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Laryngopedia

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Laryngopedia By Bastian Medical Media

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Questions about Cricopharyngeus Myotomy

Questions about Cricopharyngeus Myotomy (CPM) For Cricopharyngeus Muscle Dysfunction with or without Zenker’s Diverticulum

What is Cricopharyngeus Myotomy (CPM) and why is it done?

This procedure refers to division of a circular sphincter muscle that serves as a one-way valve or ‘gate’ at the top of the esophagus. This muscular ‘gate’ must open briefly every time we swallow, allow the food or liquid through, and then clamp shut the moment the material goes through. In some persons, the muscle fails to relax (the ‘gate’ fails to open). The surgery in essence leaves the gate open all the time, and allows the person to resume swallowing relatively normally. In a percentage of those with cricopharyngeus muscle non-relaxation, the continual high pressures of swallowing may eventually cause a “hernia” in the swallowing passage called a Zenker’s diverticulum.

What are the symptoms caused by this problem?

Cricopharyngeus muscle dysfunction (non-relaxation) may be mild at first and cause only occasional lodgment of a pill at the level of the mid-to lower neck. As the years pass, the problem becomes inexorably worse. Left untreated, the individual begins to avoid certain foods he or she has learned from prior experience do not go down well. Eventually, the affected individual can only swallow liquids and very soft foods with a thin, cream of
wheat consistency. Progression from first symptom to this final stage may take as little as a year, but more commonly several or even many years.

Does CPM always work?

The answer varies according to the degree to which the person is an ideal candidate for this surgery. When solid food dysphagia is the main symptom, and when xray studies show non-relaxation of the muscle, the procedure can dramatically restore the individual’s ability to swallow. Patient satisfaction with the results is routinely very high. “I can eat anything I want again,” is frequently-heard after surgery. Once in awhile an individual has more than one swallowing deficit, of which CPMD is only one. In this case, swallowing may be better, but still not perfect after CPM.

How is the procedure accomplished?

Under general anesthesia, in one of two ways: The preferred, newer methodology, is performed endoscopically. Using this method, a hollow, lighted “tube”—called an esophagoscope—is inserted into the throat and upper esophagus to examine the area and plan the next step. Then, a special laser scope is placed in the upper esophagus. A microscope permits a magnified, brightly-lit view of the offending ring of muscle. The laser is used to divide the muscle and break its “grip.” If a Zenker’s sac is apparent, it is “marsupialized,” which means that its opening is widened in order to be sure the sac doesn’t retain food, but instead empties its contents directly into the esophagus. Depending upon patient and surgical issues, a suction drain may be placed within the upper esophagus and brought out through the nose. A second small tube for feeding may also be placed through the nose, and down into the stomach. When placed, both tubes are removed the morning following surgery.

What is the second way of doing the procedure, and why would it be done another way?

If a clear view cannot be achieved during esophagoscopy due to difficult patient anatomy (e.g., jaws won’t open well, small lower jaw, short neck, large upper teeth), then we return to a more traditional approach through an incision on the lower left neck. In this case, the muscle is divided from outside in. Depending on a number of issues, an associated Zenker’s diverticulum may or may not be removed
at the same time. How will I know in advance which way the surgery will be done? We suggest that candidates for CPM agree to both
methods. That way, we can attempt our preferred method from within the esophagus. If that method is not possible, we switch to CPM through a neck incision. Most people want to know that when they leave the operating room, the problem will have been addressed, “one way or the other.” Still, the laser method is successful in at least 19 of 20 cases we attempt.By now this surgery is sounding horrible. Right? Actually, no. While we always see a variety of patient reactions to surgery, most people do not find this one that bad.

What are the risks of the procedure?

