Complications of type I thyroplasty and arytenoid adduction

OBJECTIVES/HYPOTHESIS: Unilateral vocal fold paralysis resulting in glottal incompetence can cause significant morbidity attributable to impaired speech, swallowing, and ability to protect the airway. Type I thyroplasty in combination with arytenoid adduction is a proven technique for medialization of the paralyzed vocal fold but must be evaluated in light of potential complications following laryngeal framework surgery. STUDY DESIGN AND METHODS: The charts of 237 patients who underwent unilateral vocal fold medialization surgery between July 1, 1991, and August 30, 1999, at a tertiary care cancer referral center were retrospectively reviewed. RESULTS: There were 98 cases of type I thyroplasty alone and 96 cases of type I thyroplasty with arytenoid adduction. The two groups had similar patient characteristics. Mean time of surgery (45 vs. 73 min, P <.0001) and length of hospital stay (1.1 vs. 1.8 d, P <.0001) were increased when arytenoid adduction was performed. Overall improvement of symptoms was similar in both groups (93%-94%), but posterior glottic closure appeared subjectively improved when arytenoid adduction was used (P =.0054). Overall complication rates were slightly higher in the arytenoid adduction group (14% vs. 19%), primarily because of transient vocal fold edema and wound complications (9 vs. 19 cases), but the increase was not statistically significant (P =.1401). Complications warranting medical or surgical intervention occurred in 8% of cases. Two patients who underwent type I thyroplasty with arytenoid adduction required tracheotomy as a consequence of postoperative complications. The three patients who had extrusion of the implant underwent type I thyroplasty alone. CONCLUSION: Using the appropriate technique, the potential benefits of improved glottic function following type I thyroplasty with arytenoid adduction outweigh the small risk of significant complications observed.     

Traction of lateral cricoarytenoid muscle for unilateral vocal fold paralysis: comparison with Isshiki' s original technique of arytenoid adduction

Between 1995 and 1997, we performed Isshiki's original method of arytenoid adduction alone or as an adjunct to type I thyroplasty for the treatment of unilateral vocal fold paralysis. From 1997 onward, we performed arytenoid adduction by traction of the lateral cricoarytenoid muscle (Iwamura's method), because it reduces discomfort to the patient and avoids rotation of the thyroid cartilage. Preliminary experiments and surgical procedures involving traction of the lateral cricoarytenoid muscle are described. Of 21 patients with a maximum phonation time of less than 9 seconds, 14 underwent type I thyroplasty as an adjunct to our method of arytenoid adduction and 7 underwent arytenoid adduction alone. Sixteen patients (76%) were able after surgery to extend their maximum phonation time beyond 10 seconds; this result compares favorably with the results of Isshiki's original adduction technique. We describe useful anatomic landmarks for approaching the lateral cricoarytenoid muscle in the hope that more voice surgeons will adopt this approach in the treatment of unilateral vocal fold paralysis.     

Combination of direct pull of lateral cricoarytenoid muscle and thyroplasty type I for severe unilateral vocal cord paralysis

Techniques and the outcome of our approach that combined two operations, a direct pull of the lateral cricoarytenoid muscle (LCA-Pull) and Isshiki's thyroplasty type I are reported. LCA-Pull is very simple and allows natural adduction of arytenoid by pulling LCA. The subjects were five patients whose maximal phonation time (MPT) were under 5 seconds. All patients achieved MPT over 13 seconds. Mean flow rates (MFR) varied from 340ml/s to over 1000 ml/s before the operation. In all patients, the post operative MFR improved to under 150 ml/s. Sometimes severe unilateral vocal cord paralysis requires both arytenoid adduction and medialization thyroplasty to obtain good voice. Combination of LCA-Pull and thyroplasty type I is very effective for severe case, and could be done in the same operating field by creating an additional window in the thyroid ala.     

Physiologic assessment of arytenoid adduction.

Arytenoid adduction as described by Isshiki is a surgical technique used to improve vocal quality by adducting the arytenoid cartilage of a paralyzed vocal fold, medializing the fold, and closing the posterior glottic aperture. Surgical results of this operation were evaluated by preoperative and postoperative voice recordings, laryngoscopy, and stroboscopy. Objective measurements of vocal jitter, shimmer, and signal to noise ratio were done to assess changes in the vibratory patterns, and analysis of data from 12 patients revealed improved glottic function postoperatively. Often an anterior medialization procedure, primarily a type I thyroplasty, was used to supplement the posterior medialization achieved by adduction of the arytenoid. Arytenoid adduction is recommended as an effective and reliable treatment for posterior glottic insufficiency.     

