I. GENERAL CONSIDERATIONS

A. Indications

1. Rule out malignancy

a. Laryngeal lesions (usually glottic) that require precise staging and anatomic localization

b. May be done in concert with rigid esophageal endoscopy, flexible fiberoptic bronchoscopy (see Panendoscopy).

2. Treatment of hoarseness (see laryngeal diagnostics protocol)

a. Vocal nodules, polyps, cysts

b. Polypoid corditis, Reinke’s space edema

c. Vocal process granulomata

d. Sulcus vocalis

e. Laryngeal web

3. Other

a. Recurrent respiratory papillomatosis (RRP) (see Pharmacotherapy for Recurrent Respiratory Papillomatosis (RRP))

b. Other laryngeal lesions

B. Contraindications

1. Unstable cervical spine

2. Unable to obtain exposure of the larynx (ie, retrognathic)

3. Consider alternatives to direct laryngoscopy

a. Exposure and instrumentations transorally employing indirect mirror

b. Flexible fiberoptic laryngoscopy employing biopsy port

c. External approach through laryngofissure

II. PREOPERATIVE PREPARATION

A. Evaluation

1. Essential preoperative studies (benign lesions)

a. Speech pathology assessment

b. Consider trial of nonsurgical therapy

c. Videolaryngoscopy

2. With history of neck arthritis or neck surgery/injury Lateral neck radiographs in flexion and extension

3. Optional studies: Acoustic and aerodynamic evaluation (see Voice Clinic protocol)

4. Offer to most patients with dentition dental prosthetics evaluation preoperatively to fashion a tailored (custom made) acrylic dental splint

a. To prevent dental injury more effectively than the standard plastic “gump”

b. To patients who will undergo multiple microscopic direct laryngoscopy procedures (hence greater possibility of dental exposure; ie, RRP) (see suggested reading Dental Protection During Rigid Endoscopy)

B. Consent for Surgery

1. Describe procedure and expected recovery: Placement of rigid tube through your mouth into your voice box to expose the vocal cords. With a bright light attached for illumination and a microscope in place for magnification, the vocal cords will then be . . . (depends on the procedure to be done)

2. Potential complications (not inclusive)

a. Bleeding, infection, reaction to the anesthesia

b. Damage to adjacent structures

(1) Lips, teeth, tongue

(2) Larynx, pharynx

c. Potential hoarseness, breathing, or swallowing problems

d. “Surgical incisions on the vocal cords always causes scarring. Our goal is to minimize the amount of scarring.”

e. Mention prolonged intubation or temporary tracheotomy if it is more than an extremely remote possibility

f. Mention possibility of developing a numb tongue or hypoglossal nerve paralysis from pressure of the laryngoscope (usually temporary)

III. NURSING CONSIDERATIONS

A. Room Setup

See Endoscopy Room Setup

B. Instrumentation and Equipment

1. Standard

a. Direct laryngoscope tray

b. Bronchoscopy tray, adult

c. Lewy laryngoscope holder tray

d. Laryngoscope instrument tray, microscopic direct

e. Telescope, Storz, Hopkins straight forward 0° 5.5 x 20 cm wide-angle

f. Storz fiber optic light cable

g. Stryker camera adapter

h. Microscope plus video unit

2. Special

a. Tracheotomy tray

b. Freche monopolar instrument tray

c. Telescope, Storz, Hopkins straight forward 0°, pediatric

d. Fedder Ossof Karlin phonosurgery instrument tray (frequent use)

e. Fedder Ossof Karlin Phonosurgery instrument tray (seldom use)

f. Ossof Karlin laryngoscope tray

C. Medications (specific to nursing)

1. 4% lidocaine solution, topical: draw up in Luer Lock syringe to secure abbocath (used to spray vocal cords)

2. 1:100,000 epinephrine

3. Oxymetazoline HCL nasal spray, 0.05%

4. FRED (fog reduction elimination device)

D. Prep and Drape

Drape

1. Place a rolled sheet for shoulder roll

2. Two unfolded pillowcases with towel clamp for a head drape oriented to protect eyes

3. Tape eyes (employ moistened eye pads and cloth tape if use of laser is possible)

4. Cloth drape across chest

E. Drains and Dressings

None

F. Special Considerations

1. Keep small amount of clean saline set aside to place biopsies in and to clean off biopsy forceps; will avoid cross-contamination between specimens

