|Year : 2019 | Volume
| Issue : 1 | Page : 121-127
Chronicles of voice restoration surgery
Vijayalakshmi Subramaniam, Sheetal Rai
Department of Otorhinolaryngology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||12-Jun-2019|
Dr. Vijayalakshmi Subramaniam
Department of Otorhinolaryngology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Laryngology has developed immensely as a subspecialty of otorhinolaryngology over the last three decades. Today, the ultimate goal of a laryngologist is preservation or restoration of good voice. Care of the professional voice is highly demanding and thereby phonosurgery is fast emerging as a superspecialty. This article takes you through the journey of voice from an era of destructive surgeries to an era of voice conservation.
Keywords: Laryngeal reinnervation surgery, microlaryngeal surgery, voice prosthesis, voice, phonosurgery
|How to cite this article:|
Subramaniam V, Rai S. Chronicles of voice restoration surgery. Arch Med Health Sci 2019;7:121-7
“The human voice is the organ of the soul.”
- Henry Wadsworth Longfellow
| Introduction|| |
Voice is a unique feature bestowed on humankind which helps us communicate our feelings. Our expressions have the power to transform, inspire, motivate and leave a lasting impression on others. The voice reveals the personality of the speaker giving him/her an ineffaceable identity. A disordered voice causes considerable trepidation to all, more so to people who use their voice for their professional needs such as singers, actors and teachers.
Phonosurgery encompasses surgical procedures performed with the intention to improve the quality of voice through rectification of defects in the larynx. These procedures include:
- Microlaryngeal procedures for excision of benign or malignant disease
- Vocal fold injection for augmentation and medialization
- Laryngeal framework surgery
- Laryngeal reinnervation procedures and
- Reconstructive and rehabilitative procedures after tumor resection.
These procedures have an interesting history which dates back to the 19th century. This article is an account of the developments that have taken place in the field of phonosurgery with time.
| History of Phonosurgery|| |
“The greatest gift of all, an object beyond price, all of us have received free of cost from our God and Creator-the glory of the human voice.” These were the words of Manuel Garcia, a singing teacher from Spain who pioneered the efforts to visualize the larynx.
In 1854, Manuel Garcia [Figure 1] discovered the laryngeal mirror for examination of the larynx. It was here that the seeds of phonosurgery were sown. At the age of 20, he along with his two older sisters was brought to New York by their father, a renowned singer and director himself, to perform Mozart and Rossini operas in New York. Garcia developed vocal strain due to frequent rehearsals and performances which destroyed his voice compelling him to retire from his stage career very early in life.
Thereafter, Garcia devoted himself to teaching other singers to help protect their voice to prevent them from going through the same predicament as he did. He used a small dental mirror to reflect the light of the sun on his own larynx and visualized the image on the hand mirror.
Few years later, Ludwig Turck, a Viennese neurologist used Garcia's technique on his patients. This technique of visualization of the larynx was popularized throughout Europe by a Prague Physiologist – Johann Nepomuk Czermak. It was only in the late 1890s that the art of direct visualization of the larynx came into practice thanks to Professor Alfred Kirsten of Berlin. This marked the beginning of laryngeal surgery.
The first century of our specialty witnessed laryngeal surgeries directed toward excision of neoplasms, mostly in the form of laryngectomies. Voice preservation always took a back seat. In the late 1950s, there was a surge of interest in procedures for improvement in functional outcome of voice. In 1963, Godfrey Arnold and Hans von Leden [Figure 2] came up with the term – “Phonosurgery.”
Use of microscope in phonosurgery
The credit for the use of microscope in visualization of the vocal folds goes to Professor Rosemarie Albrecht from East Germany. It is interesting to note that the drive behind this thought was not her familiarity with the use of microscope in otologic surgeries, but the successful usage of the microscope by her gynecology colleagues to diagnose early cervical cancer. She was one of the leading female otolaryngologists of her time, but her work was largely unknown in the then American society. Severe shortage of funds and equipment in East Germany further hindered her work. This forced her to work in the department of gynecology where she came up with the novel idea of using a colposcope with magnification for examination of the larynx.
Professor Kleinsasser [Figure 3], well known as the father of microlaryngeal surgery, was an Austrian pathologist with interest in otolaryngology. It was he who perfected the technique of microscopic visualization of the larynx. Kleinsasser began experimenting with different loupes for magnification and then went on to enlarge and taper laryngoscopes with the aim to attain binocular vision and bimanual surgery. He adapted the Zeiss microscope and eventually they came up with a 400-mm focal lens which was best suited to precisely handle the longer working distance to the vocal cords and lengthy instruments. He also published a book on microlaryngoscopy with magnified images of the larynx.
