|Year : 2012 | Volume
| Issue : 1 | Page : 7-11
Phonosurgery: A new subspeciality in otolaryngology
Department of ENT and HNS, Dr. Pinnanmaneni Siddhartha Institute of Medical Sciences, Gannavaram, Andhra Pradesh, India
|Date of Web Publication||21-Mar-2012|
Professor and Head, Department of ENT, Dr. Pinnanmaneni Siddhartha Institute of Medical Sciences, Gannavaram, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Laryngology and phonosurgery has developed as a subspeciality of otorhinolaryngology and head and neck surgery since last 3 decades.The article traces the journey of the new branch to improve the quality of the voice in the present era of increasing numbers of the voice users for and as a profession. The Indian scenario is also discussed.
Keywords: Phonosurgery, thyroplasty, microflap procedures, laryngectomy and voice restorative surgery laryngology, lasers
|How to cite this article:|
Murthy P. Phonosurgery: A new subspeciality in otolaryngology. J NTR Univ Health Sci 2012;1:7-11
The term 'Phonosurgery' was defined by Hans Von Leden together with Gottfried Arnold, as any surgery designated primarily for the improvement or restoration of voice, and had the intended goal of voice quality improvement.  The interest in the surgery for voice had resulted from a very common problem caused by paralytic dysphonia and vocal fold paralysis. Bruning,  in 1911, introduced the concept of injecting materials such as paraffin into the paralyzed vocal fold, to medialize the fold and improve the quality of the voice using a specially designed syringe, which is still used by many. However, the credit goes to Arnold who promoted injection Laryngoplasty  as the mainstay of treatment for paralytic dysphonia. Balance, in 1924, introduced medialization by reinnervation, using nerve-to-nerve anastamosis of the phrenic or descending ansa hypoglossi to the recurrent laryngeal nerve. Although the technique had lost its charm after that, interest is now again shown by Tucker  and Crumley. 
Payr, in 1915,  developed an anteriorly based rectangular cartilaginous flap that could be depressed to medialize the membranous vocal fold. The technique was further explored by several Laryngologists such as Meurman, 1952.  The framework surgery did not gain popularity until the 1970s, when Ishiki  from Japan, established the guidelines for Laryngeal Framework Surgery. Suddenly there was a paradigm shift from injection laryngoplasty procedures to External Laryngeal framework surgeries. The added advantage of operating under local anesthesia facilitated fine tuning of the voice intraoperatively like a stapedectomy and the technique became a 'functional' surgery.
Koufmann,  in USA, made several modifications to Ishiki's procedures and also coined the term, 'laryngoplastic phonosurgery'. Zeitels,  in 1998, introduced 'adductor arytenopexy' in addition to Type 1 Medialization Thyroplasty to close the the posterior glottic chink, using the cricothyroid subluxation procedure, which would increase the length and tension of the denervated vocal fold. This was a dynamic procedure compared to Medialization Thyroplasty, which re-positions the paralyzed vocal fold into a midline optimal position so that the normal vocal fold excursions produce a normal voice.
The operating microscope, suspension laryngoscopes,  and the microsurgical instruments have paved the way to a new branch of Phonomicrosurgery, which has replaced the conventional microlaryngoscopic procedures. This is due to Hirano's  observation of the structure of the vocal fold vibration − epithelium and superficial lamina propria (Cover), the underlying deep lamina propria, and the muscle (Body). Phonomicrosurgery has evolved largely to encourage minimal disruption of the microarchitecture of the vocal fold, while removing the dysphonia-inducing pathology. Then gradually phonomicrosurgery encompassed the injection laryngoplastic procedures to have a proper placement of the material exactly in the paraglottic space, to medialize the vocal fold for a good glottic closure. Teflon replaced paraffin in the early 1960s. Microflap techniques have been used in sulcus vocalis and scarred vocal fold. All the phonosurgical procedures can also be performed using rigid telescopes incorporated in the laryngoscopes, leading to a new surgical procedure of video laryngoendoscopic surgery. A lot of interest has been generated in bioimplants both for injection laryngoplasty and laryngeal framework surgery. This generated interest in bio-compatible and tissue-matching materials, such as, fat and hyalase, are comparable with the viscoelastic properties of the vocal folds.
Lasers have been introduced by Jako  and Strong  for laryngeal cancers, to make hemostatic dissection of the soft tissues more precise. The carbon dioxide laser has become a standard tool in laryngology, but the drawback is that it cannot be used for highly precise tangential cutting without causing heat-induced trauma - photothermal injury leading to fibrosis. Hence, in the 1990s, there was a return to cold steel conventional instruments  and the microflap techniques for benign epithelial vocal fold lesions. Later several lasers have been tried, but still CO2 laser is ideal for large, vascular, and deeply invasive lesions.
Management of extensive laryngeal cancers is done by widefield laryngectomy, to excise the visible cancer tissue and postoperative radiation and to take care of the cellular level micromets, leaving the patient completely aphonic. Blom and Singer  have devised a silicone stent to exactly fit into a puncture between the trachea and the esophagus, to divert the air from the trachea into the neopharynx, to create a near-normal voice. The procedure was replicated in Manipal, in 1986,  and now post laryngectomy rehabilitation by tracheo esophageal puncture (TEP) and a voice prosthesis has become the gold standard of treatment for laryngeal cancers.