Thyroplasty type I without arytenoid adduction in patients with unilateral laryngeal nerve paralysis: the montgomery implant versus the Gore-Tex implant

OBJECTIVE: The current series was designed to compare the results achieved with the Montgomery and Gore-Tex implants in thyroplasty type I without arytenoid adduction in patients with unilateral laryngeal nerve paralysis. MATERIAL AND METHODS: An inception cohort of 57 French language speakers with unilateral laryngeal nerve paralysis were managed with thyroplasty type I using Gore-Tex (Group GT; n = 24) or Montgomery (Group M; n = 33) implants. The two groups had similar patient characteristics. Morbidity, phonatory results according to self assessment by the patient and selected speech and voice parameters (fundamental frequency, jitter, shimmer, noise:harmonic ratio, phonation time, phrase grouping and speech rate) were analyzed 1 month postoperatively in both groups. RESULTS: Dyspnea, as noted in three patients, was the only immediate complication. Late complications included persistent inflammation of the vocal cord after insertion of a Gore-Tex implant, endolaryngeal extrusion of the Gore-Tex implant and dislodgment of the Montgomery implant in one patient each. Postoperatively, all patients reported improvements in speech and voice. Secondary degradation of speech and voice was noted in one patient in each group. Comparison of selected speech and voice parameters at 1 month postoperatively showed (i) a statistically significant (p < 0.01) decrease in the jitter, shimmer and noise:harmonic ratio values and (ii) a statistically significant (p < 0.01) increase in the speech rate values in Group M compared to Group GT patients. Also, a trend (0.05

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Effects and use of the suture direction mimicking only the force action of the lateral cricoarytenoid muscle in arytenoid adduction combined with thyroplasty type I

Isshiki's arytenoid adduction combined with thyroplasty type I is a useful procedure for correcting the membranous vocal fold atrophy and the height difference between the two vocal folds, particularly in patients with a large posterior glottal chink and atrophy. Conventional arytenoid adduction (Isshiki's arytenoid adduction) is designed to place a suture through the muscular process of the arytenoid attached anteriorly to the thyroid ala, stimulating the function of the thyroarytenoid muscle and lateral cricoarytenoid muscle. Combining with thyroplasty type I, the suture direction of conventional arytenoid adduction prevented inserting implant material into the pocket of the thyroid cartilage window. In contrast to conventional arytenoid adduction, the suture direction in our approach is anchored anteroinferiorly, mimicking only the action of the lateral cricoarytenoid muscle (the major adductor of the larynx). It is used the thyroid cartilage window in thyroplasty type I to determine the direction of the lateral cricoarytenoid muscle. After approaching the muscular process based on Isshiki's arytenoid adduction, two nylon sutures are tied across the muscular process or the lateral cricoarytenoid muscle nearby the muscular process. The cricoarytenoid joint is not dislocated. One of the sutures was anchored to the inferior rear corner of the thyroid cartilage window to be used with thyroplasty type I and the other was anchored to the rear lower margin of the thyroid lamina. Gore-tex medialization thyroplasty is done after tying the sutures on the thyroid ala. Subjects were 30 unilateral paralytic dysphonia. Maximum phonation of all patients improved significantly after surgery. The preoperative and postoperative mean maximum phonation times were 6.0 and 17.9 seconds. No major complications occurred in this study. Our approach effectively combined arytenoid adduction and thyroplasty type I for patients with severe insufficient glottic closure.     

Collagen injection as a supplement to arytenoid adduction for vocal fold paralysis

