1. Microlaryngeal Surgery
Surgery may be indicated for some vocal fold lesions. Because of the delicate architecture of the vocal folds, highly-skilled surgery is required to restore vibration to the vocal fold. Microlaryngeal surgery is performed through a scope that is placed in the mouth. It is performed under a high-powered microscope using delicate instruments to remove the lesion. General anesthetic is required. Postoperative voice therapy is necessary to assist in healing. Limits on voice use are typically placed to assist in healing after the procedure.
Some lesions are able to be treated with awake laser procedures performed under topical anesthetic, avoiding the risks and inconvenience of a general anesthetic.
1. Schedule a visit with the voice pathologist. When preparing for a surgery, you will meet with the voice pathologist at least one time before surgery. During this visit, the voice pathologist will evaluate and record your voice so that progress can be monitored. The voice pathologist will also review a postoperative voice rest protocol and a recovery plan for your voice and answer any further questions you may have regarding your surgery and recovery.
2. Schedule one-week postoperative visit with Dr. Rubin. Typically, one week after your surgery, you will see Dr. Rubin, who will go over pathology results and view and evaluate your vocal folds as they are healing. He will then give permission for you to start using your voice again*.
3. Schedule one-week postoperative visit with the voice pathologist. These two appointments (one week post op with Dr. Rubin and one week post-op with the voice pathologist) can often be made for the same day. Once Dr. Rubin has given you permission to use your voice, the voice pathologist will “break your silence” through a structured hierarchy of gentle exercises combined with specified periods of vocal rest. These exercises are designed to reduce inflammation and promote healing. You will also be taught to use a “confidential” or “breathy” voice to maintain gentle, low impact vibration in brief conversations (see Voice Rest Protocol). A therapy plan tailored to your needs will be discussed, which generally involves therapy appointments once a week for 6-8 sessions.
4. Make sure you have any prescriptions filled that Dr. Rubin has prescribed for you (e.g., reflux medication)
5. You may need medical clearance from your primary care doctor or other physicians. If this is the case, make appointments accordingly before the date of surgery.
6. Make sure you stop any blood thinners before the surgery.
Prepare for one week of complete voice rest following your surgery. You may use text-to-speech apps, paper and pen, dry erase board or Boogie Board to communicate, but you may not use your voice.
2. Awake Laryngeal Procedures
Numerous procedures on the vocal folds and larynx that traditionally have been performed under general anesthesia are now able to be performed on an awake patient with only topical (local) anesthesia. For those patients who do not feel they could tolerate being awake, a light sedation can be provided. In either case, patients can avoid the added risk and expense of general anesthesia. In addition, if no sedation is given, patients are able to drive themselves to and from the procedure, and return to daily activities more readily, as they do not have to wake up and feel the after-effects of general anesthesia. The development of these techniques has truly advanced the field of laryngology and care of the voice. These procedures are safe and well-tolerated. In fact, studies have shown that most patients would prefer to do these procedures awake, rather than while asleep. Every patient is different. Dr. Rubin discusses all possible treatment options and determines if an awake laryngeal procedure is appropriate for you.
The most commonly performed awake laryngeal procedures include: injections into the vocal folds to assist in vocal fold closure and strengthen the voice; laser procedures for benign and precancerous laryngeal lesions; transnasal esophagoscopy, and small biopsies of laryngeal or esophageal lesions. A brief description of each is given below.
Injection laryngoplasty is a procedure that is performed to improve the closure of the vocal folds. In general, this is most commonly performed for patients with a paralyzed vocal fold and for patients who have atrophy (thinning) of the vocal folds.
Vocal fold atrophy typically occurs with age (presbyopia). The procedure may be performed while the patient is under general anesthesia or with the patient awake with topical anesthetic. When performed awake, the patient’s nose is anesthetized with cotton pledgets soaked in anesthetic. Some topical anesthetic is also sprayed into the mouth to anesthetize the throat. Lastly, anesthetic is either dripped onto the vocal folds or injected into the trachea. A thin flexible laryngoscope (camera) is passed through the nose and held in place to visualize the larynx. Dr. Rubin is then able to pass a needle through the skin and inject filler into one or both vocal folds.
