The image is showing cordotomy incision(grey dotted line) on the posterior part of the right vocal cord. Surgery is performed under the effect of general anesthesia. The correct position of the patient is mandatory for the ideal introduction of laryngoscope. Preferably the patient should lie flat on the operating table without any head ring or sand bag beneath the shoulders. Before introduction of the laryngoscope, dental plate should be put in place. After tracheotomy, with a<unk> -safe endotracheal tube the patient is intubated with an ample exposition of the glottis. A small<unk> -protected endotracheal tube is placed in case there is no pre-existing tracheotomy. A modification to this technique is made by using<unk>  CO2<unk>  posterior cordotomy without tracheotomy to not compromise respiration by minimising the postoperative edema. This modified procedure involves a judicious excision of 3.5–4 mm C-shaped wedge in posterior vocal cord from the open edge of the membranous cord using carbon dioxide<unk> . Excision is made anteriorly to the vocal process, continuing 4 mm<unk> ally on to the ventricular band without exposing the cartilage. A 6–7 mm transverse opening is created at the posterior larynx by the surgical resection. To avoid unwanted effects of general anesthesia and prevent any infection during the operation, antibiotics, steroids, and H2 blockers are administered intraoperatively. Technique The image is showing the result of cordotomy incision on the posterior part of right vocal cord. The procedure begins with orotracheal intubation using a<unk> -safe endotracheal tube. The eyes of the patient are padded and taped followed by draping of the head and application of upper tooth guard. When the patient is anesthetized sufficiently and full relaxation is seen. The largest feasible laryngoscope is introduced, to obtain a good view of the larynx. After positioning of the laryngoscope, it is fixed in place with the help of the chest holder. The light carrier is withdrawn after the adjustment of scope in desired position and then the operating microscope is introduced. The head and face of the patient is protected with moist towels. Then the operating microscope fitted with 400 mm lens and a microspot CO2<unk>  is brought in position. The endotracheal tube cuff is protected by a moist cottonoid sponge placed in subglottis. The site for the cordotomy is determined at the preoperative examination. If any one of the vocal fold seems to have a slightest degree of motion, then cordotomy is performed on the other one. Using CO2<unk>  with a spot size of 0.2 mm and power of 3-5 Watts, a cordotomy is performed 1-2mm anteriorly to the vocal process. This is then carried<unk> ally to the thyroid lamina through the width of the vocal ligament and vocalis muscle. The cordotomy provides access to the arytenoid cartilage as well as opens the airway posteriorly. Postoperative Care After the operation, the patient is slightly immunocompromised, so to avoid infection by opportunistic organisms, oral antibiotic therapy is given for 1 week. Anti -gastroesophageal reflux treatment is given for 8 weeks to avoid the gag reflex occurring due to post operative edema. The patient should be advised to take absolute voice rest by avoiding coughing, singing and clearing of the throat. Coughing can be treated with cough suppressing and mucolytic agents. Inhalation of steam is advised twice daily. Follow-up endoscopy with flexible endoscopes is performed 3 days after the procedure, to clean up the fibrous residues. Once the mucosal healing is complete, the patients with tracheotomy can be decannulated within 6 weeks of the procedure.
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