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Special Facilites

LARYNGEAL FIBRESCOPIC SURGERY
AN ALTERNATE APPROACH TO DIFFICULT MICRO-LARYNGEAL SURGERY

* Dr.V.Anand ** Dr.Santosh.S

ABSTRACT:

Micro Laryngeal Surgery (MLS) is difficult in patients with anesthetic and cervical contra-indications. An alternative approach is proposed here using a flexible laryngeal fiberscope and specially designed laryngeal instruments under local anesthesia. Equipment and technique of the procedure is described. Indications and contra-indications are highlighted based on our experience of 99 patients.

Laryngeal Fibrescopic Surgery (LFS) in such cases was found to be a safer alternative. But this procedure cannot be used for all laryngeal pathologies.

KEY WORDS:

Micro laryngeal Surgery (MLS), General Anaesthesia (GA), Local Anaesthesia (LA), American Society of Anaesthesia (ASA), Laryngeal Fibrescopic Surgery (LFS), Laryngeal Instruments.

*Director & Consultant ENT Surgeon,
MCV Memorial ENT Trust Hospital
Address for correspondence:
MCV MEMORIAL ENT TRUST HOSPITAL,
106 Palakkad Road, Pollachi 642001,
Coimbatore District, Tamil Nadu State, India.
Tel : 0091 -4259- 225122, 223502
Fax : 0091- 4259 – 223502,Mobile : 0091- 9842210217
E- mail : anand@entanand.com Website : www.entanand.com

INTRODUCTION:

MLS with suspension laryngoscope demands general anaesthesia (GA) and resultant sharing of the airway by the surgeon and anaesthetist. In patients with ASA risk grade II and above, MLS is a decision made after careful consideration. The procedure may be technically impossible if the cervical spine cannot be extended (Fig - 3). The problem of CO2 build up and resultant cardio-vascular events by the use of a small diameter endotracheal tube is also well known. Myocardial infarction and death after MLS has also been reported6,(Fig - 3)Apart from minor complications like - lingual and glosso-pharyngeal neuralgia11. (Fig.3)

In order to overcome these disadvantages our study introduces an alternative. The LFS procedure is similar to the video-laryngoscopic system proposed by Omori and colleagues8 with local anaesthesia (LA) and custom made instruments. LFS has the advantages of being less invasive and cost effective.

SELECTION CRITERIA:

1) Patients with benign, non–neoplastic circumscribed laryngeal lesions like – polyps, papillomas etc- in whom the cervical spine cannot be extended (Fig. 3), in obese individuals with short necks and in Obstructive Sleep Apnea.

2) Biopsy of laryngeal lesions suspicious of neoplastic, tuberculous or other chronic inflammatory lesions.

3) Patients with cystic laryngeal lesions or highly vascular lesions like – rhinosporidiosis, hamartomas and non-pedunculated laryngeal polyps with wide base were excluded from our study.

MATERIALS & METHODS:
An Olympus 3mm (Model A 3056) nasopharyngo fiberscope, attached to SOPRO S51 Digital Camera System, with a Xenon Aesculap Axel 180 (OP 930) light source was used and the procedures were recorded.

Fig. 1A – Specially designed Endo- Laryngeal Instruments

The forceps (Nithya Medical Products) are designed to pass behind the tongue base and epiglottis (Fig. 1A, 1B).
They have cutting edges and a cage area to hold tissues. An eye-let in the upper jaw gives visual control till the lesion is grasped. In addition a scissors and a strongly curved anterior commissure forceps to overcome large tongue base and anteriorly placed larynx are
(Fig. 1A) also used.

Pre-operative preparation includes a Storz 90° Berci-Ward Scopy for evaluation of the laryngeal lesions. With this the feasibility of the surgery and co- operation of the patient is also assessed.

For pre-medication – Pethidine 1mg/ kg, Promethazine 25mg and Atropine 0.3mg are given intra-muscular 45 minutes before the procedure. Nasal decongestion with 0.05% Xylometazoline drops
(Fig. 1B) Close–up view of Instrument's operating tips

and an Internal Laryngeal block on both sides with 2% Lignocaine are given 5 min before the procedure. A topical 10%Lignocaine spray is administered to the laryngo-pharynx just prior to the procedure.
(Fig. 2)
Patient is comfortably seated on a chair or table and the naso-pharyngoscope is passed through the nose and positioned to get an optimal image of the glottis on the monitor. This is done either by the examiner himself or an assistant. The patient opens his mouth and holds the tongue forward with his hand. The forceps is passed intra-orally and the lesions are removed. Wide-based lesions, especially-haematogenous polyps will need a two-handed approach with forceps and scissors to cut the base without injuring (Fig. 2) the vocal cord.

Following this minimal or no bleeding is encountered. If there is blood the patient is made to lie with head-end tilted down for a few minutes so that the blood comes into the pharynx and not into the trachea. Medications to the site can also be applied via cotton balls held by the forceps.

