Direct Microlaryngoscopy and Excision of Vocal Cord Lesion

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.