The development of diagnostic modalities such as angled telescopes and stroboscopes have helped the laryngologist to make precise diagnosis of lesions. Fiberoptic laryngoscopes and electromyograms have improved the knowledge of the pathophysiological aspects of laryngeal disease.
The stimulus for phonosurgery in India started in 1995, when Professor Ishiki delivered a keynote address at the National Conference of Association of Otolaryngologists of India, held at Cuttack. Since then a number of laryngologists in India have been actively performing phonosurgical procedures. The first publication from India by Phaniendrakumar on type 1 Thyroplasty appeared in 1997,  followed by those from Nupur Kapoor Nerurkar from Mumbai  and Jayakumar from Thiruvananthapuram.  Contemporary work in Phonosurgery and Lasers in laryngology has also been initiated by Handa KK at New Delhi, Sachin Gandhi at Pune, and WVBS Ramalingam at the Army Hospitals.
Applications of phonosurgery in voice disorders:
- Laryngeal framework surgery: Since Ishiki decribed the technique of Thyroplasty there are several modifications of the techniques leading to confusion regarding the terminology. The phonosurgery committee of the European Laryngological Society has developed a new classification of the Laryngeal framework Surgery in accordance with the classification by Ishiki, depending on the intended purpose and outcome.
- Approximation Laryngoplasty includes Medialization Laryngoplasty and Arytenoid adduction  for unilateral paralyzed vocal fold [Figure 1],[Figure 2] and [Figure 3]
- Expansion Laryngoplasty: Lateralization Laryngoplasty and vocal fold abduction for bilateral abductor paralysis
- Relaxation Laryngoplasty: For shortening the vocal fold for puberphonia to change the feminine voice in a male to a normal male voice  [Figure 4]
- Tensioning Laryngoplasty: Cricothyroid approximation for Androphonia, to convert a male voice in a female to a feminine voice.
The new terminology addresses the functionality and the pathogenesis of dysphonia. It has also witnessed the development of bio-inert materials used as implants to medialize the vocal fold. Several materials have been used by various researchers, such as, silastic, hydroxyapatite, Gore-Tex, and titanium shims. Phaniendrakumar described sandwich Thyroplasty for preserving the cartilaginous flap (Personal Communication)
- Phonomicrosurgery: Developed on Hirano's principle of Body and Cover [Figure 5], various techniques were developed by means of a suspension laryngoscopy, using either a Surgical Microscope or a telescope incorporated into the Laryngoscope, for magnification [Figure 6]. Hydrodissection and microflaps helped the surgeon to excise the dysphonia producing pathology with minimal disruption of the microarchitecture of the vocal fold, which facilitated primary healing. Phonomicrosurgery encompasses several procedures for different indications.
- Microflaps are very useful in removing the benign epithelial lesions of the vocal fold [Figure 7] such as nodules, polyps, cysts, and benign masses on the surface of the vocal fold 
- Vocal fold scars and sulcus [Figure 8] and [Figure 9]: These are severe anomalies of the lamina propria resulting in loss of viscoelasticity and poor vibratory function and sometimes ineffective glottal closure. The procedures described to address vibratory or elastic characteristics of the lamina included direct implantation of fat in the vocal fold via a microflap or a Gray's mini thyrotomy and collagen implantation into the lamina propria. Injecting collagen-based materials is limited by technical difficulty and the currently available collagen materials. More compatible materials matching the native extracellular matrix proteins like hyaluronidase are being tried, with successful outcomes. Augmenting the volume of the vocal fold in a paralyzed vocal fold and recreating the lamina propria in a scarred vocal fold come under these procedures.
- Lasers have been widely used for excisions of benign or malignant tumors and vascular lesions [Figure 10]. In the recent past there has been renewed interest in the benign epithelial and mucosal lesions of the vocal folds, by creating microflaps with laser via Microlaryngoscopy or Video-assisted Laryngoscopy.
The areas of concern for further fertile research and innovation in Phonosurgery is the scarred or nonvibratory epithelium of any etiology. Gray  and Chan et al.,  have been working on this, to characterize the layered microstructure of the vocal folds biochemically and biomechanically, and are on the look out for a suitable pliable substance that will facilitate a mucosal wave.
Another area is neurolaryngology and selective innervation of the laryngeal muscles. Trials in the electrical pacing of the primary abductor of the vocal fold - the posterior cricoarytenoid muscle, will reduce the morbidity associated with airway obstruction due to bilateral abductor paralysis, by avoiding a tracheostomy.  Work on laryngeal reinnervation using ansa cervicalis to the recurrent laryngeal nerve is also been extensively researched.
Strome et al.,  reported the first laryngeal transplant for a traumatic nonfunctional larynx. Ideally the technique should be employed for laryngeal cancers, but the postoperative concomitant need for immunosuppressants for life is a major deterrent. Minimizing host rejection can make transplantation a viable option and research needs to be done in that angle.
Many professional voice users have been identified with several vocal problems and they need to be educated and treated for their problems. There is a need for comprehensive voice clinics to cater to this increasing population.
Early cancer detection and management protocols for early cancers are mandatory to prevent vocal disabilities.
| Conclusion|| |
Several innovative surgical procedures have been developed to improve the quality of the voice and improve the safety of the airway, preserving a good swallow. These three functions of the Larynx are inseparable and have long-ranging effects on each other, the larynx being involved in all three functions. Phonosurgery as a superspeciality is going to stay, to improve the quality of the voice, as voice and speech together contribute to the quality of life.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]