Robotics in Laryngeal Surgery While transoral laser microsurgery (TLM) has been the gold standard for laryngeal surgery for many years, recently transoral robotic surgery (TORS) has become a new treatment option not being restricted to a straight line of view which can be an obstacle during resection. In combination with specifically designed retractors TORS can provide a superior visualization and allows tissue manipulation especially in the narrow working space of the larynx. The present article describes the commercially available robotic systems suitable for transoral surgery in adult benign laryngeal masses and highlights on the use of TORS retractors.

Lasers in laryngeal surgery The use of lasers in laryngology has evolved over the last several decades. With improving optics, instrumentation, and applications for treatment, lasers are now routinely used during laryngeal surgery performed in both the operating room and clinic settings. A variety of laser types, including carbon dioxide (CO2), potassium titanyl-phosphate (KTP), and pulsed-dye lasers, are used to treat an array of benign laryngeal lesions. Otolaryngologists can now consider the use of lasers to treat benign vocal fold lesions including vocal fold polyps, varices/ectasias, scar, granulomas, recurrent respiratory papillomatosis, Reinke's edema, and nodules, among others.

Surgery for Vascular Laryngeal Lesions Vascular lesions of the larynx are those created by phonotrauma resulting in subepithelial bleeding. These are typically divided into two categories, hemorrhagic polyps and fibrovascular lesions (vocal nodules). Both of these types of lesions can disrupt the natural vibration of the vocal folds and cause dysphonia. In those patients whose voices are their livelihood, complete removal with preservation of as much normal superficial lamina propria and squamous epithelium is paramount. Here, we describe proper in office assessment with stroboscopy, options for treatment and techniques in surgical excision.

Surgical Anatomy of the Larynx This article provides a review of the surgical anatomy of the larynx. The external cartilaginous and bony framework of the larynx are described in relation to how these structures can be used as landmarks to identify internal features of the larynx. The overlying musculature of the larynx is also detailed. The spaces of the internal larynx are explained including the pre-epiglottic, para-glottic, and cricoid area by their borders and contents to assist in orienting the surgeon. The course of vasculature and nerves within the larynx is described in detail.

Operative management of benign nonepithelial solid laryngeal tumors Most benign tumors of the larynx are epithelial in origin, with nearly 85% being laryngeal papilloma. Nonepithelial laryngeal tumors are uncommon and more than 50% of these are malignant. Therefore, benign nonepithelial solid tumors of the larynx are quite rare. The management of these tumors varies based on the site of origin, specific pathology, tumor size, and risk for malignant transformation. Most are ultimately treated with complete surgical excision, although the potential response of the tumor to adjuvant therapy may play a role in decision making.

Surgery for adult laryngeal papillomatosis Recurrent laryngeal papillomatosis is a viral (human papillomavirus) disease that causes the growth of epithelial verrucous lesions. Patients with laryngeal papillomatosis undergo multiple surgeries due to the tendency of the lesions to reoccur and cause recurrent voice and breathing problems. The goal of the surgical treatment is to remove the lesions while protecting the delicate layered structure of the vocal folds in order to prevent scarring and permanent damage to the mucosa. This is a review of the currently performed operative procedures for treating recurrent adult laryngeal papillomatosis.

Endoscopic surgical approach to laryngoceles and saccular cysts Laryngeal saccular disorders are rare lesions presenting as abnormal saccular dilation, either mainly filled with air (laryngoceles) or fluid (saccular cysts). These are further categorized as internal when confined in the endolarynx, external, or combined. In adults, saccular disorders are mostly idiopathic with various reported proportion associated with laryngeal cancer or increased transglottic pressure. Patients may present with voice disorders, respiratory or swallowing issues. Workup should include directed history taking, laryngeal endoscopy, neck examination and imaging.

Open surgical approach to laryngoceles and saccular cysts Saccular disorders extending beyond the thyrohyoid membrane are classified as external, or combined, based on to their extension beyond the thyrohyoid membrane and the proportion of the external to the internal component. The workup is the same as for internal saccular disorders and airway safety is of utmost importance. The open/transcervical approach is currently the treatment of choice for cases with relatively large external component. Endoscopic approach was also reported for combined lesions with a relatively smaller external component.

Airway management in laryngeal surgery Airway management and anesthesia for laryngeal surgery poses many challenges. A preoperative endoscopic airway examination and discussion with the otolaryngologist helps in planning the anesthetic management. Although, securing the airway using specialized endotracheal tubes is possible in the majority of cases, the surgeon may occasionally request a ‘tubeless’ field. This can be achieved by ventilating the lungs using jet ventilation or high flow nasal oxygen (HFNO) while providing total intravenous anesthesia.

Instrumentation in endoscopic laryngeal surgery The development of transoral endoscopic approaches to the larynx have revolutionized the way we evaluate and treat various laryngeal pathologies. Nowadays, there is a large spectrum of laryngoscopes to address the various age groups, clinical needs, laryngeal pathologies, and subsites. The current paper is a review of some of the various laryngeal instruments used today in the evaluation and treatment of laryngeal pathologies, The review will cover some of the different means for evaluation of the larynx, various sizes and shapes of laryngoscopes, unique subsites in the larynx for which special laryngoscopes have been developed and finally will offer a number of pearls that may assist in achieving the best exposure and treatment outcomes.