Unless you have significant health issues, risks added together are very small. Risks may include:

1. A drug reaction, heart problem, etc., during general anesthesia.
2. Dental trauma—e.g., chipped, scratched,
broken, or dislodged tooth. We have a few instances per year of roughened enamel that doesn’t need a dentist’s attention, but
can be smoothed off in the O.R. Beyond this, about once every couple of years something more significant, such as a broken
or dislodged crown or tooth happens.
3. If surgery is done within the esophagus there is a small risk of a special, potentially
severe infection called mediastinitis. (We’ve not seen this problem with a BVI total of an estimated 120 CPM surgeries).
4. If the surgery is done through a neck incision, there is an added small risk of temporary—or rarely, permanent—paralysis of
one vocal fold, which is managed in a relatively straightforward manner.
5. The final “risk” or outcome is that we cannot guarantee the precise degree of improvement—whether the result will be “good,” “very good,” or “spectacular.” That depends to large degree on the precise components of the original problem; as we tend to know these before surgery, we can usually make a reasonably reliable estimate of the improvement we expect. The potential for harm to my teeth really bothers me. Actually, though dental injury happens so infrequently, this possibility bothers us too! That’s why we use not only a tooth guard, but also all the care and gentleness we can muster while doing this surgery. That said, please keep in mind that individuals who cannot personally accept the very small chance of a dental problem should not agree to undergo this surgery. To those entirely risk-averse for dental trauma: Risk of dental problems is reduced (not abolished) if one decides “in advance” to have the surgery through a neck incision, but risk of vocal fold paralysis is thereby added.

What other issues should I expect after surgery?

After surgery, patients return home either later the day of surgery, or the morning after, with rare exception. Of course, a family member or friend must do the driving. Most individuals have minimal anesthesia aftereffects. Nausea, for example, has become relatively uncommon. Pain medication consists of either Tylenol or Tylenol with Codeine, barring allergy or sensitivity. Water may be swallowed immediately after surgery. The first five days, diet should consist of liquids and very soft foods. Water is always the last thing swallowed after every “meal,” to “rinse out” the area of surgery. Some find that salty or acidic food / liquids will burn the area of surgery. Occasionally the teeth feel a little sore and loose, especially the upper central incisors.

Are there any problems I might have that should prompt a call to my surgeon?

All of the following are very unlikely, but they are:

1) Inability to swallow liquids.
2) Chest or back pain increasing in severity from the time of surgery.
3) Fever or chills.
4) Anything else at all that causes you concern!

What if my teeth do feel loose?

We suggest that you refrain from wiggling them, or from biting into tough foods until they tighten back up on their own. Most often this takes a week or so.

When do I see my doctor after surgery?

Typically, our office will call you within a few days of your surgery, just to make sure all is proceeding as expected, and that you have no questions. You are also invited to call if any concerns. About six weeks after surgery we schedule a video-fluoroscopic swallowing study (VFSS) to compare with the one you had before surgery. You bring a videotape copy of that study with you to a postoperative visit with your surgeon later the same day the VFSS was done. Individualized arrangements may need to be made for persons from outside the metro area, and followup visits may sometimes need to be made with the “home” otolaryngologist.



Questions about Endoscopy

Q: What is Endoscopy?

A: Endoscopy means to “look within,” in our case either the larynx (voice box), windpipe, esophagus, and throat. This might be done for many different reasons:

    1. Just to see and feel something
    2. Take a biopsy
  1. Try to widen the airway
  2. To remove something

Some common kinds of endoscopy include microlaryngoscopy and esophagoscopy.

Q: How is the procedure accomplished?

A: This is typically performed in an operating room during general anesthesia. After you are completely asleep, a hollow, lighted “tube”—a laryngoscope for example —is placed on the back of the tongue and against the sidewall of the throat, where it rests during the procedure. There is also unavoidably considerable pressure on your teeth, despite the use of a tooth guard. In order to see clearly, a microscope may be used, and the area in question magnified and brightly illuminated. Many different tools might be used, including a laser. Sometimes medications are injected into the area or painted on it. Time required for the procedure is usually short—10 to 45 minutes of operating time, but can be longer.

Q: What are the risks of the procedure?

A: Unless you have significant health issues, risks added together are very small. The main ones are:

1. A very small possibility of drug reaction, heart problem, etc., during general anesthesia
2. A very small chance of dental trauma—e.g., chipped, scratched, broken, or dislodged tooth or crown. We have several instances per year of roughened enamel that doesn’t need a dentist’s attention, but only needs to be smoothed off in the O.R. Beyond this, about every couple of years something more significant happens, such as a broken or dislodged crown, bridge, or tooth. A little more often, certain teeth may feel loose in the early days after surgery but usually tighten up without further treatment.
3. The third “risk” is that we cannot guarantee the precise degree of improvement. That depends primarily on the difficulty of the original problem that we have thoroughly discussed with you.

