” in configuration. In my experience, these are rarely ameliorated with dilation for long and typically require resection because they lack structural support for durable dilation. Membranous stenoses have normal and stable cartilaginous rings surrounding a circumferential fibrous and mucosal band in the airway. In the trachea, these are more common in inflammatory disorders, such as Wegener’s granulomatosis, and less severe endotracheal tube injuries. These are generally quite amenable to simple dilation. More comprehensive, and possibly more durable treatment, may be afforded by using radial incisions cut with a laser or definitive resection.

Biopsy of the stenosis is important to facilitate diagnosis.   SMCohen

As discussed under flexible bronchoscopy, it is important to identify tracheomalacia. In this situation, pass a rigid telescope and suction through the glottic aperture and apply suction. Collapse of anterior and lateral wall identifies segments with loss of cartilaginous support.   PWFlint
STEP 2. Dilate the stenosis using a continuous radial expansion (CRE) balloon ( Figure 5-6 ).

FIGURE 5-6 Balloon dilation of tracheal stenosis.
The balloon is inflated to dilate the stenosis and subsequently removed. The procedure may be repeated with a larger balloon, if desired. There is no great science for determining how much to dilate the patient’s airway stenosis. The risk, of course, is airway disruption with bronchopleural fistula and subcutaneous or mediastinal emphysema. Soft stenoses with cartilaginous collapse can often be dilated widely (18 to 20 mm), but will relax back to at least partially obstructed shortly following the procedure. Firm, fixed stenoses may be at greater risk of disruption during dilation. I have become more aggressive with dilating these with time and will generally dilate to about three times larger than the stenotic aperture. Most will accept dilation with a 15- to 18-mm balloon. Serial dilation in ever-increasing diameters of balloon from the original stenosis does not seem to yield any advantage over simply using the final 15- to 18-mm balloon.
Other methods of dilation, including serially increasing semirigid bougies, Jackson laryngeal dilators, and rigid bronchoscopes, may be used for simple dilation. I prefer the CRE balloons because they inflate within the airway and do not have the limitation of passing through the glottis. I would not try to pass an 18-mm bougie through the glottis. The CRE (controlled radial expansion) balloons are also gentle on the surrounding mucosa and may limit further airway injury.

New noncompliant balloons are available for tracheal dilation. I prefer to make radial incisions through areas with a large “shelf” of stenosis prior to balloon dilation with a noncompliant balloon. I typically use a 10- or 14-mm balloon. Adjuvant treatments such as mitomycin C may be applied after dilation.   SMCohen

Following dilation, redundant tissue extruding into the airway may be removed using laser ablation or excised with a 27.5-cm microdebrider with a 4-mm Tricut blade.   PWFlint
Once completed, the surgeon should be able to place a No. 6 endotracheal tube without difficulty, remove the laryngoscope, and return the patient to the anesthesiologist for emergence.

Tracheal balloon dilation can additionally be performed using flexible bronchoscopy through an LMA with spontaneous ventilation. It is important to check the length of the bronchoscope in relation to the balloon catheter. Some flexible bronchoscopes allow introduction of the balloon catheter through the working channel. Other bronchoscopes either do not have a working channel that is large enough, or the balloon catheter is not long enough to pass entirely out of the working channel. It is important not to inflate the balloon in the channel or the scope will be severely damaged. If there is a length discrepancy, a guidewire can be introduced through the working channel and into the distal tracheobronchial tree. The bronchoscope is removed leaving the wire in place. The balloon is introduced over the wire, and the bronchoscope is reintroduced alongside the balloon for visual confirmation of placement. The balloon can be inflated to allow dilation and then deflated to allow ventilation.   TKMeyer

Postoperative Considerations
Bronchoscopy is most commonly performed as an outpatient procedure. Even in cases of airway stenosis, the surgeon should be confident that the airway is larger than it was before the patient arrived.
Postoperative chest x-ray is not typically necessary.
Rarely, patients with substantial airway compromise can develop postobstructive pulmonary edema following airway interventions. Hypoxemia in the postoperative period with continued supplemental oxygen requirement and diffuse rales in the chest are characteristic. Chest x-ray will demonstrate diffuse pulmonary edema. This typically resolves with diuretics in 24 to 48 hours, but may require hospitalization. In rare circumstances, reintubation with positive pressure ventilation and slow wean may be necessary.
Hemoptysis is common following bronchoscopy, but rarely of consequence. Large-volume hemoptysis should prompt close observation and consideration of repeat bronchoscopy. Often hemoptysis occurs from tears of the pharyngeal mucosa and resolves without further intervention.

Suggested Readings

Andrews BT, Graham SM, Ross AF, Barnhart WH, Ferguson JS, McLennan G. Technique, utility, and safety of awake tracheoplasty using combined laser and balloon dilation. Laryngoscope . 2007;117:2159-2162.
Daumerie G, Su S, Ochroch EA. Anesthesia for the patient with tracheal stenosis. Anesthesiol Clin . 2010;28:157-174.
Gaissert HA, Burns J. The compromised airway: tumors, strictures, and tracheomalacia. Surg Clin North Am . 2010;90:1065-1089.
Gardner GM, Courey MS, Ossoff RH. Operative evaluation of airway obstruction. Otolaryngol Clin North Am . 1995;28:737-750.
Section B
Airway Operations
CHAPTER 6 Tracheotomy

Author James I. Cohen

Comments by Bruce J. Davidson, William M. Lydiatt, Eben L. Rosenthal
STEP 1. With the patient’s neck in the natural or neutral position or slightly flexed, mark a horizontal line at the level of the cricoid cartilage ( Figure 6-1A and B ) about 2 to 3 cm in length.

FIGURE 6-1 A, Preferred location of the incision for tracheotomy in an individual of normal size. B, Lateral view demonstrates that incision placement allows for the normal curvature of the tracheotomy tube and directs the tube into the center of the tracheal lumen.
If the skin incision is marked with the patient’s head extended, then it will end up being too low and will force the tip (and cuff) of the tracheotomy tube into the back wall of the trachea ( Figure 6-2 ). The thicker the soft tissues in front of the trachea, the higher the incision must be relative to the cricoid to accommodate the curvature of the tube (Figure 6-3) .

FIGURE 6-2 An incision that is placed too low will cause the tip of the tube to impinge on the posterior tracheal wall because of the inferior pressure on the skin edges by the tracheotomy faceplate.

FIGURE 6-3 In an obese individual the normal curvature of the tracheotomy tube and increased distance between the skin and trachea create the need for a higher incision if the tube is still to rest in the middle of the tracheal lumen.

An issue that must be considered in this regard is the level of the patient’s cricoid in the neck. This can limit the level that the incision can be placed superiorly.   BJDavidson

Extended-length tracheotomy tubes are made by certain vendors and may be helpful in obese patients; alternatively, endotracheal tubes can be adapted for the use in severely obese patients.   ELRosenthal

The absence of an inner cannula and faceplate, however, makes the use of an endotracheal tube problematic and this should only be considered in an emergency situation, when longer tubes are not available or when the longer operative time for a defatting tracheotomy is not considered a reasonable option.   JICohen
In situations in which the cricoid is too low to be palpable or its level is so close to the clavicular heads or sternum that the faceplate would impinge on these structures, it should be marked instead a sufficient distance above these structures to accommodate the faceplate comfortably. Maneuvers such as sectioning the strap muscles, defatting the neck, or using a longer tube may be needed to fit the tube appropriately.

I prefer a vertical incision of 1.5 cm staring just below the cricoid cartilage. The vertical incision keeps the line of retraction pointed laterally, facilitating exposure. Because the cosmetic deformity is primarily related to the round scar formed by the tracheotomy, this is one place where the rule of tension lines can be violated.   WMLydiatt

I typically use a vertical incision. Although the horizontal incision follows natural skin creases, the fact that a tracheotomy tube remains in the wound after the procedure reduces any cosmetic advantage to a horizontal incision. A vertical incision along the midline reduces the amount of dissection required and reduces the risk of bleeding and subsequent need for ligation of the anterior jugular veins.   BJDavidson
STEP 2. Position the patient with a horizontal shoulder roll under the scapulae, and neck fully extended.
For patients with a particularly stocky build, a vertical shoulder roll can achieve the same degree of extension but also allow the mass of the shoulders to fall more posteriorly and improve access to the surgical field. Using heavy adhesive tape to retract the shoulders and chest or breast soft tissues can be helpful in the obese individual.
STEP 3. Infiltrate the skin and subcutaneous tissues with lidocaine (Xylocaine)/epinephrine solution.
In the case of tracheotomy under local anesthesia, the deeper soft tissues should be infiltrated as well, but in general one should avoid infiltration of the trachea itself until its face is exposed because it may reduce the patient’s perception of his or her ability to breath and significantly increase his or her anxiety. Drape the patient with a folded towel wrapped under the chin and a towel clipped at the top of the head so as to keep the face exposed—this will facilitate subsequent tube untaping and retraction if the patient is intubated and prevent panic if the patient is under local anesthesia by allowing continued eye contact.

In patients with stridor undergoing urgent tracheotomy under local anesthesia, I prefer to prep and drape the patient prior to injection of anesthesia so that proprioceptive sensation from accessory respiratory muscles remains intact until the tracheotomy procedure is ready to commence.   BJDavidson
STEP 4. Incise the skin and subcutaneous tissues down to the level of the sternohyoid muscles, retracting the overlying soft tissues superiorly and inferiorly with sharp hooks and dissecting them off the strap muscles to expose the median raphe over a 2- to 3-cm distance (Figure 6-4).

FIGURE 6-4 Exposure of the median raphe of the sternohyoid muscles.
Even though the incision is relatively short, adequate undermining of the fat and subcutaneous tissues at this point will extend the functional length of the incision and facilitate subsequent dissection.

I dissect along the midline from skin to the median raphe.   BJDavidson

I prefer to do this dissection bluntly using a curved mosquito hemostat, which allows for continued placement of the children’s retractors. These retractors are slightly thinned and lower profile than army-navy retractors. The strap muscles can then be dissected and retracted laterally. One should avoid dissecting laterally beyond the trachea to avoid entering planes opened in the neck dissection. Similarly, one should avoid excessive dissection along the anterior trachea to limit the creation of a false passage when the tracheostomy tube is changed or replaced in the postoperative period.   WMLydiatt
STEP 5. After incising the middle layer of the deep cervical fascia in the midline vertically, use a curved clamp to undermine the strap muscles sufficiently on either side of the midline so as to allow the insertion of army-navy retractors for lateral retraction to expose the thyroid isthmus.
This can be done sequentially in layers, first on one side and then the other, creating a pocket for the insertion of the end of the army-navy retractor. Use the short ends of the retractors and make sure the direction of retraction is lateral and not outward because this will artificially deepen the wound and make subsequent dissection more difficult ( Figures 6-5 and 6-6 ).

FIGURE 6-5 The strap muscles are retracted laterally by sequential undermining and then retraction.

FIGURE 6-6 Exposure of the anterior trachea is facilitated by retracting the thyroid lobes superiorly and then entering through the small fat pad that sits below its isthmus.

I agree that the shortest retractor that will expose the field should be used. I use the rake end of a Senn retractor until I get to the median raphe, then the retractor end of this instrument. I find that except in obese patients, even the short end of an army-navy retractor takes up too much space and blocks access to the field. The retraction of the subcutaneous tissues and strap muscles should be lateral and downward (toward the operating room [OR] table) to keep the wound as shallow as possible. As long as dissection stays along the midline, the trachea will typically rise up between the two retractors as the overlying fascia is divided.   BJDavidson

The army-navy retractors can sometimes be awkward and bulky within a small wound. They can also push the trachea deeper into the wound and make dissection difficult. As an alternative, Senn retractors can be used for exposure particularly if a vertical incision is used.   ELRosenthal
STEP 6. Expose the pretracheal fat pad immediately below the isthmus where the investing middle layer of the deep cervical fascia is thinnest. Dissect through this fat pad vertically in the midline so as to expose the anterior face of the trachea (see Figure 6-6 ).

I routinely divide the isthmus with electrocautery. This is particularly helpful in patients with a short neck, obese patients, and patients with poor cervical extension.   ELRosenthal
Create a pocket sufficiently wide on both sides so as to allow the ends of the army-navy retractors to be inserted. The inserted ends are then retracted laterally to expose the face of the trachea and, equally important, are rotated superiorly, which facilitates retraction of the trachea superiorly into the wound by applying force to the thyroid isthmus. Draining veins can usually be retracted laterally. Going below the thyroid isthmus ensures that the tracheotomy is not placed too superiorly and does to some degree “pad” the anterior tracheal wall from the pressure the tracheotomy tube places on it, thereby reducing the possibility of an “anterior trap door deformity” that can result in tracheal narrowing after decannulation.
STEP 7. If the patient is under local anesthesia, then at this point with the anterior face of the trachea exposed, infiltrate the tracheal lumen with lidocaine (Xylocaine). If needed for exposure and to secure the exposure, the cricoid hook can be placed into the trachea at the superior edge of the exposure and the pulled superiorly and outward to make the wound as shallow and wide as possible (Figure 6-7).

FIGURE 6-7 Placement of the cricoid hook stabilizes the trachea and allows it to be retracted into the operative field, creating a wound.
If the patient is intubated, make sure the cuff is temporarily deflated prior to infiltration or cricoid hook placement to avoid rupturing the cuff and the subsequent urgency in tracheotomy tube placement that this will create. A cricoid hook is not needed at this point if the tracheal face is easily exposed and stabilized by the army-navy retractors.

