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Phonosurgery

Phonosurgery is defined as any surgery designed primarily for the improvement or restoration of the voice.

Methods of Phonosurgery

  1. Microlaryngoscopic surgery
  2. Injection laryngoplasty
  3. Laryngeal framework surgery (Thyroplasty)
  4. Recurrent laryngeal nerve reinnervation (including nerve grafting)

 

1. Microlaryngoscopy Surgery (MLS)

MLS is a minimally invasive ENT procedure performed under general anaesthesia. It plays a crucial role in diagnosing and treating voice-related disorders by providing a detailed view of the vocal folds and allowing precise surgical interventions. Microlaryngoscopy involves inserting a rigid laryngoscope into the patient’s throat to visualise the vocal folds. A microscope or telescope (0° or 30°) enhances the view, enabling surgeons to conduct biopsies, remove lesions, perform vocal fold injections procedures, or perform laser surgery.

Indications for Microlaryngoscopy Surgery

  • Vocal nodules, polyps, and cysts
  • Reinke’s oedema and intracordal cysts
  • Vocal fold varices and anterior webs
  • Granulomas, papilloma, sulcus vocalis
  • Leukoplakia and bamboo nodes

Patient Positioning: The Barking-Dog Position

The patient lies supine, with the neck flexed on the thorax (cervical-thoracic junction)  and the head extended at the atlanto-occipital joint. This alignment straightens the oral, pharyngeal, and oesophageal axis for easier rigid laryngoscope insertion. The position was first described by the ENT pioneer Chevalier Jackson. This position is also used in direct laryngoscopy, rigid bronchoscopy and rigid oesophagoscopy surgeries.

Anaesthesia Techniques in Microlaryngoscopy Surgery

  • Endotracheal Intubation. It is preferred in most cases. A small-diameter (5–6) endotracheal tube should be used to avoid unwanted vocal fold manipulation. In cases of laser surgery, Laser-safe endotracheal tubes should be used, and the tracheal balloons should be filled with normal saline.
  • Apneic Technique. In this technique, intermittent ventilation, either by mask ventilation or intermittent endotracheal intubation, is given to oxygenate and ventilate the patient, and the patient is left without active respiration during the phonosurgery. This technique is ideal for lesions in the posterior glottis as endotracheal tubes obstruct the view.
  • Jet Ventilation. It offers the best visualisation of the larynx. This technique should be avoided if bleeding is expected as it can lead to aspiration of blood.

Methods of Microlaryngoscopy Surgery

  • Instruments. Fine, sharp tools like Bouchayer forceps should be used. Surgeons must stay superficial, avoiding vocal ligament injury and limiting mucosal excision. Precise handling minimises trauma and post-op scarring.
  • Laser Surgery. The most common lasers used are CO₂, KTP, and diode. It is preferred for vascular lesions (e.g., papillomas, granulomas).
  • Microdebrider. It is also now used for various lesions, including papillomas, polyps, Reinke’s oedema, and tumours at the glottic and subglottic levels. While microdebriders offer quicker recovery, they may compromise specimen orientation and margin identification.

Post-Operative Voice Rest. Absolute voice rest for 48 hours. It minimises post-op trauma and promotes optimal vocal healing.

 

2. Vocal Fold Injection Laryngoplasty

Vocal fold injection laryngoplasty is a minimally invasive procedure aimed at medializing a paralysed vocal cord, thereby improving voice quality. This technique is particularly beneficial for patients with unilateral vocal cord paralysis, where one vocal cord does not move properly, leading to a breathy or weak voice.

