Arytenoid adduction and medialization laryngoplasty

Arytenoid adduction and medialization laryngoplasty have become the mainstay of static surgical rehabilitation of the larynx after vocal fold paralysis. The rationale for considering one versus a combination of the two procedures has not been well addressed. This article outlines the basic science of the procedures and the clinical technical modifications necessary to make the surgery easier.     

Arytenoid adduction technique for correction of paralytic dysphonia

Development of phonosurgical techniques like Medialization Laryngoplasty (M.L) or Thyroplasty has opened new horizons in the management of paralytic dysphonia. The Arytenoid Adduction (A.A) technique as originally described by Professor Isshiki of Japan, added a new dimension for improvement of voice in cases of paralytic dysphonia particularly in large posterior complimentary to medialization laryngoplasty over a period of 2 years are described.     

Aerodynamic, acoustic, and vibratory comparison of arytenoid adduction and adduction arytenopexy

HYPOTHESIS: Adduction arytenopexy (AP) with thyroplasty provides improved physiologic placement of the vocal fold and therefore provides improved acoustic, aerodynamic, and vibratory function as compared with arytenoid adduction (AA) with thyroplasty. METHODS: Five cadaveric human larynges were prepared by removing supraglottic tissues and fixing the nontest vocal fold medially on the cricoid facet with a needle in a physiologic phonating position. Each test vocal fold was then sequentially tested using an excised larynx phonation system, first with AA with silastic medialization and then converted to AP without changing the contralateral fold position or silastic wedge. The excised larynx setup allowed for simultaneous collection of data, specifically subglottic pressure (including measurement of phonation threshold pressure [PTP]), mean airflow, acoustic output, and full-frame high-speed digital video. RESULTS: Aerodynamic evaluation was similar for each group with similar subglottic pressure versus output curves. Conditions involving AP typically had PTP values that were 80% of that for comparable AA conditions. Acoustic evaluation revealed differences between the two groups. Each AA was found to be vibrating with two dominant frequencies with their associated harmonics. Each AP vibrated at a single dominant frequency with its harmonics. CONCLUSION: AP provides improved vocal outcomes by decreasing system noise and decreasing PTP, which may lead to a stronger glottal signal with decreased vocal effort.     

Controlled laryngoplasty for vocal cord medialization: a technique using tissue expansion

Laryngeal framework surgery has become an increasingly popular alternative to Teflon injection for vocal rehabilitation. Vocal cord medialization requires custom tailoring of the implant's size and shape to optimize individual vocal quality, whether it be via the interposition of Silastic implants between the thyroid ala and the inner thyroid perichondrium or through a cartilage window. A new technique is described for vocal cord medialization using an implanted miniature tissue expander. Intraoperative and postoperative vocal cord medialization was achieved in a canine model by controlled percutaneous filling of a remote injection valve. The implants were well tolerated and allowed continued control of vocal cord position for several weeks. Using this technique, vocal quality can be fine-tuned with a degree of precision not previously possible. The advantages, limitations, and technical aspects of expansion laryngoplasty are discussed.     

Sulcus vocalis: excision, primary suture and medialization laryngoplasty: personal experience with 44 cases

This is a prospective, cohort study to present personal experience on excision of sulcus, primary suture of defect and medialization laryngoplasty. An article about this subject is not present in medical literature. Forty-four patients with sulcus vocalis who were operated on by excision, primary suture of epithelial defect and medialization laryngoplasty were included. Pre- and postoperative evaluations included GRBAS, VHI-30, stroboscopy, aerodynamic and acoustic analysis. Grade, roughness and breathiness of GRBAS were significantly better postoperatively (p?<?0.05), whereas asthenia and strain were not (p?>?0.05). All VHI-30 results decreased significantly after surgery (p?<?0.01). Glottal closure and mucosal wave amplitude during stroboscopy improved significantly postoperatively (p?<?0.05), whereas symmetry and periodicity did not (p?>?0.05). Maximum phonation time, mean airflow rate, mean efficiency and mean pressure of aerodynamic analysis improved significantly after surgery (p?<?0.05). However, mean resistance and mean power were not significantly different (p?>?0.05). All parameters, except F ₀ and soft phonation index during acoustic analysis with /a/, and except F ₀, voice turbulence index and soft phonation index during acoustic analysis with constant phrase improved significantly after surgery (p?<?0.05). Surgical treatments of sulcus vocalis are not satisfactory enough, yet. Excision of sulcus, primary suture of epithelial defect and medialization laryngoplasty is one of the successful surgical options. Intact vocal ligament at the bottom of sulcus is a good prognostic sign for good postoperative voice result. Success appears to depend on how long, how wide and how deep sulcus is. Good patient selection may increase the percentage of happy patients.     