I typically do not inject the trachea of patients under general anesthesia, only in those under local anesthesia. Epinephrine should not be injected into the trachea, so in tracheotomy under local, the surgeon should ensure at the outset of the case that the OR table has prepared a syringe of plain lidocaine for injection at this point in the procedure.   BJDavidson

When the trachea is exposed, the size of the tracheotomy tube can be estimated. Have the tracheotomy tube on the Mayo stand with the balloon previously tested and now deflated. A small amount of lubricant may aid passage through the tracheal incision.   WMLydiatt

I agree with the approach below the thyroid isthmus. Occasionally the anatomy favors an approach superior to the isthmus and in this situation, bleeding from the region of the pyramidal lobe of the thyroid may be encountered. I find that division of the thyroid isthmus is rarely required. I prefer a cricoid hook in the anterior tracheal wall in most cases. I then retract caudally and laterally to maximize exposure of the trachea.   BJDavidson
STEP 8. With the cuff deflated, incise the trachea horizontally between two tracheal rings over the anterior 90 to 120 degrees of its face. Spread the incision in a vertical direction using a clamp or tracheal spreader to create sufficient room for tracheotomy tube insertion.
If not previously placed, a hook is now placed in the superior lip of the incision to pull the opening wider and up into the wound, which will facilitate tube insertion. Placing a heavy suture around the tracheal ring at the lower edge of the incision and tying it as a loop for retraction can facilitate tube insertion by widening the tracheal opening and providing countertraction at the time of tube insertion (Figure 6-8) or if decannulation occurs in the early postoperative period.

FIGURE 6-8 Placement of an inferior retraction suture to facilitate replacement of the tracheotomy tube if it becomes displaced in the early postoperative period.

If a retaining suture is not felt to be required, a second hook inferiorly can allow the tracheotomy to be retracted to allow tube insertion. I try to avoid tracheal spreaders. These take up a significant amount of space and therefore require the tracheal incision to be larger than necessary. Also tracheal spreaders can lacerate the balloon of the tracheotomy tube when the tube is inserted with a spreader in place.   BJDavidson

A horizontal incision also minimizes the sharp edges from severed tracheal rings that can inadvertently pierce the balloon. Avoid fracturing the rings above and below the incision from overly zealous spreading.   WMLydiatt

I will often not place a stabilization suture, but rather divide the third tracheal ring in the midline to allow room for the tracheotomy tube.   ELRosenthal
STEP 9. With the trachea open, pull back or have the anesthesiologist pull back the endotracheal tube so the tip is just above the tracheal opening and insert the tracheotomy tube.

After the endotracheal tube is withdrawn it is important to aggressively suction the airway through the tracheotomy site prior to placement of the tracheotomy tube.   ELRosenthal

Make sure the tracheotomy tube is perpendicular with the anterior wall of the trachea. Because the trachea is at a 10- to 20-degree angle as it descends into the chest, this will mean the tube should be pointed slightly cephalad. Once the tube can be felt to pass through the tracheal incision, it can be rotated and directed down the trachea.   WMLydiatt
Keep the endotracheal tube in the trachea until the position and function of the tracheotomy tube are confirmed. This way, if trouble with insertion is encountered, the tube can be reinserted for ventilation.
STEP 10. Secure the tracheotomy faceplate with ties tightened with the patient’s neck flexed so as to allow only two fingers within the loop (Figure 6-9).

FIGURE 6-9 Proper securing of the tube with adequate “tension” on the tracheotomy ties is facilitated by tying them over two fingers with the neck in flexion.
Sutures give a false sense of security, particularly in thicker necks, in which enough redundancy in these soft tissues exists to allow tube displacement even when they are intact. In addition, they interfere with tracheotomy site care.

I use sutures and tracheotomy ties in most tracheotomies. For patients undergoing free flap reconstruction, tracheotomy ties can compromise venous outflow, so I prefer sutures alone.
In patients with obese necks and in whom there is more than the usual concern about decannulation, sutures may be placed around the adjacent tracheal rings and tied to the faceplate of the tracheotomy tube.   BJDavidson

Editorial Comment
Few operations have as much of both dogma and variation in surgical technique as tracheotomy. As can be seen by the diversity of commentary, most surgeons have developed a set of individual tips or pearls that help them deal with myriad variations in tracheal and neck anatomy that this operation forces them to confront. The key to success is adherence to the few basic principles of proper positioning, midline dissection, and adequate exposure—the common themes in everyone’s comments. In this context all of the other variations listed should be seen as helpful hints that will allow a flexibility in approach should the need arise.   JICohen

Suggested Readings

Carron JD, Derkay CS, Strope GL, Nosonchuk JE, Darrow DH. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope . 2000;110:1099-1104.
Goldenberg D, Golz A, Netzer A, Joachims HZ. Tracheotomy: changing indications and a review of 1,130 cases. J Otolaryngol . 2002;31:211-219.
Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen JN, et al. Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Laryngoscope . 2001;111:494-500.
McWhorter AJ. Tracheotomy: timing and techniques. Curr Opin Otolaryngol Head Neck Surg . 2003;11:473-479.
Oliver ER, Gist A, Gillespie MB. Percutaneous versus surgical tracheotomy: an updated meta-analysis. Laryngoscope . 2007;117:1570-1575.
Pratt LW, Ferlito A, Rinaldo A. Tracheotomy: historical review. Laryngoscope . 2008;118:1728-1758.
Ruggiero FP, Carr MM. Infant tracheotomy: results of a survey regarding technique. Arch Otolaryngol Head Neck Surg . 2008;134:263-267.
CHAPTER 7 Laryngotracheal Reconstruction for Subglottic and Proximal Tracheal Stenosis

Author Henry A. Milczuk

Comments by Roger C. Nuss, James Sidman, James D. Smith

Preoperative Considerations
This section demonstrates the principal surgical maneuvers for successful laryngotracheal reconstruction (LTR) with costal cartilage grafts. This procedure is often performed on patients who already have a tracheostomy. If the patient’s airway is stable and controlled, then LTR should be considered only after all other medical conditions are stable. Three other important considerations must be made prior to undertaking LTR.
First, endoscopic examination, microdirectlaryngoscopy and bronchoscopy must be performed in order to accurately diagnose the site(s) of obstruction or any other synchronous lesions. True vocal cord (TVC) mobility must be known (this can be established in clinic by fiberoptic laryngoscopy), and palpation of the cricoarytenoid joint helps to define the integrity of the posterior glottis.

Preoperative fiberoptic laryngoscopy, with video recording for careful playback review, is imperative prior to the operative procedure. Assessment of vocal fold and arytenoid mobility will help determine the type of procedure, especially if a posterior graft is necessary.   RCNuss

I agree with Dr. Nuss on the importance of preoperative fiberoptic laryngoscopy.   JDSmith
During endoscopy, sites of stenosis need to be carefully evaluated: anterior and posterior subglottis, proximal trachea, suprastomal granuloma or collapse (if tracheostomy is present), and tracheomalacia are all possible in a patient with acquired laryngotracheal stenosis. The length of stenosis can be determined either by endoscopy or, when the stenosis is too narrow to allow any telescope to pass through, computed tomography (CT) can be performed.

Endoscopic measurements of the length of stenosis can be facilitated by marking directly on the telescope as one passes the distal point of obstruction and withdraws to the proximal point of stenosis.   RCNuss
Second, laryngopharyngeal reflux, if present, must be controlled medically or surgically. Eosinophilic esophagitis can also affect LTR outcomes and should be aggressively treated prior to airway surgery. If the larynx is inflamed (e.g., uncontrolled gastroesophageal reflux [GER]), then surgery should be delayed until the mucosa has settled.

Many laryngologists advocate for treatment both preoperatively and postoperatively with proton pump inhibitors (PPIs) to minimize the effects of any laryngopharyngeal reflux on surgical outcome.   RCNuss

We treat all patients with antireflux medication while intubated postoperatively, but do not perform any studies to determine the presence of gastroesophageal reflux disease (GERD). This has not affected our outcomes for LTR surgery.   JSidman
Based on the endoscopic findings, analysis of the defect permits the surgeon to determine what must be repaired. This chapter demonstrates an anterior and posterior costal cartilage graft for LTR, but it should be understood that not all cases require this type of reconstruction.
The third consideration is whether the LTR is performed as a single-stage reconstruction or a two-stage reconstruction. Generally stenting of the airway is needed after LTR in order to stabilize the cartilage grafts. In single-stage LTR an endotracheal tube is used for stenting. This implies that the patient will need to be hospitalized in the intensive care unit (ICU) for a period of time while the grafts heal. Depending on the patient this may require sedation and assisted ventilation, or if he or she is cooperative and will not manipulate the endotracheal tube, the patient may be ambulatory. Posterior grafts generally take more time to heal than anterior grafts only, and this needs to be considered by the surgeon and discussed with the patient or parents prior to surgery.
The alternative is to perform a two-stage LTR, in which a tracheotomy site is maintained. In this situation the patient who has had a tracheostomy prior to LTR will not require prolonged hospitalization. Different options for stenting the reconstructed laryngotracheal complex include Albouker stents, Cotton-Lorenz stents, Montgomery stents, or Montgomery T-tube.

Another stent to be considered is the Healy-Montgomery stent (HMS), that combines a stenting T-tube with a tracheotomy tube that has an inner cannula for easier cleaning.   RCNuss
In a two-stage LTR a T-tube can provide a tracheal airway and laryngeal stent in one piece. The other stents must be secured with sutures above the tracheostomy site. The stents are removed endoscopically after the surgeon has determined that the grafted area has healed. Typically the tracheostomy is maintained for a short time after stent removal to ensure that restenosis does not occur. Then the tracheostomy tube is removed using the head-and-neck surgeon’s usual protocol for decannulation.

We do not perform two-stage LTR for any patients, even grade 3 or 4 stenosis. We leave anterior graft patients intubated for 3 to 5 days, and anterior and posterior graft patients for 7 days. Extubation is done in the ICU without laryngoscopy. The first postoperative laryngoscopy is 4 to 6 weeks later.   JSidman
Different donor sites for cartilage used to reconstruct the larynx have been proposed. Auricular and thyroid cartilage has been discussed, and some authors have used hyoid bone for laryngotracheal grafts. However, costal cartilage offers relatively large amounts of hyaline cartilage and perichondrium, which allows greater versatility during reconstruction. Concern for donor site morbidity has led to the search for alternate sources of cartilage, but careful surgical harvest will avoid complications at the donor site. This chapter provides details for successful harvest of costal cartilage.
Because of the various possible ways one can perform an LTR (single- or two-stage, different graft sites), this chapter describes a two-stage anterior and posterior LTR. If another type of LTR is appropriate given the type of laryngotracheal stenosis, then steps described can be eliminated. For example, if a single-stage LTR is planned, then nasotracheal intubation is substituted for the steps describing stent placement. Similarly, if only an anterior graft is needed, then the surgeon ignores the steps for posterior grafting.

Anesthetic Considerations
Decisions about the type of tube to be used for ventilation during the procedure and what type of endotracheal tube will be used postoperatively (if single-stage LTR) should be made with the attending anesthesiologist prior to surgery. If a tracheostomy is present, then a flexible, cuffed tube is sewn to the chest wall opposite the rib graft harvest site. This can be an armoured tube or trimmed oral RAE tube.
The anesthesiologist and surgeon will need to communicate during the procedure when the airway is open. From time to time the ventilating tube may be removed to gain better surgical access. Prior to this the anesthesiologist may want to provide Fi O 2 of 1.0 to optimize the patient’s oxygen saturation. Mechanical ventilation should cease while the tube is out of the trachea.

It is critical that ventilation be halted during the use of electrocautery, or airway fire may ensue. Again, good communication between the anesthesia team and surgical team is an absolute must.   JSidman

When an endotracheal tube is being taken out of the airway and replaced throughout the procedure, one must be aware of O 2 concentration around and below the surgical drapes. Use of a bipolar electrocautery may help to reduce the risk of operating room (OR) fires in this setting.   RCNuss
Finally, when a single-stage LTR is planned, a decision needs to be made about what type of endotracheal tube, oral or nasal, should be placed before the anterior graft and who should place the tube. Again a complete discussion with the anesthesiologist prior to surgery will aid in a smooth execution of the LTR.
A soft enteral feeding tube is placed near the end of the procedure.

The feeding tube should be placed before grafts are placed, to be absolutely sure it is not in the airway. We place a weighted feeding tube at the beginning, before prep is done.   JSidman
Elements to successful LTR include endoscopy, rib graft harvest, careful placement of graft(s), secure airway, and postoperative ICU care.

Endoscopy (Figures 7-1 and 7-2)
STEP 1. Both awake flexible fiberoptic laryngoscopy (FFL) and microdirectlaryngoscopy and bronchoscopy (MDLB) must be performed by the surgeon before LTR. Awake FFL is performed in clinic prior to surgery with the patient sitting upright in an examination chair.

FIGURE 7-1 A, Endoscopist’s view of an anterior subglottic stenosis. B, Sagittal view illustrating the length and usual three-dimensional nature of stenosis.

FIGURE 7-2 A, Endoscopist’s view of a more circumferential subglottic stenosis. B, Sagittal view.

This is also a good opportunity to record and rate a child’s voice quality using a standardized tool such as the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scale.   RCNuss
Topical anesthesia and a vasoconstrictor are applied to the nose prior to inserting the fiberoptic laryngoscope. Pass the scope through the middle meatus, then turn inferiorly past the palate to just above the epiglottis. The patient is asked to phonate “E” for several seconds. The oropharynx, hypopharynx, and supraglottic larynx are also seen easily during FFL.

Inspection of the nasal passages before application of topical anesthetic agent helps determine which side is more patent, allowing for easier passage of the scope. The middle meatus as well as the inferior meatus are acceptable pathways for the fiberoptic scope, best decided by the anatomy of the child’s nasal passage. The preoperative FFL should be recorded to allow for careful review of the examination. The following points should be ascertained: (1) do both vocal folds/arytenoids move equally and symmetrically with respect to range and speed, (2) are vocal fold edges smooth and straight, (3) is there any evidence of scarring of the vocal fold, or presence of anterior glottic web, or any supraglottic scarring? Use of stroboscopy may help determine whether vocal fold mucosal wave is symmetric.   RCNuss
STEP 2. For MDLB the patient is placed in a supine position on the operating table. Once the patient is anesthetized, a suspension laryngoscope is inserted transorally. The tongue of the laryngoscope is positioned within the vallecula and the suspension arm attached. The operating microscope, set at a focal length of 400 mm, is then used to visualize the larynx. Microlaryngeal instruments are used to inspect, palpate, and retract the laryngeal tissues. While in suspension, rigid telescopes of different sizes and optical angles are used to gain further visualization of the pathology. The telescopes are passed into the subglottis and proximal trachea where definitive analysis of the stenosis is now done. Care is taken not to abrade the mucosa or cause further injury to the larynx.
Depending on the patient and the extent of laryngeal stenosis, pathology in the subglottis may or may not be seen during FFL. Thus to complement the awake examination as well as provide greater detail of the larynx and trachea, MDLB is scheduled.
If a tracheostomy is present, the anesthesiologist can have unencumbered access to the airway distal to the main areas of stenosis. However, if tracheostomy is not present, the surgeon and anesthesiologist must discuss the combined airway plan prior to induction. Many centers prefer spontaneous ventilation techniques for anesthesia, especially with children. The principal advantage to spontaneous ventilation is that the surgeon sees a dynamic airway during respiration. Also there are no tubes or jets to distort the view of the airway.