Q: The potential for harm to my teeth really bothers me.

A: Dental injury happens infrequently, but this possibility bothers us too! That’s why we use not only a tooth guard, but also all the care and gentleness we can while still getting the job done. Please keep in mind that you must NOT consent to surgery if you cannot personally accept the very small chance of a dental problem. BVI cannot assume this risk, because our reimbursement is so small in relation to the cost of dental work, and our practice has a much higher than average proportion of difficult cases. The only way for you to avoid this small risk, and its potential expense to you, is to not have the surgery.

Q: I’m also worried about my result. What is the chance I will be worse after surgery?

A: The point of surgery is to answer a question and /or to improve voice, swallowing, and breathing. Our expectations do vary a bit, however, according to what precisely we are trying to accomplish and your specific circumstance. This has been reviewed in detail with you, so that you know what to expect.

Q: Is there anything else I should know?

A: A family member or friend will have to drive you home. You may have after effects from the anesthesia medication. We typically give you a prescription for a pain medicine, often containing a narcotic such as codeine, if you are not allergic to it. The risk of nausea is reduced by having food in your stomach when you take it. Unless directed otherwise, you may eat whatever your appetite and throat discomfort allow, but eat cautiously the first time, to be sure your stomach is “settled.” Occasionally, salty or acidic food / liquids will burn the sore area caused by pressure from the laryngoscope. Most commonly, that pain will be on the left side. Occasionally the teeth feel a little sore and loose, especially your upper central incisors. In this case, we suggest that you refrain from wiggling them, or from biting into tough foods until they tighten back up on their own. Most often this takes a few days to a week or so. If you experience a lot of coughing, over-the-counter Robitussin DM suffices for most people. If that is not effective, you can call BVI for a stronger prescription.

Q: When do I see my doctor after surgery?

A: Typically, we will see you for the first postoperative visit at about a week after surgery.



Questions about Vocal Fold Microsurgery

Why is vocal fold microsurgery done?

The commonest reason is that there is a visible lesion such as nodules, polyps, capillary ectasia (dilated capillaries), epidermoid or mucus retention cyst, glottic sulcus, papilloma, or a known vocal fold cancer. The point is to remove the lesion to improve the sound or capabilities of the voice. Of course, if a tumor is involved, voice takes second place to removal of the lesion. Removed tissue is always examined by the pathologist, but for most individuals, the need for biopsy is much less than the need for a better voice.

Can you describe how the procedure is accomplished?

The procedure, aka Microlaryngoscopy, is typically performed in an outpatient operating room during relatively brief general anesthesia. After you are completely asleep, a hollow, lighted “tube”—called a laryngoscope—is placed on the back of the tongue and against the sidewall of the throat, where it rests during the procedure. A microscope is brought into position, aligned with the laryngoscope, and the vocal folds are highly magnified and brightly illuminated. Then, the surgeon uses tiny instruments and / or the carbon dioxide laser, to remove or ablate the problem. Both laser and non-laser tools / methodologies are available for every case, but which tools are used depend upon the nature of the problem. There is nothing innately superior about either method; it is the surgeon and not the tools that matter most. Nevertheless, one tends to use instruments for nodules, polyps, cysts, while the laser is more likely to be used for vascular abnormalities or removal of a vocal fold carcinoma. Time required for the procedure is usually short—10 to 45 minutes of operating time.

What are the risks of the procedure?

Unless you have significant health issues, risks added together are very small indeed. The three main risks include:

1) A truly remote possibility of drug reaction, heart problem, etc., during general anesthesia.
2). A very small chance of dental trauma—e.g., chipped, scratched, broken, or dislodged tooth. We have a few instances per year of roughened enamel that doesn’t need a dentist’s attention, but only to be smoothed off in the O.R. Beyond this, about once every 3 years something more significant, such as a broken or dislodged crown or tooth happens.
3) We cannot guarantee the precise degree of improvement—whether the result will be “good,” “very good,” or “spectacular.” That depends to large degree on the difficulty of the original problem. And when a known tumor is being removed, we may expect possible worsening of voice quality, as compared to “normal.”

