title: Management of vocal fold lesions in difficult laryngeal exposure patients in phonomicrosurgery.
abstract: OBJECTIVE
  Endolaryngeal microsurgery using a direct laryngoscope is a well-established procedure in phonosurgery. Adequate laryngeal exposure is essential, but in some cases sufficient view of the glottis cannot be obtained, leading to treatment failure. This study reports how to manage vocal fold lesions in difficult laryngeal exposure (DLE) cases.
  
  
  METHODS
  From 2003 to 2009, 212 patients underwent endolaryngeal microsurgery at Kyoto Medical Center and Kyoto University Hospital. Phonomicrosurgery was performed under sniffing (Boyce-Jackson) position with triangular shaped laryngoscope for laryngeal exposure. However, in DLE cases, the posture and laryngoscope were modified as needed to adequately expose the lesion. Fiberoptic laryngeal surgery (FLS) with local anesthesia was also used for the most difficult cases.
  
  
  RESULTS
  The number of the patients with DLE was 14 (6.6%). Endolaryngeal microsurgery was possible in DLE cases by selecting the appropriate posture and laryngoscope. However, the procedure could not be completed in two patients with an anterior web and a vocal fold cyst, both of which required a subsequent revision procedure. Fiberoptic laryngeal surgery with topical anesthesia was a feasible alternative for these cases.
  
  
  CONCLUSIONS
  Phonosurgery was possible even in DLE cases. It is important to modify the setup of direct laryngoscopy as needed to obtain adequate exposure. Fiberoptic surgery may also be used in certain difficult cases.
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan. s_ohno@ent.kuhp.kyoto-u.ac.jp
authors.forename: Satoshi
authors.initials: S
authors.lastname: Ohno
authors.forename: Shigeru
authors.initials: S
authors.lastname: Hirano
authors.forename: Ichiro
authors.initials: I
authors.lastname: Tateya
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Kojima
authors.forename: Juichi
authors.initials: J
authors.lastname: Ito
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004867:Equipment Design; D005260:Female; D006801:Humans; D007818:Laryngeal Diseases / Q000601:surgery*; D007822:Laryngeal Neoplasms / Q000601:surgery*; D020704:Laryngoscopes; D008297:Male; D008866:Microsurgery / Q000295:instrumentation*; D008875:Middle Aged; D056888:Patient Positioning; D012008:Recurrence; D012086:Reoperation; D014827:Vocal Cords / Q000601:surgery*; D014832:Voice Disorders / Q000601:surgery*; D055815:Young Adult