OBJECTIVES: Dysphonia associated with vocal fold paralysis can persist even after successful medialization procedures, including arytenoid adduction. It is hypothesized that laryngeal collagen injection could improve phonation following arytenoid adduction in selected patients. Our objective was to evaluate how collagen injection could result in measurable improvements in vocal function and voice quality. METHODS: Forty patients with unilateral vocal fold paralysis who had undergone arytenoid adduction underwent transoral injection of non-cross-linked bovine dermal collagen by means of indirect laryngoscopy and a curved injection device. A control group of 40 patients underwent arytenoid adduction but not collagen injection. The patients' voice quality was assessed perceptually with the GRBAS scale, and vocal function was assessed by acoustic and aerodynamic measures (maximum phonation time and transglottal DC flow). The relative glottal area was also assessed by videostroboscopy. RESULTS: Significant improvements in vocal function and voice quality were observed with collagen injection for those patients who did not achieve satisfactory glottal competence with arytenoid adduction alone. Glottal area measurements revealed that glottic insufficiency was significantly reduced after arytenoid adduction as well as after collagen injection. CONCLUSIONS: The findings suggest that collagen injection could be an effective supplementary treatment for improving voice following arytenoid adduction. It has the advantage of being a minimally invasive outpatient office procedure. The long-term efficacy of the procedure should be explored.     

Thyroplasty type I without arytenoid adduction in patients with unilateral laryngeal nerve paralysis: the montgomery implant versus the Gore-Tex implant

Objective The current series was designed to compare the results achieved with the Montgomery and Gore-Tex implants in thyroplasty type I without arytenoid adduction in patients with unilateral laryngeal nerve paralysis.

Material and Methods An inception cohort of 57 French language speakers with unilateral laryngeal nerve paralysis were managed with thyroplasty type I using Gore-Tex (Group GT; n=24) or Montgomery (Group M; n=33) implants. The two groups had similar patient characteristics. Morbidity, phonatory results according to self assessment by the patient and selected speech and voice parameters (fundamental frequency, jitter, shimmer, noise:harmonic ratio, phonation time, phrase grouping and speech rate) were analyzed 1 month postoperatively in both groups.

Results Dyspnea, as noted in three patients, was the only immediate complication. Late complications included persistent inflammation of the vocal cord after insertion of a Gore-Tex implant, endolaryngeal extrusion of the Gore-Tex implant and dislodgment of the Montgomery implant in one patient each. Postoperatively, all patients reported improvements in speech and voice. Secondary degradation of speech and voice was noted in one patient in each group. Comparison of selected speech and voice parameters at 1 month postoperatively showed (i) a statistically significant (p<0.01) decrease in the jitter, shimmer and noise:harmonic ratio values and (ii) a statistically significant (p<0.01) increase in the speech rate values in Group M compared to Group GT patients. Also, a trend (0.05<p<0.1) was noted towards an increase in the phrase grouping values in Group M compared to Group GT patients.

Conclusions Although limitations exist in the interpretation of the reported data, our results suggest that in patients with unilateral laryngeal nerve paralysis managed with a thyroplasty type I technique without arytenoid adduction, the use of a Montgomery compared to a Gore-Tex implant does not influence the success of the procedure according to the patient's self evaluation or the morbidity but does lead to a significant improvement in the values of selected speech and voice parameters.     

Combined arytenoid adduction and laryngeal reinnervation in the treatment of vocal fold paralysis

OBJECTIVE/HYPOTHESIS: Glottal closure and symmetrical thyroarytenoid stiffness are two important functional characteristics of normal phonatory posture. In the treatment of unilateral vocal cord paralysis, vocal fold medialization improves closure, facilitating entrainment of both vocal folds for improved phonation, and reinnervation is purported to maintain vocal fold bulk and stiffness. A combination of medialization and reinnervation would be expected to further improve vocal quality over medialization alone. STUDY DESIGN: A retrospective review of preoperative and postoperative voice analysis on all patients who underwent arytenoid adduction alone (adduction group) or combined arytenoid adduction and ansa cervicalis to recurrent laryngeal nerve anastomosis (combined group) between 1989 and 1995 for the treatment of unilateral vocal cord paralysis. Patients without postoperative voice analysis were invited back for its completion. A perceptual analysis was designed and completed. METHODS: Videostroboscopic measures of glottal closure, mucosal wave, and symmetry were rated. Aerodynamic parameters of laryngeal airflow and subglottic pressure were measured. A 2-second segment of sustained vowel was used for perceptual analysis by means of a panel of voice professionals and a rating system. Statistical calculations were performed at a significance level of P = .05. RESULTS: There were 9 patients in the adduction group and 10 patients in the combined group. Closure and mucosal wave improved significantly in both groups. Airflow decreased in both groups, but the decrease reached statistical significance only in the adduction group. Subglottic pressure remained unchanged in both groups. Both groups had significant perceptual improvement of voice quality. In all tested parameters the extent of improvement was similar in both groups. CONCLUSION: The role of laryngeal reinnervation in the treatment of unilateral vocal cord paralysis remains to be established.     