The spontaneous ventilation technique does indeed provide an excellent opportunity to examine the dynamic pediatric airway without endotracheal tubes to distort the surgeon’s view. This requires close communication between surgeon and anesthesiologist to adjust drips of medications to achieve the desired plane of anesthetic.   RCNuss
The findings from both endoscopic procedures can be recorded if imaging equipment is available.
Two examples of what may be found during MDLB are found in Figures 7-1 and 7-2 . Figure 7-1A depicts the endoscopist’s view of an anterior subglottic stenosis. Figure 7-1B is a sagittal view illustrating the length and usual three-dimensional nature of stenosis. Such an isolated lesion would be amenable to LTR with anterior graft only.

We would perform anterior and posterior grafts on this because it appears to be a grade 3 stenosis, despite the bulk of the stenosis being anterior. We feel that the failure rate is too high in grade 3 or 4 stenosis to justify anterior graft alone.   JSidman
Figure 7-2A shows a more circumferential subglottic stenosis, and Figure 7-2B demonstrates its length. This lesion, with its anterior and posterior scar, will need anterior and posterior grafts in order to expand the airway and eliminate stenosis.
In order to evaluate the trachea, the patient is taken out of suspension and the laryngoscope removed. If the stenosis permits atraumatic insertion, a rigid, ventilating bronchoscope is used. However, as is often the case, the subglottic airway is too small for safe passage of a bronchoscope. In these cases options include passing the bronchoscope through the tracheostomy site (if it is present), using a flexible bronchoscope with a laryngeal mask for ventilation, or using CT. By whatever means, the surgeon needs to know the status of the trachea distal to the stenosis. Tracheomalacia or other potential sites of distal airway obstruction may result in failure to decannulate and are a relative contraindication to LTR.

A telescope by itself, either 4 mm or 2.7 mm, allows for inspection of the subglottic and tracheal airway in all but the most severe degrees of stenosis. Balloon dilatation of the stenosis may offer the surgeon a temporary way to further inspect the degree and length of stenosis.   RCNuss
As with any reconstructive surgery, proper analysis of the deformities, selection of reconstructive materials, and the condition of the surrounding tissues will determine which techniques will most likely correct the problem. Laryngotracheal reconstruction requires that extralaryngeal sources of obstruction be corrected first. For example, children with large tonsils or adenoids may benefit from adenotonsillectomy before LTR.

This is an excellent point that cannot be overstated.   RCNuss
The principal method to evaluate the larynx and trachea prior to LTR is endoscopy. Awake flexible fiberoptic laryngoscopy provides the surgeon information about the nasal and pharyngeal airway. It is important to assess motion of the vocal folds and their status.

If the patient already has a tracheostomy, it can be very difficult to diagnose supraglottic pathology such as laryngomalacia. This is because many patients with tracheostomy do not use their upper airway, and so the arytenoids appear swollen and obstructed. This usually self-resolves after LTR surgery and the upper airway is being used.   JSidman
If vocal cord pathology is evident, this should be addressed before LTR. For example, most surgeons will start PPI medications to minimize the inflammatory effects of laryngopharyngeal reflux. In some patients a swallowing assessment may be indicated. A modified barium swallow with the aid of a speech and language pathologist, or functional endoscopic examination of swallowing (FEES), can be performed prior to surgery.

Evidence of aspiration on preoperative examination may be either an absolute or relative contraindication to airway reconstructive surgery.   RCNuss
MDLB must be performed prior to LTR. The optical resolution of the endoscopes and microscope, in addition to the ability to palpate the tissues, provides essential information to the surgeon. During MDLB careful analysis of the sites of scarring, degree of stenosis, length of subglottic and tracheal involvement, problems at the tracheostomy site, and any distal lesions will lead the surgeon to decide how best to reconstruct the airway in order to decannulate the patient. A vallecular laryngoscope, as opposed to an anterior commissure laryngoscope, provides a more complete view of the larynx. Microlaryngeal instruments allow palpation and movement of the cricoarytenoid joints. Also the posterior glottis and interarytenoid space are evaluated for webbing. It is important to determine where the subglottic stenosis starts in relation to the vocal cords, especially if there is limited cord mobility. Palpation with a blunt probe will assess of the texture of the cicatrix; is it firm and mature or soft and edematous? Reconstructive surgery has a greater chance of success if the larynx is not inflamed.
If there is high-grade or complete (Myer-Cotton grade 4) subglottic stenosis, assessing the distal airway can be challenging. These patients invariably have a tracheostomy, which allows the bronchoscope to visualize from the stoma distally. Compliant patients may allow this to be done in clinic, but if there are any concerns with airway control, then bronchoscopy must be done in the OR. One site that may not be seen well by endoscopy is the airway proximal to the stoma. Especially in children, or if there is suprastomal collapse or granuloma, neither flexible or rigid endoscopes may adequately visualize this important area. Knowledge of the proximal trachea will determine the length of anterior graft. A CT of the neck and chest may demonstrate lesions not well seen by endoscopy.

Positioning (Figure 7-3)
STEP 3. The patient is placed in a supine position with a shoulder roll to optimize neck extension. The neck and right anterior chest are prepped and draped sterile. If the patient has a tracheostomy, a flexible, cuffed tube is sewn to the chest wall opposite the planned costal cartilage donor site. This tube can be an Armour tube or cut oral RAE tube. A portion of the tracheal ventilation tube is kept within the sterile field. The anesthesia circuit can be placed under the sterile drapes; this allows access by the anesthesiologist during the procedure, if needed. The bed is not turned. The surgeon and assistant are on opposite sides of the table.

FIGURE 7-3 Positioning and incisions.

The head should be stabilized with a scroll or donut to prevent turning during surgery and loss of evaluation of the neck midline.   JSidman
STEP 4. Next injections of 1% lidocaine with 1 : 100,000 epinephrine are performed subcutaneously at the incision sites and deeper in the midline along the laryngotracheal complex that is to be exposed during the procedure. A single dose of intravenous (IV) steroids and antibiotics is given preoperatively.
Keeping the head of the patient toward the anesthesia station allows the anesthesiologist easy access for adjusting the ventilating tubes intraoperatively.

Anesthesia can also be at the foot of the table, allowing the surgeon easier access to the field for intraoperative endoscopy.   JDSmith
The anesthesiologist can also observe the surgical field, which aids in the combined airway management. A local anesthetic may limit the use of narcotics during surgery if emergence is planned after surgery. Injecting epinephrine will help limit blood loss when the surgical field has a scar as is often the case in LTR cases (previous tracheotomy or neck surgery). Antibiotics are directed against skin and upper airway flora. Cefazolin is a good choice in many cases, or clindamycin can be used especially if there is a history or high incidence of methicillin-resistant Staphylococcus aureus (MRSA). Dexamethasone is the preferred steroid for its strong antiinflammatory effects with minimal aldosterone-like activity.

The choice of perioperative antibiotics is somewhat arbitrary, though good Staphylococcus (staph) coverage for skin flora makes sense. A preoperative Gram stain and culture of tracheal secretions help guide more directed antibiotic therapy in the postoperative period. For patients with preexisting tracheostomy, there is frequent colonization with Pseudomonas as well as Staphylococcus .   RCNuss

We use perioperative combination of clindamycin and ceftazidime. We have found this prevents migrating atelectasis during the intubated postoperative period of single-stage LTR surgery.   JSidman

Costal Cartilage Graft Harvest (see Figure 7-3)
STEP 5. Incision with scalpel is made over the fourth or fifth rib from the sternum laterally in the inframammary fold. The subcutaneous fat and pectoralis muscles are divided with electrocautery to optimize hemostasis. Care is taken while removing the last muscle fibers from the anterior perichondrium of the rib. The anterior perichondrium must be preserved. Scissors work well in removing the remaining muscle tissue adhering to the perichondrium.

The decision as to which rib should be harvested will depend on the length of the cartilaginous component of the rib, as well as its width and flatness. A wide, flat costal cartilage is preferable to a narrow and more twisted or curved rib.   RCNuss

It is critical not to damage the perichondrium with the cautery or sharp instruments because this creates a surface on which granulomas form postoperatively.   JSidman
Camouflage of the incisions will be greatly appreciated by any patient. In women the inframammary fold offers a natural site for incisions (e.g., used during mammoplasty). Monopolar cautery at 15 to 20 watts typically achieves dissection and hemostasis without too much thermal tissue injury. The anterior perichondrium becomes the fibrous scaffold on which the respiratory mucosa grow. Bare cartilage does not support epithelial growth (and it was the exposed cartilage that likely led to airway stenosis initially), thus great care must be used at all stages of handling the costal cartilage graft to preserve this perichondrium.

Incisions on Rib (Figure 7-4)
STEP 6. The scalpel is used to incise the perichondrium along the superior and inferior edges of the rib. Bleeding may occur from the inferior incision because the vascular pedicle to the rib runs along the inferior edge. This can be avoided by staying anterior with the scalpel.

FIGURE 7-4 Incisions on rib.
There is typically an anterior ridge along the inferior rib. Just posterior to this ridge is the vascular pedicle that should be avoided. Avoid an incision that penetrates the cartilage because the plane beneath the posterior perichondrium must be found in the next step.

Elevating Posterior Perichondrium (Figure 7-5)
STEP 7. Using a Cottle or Freer elevator the posterior perichondrium is left down and the cartilaginous portion of the rib is separated from it.

FIGURE 7-5 Elevating the posterior perichondrium.

The Doyen (“pigtail”) elevator can be used to separate the posterior perichondrium from the rib and help avoid a pleural tear.   JSidman

I use a rib periosteal elevator with a sharp edge to start the elevation.   JDSmith
Separate the posterior perichondrium from the entire length of costal cartilage that is planned for harvest. Place a malleable retractor or other instrument between the posterior perichondrium and the cartilage.
STEP 8. A scalpel is then used to divide the cartilage starting at one of the bone-cartilage junctions. Once the cartilage is cut, a skin hook can be placed into cartilage to help expose the posterior surface of cartilage. Use the Cottle elevator to complete the separation of cartilage and perichondrium if needed. Protect the pleura by using the malleable instrument when the second incision is made to separate bone and cartilage and release the graft. Wrap the graft in a moist sponge and put in a secure place on the back table.
STEP 9. Next fill the chest wound with sterile saline. Ask the anesthesiologist to perform a Valsalva maneuver to check for injury to the pleura. If no air bubbles are seen, it is safe to close the wound.
STEP 10. Close the chest wound in layers. Absorbable Vicryl sutures are used to reapproximate the muscle and pectoralis major fascia. Place a Penrose drain beneath the muscle. Skin and subcutaneous tissue may be closed in one or two layers based on surgeon preference. Cover the wound with an occlusive dressing, then use sterile drapes to cover the chest.
Violation of the posterior perichondrium can lead to injury to the parietal pleura and subsequent pneumothorax. This must be considered at all times during this part of the dissection. The rib has a triangular shape in cross-section, and the perichondrium is often more adherent closer to the sternum. Thus it may be easier to start laterally and use both anterior and posterior perichondrial incisions to find this plane. Once the subperichondrial plane is established a “pigtail” elevator can sometimes be used to complete the dissection along the length of the rib. Placing an instrument beneath the planned incision to release the rib protects against injury to the pleura. Further assurance is gained by testing for an air leak during a Valsalva maneuver.

A tear in the pleura is easily identified with this maneuver. If present, a suction catheter is placed through the tear and a figure-of-eight suture is placed while suctioning. Alternatively, a chest tube can be placed but is rarely necessary.   JSidman
I prefer to do the costal cartilage harvest first. The chest wound is closed prior to opening the airway and contaminating the field. By doing this there is no need for regowning or using separate instrument trays (the surgeon goes from “clean to dirty”). This strategy requires protection of the chest wound with an occlusive dressing and additional drapes. If the entire length of cartilaginous rib is harvested there usually is sufficient graft material for nearly any LTR.

Knowing the length of the stenosis prior to costal cartilage harvest, as well as plans for anterior only versus anterior and posterior grafts, allows for the collection of an appropriate length of donor costal cartilage. Preservation of the posterior perichondrium allows for regrowth of the patient’s rib over time.   RCNuss

Neck Incisions (Figure 7-6)
STEP 11. If tracheostomy is present, an apron flap including an elliptic incision around the stoma is created. The lateral limbs of this incision are at the anterior border of the sternocleidomastoid muscle. The superior extent is to the hyoid bone.

FIGURE 7-6 Neck incisions.

We simply make a fusiform incision around the tracheotomy, about 3 cm long. The subplatysmal dissection is carried superiorly to the palpated hyoid bone.   JSidman
If no tracheostomy and a single-stage reconstruction are planned, a shorter apron flap from the level of the cricoid to the hyoid can be fashioned. Raise subplatysmal flaps to hyoid using electrocautery dissection.
STEP 12. Next, split the strap muscles in the midline and retract them laterally. Handheld retractors (e.g., army-navy retractor) or sutures tied to the strap muscles can be used.
A standard subplatysmal apron flap provides reliable healing, presentation of the relevant neck anatomy, and reasonable camouflage of the incisions. The ellipse of soft tissue around the tracheostoma can be used as a handle to minimize trauma to the trachea and mucosa. It can also aid with maintaining the ventilating tube in position. The strap muscles should not be dissected off of the hyoid unless necessary for visualization. It is important that they close over the airway and the anterior graft because they may promote survival of the graft through inosculation.
For clarity, the thyroid gland is not shown in these illustrations. However, the surgeon should be prepared to split the thyroid gland in the midline if the isthmus lies over a part of the anterior trachea that requires reconstruction. Care should be taken to preserve the anterior perichondrium of the trachea. This situation is more commonly found in children than adults.

