Innovations and Challenges in Vocal Fold Surgery with Prof Nupur Nerurkar

In this episode, host Natalie Watson speaks with keynote speaker Prof Nupur Nerurkar, who joined the Cutting Edge Laryngology Conference 2024 in London. Nupur shares her expertise on vocal fold cysts, sulci, and mucosal bridges, detailing insights from her research and clinical practice. She discusses advancements in diagnosing and treating these challenging conditions, including her laser-assisted techniques and classifications that aim to improve outcomes for patients.

Prof Nerurkar also highlights the role of hydration in preventing vocal fold cysts, the importance of tailored surgical techniques, and the significance of involving speech therapists in post-surgical care. The conversation concludes with a look at mucosal bridges, their complexities, and opportunities for future research.

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Transcript

Host Natalie Watson

Hello and welcome to the BLA Connections: A Clear Voice, Series 6 - this is the finale! We'll be closing with a collection of five podcasts, which we recorded back at Cutting Edge Laryngology, 2024 in London, UK. We have three amazing keynote speakers, Marc Remacle, talking about his 30 years; ‘What did I learn?’ Anais Rameau from New York, talking about AI and the future of laryngology. And Nupur Nerurkar on vocal folds, cysts, sulci and mucosal bridges.

We also listened to Martin Birchall and Marc Remacle talk on hard and soft robotics. Martin was one of our previous presidents. And we finally have the remarkable, amazing Professor David Howard, our first president of the BLA, talking about his career in laryngology, and also what he's doing now and what he is planning to do in the future.

With regards to Cutting Edge 2024, we're very pleased to announce that all the talks and presentations are live on talking slides, which you can access if you're a BLA member or delegate of the conference. We hope that you enjoy our podcast. Please do have a listen.

Host Natalie Watson

Welcome to the BLA Connections: A Clear Voice. My name is Natalie Watson. I'm your host today, and welcome to Cutting Edge Laryngology 2024. I'm delighted today to introduce Nupur Nerurkar from Bombay Hospital. We're delighted that she joined us for this whole conference as a keynote speaker, and today she wowed us with information about vocal cysts, vocal sulci and mucosal bridges. So welcome.

Nupur Nerurkar

Thank you so much. It's indeed a pleasure for me to be back at Cutting Edge Laryngology. I did attend the very first conference in 2011 and it's always a fantastic meeting, which I look forward to.

Host Natalie Watson

Well, and we're pleased because we have a prize winner in today! You won the David Howard prize in 2012?

Nupur Nerurkar

I did, and that was the conference, I think, which was held in Malaysia? And it was a big high for me and my career. And so it means a lot that I'm now, after 12 years, a keynote speaker.

Host Natalie Watson

Oh, it's amazing. Well, let's go through and dissect (excusing the pun), the three main areas of your talk today. So you started with vocal cord cysts, can you expand on that?

Nupur Nerurkar

So first of all, I call this cyst sulci mucosal bridge, a difficult family, because very often all three of them are found in association with one another, and all three of them can be challenging to diagnose and then also treat. So therefore, ‘the difficult family’. So I started my talk with vocal fold cysts. And we do see a lot of cysts in our practice. In fact, interestingly, over the last 10 years, we seem to be operating on more cysts than even vocal fold polyps, which we find a very interesting phenomena, because typically it's vocal fold polyps which are the commonest benign, glottic lesions, one excises. But I think this is something which other people also have found more and more cysts. So we did a little bit of research to try and understand, why are we seeing more cysts?

And in a nutshell, what our research showed us, and this is published in the Laryngoscope, in 2020, is that possibly there is some correlation with drinking less water, or decreased hydration. So we did find that people who have less than maybe four glasses of water a day, or who have more than eight caffeinated beverages, may have an increased chance of developing maybe thick secretions which block the serum mucinous ducts, which may result in the formation of the mucus retention cyst variety, which is 92% of the cysts that we are excising in our practice. So that's a simple kind of take home as far as the cyst is concerned.

But with cysts also, I think what I like to highlight on is the importance of a complete excision, because you have cysts in other places in the body where you can marsupialise them, and just take the hood out, and leave them be, but on the vocal fold, because the skin grows back, if even a teeny bit of epithelium is there on the cyst wall, then the chance of recurrence is pretty high. So even if the cyst bursts during surgery, I think what's important is to get the whole cyst wall out. If you have a laser in your armamentarium, then it becomes very helpful for that little bit of cyst wall. But of course, the surgeries can be done as nicely with cold steel, also with people who are familiar with the micro laryngeal and phonomicro surgery. So I think that was primarily my takeaway thing with the cysts.

