Care & Treatment

Phonomicrosurgery includes a variety of procedures with the goal of improving voice quality by precisely removing or treating benign lesions of the true vocal folds.

We offer endoscopic treatment for early stage disease with and without laser and larynx-preserving open partial laryngectomy for some later stage disease. An open partial laryngectomy is a procedure performed through an incision in the neck removing part, but not all of the larynx to treat laryngeal cancer.  Some but not all patients with more advanced stages of laryngeal cancer are candidates for these procedures.  It requires a temporary tracheostomy tube with the goal of eventually removing the tracheostomy after a period of healing.

Arytenoid repositioning surgery includes both arytenoid adduction and adduction arytenopexy procedures.  They are indicated for patients with a paralyzed vocal fold with a wide gap posteriorly (in the back of the voice box).  This procedure is usually performed in conjunction with a thyroplasty or laryngeal reinnervation procedure.

Medialization Thyroplasty or Isshiki Type I Thyroplasty is a procedure performed to improve voice in patients with glottic insufficiency. The insufficiency may be due to vocal fold paralysis, paresis, bowing or atrophy related to aging of the vocal folds. The procedure is done with the patient awake with twilight anesthesia and local anesthesia injected into the operative site (the neck). An incision is made in the center of the neck to expose the cartilages of the larynx. A hole is made in the thyroid cartilage of the larynx and a small implant of either silicone or Gortex is placed through this hole to support and even move the affected vocal fold into a better position for speaking. We have the patient speak as we adjust the implant into the appropriate size and shape to optimize the voice.

A paralyzed vocal fold does not move and is usually bowed and loose. Because of the bowing, even if the other vocal fold is able to come together and meet the paralyzed vocal fold the floppyness of the vocal fold or lack of bulk prevents adequate vibration and results in a breathy, whisper-like voice. Laryngeal reinnervation for vocal fold paralysis does not restore vocal fold motion; however, it can increase vocal fold tone (bulk) and decrease bowing.  If the vocal fold is in an appropriate position (usually with an arytenoid repositioning procedure) the improved tone from the reinnervation will improve the quality of the voice by decreasing the breathiness.

Some patients with subglottic or tracheal stenosis can be treated and managed well with dilation procedures to stretch open the areas of narrowing. There are several different techniques available to dilate the airway including balloon dilation or rigid dilators with or without first cutting the scar with instruments or a laser. The technique chosen depends on the location of the stenosis and the type of stenosis being treated. Depending on the cause of the stenosis, a patient may require multiple dilation procedures over time to keep the airway open.

For some patients with masses or lesions in the pharynx or larynx who cannot undergo a direct laryngoscopy with general anesthesia in the operating room, biopsies can be performed in the clinic through a flexible laryngoscope. The patient’s throat is first anesthetized with topical numbing medicine. Then a flexible laryngoscope is passed through the patient’s nose to visualize the pharynx and larynx. Biopsy forceps are then passed through a working channel of the scope and biopsies are taken. The tissue is sent to the pathologists to obtain a diagnosis.

Flexible Endoscopic Evaluation of Swallowing (FEES) is a diagnostic study performed by either a laryngologist or speech language pathologist to assess swallowing function. It is performed by visualizing the larynx and pharynx with a flexible laryngoscope passed through the nose while the patient swallows different consistencies of food or liquids.

Cricotracheal resection is an open surgery to remove a portion of the cricoid and the trachea which is narrowed or stenosed. It is indicated for patients with narrowing of the airway below the vocal folds who have either failed more conservative treatments or no longer wish to pursue the required repeated treatments.

A Zenker’s Diverticulum can be treated endoscopically through a diverticuloscope passed through the patient’s mouth. The diverticuloscope exposes the common wall between the diverticulum or pouch and the esophagus. This wall is then cut using either a stapling device or a laser. In cutting the common wall, we are also cutting the cricopharyngeus muscle, the main muscle of the upper esophageal sphincter which is theorized to be an underlying cause of developing a Zenker’s Diverticulum is cut to prevent recurrence of the diverticulum. In some patients adequate exposure cannot be obtained through the mouth, and the diverticulum must be treated with a transcervical approach with an incision in the neck.

A Zenker’s Diverticulum can be treated through an incision in the neck (usually on the left side). The diverticulum or pouch is usually removed (and rarely pexied or stitched up). Additionally the tight cricopharyngeus muscle, the main muscle of the upper esophageal sphincter which is theorized to be an underlying cause of developing a Zenker’s Diverticulum is cut to prevent recurrence of the diverticulum.

Esophageal dilation is a procedure to enlarge the lumen of the esophagus. It is indicated when a patient has a narrowing of the esophagus from various causes. There are several different dilation techniques available and these techniques are individually tailored to the patient.

Cricopharyngeal myotomy is a procedure that cuts the main muscle of the upper esophageal sphincter. It is indicated when patients have a cricopharyngeus muscle that does not relax normally to allow food to pass with swallowing. An endoscopic cricopharyngeal myotomy is performed through a laryngoscope or a diverticuloscope passed through the patient’s mouth. Once exposed, the muscle is usually cut with a laser. Sometimes adequate exposure to perform the procedure endoscopically cannot be obtained, which may require the procedure to be performed instead through an incision in the neck.

Cricopharyngeal myotomy is a procedure that cuts the main muscle of the upper esophageal sphincter. It is indicated when patients have a cricopharyngeus muscle that does not relax normally to allow food to pass with swallowing. A transcervical cricopharyngeal myotomy is performed through an incision in the neck (usually on the left side).

Selective Laryngeal Adductor Dennervation – Reinnervation (SLAD-R) or DeRe is a surgical procedure to definitively treat adductor spasmodic dysphonia. In this procedure a branch of the recurrent laryngeal nerve within the larynx going to the thyroarytenoid muscle is cut and then reinnervated with the ansa cervicalis nerve. This is performed on both sides of the larynx. The procedure it is performed under general anesthesia and requires a horizontal incision in the center of the neck. Initially following the surgery the patient’s voice is breathy, but without breaks.  Over the next 6 months, as the reinnervation occurs, the strength of the voice improves. SLAD-R works best for patients with adductor spasmodic dysphonia without tremor who respond well to Botox injections, but either are unable to or are unhappy with continuing receiving Botox injections.

A tracheoesophageal puncture is one of the speaking options for patients following a total laryngectomy. A hole is surgically created between the trachea and the esophagus (tracheoesophageal puncture) within the laryngectomy stoma. A One-way speaking valve is placed in this small hole. This valve allows the patient to force air through the hole into the esophagus when the patient covers his or her laryngectomy stoma and breaths out. The air passing through the esophagus causes the walls of the pharynx to vibrate mimicking the vibration of vocal cords to create sound used for speech.