Anterior Airway Incision (Figure 7-7)
STEP 13. A fresh scalpel is used to make a midline incision through the cricothyroid membrane and cricoid cartilage. Its inferior extent is dictated by the length of stenosis.

FIGURE 7-7 Anterior airway incision; laryngofissure.

This is a very important step in the operation. The previously done laryngoscopy helps determine how high the anterior tracheal incision needs to go and depends on the exact location of the subglottic stenosis. Only a No. 15 blade should be used here and not a No. 11, to avoid accidental damage to the posterior tracheal wall. We have the assistant surgeon place a McCabe dissector in the airway through the stoma and in the midline. The surgeon then slowly cuts from inferior to superior. First the tracheal rings above the stoma are cut, then the cricoid cartilage exactly in between the easily identified cricothyroid muscle insertions. Lastly, the inferior portion of the thyroid cartilage is cut, no higher than the vocal cords. Laryngofissure is not indicated in this operation and destabilizes the larynx.   JSidman
If there is suprastomal granuloma or collapse (based on endoscopic evaluation), the incision is carried to the stoma. If necessary, elevate stomal soft tissue from the tracheal wall preserving the tracheal perichondrium. The incision is also carried superiorly to just below the anterior commissure.

This may be a point at which endoscopic evaluation of the glottis and subglottis by an assistant can prove invaluable. The concern is to create the incision high enough to completely traverse the stenotic segment and to avoid trauma to the vocal folds and anterior commissure. If necessary, as in the presence of an anterior glottic web, the incision can be endoscopically guided exactly through the anterior commissure.   RCNuss
This incision should be precisely in the midline and cleanly through cartilage. A fresh scalpel blade will help. If there is dense fibrosis laterally along the cricoid, this may be removed sharply. However, the mucosa overlying this area must be preserved. Gently elevate the mucosa, then use a scalpel to excise the fibrosis beneath it while maintaining the integrity of the lateral lamina of the cricoid. The idea is to re-create the “signet ring” lumen of the natural subglottic airway. A ridge within the subglottic airway could result in excessive transluminal pressure from the airway stent with resulting failure of proper healing. The subglottic lumen may be significantly narrowed in the transverse dimension. If the cricoid is divided laterally, the “four-quadrant” LTR will require additional time to heal and extubation may be delayed. Again, careful analysis of the airway stenosis by endoscopy will determine the reconstructive needs.

We do not perform the four-quadrant LTR and have found that large anterior and posterior grafts solve the problem in all except grade 4 stenosis. For these we often perform cricotracheal resection.   JSidman
If a single-stage LTR is planned (no tracheostomy at the end of the procedure), the cuff of stomal soft tissue can be removed at this point. The distal ventilation tube will now require monitoring because it is likely to fall out during the next stages of the open laryngeal surgery. The ventilation tube is replaced prior to placement of the anterior graft in a single-stage LTR. If a two-stage LTR is planned, then preserving the stoma aids postoperative care. The patient will not have a fresh stoma once the LTR is completed.

Laryngofissure (see Figure 7-7) and Inset of Suture to Secure the TVCs (Figure 7-8)
STEP 14. In adult patients who require a posterior graft, a laryngofissure may be necessary to expose the superior extent of the posterior subglottis and cricoid lamina. However, most children do not require complete separation of the thyroid cartilage, as shown in Figure 7-7 . The child’s posterior lamina of the cricoid can be accessed without dividing the anterior commissure. Complete laryngofissure destabilizes the larynx and, if not precisely performed, jeopardizes the true vocal cords and voice results. (If only an anterior graft is needed, incision through the anterior commissure is not needed.)

FIGURE 7-8 Securing the TVCs.
The laryngofissure should be done only if there is an anterior glottic web or if the superior part of the posterior cricoid (or interarytenoid space) cannot be reached without splitting the anterior commissure.
The incision of the anterior commissure must be precisely in the midline and extend from the inferior edge of the thyroid cartilage to the thyroid notch. Secure the anterior commissure using 6-0 Prolene on the anterior true vocal cords, to be used later to sew to contralateral thyroid cartilage (see Figure 7-8 ). Prior to completing the incision through the thyroid notch, mark the sites of the anterior commissure on each thyroid lamina with methylene blue or other indelible marker.
STEP 15. Once the anterior larynx is split to create the needed exposure, 3-0 Prolene sutures placed lateral to the thyroid cartilage incision are used to retract the two sides laterally. Additional 1% lidocaine with 1 : 100,000 epinephrine is injected into the posterior subglottis in the midline.

This injection is an extremely helpful maneuver and will significantly help reduce oozing and improve the surgeon’s exposure.   RCNuss
Wait several minutes for vasoconstriction. If there is no contraindication, additional 0.5% oxymetazoline or dilute (1 : 100,000) epinephrine may be applied to the mucosa on a cottonoid pledget. At this point the ventilating tracheal tube can easily become dislodged from the airway. It is incumbent on the surgeon to remain vigilant throughout the remainder of the procedure and reinsert the tube if needed.

An equally common event may be pushing the endotracheal tube too distally, causing hypoventilation of one lung. This must also be addressed promptly.   RCNuss
The laryngofissure must be precisely in the midline in order to preserve true vocal cords. Some centers perform this incision while the assistant does direct laryngoscopy. This allows endoscopic guidance of the laryngofissure. This maneuver is awkward, however.
Once the anterior commissure is divided, its location is marked on the thyroid laminae so the two points can be realigned precisely during repair. Also the anterior true vocal cords are secured with fine monofilament suture or they will retract and correct reconstruction of the anterior commissure will be impossible; do not cut needles from the suture. A bulldog clamp or other atraumatic clamp can be used to tag these sutures. Once the posterior lamina of the subglottis is fully exposed, local vasoconstriction helps visualize the next critical incision.

Posterior Cricoid Split (Figure 7-9)
STEP 16. Another fresh scalpel is used to make a midline incision through the posterior subglottis.

FIGURE 7-9 Posterior cricoid split.

We inject the posterior cricoid mucosa with local anesthesia with epinephrine 1 : 100,000. The posterior cricoid limits are easily palpated with an instrument, and the novice is always surprised at how much taller it is than the anterior cricoid. Hence the term “signet ring” (which has no meaning to many surgeons!).   JSidman
This incision splits the cartilaginous lamina from the interarytenoid space superiorly to the posterior tracheal wall inferiorly. Care is taken not to create multiple incisions in the cartilage. The depth of this incision is to the posterior perichondrium of the cricoid. The posterior cricoarytenoid muscles are not divided. It is extremely important that the retrocricoid mucosa is kept intact.

This is important to avoid violating the esophagus.   JSidman
STEP 17. Elevate the outer (posterior) perichondrium from posterior lamina to create a pocket. A Cottle elevator or a Rosen knife (otologic instrument) works well. This subperichondrial pocket should extend the length of the cricoid lamina and extend a few millimeters laterally from the midline.

We do not perform this step. We feel that elevating posterolaterally creates a space into which the posterior graft sinks toward the esophagus, and so the surface of the graft will not be flush with the cut cricoid edges. We allow the insertion of the graft to perform the little undermining necessary.   JSidman
The posterior lamina of the cricoid is typically thicker than the anterior portions. Stay within a single incision in order to aid in cartilage healing. Once the posterior perichondrium is identified, the incision ceases. Division of the retrocricoid mucosa can lead to contamination of the LTR wound with saliva, chondritis, and failure of the surgery.
Do not divide the interarytenoid muscles unless there is a web. If there is a web, it can be repaired with a flap of perichondrium from the posterior cartilage graft interposed between the incised web (not illustrated).
Elevating the posterior perichondrium is a difficult part of the procedure and its proper execution will greatly influence reconstruction and healing. The angles for dissection are impaired by the contralateral larynx. A pocket that can secure the flanges of the posterior graft will minimize or eliminate intraluminal sutures on the graft site.

Creating a pocket of “just the right size” will indeed help with the placement of the posterior graft. Too large a pocket may allow the graft to slide laterally, and too small a pocket will not allow the flanges to fit in correctly.   RCNuss

Placing a Posterior Graft (Figure 7-10)
STEP 18. Multiple scalpel blades will be needed for cutting and carving cartilage. A Teflon block is helpful as a cutting board for the cartilage graft. An angled elevator, such as a Rosen knife from a middle ear tray, may also be useful. An elliptic or pentagonal cartilage graft is carved from the rib graft. The perichondrium faces the lumen of the larynx. A narrow point should extend superiorly toward the interarytenoid space.

FIGURE 7-10 Placing the posterior graft.

We carve the graft slightly trapezoidal, with dimensions usually about 4 by 3 by 7 mm long. The shelf on each side is 1 to 2 mm and is snap fit under the posterior cricoid lamina without any previous undermining. This graft is quite solid and no sutures are placed. We abandoned the sutures technique about 10 years ago, and it has markedly reduced the problem of postoperative granuloma formation.   JSidman
A posterior ledge about 3 mm surrounds the graft. This ledge will insert into the subperichondrial pocket just created. Skin hooks applied to the cricoid cartilage and rotating it help expose the pocket. The graft should “snap” into place. Use a monofilament absorbable suture on a noncutting needle to place at least four horizontal mattress sutures in order to secure the graft.
If a single-stage procedure is planned, once the posterior graft is secure, pass a cuffed endotracheal tube into the trachea (see Anesthetic Considerations ). The surgeon directs the tube across the posterior graft and into the distal trachea. The initial tracheal ventilating tube is removed and ventilation proceeds via the newly placed tube.
The width of the graft will depend on the degree of posterior stenosis and the mobility of the tissues. The thickness of the graft should approximate the thickness of the posterior lamina. The thickness of the posterior lamina and the graft can be measured with calipers. The perichondrium provides the scaffold for respiratory mucosa to grow. It is important to minimize any gaps between the graft and the subglottic mucosa. In a severely scarred larynx, achieving enough mobility to insert and secure the graft without sutures may be difficult. A monofilament, double-armed suture (e.g., PDS, Monocryl, Maxon) is less traumatic to the tissues.

Burying the sutures so that there is no exposed suture material intraluminally, helps prevent the development of granulation tissue or suture granulomas in the postoperative period.   RCNuss
Likewise, skin hooks reduce trauma to cartilage compared with forceps. The endotracheal tube should be at least a half-size smaller than one would normally use, or smaller still if cuff pressure can be limited. A small tube that is still adequate for low-pressure ventilation during the postoperative period minimizes the transmural pressure against the reconstructed subglottis. Good capillary perfusion optimizes wound healing.

Stent Placement for Two-Stage LTR (Figure 7-11)
STEP 19. If a two-stage repair is planned, the surgeon places the stent over the posterior graft instead of the endotracheal tube. The stent is secured by passing a 2-0 nylon suture on a large cutting needle. A Teflon button is placed on the lateral edge on one side of the skin incision. Suture is passed through the strap muscles, lateral cricoid, stent, and around the contralateral sternocleidomastoid muscle and back in a mattress fashion.

FIGURE 7-11 Stent placement for two-stage laryngotracheal reconstruction (LTR).
Monofilament suture passes more easily through these tissues when it comes time to remove the stent. Tying the knot over a Teflon button on the surface of the skin minimizes trauma to the skin, and it becomes simple to find the suture to cut at the time of stent removal.
Several types of stents have been described for LTR (complete discussion is beyond the scope of this chapter). What is important is the size of the stent, or a stent that can be fashioned to fit the laryngotracheal defect that needs support. Also most stents are made from milled (smooth) Teflon or Silastic, which limits the reactivity of the airway to this foreign body. In young children manufactured stent choices are limited; most are made for school-age children and larger patients.
If a single-stage procedure is planned, at this point the endotracheal tube is passed by the anesthesiologist. Often it is a nasotracheal tube because this offers some security against accidental extubation.

We also prefer nasotracheal intubation. The anesthetist intubates by standard technique as the surgeon guides the tube after it is in the subglottis. Be careful not to use a nasal RAE tube because this has two curves that are very difficult to suction in the pediatric ICU (PICU) postoperatively. A straight nasal tube suffices here.   JSidman
I like to present a tonsil clamp or other long-handled clamp through the larynx. This provides the anesthesiologist with a target. I like to grasp the tip of the endotracheal tube and deliver it through the operative field to the distal trachea. At this point the trimmed RAE tube is removed and ventilation continued via the endotracheal tube.

Anterior Graft “Parachuting” into Place (Figure 7-12)
STEP 20. Once the airway is secured (or stent in place), the anterior repair with cartilage graft is performed over the tube. The remaining costal cartilage is carved to create the anterior graft. Again the graft is oriented so that perichondrium faces the airway lumen. An elliptic or hexagonal shape is used to repair the defect in the anterior airway. The ledge that extends laterally from the graft should be at least 5 mm. Monofilament sutures with noncutting needles are used. The sutures do not violate mucosa or perichondrium and are placed through the graft so that that perichondrium aligns with the mucosa. All sutures are placed first to allow parachuting the graft into place.

FIGURE 7-12 Anterior graft “parachuting” into place.

The key to this suture is placing the needle into the “crotch” between the shelf and the perichondrium edge, forcing the perichondrium and the tracheal edge together. We also do not tie the sutures until they are all placed. We attempt to achieve an airtight closure to about 20 cm H 2 O pressure delivered by the anesthesiologist in the saline-filled wound.   JSidman
The shape of the graft allows the surrounding airway tissues to more easily close around the recipient site. This limits the amount of air leak through the repair. The ledge around the anterior graft prevents displacement into the airway lumen. It can also provide a surface on which the suture knot can be tightened atraumatically. More accurate suture placement is achieved by passing all sutures first, then positioning the graft (parachuting) within the anterior defect.

