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Involving family members in a thyroplasty procedure
FEBRUARY 2003, VOL 77, NO 2 C A S E C O M M E N T A R Y
Involving family members in a thyroplasty procedure
T
hyroplasty is a surgical procedure performed to restore vocal quality to those patients affected by vocal cord paralysis. This is achieved through medialization or the repositioning of the paralyzed cord to the midline, which allows the nonparalyzed cord to meet the paralyzed cord on phonation. Paralysis can be caused by several factors, including injuring the recurrent laryngeal nerve during a procedure, such as carotid endarterectomy or thyroidectomy, or injuring the vocal cord itself during a difficult intubation. The symptoms of unilateral vocal cord paralysis include a weak, breathy voice and/or a change in pitch. The change in pitch is caused by the cord's inability to become taut. Aspiration and choking also may occur. Generally, unless paralysis persists for six months or more, no interventions are attempted because paralysis usually resolves spontaneously. Several techniques can be used to perform thyroplasty. The most common are carving and implanting a wedge of silastic block to achieve medialization of the affected cord; injecting polytetraflouethylene paste, absorbable gelatin film, collagen, fat, or donated human tissue that has been processed for use as a minimally invasive tissue graft into the affected cord; or using a prefabricated thyroplasty implant.
The premade thyroplasty implant system consists of sizing kits and precut silicone implants, as well as a set of insertion instruments. The insertion instruments include calipers, curved hooks, dull hooks, 3-mm and 5-mm duckbill elevators, chisels, and implant inserters. THE PROCEDURE Preoperatively, staff members from surgery, anesthesia, and nursing see patients in the preoperative center. Any needed laboratory work is completed, a history is taken, and a physical examination is performed. Preoperative education is provided at this time. The anesthesia care provider explains to the patient that he or she will need to be awake during the procedure to allow the surgeon to test the implant and the voice achieved with it. The surgeon or perioperative nurse explains that the surgeon will have the patient repeat phrases and sounds throughout the procedure, such as "eeeee" or " 12-3." It is important that the patient understand the surgeon's expectations during the procedure so that he or she will be prepared to participate and follow instructions. Other preoperative education includes an explanation of the use of the nasolaryngoscope and of monitored anesthesia care and local anesthesia. On the day of surgery, the REBECCA T. FERGUSON, RN, BSN, CNOR, is a stafnurse, Tampa General Hospital, Fla. 418 AORN JOURNAL
patient is admitted through the one-day surgery department and subsequently transferred to the preoperative holding area. In the preoperative holding area, the preoperative nurse, circulating nurse, anesthesia care provider, and surgeon interview the patient. The anesthesia care provider starts the necessary IVs. The circulating nurse and scrub person prepare the OR by opening the sterile field and gathering all the needed equipment and instruments. Equipment needed includes a nasolaryngoscope, bipolar forceps, suction, and a power source for the saw. Surgical instruments needed include the thyroplasty instrument set, a small oscillating saw, and a plastic instrument set consisting of a small iris scissors, B small tenotomy scissors, m a freer elevator, m hemostats, m mosquitoes, m Webster needle holders, and m other soft tissue instruments. The anesthesia care provider and circulating nurse transfer the patient from the preoperative holding area to the OR and help him or her move onto the OR bed. The patient is positioned supine with both arms tucked at his or her sides. The anesthesia care provider sedates the patient to achieve an appropriate monitored anesthesia care level. After the patient is resting comfortably, the surgeon injects 1% lidocaine with epinephrine 1:100,000 into the region of the thyroid cartilage.
