Milutinović Z
Department of Otorhinolaryngology, Maxillofacial and Cervical Pathology, Zemun Clinical and Hospital Centre, Belgrade.
Srp Arh Celok Lek. 1996 Sep-Oct;124(9-10):236-40.
The aim of phonosurgery is to improve the state of voice and speech, while surgical treatment of benign vocal fold lesions belongs to the category of extirpation phonosurgery. Excellent functional results can be achieved with the aid of modern light sources and monitoring systems [8-19]. The aim of this study was to stress the advantages and shortcomings of direct suspension microlaryngoscopy, indirect microstroboscopy and indirect videostroboscopy, as well as indications for their use.
Over a 10-year period 1550 patients with benign lesions of the vocal folds were operated by direct microlaryngoscopy, indirect microstroboscopy and indirect videostroboscopy. Basic parameters which influence the selection of a particular surgical method were established, while a comparison was made among these various surgical techniques.
Our surgical experience led us to conclusion that indirect procedures should be used in the majority of functional benign lesions of the vocal fold (Table 1). Selection of a particular surgical technique depends on several parameters (Table 2). Indirect procedures are indicated for small lesions with narrow base and with a distinct demarcation to the vocal tissue. Other cases are better approached by direct microlaryngoscopy, which is also indicated for submucosal lesions, sulcus vocalis etc., when bimanual instrumentation is required. Unfavourable local anatomy and "difficult" localization of a lesion (anterior commissure and posterior glottis) are better approached by indirect videostroboscopy. Indirect surgery is also required for cases when direct microlaryngoscopy is contraindicated and vice versa (contraindication for general anaesthesia or insufficient effect of epimucous anaesthesia). The patient should be allowed to express his preference for a particular surgical technique.
Binocular vision and bimanual procedure are significant advantages of direct microlaryngoscopy, related to indirect procedures. However, some inadequacies of this technique and advantages of indirect procedures with modern light sources, magnification and videostroboscopic control make, in our experience, indirect videostroboscopy a procedure of choice for about two thirds of functional benign lesions of the vocal fold. Indirect videostroboscopy is technically simpler in relation to indirect microstroboscopic surgery, while indications for direct microlaryngoscopic and indirect videostroboscopic surgery are complementary. Laser surgery should be avoided in functional benign lesions of the vocal fold for its inferior functional results [25, 26].
嗓音外科手术的目的是改善嗓音和言语状况，而良性声带病变的外科治疗属于切除性嗓音外科手术范畴。借助现代光源和监测系统可取得优异的功能效果[8 - 19]。本研究旨在强调直接悬吊式显微喉镜检查、间接显微频闪喉镜检查和间接视频频闪喉镜检查的优缺点及其使用指征。
在10年期间，对1550例声带良性病变患者进行了直接显微喉镜检查、间接显微频闪喉镜检查和间接视频频闪喉镜检查。确定了影响特定手术方法选择的基本参数，并对这些不同的手术技术进行了比较。
我们的手术经验使我们得出结论，对于大多数声带功能性良性病变应采用间接手术方法（表1）。特定手术技术的选择取决于多个参数（表2）。间接手术适用于基底窄且与声带组织界限分明的小病变。其他情况采用直接显微喉镜检查更好，当需要双手操作器械时，直接显微喉镜检查也适用于黏膜下病变、声带沟等。局部解剖结构不利以及病变“定位困难”（前联合和后声门）的情况采用间接视频频闪喉镜检查更好。当直接显微喉镜检查禁忌时（如全身麻醉禁忌或黏膜上麻醉效果不佳）也需要进行间接手术，反之亦然。应允许患者表达对特定手术技术的偏好。
与间接手术相比，双目视觉和双手操作是直接显微喉镜检查的显著优势。然而，根据我们的经验，该技术的一些不足之处以及间接手术在现代光源、放大倍数和视频频闪喉镜控制方面的优势，使间接视频频闪喉镜检查成为约三分之二声带功能性良性病变的首选手术方法。与间接显微频闪喉镜手术相比，间接视频频闪喉镜检查在技术上更简单，而直接显微喉镜检查和间接视频频闪喉镜检查的指征是互补的。对于声带功能性良性病变，应避免使用激光手术，因为其功能效果较差[25, 26]。
