Presentation

entsociety.co.za

Presentation

Challenging Cases

Michael S. Benninger, Benninger,

MD

Head and Neck Institute

The Cleveland Clinic

Unilateral Vocal Fold Paralysis

62 year old executive

Unilateral vocal fold paralysis after

thyroidectomy 1991

1993 teflon injection left vocal fold

Voice not better so the patient was reinjected

with teflon

Voice was now worse than before the initial

injection

Coblation for Teflon Granulomas

Coblation for the Treatment

of Laryngeal Lesions

Michael S. Benninger, Benninger,

MD

Head and Neck Institute

The Cleveland Clinic

Teflon Granuloma

Did nothing for 10 years

2002 had laser removal

of teflon

Minimally improved but

worsened over time

Had 2 subsequent

removal attempts in

2004, 2006 without

improvement

TEFLON INJECTION OF THE

RIGHT VOCAL FOLD

inside the wrong layer of the epithelium


Teflon Granuloma

She is Manager in a large

international company

and has been passed over

for advancement since

she cannot give pubic

presentations

VHI: 86

MPT: 9 seconds

How would you manage this?

1. Endoscopic surgical excision with laser

2. Endoscopic surgical excision with microflap

and cold-knife cold knife excision

3. Open thyrotomy with removal granuloma

4. None of the above

Options for Excision of Laryngeal

Lesions

Cold Steel

Microinstruments

Lasers

CO2

Pulse Dye

KTP

Microdebrider

Electrocautery

Coblation Pre-Post Pre Post Teflon Granuloma


Teflon Granuloma with Coblation

Pre-operatively

Pre operatively

VHI: 86

MPT: 9 seconds

Uses electro-dissociation electro dissociation technology for

incision

Plasma based technology –

radiofrequency in a conductive medium

(saline) creates charged particles which

breaks tissue bonds and disintigrates

tissue

Versus burning or cutting tissue as with

Radiofrequency techniques

Conventional electrosurgery 400-600 400 600ºC

Lower temperature 60-160 60 160ºC

Lower frequency

Higher impedence

Less collateral tissue damage

Simultaneously achieves hemostasis

Post-operatively

Post operatively

VHI: 27

MPT: 23 seconds

STUDY DESIGN

Coblation

Laryngeal Cobalation Wand

Redesigned wand

Longer with small head

Initial wands faulty

Coblation Pre-post Pre post

Methods

Canine Model – 4 dogs

IACUC approval

Coblation Injury Performed

3 settings

Animal Sacrificed on POD #0, 4, 7, and 28

Stroboscopic Images obtained prior to sacrifice

Larynges harvested and sent for pathologic

evaluation

Dogs do not have a deep layer of the lamina

propria


Re-epithelialization

Re epithelialization

Preservation of

underlying muscle

Remodeling of

collagen in the SLP

H+E day 28

Day #28

Trichrome, Trichrome,

Post-op Post op day 28

Area of

remodeling

collagen

No injury to

underlying muscle

Day #28

Verhoff–Elastin

Verhoff Elastin, , Post-op Post op day 28

Elastin fibers have

regained their

orientation

Can now again be

seen as black dots

Trichrome (Collagen, muscle, fibrin,

and RBCs), RBCs , Post-op Post op day 7

Remodeling in the

periphery of the

initial injury

Complete epithelial

re-growth re growth over the

area of injury

In the middle of

slide, new blood

vessels forming

Verhoff–Elastin

Verhoff Elastin, , Post-op Post op day 7

Elastin fibers

remodelling on right

side of injury

Full epithelialization

has occurred

Elastin fibers well-

oriented at

periphery of injury

Teflon Granulomas

Difficult to manage

No easy technique

Lasers-too Lasers too much heat and sparking

Microdissection-too Microdissection too much bleeding

Microdebriders-poor Microdebriders poor control deep in the tissue,

bleeding needs to be controlled

Coblation: Coblation:

three patients

Quick procedure


Recurrent Respiratory

Papillomatosis

Prior tracheal diversion for papilloma

Post Coblation Ventricular Granuloma

Granuloma Hemangioma


Neurofibroma

Challenging case 2

Conclusions

Coblation in the Larynx

Solid animal evidence of

mechanism of action and safety

Currently being used for

papillomas

? Role on free margin of the vocal

folds

May be indicated in

inflammatory or vascular lesions

Granulomas

Neurofibromas

Hemangiomas

Congenital or acquired.

Phonotrauma.

Phonotrauma

Surgery required.

Vocal Fold Cyst

Vocal Fold Cyst, Pre-op Pre op VHI:72, MPT: 15


Excision of Vocal Fold Cyst

Microflap – Incise Mucosa

Microflap – Dissect Deep to

Lesion

Courtesy Rosen/Simpson

Courtesy Rosen/Simpson

Right vocal fold cyst 5 weeks post

excision

VHI: 14, MPT:32

Microflap – Elevate Flap

Microflap –Release Release

Anterior/Poster Attachments

Courtesy Rosen/Simpson

Courtesy Rosen/Simpso


Microflap – Re-Drape Re Drape Flap

Courtesy Rosen/Simpson

Surgical Excision of Vocal Fold

Cyst

Incision through

overlying mucosa.

Elevate mucosa over

cyst.

Remove cyst without

rupturing it or

damaging vocal

ligament.

Preserve all normal

mucosa if possible.

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