Many other laryngologists attempted to improve microlaryngoscopy using Lynch suspension laryngoscope (Anthony Scalco) and monocular and binocular loupes for magnification (Albert Andrew, Levy and Hans von Leden) but were unsuccessful. Moreover, the use of local anesthesia for endolaryngeal surgery posed difficulty in achieving precision, as the patient being awake would move involuntarily.
Geza Jako, a contemporary of Kleinsasser, developed an improved laryngoscope and designed microlaryngeal instruments that are in use even today. This technique faced criticism from many senior laryngologists in the beginning, and many were reluctant to use general anesthesia for this purpose. Eventually, with the help of skilled anaesthesiologists, microlaryngoscopy became a routine surgical procedure for vocal cord pathology.
Phonosurgery in vocal fold paralysis - Vocal fold injection for augmentation and medialization
In 1911, Wilhelm Brunings [Figure 4] presented a unique technique for treatment of unilateral vocal fold paralysis. He injected the paste of hard paraffin (at a melting point of 46°) into the paralyzed vocal fold displacing it medially. He managed to achieve satisfactory approximation of the two folds during phonation thus giving back the patient his voice. Brunings also devised the laryngeal syringe for the endolaryngeal injection of prosthetics in patients with unilateral vocal fold paralysis. Subsequently, bovine bone dust, tantalum powder, silicone, Teflon paste, bovine collagen and autologous fat were used as fillers.
During World War I, Professor Erwin Payr, who was then serving as a general in the medical department of the German Army, performed vocal cord medialization procedure on a soldier who could not speak after a hemithyroidectomy surgery. He created a trap door on the thyroid cartilage which pushed the vocal cord medially restoring the patient's voice. Further modification in this technique was brought about by Professor Meurman of Helsinki during World War II (1942). He used autologous costal cartilage to medialize the vocal cord by placing it between thyroid ala and vocalis muscle. Bioinert materials are being used now by researchers such as silastic, hydroxyapatite, Gore-Tex and titanium shims.
Phonosurgery of the laryngeal framework
Voice restoration with laryngeal framework surgery also known as laryngoplastic phonosurgery was initiated in the beginning of the 20th century. Payr in 1915 performed the first laryngeal framework surgery on a patient with unilateral vocal cord paralysis. Meurman further examined Payr's technique of medialization of the musculomembranous vocal fold. Japanese Laryngologist Nobuhiko Isshiki [Figure 5] is the trailblazer behind the present day thyroplasty procedures. He described the four types of thyroplasty in 1974 of which type 1 is the medialization procedure using synthetic implants, type 2 is the lateralization procedure, type 3 is the shortening of vocal cords to reduce pitch, and type 4 lengthening procedure to elevate the pitch. Thyroplasty Type 1 involves insertion of a prosthesis to medialize the vocal fold after cutting a window in the thyroid cartilage ala. Minoru Hirano and Shigezi Saito were the torch bearers of thyroplasty techniques in the 1970s along with Isshiki in Japan. The procedure was performed under local anesthesia and permitted auditory feedback from the patient's voice enabling fine tuning. James A. Koufman of the USA developed significant proficiency in this surgery and published his experience. He reported greater improvement of voice in patients with bowed vocal folds by placing silastic implants between the thyroarytenoid muscles and thyroid alae in 1989. Flint P, Blaugrund S, Cummings C, Ford C, Sataloff R, Gould WJ and Sasaki C from the United States carried out further work on the Isshiki's technique.
A variety of materials have been used as prosthesis thereafter. Montgomery developed a preformed silastic shim while Cummings et al. used a shim made of hydroxylapatite. Based on studies showing better tissue tolerance to hydroxylapatite, the VoCom implant system was developed by Smith and Nephew Richards. Titanium implants were used by Friederich. Use of expanded polytetrafluoroethylene (Gore-Tex) cut in strips and inserted through the thyroplasty window into paraglottic space was recommended by McCulloch and Hofmann (1998) and further emphasized by Giovanni. Netterville et al. (1993) propagated a combination of medialization thyroplasty with arytenoid adduction to address the problem of glottic insufficiency. Disarticulation and subluxation of the cricothyroid joint were advocated by Zeitels et al. (1998) to improve vocal fold tension. Optimal placement and function of vocal folds with restoration of normal phonation time and minimal acoustic perturbation have been reported to be achieved by a combination of arytenoidopexy, medialization thyroplasty and cricothyroid subluxation as evidenced by comprehensive objective assessments of the voice.,,,,,,
Laryngeal framework surgery has also taken substantial strides in India with Dr Phaniendra Kumar, Dr. Jayakumar Menon, Dr. KK Handa, Dr Sachin Gandhi, Dr. Nupur Kapoor Nerurkar and Dr. WVBS Ramalingam being the forerunners.
