PHONOSURGERY

(20 Marks - RGUHS ENT Examination)

DEFINITION

• Scott-Brown's Otorhinolaryngology, 8th ed., p. 991
• Friedrich et al. (European Laryngological Society) formally defined and classified phonosurgery in 2001

HISTORICAL LANDMARKS

RELEVANT ANATOMY

Microstructure of the Vocal Fold (Hirano's Body-Cover Theory)

VOCAL FOLD LAYERS (from superficial to deep)
┌─────────────────────────────────────────────┐
│  COVER                                      │
│  ├── Epithelium (squamous, non-keratinizing)│
│  └── Lamina Propria:                        │
│       ├── Superficial layer = Reinke's space│
│       ├── Intermediate layer (vocal ligament│
│       └── Deep layer        (vocal ligament)│
│  BODY                                       │
│  └── Vocalis muscle (thyroarytenoid)        │
└─────────────────────────────────────────────┘

KEY: Surgery must stay in Reinke's space for
     benign lesions - deeper = scar = bad voice

Surface Anatomy of Thyroid Cartilage for Thyroplasty

       Thyroid notch
           ↑
    ┌──────┬──────┐
    │      │      │    ← Thyroid cartilage
    │  L   │  R   │
    │      │      │
    │  ←Window    │    ← Window: 4-5mm posterior to midline
    │    (Type I) │         at level of true vocal fold
    └──────┴──────┘
           ↓
    Cricoid cartilage

CLASSIFICATION OF PHONOSURGERY

┌─────────────────────────────────────────────────────────────┐
│                    PHONOSURGERY                             │
├──────────┬──────────┬──────────┬──────────┬────────────────┤
│  1. Phono│  2. Injec│  3. Laryn│  4. Laryn│  5. Laryngeal  │
│  micro-  │  tion    │  geal    │  geal    │  Pacing /      │
│  laryngo-│  laryngo-│  Frame-  │  Reinner-│  Reconstructive│
│  scopy   │  plasty  │  work    │  vation  │  Surgery       │
│  (PML)   │  (ILP)   │  Surgery │          │                │
└──────────┴──────────┴──────────┴──────────┴────────────────┘

1. PHONOMICROLARYNGOSCOPY (PML)

Patient: Supine, neck extended (Boyce-Jackson position)
         ↓
Rigid laryngoscope (Kleinsasser/Lindholm) suspended
         ↓
Operating microscope (400 mm focal length)
         ↓
0° and 30° Hopkins rod telescope also used
         ↓
Crocodile laryngeal forceps for palpation

• Preserve as much mucosa as possible
• Never strip the mucosa of the vocal fold
• Stay within Reinke's space for benign lesions
• Surgery should be confined to the periphery or surface of the lesion
• Vocal fold preservation is the paramount concern

• Kleinsasser/Lindholm laryngoscopes
• Jako/Albrecht microlaryngeal instruments (scissors, forceps, curettes)
• CO2 laser (10,600 nm), KTP laser (532 nm), Diode laser
• Laryngeal microdebrider

• General anaesthesia is standard
• Jet ventilation (Hunsaker catheter) - avoids endotracheal tube obstruction
• Total intravenous anaesthesia (TIVA) preferred with lasers
• Local anaesthesia with topical application described for selected outpatient procedures

• Vocal fold nodules (bilateral, failed voice therapy >3 months)
• Vocal fold polyps
• Vocal fold cysts
• Reinke's oedema (Polypoid corditis)
• Granulomas
• Leukoplakia / carcinoma in situ
• Recurrent respiratory papillomatosis (RRP)
• Sulcus vocalis
• Mucosal bridges

MICROFLAP TECHNIQUE

MEDIAL MICROFLAP                    LATERAL MICROFLAP
─────────────────                   ─────────────────
Incision: free edge of VF           Incision: superior surface, lateral
Approach: medial vibrating edge     to lesion
Best for: nodules, small polyps     Best for: cysts, lesions close to
                                    vocal ligament