New surgical techniques for voice improvement

Laryngeal framework surgery for improving or changing the voice is a challenging development in phoniatric surgery. Basically two categories can be distinguished: (1) attempted medialization of the vocal fold, as for the treatment of paralytic dysphonias (arytenoid rotation technique and Isshiki's type I thyroplasty); (2) adjustment of the vocal fold's tension to produce changes in vocal pitch, as for the treatment of transsexuals or mutational dysphonia (cricothyroid approximation, Isshiki's type III thyroplasty and LeJeune's anterior commissure laryngoplasty). Both types of surgery are best performed with the patient under local anesthesia so that fine tuning of the voice is possible by monitoring the voice during the surgical procedure. The techniques of arytenoid rotation and Isshiki's type I thyroplasty are described in detail and the result of a combination of these procedures is illustrated by a case history of an aphonic patient with unilateral vagus nerve paralysis and subsequent severe incomplete glottal closure during phonation. In addition, the results achieved in several other patients are presented. Our current experience with laryngoplastic surgery and its variations is such that endolaryngeal Teflon or collagen injections are no longer used in our department. To date, we have seen no complications from the laryngoplasties and the voice results have been excellent.     

A "fenestration approach" for arytenoid adduction through the thyroid ala combined with type I thyroplasty

OBJECTIVE: To develop and evaluate the voice outcomes of an approach of arytenoid adduction (AA) through a fenestration of the thyroid ala for unilateral vocal cord paralysis. STUDY DESIGN: Twelve consecutive patients with severe unilateral vocal cord paralysis, whose maximum phonation times (MPTs) were less than or equal to 5 seconds, underwent laryngoplasty using an approach of AA performed through a fenestration of the thyroid ala combined with type I thyroplasty. METHOD: Two surgical windows were made in the lower part of the thyroid ala. The anterior window was for typical type I thyroplasty, and the posterior window was for AA. AA was performed by pulling the lateral cricoarytenoid muscle (LCA) (5 patients) or muscular process (7 patients) through the posterior fenestration in the contractile direction of the LCA without releasing the cricoarytenoid joint. The operation was performed under local anesthesia with sedation except in two patients who underwent general anesthesia using a laryngeal mask. The vocal cord medialization was confirmed endoscopically during the operation. For all patients, the MPT and mean airflow rate (MFR) were measured before and after the operation. The postoperative voices were analyzed using shimmer and jitter. RESULT: All patients achieved a MPT of over 12 seconds. The MFR, which ranged from 340 to 1902 mL/second before the operation, improved to less than 200 mL/second, except in one patient whose MFR was 210 mL/second. Shimmer and jitter improved significantly after the operation. Perceptual evaluation using the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale also improved significantly. CONCLUSION: A fenestration-based approach simplified the combination of AA and type I thyroplasty because the two treatments could be performed in the same operating field and provided good voice improvement. Pulling the AA braid in the contractile direction of the LCA and endoscopic vocal cord observation during surgery may have contributed to the positive results.     

Anterior and posterior medialization (APM) thyroplasty

OBJECTIVE: In unilateral vocal fold paralysis with dysphonia, most of the paralyzed vocal folds may be medialized effectively by medialization laryngoplasty. However, if the posterior glottal gap is wide, these procedures may sometimes have a limit to medialize the posterior glottis and cannot be effective for acceptable voice quality. The objective of this study is to introduce a new surgical technique for medializing the membranous and cartilaginous portions of the paralyzed vocal fold: anterior and posterior medialization (APM) thyroplasty. METHOD: Six patients underwent APM thyroplasty. They completed preoperative and postoperative evaluation with acoustic analysis and video laryngoscopy. RESULTS: All patients satisfied their voice subjectively after surgery. The paralyzed vocal folds, membranous and cartilaginous parts, were medialized well, and the paralyzed arytenoid showed less anterior tipping postoperatively. On voice analysis all patients showed prolonged phonation times and decreased perturbations after surgery. CONCLUSION: The advantages of this procedure are to medialize the membranous and cartilaginous portions of the paralyzed vocal fold directly and to correct vertical mismatch between two vocal folds. This procedure might be especially indicated in the lateralized position of the paralyzed vocal fold but not in the higher paralyzed vocal fold compared with the normal vocal fold.     

