When patient develops hoarseness of voice and if the cause is a benign vocal cord polyp, granuloma, etc, the prognosis depends on the site of the lesion and control of voice abuse. The vocal cord is divided into anterior 2/3rd membranous and posterior 1/3rd cartilaginous portions. Recurrence rates are very high in granulomas arising from the junction of these two areas namely the vocal process. These lesions are also called Jackson's contact granuloma.

The reason for recurrence is the underlying low grade perichondritis of cartilage. Hence as cartilage is involved LASER should not be used in these lesions. As reflux oesophagitis and vocal abuse are directly associated, they are controlled medically.

In our patient Mrs.Sa such a granuloma was excised by MLS elsewhere and was proven by biopsy to be benign. We documented the lesion before removing by ELS. Unlike MLS, ELS is an OPD procedure under local anaesthesia. We also used 20% silver nitrate application on the lesion. When the oozing stopped mitomycin was applied by ELS technique. The mitomycin impregnated cotton was held in place for 2 minutes. Following this the raw area has been covered by epithelium and no recurrent growth has occured in the last six months.

DIFFICULT SURGICAL SITUATIONS
How we do it?

Post maxillectomy reconstruction of palate has been traditionally done by suitable dental prosthesis.

Following this the patient is not able to chew food on the operated side and is also unable to gargle as water leaks from the nose. Ill fitting palatal prosthesis also produces speech disturbances making the speech unintelligible (it sounds like as if somebody is talking with food inside the mouth). Unless sterlised everyday bacterial growth on the prosthesis on the nasal side produces bad odour causing social problems. We have been using a nasal septal full thickness inferiorly based flap for reconstructing the palate.

CASE-1: The first patient who benefited with this technique was a 24 year old engineer Mr.P who had partial maxillectomy for malignant tumour of the alveolus. Following the reconstruction he underwent radiotherapy with no ill effect to the well vascularised flap.

CASE-2: Mr.A. 61 year old male patient had recurrent ameloblastoma treated by maxillectomy elsewhere .He came to us with a total maxillectomy cavity on the left with tumour recurrence on the inferior aspect of right maxilla. He was using a denture which did not serve the purpose. He was taken up for partial excision of right maxilla with preservation of the hard palate and a septal rotation flap and reconstruction of the previously excised left hard palate. Following wound healing he has been fitted with a better fitting upper denture. He has now intelligible speech much better than the pre op status.
All these patients have reconstruction with tissue having normal neural sensation which makes it more suitable for masticating food and for speech production. As the lateral free surface of the flap makes strong fibrous union with the cheek the reconstruction provide a solid buttress for the dentures hence allowing the patient to chew on both sides. Due to the water tight nature the patient can gargle his mouth and blow the nose clean thus avoiding bad odour due to stagnant secretions