Phonomicrosurgical management of intracordal cysts

@ PHONOMICROSURGICAL MANAGEMENT OF INTRACORDAL CYSTS ALBERT L. MERATI, MD, ROBERT J. ANDREWS, MD, MARK S. COUREY, MD, C. GAELYN GARRETT, MD, ROBERT H. OSSOFF, DMD, MD

Patients with intracordal lesions complain of an increase in vocal roughness, early vocal fatigue, and a loss of range. The term intracordal may be misleading; the lesions discussed in this article are nonmalignant masses in or just below the epithelial cover of the vocal fold. Laryngeal videostroboscopy (LVS)is the gold standard for the evaluation of patient's intracordal lesions. The timing of surgery depends on the presence of continued dysfunction despite maximal medical and behavioral interventions. The microflap surgical technique is based upon the immunohistochemical characteristics of benign vocal fold lesions, including intracordal cysts. The dissection, within the superficial layer of the lamina propria, spares the overlying mucosal cover and underlying vocal ligament, optimizing vocal outcome.

Dysphonia may be secondary to many different types of laryngeal disease. Functional disorders may be the sole cause of a patient's dysphonia, or they may compound the problems created by benign vocal fold lesions. In addition, functional disorders may result in the formation of benign vocal fold lesions. Intracordal cysts often present with either of these two clinical pictures. These lesions can be true epithelial-lined cysts or pseudocysts. 1 Their diagnosis can be missed without videostroboscopy. In this article we review the diagnostic and treatment regimens used at the Vanderbilt Voice Center in the management of lesions in or just below the epithelial cover of the true vocal fold. The term intracordal may be misleading; the lesions discussed in this article are nonmalignant masses in or just below the epithelial cover of the vocal fold. They are not intracordal in the sense that they are deep to the ligament or buried in the thyroarytenoid muscle. An intracordal mass must be suspected in every dysphonic patient when there is no obvious lesion on indirect laryngoscopy. They are rarely the cause of other laryngeal symptoms such as stridor, aspiration, globus sensation, or dysphagia. The relationship of intracordal lesions to vocal over-users is difficult to delineate. The incidence of intracordal lesions in the general population is not known. Because the group of patients who present to a voice clinic

From the Vanderbilt Bill Wilkerson Department of Otolaryngology and Communicative Sciences, Vanderbilt University School of Medicine, Nashville, TN. Address reprint requests to Mark S. Courey, MD, Vanderbilt Voice Center, 1500 21 st Ave S, Suite 2700, Nashville, TN 37212. Copyright © 1998 by W.B. Saunders Company 1043-1810/98/0904-0008510.00/0 230

features a high percentage of professional voice users, this number cannot be extrapolated to the general population. Generally, patients with intracordal lesions have dysphon i a that is worsened by overuse. They complain of a slight increase in vocal roughness, early vocal fatigue, and a loss of range. Although there are exceptions to this, the development of maladaptive compensation to an intracordal lesion can be the most challenging obstacle to a patient's rehabilitation. When a patient complains of complete aphonia, a significant functional component can be expected.

EXAMINATION

LVS is the gold standard for the evaluation of patients' intracordal lesions. 2 LVS is indicated in patients with significant dysphonia and no appreciable lesion on direct (either 90 ° or flexible) laryngoscopy. LVS is also valuable in patients with clinically apparent lesions to provide video documentation as well as to search for subclinical lesions, such as a contact area on the contralateral vocal fold or a sulcus vocalis. The presence or absence of the mucosal wave must be described. Its reappearance over time may predict recovery before a patient's complaints have subsided. When the larynx is inflamed or functioning in an inhospitable environment, diagnosis of an intracordal lesion is difficult to make. Laryngeal hygiene measures must be instituted not only for management, but also to aid in the examination of the larynx by LVS. These measures consist of increasing daily water intake to 8 to 10 glasses, controlling reflux, and reducing caffeine and chocolate intake. Guaifenesin is particularly useful as a mucolytic. If these measures are not adequate, or if there is vocal fold

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 9, NO 4 (DEC), 1998: PP 230-237

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FIGURE 1. Lateral Microflap Approach: (A) Mucosal incision with cycle knife. (B) Extension of incision with micro scissors.

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FIGURE 1. (Cont'd) (C) Elevation of plane within superficial lamina propria. (D) Exposure of cyst with separation from vocal ligament and overlying cover. 232

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FIGURE 1. (Cont'd) (E) Injection of corticosteroids into superficial lamina propria pocket (SLLP) created by cyst excision. (F) Redraping of flap.