Vocal fold atrophy is particularly common in the elderly (aging voice). Awake injection laryngoplasty is a wonderful technique to help the aging voice without putting the elderly patient at risk of general anesthesia.
Awake pulsed KTP laser ablation of laryngeal lesions can be performed using a fiber laser passed through a port in a flexible laryngoscope. The laryngoscope is passed through the nasal cavity after the appropriate anesthetic is applied (see above). This is particularly useful for recurrent lesions of the vocal fold, such as laryngeal papilloma (HPV) and dysplasia (precancerous changes). These lesions can recur very rapidly and have the potential to advance to cancer. In the past, patients had to be put to sleep on numerous occasions to treat these lesions. Dr. Rubin uses the pulsed KTP laser to treat these lesions in the awake or lightly sedated patient. This laser targets blood vessels. In general, papilloma and dysplasia are highly vascularized so the laser targets these lesions while sparing the rest of the vocal fold. This minimizes trauma to the normal vocal fold tissue, resulting in excellent voice recovery. Abnormal blood vessels (ectasias and varices) which may cause voice changes or recurrent hemorrhages can also be cared for in this fashion. Other benign lesions such as hemorrhagic (traumatic) polyps and cysts may be treated this way, however, in general, hemorrhagic polyps and cysts are more precisely excised with microlaryngeal surgery.
3. Injection Laryngoplasty
Injection laryngoplasty is a temporary procedure to improve the closure of the vocal folds, usually due to vocal fold paralysis or the aging voice. It involves injecting a filler into the vocal fold to “plump it up” and help it make contact with the other vocal fold. Sometimes the procedure is done to help the patient with a paralyzed nerve while the nerve is regaining function. Other times it is used as a “trial” to see if additional vocal fold closure will help the voice. The procedure may be performed through a scope in the mouth with the patient under a general anesthetic (like microlaryngeal surgery) or with a topical anesthetic only as an awake laryngeal procedure.
4. Laryngeal Framework Surgery
Laryngeal framework surgery is designed to improve the function of the larynx when the vocal folds cannot close well. This is often seen in the case when one vocal fold is paralyzed (vocal fold paralysis) and in the aging voice. Voice therapy is often tried first. Sometimes, injection laryngoplasty will be tried prior to performing the permanent laryngeal framework surgery.
Thyroplasty is the most common framework surgery performed. This involves exposing the larynx with a small incision in the skin of the neck. A window is then drilled within the cartilage of the larynx. An implant is placed through the window and pushes the vocal fold toward the midline so that contact with the other vocal fold is improved. This results in a stronger voice and cough. It also helps with the “windedness” one might feel when he or she cannot close the vocal folds.
Arytenoid adduction is an additional procedure to help with vocal fold closure when a thyroplasty is not sufficient. This involves exposing the cartilage that rotates the vocal fold to close. A stitch is placed through it to mimic the natural action of the cartilage and rotate the vocal fold more to the midline.
Voice Rest Protocol
- Week One: For the first week following your surgery, you are on Complete Voice Rest. This means no speaking, no singing, no whispering, no whistling, no humming, no throat clearing, no coughing, no heavy lifting, and nothing that presses the vocal folds together.
- Week Two: After Dr. Rubin gives you permission to use your voice again, you are advised to perform gentle voice exercises approximately one minute every 15 minutes. Each week, you will add more exercises and one additional minute per every 15 minutes, so that by week 6 you will be speaking approximately 5 minutes per every 15 minutes, which is said to be the average amount of voice use for the average person. Your voice pathologist will go over this protocol with you in more detail at your preoperative therapy visit.