Surgery to William W.





\s=b\ A glottic closure procedure rather than laryngectomy is suggested for patients with loss of laryngeal sphincter function. The operation allows restoration of respiration and swallowing without aspiration, but sacrifices phonatory function. No patient has had sufficient recovery of laryngeal sphincteric function to warrant an attempt to reverse the laryngeal closure operation.

Fig 1 .—A, Tracheotomy converted to tracheostomy. Thyroid cartilage exposed using horizontal cervical incision. B, Thyroid laminae being incised in vertical midline. C, Thy¬ roid laminae separated without disturbing underlying soft tissues. Anterior commissure is incised in exact midline.

(Arch Otolaryngol 101:679-682, 1975)

operation designed to elimior seal a glottis with an is distasteful to the lumen adequate laryngeal surgeon, since much of his efforts and thoughts are directed toward methods for rehabilitating an inadequate laryngeal airway. A to¬ tal laryngectomy, a Lindeman diver¬ sion operation1 (tracheoesophageal anastomosis), and the epiglottis flap operation (Habal and Murray2) have been successfully employed to elimi¬ nate the misery of constant aspira¬ tion in patients with chronic loss of laryngeal sphincteric function. A cuffed tracheotomy tube is only partially effective in controlling aspi¬ An


ration and cannot be used for



longed period.

This article introduces a relatively simple, yet effective method for clos¬ ing the glottis in patients with a functionless larynx. This procedure eliminates the necessity for a total laryngectomy. The operation has been employed during the past six years to eliminate aspiration and re-establish Accepted for publication June 26, 1975. From the Department of Otolaryngology, Harvard Medical School, and the Massachusetts Eye and Ear Infirmary, Boston. Reprint requests to the Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (Dr Montgomery).

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Ventricular fold

Incise thru

(false vocal cord)



Laryngeal ventricle

Vocol fold

(true vocal cord)





"Hot" knife

Fig 2.—A, Mucosal incisions are made to outline mucous membrane removal. B, Mucous membrane is being removed from true and false vocal cords, laryngeal ven¬ tricle, and posterior commissure. in a variety of neuro¬ muscular disorders involving the la¬ ryngopharynx. The types of disorders, and the number of patients who have undergone surgery are as follows: (1) primary brain tumors, 4 patients; (2) vascular disorders of the central ner¬ vous system, 3; (3) metastatic cancer of the medulla, 1; (4) progressive cere¬ bellar atrophy, 1; (5) axial Parkinson disease, 1; and (6) bilateral laryngeal paralysis in abduction, 2 patients. A patient with an inadequately functioning larynx, fed by the naso¬ gastric or gastrostomy tube and ex¬ isting with a cuffed tracheotomy tube to control the misery of continuous aspiration, is indeed a difficult medi¬ cal problem. As a general rule, the cuff of the tracheotomy tube must be deflated for ten minutes every hour to prevent pressure necrosis of the trachea. During this ten-minute pe¬ riod, almost constant suctioning of the trachea is necessary. Thus, the patient must be continuously hospi¬ talized and requires much nursing care. Repeated pulmonary infection is common among these patients. The patient who suffers from chronic aspi¬ ration will gladly sacrifice phonatory function (if present) for restoration


of respiratory and deglutitory func¬ tion without aspiration. However, it is most important to inform both the patient and his family that the oper¬ ation will take away his voice. SURGICAL TECHNIQUE Anesthesia is administered by way of a transoral endotracheal tube rather than through the existing tracheotomy. An en¬ dotracheal tube between the vocal cords simplifies the thyrotomy (laryngofissure) approach to the glottis, and allows the sur¬ geon to convert the tracheotomy to a tra¬ cheostomy. The latter is an attempt to eliminate the necessity for use of a trache¬ otomy tube and to reduce the need for tra-

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cheal care. The multiple flap technique has been used in this instance to convert the

tracheotomy to a tracheostomy (Pig IA). These skin flaps are elevated, advanced, and their margins are sutured to the tra¬ chéal mucous membrane. A horizontal anterior cervical skin inci¬ sion is made midway between the thyroid notch and the cricothyroid membrane as an approach to the anterior aspect of the thyroid cartilage (Fig IA). The fasciai layer over the sternohyoid and omohyoid muscles is exposed by dissecting superiorly and inferiorly. The sternohyoid muscles are separated in the midline, exposing the thyroid notch, anterior aspect of the thy¬ roid cartilage, and the cricothyroid mem¬ brane.