Functional significance of arytenoid adduction with the suture attaching to cricoid cartilage versus to thyroid cartilage for unilateral paralytic dysphonia

OBJECTIVE: In the treatment of unilateral paralytic dysphonia, traditional arytenoid adduction is designed to place suture through the muscular process of the arytenoid attaching anteriorly to the thyroid ala. In contrast with the suture direction of this technique, a new paramedian approach to arytenoid adduction anchors anteroinferiorly to the cricoid cartilage, mimicking the force action of the lateral cricoarytenoid muscle (the major adductor of the larynx). This study investigated the influence of these changes in suture direction on the vocal fold level as well as the vocal outcomes in these two techniques of arytenoid adduction. STUDY DESIGN: A prospective clinical series. METHODS: Thirty patients with unilateral paralytic dysphonia underwent medialization laryngoplasty with arytenoid adduction and strap muscle transposition. Under local anesthesia, the thyroid lamina on the involved side was paramedially separated. The inner perichondrium was carefully elevated away from the overlying thyroid cartilage, carrying the dissection posteriorly to the level of the superior and inferior cornua. The lamina was retracted laterally, the inner perichondrium was opened near the midpoint, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 Prolene suture was placed through the muscular process and temporarily tied to the anterolateral aspect of the thyroid ala (AA-thyroid suture). Intraoperative acoustic and perceptual assessments were performed. After releasing the tie, the suture was anchored to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle (AA-cricoid suture). Voice assessments were repeated, and the outcomes of the two tests were compared. The choice of the type of arytenoid adduction suture was made intraoperatively according to which condition provided better vocal performance. After securing the suture, a bipedicled strap muscle flap was transposed into the space between the lamina and inner perichondrium and the thyroid cartilages sutured back into place. RESULTS: The intraoperative acoustic and perceptual assessments revealed the vocal performance was significantly better with AA-cricoid suture than the AA-thyroid suture in this series. No major complications occurred in the study. CONCLUSION: This study suggests that arytenoid adduction with suture attachment along the longitudinal axis of the lateral cricoarytenoid muscle to the cricoid cartilage is more physiologic and effective than that attaching the suture to the thyroid ala. A paramedian approach to arytenoid adduction with or without strap muscle transposition is a safe and effective method for treatment of unilateral paralytic dysphonia.     

Anesthetic management for medialization laryngoplasty using concurrent infusions of dexmedetomidine,remifentanil, and propofol versus controls

Purpose

Medialization laryngoplasty (ML)?±?arytenoid adduction (AA) surgery poses a unique anesthetic challenge that requires periods of deep sedation and patient cooperation with phonation to assess voice function. The purpose of this study was to assess if the protocolized administration of dexmedetomidine, remifentanil, and propofol (DRP) is associated with reduced procedural duration and administration of other sedating medications.

Outcomes of structural fat grafting for paralytic and non-paralytic dysphonia

Aims of this prospective study were to evaluate the results of vocal fold structural fat grafting for glottic insufficiency and to compare the outcomes obtained in unilateral vocal fold paralysis (UVFP) and congenital or acquired soft tissue defects in vocal folds. Sixty-six consecutive patients with breathy dysphonia, in 43 cases (aged 16-79 years) related to UVFP and in 23 cases (aged 16-67 years) related to vocal fold iatrogenic scar or sulcus vocalis, underwent autologous structural fat grafting into vocal folds. Lipoaspirates were centrifuged at 1200 g for 3 min to separate and remove blood, cell debris and the oily layer. The refined fat was injected under direct microlaryngoscopy in a multilayered way. The main outcome measures were grade, roughness, breathiness, asthenicity and strain (GRBAS) perceptual evaluation, maximum phonation time (MPT), self-assessed Voice Handicap Index (VHI), and voice acoustic analysis, considered pre-operatively and at 3 and 6 months after fat grafting. After surgery, MPT, VHI, G and B improved in both groups (p < 0.05). In particular, G and VHI functional subscales showed a significantly greater decrease in patients with UVFP (p < 0.05). The acoustic variables improved significantly only in the UVFP group (p < 0.005). From 3 to 6 months postoperatively, most variables showed a trend with further improvement. Vocal fold structural fat grafting was significantly effective in treating glottic insufficiency due to UVFP or soft tissue defects. Perceptual, acoustic and subjective assessments confirmed that patients with UVFP had better outcomes than those with soft tissue defects.     

