Transcervical arytenoid cartilage excision for vocal cord externalization

Transthoracic circumflex cartilage is the earliest procedure used by Woodman. Because the operation has the advantages of not damaging the intralaryngeal mucosa and being able to externally shift the vocal cords more accurately, it is a common surgical procedure for treating bilateral vocal cord abduction and paralysis at home and abroad. The advantages are: 1 The operation is performed outside the throat, does not enter the throat, does not damage the mucosa in the larynx, and is not susceptible to infection after surgery. 2 When the submucosal tissue of the vocal cord is fixed to the thyroid cartilage, the position of the vocal cords can be observed under the direct laryngoscope, and the degree of vocal cord migration can be adjusted at will. Curing disease: Indication Transjugation of the vocal cords through the cervical cartilage is applicable to: 1. The sacral cartilage is fixed due to nerve palsy or joint rigidity, and the breathing is not good. 2. The tracheotomy is performed due to bilateral vocal cord paralysis, and the patient is not willing to wear the tube for a long time. Contraindications Those who have trauma on the surgical side or who have undergone surgery are relatively contraindicated for surgery. Preoperative preparation 1. Take a lateral radiograph of the neck to exclude tracheal stenosis. 2. Pulmonary function test. 3. Perform a direct laryngoscope or bronchoscopy before surgery, and move the sacral cartilage to determine the activity of the sacral cartilage. 4. Wash the neck skin with water and soap 1 day before surgery to scrape the hair. 5. 30 minutes before surgery, intramuscular injection of phenobarbital 0.1g, atropine 0.5mg, children reduce. 6. Special surgical instruments: tracheal hooks, electric drills, ophthalmic small scissors (bend, straight 2 kinds), front combined laryngoscope. Surgical procedure Tracheotomy First, a tracheotomy was performed under local anesthesia, a cannula for endotracheal anesthesia was inserted, and general anesthesia was performed. If the patient has had a tracheotomy, the tracheal cannula should be replaced under local anesthesia or tracheal surface anesthesia. 2. Position In the supine position, the head is biased to one side and slightly extended. Choose a vocal cord that is fixed longer and has a more severe side for surgery. 3. Incision An oblique incision was made along the anterior border of the sternocleidomastoid muscle, and the upper edge of the upper thyroid cartilage was placed to the lower edge of the annular cartilage. Cut the skin, subcutaneous tissue and platysma. 4. Exposing the posterior border of thyroid The skin and subcutaneous tissue are separated back and forth along the incision. The anterior border of the sternocleidomastoid muscle is pulled backward, and the scapula and sternum muscles are pulled forward. The thyroid gland muscle is attached to the front edge of the thyroid cartilage, and the pharyngeal muscle is attached to the posterior edge of the thyroid cartilage. . At the lower end of the incision, the ring-shaped joint of the thyroid cartilage and the annular cartilage can be seen as an important marker for surgical operation. The larynx is pulled slightly to the opposite side, from the upper edge of the thyroid cartilage, down to the annulus, and the inferior pharyngeal muscle and perichonum are cut perpendicularly along the posterior edge of the thyroid cartilage. Do not damage the cartilage. 5. Separate the ring joint and expose the sacral cartilage A stripper was used to incision along the perichondrium, and the inferior pharyngeal muscle was separated under the perichondrium to the posterior edge of the thyroid cartilage. Then use the stripper to bluntly separate the ring joint (Fig. 9.6.4.1.2.25), the posterior margin of the thyroid cartilage is free, and the posterior edge of the thyroid cartilage is pulled forward with the hook, along the side of the annular cartilage, and vertically separated from the ring armor. The posterior iliac crest muscle and the iliac crest muscle are cut at the sacral cartilage, and the perichondrium at the sacral cartilage is cut to expose the sacral cartilage. 6. Separation of sickle cartilage The sacral cartilage is separated under the perichondrium by a stripper, the ankle joint is separated, and the vocal folds of the sacral cartilage are cut off. A small piece of cartilage is retained in the tissue to prevent the suture from slipping off and avoid damage to the larynx mucosa. Remove the sacral cartilage. 7. The vocal cords are externally fixed to the thyroid cartilage When the sacral cartilage has not been resected, a suture can be drawn in the middle of the sacral cartilage, and the sacral cartilage is pulled outward and downward, which helps to see the position of the vocal fold. Use a curved needle with a thin gut or nylon thread to pass through or bypass the vocal cords under the mucosa, including vocal cord muscle fibers and nail muscle fibers. The needle insertion site should be at the posterior vocal folds, causing the mucosa to move outward. . If the needle-punching part is too far forward, it is easy to make the vocal cord membrane part move too much and affect the sound; if the needle-punching part is too far back, the vocal cord of the sacral cartilage will be rotated internally, and the glottis is not large. Pull the suture outward and ligature around the lower corner of the thyroid cartilage. The laryngeal body is reset, and the suture is pulled under the direct laryngoscope or the fiber laryngoscope, and the degree of vocal cord migration is observed, and the vocal cord is moved outward by 4 to 5 mm. The suture is ligated and fixed. Fixing the suture on the lower corner of the thyroid cartilage may cause the externally displaced vocal cords to be lower than the contralateral vocal cords, resulting in aspiration and poor vocalization. Therefore, it has been suggested that the suture can be fixed at the corresponding portion of the thyroid cartilage wing to avoid the above problems. 8. Suture incision The inferior phlegm muscle was sutured and the subcutaneous tissue and skin were sutured in turn. A drainage strip is placed in the wound. complication 1. The granulation tissue may occur in the posterior part of the laryngeal cavity, which is caused by the damage of the laryngeal mucosa or the suture through the laryngeal mucosa. The granulation tissue can be removed by laser under a direct laryngoscope or a fiber laryngoscope. 2. Laryngeal edema or laryngitis may occur after operation. In severe cases, cartilage necrosis may occur, which may be caused by injury to the laryngeal mucosa and infection during surgery. Sufficient antibiotics should be given before and after surgery to prevent this complication. 3. For patients with coronary heart disease, embolization can occur when the carotid sheath is pulled during surgery. 4. Excessive traction of the thyroid cartilage in the operation can cause distortion of the lower pharynx and the upper part of the esophagus, and it is easy to be damaged when the inferior pharyngeal muscle is cut.