FEBRUARY 2003, VOL 77, NO 2
The circulating nurse applies an electrosurgical grounding pad and preps the patient with povidoneiodine scrub and paint. The patient then is draped with four towels and a split sheet. The patient’s face remains exposed with an anesthesia barrier up. The surgeon identifies the anatomical landmarks (ie, thyroid notch, cricothyroid membrane, inferior margin of the cricoid cartilage) and marks them. He or she then makes the incision, exposing the thyroid cartilage. A window is cut into the thyroid cartilage, measuring approximately 5 mm by 10 mm. The window then is pried out using a sharp hook and a duckbill elevator or a freer elevator, and the sizers are inserted into the window. The surgeon asks the patient to clear his or her throat, cough, and say “1-2-3, 1-2-3.” While the patient is speaking, the anesthesia care provider views the vocal cords with the nasolaryngoscope to determine whether medialization of the paralyzed cord has been achieved. The surgeon also views the cords through the nasolaryngoscope. Various sizers are used until good phonation and projection are achieved with good medialization of the paralyzed cord. When the appropriate size implant is chosen, the surgeon places it in the window and sews it over with fascia. The surgical wound then is closed and dressed with self-adhesive wound approximating strips. CASE STUDY Mr S, a 69-year-old Caucasian male, presented with left true vocal cord paralysis after a left carotid endarterectomy. Immediately postendarterectomy, Mr S suffered from severe hoarseness
and decreased phonation. During the next eight months, he was unable to speak louder than a whisper. He was scheduled for a left thyroplasty to achieve medialization of the paralyzed cord. Mr S was admitted through the
To confirm that Mr S’s voice was similar to his voice before the injury, Mrs S spoke to him on the telephone. one-day surgery department on the day of surgery. The standard admitting process was followed, and Mr S was moved from the one-day holding area to the preoperative holding area just outside the OR. When Mr S was admitted, his voice was barely audible. After he answered all of the appropriate questions and the IV was placed, the anesthesia care provider and circulating nurse transferred Mr S to the OR suite. He moved from the stretcher to the OR bed, and the circulating nurse positioned him in the supine position with both arms tucked at his sides. The anesthesia care provider administered adequate sedation to keep Mr S comfortable while still enabling him to respond to questions. The surgeon then injected local anesthetic into the surgical site. The circulating nurse prepped Mr S for the procedure, and the scrub person and surgeon draped him. The surgeon made the inci419 AORN JOURNAL
sion at the level of the thyroid cartilage and removed a window measuring 5 mm by 10 mm using the 5-mm duckbill elevator, thus providing the access required to achieve medialization of the paralyzed cord. With the window removed, the surgeon tried various sizers to achieve proper medialization of the cord. With each sizer attempted, the surgeon asked Mr S to clear his throat, cough, and say “1-2-3, 1-2-3” while the anesthesia care provider visualized the vocal cords with the nasolaryngoscope. Various sizers were used before a voice that projected well was achieved. A size eight implant achieved the best result and subsequently was implanted. Although Mr S’s voice with the implant was not the same as his voice before injury, he stated that he was pleased. Mrs S, who was in the family waiting room, was telephoned to confirm that Mr S’s voice with the implant was indeed similar to his voice before the injury. For the first time in eight months, she was able to hear his voice clearly. She was extremely pleased with the results. With both Mr and Mrs S’s approval, the incision was closed. The surgeon covered the implant with fascia and closed the incision using a subcuticular closure. No drains were necessary because the field was dry. The incision then was dressed with self-adhesive wound approximating strips. Mr S was moved onto a stretcher and transferred to the recovery room completely awake and communicating well. CONCLUSION This procedure was unique because never before had the surgeon involved family members to confirm results of the medialization. Perhaps this should be
FEBRUARY 2003, VOL 77, NO 2
the standard of care. The patient and his wife were very pleased with both the results of the procedure and the care that Mr S received. This extra attention
proved to be a very important communication between the health care providers and family members. Nurses and physicians in the OR often get so caught up
in the procedure at hand that they forget the patient on the bed is a person and that this person is connected to many others outside the double doors. A
RESOURCES
Luryngoscope 1 10 (August 2000) 1306-131 1.
Bielamowicz, S; Berke, G S. “An improved model of medialization laryngoplasty using a three-sided thyroplasty window,” Laryngoscope 105 (May 1995) 537539. Bielamowicz, S; Berke, G S; Gerratt, B R. “A comparison of type I thyroplasty and arytenoid adduction,” Journal of Voice 9 (December 1995) 466-472. Corbridge, R J. “Regaining a voice: Thyroplasty-a review,” The British Journal of Theatre Nursing 8 (October 1998) 5-8. D’Antonio, L L; Wigley, T L; Zimmerman, F J. “Quantitative measures of laryngeal function following Teflon injection or thyroplasty type I,” Laryngoscope 105 (March 1995) 256-262. Koufman, J A. “Laryngoplasty for vocal cord medialization: An alternative to Teflon,” Laryngoscope 96 (July 1986) 726-731. McCulloch, T M, et al. “Arytenoid adduction combined with Gore-Tex medialization thyroplasty,”
McLean-Muse, A, et al. “Montgomery thyroplasty implant for vocal fold immobility: Phonatory outcomes,” The Annals of Otology, Rhinology, and Laryngologv 109 (April 2000) 393-400. Montgomery, W W, Montgomery, S K. “Montgomery thyroplasty implant system,” The Annals of Otology, Rhinology, and Laryngologv-Supplement 170 (September 1997) 1-16. Razzaq, I; Wooldridge, W. “A series of thyroplasty cases under general anaesthesia,” British Journal of Anaesthesia 85 (October 2000) 547-549. Righi, P D; Wilson, K M; Gluckman, J L. “Thyroplasty using a silicone elastomer implant,” Otolaryngologic Clinics of North America 28 (April 1995) 309-316. Tucker, H M. “Combined laryngeal framework medialization and reinnervation for unilateral vocal fold paralysis,” The Annals of Otology, Rhinology, and Laryngology 99 (10 pt 1) (October 1990) 778-781.