The potential for harm to my teeth really bothers me.

Actually, though dental injury happens so infrequently, this possibility bothers us too! That’s why we use not only a tooth guard, but also all the care and gentleness we can muster while doing your surgery. That said, please keep in mind that you must NOT do this surgery if you cannot personally accept the very small chance of a dental problem. The only way for you to avoid this small risk, and its potential expense to you, is to not have the surgery.

I’m also terribly worried about my voice. What is the chance it will be worse after surgery?

Again, the very point of most microlaryngoscopy surgeries is to improve the voice. When we do this kind of surgery in singers—the most discriminating judges of the results of this kind of surgery—both singer/patient and surgeon, not to mention voice teachers, are routinely pleased with the result of surgery. Our expectations do vary a bit, however, with the kind of lesion we are removing. For example, we expect extremely good results within days with capillary ectasia, nodules, and polyps; good results after cyst or sulcus surgery, though with a much longer and more gradual recovery of voice over months’ time, and so forth. Your surgeon should be able to provide you with an estimate of what kind of voice result is realistic to expect after your surgery.

What if I forget and talk, or talk in my sleep?

No harm done, just don’t talk knowingly during the initial post-surgery days.

What other issues should I expect after surgery?

You will go home the day of surgery, with rare exception. Of course, you will have to be driven by family member or friend. Most have minimal aftereffects from the anesthesia medication. Nausea, for example, has become relatively uncommon. You may choose to take medication for a sore throat consisting of either Tylenol or Tylenol with Codeine, barring allergy or sensitivity. You may eat whatever your appetite and throat discomfort
allow. We do suggest that your first postoperative food be relatively bland, and a small amount, to be sure your stomach is “settled.” Occasionally, salty or acidic food / liquids will burn the sore area caused by pressure from the laryngoscope. Most commonly, that pain will be on the left side. Occasionally the teeth feel a little sore and loose, especially your upper central incisors.

What if my teeth do feel loose?

We suggest that you refrain from wiggling them, or from biting into tough foods until they
tighten back up on their own. Most often this takes a week or so.

What about voice use?

Specific advice may vary with the individual. That said, here are the usual voice use restrictions:

Nodules, polyps, capillary ectasia:

No talking for 4 days—usually this means from the day of surgery (Wednesday, for example) to Sunday. During those days, we usually suggest gentle sighing sounds for 10 seconds or so every few hours. Talking resumes on Sunday (4th day), but at a restricted amount: you may be a “3” on our 7-point talkativeness scale for one week. If a singer, you may begin vocalizing for 5 minutes twice a day, also beginning Sunday. Additional details of postoperative voice use will be explained at your first postoperative visit. (Typically, you are a “4” for a week; a “5” for a week, and so forth. Vocalizing increases by 5 minutes each practice session, week by week.) For singers, we suggest a first (short) voice lesson in the second or third week after surgery.

Cyst, sulcus, papilloma, stenosis, early vocal fold cancer:

No voice rest at all, other than one week of what we term “vocal prudence.” This means to talk when you need to, to get the business of life done, but limit “pleasure” talking, and certainly don’t join any street demonstrations!” When do I see my doctor after surgery? Typically, we will see you for the first postoperative visit at about a week after surgery. You will have been talking a couple of days by this time. If flying home, you may depart the morning after the surgery. It is preferred to see you at some point in the future, but we understand that logistical and cost issues may mean that we never get to see you again! In that case, we do phone follow-ups, and suggest followup visits with a laryngologist nearer your home—usually the one who sent you to us in the first place.

Suppose I develop a cough after surgery. Will that ruin my voice result?

No—so far the worst outcome I’ve seen in the few times this has occurred is that the person is hoarse a little longer after surgery—it takes somewhat longer for the very early “surgical laryngitis” to resolve. If you do experience a lot of coughing, over-the-counter Robitussin DM suffices for most people. If that is not effective, you can call BVI for a stronger prescription.



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