Direct Microlaryngoscopy and Excision of Vocal Cord Lesion
Main Text
Table of Contents
Laryngeal granulomas are benign non-neoplastic lesions, primarily located on the posterior third of the vocal folds, particularly on the vocal process or in the arytenoid region.1 These lesions often arise as complications of vocal abuse (33%), gastroesophageal reflux disease (GERD) (30%), external laryngeal trauma, or resulting from prior endotracheal intubation (23%).2 Laryngeal granulomas present with clinical signs and symptoms including dysphonia, hoarseness, discomfort or pain in the throat, and dyspnea. Notably, vocal granuloma, despite its name, pathologically is not a true granulomatous process. Instead, it is characterized as a reactive/reparative process where intact or ulcerated squamous epithelium is underlaid by granulation tissue or fibrosis. Although granulomas are typically of benign nature, they often require surgical treatment. Other options for treatment include proton-pump inhibitors (PPIs) and steroid inhalations, botulinum neurotoxin injection, and phonotherapy. Nearly half of the cases usually remit through clinical management involving PPIs, topical inhalant steroids, and phonotherapy. Additionally, surgical removal of the granuloma, when combined with clinical management, proved effective in 90% of cases.4
This patient underwent initial conservative therapy with PPIs and inhaled steroids, which did not result in remission. A decision was made to proceed with surgical removal of the lesion after obtaining the patient’s informed consent.
This video illustrates the steps taken to achieve optimal outcomes during vocal fold granuloma surgical excision. In this clinical case, the patient had undergone two prior surgical interventions, resulting in the formation of the granuloma.
The initial part of the video focuses on positioning the endoscopic tube anteriorly, facilitating visualization of the granuloma and its distinct separation from cartilaginous structures, specifically the arytenoid. Protective measures, including a mouthguard and specific patient positioning, are emphasized for safety. The laryngoscope is securely affixed to a Mayo stand positioned over the patient’s chest, ensuring stability and optimal positioning for the surgical team. To enhance ergonomics and precision, the operator employs specific techniques. Elbow rest and left-hand stabilization of the right hand at the laryngoscope entrance can provide stability during the procedure.
In subsequent phases, the granuloma is targeted for excision with careful consideration given to its anatomical location. The meticulous approach involves navigating underneath the granuloma to avoid unintended exposure of surrounding cartilage or perichondrium. Observations regarding instrument handling and potential obstructions are acknowledged, with adjustments made to guarantee unrestricted instrument mobility. The surgeon’s commitment to providing adequate room for the assistant is evident, emphasizing the collaborative nature of the surgical team. Minimizing potential complications related to instrument entanglement is crucial.
Further steps involve identifying a precise junction between the granuloma and healthy tissues. A minor mucosal fold and slight swelling are noted in the designated area. Suction plays a crucial role in ensuring optimal visibility and aids in the precise and careful excision process. Alternative techniques, such as inserting scissors underneath the granuloma for elevation, are considered. Additionally, if the lesion is sessile, submucosal infiltration with a local anesthetic combined with a vasoconstrictor at the base of the lesion can aid in dissection and hemostasis.
The surgeon selects the appropriate scissors, guiding the assistant in skillfully excising the granuloma while maintaining control over the surrounding tissue. Following successful removal, hemostasis is achieved by topically applying an epinephrine pledget, carefully pressed onto the bleeding area. The surgical technician handles the specimen, using a needle to remove it from the forceps for pathology examination.
As the procedure is coming to its end, the visual representation on the screen is evaluated by the surgeon, ensuring a clear operative field.
The significance of voice therapy, including vocal rest and speech therapy postoperatively, is highlighted. The patient will be required to refrain from speaking for 1 week. Subsequently, she is directed to commence speaking for brief intervals as required employing a volume enough to be heard by an individual seated next to her. Both yelling and whispering should be avoided to prevent aggressive stimulation of vocal cords.3
In conclusion, this video provides a detailed narrative of this surgical intervention, encompassing procedural nuances, collaborative decision-making, and postoperative care considerations.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Devaney KO, Rinaldo A, Ferlito A. Vocal process granuloma of the larynx - recognition, differential diagnosis and treatment. Oral Oncol. 2005;41(7). doi:10.1016/j.oraloncology.2004.11.002.
- De Lima Pontes PA, De Biase NG, Gadelha MEC. Clinical evolution of laryngeal granulomas: treatment and prognosis. Laryngoscope. 1999;109(2). doi:10.1097/00005537-199902000-00021.
- Rubin AD, Praneetvatakul V, Gherson S, Moyer CA, Sataloff RT. Laryngeal hyperfunction during whispering: reality or myth? J Voice. 2006;20(1). doi:10.1016/j.jvoice.2004.10.007.
