A unique complication of microflap surgery of the vocal fold.

A 39-year-old woman (a nurse liaison) complained of a long-term rough and raspy voice. As a result, she said she was often mistaken for a man on the telephone. She had had a globus sensation for the previous 2 years. She was not a singer, but she did an excessive amount of talking as part of her job, and she used her voice extensively in social situations.

Her medical history was significant for multiple sclerosis and for active tobacco and alcohol abuse. A medical speech evaluation revealed that her speaking voice had a low fundamental frequency (101 Hz) and that she had a forceful upper thoracic breathing pattern. Significant and regular hard glottal onsets in her speech were also identified. Her voice handicap index (VHI) was 26, and she rated herself a 7 on a talkativeness scale that ranges from 0 to 7 (7 being the greatest amount of talking).

Laryngovideostroboscopy (LVS) showed bilateral diffuse vocal fold lesions that were consistent with Reinke' s edema (figure 1). In addition, reflux laryngitis was seen (erythema, edema, and cobblestoning of the posterior portion of the larynx).

[FIGURE 1 OMITTED]

A course of voice therapy and medical treatment for reflux was proposed to her, and she was encouraged to reduce her tobacco abuse. On followup, she was found to be both dysphonic and symptomatic despite compliance with her voice therapy and a reduction in smoking. Microsuspension laryngoscopy was performed with microflap excision of the bilateral Reinke's edema and with bipolar cautery of multiple ectatic vessels on the superior surface of each vocal fold.

On postoperative day 6, LVS showed a partial necrosis of the left microflap and the appearance of a mucosal bridge in the area of the left microflap (figure 2). She underwent additional voice rest for 6 days, but her voice did not improve, even though her right vocal fold was found to be healing well. She was returned to surgery and found to have a mucosal bridge in the region of the microflap on the left. The vocal fold tissue underneath the elevated mucosa had completely reepithelialized. The mucosal-bridge-like lesion was excised, and the patient was prescribed an additional 5 days of voice rest.

[FIGURE 2 OMITTED]

The patient was then treated with postoperative voice therapy and antireflux medication. Her 1-month followup visit revealed mild Reinke's edema, but a significant improvement in the quality of her voice, which was confirmed by a VHI score of 7. During followup visits over a period of 12 months, she continued to exhibit mild Reinke' s edema and a steady improvement in voice quality, without fatigue or breaks.

This case represents a unique complication of microflap surgery of the vocal folds. This complication might have been caused by an accidental incision of the inferior aspect of the microflap during the elevation or aspiration of the Reinke' s edema material. Other possible mitigating factors include poor compliance with postoperative voice rest and postoperative coughing.

From the Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, and the University of Pittsburgh Voice Center.