Microlaryngeal Surgery

Microscopic laryngeal surgery, also known as micro-laryngoscopy, is a procedure for viewing and operating on the larynx, by utilizing an operative microscope and special dissection instruments.

Vocal cord lesions are non-cancerous growths that usually present as hoarseness in the voice. Also referred to as vocal fold lesions, these typically develop due to frequent overuse or misuse of the voice or due to vocal cord trauma. They are treated through speech therapy and medicines. However, in case the lesions cannot be effectively treated in such a manner, microlaryngeal surgery becomes necessary.

Some of the conditions of the larynx that are diagnosed/treated by microlaryngeal surgery are:

• Papillomatosis: small, fleshy bump on the skin or mucous membrane caused by human papillomavirus
• Mild leukoplakia: white patch-like lesion on the surface of vocal cords
• Laryngeal cancer
• Vocal cord nodules: also called singer’s nodules, these occur due to repeated overuse or misuse of the voice
• Vocal cord cysts: growths having a sac-like pocket filled with fluid or semisolid tissues
• Polyps: these are like blisters on vocal cords and are reddish in appearance
• Reinke's oedema: a type of vocal fold polyp that is characterised by swelling. Also called polypoid corditis
• Granuloma disorder: swollen tissue in the larynx due to inflammation in the body
• The appearance of scar: damage to vibratory tissues of the vocal fold
• Sulcus vocalis: caused due to rupture of a vocal fold, cyst or due to scar
• Sulcus vergeture: a crease or cavity formed due to being turned inside out (invagination) along the entire length of the vocal fold
• Vascular lesions: caused due to haemorrhage when small blood vessels on the top surface of the vocal fold rupture
• Glottic web: the presence of a band of tissue joining the vocal folds
• Vocal fold paralysis: when one or both vocal folds don’t open or close properly due to disruption of nerve impulses

The above conditions typically present with the following symptoms:

• Voice problems: weak or no voice, hoarseness or breathiness while speaking
• Injury to the throat
• Difficulty in swallowing
• Lump in the throat
• Pain in the throat (or pain in the ear)
• Mucous or blood in saliva/mouth
• Difficulty breathing/shortness of breath
• Persistent or bloody cough

Microlaryngeal surgery is considered a very safe procedure. However, in the following conditions, the doctors may decide not to proceed with the surgery:

• Breathing difficulties may occur in people with pre-existing lung disease or heart conditions
• Allergic reactions to general anaesthesia
• Factors that can increase the risk for general anaesthesia: high blood pressure, obesity, history of stroke, alcohol use, certain medications
• Unstable cervical spine

The surgery is performed by an ENT surgeon. The patient’s detailed history including medications history is taken. This is followed by a physical examination. An evaluation at this stage by anaesthesiologists is also necessary for airway management during the surgery. For this purpose, pre-existing cardiovascular and respiratory diseases, allergies, systemic conditions, and congenital disorders are to be examined. Further, history of prior surgeries if any, ongoing treatments and any difficult history of air intubation are also to be considered.

Certain tests such as chest X-ray, CT scan, MRI scan, etc. may also be required to ascertain the severity, location and size of the lesions.

Depending on the diagnosis, non-surgical interventions such as voice therapy AND managing acid reflux are to be increased in the days leading up to surgery along with cessation of smoking.

To reduce the chances of dental injury during the surgery, dental prosthetics or protectors may also be prepared.

After the pre-operative evaluation is complete, the necessary equipment and team need to be available in the operating room to manage potential emergencies during anaesthesia. The surgery is a daycare admission. The patient is asked to arrange for a ride back home after the surgery. On the day of the surgery, the patient is admitted and asked to change into a hospital gown. Thereafter, a final review is carried out by the surgeon and nurses to clear the patient for surgery. Post this, the patient is shifted to the operating theatre.

The patient is made to lie in the supine position, with the head of the bed slightly elevated. A monitor is attached to track the patient's vitals. An IV cannula is placed in the arm to administer any medications required. Thereafter, the patient is anaesthetized sufficiently enough that the mouth of the patient can be kept open and no gagging occurs once the laryngoscope would be inserted by using a local anaesthetic.

Once the person is unconscious, a plastic tube is gently guided through the mouth and into the throat towards the airway (called an endotracheal tube). Once in place, a small balloon at the end of the tube is inflated to secure it in place and on the outside, the tube is secured using tape. This process is called intubation and helps in providing oxygen to the patient and removing carbon dioxide produced in the lungs.

After intubation, a flexible laryngoscope is inserted through the nose. This is a thin lighted tube, with a camera at its end that allows the doctor to view the vocal folds with great precision. The doctor then proceeds to locate the lesion and using tiny surgical tools threaded through the laryngoscope or carbon dioxide laser, the required operation is carried out, viz. removing damaged tissue. Thereafter, the laryngoscope is gently removed followed by removing the endotracheal tube.

The entire surgery typically takes sixty to ninety minutes.

Microlaryngeal surgery is considered to be very safe. However, the following are some of the risks and complications associated with it:

• Side effects related to general anaesthesia: sore throat, muscle aches, dry mouth, vomiting, nausea
• If any tissue has been removed, it is common to have a sore throat and some hoarseness
• Risks related to laryngoscope: temporary pain, tingling and numbness in the tongue, bruising of lips and very rarely, chipped teeth
• The patient may experience some difficulty in breathing, which eases with time
• Scarring is likely to occur in case a tissue has been removed.

After the surgery is complete, the patient is monitored for some hours before getting discharged. To address pain, over-the-counter analgesics are prescribed. In case the pain is more severe, corticosteroids may also be prescribed by the doctor for some time. Cough medicine may also be suggested to avoid disturbing the sensitive tissue of the larynx while it heals. Acid reflux medications are also recommended to ensure that acid from the stomach does not interfere with the recovering tissue.

A follow-up visit is as per the doctor’s instructions, though typically happens seven to ten days after surgery. Generally, the patient can resume work post that.

The postoperative care instructions typically include the following:

• Strict voice rest: the patient should not speak anything for at least 48 hours after surgery. After this duration, if the person is required to speak, they should use a normal voice and not whisper
• The person should strictly avoid clearing their throat or trying to cough
• No smoking
• To avoid acid reflux, the person should avoid eating or drinking anything within a few hours prior to sleep
• Drinking cool liquids but avoiding caffeinated items such as tea, coffee, soda, etc
• No hot or spicy foods for three to five days
• Sleeping with the head in the raised position

The doctor will provide detailed guidance on the limitations of voice used for the first few weeks, post-surgery. Thereafter, once the doctor is assured that the larynx has healed properly, the patient can resume normal vocal activities. Voice therapy is also usually advised for helping improve and maintain voice quality.

Microlaryngeal surgery is a minimally-invasive common surgery used to treat lesions in the larynx. It allows the doctor to view the lesions in greater detail, thus permitting the execution of the required operation with greater precision. Only the affected tissue is removed, without damaging the surrounding area.

Patients who undergo microlaryngeal surgery can recover more quickly than those who go through traditional laryngeal procedures. Microlaryngeal surgery also has superior outcomes in terms of voice quality.

The risks and complications arising from the surgery are slight and can often be determined prior to surgery. Aftercare and follow-up visits are very important so that the larynx can gradually heal.