The study of vocal fold vibratory patterns in patients with unilateral vocal fold paralysis before and after type I thyroplasty with or without arytenoid adduction

Type I thyroplasty and arytenoid adduction have been used for the treatment of symptomatic unilateral vocal fold paralysis since the mid-1970s. To this date, the vibratory patterns of the vocal folds in patients with unilateral vocal fold paralysis undergoing thyroplasty have not been studied in depth. Abnormal vibration of the vocal fold mucosa often contributes to voice problems in persons diagnosed with vocal diseases or disorders. The preoperative and postoperative videostroboscopic vibratory patterns including mucosal wave, amplitude, glottic closure, and symmetry were studied in 12 patients who underwent unilateral type I thyroplasty separately or in combination with an arytenoid adduction. The observed changes and clinical implications are discussed.     

Early Arytenoid Adduction for Vagal Paralysis After Skull Base Surgery

Objectives To evaluate the efficacy of early arytenoid adduction in the management of vagal paralysis after skull base surgery. Study Design Retrospective evaluation at a tertiary care skull base center. Methods Aggressive surgical management of skull base lesions has become increasingly popular owing to advances in surgical technique and intraoperative monitoring. Temporary and permanent lower cranial neuropathies occur frequently, especially after the surgical management of lesions involving the vertebrobasilar system and the jugular foramen. An injury to the proximal vagus nerve is usually associated with dysphonia and swallowing dysfunction. An early arytenoid adduction has been employed in 26 patients with a vagal paralysis after skull base surgery. Most commonly, the neurosurgical patient underwent an arytenoid adduction under general anesthesia on postoperative day 2. Results Videostroboscopy after arytenoid adduction demonstrated 76% of patients had complete glottic closure. Of those with inadequate glottic closure, all demonstrated a well‐medialized posterior glottis with a persistent anterior glottal gap. These patients were easily treated with a secondary type I thyroplasty under local anesthesia with sedation resulting in complete glottic closure. Despite excellent voice outcomes, 66% of these patients had dysphagia requiring enteral feedings for nutritional support. Conclusions An early arytenoid adduction is an excellent medialization technique that can be performed safely in the early postoperative period under general anesthesia after skull base surgery.     

New surgical techniques for voice improvement

Summary Laryngeal framework surgery for improving or changing the voice is a challenging development in phoniatric surgery. Basically two categories can be distinguished: (1) attempted medialization of the vocal fold, as for the treatment of paralytic dysphonias (arytenoid rotation technique and Isshiki's type I thyroplasty); (2) adjustment of the vocal fold's tension to produce changes in vocal pitch, as for the treatment of transsexuals or mutational dysphonia (cricothyroid approximation, Isshiki's type III thyroplasty and LeJeune's anterior commissure laryngoplasty). Both types of surgery are best performed with the patient under local anesthesia so that fine tuning of the voice is possible by monitoring the voice during the surgical procedure. The techniques of arytenoid rotation and Isshiki's type I thyroplasty are described in detail and the result of a combination of these procedures is illustrated by a case history of an aphonic patient with unilateral vagus nerve paralysis and subsequent severe incomplete glottal closure during phonation. In addition, the results achieved in several other patients are presented. Our current experience with laryngoplastic surgery and its variations is such that endolaryngeal Teflon or collagen injections are no longer used in our department. To date, we have seen no complications from the laryngoplasties and the voice results have been excellent.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29 September 1988     

Type I thyroplasty for acute unilateral vocal fold paralysis following intrathoracic surgery

Patients who undergo intrathoracic operative procedures for malignancy may require sacrifice of a recurrent laryngeal nerve. Postoperative vocal fold paralysis may lead to diminished cough with secretion retention, aspiration, and life-endangering pneumonia. This study retrospectively reviews our institution's experience of 23 patients who underwent type I thyroplasty within the 2-week (acute) period after thoracic surgery. Primary lung cancer (n = 16) was the most common disease. Upper lobectomy (n = 9) and pneumonectomy (n = 7) were the most frequent surgical procedures. Silicone medialization alone (n = 11) or with arytenoid adduction (n = 12) was performed. There were no significant postoperative complications. Improvements in hoarseness (86%), dyspnea (72%), dysphagia (50%), and aspiration (79%) were noted. Pulmonary status improved after vocal fold medialization, as reflected by decreased need for therapeutic bronchoscopy in the majority of patients in the postoperative period. Type I thyroplasty for vocal fold paralysis in the acute phase following thoracic surgery is well tolerated and is associated with improved patient outcome with no postoperative deaths in this high-risk patient population.     

