Vocal Cord Stripping - Procedure, Advantages, and Disadvantages

Introduction

Vocal cords are a pair of tissue folds located in the larynx (voice box). They have three important functions: voice production, to prevent choking, and air regulation into the lungs. The vibration in the vocal cords during their meeting creates the sound or the voice. They are connected to muscles and cartilage that allow their free movement.

What Are the Surgical Treatments for Vocal Cord Disorders?

Vocal cord disorders are laryngitis, nodules, polyps, and cysts. Benign and malignant tumors of the larynx are also common. Reinke’s edema and spasm in the larynx (laryngospasm) are other conditions. Surgery for vocal cord disorders is usually performed under general anesthesia. It can be done through a neck incision (open surgery) or an endoscope inserted through the mouth.

Although an open surgery provides better management of the vocal cords, the endoscopic approach is more conservative. Endoscopic laryngeal surgery is called micro laryngoscopy as it provides a magnified view of the vocal cords. Another technique is vocal cord stripping, in which a segment of the vocal cords is removed.

What Is the Basis of Vocal Cord Stripping?

In 1932, Lore performed a thyrotomy. In a thyrotomy, an incision is made into the thyroid cartilage to gain access to the larynx. He observed vocal cord regeneration in a short time following the procedure. With that thought in mind, he conducted experiments on cats in which he removed a part of the vocal cords.

Lore observed that it has no harmful effect on the microscopic picture of the larynx. The regenerated mucous membrane was almost similar to the removed one. Since then, ear, nose, and throat specialists (ENT) have done numerous surgeries using vocal cord stripping.

The surgeon will ensure the procedure creates a favorable straight edge for adequate healing. An irregular edge will lead to unfavorable healing and loss of function.

How Is Vocal Cord Stripping Performed?

Traditionally, vocal cord stripping was performed without general anesthesia. The laryngoscope was not used. Hence, no magnification was present. As a result, large parts of the vocal fold mucosa are grasped by forceps and incised. It resulted in an incorrect method of surgery where excessive mucosa (epithelium) was removed. Hence, surgeons frequently observed a prolonged healing period and scarring.

Vocal cord stripping with manual instruments is a rare method these days. It is done with a laser and an endoscope which gives precise results. It is especially useful in leukoplakia and early-stage cancers. Carbon dioxide laser (CO2) is the most commonly used laser in vocal cord surgery. A pulsed dye laser (PDL) or solid-state laser is used in the angiolytic stripping of the vocal cord. In angiolytic laser stripping, selective destruction of abnormal blood vessels without altering the normal structure is done. The technique is as follows.

1. Following general anesthesia, an assessment of the magnified vocal folds is done.

2. After directing the flexible laser fiber tip to the target, the PDL laser delivers about 50 to 70 pulses.

3. After irradiating the lesion, the lesional epithelium is separated from the unaffected zone. Then, any additional biopsy can be performed, and the specimen can be sent for histology.

Before the procedure, certain precautions must be taken. Proper hydration is a must. Patients should stop smoking and drinking alcohol. Some patients have acid reflux (gastro-esophageal reflux disease- GERD). In those cases, a proton pump inhibitor (PPI) is given to reduce acidity. Strict voice rest is also advised.

What Are the Indications of Vocal Cord Stripping?

The indications of vocal cord stripping are:

1. Chronic Hypertrophic Laryngitis: Vocal cord stripping is especially indicated for the chronic inflammatory condition of the larynx, also called chronic hypertrophic laryngitis. It is a result of long-term abuse of the larynx. The causes can be repeated acute infection, trauma, or both. The procedure is promising when all other conservative methods have failed.

2. Vocal Cord Polyps: A polyp is a tissue growth. Multiple polyps form a condition called polyposis. Vocal cord stripping is used for this condition.

3. Reinke’s Edema: The space under the vocal cord is called Reinke’s space. Fluid accumulation in this space leads to a condition known as Reinke’s edema. In addition, the degenerative changes due to polyps can also lead to this condition.

4. Benign Growths: Papilloma is a growth resembling a wart. It occurs on the surface of the vocal cord. A viral infection causes it. Single or multiple papillomas can be treated with vocal cord stripping. It is also used for managing cysts and nodules.

5. Premalignant Disease: Vocal cord stripping is used in diagnosing premalignant diseases of the vocal cord. Premalignant diseases are those which have the potential to develop into cancer. Leukoplakia is an example of a common premalignant disease. Therefore, a biopsy can also be done using this technique for leukoplakia.

6. Early-Stage Cancer: Vocal cord stripping is done for stage 0 cancers confined to the vocal cords. Lim et al. in 2018 used PDL laser for stripping in patients with vocal fold leukoplakia (vocal folds are present near vocal cords and lack any muscle). The technique was compared to CO2 laser surgery. The results indicated that angiolytic laser stripping was a safe and feasible treatment for vocal fold leukoplakia. Further, voice quality was significantly improved in the PDL laser group.

What Are the Advantages of Vocal Cord Stripping?

1. As the technique removes only the superficial layer of the epithelium, the structure and function of vocal cords are preserved.

2. Laser stripping is an advanced modality that reduces the risk of bleeding. Hence, it is a minimally invasive procedure.

3. Vocal fold stripping is an encouraging technique in patients without any positive response after non-surgical treatments.

What Are the Disadvantages of Vocal Cord Stripping?

1. It is technique sensitive. If an irregular edge is left after the procedure, healing is compromised. Also, it leads to loss of flexibility, vibration, and poor function.

2. Using a laser can increase the risk of surgeon-induced injuries, also called iatrogenic injuries. So, it is because it can burn adjacent tissues if used without caution.

3. Short-term side effects are infection, breathing problems, hoarseness, and change in voice quality.

4. Long-term side effects include scarring. In addition, it risks additional surgery in the future.

Conclusion

At present, vocal cord stripping is not commonly used. With the advent of many surgical procedures, it is considered obsolete in many laryngeal conditions, such as voice restoration. However, it is still used in premalignant conditions and malignancies of the larynx.