2. INJECTION LARYNGOPLASTY (ILP)

┌──────────────────────────────────────────────────────────┐
│              INJECTION ROUTES                            │
├────────────────┬─────────────────┬───────────────────────┤
│ Transcutaneous │  Transoral      │  Direct laryngoscopy  │
│ (cricothyroid/ │  (thyrohyoid/   │  (under GA)           │
│  thyroid mem-  │  transnasally   │                       │
│  brane)        │  with flexible  │                       │
│                │  scope)         │                       │
└────────────────┴─────────────────┴───────────────────────┘

• Paraglottal space (lateral to vocalis) - for medialization/paralysis
• Superficial lamina propria (deep to epithelium) - for soft tissue defects/sulcus

Injectable Materials - Comparison Table

• Under-injection (inadequate medialization)
• Misplaced injection (subglottic, supraglottic)
• Over-injection (airway compromise, vocal quality worsening)
• Foreign body reaction / granuloma (especially Teflon)

3. LARYNGEAL FRAMEWORK SURGERY (LFS)

ISSHIKI'S FOUR TYPES OF THYROPLASTY

┌──────────────────────────────────────────────────────────────────┐
│            ISSHIKI CLASSIFICATION (1974)                         │
│              European Laryngological Society (2001)              │
├──────────┬───────────────────────┬───────────────────────────────┤
│  TYPE    │  ELS TERM             │  MECHANISM & INDICATIONS      │
├──────────┼───────────────────────┼───────────────────────────────┤
│ TYPE I   │ Approximation/        │ Medialization of vocal fold   │
│          │ Medialization         │ Indications: Unilateral VFP,  │
│          │ Laryngoplasty         │ presbyphonia, VF bowing,      │
│          │                       │ sulcus vocalis                │
├──────────┼───────────────────────┼───────────────────────────────┤
│ TYPE II  │ Lateralization        │ Lateralization of vocal fold  │
│          │ Laryngoplasty         │ Indications: Spasmodic        │
│          │                       │ dysphonia, bilateral adductor │
│          │                       │ paralysis (to open glottis)   │
├──────────┼───────────────────────┼───────────────────────────────┤
│ TYPE III │ Shortening/Relaxation │ Shortening vocal fold;        │
│          │ Laryngoplasty         │ lowers pitch                  │
│          │                       │ Indications: High-pitched     │
│          │                       │ voice, mutational dysphonia   │
│          │                       │ (male transgender surgery)    │
├──────────┼───────────────────────┼───────────────────────────────┤
│ TYPE IV  │ Elongation/Tensioning │ Lengthens & tensions VF;      │
│          │ Laryngoplasty         │ raises pitch                  │
│          │                       │ Indications: Low-pitched      │
│          │                       │ voice, pitch elevation for    │
│          │                       │ transgender females (MtF)     │
│          │                       │ (cricothyroid approximation)  │
└──────────┴───────────────────────┴───────────────────────────────┘