Phonosurgery of the laryngeal nerves – Laryngeal reinnervation procedures
End-to-end neural anastomosis was a procedure surgeons have been trying to master for decades. With the improvement in microsurgical techniques, this became possible. In 1969, Patrick Doyle of Portland and few others succeeded in treating few patients with this procedure. Miehlke of Gottingen and Julius Berendes of Marburg, Germany, successfully used greater auricular nerve as an autogenous transplant for recurrent laryngeal nerve. By 1926, Charles Frazier of Philadelphia had succeeded in anastomosing paralyzed recurrent laryngeal nerve to descending ramus of the hypoglossal nerve.
Direct nerve transplantations into posterior cricoarytenoid muscle using proximal segment of recurrent laryngneal nerve and phrenic nerve have also been tried. However, nerve–muscle pedicle transfer described by Harvey Tucker [Figure 6] in 1975 was more successful. He transplanted a branch of ansa hypoglossi nerve to anterior belly of omohyoid muscle along with its surrounding muscle attachment, directly into the posterior cricoarytenoid muscle. He also transplanted a similar pedicle into thyroarytenoid muscle through a window in the thyroid cartilage.
Phonosurgery for spasmodic dysphonia
Godfrey Arnold and Hans von Leden tried injection of local anesthetic into the laryngeal nerves to relieve spasmodic dysphonia, but the effect was temporary. Herbert Dedo was successful in relieving his first patient of spasmodic dysphonia by severing off the recurrent laryngeal nerve. Subsequently, he realized that the procedure did not benefit all patients with the condition. In 1986, Andrew Blitzer and Mitchell Brin from New York introduced the injection of Botulinum toxin into the vocalis muscle to relieve spasticity which is used even today.
Reconstructive and rehabilitative procedures after tumor resection – Phonosurgery after laryngectomy
Loss of voice is an after effect of total laryngectomy which incapacitates a person considerably. Several attempts have been made to restore voice ever since the first laryngectomy was performed for laryngeal cancer by the Viennese surgeon Christian Albert Theodor Billroth in 1872.
External devices, esophageal speech, internal voice prosthesis, and surgical creation of tracheoesophageal fistula are the methods that have been contrived for restoration of voice.
The first artificial larynx was conceived and designed by Johann Nepomuk Czermak in 1859 even before the first laryngectomy was performed. He diverted airflow from a tracheal cannula through a reed containing tube to the mouth of a patient with complete laryngeal stenosis to reinstate speech.
Vincenz von Czemy attempted restoration of voice in laryngectomized dogs using a cannula made by an instrument maker, J Leiter fostering further exploration on the development of artificial larynx as early as 1870. Carl Gussenbaeur, an associate of Billroth, designed the first internal prosthesis for voice restoration. His pioneering work was stirred by the earlier work of Czemy. His device made of rubber consisted of a tracheal cannula, a pharyngeal cannula, and a phonation cannula with a metal reed. The tracheal cannula was inserted on the 21st day after surgery followed by the pharyngeal cannula. Occluding the cannula and diverting air from trachea to pharynx resulted in production of sound through vibration of the metal reed. A metal lid attached to the pharyngeal cannula helped prevent aspiration by serving as a pseudoepiglottis.
The Gussenbaeur prosthesis was modified by a British surgeon David Foulis in 1877 to produce a less metallic voice. This prosthesis did not have a separate phonation cannula but had a metal piece made of an alloy of silver and copper. The pharyngeal cannula was inserted prior to the tracheal cannula. This prosthesis enabled a better voice quality.
