Phonomicrosurgery - Principles, Procedure, and Complications

Introduction

Phonomicrosurgery comes under the surgical procedure called phonosurgery. Phonosurgeries are performed to maintain, restore or enhance the human voice. It can be done in the form of microsurgery, injections, or open surgery. The term phonosurgery was coined in the early 1960s by Hans Von Leden and Gottfried Arnold.

What Are the Types of Phonosurgery?

The phonosurgery consists of the following procedures which include -

1. Phonomicrosurgery - This surgery is done to the folds of vocal cords with the help of an endoscope. In this procedure, the first layer of the tissue on the vocal cords, called the epithelium, is elevated, and then the lesion is dissected. After the lesion, such as a cyst or polyp, is removed, the epithelium layer is placed back into position. This procedure does not cause any scarring of the tissue.

2. Laryngoplastic Phonosurgery (Thyroplasty) - In this procedure, an implant is placed inside the larynx (voice box) alongside the vocal cord. This implant pushes the vocal cord closer to the middle so that it produces a strong voice. For this procedure, a small incision is made in the neck to access the larynx. The implant is placed in position through this hole, and the vocal cord function is checked before the hole is closed. This procedure is performed under local anesthesia when the patient awakens, and their voice can be monitored.

This method is usually performed in patients with puberty dysphonia, where a man has a high-pitched voice like a girl.

3. Laryngeal Injections - This procedure is done in cases with weak or paralyzed vocal cords. The injections are administered into the tissues next to the vocal cords to bulk up the vocal tissues and bring the vocal cords closer together, which helps strengthen the voice.

Why Is Phonomicrosurgery Done?

Phonomicrosurgery is done in patients with pathologies like vocal fold nodules and polyps.

• Vocal fold nodules are benign (non-cancerous) growth on the vocal folds. These nodules generally appear in a patient who misuses their voice. The vocal folds may swell over time, and the swollen spots can get harder with time. It becomes a nodule that gets larger and harder with time if vocal abuse continues.

• Polyps are like a swollen spot or bump or a long thin growth that can be found on one or both of the vocal folds. The polyps are usually bigger than the nodules, also called polypoid degeneration or Reinke’s edema.

Therefore in phonomicrosurgery these pathologies are evaluated carefully using a microscope and are excised while minimizing the dissection area and preserving the maximum amount of epithelium. Other than this phonomicrosurgery is also done in conditions like -

• Dysplasia (presence of abnormal cells in tissues or organs).

• Granuloma.

• Scar tissue.

• Papilloma (a benign tumor on the epithelial surface).

• Chronic laryngitis.

• Recurrent nerve paralysis.

What Are the Signs and Symptoms of Vocal Nodules or Polyps?

The signs and symptoms of nodules and polyps are very similar and include the following -

• Hoarseness.

• Breathiness.

• A rough or scratchy voice.

• Shooting pain from ear to ear.

• A harsh-sounding voice.

• Feeling a lump in the throat.

• Neck pain.

• Less ability to change the pitch.

• Voice and body tiredness.

What Are the Preoperative Considerations of Phonomicrosurgery?

The necessary preoperative measures that should be taken before phonomicrosurgery include -

• Avoiding medicines such as Aspirin, nonsteroidal anti-inflammatory medications, or other anticoagulation medications.

• Avoid any vocal abuse (straining vocal cords) before the surgery.

• Women should avoid surgery during the menstrual cycle.

What Are the Principles of Phonomicrosurgery?

The principles of phonomicrosurgery include the following -

• Making an incision through the epithelium close to the pathology.

• Using minimally invasive techniques by not disrupting the surrounding tissues.

• Staying in the superficial plane as much as possible.

• Preserving the overlying mucosa.

How Is Phonomicrosurgery Performed?

• Phonomicrosurgery is a minimally invasive technique that is performed under general anesthesia. Which means the patient will be completely asleep or unconscious during the procedure. Therefore, a breathing tube would be inserted to facilitate the breathing.

• In this procedure, a microscope is used as the vocal folds have a length of only 10 to 15 mm (millimeters). It is a painless and short-duration procedure in which small lesions are removed from the surface of vocal cords.

• After administering general anesthesia, the surgeon will use a metal scope to keep the mouth of the patient open to access the vocal folds. After that, a microscope will magnify the area of interest.

• This surgery is a one-day procedure and does not require an overnight patient stay. Patients are advised to exercise vocal rest after the surgery, and some patients can feel pain, for which painkillers can be prescribed.

What Are the Complications of Phonomicrosurgery?

Phonomicrosurgery is a minimally invasive surgery of short duration, which usually does not cause any complications. However, no matter what type of surgery is performed on the body, it always has a one to two percent chance of causing complications. Therefore, some of the potential complications that can occur in phonomicrosurgery include -

• Injury to the teeth.

• Swelling or cuts on the lips or inside of the mouth or throat.

• Change in taste.

• Temporary or permanent tongue numbness.

• Swelling of the bottom of the mouth or chin.

• Temporary or permanent tongue weakness.

• Bleeding.

• Discomfort or pain in the jaw.

• Jaw dislocation.

• Neck discomfort or pain.

• Persistent or worsening hoarseness after surgery.

• Temporary difficulty with swallowing.

• Burns to exposed skin if a laser is used during the procedure.

• Airway obstruction.

What Are the Post-operative Instructions?

After the procedure of phonomicrosurgery, the patient is advised a period of total voice rest. The duration of the voice rest should be based on the nature of the pathology treated during the surgery, the compliance of the patient, and the amount of dissection performed to remove the lesion. The total voice rest includes no -

• Speaking.

• Whispering.

• Singing.

• Humming.

• Clicking.

• Throat cleaning.

Voice rest is usually recommended for at least two to ten days depending upon the condition. After complete voice rest, light voice is advised for at least seven to ten days.

Conclusion

Phonomicrosurgery is performed to improve the vocal function of the patient. For the success of treatment, appropriate instruments, maximum magnification, and patient compliance are required. It is a technique-sensitive surgery and requires skill, patience, and careful attention.