TYPE I THYROPLASTY (MEDIALIZATION LARYNGOPLASTY) - Most Common

MEDIALIZATION THYROPLASTY - TECHNIQUE FLOWCHART

┌─────────────────────────────────────────┐
│ PREOPERATIVE                            │
│ • Videostroboscopy, LEMG                │
│ • Confirm VF position (paramedian/      │
│   lateral), height differential         │
│ • Choose implant system                 │
│   (VoCoM/Silastic/Gore-Tex)             │
└──────────────┬──────────────────────────┘
               ↓
┌─────────────────────────────────────────┐
│ SETUP                                   │
│ • Patient: Supine, neck extended        │
│ • Local anaesthesia (lidocaine 1% +     │
│   epinephrine 1:100,000)                │
│ • Awake procedure preferred             │
│   (for intraoperative voice monitoring) │
└──────────────┬──────────────────────────┘
               ↓
┌─────────────────────────────────────────┐
│ INCISION                                │
│ • 4-5 cm horizontal paramedian          │
│   incision at mid-thyroid level         │
│ • Platysma elevated, strap muscles      │
│   split in midline, retracted laterally │
│ • Outer perichondrium preserved         │
└──────────────┬──────────────────────────┘
               ↓
┌─────────────────────────────────────────┐
│ WINDOW CREATION                         │
│ • Mark window template on ipsilateral   │
│   thyroid ala                           │
│ • Window position:                      │
│   - Vertical: at level of true VF       │
│   - Anterior: 5-8 mm (♀), 8-10 mm (♂)  │
│     from anterior midline               │
│ • Window size: 6 mm (V) × 10 mm (H)    │
│ • Outer perichondrium incised, elevated │
│ • Cartilage removed (drill/Kerrison     │
│   punch if ossified)                   │
│ • Inner perichondrium elevated and      │
│   preserved                            │
└──────────────┬──────────────────────────┘
               ↓
┌─────────────────────────────────────────┐
│ IMPLANT SIZING AND PLACEMENT            │
│ • Sizing prostheses (3-8 mm) inserted   │
│   through window, rotated 90°           │
│ • All retractors removed               │
│ • Patient asked to phonate             │
│ • Template moved through 4 quadrants   │
│ • Optimal size/position selected        │
│ • Definitive implant inserted +         │
│   secured with shim/mini-plate suture  │
└──────────────┬──────────────────────────┘
               ↓
┌─────────────────────────────────────────┐
│ CLOSURE                                 │
│ • Small suction drain placed            │
│ • Strap muscles approximated (4-0 abs.) │
│ • Platysma + skin closed                │
│ • Dexamethasone given pre-op           │
└──────────────┬──────────────────────────┘
               ↓
┌─────────────────────────────────────────┐
│ POSTOPERATIVE                           │
│ • Most cases: day-surgery               │
│ • Observation if: bilateral procedure, │
│   OSA, anticoagulation, high-risk       │
│ • Voice rest 1-2 weeks                  │
└─────────────────────────────────────────┘

1. Performed under local anaesthesia with voice monitoring
2. Potentially reversible (implant can be removed/revised)
3. Structural integrity of VF preserved (no mucosal disruption)
4. Improved glottal efficiency and reduced oscillation threshold
5. Can be outpatient procedure

1. Open procedure, technically demanding
2. Limited closure of posterior glottic chink
3. No effect on VF muscle mass or innervation

• Carved/prefabricated Silastic (Montgomery, Netterville system)
• Dense hydroxyapatite (VoCoM system, prefabricated 3-8 mm)
• Gore-Tex (expanded PTFE strips) - adaptable but risk of granuloma

• Inadequate medialization (failure)
• Penetration of endolaryngeal mucosa
• Wound infection, chondritis
• Implant migration or extrusion
• Airway obstruction (especially with bilateral procedures or co-existing arytenoid adduction)
• Worsening voice

TYPE II THYROPLASTY (LATERALIZATION LARYNGOPLASTY)

• Indicated for spasmodic dysphonia (adductor type) or to open glottis in bilateral VF paralysis
• Isshiki's technique: spreader placed between thyroid laminae in midline to separate them (titanium bridge)
• Alternative: Wilson's lateralization (suture lateralization under endoscopy)

TYPE III THYROPLASTY (SHORTENING/RELAXATION LARYNGOPLASTY)

• Midline vertical incision through thyroid cartilage
• Anterior commissure pushed posteriorly, overlapping the cut edges
• Shortens VF, reduces tension, lowers pitch
• Indication: mutational falsetto, high-pitched voice, male transgender patients

TYPE IV THYROPLASTY (ELONGATION/TENSIONING - CRICOTHYROID APPROXIMATION)

• Suture placed between inferior border of thyroid cartilage and superior border of cricoid (cricothyroid approximation)
• Increases cricothyroid distance, stretches/tenses VF, raises fundamental frequency
• Indication: low-pitched voice, pitch elevation in transgender females (MtF)
• Wendler Glottoplasty (anterior glottic web creation) - alternative for pitch elevation