A 5-mm ledge is indeed very generous. It is also possible to fashion an anterior graft that is completely fusiform in shape, or has a square caudal portion (similar to a “square-backed canoe”) if one is incorporating and closing the tracheostomy stoma in the repair.   RCNuss

Laryngofissure Repair (Figure 7-13)
STEP 21. Repair of laryngofissure and anterior commissure requires precise realignment. Using the methylene blue marks as a guide, pass the 6-0 Prolene through the contralateral thyroid lamina. Do this on each side, then carefully bring tension on the sutures as you align the marks on the thyroid lamina. Tie down each Prolene separately while maintaining tension on the other. Then monofilament suture can be used to repair the thyroid lamina on both sides of the commissure.

FIGURE 7-13 Laryngofissure repair.

I use PDS to avoid the possibility of later “spitting” of the sutures through the laryngeal mucosa.   JDSmith
If two-stage LTR was performed, insert sterile tracheostomy tube after laryngofissure repair.

As noted, we do not perform laryngofissure as part of a standard LTR.   JSidman

In general, it is wise to avoid a complete laryngofissure with division of the anterior commissure unless this is absolutely necessary, such as for repair of a glottic web.   RCNuss
STEP 22. Reapproximate the strap muscles over the laryngotracheal complex. Vicryl or other absorbable suture is used. A Penrose drain is placed beneath the inferior edge of strap muscles, and strap muscles are loosely closed. The apron flap is now returned to position and layered closure performed. Absorbable suture is used to close the platysma and subcutaneous tissues. Skin closure can be done with suture or staples.
Because of the precision needed to correctly reconstruct the anterior commissure and true vocal cords after laryngofissure, some centers will do this with endoscopic guidance assisting the surgeon. The endoscopic manipulation of the larynx can impede the closure of the larynx, however. Careful initial markings (see Figures 7-11 and 7-12 ) obviate the need for endoscopic assistance.
An airtight seal is rarely possible after the anterior graft is placed; therefore, to prevent pneumomediastinum, the Penrose drain is used. Meticulous technique and good hemostasis will limit the amount of serosanguineous drainage. Skin and flap closure can be done by the surgeon’s preference.

We do strive for and achieve airtight closure up to a pressure of at least 30 cm H 2 O. Fill the repair site with saline, deflate the endotracheal tube cuff, ask the anesthesiologist to perform a Valsalva maneuver, and look for air bubbles. A few additional sutures will help seal the leak and may save problems in the postoperative period by minimizing the chance of pneumomediastinum.   RCNuss

Postoperative Management
The patient is transferred directly from the OR to the ICU or other unit where nursing and respiratory care is skilled in airway and ventilator management. A chest radiograph is obtained to ensure that a pneumothorax does not exist. Initial focus is on respiratory status. If the patient is to become ambulatory, either with a tracheostomy or nasotracheal tube, then weaning from the ventilator is discussed with the attending intensivist. If the patient will not be ambulatory during the postoperative period while grafts are healing, a sedation plan is discussed with the ICU team. Avoiding paralysis of the patient will avoid challenges in fluid management, though this may not be possible with young children who, when agitated, unintentionally extubate themselves. Enteral feeding is begun within the first 24 hours and continued until extubation. The drain placed in the chest donor site is left in place for 24 to 48 hours or until the drainage has ceased. The neck drain is kept until there are no signs of air leak.

It is also reasonable to leave the neck drain in place until the patient is extubated.   RCNuss

We do not routinely place a chest donor site drain. We do, however, always place a drain under the strap muscles, even when we achieve an airtight closure.   JSidman
Once drains are removed, dressings are no longer needed on the wounds. Application of ointment to keep the incision moist is all that is needed; if used, nonabsorbable sutures or staples are removed per the surgeon’s routine. Antibiotics are used while drains are in place, then discontinued once they are removed. Antireflux medications are begun (or resumed) immediately after surgery and continued for at least 2 months. If the patient has a nasotracheal tube the nasal ala must be watched for signs of pressure ischemia. Adjusting the position of the tube and using taping techniques can prevent alar rim necrosis.

This is an excellent point. This has to be reinforced to all medical providers and to the parents. Educating everyone about this preventable problem is time well spent.   RCNuss
The decision to return the patient to the OR for microdirectlaryngoscopy and timing for extubation are based on the extent of reconstruction, number of grafts used, and overall patient status. Knowing that the airway edema has subsided is also an important consideration. Airway edema can be determined by what pressure an air leak can be generated around the endotracheal tube. Using a manometer and an Ambu bag, the endotracheal tube cuff is deflated, and the air pressure is measured once air is heard escaping from the patient’s mouth. Successful extubation is most likely if the pressure is less than 20 cm H 2 O. The patient should not be paralyzed during this maneuver.
In general it takes 4 to 7 days for an anterior graft–only LTR to heal. Ten to 14 days are often needed to allow the posterior graft to heal. The posterior graft is more difficult to position and is subject to more deformational pressures (swallowing, tube movement, etc.).

“Healing” is hard to define in this setting. The strength of the repair may not develop for several weeks. Thus the integrity and positioning of the graft are completely dependent on the shape and fit of the graft as well as the sutures for at least the first few weeks. The length of time to keep a patient intubated after a single-stage LTR is somewhat arbitrary, based on tradition and good results on past experience. One may also consider extubation much sooner, once perioperative edema has subsided. A sooner extubation helps avoid postoperative complications related to prolonged periods of sedation or bedrest. One may also argue that healing occurs sooner with the stent or endotracheal tube out.   RCNuss
In an awake, single-stage LTR patient who has an air leak at less than 20 cm, extubation may be performed at the bedside. In most cases, though, it is advised to return the patient to the OR prior to extubation. MDLB allows the surgeon to assess the larynx and trachea for the status of the grafts and for granulomas or other lesions that could complicate extubation. The grafts should show evidence of epithelialization when the white perichondrium starts turning pink. Often granulomas are excised, either sharply or with laser. If there are no major obstructing lesions, the patient is carefully reintubated by the surgeon using a slightly smaller oral endotracheal tube, especially if the patient has had prolonged sedation. This approach allows the patient to be properly weaned from the sedating medications and neuromuscular status more fully restored prior to finally extubating the patient. Failure at extubation after LTR has many causes including edema, restenosis, graft failure, and respiratory failure. Steroids given within 8 hours prior to extubation may help prevent postextubation stridor.

As noted, we do not perform extubation in the OR, but wait about 6 weeks for the first laryngoscopy. We use 3- to 5-day intubation for anterior-only grafts, and 7 days for anterior and posterior grafts.   JSidman
The patient should be monitored carefully for at least 24 hours after extubation. Pulse oximetry and cardiac monitoring will help detect impending respiratory compromise. Especially if the patient was kept sedated or paralyzed while intubated he or she will be weak and require physical therapy in order to resume activities of daily living once extubated.

Tapering of benzodiazepines or narcotics may be necessary if these were used for sedation after the initial surgery.   RCNuss
A speech and language pathologist can also perform a swallowing evaluation to ensure that the patient is not aspirating and that it is safe for the patient to eat. Ideally, when discharged the patient has resumed a regular diet and normal activities.

It is common for children to be uncoordinated and disoriented following 5 to 7 days of intubation and sedation. We don’t start oral feeding until they are oriented, and do not routinely perform swallow studies.   JSidman

Of note, patients who have undergone an LTR with both anterior and posterior grafts may have a higher risk of aspiration of thin liquids, especially if there is noted to be vocal fold immobility prior to the surgery.   RCNuss
In two-stage LTR the patient does not require the same degree of vigilance postoperatively, especially if the stomal soft tissue is preserved as a “mature stoma.” These two-stage LTR patients should be able to resume their preoperative tracheostomy care routine within a couple of days after surgery. Enteral feeding is advised to minimize the risk of aspiration and limit laryngeal movement.
Stent removal is planned at least 3 weeks after surgery. The length of time the stent remains is place is determined by the condition of the laryngotracheal complex at the time of LTR. If the recipient cartilage framework and mucosa were in good condition with limited fibrosis, early stent removal is planned. However, more severely damaged (or missing) framework or larger areas of mucosal injury mean that the stent will be needed to support healing for a longer time.
Stent removal is performed during microdirectlaryngoscopy. The surgeon can grasp the stent with microlaryngeal forceps and remove it once the suture is cut and pulled through. This maneuver should be done with minimal trauma to the larynx. Once the stent is out, the surgical site can be inspected and granulation tissue removed, if needed. I prefer to decannulate the patient weeks later once it is clear that laryngeal function has returned and there are no signs of restenosis.

Editorial Comment
The technique described in this chapter is an excellent summary of both a one- and two-stage LTR. Although one commentator does only one-stage LTRs, the beginner or occasional operator should understand the two-stage procedure and consider it in the more severe or complicated stenosis repairs. The choice also is influenced by the ICU and nursing care available. If patients are not cared for on a regular basis by very experienced ICU nurses, ICU personnel, and physicians, it may be safer to do a two-stage procedure from the standpoint of postoperative airway control. Although it requires more time and procedures, the final results from correction of the stenosis should be the same with both procedures. Therefore, the ultimate decision should be based on what is safest for the patient’s postoperative airway care in your hands and setting.   JDSmith

Suggested Readings

Goldenberg D, Esclamado R, Flint PW, Cummings CW. Surgical management of upper airway stenosis. In: Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, et al, editors. Cummings otolaryngology head & neck surgery . ed 4. Philadelphia: Mosby; 2005:2103-2127.
Postic WP, Cotton RT, Handler SD. Surgical pediatric otolaryngology . New York: Thieme Medical Publishers; 1997. pp 384-403
CHAPTER 8 Cricotracheal Resection for Subglottic Stenosis

Author Peter E. Andersen

Commentary by James I. Cohen, Robin T. Cotton, Paul W. Flint
Perform suspension laryngoscopy or tracheoscopy to inspect the nature of stenosis. On conclusion, intubate with a small endotracheal tube (ETT) with the cuff positioned below the area of stenosis (Figure 8-1) .

FIGURE 8-1 Position the balloon of the endotracheal tube distal to the level of the stenosis.

Especially in children, an alternative to a cuffed ETT is to use the appropriate ETT sized to the area of stenosis. In cases of severe stenosis, balloon dilatation may be used to increase the airway diameter to place a larger ETT before proceeding with surgical correction. This may provide a temporary but safer airway during the surgical procedure.   RTCotton

Using a zero-degree rigid telescope to visualize the stenosis allows for accurate measurement of length to be resected. By marking the telescope with a blue marker at the hub of the laryngoscope as the telescope passes the level of the vocal folds, and the proximal and distal limits of the stenosis, length of the stenosis and proximity to the vocal folds is determined.   PWFlint
I use jet ventilation during the laryngoscopy and tracheoscopy.

In children, inhalation anesthesia with an apneic technique is the preferred method during microdirectlaryngoscopy and bronchoscopy (MDLB). Surgical planning is often made at a prior MDLB before proceeding to a definite reconstructive procedure. A Maloney esophageal bougie is placed to help define the esophagus during the tracheal dissection later in the procedure to prevent accidental entry into the esophagus.   RTCotton
STEP 1. The patient is in the supine position with a horizontally placed shoulder roll. The ETT should be brought over the head as shown. Make sure to have ready access to the ETT pilot balloon and the tape securing the ETT in place. The operating room (OR) setup is as shown (Figure 8-2).

FIGURE 8-2 Operating room layout.
STEP 2. The skin incision is very similar to that used for thyroid surgery. Elevate the subplatysmal skin flaps up to the hyoid bone and down to the sternal notch (Figure 8-3).

FIGURE 8-3 Location of incision.

If a laryngeal release is planned, I will do it at this point because the exposure is easiest.   JICohen

The setup can be reversed depending on the surgeon’s preference.   RTCotton
STEP 3. Divide the strap muscles in the midline from hyoid bone to sternal notch (Figure 8-4).

FIGURE 8-4 Vertical division of strap muscles in the midline.

I elevate the strap muscles off the thyroid and pretracheal tissues fully because I think this helps with overall mobilization of the laryngotracheal complex so that subsequent reanastomosis is tension free.   JICohen
STEP 4. Divide the thyroid isthmus and reflect the thyroid lobes laterally off of the trachea and cricoid cartilage. Divide the pretracheal fatty tissue and reflect this laterally and off the trachea. You should now have the area of stenosis exposed with at least three rings of normal trachea visible below the area of stenosis (Figure 8-5).

FIGURE 8-5 Elevation of strap muscles off of the thyroid gland, larynx, and trachea. Dotted line indicates location of division of the thyroid isthmus.

I make every effort to dissect at least the anterior 180 degrees of the trachea and cricoid free because this significantly improves mobilization. To protect the nerve, this often means a subperichondrial dissection in the region of Berry’s ligament.   JICohen
As long as you hug the trachea during this maneuver you will not injure the recurrent laryngeal nerve. The closer you get to the cricoid, the more careful you have to become. It is not necessary to visually identify the nerve during this maneuver.
STEP 5. Begin your releasing maneuvers by bluntly dissecting the fatty tissue off of the anterior wall of the trachea with your finger. Continue this blunt dissection into the mediastinum as far as possible (preferably to the carina). Sweep laterally along the trachea on both sides to free up approximately 270 degrees of the trachea from the surrounding tissues (Figure 8-6).

FIGURE 8-6 A, Reflection of thyroid lobes off of the trachea and cricoid cartilage up to the ligament of Berry and blunt dissection of trachea within the mediastinum using finger (inset). B, Skeletonization of central portion of hyoid and division of hyoid at lesser cornu to release tension during closure (this maneuver is not required in all cases).

Superior retraction on the larynx facilitates extending this dissection as inferiorly as possible. When complete there should be no scar bands tethering the trachea from the level of the cricoids to the carina with a single plane of dissection.   JICohen

Care should be taken with this maneuver to identify the innominate artery and prevent accidental injury. Preservation of the lateral attachments is crucial for vascular supply to the trachea.   RTCotton
If a suprahyoid release is needed for closure, perform it now by dividing the suprahyoid muscles from the hyoid bone from lesser cornu to lesser cornu. Divide the hyoid bone just lateral to the lesser cornua with a saw or bone cutter.