Nut Consumption Lowers Women’s Type 2 Diabetes Risk Women who eat nuts or peanut butter at least five times per week can lower their risk for type 2 diabetes significantly, according to a Nov 26,2002, news release from the Harvard School of Public Health, Boston. Researchers tracked more than 83,000 women with no history of diabetes, cardiovascular disease, or cancer from 1980 to 1996. Participants were sent food frequency questionnaires approximately every four years. The questionnaires included information about nut and peanut butter consumption. Women who reported frequent consumption of peanut butter reduced their risk for type 2 diabetes by nearly 20% compared to those who reported rarely eating peanut butter. Women who reported eating nuts at least five times per week reduced their risk for type 2 diabetes by nearly 30% compared to women who reported rarely or never eating nuts. Reduced risk was independent of known risk factors for type 2 diabetes, including body mass index, fam-
ily history, level of physical activity, tobacco use, alcohol use, and dietary factors. People with type 2 diabetes do not produce adequate amounts of insulin, or their bodies do not use insulin effectively. Nuts contain monounsaturated and polyunsaturated fats, which improve insulin sensitivity and lower serum cholesterol. They also are rich in antioxidant vitamins, minerals, plant protein, and dietary fiber. Researchers suggest, however, that people substitute nuts for less healthy foods, such as refined carbohydrates and red meat, instead of adding caloric intake from nuts to their regular diets because nuts have high fat content. Women Who Eat Nuts or Peanut Butter Regularly Significantly Reduce Their Risk for Type 2 Diabetes (news release, Boston: Harvard School of Public Health, Nov 26, 2002) htlp:/hww hsph.harvard.eddpresdreleasedpress 1 1262002.html (accessd6 Dec 2002).
420 AORN JOURNAL
Involving family members in a thyroplasty procedure
T
hyroplasty is a surgical procedure performed to restore vocal quality to those patients affected by vocal cord paralysis. This is achieved through medialization or the repositioning of the paralyzed cord to the midline, which allows the nonparalyzed cord to meet the paralyzed cord on phonation. Paralysis can be caused by several factors, including injuring the recurrent laryngeal nerve during a procedure, such as carotid endarterectomy or thyroidectomy, or injuring the vocal cord itself during a difficult intubation. The symptoms of unilateral vocal cord paralysis include a weak, breathy voice and/or a change in pitch. The change in pitch is caused by the cord's inability to become taut. Aspiration and choking also may occur. Generally, unless paralysis persists for six months or more, no interventions are attempted because paralysis usually resolves spontaneously. Several techniques can be used to perform thyroplasty. The most common are carving and implanting a wedge of silastic block to achieve medialization of the affected cord; injecting polytetraflouethylene paste, absorbable gelatin film, collagen, fat, or donated human tissue that has been processed for use as a minimally invasive tissue graft into the affected cord; or using a prefabricated thyroplasty implant.