2. Open 18-gauge needle when taking biopsies to remove tissue from forceps

3. May use silver nitrate sticks to control bleeding

4. Have neurosurgical cottonoids in 1/4 x 1/4 in available to open, if biopsies or other manipulation of vocal cords occurs

5. Topical 1:100,000 epinephrine or oxymetazoline for application to vocal folds on (1/4 in x 1/4 in neurosurgical cottonoid for hemostasis

6. Patients may have premade tooth guards

7. Instruments should be set up prior to induction and remain assembled until patient is extubated and patent airway is established

8. Tracheotomy tray should be available for emergency tracheotomy

9. Second mayo stand for use as support for surgeon to rest hands during microlaryngeal surgery

10. Rigid telescope with fiber optics attached to television with Polaroid film for immediate still pictures to be entered into chart at time of laryngoscopy

11. Laser is generally not used except for papillomata and occasionally for malignancy to improve the airway. Laser attachment to the microscope can be placed preoperatively if lateral cordotomy is to be made to “spot weld” the mucosa back together (rarely needed).

12. Laryngoscopes

a. Jackson laryngoscope: rarely used, best to introduce rigid bronchoscope

b. Hollinger anterior commissure laryngoscope: poor monocular exposure; useful when exposure is impossible with other laryngoscopes

c. Dedo laryngoscope: the “workhorse” provides adequate exposure in most patients; limited for laser surgery by absence of smoke evacuation port

d. Ossoff-Karlin laryngoscopes: good exposure but cannot be used in all patients because of larger size; best for laser surgery because of smoke evacuation port

e. Weerda laryngoscope expands both proximally and distally to provide excellent exposure for supraglottic surgery

IV. ANESTHESIA CONSIDERATIONS

A. General Anesthesia

1. Communication with anesthesia staff is essential

a. Oral endotracheal intubation with small (5.5 to 6.0) endotracheal tube (MLT tube = microlaryngeal/tracheal tube)

b. Short-term paralysis (duration dependent on procedure; communicate with anesthesiologist)

c. Consideration for alternative methods

(1) Jet anesthesia

(2) Apnea

(3) Local anesthesia with sedation (see Local anesthesia for rigid endoscopy protocol)

(4) The surgeon should be in the operating room during induction if there is potential for airway compromise

B. Preoperative Systemic Medications

1. Glycopyrrolate 0.1 to 0.2 mg IM on call to operating room

a. The drying effect improves exposure; consider avoiding in patients with xerostomia

b. Vagolytic effect

2. Consider Decadron 8 to 10 mg IV when IV started to diminish edema Contraindications: diabetes, ulcer disease, other

3. Antibiotics administered only if biopsies or incisions are made in an infected or contaminated region (not usually employed for vocal fold surgery) (see Antibiotic protocol)

C. Positioning

1. Head of table turned 90° from anesthesia

2. Arms tucked for placement of suspension laryngoscopy support

3. Neck extended with a shoulder roll

4. Head of bed elevated 15° to 30°

V. OPERATIVE PROCEDURE

A. General Principles

1. Respect the integrity of the vocal fold and, in particular, the vocal ligament

2. Perform a systematic search (inspection/palpation) for synchronous laryngeal pathology not identified preoperatively (ie, sulcus vocalis, scarring, webs).

3. Perform a conservative resection of diseased tissue.

4. Avoid operative treatment of the anterior aspect of both vocal folds at the same time to avoid webbing.

5. Employ the largest laryngoscope possible to maximize exposure

6. Hemostasis:

a. Topical application of ephedrine or epinephrine

b. Judicious use of needle tip Freche monopolar electrocautery

7. Avoid procedures that increase risk of vocal fold scarring:

a. Better to leave benign diseased tissue rather than excise too much normal tissue

b. An irregular edge to the vocal fold with preservation of pliable mucosa is usually a better phonatory result than a scarred straight edge

8. Infusion of 1% lidocaine with 1:100,000 epinephrine into the superficial layer of the lamina propria may be of benefit in selected cases to define the vocal fold lesion.

9. Although it is not clearly established to be of value, placement of Kenalog 10 into or onto the surgical bed may be beneficial in selected cases.

