Open Access Atlas Of Otolaryngology Head Amp Neck Operative -Books Pdf

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY HEAD amp NECK OPERATIVE

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OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY LARYNGOFISSURE / MEDIAN THYROTOMY Johan Fagan Laryngofissure, also known as median thyrotomy, refers to vertically splitting the thyroid cartilage in the midline to gain access to the endolarynx. It provides good exposure to both anterior and posterior laryngeal structures with very minor morbi-dity (Figure 1). Figure 1: Good .




Surgical technique
Because the airway is entered clean
contaminated wound the patient must
have perioperative 24hrs broad spec
trum antibiotics
Tracheostomy is done to permit surgi
cal access to the endolaryngeal structu
res and to secure the airway until
postoperative swelling has abated
Perform direct laryngoscopy to assess
the laryngeal pathology
Position the patient with neck extended
Make a transverse skin crease incision
midway between the thyroid prominen
ce and the cricoid Figure 3
Figure 4 Raphe between sternohyoid mus
cles has been divided to expose the thyroid
cartilage
Thyroid
prominence
Cricothyroid
membrane
Cricoid
Figure 3 Surface anatomy and incision
yellow line
Raise skin flaps superiorly and inferior
ly platysma is generally absent in the
midline
Incise the midline raphe between the
sternohyoid muscles to expose thyroid
cartilage Figure 4
Clear all the soft tissue off the thyroid
cartilage cricothyroid membrane and Figure 5 Thyroid cartilage cricothyroid
cricoid in the midline Figure 5 membrane and cricoid exposed in midline
Expose the cricoid cartilage and crico and cricothyrotomy incision visible
thyroid membrane
Incise thyroid perichondrium vertically Make a transverse cricothyrotomy inci
in the midline and strip it off the carti sion through the cricothyroid membra
lage to expose a midline strip of carti ne Figure 5 Anticipate some bleeding
lage from the cricothyroid artery a small
2
branch of the superior thyroid artery
which courses across the upper part of
the cricothyroid membrane and commu
nicates with the artery of the opposite
side Figure 6
Cricothyroid
artery
Figure 7 Completed thyrotomy
Figure 6 Cricothyroid artery branching
from the superior thyroid artery
Precisely determine the position of the
anterior commissure so that the thyro
tomy is made through the anterior com
missure If this is not achieved then
either vocal cord will be damaged The
position of the anterior commissure can
be determined by passing the tips of a
small curved artery forceps through the
cricothyrotomy and cephalad between
the vocal cords By elevating the thyroid
cartilage anteriorly with closed tips of
the artery forceps the artery will lodge
in the anterior commissure indicating
precisely the line in which the thyroto
my should be made
Vertically divide the thyroid cartilage in
the midline aiming for the upturned tips
of the artery forceps This can be ach
ieved with a scalpel in older people
Figure 8 Note excellent view of the false
with ossified cartilage it can be done
vocal cords ventricles true cords and
with an oscillating saw or a heavy pair
posterior larynx
of scissors Figure 7
Part the cut ends of the thyroid cartilage
and inspect the endolarynx using an
operating microscope or loupes if nec
essary Figures 8 9
3
Figure 9 Note excellent view of false vocal Figure 10 Lesion of glottis being excised
cord ventricle true cord and subglottis
A lesion of the glottis may then be exci
sed under direct vision Figures 10 11
Reattach the anterior ends of the vocal
cords to the cut edges of the thyroid car
tilage with permanent monofilament
material e g nylon to prevent retraction
and shortening of the cords
If there is a concern about webbing ac
ross the anterior commissure due to
denuding of both vocal cords a silastic
keel can now be placed and secured
Figure 2
Reapproximate the cut edges of the car
tilage accurately by using sutures or
miniplates
Suture the thyroid perichondrium
Reapproximate the strap muscles in the
midline Figure 11 Cordectomy defect
Insert a pencil or corrugated drain to
avoid surgical emphysema Complications
Suture the skin
Remove the tracheostomy tube once the Webbing of anterior commissure this is
airway is adequate due to failure to reapproximate the vo
cal cords to the anterior edges of the
laryngofissure or not inserting a silastic
keel when the opposing mucosae of the
vocal cords have been traumatised
4
Non healing thyrotomy e g following
previous radiation therapy
Laryngocutaneous fistula this generally
closes spontaneously
Malunion of the thyrotomy may cause a
poor voice
Useful reference
AfHNS Clinical Practice Guidelines
for Glottic Cancers in Developing
Countries and Limited Resource Settings
Author and Editor
Johan Fagan MBChB FCS ORL MMed
Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town South Africa
johannes fagan uct ac za
THE OPEN ACCESS ATLAS OF
OTOLARYNGOLOGY HEAD
NECK OPERATIVE SURGERY
www entdev uct ac za
The Open Access Atlas of Otolaryngology Head Neck
Operative Surgery by Johan Fagan Editor
johannes fagan uct ac za is licensed under a Creative
Commons Attribution Non Commercial 3 0 Unported
License
5


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