MDL - Polyp
Considerations
Polyp
A pathologic process of the lamina propria that involves typically an exophytic or pedunculated lesion of the midmembranous vocal fold that can be unilateral or bilateral
Does not respond to non-surgical therapies
Anatomy
True vocal fold
5 histologic layers
Epithelium
Superficial lamina propia
Intermediate lamina propia
Deep lamina propia
Thyroarytenoid muscle (aka vocalis muscle)
Functional comparison, according to 2005: Surgical procedures for voice restoration
Key: The propensity of the superficial lamina propria to regenerate is minimal, therefore, maximally preserve it
Technique
For Dr. Jiang and Dr. Durr, see the book Operative Techniques in Laryngology (2008) by Rosen and Simpson, Chapter 15 (page 99)
Preparation
ETT: Smallest armored tube
Tape to left lower lip
Eyes: Paper tape over lids
Wet "eye pads" over tape
Another long strip of paper tape over both eye pads
Head: Wrap with 2 blue towels
Avoid towel clamp
Split drape
Do not remove sticky cover
Tooth guard
Microscope
Balance
Place assistant viewfinder on right
Laser (KTP) settings for hemorrhagic polyp
15 watts (blanching effect) up to 30 watts (vaporizing effect)
15 millisecond exposure
2 pulses per second
.4 mm fiber
Check all equipment including light cables and light sources
Back table and mayo stand
Procedure
Place the operative laryngoscope in suspension
Dedo laryngoscope
Position the head and neck
Start in a neutral position, adjust as needed
Sniffing position (neck flexion with head extension)
Place a small pillow behind the patient’s head, resulting in atlanto-occipital extension and cervical vertebral flexion
Anterior tracheal pressure with tape, as needed
Inspect and palpate the VFs, including the medial and inferior surfaces
Examine the contralateral VF for reactive changes
Photograph using both 0 and 30 degree Hopkins rod endoscope
Bring in the operative microscope
Using the KTP laser, coagulate (blanch) and "feeding vessels" to hemorrhagic lesions
Perform the planned polyp excision using phonomicrosurgical technique via one of two approaches
Microflap
Expose the lesion, preferably the entire membranous vocal fold
Apply topical epinephrine (1:10,000) to the lesion via a Cottonoid; Avoid local infiltration
Epithelial cordotomy at the junction of the lateral aspect of the polyp and the normal vocal fold mucosa, along the superior surface of the vocal fold
The microflap elevation is performed medial to the incision to expose the subepithelial pathologic contents of the polyp
Vocal fold polyp material is removed via either microsuction or direct removal of the abnormal material with small microcup forceps (1 mm)
Alternatively, the lesion can be dissected medially with a 30° flap elevator, preserving additional inferior microflap mucosa
Redrape the microflap back over the vocal fold and evaluate the nature and status of the microflap mucosa
Trim abnormal mucosa that appears to have adherent polyp material, or is extremely thin and atrophic, or is excessive and will not serve as normal mucosa during the postoperative healing
Redrape the remaining microflap mucosa. Once the flap is redraped, use a blunt instrument (curved elevator) to palpate the operative site to ensure there is no remaining pathology under the flap
Treat the associated vascular lesion if needed
Truncation - usually preferred
Expose the lesion, preferably the entire membranous vocal fold
Apply topical epinephrine (1:10,000) to the lesion via a Cottonoid; Avoid local infiltration
Grasp the polyp with small triangular forceps in a medial direction
Grasp in a location and manner that is perpendicular to the longitudinal axis of the vocal fold.
With the non-dissecting hand, careful control and gentle application of tension should be applied to the vocal fold polyp
Microscissors that are either slightly curved (away from the vocal fold) or straight up-cutting scissors are then used to incise the vocal fold polyp at the junction of the polyp and the vocal fold
After removal of the majority or the entire vocal fold polyp, careful examination and palpation should be performed to see if there is any residual abnormal mucosa at the vocal fold polyp site that should be removed
To help with this assessment, an epinephrine-soaked Cottonoid can be placed on the operative site for several minutes.
If there is residual abnormal mucosa, then a 1-mm micro can be used to remove this tissue
An alternative removal technique involves grasping of the “dogeared” mucosa with a microcup forceps or small triangle forceps and excising the material with a microcurved scissors
Obtain hemostasis with small pledget soaked with topical 1:1000 Epinephrine
Photograph using both 0 and 30 degree Hopkins rod endoscope
Spray the glottis with 3 ml topical 4% Lidocaine
Remove the laryngoscope and tooth guard
Examine the airway for any unintentional injury
Post-op
Voice rest
For Dr. Durr, use the the University of Texas Voice Rest protocol here
See the smartphrase by J Gilde: JEGPIVOICERESTPO
For Dr. J, the key is deciding a time period for strict voice rest; Many patients are noncompliant with a complicated voice rest schedule
Tylenol #3 as needed
Colace
Regular diet
Light activity for the first week
Avoid straining
RTC 2-3 weeks