This study was conducted at our hospital from Jan. 2002 to Feb 2008. LFS was performed for 124 patients ranging from 30 to 73 yrs of age (Table-1). Evaluation and video documentation of these cases were also done post–operatively.

RESULTS:

LFS was accomplished in 117 of 124 cases (94.3 %). In 7 cases the operation could not be done due to excessive gag and patient non-compliance. No major post-operative complications occurred. In few cases the transient post-operative bleeding resolved spontaneously. Post-operative recurrence, scarring or persistent hoarseness were not noticed in patients with vocal cord polyp (N =66).

LFS PROCEDURES FROM JAN.2002 –FEB 2007

SL.NO.	INDICATIONS	NO. OF PATIENTS (N=117*)
1	Vocal cord polyp	66
2	Recurrent adult respiratory papilloma	9
3	Laryngo-pharyngeal growth for biopsy.	36
4	Recurrent contact granuloma	6
* 7 OUT OF 124 CASES LFS WAS NOT POSSIBLE

DISCUSSION:

The proposed procedure is done with a Fibreoptic naso-pharyngoscope and curved laryngeal instruments passed trans-orally. The method is similar to the technique proposed by Omori et al8. Duration of the surgery is about 5 minutes and the patient leaves the hospital within 4 hours. The unique advantage of this technique is its magnified view of the laryngopharynx. A two-handed technique can also be performed where the assistant parks the flexible scope at a suitable site and the surgeon uses both hands for operating.

Previous authors9, 10 have used Nagashima forceps for a similar surgery. NMP has built a set of four forceps and Laryngeal scissors to cater to different locations of the lesion. Our study has made provision for lesions at different levels of the glottis and supra – glottis. The strongly curved forceps is used to overcome large tongue base and anteriorly placed larynx, which is otherwise not accessible by regular instruments.

LFS is a day-care surgery. With this method, chances of tissue injury and edematous changes are not seen. Thus biopsies in laryngo-pharyngeal malignancies can be taken without a preliminary tracheostomy. The disadvantages in LFS is, even with two-handed technique the precision work seen with MLS may not be achieved. Hence this technique is not recommended for excision of intra-Cordal cysts, Reinke`s odema, hamartomas and in situations where MLS and Lateral Flap–Door techniques are more suitable.

CONCLUSION:

LFS is indicated in cases where MLS or GA is contra-indicated. Pre-medication, LA of internal laryngeal nerves and lignocaine topical spray allows surgery in majority of the patients. Post-operative healing of the vocal fold mucosa and resultant voice was found to be acceptable.

REFERENCES (BIBLIOGRAPHY) :

1. Kleinsasser O. Indications, contraindications and preoperative procedures Microlaryngoscopy & Endolaryngeal microsurgery. P.A 3rd Edn 1991; p 17.

2. Saito S. Phonosurgery basic study on the mechanism of phonation and endolaryngeal microsurgery. Otol Fukuoka 1977; 23: 280 -1.

3. Saito S, Fukuda H,Kitahara S. Stroboscopic microsurgery of the larynx.
Arch Otolaryngol 1975; 101: 196-201.

4. Mahieu HF, Dikkers FG. Indirect Microlaryngostroboscopic surgery.
Arch Otolaryngol Head Neck Surgery 1992; 118: 21-4.

5. Ino T , MurakamiY, Nameki H, Kawahara N, Sudon I, Nakao H, Laryngomicro Examination under Neuroleptanalgesia without intubation. Jpn JOtolaryngol 1971;74: 1627-30.

6. Robison PM – Complications of microlaryngeal surgery – Clinical Otolaryngology & Allied Sciences 1989 ;14(6) :545 -9.

7. Nonomura M, Kojima H, Omori K, Hirano S. Fiberoptic laryngomicrosurgery With stroboscope under local anaesthesia. Pract Otol (Kyoto) 1991: 84:645-9.

8. Omori K, Shinohara K, Tsuji T, Kojima H. Videoendoscopic laryngeal surgery.
Annals of Otology,Rhinology &Laryngology 2000 :109:149-155.

9. Tai SK, Chu PY, Chang SY. Transoral laryngeal surgery under flexible Laryngostroboscopy.
J Voice 1998 :12:233-238.

10. Vuan – Ching Guo, Shyn-Kuan Tai, Tung- Lung Tsai, Jui-Lin Huang, Shyue- Yih Chang,Pen- Yuan Chu. Removal of Unapproachable Laryngopharyngeal Foreign bodies under flexible video laryngoscopy. The Laryngoscope 2003:113: 1262 – 1265.

FIGURE LEGENDS:

Fig. 1A – Specially designed Endo - Laryngeal Instruments.
Fig. 1B – Close–up view of Instrument's operating tips.
Fig. 2 – LFS procedure.
Fig. 3 – Pre–operative Osteophyte X-ray (DISH).