OT Procedure for Vocal Cord Polyps

What It Is

Pre-operative Preparation

• Consent for microlaryngoscopy + polypectomy, with risk of voice change, bleeding, tooth injury
• Pre-op assessment: indirect/video laryngoscopy, stroboscopy to confirm lesion
• Anaesthetic assessment: anticipated difficult airway must be flagged
• Position: Supine with neck extended (sniffing/Rose position) to align oral-laryngeal axis
• Dental guard applied to protect upper teeth from the laryngoscope

Anaesthesia

• General anaesthesia (GA) is required
• Airway options (discussed with surgeon):
  • Small-calibre oral endotracheal tube (microlaryngoscopy tube, MLT) - most common; sits in subglottis, keeps the cords accessible
  • Jet ventilation (HFJV or intermittent) via a catheter - used when the cords need to be completely free
  • For laser cases: use laser-safe ETT and FiO₂ <0.3 (no N₂O) to prevent airway fire - Miller's Anesthesia, p. 9801
• Muscle relaxation (paralysis) provides optimal cord visualisation and prevents coughing/movement

Equipment

• Suspension laryngoscope (e.g., Kleinsasser, Lindholm) suspended over the patient's chest - provides a hands-free binocular view
• Operating microscope (Zeiss type) - provides high magnification (~6-40x)
• Microlaryngeal instruments (approximately 30 cm long to pass through the laryngoscope):
  • Right-angled and curved forceps
  • Micro scissors (straight, upturned)
  • Micro suction
  • Blunt probe (for palpation and sizing)
• Optional: CO₂ laser coupled to microscope

Step-by-Step Operative Procedure

1. Patient positioned supine; neck extended; dental guard placed
2. Laryngoscope introduced - suspension laryngoscope passed over the tongue, posterior surface of epiglottis lifted to expose the glottis
3. Laryngoscope suspended on a chest support/Mayo stand arm - freeing both surgeon's hands
4. Microscope brought in - vocal cords examined under magnification; polyp identified and assessed (size, attachment, base)
5. Probe used to palpate the lesion - determine whether pedunculated or sessile, and the precise base of attachment
6. Incision at the base - micro scissors or CO₂ laser used to make an incision at the base/stalk of the polyp, staying superficial in Reinke's space to preserve normal mucosa and vocal ligament
7. Polyp grasped with micro forceps and excised - the goal is to remove the polyp while preserving the underlying mucosa and vocal ligament; avoid stripping the epithelium
8. Haemostasis - usually achieved by the CO₂ laser or by gentle pressure; bleeding is typically minimal
9. Specimen sent for histopathology (to exclude dysplasia/malignancy)
10. Opposite cord inspected for any contralateral lesions
11. Laryngoscope removed - airway checked; extubation

Key principle: Preserve the mucosal cover - do NOT strip the epithelium or damage the vocal ligament, as this causes scarring, sulcus vocalis, and permanent dysphonia. - Schwartz's, p. 651-652

Cold Steel vs. CO₂ Laser

Post-operative Care

• Voice rest - 5-7 days (absolute rest for the first 2-3 days)
• Day care procedure - most patients go home the same day
• Anti-reflux therapy (PPI) if LPR is a contributing factor
• Smoking cessation strongly advised
• Voice therapy - commences after healing (~2-4 weeks post-op); critical for long-term voice recovery
• Follow-up laryngoscopy at 4-6 weeks to assess healing

Complications

Pathology of Vocal Cord Polyp (for context)

• Usually unilateral, exophytic lesion at the mid-cord (maximum vibration point)
• Subepithelial accumulation of unorganised gelatinous/hemorrhagic debris in Reinke's space
• More common in males and those with vocal abuse, smoking, LPR
• Hemorrhagic polyps more common in patients on anticoagulants
• Conservative measures (voice rest, voice therapy, smoking cessation, reflux management) usually fail, making surgery necessary - Schwartz's Principles of Surgery, p. 651