Alternatively, you may leave this decision until after the resection. A high stenosis at the level of the cricoid may be closed without this maneuver. Extension of the stenosis into the cervical trachea and/or resection of a tracheotomy site increases the likelihood that a suprahyoid release will be required.   PWFlint

I find it helpful to use a right-angle clamp to dissect underneath the hyoid at the area it is to be divided and elevate it forward. This facilitates its division.   JICohen

It may be preferable to perform the suprahyoid release when assessing the anastomotic closure. The tension on the anastomosis and the mobility of the trachea will often dictate whether a suprahyoid release is needed. Releasing the musculature from the superior attachments of the hyoid is often all that is needed.   RTCotton
STEP 6. Enter the trachea through the area of stenosis and using scalpel or scissors gradually remove the stenotic anterior and lateral trachea up to the cricoid cartilage and inferiorly until you have reached healthy trachea (Figure 8-7).

FIGURE 8-7 Entry into the trachea.

I prefer to enter in a vertical manner at the midline of what appears to be the tightest area of the stenosis. I then extend this superiorly and inferiorly until I come to what appears to be a more normal airway. At this point I “T” it laterally. I find this allows me to be most precise in terms of preserving as much of the normal airway as possible.   JICohen
I enter the trachea vertically through a less than 1-cm tracheotomy and then gradually remove trachea until I have reached healthy tissue. Take care not to puncture the balloon of the ETT during this maneuver.

A vertical incision through the stenotic segment allows the surgeon to adapt the operation to a laryngotracheoplasty with cartilage augmentation if the stenotic segment is found to be longer intraoperatively than what was appreciated on endoscopy. Endoscopically assisted division is often helpful in revision cases, in which a second surgeon performs the endoscopy during the laryngotracheal fissure.   RTCotton

Visualization of the airway is facilitated by placing skin hooks in the anterior wall for lateral displacement. If the area of stenosis is not readily apparent, direct laryngoscopy may be performed and the airway visualized with a telescope as a needle is passed into the trachea from the surgical field, providing precise external landmarks.   PWFlint
STEP 7. Intubate the patient through the operative field (Figure 8-8).

FIGURE 8-8 A and B, Removal of oral endotracheal tube from the operative field and replacement with endotracheal tube into distal trachea. Catheter sewn to tip of removed endotracheal tube facilitates reinsertion (inset).
I find that sewing a red rubber catheter to the oral endotracheal tube prior to withdrawing it greatly facilitates the oral endotracheal reintubation at the latter stages of the operation.

A second sterile ETT then can be placed through the fissure and used to ventilate the patient and the oral placed tube can be removed. Cuffed anode tubes or a cut oral ray are preferable. The tube can be secured by sutures to the neck or chest skin. We do not place a red rubber catheter through cricoid to provide better visualization and assessment of the resection; 2-0 Prolene lateral retention stitches are placed around a single trachea ring in the distal tracheal segment and clamped. These ensure that the tracheal stump is secured once the trachea has been transected.   RTCotton

This maneuver is a time saver at the end of the case. Alternatively, the ETT may be passed over a nasogastric (NG) tube fed retrograde through the tracheotomy. This technique reduces the number of objects within the operative field.   PWFlint
STEP 8. Divide the posterior tracheal wall and resect the posterior wall up to the cricoid cartilage (Figure 8-9).

FIGURE 8-9 A, Separation of posterior tracheal wall from esophagus. B, Division posterior tracheal wall and dissection of distal trachea off of esophagus.

Although some redundancy of the posterior wall is well tolerated and smoothes out with time, I agree that it should be resected even with the level of anterior tracheal resection. However, I prefer to divide it horizontally at the midpoint of the area of stenosis and trim it only after fully mobilizing the airway off the underlying esophagus. I find there is often some distortion of the back wall until this is performed and a more accurate assessment of the level to trim it can be done.   JICohen
During this maneuver it is tempting to leave the posterior wall intact if it is not diseased. However, I find this to be counterproductive because during the closure this tissue will bunch up posteriorly as the tracheal anastomosis is performed.
If there is substantial scarring in the posterior subglottis and the posterior tracheal wall is in good shape, consider leaving some of the posterior wall attached to the tracheal stump. This can be advanced into the posterior subglottis during closure to cover exposed cricoid cartilage. If not needed it can be discarded later.

If identification of the tracheoesophageal groove and common party wall is not easily accomplished because of scar, you may choose to divide the anterior and posterior walls at the proximal end of the stenosis to facilitate separation of the trachea from the esophagus.   PWFlint

After the midline incision to divide and assess the stenosis, the lateral aspects of the stenotic segment are then skeletonized hugging the tracheal cartilage. The cricothyroid muscle is peeled off the cricoid from medial to lateral. Care must be taken around the cricothyroid joint to not inadvertently injure the recurrent laryngeal nerves. A horizontal incision is made in the posterior wall of the cricoid and the mucosa is dissected off the cricoid inferiorly to the end of the cricoid. The posterior tracheal wall is then dissected away from the esophageal party wall using the bougie to help identify the esophagus. Blunt dissection is then used to free up the posterior trachea. Preservation of the lateral attachments ensures vascular supply to the trachea and prevents injury to the recurrent laryngeal nerves. The stenotic tracheal segment can then be removed. A posterior tongue is left to help cover the denuded posterior cricoid.   RTCotton
STEP 9. Dissect the trachea off of the esophagus for no more than five rings (Figure 8-10). The five-ring limit is to decrease the risk of ischemia of the tracheal stump.

FIGURE 8-10 Circumferential mobilization of distal trachea (about five rings can be circumferentially mobilized without risk of avascular necrosis).

This maneuver may be delayed until just prior to closure and after assessing the amount of tension necessary to approximate the trachea to the cricoid. A suprahyoid release should be considered at this time as well. Limiting posterior dissection minimizes the risk of ischemia and subsequent dehiscence or restenosis.   PWFlint

More dissection can be used, especially in children, to gain appropriate mobility of the trachea. Once the tracheal dissection is complete, the esophageal bougie can be removed.   RTCotton
STEP 10. Elevate the cricothyroid muscles off of the anterior and lateral aspects of the cricoid (Figure 8-11).

FIGURE 8-11 Reflection of the cricothyroid muscles off anterior and lateral aspect of cricoid cartilage.
The attachments of the cricothyroid muscle anteriorly are divided using the bipolar cautery. More laterally dissection in a subperichondrial plane with a periosteal elevator.

The goal is to join this plane inferiorly to the previous plane of dissection of the thyroid off the trachea so that the upper segment of the airway is fully exposed and mobilized as much as possible.   JICohen
STEP 11. Remove the anterior arch of the cricoid cartilage (Figure 8-12).

FIGURE 8-12 Removal of the anterior arch of the cricoid cartilage.
This can be done quickly with a pair of heavy scissors. In addition, resect the soft tissue of the cricothyroid membrane up to the inferior aspect of the cricoid cartilage.

The cricoid can be assessed. The anterior and lateral arch can be removed using a Beaver blade. This excision often is beveled to prevent injuring the recurrent nerves. If the posterior cricoid plate is scarred and thick, a diamond drill bit can be used to thin the posterior cricoid plate.   RTCotton
STEP 12. Elevate the mucosa off of the inner aspect of the remaining lateral cricoid bilaterally and then resect the exposed cricoid cartilage using a Lempert rongeur (Figure 8-13).

FIGURE 8-13 Reflection of the mucosa off the interior aspect of the lateral arches of the cricoid cartilage. Nibble back the lateral cricoid cartilage to just anterior to the cricoarytenoid joint (inset).
The goal here is to remove as much of the lateral cricoid cartilage as possible without disrupting the cricoarytenoid joints. If the posterior subglottis is scarred, you can either resect the involved mucosa and advance the posterior tracheal flap (described in Step 10) into the defect or elevate just the mucosa off of the underlying fibrous tissue and perform a submucosal fibrosectomy.

Preservation of the lateral aspect of the cricoids cartilage facilitates closure and improves the strength of the closure. A modification of the technique described here entails pulling the tracheal rings inside the cricoid remnant in a telescoping manner and suturing the proximal tracheal ring to the cricoid juxtaposed in a side-by-side manner.   PWFlint
STEP 13. Close the posterior tracheal wall with interrupted sutures of 3-0 Maxon (Figure 8-14).

FIGURE 8-14 Closure of the posterior wall to the trachea to the posterior cricoid lamina and mucosa.
I find that five sutures are usually needed. Place all the sutures before tying. Make sure that the knots are on the outside of the trachea.

Depending on the amount of tension and exposure, I will sometimes lay in all the sutures (anterior and posterior) before tying them because I can place them more accurately. To do this I begin in the midline posteriorly and tag each suture, placing the sutures in order on an arm-navy style retractor—one on each side of the field. After they are all placed, I reverse the retractor and take them off to tie them in reverse order beginning posteriorly.   JICohen

In this step the shoulder roll should be removed and the neck flexed slightly. If tension is too great and there is concern about tearing of the mucosal layer, consider tagging the posterior wall sutures, and place and tie the lateral sutures from the cricoid to tracheal ring first, thus reducing tension on the mucosal layer (see Steps 15 and 16 ). This method requires placement of the ETT prior to securing the lateral and anterior sutures.   PWFlint

Two 2-0 PDS retention lateral mattress sutures are then placed through the thyroid cartilage and exiting the posterior lateral aspect of the cricoid. The suture is then placed submucosally on the tracheal stump to loop around a cartilage ring and then back through cricoid and out thyroid cartilage. These sutures help to relieve tension on the anastomosis and provide stability during the closure. The anastomosis can be made as described previously, or per our preference, which has been to use a double-armed 4-0 PDS suture to perform a running closure. Once the initial posterior sutures have been placed, the running anastomosis is tightened using a nerve hook to ensure a tight closure. The patient can then be intubated orally or transnasally if the plan is to leave the patient intubated. After securing the running closure, the lateral retention sutures can be secured and tied down.   RTCotton
STEP 14. Reintubate the patient orotracheally (Figure 8-15).

FIGURE 8-15 Reintubation of the patient orotracheally.
Make sure the cuff of the ETT is not too far into the trachea because as you close the anterior and lateral parts of the anastomosis it is easy for the tube to wind up in the right mainstem bronchus.
STEP 15. Close the lateral and anterior portions of the anastomosis using interrupted 3-0 Maxon sutures (Figure 8-16).

FIGURE 8-16 Closure of the lateral and anterior aspects of the anastomosis.
Place all the sutures prior to tying them. The lateral sutures are placed from the trachea to the remaining lateral cricoid cartilage. The anterior sutures are placed from the trachea to the anterior aspect of the thyroid cartilage. You may need to drill holes for the sutures in the thyroid cartilage.

Taking the patient out of neck extension at this point can facilitate reanastomosis.   JICohen
Coat the anastomosis with fibrin glue.

I have not found this to be necessary.   JICohen

A leak test is often performed prior to placing the fibrin sealant to assess for potential anastomotic leak. Sterile saline is placed in the wound and the anesthetist tests the anastomosis to 30 mm Hg pressure. Any leaks are addressed with interrupted sutures, and the anastomosis is tested until no more leaks are noted. Fibrin sealant is then placed.   RTCotton
STEP 16. Close the wound over a -inch Penrose drain. Close the strap muscles in the midline and the skin according to the surgeon’s preference (Figure 8-17).

FIGURE 8-17 Wound closure.

Alternatively, you may use a closed suction drain to monitor for air leak. I find this useful in more difficult closures in which intubation postoperatively is considered.   PWFlint

If I am significantly concerned about the airway I will leave the most anterior anastomotic suture long and bring it out through the wound should emergent tracheotomy be necessary.   JICohen

The strap musculature is then reapproximated. The Penrose drain is placed on top of the strap musculature. The straps provide important vascular supply to the reconstruction and the Penrose left between the trachea and the muscle can interfere with this process. The distal retention sutures are then looped around the hyoid bone using a free large Keith needle. These allow for additional detensioning of the anastomosis.   RTCotton
I routinely extubate these patients in the OR and do not send them to the intensive care unit (ICU) postoperatively. The airway is much larger after the operation than it was before and therefore whatever airway swelling occurs is not problematic. I do not suture the chin to the sternum, nor do I use a neck brace.

I do not use a neck brace to maintain flexion, but if I have concerns I keep the patient on a couple of pillows to maintain flexion when he or she is supine and counsel him or her to avoid significant extension. A standard cervical collar can be useful in this regard.   JICohen

The Grillo stitch does seem unnecessary today, given that other options including neck brace are available when an extended resection is performed and neck flexion needs to be maintained.   PWFlint

Children often will need to be transnasally intubated for 7 to 10 days. Additionally, cases in which the resection is close to the vocal folds are much more prone to glottic edema and often need intubation until this subsides. We typically leave patients in a C-collar or place chin-to-chest sutures for 10 to 14 days. Stitches should be placed through the periosteum of the mandible and through the periosteum of the clavicular head. There was a brief period when we did not use either of these methods and had a significant increase in dehiscence rates.   RTCotton

Editorial Comment
Otolaryngologists have been relative latecomers to the performance of this operation rather than expansion laryngoplasties or tracheoplasties. However, its advantages, in terms of being a reliable one-stage procedure without the need for tracheotomy, have allowed it to quickly assume a prominent role in the management of upper airway stenosis.
Although conceptually a straightforward operation, the details as outlined by the author and commentators that focus on the creation of a tension-free anastomosis and protection (without identification) of the recurrent laryngeal nerves are critical to its performance and are accomplished similarly in adults and children.   JICohen

Suggested Readings

Grillo H, Mathisen D, Ashiku S, Wright C, Wain J. Successful treatment of idiopathic laryngotracheal stenosis by resection and primary anastomosis. Ann Otol Rhinol Laryngol . 2003;112:798-800.
Grillo H, Mathisen D, Wain J. Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg . 1992;53:54-63.
Sandu K, Monnier P. Cricotracheal resection. Otolaryngol Clin North Am . 2008;41:981-998.
CHAPTER 9 Surgery for Unilateral Vocal Fold Paralysis

Author Joshua S. Schindler

Commentary by Mark S. Courey, C. Gaelyn Garrett, C. Blake Simpson

Preoperative Considerations
Treatment of unilateral vocal fold motion impairment depends on the symptoms and position of the vocal fold. Though most patients with a truly paralyzed vocal fold and glottic insufficiency complain of occasional coughing when swallowing liquids, swallowing difficulties are generally very mild in isolated cases of vocal fold motion impairment.