Indications:

  • Expected recovery of vocal cord function
  • Small glottic gap (2–3 mm)
  • Absence of posterior gap
  • Terminal illness with aspiration or voice loss

Common Injectables:

  • Calcium hydroxyapatite: Preferred, provides effects lasting around one year.
  • Autologous fat: Natural option, though partially absorbed over time.
  • Carboxymethylcellulose gel: Offers variable longevity and is well-tolerated.
  • Micronized human dermis
  • Hyaluronic acid
  • Bovine collagen
  • Glycerine: Temporary solution with shorter duration.
  • Silicone: Limited use
  • Teflon paste (done for permanent medialisation but rarely used now due to granuloma risk)

Procedure

The procedure involves injecting a biocompatible material into the paralysed vocal fold to bulk it up, allowing the healthy opposite cord to make better contact during speech. The choice of material depends on factors such as the desired duration of effect and patient-specific considerations. Commonly used injectable materials include:

  • Calcium hydroxyapatite: Preferred, provides effects lasting around one year.
  • Autologous fat: Natural option, though partially absorbed over time.
  • Collagen: Offers variable longevity and is well-tolerated.
  • Glycerine: Temporary solution with shorter duration.
  • Silicone: Limited use
  • Teflon:  Done for permanent medialisation but rarely used now due to granuloma risk

Anaesthesia and Technique

Vocal fold injections can be performed under local anaesthesia under flexible laryngoscopy control. Local anaesthesia allows for real-time voice assessment during the procedure, which can be advantageous for precise placement. It may also be performed via direct laryngoscopy under general anaesthesia. The material is injected laterally to the vocal ligament in the thyroarytenoid muscle bulk. It should not be injected superficially, which may cause stiffening of the lamina propria (superficial mucosal layer) and disruption in the mucosal wave critical for normal voice.

Approaches include transcutaneous and transoral techniques, selected based on patient anatomy and surgeon preference. Techniques include:

  • Transcricothyroid membrane
  • Trans-thyroid cartilage
  • Trans-thyrohyoid membrane
  • Per-oral or transnasal endoscopic routes

 

3. Laryngeal Framework Surgery (Thyroplasty)

Laryngeal framework surgery encompasses a group of procedures that modify the cartilaginous structure of the larynx to improve voice quality. First described by Isshiki in 1974, these surgeries are particularly effective for patients with vocal cord paralysis or bowing (prebylaryngis). Typically performed under local anaesthesia, these procedures allow for intraoperative voice monitoring.

Indications

Laryngeal framework surgeries are indicated for:

  • Unilateral or bilateral vocal cord paralysis
  • Presbylaryngis (age-related vocal cord atrophy)
  • Voice pitch modification in gender-affirming care

Types of Thyroplasty

Isshiki classified thyroplasty into four types:

  1. Type I (Medialization Thyroplasty): An implant (e.g., silicone, Gore-Tex®, or calcium hydroxylapatite) is inserted into the paraglottic space through a window made in the thyroid ala to push a paralysed vocal fold towards the midline, enhancing glottic closure. Position the window below the midpoint of the thyroid cartilage’s vertical height. Avoid false cord medialization and poor voice outcomes. Use the Koufman formula to calculate the window, which typically measures 10–12 mm wide and 4–6 mm high. Arytenoid adduction may be added for better results when there is a poorly supported arytenoid or a posterior gap, but the surgery is more complex and carries higher risks. The implant size depends on laryngeal anatomy. Men usually need a larger window than women.
  2. Type II (Lateralization Thyroplasty): Lateralizes the vocal fold to widen the airway, beneficial in conditions like bilateral vocal cord paralysis. A titanium bridge widens the anterior commissure, reducing the glottic insufficiency,
  3. Type III (Shortening / Relaxation Thyroplasty): Shortens the vocal cords to change high pitch voice to lower pitch voice (female to male voice), used in cases like puberphonia or gender transformation surgeries.
  4. Type IV (Lengthening/ Tensioning Thyroplasty): Lengthens the vocal cords to raise the low pitch voice to high pitch voice (male to female voice), used in cases like presbylangis, where the vocal cords have become lax and bowed due to increasing age or gender transformation surgeries.

 

4. Recurrent Laryngeal Nerve Reinnervation

Recurrent Laryngeal Nerve (RLN) reinnervation is a microsurgical procedure aimed at restoring nerve function (muscle tone and movement) to the paralysed vocal fold, particularly in cases of unilateral or bilateral vocal cord paralysis. It does not restore the nerve to its original functionality, but helps reanimate the vocal fold for better closure and voice production. It is done under general anaesthesia.

