Phonosurgery is a term that was adopted in the fall of 1963 over a conversation about the surgical potential for enhancement of vocal function between Hans von Leden and Godfrey Arnold in a bar of the Roosevelt Hotel in New York. Phonosurgery refers to any surgery designed primarily for the improvement or restoration of the voice. The term is often confused with phonomicrosurgery, a term referring to the convergence of theories that guide endoscopic vocal fold surgery with theories that explain voice production. The underlying premise of the surgical approach of phonomicrosurgery is that optimal postoperative voice will be achieved, if there is maximal preservation of the vocal fold's structure.
Phonomicrosurgery is one of the newer surgical modalities in the armamentarium of the otolaryngologist and is fundamentally rooted in the historical development of improved visualization and surgical manipulation of the vocal folds. An attempt at understanding the concept of voice production can be traced back to ancient Egypt dating to 3000 BC, when the voice was believed to be a magic or religious phenomenon originating in the lungs. The Egyptians had a great respect for the lungs and depicted them often, but they may not have had any awareness of the relation between respiration and voice.
The Greek physician Claudius Galen (Clarissimus, 130–200) was probably the most influential medical author of all time. He is accepted as the founder of laryngology and certainly the godfather of phoniatrics and voice science. Galen taught that the “trachea prepares and prearranges the voice for the larynx (the cartilages) increase it and it is still further augmented by the vault of the throat, which acts like a sounding board” ! (De usu partium VII, 5).
Galen's work undoubtedly influenced the great Persian physician, philosopher, statesmen and poet, Abu Ali Al Husayn Ibn Sina (Avicenna, 980–1037). Ibn Sina's sentinal work, Al-Qanun fial-Tibb or Canon of Medicine, was considered a Medical Bible for a longer period than any other work and some argue that it is the most famous book ever written. The Quanun includes important data on laryngeal anatomy and physiology and devotes a whole chapter to production of voice and voice disturbances. Five hundred years after its publication, the Quanun was still a required textbook at the University of Vienna and other major continental and British universities.
The phonating larynx was visualized directly only recently. Bozzini was the first individual to report on mirror visualization of the larynx in 1807. He designed an ingenious handle that housed a candle with a reflector as an artificial light source. A variety of speculae could be attached to the universal handle for examining different body cavities, including one speculum that had a self-contained mirror for examining the larynx. Bozzini's brilliant concept of employing an extracorporeal light source to illuminate the internal body cavities is the guiding premise of all endoscopy.
In 1854, a Professor of Voice of the Conservatoire in Paris, Manuel Garcia, used a small dental mirror to reflect the light of the sun on his own larynx and visualized the phonating organ on a hand mirror. This independent discovery of mirror laryngoscopy was presented to the Royal Society of Medicine in a report on the Physiological Observation on the Human Voice on March 13, 1855, and stimulated new interest in the medical community in the application of this technique for the management of laryngeal disease.
Ludwig Türck was the first physician subsequent to Garcia's presentation to adopt mirror laryngoscopy; however, he depended on sunlight for illumination. The ability to see the larynx well was catalytic for making transoral, mirror-guided surgical manipulation reliable and effective.
The adaptation of the surgical microscope for magnification of the endolarynx was a key to the evolution of phonomicrosurgery. Microlaryngoscopy arose from the need and desire to perform more precise vocal fold surgery. Microscopic visualization of the vocal folds was described first in 1954 by Professor Rosemarie Albrecht of the Medical Academy in the German city of Erfurt. Albrecht adapted the microscope for laryngeal diagnosis as an attempt to emulate the success of her gynecologic colleagues in diagnosing early malignancies of the uterine cervix. The credit for the perfection of this technique 4and popularizing the art and science of microlaryngoscopy belongs to the Austrian, Professor Oskar Kleinsasser. Initially, he used different loupes for magnification but the results were less than encouraging. Gradually, he enlarged and tapered the laryngoscope until he was able to accomplish binocular vision and bimanual surgery. By 1962, Kleinsasser had adapted the Zeiss microscope for selected cases of laryngeal diagnosis. Shortly thereafter, Zeiss developed a 400 mm focal length lens that permitted the use of the long-handled laryngeal instruments for precision surgery on the vocal folds with vastly improved functional results.