DIAGRAM: OVERVIEW OF LARYNGEAL FRAMEWORK SURGERY

         Thyroid notch
              │
    ══════════╪══════════   ← Thyroid cartilage lamina
    │         │         │
    │  ┌────┐ │          │   ← TYPE I window (medialization)
    │  │    │ │          │     Implant pushed medially ►
    │  └────┘ │          │
    ══════════╪══════════
              │
    ══════════╪══════════   ← Cricoid cartilage
              │
    TYPE III: vertical cut at midline, overlap → shorten VF
    TYPE IV:  suture thyroid to cricoid → elongate/tense VF
    TYPE II:  spread thyroid laminae apart → lateralize VF

4. ARYTENOID ADDUCTION

• Unilateral VFP with large posterior glottic chink (not corrected by Type I alone)
• VF at different heights (height differential)
• When Type I thyroplasty alone is insufficient

• Type I thyroplasty + arytenoid adduction = best results for large posterior gap
• Arytenoid adduction + reinnervation (NMP)

5. LARYNGEAL REINNERVATION

┌──────────────────────────────────────────────────────┐
│              REINNERVATION PROCEDURES                │
├─────────────────────┬────────────────────────────────┤
│ NON-SELECTIVE       │ SELECTIVE                      │
│ Ansa cervicalis to  │ C3 phrenic nerve (via great    │
│ RLN anastomosis     │ auricular cable graft in Y) to │
│                     │ both PCA muscles               │
│ Indication: Hoarse- │ + Ansa hypoglossi to RLN       │
│ ness (unilateral    │ bilaterally                    │
│ adductor paralysis) │                                │
│                     │ Indication: Stridor due to     │
│                     │ bilateral abductor paralysis   │
├─────────────────────┴────────────────────────────────┤
│ Nerve-muscle pedicle (NMP) implants:                 │
│  - Omohyoid-ansa cervicalis pedicle into TA muscle   │
│  - Restores bulk and tone, maintains medialization   │
│  - Combined with arytenoid adduction - best results  │
└──────────────────────────────────────────────────────┘

6. LARYNGEAL PACING

• Electrodes implanted into each posterior cricoarytenoid (PCA) muscle
• Connected to external/subcutaneous pacing device (similar to cardiac pacemaker)
• Causes automatic abduction/adduction of VF
• Still being evaluated in clinical trials
• (Scott-Brown's p. 992)

FLOWCHART: MANAGEMENT OF DYSPHONIA / DECISION FOR PHONOSURGERY

PATIENT WITH DYSPHONIA
        │
        ▼
FULL VOICE ASSESSMENT
• History (duration, profession, trauma, surgery)
• Perceptual assessment (GRBAS scale)
• Videostroboscopy
• Laryngeal EMG (if paralysis suspected)
• Acoustic analysis (jitter, shimmer, HNR)
• Voice Handicap Index (VHI-10)
        │
        ▼
IDENTIFY AETIOLOGY
        │
   ┌────┴─────────────────────────────┐
   ▼                                  ▼
STRUCTURAL LESION              VOCAL FOLD PARALYSIS/
(nodule/polyp/cyst/            GLOTTAL INSUFFICIENCY
Reinke's/granuloma)                   │
   │                             ┌────┴──────────┐
   ▼                             ▼               ▼
Voice therapy first          UNILATERAL       BILATERAL
(nodules - 3 months)         VFP              VFP
   │                             │               │
   ▼                             ▼               ▼
Failed therapy?            Recovery        No recovery
   │                       expected?        anticipated
   ▼                          │                 │
Phonomicrolaryngoscopy    Temporary ILP    Permanent Procedure
(Microflap technique)     (Gelfoam/HA)         │
                               │         ┌──────┴───────┐
                          Recovery   Type I Thyroplasty ±
                           occurs?   Arytenoid Adduction ±
                              │      Reinnervation
                          Yes → Implant
                          removal if needed