Electromyographic studies of vocal fold activity during swallowing demonstrate that thyroarytenoid muscle contraction occurs during the later stages of the swallow. Therefore, if glottic closure is not complete, aspiration of retrained pharyngeal contents can occur after the swallow. This is clinically significant if injury to the motor pharyngeal and sensory branches of cranial nerve (CN) X occur in conjunction with injury to the motor branches of the recurrent laryngeal nerve. In such cases, patients may not have normal pharyngeal function to allow stripping of the contents during the swallow or normal pharyngeal sensation to trigger a second swallow of retained food products.   MSCourey
Vocal quality is generally of greater concern. Rarely, the immobile or weak vocal fold rests in a median position, allowing satisfactory to excellent voicing ( Figure 9-1 ) . Unfortunately, the majority of patients assume a paramedian to lateral (sometimes called the cadaveric) position of the weak vocal fold with variable degrees of glottic insufficiency. With a paramedian position and good compensation from the opposite side, some patients experience only vocal fatigue and a vague globus sensation from the added work necessary to close the glottic gap and attain adequate voice. Raising vocal intensity (e.g., yelling) and lowering pitch often expose the true limitations in voice as the glottic insufficiency increases. However, with a paramedian to lateral position of the vocal fold and inadequate compensation from the opposite vocal fold, patients will experience a breathy aphonia that is terribly effortful to use and precludes adequate phonation in most cases. Patients with poorly compensated glottic insufficiency are candidates for medialization.

FIGURE 9-1 Vocal fold position in unilateral paralysis.

For unknown reasons it is estimated that up to 30% of patients with unilateral vocal fold immobility due to neurologic injury have adequate voice and swallow function and do not desire intervention for management of their injury. In this case, adequate voice does not mean “normal voice.” Rather it means acceptable voice for the patient.   MSCourey

Another symptom associated with glottal insufficiency that is frequently overlooked is a sensation of shortness of breath when talking and occasionally with mild aerobic exercise such as climbing stairs. This air escape usually improves after medialization.   CGGarrett

Vocal fold motion occurs in both the horizontal and vertical planes. This is due to the angled position of the cricoarytenoid joint and the action of the intrinsic laryngeal muscles, which direct the vocal process of the arytenoids downward during adduction. Therefore the immobile vocal process is usually at a higher level than the mobile vocal process during adduction for phonation. As such, failure of vocal fold closure can occur from horizontal insufficiency as well as vertical insufficiency or height mismatch because the upper and lower lip regions of the vocal fold are not well approximated if the vocal processes of the arytenoids do not meet in the vertical plane. This vertical dimension of motion is difficult to evaluate because we typically use a monocular, two-dimensional endoscopy system during indirect laryngoscopy for laryngeal evaluation.   MSCourey
Medialization procedures aim to restore glottic competence by placing the immobile or weak vocal fold in or near the midline with adequate support to prevent displacement with subglottal air pressure during voicing.
The vocal folds can be accessed in the lower half of the thyroid cartilage ( Figure 9-2 ) . The upper edge of the vocal fold typically runs from Montgomery’s tubercle at the anterior commissure to the vocal process. Unfortunately, Montgomery’s tubercle lies on the inner thyroid lamina, but the location of the anterior commissure can be estimated from the surface of the thyroid cartilage by identifying a point midway between the lower border of the thyroid cartilage and the inferior-most point of the thyroid notch. There is often a small blood vessel in the cartilage here running to Broyles’ ligament.

FIGURE 9-2 Surface anatomy of the laryngeal cartilages.

The vocal fold often lies at a level below the midway point between the lower border and the inferior point of the notch.   MSCourey
The angle of the vocal fold may be approximated from this spot as a line parallel to the true inferior border of the thyroid cartilage. It is important to identify the tubercle of the thyroid cartilage and find the inferior border posterior to this landmark to accurately identify this line. Everything inferior to this line inside the thyroid lamina represents the paraglottic space, inclusive of the thyroarytenoid muscle complex, vocal ligament, lamina propria, and mucosa of the vocal fold (see Figure 9-2 ).
The best results can allow completely normal voicing with little or no compensation on the part of the opposite vocal fold. To achieve this, the immobile or weak vocal fold needs to be able to vibrate at the same frequency, phase, and amplitude as the normal vocal fold without an anterior glottic gap. Excessive medialization and midvocal fold tension can perturb vocal quality just as much as inadequate medialization or midfold support. Although stroboscopy is tremendously helpful in assessing results (particularly failures), it is impractical in most situations during the procedure, and the surgeon “tunes” the voice with his or her ear. This is why most definitive medialization procedures are performed under light conscious sedation and local anesthetic.

Although significant improvement in the speaking voice is expected, patients need to be advised that improvement in the singing voice may be variable because of the persistent inability to dynamically change the tension and length of the paralyzed vocal fold.   CGGarrett
Vocal fold augmentation to correct glottic insufficiency occurs through two basic means: percutaneous injection and open external medialization.
Percutaneous or transoral injection of “filler” materials allows temporary improvement in glottic closure, voice, and swallowing in a brief outpatient or office-based procedure. Teflon paste is the only permanent injectable material available, but has been associated with chronic inflammatory responses and granulomas in some patients. Although no safe permanent injectable material exists, the duration of effect between available injectables varies from 4 weeks to as many as 2 years. This often allows adequate time for return of function in cases of neuropraxia. Most weakness is considered permanent 1 year following injury or noted absence of function.

Teflon paste has been abandoned for use in medialization procedures by most surgeons because of the significant incidence of inflammatory response and the more reliable outcomes by other temporary and permanent means. Also, the use of temporary injection augmentation does not seem to affect the recovery of a neuropraxic injury. Even partial recovery of innervation during this time can result in improved vocal fold tone and possible avoidance of further treatment.   CGGarrett
Permanent medialization is typically performed when the deficit is determined to be permanent and stable. These procedures typically incorporate some form of implant. These implants vary in composition from polytetrafluoroethylene (PTFE [Gore-Tex]) tape, solid polymerized silicone (Silastic), adjustable metal shim, and preformed calcium hydroxylapatite. All have the same goal of re-creating glottal competence through stable medial displacement of the vocal fold.

Medialization procedures do not directly address the vertical dimension of vocal fold motion and glottic closure. Cadaveric studies demonstrate that the arytenoid cartilage does rotate during filling of the paraglottic space. This rotation is an accidental byproduct from filling the paraglottic space and cannot reliably be controlled. Arytenoid adduction from sutures placed through the muscular process of the arytenoids allows controlled repositioning of the arytenoids such that the vertical height of the vocal process can be adjusted.   MSCourey
Additional procedures, including arytenoid adduction, reinnervation, and muscle flaps, can be used instead of or in addition to an implant for medialization. These procedures are not discussed in this chapter.

In selecting the medialization technique, the surgeon needs to consider the three-dimensional structure and dynamic function of the cricoarytenoid joint. Simple medialization with some materials does not always position the vocal fold at the same level as the mobile vocal fold nor does it always provide the needed bulk in the vertical dimension. Alternative implant materials or the other adjunctive procedures mentioned previously should be considered in these cases. Medialization outcomes with a fixed cricoarytenoid joint as opposed to a passively mobile but paralyzed vocal fold are generally poorer, and proper patient counseling preoperatively will help set appropriate expectations.   CGGarrett

Transoral Injection Laryngoplasty
STEP 1. The oropharynx and larynx are anesthetized locally with 2% to 4% lidocaine applied topically.

Anesthesia can be achieved by dripping topical anesthetics directly onto the larynx and pharynx, swabbing the larynx and pharynx with cotton soaked in topical anesthetics and held with a McGill forceps or through inhalation of nebulized agents.   MSCourey
The glottis may be exposed with a mirror while the patient holds his or her tongue.

A more facile way to perform this is to have an assistant use a flexible endoscope for guidance. This allows the surgeon to use both hands for the injection; the nondominant hand holding the tongue and the dominant hand holding the injection device. The surgeon is then able to stabilize the shaft of the needle on the index finger of the hand grasping the tongue.   CBSimpson
STEP 2. Entry into the paraglottic space is performed with a curved needle or cannula. Entry is best about 2 mm anterior to the vocal process, about 3 mm lateral to the edge of the vocal fold and about 4 mm deep into the tissue (Figure 9-3).

FIGURE 9-3 A, Transoral vocal fold injection. B, Needle placement for vocal fold injection.
Temporary injection laryngoplasty allows safe, fast, and minimally invasive correction of glottic insufficiency. It is often used in the acute setting and does not alter the likelihood of return to normal function with resolution of neuropraxia.
There are two primary means to access the paraglottic space for injection of the weak vocal fold: transoral and percutaneous transthyroid or thyrohyoid space.
Sometimes, the addition of a superior laryngeal nerve block can aid in regional anesthesia.
Improvement in cough and valving for swallowing are reliable and often critical in patients at risk for aspiration following cervical or thoracic surgery.
Although the vocal quality can be excellent following injection laryngoplasty, the voice results are probably less reliable than formal medialization thyroplasty with an implant and will fade with time. The efficacy of injection depends on location of the injection and amount injected. This places the material into the paraglottic space near the vocal ligament posteriorly, where most of the medialization needs to occur. Careful injection, often with a Bruning or similar syringe, allows gentle fusiform filling of the paraglottic space from posterior to anterior. The amount of material injected varies based on the size of the patient, precise location of injection, adequacy of filling, and type of injectable, but it is typically about 0.4 to 0.6 mL.
The choice of injection material is up to the surgeon and depends on the expected duration of vocal fold recovery. Injectable materials that disappear rapidly (months) should be “overinjected” by as much as 30% beyond what appears appropriate or provides a good vocal quality to allow for displacement or clearance of the material with time, whereas those that last for a year or more should be injected to good vocal quality. After overinjection with short-acting material, the patient’s voice will be very tight and pressed, but the patient can be reassured that this will improve over 5 to 14 days depending on the degree of injection. No voice restriction is necessary.

Although overinjection is usually required for these temporary injectables, the percentage of overinjection can vary among the type used. Anecdotally, the use of reconstituted collagen-based materials requires more overinjection as a result of the loss of saline within the first several days postinjection. Less overinjection (about 10%) may be required for the ready-to-use injectables such as calcium hydroxylapatite paste.   CGGarrett

This technique requires excellent topical anesthesia and operative experience or skillfulness on the part of the surgeon. The technique can be difficult to learn and requires practice for best results. The technique is considered difficult even by surgeons who have practiced their techniques. The procedure requires so much skill that when Teflon was first developed, it was proposed that the injection be limited to a number of surgeons with demonstrated abilities.   MSCourey

Generally an additional 0.1 to 0.2 mL of material is injected after the vocal fold is straight, giving it a convex, rounded contour.   CBSimpson

Percutaneous Transthyroid Injection Laryngoplasty
STEP 1. The patient’s nose is treated with aerosolized topical anesthetic and decongestant. The surgeon then palpates the larynx to identify the thyroid notch, cricothyroid space, and posterior border of the thyroid cartilage. The skin overlying the lower half of the thyroid cartilage is anesthetized with 1% to 2% lidocaine.
Selection of the point of entry is the most difficult part of this procedure and is roughly based on the midpoint of thyroid cartilage in the anteroposterior dimension and midpoint of the lower half of the thyroid cartilage.
STEP 2. An assistant exposes the glottis with a flexible laryngoscope and projects the image on a video screen for the surgeon to see.
Often, entry in the contralateral naris will allow the best view of the weak vocal fold.
STEP 3. The paraglottic space is accessed percutaneously directly through the thyroid cartilage with a 23- to 25-gauge needle, depending on the viscosity of the injected material (Figure 9-4).

FIGURE 9-4 Percutaneous transthyrohyoid injection of the vocal fold.
Gentle “coring” rotation of the needle allows passage through even the densest of thyroid laminas. Once through inner table of the thyroid lamina, careful advance of the needle into the paraglottic space after breaching the inner thyroid perichondrium will demonstrate “tenting” of the vocal ligament in the posterior third of the vocal fold.
Accidental entries into the ventricle, subglottis, and false vocal fold are common and provide the surgeon with a means to assess position and allow for replacement of the needle into the correct location. If possible, the surgeon should avoid mucosal violation because the small amount of bleeding will obscure the view from the laryngoscope and cause the patient to cough.

This technique, the “point touch technique,” is somewhat easier to master than the transoral injection technique. Because ideally the needle does not enter the airway or pass the oropharynx, coughing and gagging are reduced. The surgeon can spend time repositioning the needle. However, passing the needle through the thyroid cartilage stimulates sensory nerve fibers and is perceived as painful by most patients. Therefore, the technique is not recommended for patients with low pain tolerance or even those with laryngeal hypersensitivity who are difficult to examine with indirect techniques.   MSCourey

Injection location within the larynx is key to optimal result. The most common complication is to inject too superficially within the superficial layer of the lamina propria (SLP). Regardless of material used, the injection should be lateral into the vocalis muscle or paraglottic space. Entry into the SLP can result in a stiff vocal fold or even an inflammatory response that can take several weeks to resolve.   CGGarrett
STEP 4. When the needle is properly positioned in the paraglottic space, the surgeon injects the laryngoplasty material.
The needle should be withdrawn a few millimeters into the paraglottic space and the vocal fold filled to the desired degree.
If the lateral percutaneous approach fails to allow adequate placement of injectable, a transthyrohyoid approach may be considered. Local anesthesia of the vocal fold mucosa and airway is typically required for this approach (see Amin, 2006 ).
In patients who cannot tolerate unsedated transoral or percutaneous injection laryngoplasty, the procedure may be performed under brief general anesthetic by direct laryngoscopy by using a long needle or cannula through a laryngoscope transorally. The procedure may be performed with a small endotracheal tube in place or with mask ventilation under apneic conditions. The injection point and degree of fill are identical as for transoral unsedated injection. A microscope or telescope and suspension bar may facilitate placement of injection. It is, however, impossible to assess adequacy of injection by vocal quality for longer-acting injectables with this technique.