Transcutaneous injection laryngoplasty through the cricothyroid space in the sitting position: anatomical information and technique

A variety of approaches have been introduced to perform injection laryngoplasty under local anesthesia. Among these reported methods, transcutaneous injection through the cricothyroid space offers many advantages, but it possesses some technical difficulties during access to the vocal fold. The aim of this study was to assess the anatomic references related to transcutaneous injection laryngoplasty through cricothyroid space using 3-dimensionally reconstructed computed tomography to provide guidelines and to achieve higher efficacy during the procedure. The study group consisted of 14 patients (7 male, 7 female) with unilateral vocal fold paralysis and who had undergone multi-detector array computed tomography (MDCT) between January 2004 and December 2005. Assumption was made that transcutaneous injection is approached from the surface at lower margin of the thyroid cartilage and 7 mm lateral to the midline through the cricothyroid membrane and spot at the posterior 1/3 of true vocal cord is the target for injection laryngoplasty. From the surface of the injection point to the target, a line was drawn. Its length and the angle formed between it and the approach direction of needle was measured. Based on these measurements, 15 patients (8 male, 7 female) with unilateral vocal fold paralysis received 15 trials of transcutaneous injection laryngoplasty through the cricothyroid space. The average length from the surface of the injection point (7 mm lateral to the midline) to the posterior 1/3 of the true vocal cord (target of the injection) was 15.75 mm in men and 13.91 mm in women. The average of the angle in medial direction at the surface needed to reach the target of the injection was 10.57° in men and 12.71° in women, and in superior direction was 47.57° in men and 47.43° in women. Injection laryngoplasty performed under acquired reference measurements were successful in 14 trials (93.3%) out of 15 trials in 15 patients. We suggest that knowledge of the anatomic references regarding the transcutaneous injection laryngoplasty through cricothyroid space will provide guidelines for beginners and improve the understanding of the procedure, eventually leading to easier and more precise access to the vocal cord.     

A new paramedian approach to arytenoid adduction and strap muscle transposition for vocal fold medialization

OBJECTIVE: To develop a prosthesis-free medialization laryngoplasty for the treatment of glottal incompetence. STUDY DESIGN: Twenty-two consecutive patients with glottal incompetence underwent vocal fold medialization using a new paramedian approach to arytenoid adduction and/or strap muscle transposition. METHODS: Under local anesthesia, the thyroid lamina on the involved side was parasagittally separated 5 mm off the midline. The inner perichondrium was carefully freed from the overlying thyroid cartilage. After dividing the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally, the inner perichondrium was opened, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 or 3-0 Prolene suture was placed through the muscular process and tied to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle. A bipedicled strap muscle flap was then transposed into the space between the lamina and the inner perichondrium and the thyroid cartilages sutured back into place. Pre- and postoperative voice evaluations measured mean fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, and maximal phonation time, as well as assessments of voice quality. RESULTS: Vocal improvement was obtained in 95% (21 of 22) of patients. There was a significant improvement (P <.05) in all parameters except shimmer. No major complications were noted in any patient, except for dyspnea in one patient resulting from arytenoid overrotation. CONCLUSION: The results suggest that a paramedian approach to arytenoid adduction combined with strap muscle transposition is a safe and effective method for treating glottal incompetence, particularly in patients with unilateral paralytic dysphonia.     

Evidence-based treatment of paralytic dysphonia: making sense of outcomes and efficacy data

The criteria used to determine the success or failure of a given treatment for vocal fold paralysis are fundamental components of routine clinical practice and treatment outcomes research for the surgeon and voice therapist. The purpose of this article is to offer a guide to the critical interpretation of available measures of out-come and efficacy for this patient population. Such data form the basis for the practice of evidence-based medicine and voice therapy,essential if the standard of care is to evolve to the benefit of the patient. A better understanding of the potentials and limitations of each measure is important for treatment planning and patient counseling and, ultimately, for the conception of future well-designed clinical research. The complex issues regarding outcomes measurement are addressed here within the context of current treatment literature on vocal fold paralysis. Particular emphasis is placed on realistic data gathering within clinical practice.