The Gussenbaeur prosthesis had demerits in the sense that it had to be removed while eating and it gave a strange voice quality. Further, patients could not phonate with accumulation of saliva and mucus in the phonation cannula. Based on these demerits, Victor von Bruns introduced his modification of the internal laryngeal prosthesis in 1878 which was made of silver and comprised a tracheal cannula with a wide oval opening through which the pharyngeal cannula or phonation cannula was introduced. A valve made from gutta-percha membrane was fixed to the external opening of the tracheal cannula with two small rods. A rubber reed pipe attached to the cranial end of the pharyngeal cannula served as a phonation cannula. Paul von Bruns, the illustrious son of Victor von Bruns, made several modifications to the prosthesis designed by his father with a view to make it less cumbersome for the patients to assemble the device and also to enable hands-free phonation. His design allowed for patients to breathe through mouth and nose, thus permitting olfaction and air-conditioning of inspired air.
Further work was carried out by Julius Wolff and Eugen Kraus which was grounded on von Brun's design. Wolff in 1892 introduced a modification with an objective of reducing crusting and reported that his prosthesis enabled patients to maintain pitch and sing. Kraus too made a design with the aim of minimizing crusting. Later, RG Brown of Austria devised an internal laryngeal prosthesis which could be introduced and removed by the patient himself. It was cone-shaped tapering from 4 to 2.5 mm and made of a metal pitch pipe attached to an aural speculum made of gold. The device was introduced into the tracheoesophageal fistula and fixed to neck using a shield.
Although there are reports of success with internal voice prosthesis, there were high complication rates and morbidity as high as 50%. There was a significant risk of aspiration. Complete pharyngeal closure was achieved by Gluck, Zeller, and Sorenson in their modified surgical technique in 1881, thereby reducing mortality to 10%, but this did not permit use of tracheal cannulas and hence thoughts were stirred for the introduction of alternate methods of voice rehabilitation.,,
The release of air taken in from the oral and pharyngeal space into the upper esophageal segment in a controlled manner caused the pharyngoesophageal segment to vibrate. This method of producing esophageal speech was first described by Strubing and Landois in 1889 and later in 1896 Stork negated the need for voice prosthesis from the findings of his study on a large group of laryngectomized patients who successfully used the esophageal voice. Different techniques of drawing air into the esophagus were described and attempted Georg Gottstein (1900), Bohme M Seemann (1920), Moolenarr-Bijl, Damste, and Burger and Kaiser (1950s). Due to its low complication rates, esophageal speech became the most accepted method of voice rehabilitation after laryngectomy until the 1980s in spite of having disadvantages such as frequent interruptions in the flow of speech and difficulty in achieving mastery over the technique.
External voice devices began to be developed for restoration of voice from 1880 to 1910, the first of these was developed by Hochenegg in 1892. Later, Gluck developed an electromechanical device followed by an external pneumatic device. Several modifications of external devices were developed by Georg Gottstein, Nicholas Taptas, Paul Sudeck, and RR Riesz. However, voice produced by these devices was monotonous and of limited frequency range. Iglauer in 1936 developed an artificial larynx which had better pitch range and was relatively easy to clean.
RT Barton in 1965 created a submental fistula connecting the superior portion of the trachea and anterior mouth floor and inserted a T-shaped silicone cannula to direct air into the oral space so as to generate voice. Voice Bak prosthesis was then conceived by Taub and Spiro in 1972 to do away with the problem of aspiration and shunt closure. This involved creation of an end tracheal stoma and an esophagocutaneous fistula at the lower lateral one-third of the neck. A silicone tube attached to an airflow valve was fitted to the tracheostoma to divert exhaled air to the esophagostoma after 3 weeks. The esophagus was connected to the airway and an antireflux check valve was used to protect the airway. The voice quality with this device was good but the size of the device, difficulty in maintaining hygiene, and tissue intolerance caused problems.