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FIGURE 1. (Cont'd) (G) Final appearance.

edema, I to 2 weeks of decreased voice use (possibly even complete rest), with or without a tapering course of oral steroids, can be prescribed to determine the medical reversibility of the pathologic condition as well as to facilitate LVS examination. Ideally, the patient should finish the taper about the same time as the clinic visit. Often, the surrounding inflammatory response to a lesion is controlled, thus rendering the mass more discrete on LVS. DECISION MAKING

The timing of surgery depends on the presence of two key factors. The first is continued dysfunction despite maximal medical behavioral, and therapeutic intervention. The second is the presence of a defined lesion. A functioning patient with a discrete intracordal lesion is not necessarily a candidate for surgery, nor is a dysfunctional patient with a partially or ill-defined abnormality or "fullness." Once the diagnosis has been made and the indications for surgical intervention clarified, preoperative speech language evaluation and intervention can be very useful. Laryngeal hygiene and the patient's general medical condition are maximized before surgery. Whereas the phonomicrosurgical approach to a lesion can be planned preoperatively, the ultimate decision is made once the vocal fold is palpated at the time of suspension microlaryngoscopy. LVS revealing a diminished or absent mucosal wave is a key finding in planning the surgical approach, but it is not in itself predictive of the technique necessary for treatment. Intracordal cysts usually present with a reduced or absent mucosal wave; therefore, these lesions frequently require a lateral microflap. 3 This approach uses the configuration of the vocal

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ligament and its overlying cover to circumscribe a given lesion with a minimum of trauma to the uninvolved tissues. There is no normal mucosa excised; this allows for primary healing and the avoidance of scar contracture over the operative bed. The incision site is placed away from the critical medial vibratory edge of the vocal fold. Another advantage is that the lateral incision and approach allow for the early identification of the vocal ligament away from the lesion. This is particularly useful in scarred or otherwise less discrete lesions. The medial microflap technique 4 tends to be better suited for lesions that are either more superficial medial or both. Before intraoperative palpation and examination, LVS may predict a lesion's amenity to the medial microflap technique by indicating the presence of an intact or relatively undisturbed mucosal wave on the side of the lesion. If the lesion moves over the vocal fold with palpation, this supports the decision to use the medial technique. This approach is also useful when the cover overlying the lesion is atrophic or otherwise abnormal and does not tolerate microdissection. TECHNIQUE AND INSTRUMENTATION

The patient is brought to the operating room, and general endotracheal anesthesia is administered via a small (5.0 or 5.5mm) tube. If the use of a laser is anticipated, a laser-safe endotracheal tube is placed at the outset. An athletic-style mouthguard is placed to protect the maxillary dentition. In the edentulous patient, two rolled-up, moist 4 × 4 sponges are used to protect the alveolar mucosa. Most patients are best exposed in the classic sniffing position, although the surgeon should be prepared to try other maneuvers if this is unsatisfactory. Complete direct laryngoscopy is per-

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FIGURE 2. Medial Microflap: (A) Incision of lesion on medial surface of vocal fold. (B) Identification of lesion within the lamina propria. (C) Identification of vocal ligament. (D) Excision of lesions with a portion of overlying cover.

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FIGURE 2. (Cont'd) (E) Redraping of flap and final appearance. formed before suspension. Once the larynx is exposed and suspended, photodocumentation is performed. Intraoperative palpation is achieved by use of straight and rightangled blunt probes (V. Mueller, Deerfield, IL). The feel of the lesion and its mobility with respect to the rest of the vocal fold is appreciated. Most intracordal cysts are superficial to the vocal ligament but alter the mucosal wave by virtue of their size and associated inflammation, which cause the cover to the stick to the body. Thus, mucosal wave propagation cannot occur. These subepithelial lesions are approached with the lateral microflap technique. With the patient in suspension and under stereoscopic magnification, as provided by an operating microscope, a mucosal incision is made lateral to the lesion with a microsurgical sickle knife (Fig 1A). By placing the incision in an area free of the lesion, the surgeon is able to identify the vocal ligament and the potential plane of dissection within Reinke's space. Depending on the size of the lesion, this may be as far lateral as the junction of the vocal fold with the ventricle. The length of the incision is somewhat variable but must extend I to 2 mm beyond the anteroposterior (AP) dimensions of the lesion (Fig 1B). This allows the surgeon the freedom to dissect in the AP direction while slowly working from lateral to medial. The vocal ligament is identified visuall)5 and the "pocket" is carefully and slowly expanded until the cyst or other intracordal lesion is encountered (Fig 1C). Dissection is undertaken by using a set of microinstruments (Karl Storz, St Louis, MO and Pilling Meck, Inc, Research Triangle Park, NC). Once the relationship between the lesion and the vocal ligament is established, the mucosa overlying the lesion is carefully dissected free (Fig 1D). Although the order of these steps can be variable, the final maneuvers often require angled microscissors to free the anterior and posterior deep attachments of the cyst. Small bleeders can be treated with topical adrenaline (1:10000) or with the carbon dioxide laser if the proper precautions are taken for the safety of the patient and operating room personnel. Iced saline cottonoids or adrenaline-soaked cottonoids can be applied to lesions that appear vascular or inflamed to allow for better hemostasis. Other authors have advocated s the use of hydrodissection by subepithelial injection for