B. Nodules

1. Strict attention to the proper selection of patients in need of surgery

a. Remove nodules only after a long period of voice therapy

b. Remove nodules only after behavior has been modified to diminish the risk of nodule recurrence after resection

2. Nodules are superficial mucosal lesions

a. Conservative removal of superficial abnormal mucosa

b. Avoid use of laser

C. Polyps

1. Preoperatively speech pathologists are generally involved in the evaluation; speech therapy usually employed postoperatively

2. Polyps are usually superficial lesions and often are associated with a “feeding blood vessel”

a. Preservation of all of the abnormal epithelium overlying the polyp is usually not useful.

b. Endoscopic suturing or use of fibrin glue to reapproximate epithelium after removal is of questionable benefit.

c. Monopolar cautery (Freche) is done very superficially and on a low setting to the feeding blood vessel.

D. Cysts

1. Preoperatively speech pathologists are generally involved in the evaluation; speech therapy usually employed postoperatively.

2. A lateral cordotomy is generally the best approach to cyst removal with preservation of overlying epithelium and underlying vocal ligament.

a. Ensure that epithelium overlying cyst is normal before performing a lateral cordotomy.

b. If the epithelium overlying the cyst is abnormal, access for removal the cyst may be done through judicious resection of the abnormal epithelium.

E. Vocal Process Granuloma

1. Indications for removal

a. Biopsy to rule out cancer

b. Airway compromise

c. Persistent with symptoms despite adequate nonsurgical therapy

2. Nonsurgical therapy

a. Antireflux measures

b. Consider Nissen fundoplication for refractory cases

c. Consider voice therapy

d. Consider a trial of antibiotics and steroids

3. Operative approach

a. Inject base before excision with Kenalog

b. Grasp granuloma with forceps and resect with scissors

c. Avoid use of laser if possible

d. Employ perioperative antibiotics

VI. POSTOPERATIVE CARE

A. Most procedures are done as outpatient; concern regarding adequacy of airway may warrant hospitalization.

B. Medications

1. Consider additional IV Decadron postoperatively if laryngeal manipulations cause edema.

2. Consider antibiotics (Ancef/Keflex) if implants placed or if there is infection identified.

3. Consider Zantac/Prilosec/omeprazole with antireflux instructions if findings suggestive of laryngopharyngeal reflux (LPR) (see Antireflux instructions).

4. Humidification (bedside humidifier)

5. Hyd on (drink noncaffeinated fluids “until your urine is pale”)

C. Voice Rest

1. Usual: absolute voice rest for 48 hours (provide writing pad and bell). “Arm’s length rule” ensures voice conservation for 2 weeks postoperatively. Do not speak to anyone farther away than arm’s length.

2. Confer with speech pathologist regarding special cases. Voice professional may require longer period of voice rest.

3. Usual follow-up

a. Reevaluate 2 weeks postoperatively (earlier if cancer diagnosed).

b. Videoendoscopy with speech pathology assessment at 6 weeks postoperatively.

c. Further follow-up is individualized.

VII. CPT CODING

A. 31526, Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope

B. 31531, Laryngoscopy direct, operative, with foreign body removal, with operating microscope

C. 31536, Laryngoscopy, direct, operative, with biopsy, with operative microscope

D. 31541, Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope

VIII. SUGGESTED READING

A. Hoffman H. Review of Woo et al. Aerodynamic and stroboscopic findings before and after microlaryngeal phonosurgery. J Voice. 1994;8:186-194. Otolaryngol J Club. 1995;2:143-147.

B. Hoffman H, Karnell M. Hoarseness and laryngitis. In: Conn HF, Rakel RE, eds. Conn’s Current Therapy, eds. Philadelphia, PA, WB Saunders. 1996:28-36

C. Olsen GT, Moreano EH, Arcuri MR, Hoffman HT. Dental protection during rigid endoscopy. Laryngoscope. 1995;105:662-663.

D. Pinkston DR, Gartlan MG, Hoffman HT. Pathology quiz case ductal cysts of the larynx. Arch Otolaryngol. 1992;101:1266-1268.

E. Verdolini-Marston K, Hoffman HT, McCoy S. Nonspecific laryngeal granuloma: a case study of a professional singer. J Voice. 1994;8:352-358.