The two main types of RLN reinnervation are Non-selective and Selective.

  • Non-Selective Reinnervation. It is primarily indicated in unilateral vocal cord paralysis due to adductor muscle dysfunction. A neck incision is made on the same side as the paralysis, near the level of the cricoid cartilage. The ansa cervicalis nerve is identified and anastomosed (connected) to the recurrent laryngeal nerve using microsutures (e.g., 9/0 nylon). Over time, axonal growth allows the reinnervated muscles to regain tone and bulk, leading to improved glottic closure.
  • Selective Reinnervation. It is primarily indicated in bilateral vocal cord paralysis, causing airway obstruction and stridor. It aims to restore posterior cricoarytenoid (PCA) muscle function, which is responsible for abduction (opening) of the vocal cords during breathing. A more extensive neck incision is given. The C3 root of the phrenic nerve is identified and used as the motor donor nerve. A Y-shaped nerve graft, usually harvested from the great auricular nerve, is used to connect the phrenic nerve to the posterior cricoarytenoid muscles on both sides. Simultaneously, the ansa hypoglossi and RLNs are identified bilaterally and connected to support adductor muscle function, helping to preserve voice quality.

Benefits of RLN Reinnervation

  • Long-term voice improvement (especially in younger patients).
  • Preservation of vocal fold bulk and position.
  • Reduced need for repeated vocal fold injections or other temporary measures.
  • Avoidance of permanent voice-altering procedures in some cases.

Limitations

  • Delayed voice improvement (benefits are usually seen 6–12 months post-op).
  • Requires intact laryngeal musculature.
  • Not suitable if muscle atrophy is advanced or longstanding.
  • In selective reinnervation, airway function restoration may vary.

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Reference Textbooks.

  • Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
  • Cummings, Otolaryngology-Head and Neck Surgery.
  • Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
  • Ballenger’s, Otorhinolaryngology Head And Neck Surgery
  • Susan Standring, Gray’s Anatomy.
  • Frank H. Netter, Atlas of Human Anatomy.
  • B.D. Chaurasiya, Human Anatomy.
  • P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
  • Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
  • Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
  • Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
  • Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
  • Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
  • Ganong’s Review of Medical Physiology.
  • Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla ENT Textbook

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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Keywords:Phonosurgery, Vocal cord paralysis treatment, Voice surgery, Injection laryngoplasty, Thyroplasty, Microlaryngoscopy, Recurrent laryngeal nerve, Vocal cord reinnervation, Voice restoration surgery, Phonosurgery Explained: Voice Restoration Techniques for Vocal Cord Paralysis, Top 4 Phonosurgical Procedures for Vocal Cord Disorders: A Complete Guide, Thyroplasty, Microlaryngoscopy, and Beyond: Modern Voice Surgery Methods in ENT, How ENT Surgeons Restore the Voice: Phonosurgery Techniques You Should Know, Injection Laryngoplasty vs Thyroplasty: Choosing the Right Vocal Fold Procedure, ENT surgery for voice disorders, CO₂ laser microlaryngoscopy, Presbylaryngis, Vocal fold injection materials, Unilateral vocal cord paralysis, Understanding Recurrent Laryngeal Nerve Reinnervation in Voice Surgery, What Is Injection Laryngoplasty? Indications, Techniques, and Recovery, Microlaryngoscopy: The Gold Standard in Vocal Fold Lesion Treatment, Voice Surgery for Gender Affirmation: Type III & IV Thyroplasty Explained, Vocal fold injection laryngoplasty, Laryngeal framework surgery, Thyroplasty types, Voice restoration procedures, Vocal cord paralysis treatment, Recurrent laryngeal nerve reinnervation, Vocal cord paralysis surgery, Non-selective reinnervation, Selective reinnervation, Hoarseness treatment, Unilateral vocal cord paralysis, Bilateral vocal cord paralysis, Voice restoration surgery

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