The premade thyroplasty implant system consists of sizing kits and precut silicone implants, as well as a set of insertion instruments. The insertion instruments include calipers, curved hooks, dull hooks, 3-mm and 5-mm duckbill elevators, chisels, and implant inserters. THE PROCEDURE Preoperatively, staff members from surgery, anesthesia, and nursing see patients in the preoperative center. Any needed laboratory work is completed, a history is taken, and a physical examination is performed. Preoperative education is provided at this time. The anesthesia care provider explains to the patient that he or she will need to be awake during the procedure to allow the surgeon to test the implant and the voice achieved with it. The surgeon or perioperative nurse explains that the surgeon will have the patient repeat phrases and sounds throughout the procedure, such as "eeeee" or " 12-3." It is important that the patient understand the surgeon's expectations during the procedure so that he or she will be prepared to participate and follow instructions. Other preoperative education includes an explanation of the use of the nasolaryngoscope and of monitored anesthesia care and local anesthesia. On the day of surgery, the REBECCA T. FERGUSON, RN, BSN, CNOR, is a stafnurse, Tampa General Hospital, Fla. 418 AORN JOURNAL
patient is admitted through the one-day surgery department and subsequently transferred to the preoperative holding area. In the preoperative holding area, the preoperative nurse, circulating nurse, anesthesia care provider, and surgeon interview the patient. The anesthesia care provider starts the necessary IVs. The circulating nurse and scrub person prepare the OR by opening the sterile field and gathering all the needed equipment and instruments. Equipment needed includes a nasolaryngoscope, bipolar forceps, suction, and a power source for the saw. Surgical instruments needed include the thyroplasty instrument set, a small oscillating saw, and a plastic instrument set consisting of a small iris scissors, B small tenotomy scissors, m a freer elevator, m hemostats, m mosquitoes, m Webster needle holders, and m other soft tissue instruments. The anesthesia care provider and circulating nurse transfer the patient from the preoperative holding area to the OR and help him or her move onto the OR bed. The patient is positioned supine with both arms tucked at his or her sides. The anesthesia care provider sedates the patient to achieve an appropriate monitored anesthesia care level. After the patient is resting comfortably, the surgeon injects 1% lidocaine with epinephrine 1:100,000 into the region of the thyroid cartilage.
FEBRUARY 2003, VOL 77, NO 2
The circulating nurse applies an electrosurgical grounding pad and preps the patient with povidoneiodine scrub and paint. The patient then is draped with four towels and a split sheet. The patient’s face remains exposed with an anesthesia barrier up. The surgeon identifies the anatomical landmarks (ie, thyroid notch, cricothyroid membrane, inferior margin of the cricoid cartilage) and marks them. He or she then makes the incision, exposing the thyroid cartilage. A window is cut into the thyroid cartilage, measuring approximately 5 mm by 10 mm. The window then is pried out using a sharp hook and a duckbill elevator or a freer elevator, and the sizers are inserted into the window. The surgeon asks the patient to clear his or her throat, cough, and say “1-2-3, 1-2-3.” While the patient is speaking, the anesthesia care provider views the vocal cords with the nasolaryngoscope to determine whether medialization of the paralyzed cord has been achieved. The surgeon also views the cords through the nasolaryngoscope. Various sizers are used until good phonation and projection are achieved with good medialization of the paralyzed cord. When the appropriate size implant is chosen, the surgeon places it in the window and sews it over with fascia. The surgical wound then is closed and dressed with self-adhesive wound approximating strips. CASE STUDY Mr S, a 69-year-old Caucasian male, presented with left true vocal cord paralysis after a left carotid endarterectomy. Immediately postendarterectomy, Mr S suffered from severe hoarseness
and decreased phonation. During the next eight months, he was unable to speak louder than a whisper. He was scheduled for a left thyroplasty to achieve medialization of the paralyzed cord. Mr S was admitted through the
To confirm that Mr S’s voice was similar to his voice before the injury, Mrs S spoke to him on the telephone. one-day surgery department on the day of surgery. The standard admitting process was followed, and Mr S was moved from the one-day holding area to the preoperative holding area just outside the OR. When Mr S was admitted, his voice was barely audible. After he answered all of the appropriate questions and the IV was placed, the anesthesia care provider and circulating nurse transferred Mr S to the OR suite. He moved from the stretcher to the OR bed, and the circulating nurse positioned him in the supine position with both arms tucked at his sides. The anesthesia care provider administered adequate sedation to keep Mr S comfortable while still enabling him to respond to questions. The surgeon then injected local anesthetic into the surgical site. The circulating nurse prepped Mr S for the procedure, and the scrub person and surgeon draped him. The surgeon made the inci419 AORN JOURNAL
sion at the level of the thyroid cartilage and removed a window measuring 5 mm by 10 mm using the 5-mm duckbill elevator, thus providing the access required to achieve medialization of the paralyzed cord. With the window removed, the surgeon tried various sizers to achieve proper medialization of the cord. With each sizer attempted, the surgeon asked Mr S to clear his throat, cough, and say “1-2-3, 1-2-3” while the anesthesia care provider visualized the vocal cords with the nasolaryngoscope. Various sizers were used before a voice that projected well was achieved. A size eight implant achieved the best result and subsequently was implanted. Although Mr S’s voice with the implant was not the same as his voice before injury, he stated that he was pleased. Mrs S, who was in the family waiting room, was telephoned to confirm that Mr S’s voice with the implant was indeed similar to his voice before the injury. For the first time in eight months, she was able to hear his voice clearly. She was extremely pleased with the results. With both Mr and Mrs S’s approval, the incision was closed. The surgeon covered the implant with fascia and closed the incision using a subcuticular closure. No drains were necessary because the field was dry. The incision then was dressed with self-adhesive wound approximating strips. Mr S was moved onto a stretcher and transferred to the recovery room completely awake and communicating well. CONCLUSION This procedure was unique because never before had the surgeon involved family members to confirm results of the medialization. Perhaps this should be
FEBRUARY 2003, VOL 77, NO 2
the standard of care. The patient and his wife were very pleased with both the results of the procedure and the care that Mr S received. This extra attention
proved to be a very important communication between the health care providers and family members. Nurses and physicians in the OR often get so caught up
in the procedure at hand that they forget the patient on the bed is a person and that this person is connected to many others outside the double doors. A
RESOURCES
Luryngoscope 1 10 (August 2000) 1306-131 1.