SPECIFIC LESIONS AND THEIR PHONOSURGICAL MANAGEMENT

Vocal Fold Nodules (Singer's nodules)

• Bilateral, at junction of anterior 1/3 and posterior 2/3 of VF
• First line: Voice therapy (minimum 3 months)
• Surgery: Rarely needed; microflap/medial microflap only if therapy fails
• Rule: Never strip - preserves superficial lamina propria

Vocal Fold Polyps

• Usually unilateral, pedunculated or sessile, at free edge
• Surgery: Microlaryngoscopy, careful dissection at base
• CO2 laser for vascular/hemorrhagic polyps

Vocal Fold Cysts

• Surgery: Lateral microflap approach to avoid rupture
• Excise entire sac to prevent recurrence

Reinke's Oedema (Polypoid Corditis)

• Bilateral, associated with smoking
• Surgery: Microflap, suction/decompression of Reinke's space
• No mucosal stripping
• Concurrent smoking cessation mandatory

Granulomas

• Posterior laryngeal / vocal process
• Surgery: Laser excision + Botox injection simultaneously (reduces recurrence)
• Treat underlying LPR/GERD

Recurrent Respiratory Papillomatosis (RRP)

• HPV 6 & 11
• Surgery: Microdebrider or CO2 laser debulking; preserve normal tissue
• Avoid jet ventilation (seeds lower airway)
• Intralesional cidofovir (risk of malignant transformation)

Sulcus Vocalis

• Pit/groove in VF mucosa causing stiffness
• Surgery: Microflap, fat injection, or medialization procedures for associated bowing

PREOPERATIVE WORKUP - SUMMARY

PREOPERATIVE ASSESSMENT FOR PHONOSURGERY

1. Indirect laryngoscopy / Flexible nasolaryngoscopy
2. Videostroboscopy (gold standard for VF assessment)
3. Acoustic analysis (fundamental frequency, jitter, shimmer, HNR)
4. Aerodynamic analysis (phonation threshold pressure, airflow)
5. Perceptual assessment (GRBAS / CAPE-V)
6. Voice Handicap Index (VHI-10) - subjective patient assessment
7. Laryngeal EMG (for VFP - to assess reinnervation potential)
8. CT/MRI neck if malignancy or anatomical distortion suspected

RECENT ADVANCES IN PHONOSURGERY (2020-2025)

1. Flexible Endoscopic Phonosurgery (FEP)

• Office-based procedures under local anaesthesia via flexible laryngoscope
• Injection laryngoplasty, laser treatments, biopsy
• Avoids general anaesthesia; suitable for high-risk patients
• Magnani et al., Acta Otorhinolaryngol Ital 2024 (PMID: 38745512)

2. Injection Laryngoplasty vs. Medialization Thyroplasty - New Meta-Analysis

• Largest systematic review (2025) comparing ILP vs. Type I thyroplasty for unilateral VFP
• Both achieve significant voice improvement; thyroplasty shows superior durability
• ILP preferred for: temporary use, awaiting recovery, elderly/frail patients
• Baali et al., Eur Arch Otorhinolaryngol 2025 (PMID: 41136562)

3. Wendler Glottoplasty / Pitch-Raising Surgery for Transgender Patients

• Wendler glottoplasty (anterior glottic web creation) gains popularity for MtF transgender patients
• Raises fundamental frequency effectively; combines with Type IV thyroplasty
• Meta-analysis (2024) confirms significant acoustic improvement
• Rogalska et al., Eur Arch Otorhinolaryngol 2024 (PMID: 38315177)

4. Laryngeal Reinnervation - Growing Role

• Ansa cervicalis-to-RLN anastomosis now increasingly combined with arytenoid adduction
• Better long-term VF tone, bulk, and muscle mass restoration
• Nerve-muscle pedicle (NMP) combined with arytenoid adduction shows superior results over Type I alone