Host Natalie Watson

Perfect. And I loved your videos. She shared beautiful videos of your phonosurgery. And if I may ask about your CO two lasering? I mean, you wielded it like it was, like a magic wand! And when you use it, what settings are you using?

Nupur Nerurkar

I love your question, because, in fact, some of the delegates who were attending did ask me exactly the same question. And even in the annual workshops we have in Bombay Hospital, one of the most popular questions is, what is the power? Specifically, the question is, what is the power you're using with your laser? So typically, I use a CO2 laser. And what I keep trying to highlight is that power is not the only factor, and power has no meaning if you don't talk about the other two very important parameters. The power will tell you (which we measure in Watts), as to the strength of the current, yes, of the laser beam. But you need to know in what source area is that power getting distributed? Because 10 watts in one millimeter of area, and 10 watts in 10 millimeters of area, is very different. And then you get the third variable in, which is the time factor; how many seconds is the laser beam on? And then how long have you given for the cooling time? And then how quickly does it come on again? So when we have all these three variables together, then it's called the ‘fluence’ of the system. And that's what you really want to know, because just the power and the surface area, that's irradiance, like a bulb as irradiance. But when you get the time factor in also, then that gives you the fluids. So you must have the perfect fluence for every laser system, typically, five joules per centimeter square is the perfect fluence. And the lasers are almost like mini robots, they have it all integrated in. So when you put it on, it typically shows you the best fluence for the system. And that's how we use it, in Super pulse mode and not continuous, because that's like, continuous means that heat dissipation is happening all through, there's no cooling time.

So you were right that it almost is like a magic wand, really. Using the joystick takes away all those little bits of shakes that the hand develops over age. And because the joystick can be moved by 360 degrees and upward, downward, etc. It's like the beam can just move so beautifully while you're operating. And as you get more familiar with it, it's not that your eyes are moving away, your hand is just moving, and you're seeing what's happening at the point of surgery. So I love using the laser.

Host Natalie Watson

Oh yes, I can see. It's beautiful. So moving on to sulci? You discussed that in detail, and you were talking about classifications, and whether or not you had polyps involved?

Nupur Nerurkar

For some reason, we seem to see a lot of sulci in India, as compared to the rest of the world. In fact, we are currently doing research which is multi institutional in various countries of the world, to try and see what are their demographics of sulcus. But basically, sulcus is like a depression in the vocal fold. It may be along the whole length when it's known as vergeture, or just a particular area where it's called a sulcus vocalis. And these were classifications put forth by Bucha many years ago.

So the challenge with sulcus is, first of all, very difficult to diagnose, sometimes if they are superficial, even with stroboscopy or high definition imaging. And the second challenge is because it's so difficult to even see, that to quantify the length of the sulcus, or the depth of the sulcus, can be very challenging. So if you are operating on a sulcus which is really deep, and I'm operating on sulcus which is superficial, the results of surgery are bound to be different. So therefore, we've proposed a classification which is after general anesthesia. When you can see the sulcus under high bar, you can palpate it, you can infiltrate and see the depth. And then we've given a classification on my name, called the Nerurkar classification. And then we've described a new type of surgery, if I may, called the laser assisted sulcus release.

Host Natalie Watson

I loved this!

Nupur Nerurkar

For this condition, it's a very simple surgery. The surgery is so simple, anybody who has a laser can do it because it's just simple. Which I think, when one is doing surgeries, if it's simple, it's just easy to replicate for others. If it's very cumbersome, suturing in the vocal fold, its cumbersome. The problem is that the healing is not easy, and it's not predictable for every patient. So when we are doing these small laser cuts to release the medial and the lateral lip of the sulci, we're trying to keep intervening mucosa, so that you have a raw area epithelium, raw area epithelium, and then the pockets fill in. If the new epithelium grows in the same plane, the healing is better. But we've seen even with the deeper sulci, when we cut the ligament, the healing is very often good. Maybe the muscle fills in the gap. It's possible.

