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  • 1. Direct Laryngoscopy
  • 2. Microscopic Exposure
  • 3. Lesion Excision

Direct Microlaryngoscopy and Excision of Vocal Cord Lesion

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Seth M. Cohen, MD, MPH; C. Scott Brown, MD
Duke University Medical Center

Main Text

Table of Contents

  1. Case Overview
    1. Citations

    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. The treatment methods for laryngeal granulomas depend on the underlying cause. Although granulomas are typically of benign nature, they often require surgical treatment.

    This video illustrates the steps taken to achieve optimal outcomes during vocal fold granuloma surgical excision. In this clinical case, the patient has undergone two prior surgical interventions, resulting in formation of the granuloma. The initial part of the video focuses on the positioning of the endoscopic tube anteriorly, facilitating the 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 and precision. The laryngoscope is securely affixed to a Mayo stand positioned over the patient's chest, ensuring stability and optimal positioning for the surgical team.

    In the subsequent phases of the procedure, 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 battling 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. The importance of minimizing potential complications related to instrument entanglement is highlighted. Further steps involve the identification of a precise junction between the granuloma and healthy tissues. A minor mucosal fold and slight swelling are noted in the designated area. The utilization of suction plays a crucial role in ensuring optimal visibility and aids in the precise and careful excision process. Alternative techniques are given consideration for the insertion of scissors underneath the granuloma for elevation.

    The right scissors are selected by the surgeon, and guidance is provided to the assistant in the skillful excision of the granuloma while maintaining control over the surrounding tissue. Following the successful removal of the granuloma, hemostasis is achieved by topically applying an epinephrine pledget, which is carefully pressed onto the bleeding area. The surgical technician plays a pivotal role in handling 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.

    Citations

    1. 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.
    2. 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.
    3. 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.

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    Duke University Medical Center

    Article Information

    Publication Date
    Article ID276
    Production ID0276
    VolumeN/A
    Issue276
    DOI
    https://doi.org/10.24296/jomi/276