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phonomicrosurgery. Although this may be useful when the mucosa is removed, as in the case of neoplastic disease, we have not found this necessary in the lateral microflap technique. Once the lesion is excised, the mucosa is redraped over the operative site, and triamcinolone (40mg/ ml) is deposited into the dissected area in an attempt to reduce scar formation (Figs 1E-F). The use of this measure is being evaluated in the canine model 6 (Fig 1G). The medial microflap technique first differs in the placement of the incision at or just immediately lateral to the lesion 4 (Fig 2A). These are typically medial and somewhat more mobile lesions. The vocal ligament is identified after the incision is made (Fig 2B), and the angled microdissectors are used to circumscribe the lesion (Fig 2C). The mucosa overlying these masses is often abnormal. In many cases, even when it can be preserved, it is redundant and requires some conservative sacrifice of mucosa (Fig 2D). Coaptation of the mucosal edges occurs naturally, and suture or other closure techniques are not necessary (Fig 2E). In some cases, triamcinolone can be deposited into the surgical bed as well. Photodocumentation is obtained and topical lidocaine (4%) is sprayed on the vocal folds. Sponge, needle, and cottonoid counts are confirmed before extubation. The patient is brought to the recovery area with a mist mask.

POSTOPERATIVE CARE A N D RESULTS The patient is placed on strict voice rest for 1 to 2 weeks after microflap surgery. Patients with more extensive dissections may be placed on a short course of corticosteroids. All patients receive antibiotics and a mild narcotic for pain relief. Patients with symptoms or findings of laryngopharyngeal reflux are placed on omeprazole twice a day in the perioperative period. At the two-week postoperative visit, LVS is performed, and the patient resumes therapy with the speech language pathologist. There is a gradual return to voice use over the first few weeks. Most patients can expect to achieve 90% of their premorbid voice at about 3 months postoperatively. Often, the LVS will reveal the return of a mucosal wave before the patient is able to appreciate any noticeable change in their voice. This is a meaningful finding and can be a significant point of reassurance to a patient waiting for his or her voice to return to normal. Overall, in our series here at Vanderbilt from 1993 to 1995, 85% of patients with an absent wave preoperatively regained their mucosal wave. Ninety-seven percent of patients with an intact preoperative wave retained this important parameter. Blinded comparison of preoperative and postoperative voice samples from this series showed that the postoperative voice was rated as better in 100% (48 of 48) of the patients.

CONCLUSIONS Lesions of Reinke's space are often amenable to one of two microflap techniques described here. The intracordal cyst that does not freely move with palpation and has diminished the preoperative mucosal wave as seen on LVS is best addressed by the lateral approach. The mobile, medial lesions can be addressed by the medial microflap technique. The key to recognizing these difficult lesions is to maximize the laryngeal examination in clinic by hygiene and even pharmacological measures. This may reveal the subtle stroboscopic appearance of a significant intracordal cyst. These patients often have compounding functional issues that need to be addressed both preoperatively and postopera-

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tively w i t h expert s p e e c h l a n g u a g e intervention. T h e recove r y f r o m m i c r o f l a p s u r g e r y is r e w a r d i n g b u t p r o c e e d s at a g e n t l e pace, p a r t i c u l a r l y for the lateral microflaps. Patients m u s t be p r e p a r e d for this before surgical intervention.

REFERENCES 1. Courey MS, Scott MA, Shohet JA, et al: Immunohistochemical characterization of benign laryngeal lesions. Ann Otol Rhinol Laryngol 31:1-7, 1996

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2. Colton RH, Woo P, Brewer DW, et al: Stroboscopic signs associated with benign lesions of the vocal folds. J Voice 9:312-325,1995 3. Courey MS, Gardner GM, Stone RE, et al: Endoscopic vocal fold microflap: A three year experience. Ann Otol Rhinol Laryngol 104:267273, 1995 4. Courey MS, Garrett CG, Ossoff RH: Medial microflap excision of benign vocal fold lesions. Laryngoscope 107:340-344,1997 5. KassES, HiUmanRE, Zeitels SM:Vocalfold submucosal infusion technique in phonomicrosurgery.Ann Otol Rhinol Laryngo1105:341-347,1996 6. Coleman JR, Smith S, Reinisch L, et ah Histomorphometric and laryngeal videostroboscopic analysis of the effects of corticosteroids on microflap healing in the dog larynx. ,ann Otol Rhinol Laryngol (accepted for publication), 1998

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