What was very striking in our study, retrospectively done, was that people who were younger, under 21 years, seemed to do so much better than people who were older. Maybe there's something about neuroplasticity involved in this. And the other thing about this surgery is that in sulcus, typically, you have the pitch go up, with this surgery, the pitch does not drop. So that's a disadvantage in males. The females don't mind a high pitch, but it's a definite disadvantage in the male population. And we have always the speech language pathologists involved in all of our surgeries. In this particular surgery, they are so critically important because after the seven to 10 day voice rest, which we give these patients to allow for the primary epithelization. The SLP comes in, starts with the relaxation therapy, by one month, we do a repeat strobe, if everything is healing well, then they start with the strengthening therapy. And then by two months, they put the patient onto a maintenance therapy, and usually the complete healing happens, you know, by three months time. So we tell the patients preoperatively that it's not a quick fix and you need to do your bit of the work. It's a two way thing, and otherwise it's not going to do well. So that's something we definitely have a long discussion with the patient before we venture into surgery, and we typically wait for the patient to say, I've done enough therapy, can I have the surgery, please? So then they are committed.

Host Natalie Watson

Yes. Question about the sulci. When you have, sometimes you have two kind of parallel on the same vocal cord, can you still use this for those as long as you're keeping enough mucosa in between?

Nupur Nerurkar

Exactly, absolutely. So we've had patients who have four sulci, two on either vocal fold. And we do the infiltration, which is very important because it plays apart the medial lateral lip of both the sulci, and gives you a little bit of more space  with Seline adrenaline, 1 in 10,000, and then we do the LASR on medial lateral lip of both the sulci. But just keeping in mind that we want that tiny bit of epithelium in between every cut. As long as the anterior commissure is respected, which is the anterior most three millimeters on either side, we're okay to operate bilaterally without worry of anterior glottic web or synetic formation. So we do the surgeries bilaterally, yes.

Host Natalie Watson

Perfect. Now your final part of the talk was all about mucosal bridges, which is a real heart sink, particularly, I always see them in professionals, and it's like, oh, what do you do?

Nupur Nerurkar

What do you do, yes? So really, there is no straight answer to that, because I don't think anyone knows what you do. We don't really have any very standardised results, because, unfortunately, mucosal bridges are usually found in association with other lesions, and you're taking care of those other lesions usually, whether it's a cyst or a polyp, so that when you take care of the voice improves. So you don't know your handling of the mucosal bridge, did it help or not? But I think common sense wise, the thin epithelial mucosal bridges, whether you leave them or excise them, I don't think it matters too much. But when the mucosal bridges are thick, and some, as you saw in today's presentation, were really thick. If you excise those, then your vocal fold volume gets like really, half, almost and then you're going to be fighting because of a lot of breathiness, and then augmentation of that vocal fold. So I would definitely not recommend excising the thick mucosal bridges. Maybe one could consider making the opposing surfaces raw and even just leave them and they tend to stick with one another. But as you saw in one of the patients, even when I did nothing to the thick mucosal bridge, it worked fine.

The question is, long term, was that thick mucosal bridge, over time, responsible for the polyp formation, is the question. Maybe one could consider getting them together with fibrin, glue or suture. It's an area which I think is asking for research, as is sulcus I think. There's a lot of opportunity for us to do a lot of research here, and I have introduced a new type of mucosal bridge, called the incomplete mucosal bridge, which is also something which we've been seeing, where you have a slit, you palpate a slit, but the instrument kind of just enters into a like a slid, slides down a cave, so to speak. And it's like a mucosal bridge which just didn't manage to open up near the laryngeal introitus. So I don't know what the clinical significance of that is, but we do see a lot of incomplete mucosal bridges too. Yeah,

Host Natalie Watson

Yeah and as you were saying, refreshing the edges, a bit like a tympanoplasty, which we're used to doing a little pepper pot type of stamp area, and then trying to refresh the edges to try and promote some healing. So that's the only thing that I've really ever done with the mucosal bridges.

Nupur Nerurkar

And I think that less is more. Yes. I think so.

Host Natalie Watson

Yes. Brilliant. What an amazing summary. I always find with the keynote lectures and speeches that you present all this data, it takes about 40 minutes to present, but you can tell it's taken years. Every one slide is like 10 years worth of work to get to that point. So it's just amazing how you can just summarise your career to date, and your research to date, in just such a short period of time. But we thank you so much for summarising it all today for the podcast, and we appreciate you coming all the way to London.

Nupur Nerurkar

I'm delighted to be here for Cutting Edge Laryngology 2024, it's a delight, and I'm so happy to be given this opportunity, and lovely to meet with you.