Certainly, office-based procedures are attractive for obvious reasons including the avoidance of general anesthesia, for example. For my patients, I offer both in-office and general anesthesia approaches. In my practice the transoral approach in the operating room is the preferred method because of patient choice and procedure outcome. A more precise injection can be accomplished under direct laryngoscopy and any material injected too superficially can be easily removed. The patient is allowed to talk immediately after surgery to mold the material within the vocal fold. At least two recent studies comparing awake versus operating room injection revealed equivalent voice outcomes but slightly higher complication rates with the in-office approach (see references). The approach used should be the one best suited for the clinical situation and the experience of the surgeon.   CGGarrett

Type I Medialization Thyroplasty
STEP 1. The patient is positioned in the “beach chair” position for comfort. The back is up at about 30 degrees with the knees and hips comfortably flexed to keep the patient from sliding off the table.
This procedure is best performed under local anesthesia with mild sedation to allow intraoperative assessment and “tuning” of the voice. Adequate preoperative assessment of vocal fold position, including degree of atrophy, height discrepancy relative to the normal vocal fold, and integrity of the lamina propria is best achieved with videostroboscopy. The procedure described here is much as described by Netterville and produces reliable results.
STEP 2. The neck is gently extended and carefully palpated for surface landmarks. The cricoid, cricothyroid space, thyroid notch and lateral border of the thyroid cartilage are identified.
STEP 3. An incision is marked out just above the inferior border of the thyroid cartilage from the midline to the lateral border of the thyroid cartilage in or parallel to a skin crease. This is anesthetized with a mixture of 1% lidocaine and 0.25% bupivacaine containing 1 : 200,000 epinephrine (Figure 9-5).

FIGURE 9-5 Incision placement for medialization thyroplasty.
In women—who have a very subtle thyroid notch—it is advisable to identify the hyoid bone and thyrohyoid space to confirm location of the entire thyroid lamina.
Wide injection and addition of a small amount of sodium bicarbonate allow a field block and limit patient discomfort. Additional local anesthetic may be needed throughout the procedure.
Sedation is best kept at a minimum because patients who are deeply sedated may become disoriented and suffer airway embarrassment if prone to sleep apnea.

My approach to the level of patient sedation has been modified over time. A careful discussion with the anesthesia team before surgery avoids any misunderstanding as to the level of alertness required to achieve optimal outcome. My practice is to avoid any sedation (including anxiolytics) until just prior to injection of the local anesthesia (a 1 : 1 mixture of 1% lidocaine with 1 : 100,000 epinephrine and 0.5% bupivacaine with 1 : 200,000 epinephrine). The contralateral naris is anesthetized with a cottonoid pledget saturated with a mixture of tetracaine and oxymetazoline. The patient is given intravenous propofol just prior to injection and placement of the transnasal laryngoscope, then allowed to awaken fully and remain unsedated for the remainder of the procedure. Communication with the patient during surgery is vital. Intravenous anxiolytics can be avoided in all cases with this approach. If needed, intravenous fentanyl is used for patient comfort during the procedure. This approach is extremely well tolerated by patients and allows them to cooperate fully during the procedure.   CGGarrett

The choice of medication(s) for sedation is important. Generally, a dexmedetomidine (Precedex) drip is preferred, which allows adequate sedation without disinhibition. The patient is generally able to respond to commands quite readily when the medication is stopped. Propofol (Diprivan) should be avoided.   CBSimpson
STEP 4. Visualization of the vocal folds can be attained during the procedure by suspending a flexible laryngoscope attached to a camera and video monitor (Figure 9-6).

FIGURE 9-6 Flexible videolaryngoscopy during medialization thyroplasty.
The nose may be topically treated with 4% cocaine solution on a cotton-tipped applicator to allow adequate vasoconstriction and analgesia for flexible laryngoscopy.
Visualization of the larynx during the procedure aids the surgeon in medialization at the appropriate height and helps prevent medialization of undesired structures, such as the false vocal folds. It can also aid in troubleshooting if the vocal quality is not as good as expected.
The patient can be prepped and draped using a clear plastic drape over the laryngoscope to allow manipulation during the procedure.
STEP 5. Skin incision is made and subplatysmal flaps are raised to just above the hyoid bone superiorly and below the cricoid inferiorly.
Careful undermining medially and laterally at the edges of the incision facilitates maximal exposure through a small incision.
STEP 6. The sternohyoid and sternothyroid muscles are separated in the midline from the hyoid bone to the lower border of the cricoid cartilage.
The surgeon should avoid cutting the sternothyroid and thyrohyoid muscles because these are extralaryngeal muscles that may be useful for compensation even following medialization thyroplasty to facilitate voicing.
STEP 7. The spine of the thyroid cartilage is identified and the perichondrium is incised sharply.
STEP 8. The perichondrium is carefully elevated on the ipsilateral side over the thyroid lamina using a combination of Freer and Cottle elevators (Figure 9-7A).

FIGURE 9-7 A, Exposure of thyroid cartilage. B, Placement and creation of the window.
Extension of the perichondrium cuts should be made laterally across the inferior and superior borders of the thyroid cartilage to develop a flap and provide access to the entire thyroid lamina.
A single hook in the thyroid notch stabilizes the thyroid cartilage and facilitate dissection and visualization.
Dense muscular attachments will be encountered at the tubercle of the thyroid cartilage from the cricothyroid muscle. These should not be completely detached to allow elevation of pitch following the procedure, but the surgeon must elevate beyond these attachments to identify the true inferior border of the thyroid cartilage (see Figure 9-2 ). The vocal folds are parallel to this true inferior border, and the surgeon can use this line to ascertain the trajectory of the vocal folds and better orient the implant.

The cricothyroid muscular attachments need to be detached enough to allow room for the inferior flanges of the implant. Failure to detach these fibers may lead to difficulty inserting the implant and possibly superior rotation of the implant.   CBSimpson
Modest elevation of the contralateral perichondrium allows better visualization of the spine of the thyroid cartilage and facilitates closure of the perichondrium at the conclusion of the procedure.

In order to obtain adequate exposure, the outer perichondrium of the thyroid lamina is elevated posterior to the attachments of the pharyngeal constrictor muscles. These muscles are elevated along with the outer perichondrium. If simultaneous arytenoid adduction is planned, the outer perichondrium and associated muscles can be elevated all the way to the posterior border of the thyroid lamina. This allows exposure of the posterior and piriform sinus mucosa in a relatively bloodless plane.   MSCourey

This is a posteriorly based flap. One should use caution in making the initial incision over the thyroid ala to avoid penetration through noncalcified cartilage that can be seen in some patients (especially young patients).   CBSimpson
STEP 9. The midline of the spine of the thyroid cartilage is identified. A mark is placed 5 mm laterally from this spot in a woman and 7 mm laterally in a man. This marks the anterior border of the thyroid cartilage window. A rectangular window is then fashioned posterior to this spot as determined by the implant type used for the procedure (see Figure 9-7B ).
If carving from a silicone block or using a Netterville thyroplasty implant (Medtronic Xomed, Jacksonville, Fla.), the window will be 6 by 13 mm. The window should be oriented parallel to the true inferior border of the thyroid cartilage.
Regardless of implant type, the window must be at least 3 mm from the inferior border of the thyroid cartilage near its anterior border to prevent fracture of the cartilage at this site. Other implant systems are similar, but may use windows of different sizes. If using Gore-Tex tape, the window is typically smaller to prevent lateral displacement of the tape through the window.
Once marked, a window in the thyroid cartilage may be excavated using a 3-mm cutting burr, Beaver 69 blade, Kerrison rongeurs, and/or mastoid curettes.
Very careful attention must be paid to maintain the inferior strut of cartilage and keep the window sharply defined to a rectangular 6 by 13 mm, or as determined by the system used. Oversized or fractured windows do not allow stable placement of the implant and may not allow optimal position of the implant for voice restoration.

My approach is similar to that described, using the Medtronic Netterville Silastic implant. I am now using a smaller window, though, usually measuring 5 by 9 to 10 mm.   CGGarrett

It is critical to maintain the anterior to posterior support and dimension of the ipsilateral thyroid lamina. If the inferior strut is interrupted or the cricothyroid joint fractured, pull of the ipsilateral intrinsic laryngeal muscles results in shortening of the injured side of the larynx. The patient will not be able to maintain symmetric laryngeal tension and closure will be permanently impaired.   MSCourey
STEP 10. The inner perichondrium is carefully incised with a Beaver blade and removed to provide access to the paraglottic space just lateral to the thyroarytenoid muscle fascia, nerve bundle, and vasculature.

Original descriptions of the procedure by Isshiki stressed the importance of keeping the inner perichondrium intact. It was thought that this provided a barrier to infection. The concept was derived from early 20th century reports of the procedure in which the inner perichondrium was violated and infection developed. This was before the availability of antibiotics. If one attempts to medialize the vocal fold with an intact inner perichondrium, then the entire inner perichondrium must be elevated from the inside of the thyroid lamina to achieve adequate medialization. If the inner perichondrium is incised or removed, the paraglottic space is entered. The fascia of the thyroarytenoid muscle serves as a barrier and creates a relatively bloodless plane or potential space in which dissection can be undertaken and an implant placed. The surgeon needs to exercise caution not to violate the ventricular mucosa. This mucosa is closest to the thyroid cartilage at the anterior and superior portions of the window. If the overhead lights in the room are dimmed, the light from the flexible laryngoscope will be visualized transilluminating through the mucosa. If the ventricular mucosa is violated, the breach must be closed primarily, then oversewn with a fascia patch and the wound irrigated. Careful attention to this detail can allow the surgeon to continue with the procedure without significant increased risk of implant extrusion. Infection and implant extrusion from type 1 thyroplasty is most likely secondary to unrecognized perforation of the ventricular mucosa.   MSCourey

This step may not be necessary. When the Kerrison forceps are used to remove the cartilage from the window, the inner perichondrium tends to be removed with each bite of the instrument. Once the window has been completely removed, the remaining perichondrium at the perimeter of the excision can often be visualized as a slightly frayed, white fibrous tissue adherent to the inner aspect of the cartilage.   CBSimpson
There is a small, vertically oriented blood vessel immediately deep to the inner thyroid perichondrium in the anterior third of the window. Judicious bipolar cautery will be necessary if bleeding is encountered.

This vessel is commonly identified running in proximity to the adductor branches of the recurrent laryngeal nerve. Care should be taken to avoid injuring the vessel because cautery will likely damage the nerve and disrupt the innervation responsible for vocal fold tone.   MSCourey
STEP 11. Elevate the paraglottic space using right-angle and “hockey stick” elevators to free the muscle from the inner thyroid perichondrium (Figure 9-8A).

FIGURE 9-8 A, Elevation of the paraglottic space. B, Measuring medial displacement of the vocal fold.
Elevation should always take place posteriorly and inferiorly first. Elevation should proceed to the arytenoid and allow medialization of the vocal process. This is at least 5 mm posteriorly in most patients and may be visualized on the flexible laryngoscope; 5 mm of inferior elevation should be completed and the surgeon will see the paraglottic space displace medially through the window with inspiration. Very careful superior and anterior elevation should also be performed, staying closely approximated to the thyroid cartilage. The upper border of the window is often immediately adjacent to the ventricle and it is easy to enter the laryngeal lumen at this site. Very careful attention should be paid not to violate the mucosa because this may allow extrusion of the implant into the airway after placement. Usually only 3 mm of superior elevation and 1 to 2 mm of anterior elevation is necessary.
Elevation is complete when the surgeon can depress the paraglottic space 8 to 9 mm from the inner border of the thyroid cartilage without difficulty.
The site should be tested for mucosal violation by filling the window with saline and having the patient cough. Airflow through the window indicates a leak. If confirmed, the procedure should be aborted to allow time for healing.

Anterior elevation through the window has the greatest chance of resulting in mucosal perforation. For this reason I avoid anterior elevation and usually have about 5 to 7 mm of medial displacement of the paraglottic contents.   CGGarrett

This is especially true anteriorly, where the ventricular mucosa often approximates the cartilage. In general, the undermining within the paraglottic space occurs inferior, posterior and superior to the window. To avoid perforating airway mucosa no anterior elevation should be performed, as mentioned earlier.   CBSimpson
STEP 12. Determine the location of the window relative to the vocal fold by depressing within the window and viewing the vocal fold on the monitor.
Typically, the window is high relative to the optimal medialization point and the lower border of the window medializes the vocal fold without medializing the false vocal fold, but the position of the vocal fold relative to the window varies based on the size of the larynx and support of the arytenoid. Medialization of the false focal fold may result in vibration of this tissue and a rough vocal quality despite an optimally medialized true vocal fold.
STEP 13. Depression on the paraglottic space near the posterior aspect of the window with a measuring rod medializes the vocal fold and vocal process, closing the glottic gap (see Figure 9-8B ).
STEP 14. While elevating within the paraglottic space, test the voice with sustained vowel phonation, counting, yelling, and even singing. When completed, the surgeon prepares the implant material. Parameters for working with carved Silastic are demonstrated in Figure 9-9 .

FIGURE 9-9 A to C, Creation of the thyroplasty implant.
Because these procedures are considered permanent, the surgeon should make every effort to attain optimal vocal quality with repositioning.

Typically, in the male larynx optimal medialization is at the posterior inferior aspect of the window. However, in the female larynx, it is not infrequent that the optimal area for medialization is at the midpoint of the window or even at the anterior aspect.   CBSimpson
Often, the patient acquires compensatory laryngeal and extralaryngeal hyperfunction that is not desired once the vocal fold in repositioned. A basic understanding of voice therapy and experience can help the surgeon tremendously in assessing voice and adequate medialization during thyroplasty.

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