- Lemos EM, Sennes LU, Imamura R, Tsuji DH. Vocal process granuloma: clinical characterization, treatment and evolution. Braz J Otorhinolaryngol. 2005;71(4):494-498. doi:10.1016/s1808-8694(15)31205-2.
Cite this article
Cohen SM, Brown CS. Direct microlaryngoscopy and excision of vocal cord lesion. J Med Insight. 2024;2024(276). doi:10.24296/jomi/276.
Procedure Outline
Table of Contents
- Suspension
Transcription
CHAPTER 1
Is it working now? No, it was a little bit better before - that's good. She has it. I have it. Let's get it set up on suspension. Okay.
We'll then get exposure. It's smaller back there in the picture. Can I see the suction? So she's had two prior surgeries, which led to this granuloma down there. So we've got the tube anterior, so we can see this lesion, and you can see that it kind of pulls away from the cartilage there - the arytenoid, so we can come underneath that base. Usually we don't operate on granulomas. but because she had a discrete injury and because there's a base to it, we can come under - the granuloma, probably in this region around there and not expose any cartilage or perichondrium there. And remove that.
CHAPTER 2
All right, so that looks good, so you have a good view. Suction? Suction. You move the tube anteriorly - with your scope. So what we want to do is we want to remove this without exposing perichondrium or cartilage, or this will recur. If we can't get good enough retraction with suction, we'll have to use a little cup forceps to hold it. Yeah, I worry it's just going to drop it into it, so let's do that. Do you have cups, Laura? Yep. I just worry like as we're going to cross it, it'll drop out. So do you see the mucosa tent as you retract? The granuloma. Your reserve is - possibly, you're going to have to switch to a straight scissors. I'm fighting my hands here a little bit. Maybe an up-cups would be better? Put your hand out of the way - that's straight scissors. Yeah. Can I see an up-cut? And straight scissors. That might have too much of a curve. And you might even need - take the straight scissors upside down. Thank you. Keep your hands separated. Can't see if I'm moving the scope at all, but I'll leave you a bit more room. How's that? And sometimes the light carrier from the scope sticks out into the lumen. And so if we back that up just a little bit, we will not roll - your instrument around the light cord. See, these are battling each other more.
CHAPTER 3
How's that? Good. Perfect. Good job, that looks very impressive. He did some trimming - that's why. Does it still look okay on the screen now? It does - it looks great. Hey, I mean it's more the technique and the work of it that's important though. All right, so you can see where that junction is. So we're going to come right underneath that margin. There's just that little mucosal fold there and some swelling. Can I see the suction, please? Right there. Can I see the cuts again, please. I mean, you could even try to slide in just some scissors underneath it. It's kind of small and hard to grab - see if you can start getting it to elevate off. You might even get a curved with this one instead of straight. Can I see the right scissors, please? Yes. Yeah, see if you just kind of come right - that looks pretty good. There you go. Yes. Nice. Yeah, good. And now the granuloma's gone. Can I see an epi pledget? Yep. Now the key is you've got to get this to dry out. Mm. Perfectly dry, so that we don't have... So you put a pledget on there, and you put pressure until it stops. Can I have a spatula? Yep. We're about done here. What do you want to call that? Left vocal fold granuloma. For permanent, right? For permanent, yeah. There was a... Okay. And again, these are regular pills. Yeah. Can I see another pledget? She's coming back next week, and then I'll see her in a month, and we'll just make sure it's healed and nothing's recurred. I think it was just a matter of focusing that lightning a little bit more... That and like she was saying that when she had them before - the two, and they would rub against each other- it's really irritating, and then even with the... she was still feeling a catch whenever she was eating, drinking, talking - that kind of thing. That's one of the rare cases you get where... And then a total, right? And then she called back a couple weeks later and said I'm getting worse - and she had actually two granulomas. Mm. She's got a little pressure. You want one more, Scott? One more. I mean most granulomas mature and fall off, right? Because you can see - you can pull it away from the cartilage. It is right on there, and if you cut that thing off, you are staring at raw cartilage. Mm. That's why those never work. They have to have a stalk. And oftentimes it's really the - You pick up scissors, you come on in, you grab that stalk, you go right next to the thing, and you cut it off. Yeah. I think you're right. Hold pressure to make sure the stalk doesn't bleed, and lead to a new granuloma. I think being able to come out with the scissors from that last... Well this is a little too small to have two things done. When it's bigger, same thing, you kind of use a little suction and then once you see it, you take a scissors, and it's all by feel. One more, and I think she'll be really good. That sounds great. Can I have one more pledget? Yep. And that looks - it looks good. Actually, you know what - wow. Pledget. Thank you. Just suction that blood out, maybe we can see... That distal blood? Yeah, just so she doesn't pop after the fact. Okay.