While prosthetic devices were being designed and improvized, creation of tracheoesophageal fistula for voice rehabilitation also began to be reconsidered. MR Guttmann, an American head and neck surgeon, did a tracheoesophageal puncture using a needle connected to a diathermy in 1932. Some other surgeons made similar attempts too, but the problem of aspiration and spontaneous closure of fistula made them give up this technique. John Conley in 1958 suggested a mucosal shunt between the esophagus and trachea. A special cannula was employed to route air into the esophagus. In 1963, Ryozo Asai of Japan described the laryngoplasty procedure in three stages, the first stage involving construction of two tracheal stomata separated by a thin bridge of tracheal wall. A pharyngeal fistula was made in the second stage and a dermal tube was created to connect upper tracheal stoma to pharyngeal fistula. Alden Miller, William Montgomery, and Frederick Turnbull Jr in the United States, Minnigerode in Germany and other European surgeons modified the Asai Laryngoplasty technique. One-stage modifications of the Asai technique were proposed by McGrail and Oldfield; Calcaterra and Jafek (1971) and Komorn (1974). Aspiration remained a problem with these procedures. Biological valves of the pharynx began to be created. While Arslan and Serafini proposed epiglottohyoidopexy, Staffieri and Serafini created a tracheoesophageal shunt using pharyngeal musculature as a sphincter. Further modifications included use of a microanastomozed jejunal interposition graft (jejunum siphon) by Ehrenberger (1985), revascularized forearm flap and auricular and thyroid cartilage by R Hagen (1990), modified Asai Laryngoplasty technique by H. Maier and H. Weidauer (1994) and free ileocecal patch graft by Kobayashi et al. (2003).
The first semipermanent voice prosthesis made of silicone was designed in 1972 by Mozelowski et al. in Poland. This had a shaft made of polyethylene or polyvinyl. A valve made of two or three layers of polyethylene foil of 0.007 mm thickness was attached to the esophageal flange. The lumen of the polyethylene tube collapsed during deglutition, thus preventing aspiration. The tracheal flange helped hold the prosthesis in the tracheoesophageal fistula. Insertion of prosthesis was done in a retrograde method through the oropharynx. In 1978, the duckbill voice prosthesis was developed by Eric D Blom [Figure 7] and Mark I Singer [Figure 8] which was inserted secondarily by puncturing through the posterior tracheal wall. The one-way valve of the prosthesis allowed air during expiration to enter the pharynx and produced sound by vibrating the mucosa of the pharyngoesophageal segment. The valve closed while swallowing preventing the salivary soiling of the airway. This was a nonindwelling prosthesis and hence had to be removed, cleaned, and reinserted by the patient. A number of modifications to this voice prosthesis were developed by Nijdam, Groningen, Panje, Herrman, Traisac, Algaba, and Bonelli. The Provox indwelling voice prosthesis was introduced in 1988 by Hilgers and Schouwenburg. Further modifications to this prosthesis were done and the Provox Activalve and Provox Vega system were introduced in 2003 and 2010 to reduce biofilm growth, decrease airflow resistance, and optimize the fit of the prosthesis.,,,
A totally implantable voice prosthesis was introduced for the first time by Debry et al. in 2012. The device comprised a titanium tube placed on to the trachea prepared by chimney technique. The tube was wrapped by pectoralis muscle myofascial flap to avoid issues with healing and was placed in front of the completely closed pharyngeal tube. After healing, the pharyngeal tube was opened at the cranial end of the tube during transoral rigid endoscopy and a flap mechanism was added. Following the closure of the tracheostoma, the patient was able to breathe through the mouth or nose and produce a pseudowhispering voice.
A low-cost voice prosthesis named AUM voice prosthesis has been developed by Indian head and neck surgeon Vishal Rao US [Figure 9] and Sataksi Chatterjee for as low as 1 dollar and piloted on 30 patients from 2015 to 2016 with excellent results.
Professor Paul Kluyskens of Belgium is accredited with performing of the only successful laryngeal transplant surgery till date. Although the voice quality after surgery was acceptable, the patient died 4 months after surgery. The challenges with laryngeal transplant include difficulty in restoration of sensory and motor functions of the larynx, microsurgical anastomosis of small vessels, and immunosuppressive therapy.
Lasers in phonosurgery
The advent of lasers has further revolutionized the field of Phonosurgery – also called Voice Laser Surgery. The CO2 laser is used for this purpose. The laser beam is channeled through a micromanipulator attached to the operating microscope unit and directed into the larynx. Laser is used for excision of benign and malignant lesions on the vocal cords and endolarynx, transverse posterior cordectomy with partial arytenoidectomy procedure for bilateral cord palsy, thyroarytenoid muscle ablation for spasmodic dysphonia, treatment of congenital laryngeal lesions such as laryngomalacia, laryngeal web, and subglottic hemangioma.
The trend is now shifting towards the development of comprehensive voice clinics to cater to the needs of professional voice users.
| Conclusion|| |
From microlaryngeal surgery for benign vocal cord lesions to phonosurgery and voice rehabilitation, we have come a long long way. Phonosurgery is emerging as a superspecialty in otolaryngology and is here to stay to improve the quality of voice and speech and thereby improve the overall quality of life.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]