5. Calcium Hydroxyapatite (Radiesse/Prolaryn Plus)

• Replaced Teflon as the preferred long-duration injectable
• Duration 12-18 months, good safety profile, no significant granuloma risk
• Can be performed in-office under topical anaesthesia

6. Hyaluronic Acid Vocalization Augmentation

• Increasingly used for temporary augmentation, sulcus vocalis, and presbyphonia
• Reversible with hyaluronidase injection

7. Robotic-Assisted Laryngeal Surgery

• Transoral robotic surgery (TORS) for selected laryngeal lesions
• Improved access and precision; still limited evidence for phonosurgery specifically

8. Vocal Fold Tissue Engineering

• Experimental: bioengineered VF scaffolds, stem cell-derived VF mucosa, injectable biomaterials to restore lamina propria
• Promising for scarred/sulcus vocalis VF

9. Botulinum Toxin (Botox) in Phonosurgery

• First-line for spasmodic dysphonia (adductor and abductor types)
• Adjunct to surgery for granulomas and supraglottic hyperfunctional disorders
• Combined with endoscopic procedures

POSTOPERATIVE CARE AND REHABILITATION

1. Voice rest: 1-2 weeks post microlaryngoscopy
2. Humidification, proton pump inhibitors (for LPR)
3. Post-operative voice therapy / speech-language pathology
4. Regular videostroboscopy follow-up at 4-6 weeks, 3 months, 6 months
5. Remove drain after 24 hours (framework surgery)
6. If implant migration: revision surgery within 2-4 weeks before scarring

COMPLICATIONS OF PHONOSURGERY - SUMMARY TABLE

KEY POINTS FOR EXAMINATION

1. Phonosurgery = surgery for maintenance, restoration, or enhancement of voice (Friedrich/Scott-Brown)
2. Isshiki (1974) described 4 types of thyroplasty; Type I (medialization) is most common
3. European Laryngological Society (2001) reclassified as "laryngoplasties" (approximation, lateralization, shortening, elongation)
4. Teflon injection is now contraindicated - calcium hydroxyapatite and hyaluronic acid are preferred
5. Videostroboscopy is the gold standard for pre- and post-op evaluation
6. LEMG is the only test to evaluate integrity of the laryngeal motor unit
7. Nodules rarely require surgery - voice therapy first
8. Microflap technique preserves Reinke's space - no mucosal stripping ever
9. Type I thyroplasty is ideally done under local anaesthesia for intraoperative voice monitoring
10. Recent meta-analysis (2025): Thyroplasty > ILP for durable results; ILP preferred for temporary use

REFERENCES

1. Scott-Brown's Otorhinolaryngology Head & Neck Surgery, 8th ed. - Chapter: Phonosurgery including medialization procedures, pp. 991-992
2. Cummings Otolaryngology Head and Neck Surgery, 7th ed. - Ch. 62: Medialization thyroplasty and vocal fold injection; Ch. 64: Laryngeal reinnervation
3. K.J. Lee's Essential Otolaryngology, 11th ed. - Laryngology chapter
4. Dhingra, Diseases of Ear Nose and Throat - Phonosurgery chapter
5. Hazarika's ENT - Laryngology section
6. Friedrich G et al. "Laryngeal framework surgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society." Eur Arch Otorhinolaryngol 2001;258(8):389-396.
7. Baali MH et al. "Injection laryngoplasty versus medialization thyroplasty for unilateral vocal cord paralysis: a comprehensive systematic review and meta-analysis." Eur Arch Otorhinolaryngol 2025. [PMID: 41136562]
8. Rogalska M et al. "Impact of Wendler glottoplasty on acoustic measures and quality of voice in transgender women: a systematic review and meta-analysis." Eur Arch Otorhinolaryngol 2024. [PMID: 38315177]
9. Magnani M et al. "Flexible endoscopic phonosurgery for treatment of functional sequelae after laryngeal oncologic surgery: a narrative review." Acta Otorhinolaryngol Ital 2024. [PMID: 38745512]