Surgical improvement of the human voice by a systematic approach to surgery of the laryngeal skeleton was presented by Nobuhiko Isshiki. In a seminal article, Isshiki and colleagues described four basic procedures to alter the laryngeal skeleton and thereby, the resulting voice. These four operations lengthen or shorten the vocal folds and compress or expand the interior of the larynx. Since his original description, Isshiki has modified some of these basic steps to improve the functional results and has also designed a series of new procedures to achieve this objective. A more comprehensive review of the history of voice surgery can be found elsewhere.1
Phonomicrosurgery reflects the convergence of theories that guide endoscopic vocal fold surgery with theories that explain voice production and the contributions of the numerous physicians to this science far exceed the breadth of this chapter. The underlying premise of this surgical approach is that optimal postoperative voice, which is observed as a pliable vocal fold cover, will be achieved if there is maximal preservation of the vocal fold's layered microstructure. Today, the laryngologist may select from a variety of instrumentation to help achieve the optimal surgical result.
Laryngeal surgery may be performed endoscopically (indirect or direct) or through an external approach. Laryngeal surgeons should understand and master all approaches in order to provide optimal care. Most surgical procedures for voice disorders can be performed endoscopically, obviating the need for external incisions and minimizing the amount of tissue disruption. Although endoscopic microsurgery seems intuitively more “conservative”, this supposition holds true only when the equipment provides good exposure of the surgical site and the abnormality can be treated meticulously and thoroughly with endoscopic instruments. When endoscopic visualization is not adequate because of patient anatomy, disease extent or other factors, the surgeon should not compromise the results of treatment or risk patient injury by attempting to complete an endoscopic procedure. In such patients, it may be safer to leave selected benign lesions untreated or to treat the pathology through an external approach.
This atlas reviews selected approaches and procedures for vocal fold surgery. While it focuses almost exclusively on endoscopic surgery, a few of the most common nonendoscopic procedures have been included as well. Extensive additional information on these topics is available in other literature.2–9
CONCLUSION
The large part of the history of laryngeal surgery is devoted to the removal of neoplasms with potential improvement in voice as only an afterthought. Additional information can be found in other sources.10 Although there have been attempts to improve the voice in the past, only during the last 30 years have concerted international efforts established reliable and effective procedures for transforming the human voice. Improved understanding of the physiology of voice among surgeons has led to enlightened advances in surgical technique theory. These principles have been joined with the technological developments of microlaryngeal surgery and have led to current concepts of phonomicrosurgery.
REFERENCES
- von Ledon HL. A Cultural History of the Larynx and Voice. In: Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. Plural Publishing, Inc.; San Diego, CA: 2005. pp. 9–88.
- Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. Plural Publishing, Inc.; San Diego, CA: 2005.
- Rubin J, Sataloff RT, Korovin G. Diagnosis and Treatment of Voice Disorders, 3rd edition. Plural Publishing, Inc.; San Diego, CA: 2006.
- Fried MP, Ferlito A, (Eds). The Larynx. Plural Publishing, Inc.; San Diego, CA: 2009.
- Ossoff RH, Shapshay SM, Woodson GE, et al. The Larynx. Lippincott, Williams and Wilkins; Philadelphia, PA: 2003.
- Rosen CA, Simpson CB. Operative Techniques in Laryngology. Springer-Verlag; Berlin: 2008.
- Tucker HM. The Larynx, 2nd edition. Thieme; New York, NY: 1993.
- Zeitels SM. Atlas of Phonomicrosurgery. Singulair Publications; San Diego, CA: 2001.
- Isshiki N, et al. Thyroplasty as a New Phonosurgical Technique. Acta Otolaryngol. 1974;78(5–6):451–7.
- Zeitels SM. The History and Development of Phonomicrosurgery. In: Sataloff RT. Professional Voice: The Science and Art of Clinical Care, 3rd edition. Plural Publishing, Inc.; San Diego, CA: 2005. pp. 1115–36.