Fig 3.—A, Suture passes through anterior aspect of ipsilaterai thyroid lamina and vo¬ cal cord. B, Suture passes through contralateral vocal cord. C, Suture returns through ipsilaterai thyroid lamina.

The laryngeal scissors technique for ex¬ ecuting a thyrotomy has been abandoned. Rather, a layered technique in order to

prevent deviation from the anterior


missure is used. The thyroid cartilage is in¬ cised at the anterior vertical midline using a number 10 surgical blade if the cartilage has not undergone ossification. An electric ossilating saw is used to accomplish this in¬ cision if ossification has occurred (Fig IB). Using small skin hooks (Fig IC), the two thyroid laminae are slightly separated af¬ ter the thyroid cartilage incision has been completed. The airway is entered through a vertical incision in the cricothyroid mem¬ brane (Fig IC). This incision is continued superiorly in the anterior midline under di¬ rect vision of the vocal cords. Using this

technique, the anterior commissure can be accurately incised in the midline. At this point, the transoral endotracheal tube is removed and a sterile endotracheal tube is inserted into the trachea through the tra¬ cheostoma. The endotracheal tube is con¬ nected to sterile anesthesia tubing that is directed to the anesthesiologist. The thyroid laminae are retracted later¬

self-retaining thyrotomy re¬ large skin hooks. An incision electrical knife is made along the

ally using tractor



with an medial convexities of the true and false vo¬ cal cords. These incisions are continued across the posterior commissure (Fig 2A). The glottis is denuded of epithelium circumferentially by resecting a strip of mucous membrane between the two paral-

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lei incisions (Fig 2B). A 3-0 polyethylene suture is passed through the anterior aspect of an ipsilat¬ erai thyroid lamina and true vocal cord (Fig 3A). The suture is then inserted into the anterior aspect of the contralateral vo¬ cal cord, through its musculature and the vocal process of the arytenoid. At this point, the suture re-enters the laryngeal lumen posteriorly (Fig 3B). The final pass of the suture is through the posterior as¬ pect of the ipsilaterai vocal cord and thy¬ roid lamina (Fig 3C). An identical suture is passed, using the opposite thyroid lamina (Fig 4A). The glottis is closed as the sutures are tied securely on the lateral surface of each thy¬ roid lamina (Fig 4B and 5B). In some pa¬ tients, the margins of the false vocal cord mucous membrane have been approximated with interrupted 3-0 chromic catgut su¬ tures. These sutures are placed in holding before the first suture (posterior) is tied (Fig 5A). The operation should be drained, as illustrated in Fig 5C.


The laryngeal closure has been suc¬ cessfully applied to 12 patients who suffered from chronic aspiration dur¬ ing the past six years. The first pa¬ tient, a 5-year-old boy with an astrocytoma, required revision surgery to accomplish a complete glottis seal.

Fig 4.—A, Path of sutures used for laryn¬ geal closure operation: (a) arytenoid; (b) thyroid lamina; (c) denuded vocal cord; and (d) de-epithelialized posterior com¬ missure. B, Two sutures have been tight¬ ened and tied on lateral aspect of thyroid laminae to accomplish closure of glottis.

Fig 5.—A, Two polyethylene sutures that will close glottis are in place. Interrupted sutures may be applied to approximate su¬ perior mucosal margins. B, Glottis is closed and thyroid laminae approximated anteriorly. C, Operation should be drained.

In all patients, the operation has eliminated aspiration and restored

deglutition. Three patients

have been able to communicate with others following the laryngeal closure operation by using an electronic larynx. None have learned esophageal speech. No patient has yet recovered suffi¬ ciently from his disease to warrant reversal of the glottic closure oper¬ ation. It should be possible to restore respiratory and phonatory function of the glottis by combining the oper¬ ations for posterior and anterior glot¬ tic stenosis with insertion of the sili¬ cone laryngeal keel.3

References 1. Lindeman RC: Diverting the paralyzed larynx: A reversible procedure for intractable aspi-

ration. Laryngoscope 85:157-180, 1975. 2. Habal MA, Murray JE: Surgical treatment of life-endangering chronic aspiration pneumonia. J Plast Reconstr Surg 49:305-311, 1972. 3. Montgomery WW: Surgery of the Upper Respiratory System. Philadelphia, Lea & Febiger Publishers, 1973, pp 565-588.

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Surgery to prevent aspiration.

A glottic closure procedure rather than laryngectomy is suggested for patients with loss of laryngeal sphincter function. The operation allows restora...
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