Endolaryngeal extrusion of expanded polytetrafluoroethylene implant after medialization thyroplasty

Various nonresorbable implants are currently used worldwide for medialization thyroplasty in patients with unilateral vocal cord paralysis. The Gore-Tex (expanded polytetrafluoroethylene) implant was introduced in the late 1990s. At our institution, 27 patients with unilateral laryngeal nerve paralysis had medialization thyroplasty with a Gore-Tex implant during the years 1998 to 2002. The current report documents our first case of endolaryngeal extrusion of a Gore-Tex implant.     

Cricothyroid subluxation: a new innovation for enhancing the voice with laryngoplastic phonosurgery

Laryngoplastic phonosurgery has evolved to become a dominant treatment modality for paralytic dysphonia. Current surgical procedures have addressed primarily the position of the musculomembranous vocal fold and the arytenoid in the axial and vertical planes. However. dynamic range capabilities and vocal flexibility have been limited secondary to the flaccid, denervated vocal fold tissue. Therefore. a new procedure was conceived to enhance the acoustic vocal outcome from operations that reposition the vocal edge. Cricothyroid (CT) subluxation was designed as a technique to increase the distance between the cricoarytenoid joint and the insertion of the anterior commissure ligament. Cricothyroid subluxation was done without complication in 9 patients who underwent combined adduction arytenopexy and medialization laryngoplasty, and in 4 patients with medialization laryngoplasty alone. Postoperative stroboscopic assessment was done in all of the 13 patients, while complete analysis of vocal function was available in 10 of the 13 patients; this revealed improvement (as a group) on almost all objective measures over the preoperative state. All patients who underwent CT subluxation had a normal maximum frequency range (pitch variation of more than 2 octaves), as compared with 22% of a prior similar cohort of patients who did not undergo CT subluxation. All patients who underwent CT subluxation had normal glottal airflow and a normal noise-to-harmonics ratio. Cricothyroid subluxation is a relatively easily adjustable procedure that increases the length and viscoelastic tension of the denervated vocal fold. The modified biomechanical properties resulted in improved vocal outcome in all of our patients, which was most remarkable in terms of maximal range capabilities. Cricothyroid subluxation enhanced the postoperative voice of patients regardless of whether they required medialization laryngoplasty alone or whether they also required adduction arytenopexy.     

Laryngeal Collagen Injection as an Adjunct to Medialization Laryngoplasty

Objectives/Hypothesis Dysphonia associated with laryngeal paralysis may be identified in the short term postoperatively or may develop years after successful medialization laryngoplasty. In selected cases, laryngeal collagen injection permits further medialization of one or both vocal folds by small increments to improve phonation after medialization thyroplasty. The study seeks to determine whether collagen injections result in measurable improvements in voice quality and vocal function when offered to select patients who have received medialization thyroplasty. Study Design Retrospective review of patient charts and voice database. Methods Seven patients were treated with Zyderm II collagen using indirect mirror laryngoscopy and a curved injection apparatus. Changes in voice quality and function were assessed by comparing measures obtained before treatment (mean period, 5.6 d), shortly after treatment (mean period, 38.1 d), and in the long term after treatment (mean period, 226 d). Results Mean self‐ratings of the patient, clinician's ratings, and objective measures demonstrated measurable improvement in vocal function after collagen injection. Conclusions The office‐based procedure offers a simple, efficient adjunct to open techniques of medialization laryngoplasty. Techniques of anesthesia, injection, and patient selection are discussed.     

A new procedure of arytenoid adduction combined with type I thyroplasty under general anesthesia using a laryngeal mask

Laryngeal framework surgery is usually performed under local anesthesia. However, some patients are unable to tolerate extended surgery. A case of an 82-year-old woman who underwent medialization thyroplasty and arytenoid adduction of direct lateral cricoarytenoid (LCA) muscle pulling at the same time under general anesthesia using a laryngeal mask is reported. Endoscopic observation through the laryngeal mask allows direct visual control of the vocal cord. The LCA pulling method does not touch the posterior border of the thyroid cartilage so that the laryngeal mask does not disturb the arytenoid adducts.