Bielamowicz, S; Berke, G S. “An improved model of medialization laryngoplasty using a three-sided thyroplasty window,” Laryngoscope 105 (May 1995) 537539. Bielamowicz, S; Berke, G S; Gerratt, B R. “A comparison of type I thyroplasty and arytenoid adduction,” Journal of Voice 9 (December 1995) 466-472. Corbridge, R J. “Regaining a voice: Thyroplasty-a review,” The British Journal of Theatre Nursing 8 (October 1998) 5-8. D’Antonio, L L; Wigley, T L; Zimmerman, F J. “Quantitative measures of laryngeal function following Teflon injection or thyroplasty type I,” Laryngoscope 105 (March 1995) 256-262. Koufman, J A. “Laryngoplasty for vocal cord medialization: An alternative to Teflon,” Laryngoscope 96 (July 1986) 726-731. McCulloch, T M, et al. “Arytenoid adduction combined with Gore-Tex medialization thyroplasty,”
McLean-Muse, A, et al. “Montgomery thyroplasty implant for vocal fold immobility: Phonatory outcomes,” The Annals of Otology, Rhinology, and Laryngologv 109 (April 2000) 393-400. Montgomery, W W, Montgomery, S K. “Montgomery thyroplasty implant system,” The Annals of Otology, Rhinology, and Laryngologv-Supplement 170 (September 1997) 1-16. Razzaq, I; Wooldridge, W. “A series of thyroplasty cases under general anaesthesia,” British Journal of Anaesthesia 85 (October 2000) 547-549. Righi, P D; Wilson, K M; Gluckman, J L. “Thyroplasty using a silicone elastomer implant,” Otolaryngologic Clinics of North America 28 (April 1995) 309-316. Tucker, H M. “Combined laryngeal framework medialization and reinnervation for unilateral vocal fold paralysis,” The Annals of Otology, Rhinology, and Laryngology 99 (10 pt 1) (October 1990) 778-781.
Nut Consumption Lowers Women’s Type 2 Diabetes Risk Women who eat nuts or peanut butter at least five times per week can lower their risk for type 2 diabetes significantly, according to a Nov 26,2002, news release from the Harvard School of Public Health, Boston. Researchers tracked more than 83,000 women with no history of diabetes, cardiovascular disease, or cancer from 1980 to 1996. Participants were sent food frequency questionnaires approximately every four years. The questionnaires included information about nut and peanut butter consumption. Women who reported frequent consumption of peanut butter reduced their risk for type 2 diabetes by nearly 20% compared to those who reported rarely eating peanut butter. Women who reported eating nuts at least five times per week reduced their risk for type 2 diabetes by nearly 30% compared to women who reported rarely or never eating nuts. Reduced risk was independent of known risk factors for type 2 diabetes, including body mass index, fam-
ily history, level of physical activity, tobacco use, alcohol use, and dietary factors. People with type 2 diabetes do not produce adequate amounts of insulin, or their bodies do not use insulin effectively. Nuts contain monounsaturated and polyunsaturated fats, which improve insulin sensitivity and lower serum cholesterol. They also are rich in antioxidant vitamins, minerals, plant protein, and dietary fiber. Researchers suggest, however, that people substitute nuts for less healthy foods, such as refined carbohydrates and red meat, instead of adding caloric intake from nuts to their regular diets because nuts have high fat content. Women Who Eat Nuts or Peanut Butter Regularly Significantly Reduce Their Risk for Type 2 Diabetes (news release, Boston: Harvard School of Public Health, Nov 26, 2002) htlp:/hww hsph.harvard.eddpresdreleasedpress 1 1262002.html (accessd6 Dec 2002).
420 AORN JOURNAL