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Medialization Laryngoplasty and Arytenoid Adduction


Introduction

Medialization laryngoplasty (type I thyroplasty) and arytenoid adduction are excellent surgical options for rehabilitation of the voice in patients suffering from glottic insufficiency. These are great options for surgical therapy to augment and reposition the vocal folds to improve vocal fold closure and thereby improve vocal function. Glottic insufficiency may be caused by any combination of the following: vocal fold atrophy (presbylarynges), vocal fold scar, vocal fold paresis, or vocal fold paralysis. These procedures can also be used to address soft tissue deficits of the vocal folds after surgery or trauma.

A variety of implant materials have been used to medialize the vocal folds in medialization laryngoplasty, including Silastic, hydroxylapatite block, and Gore-Tex. This chapter discusses the general approach to medialization laryngoplasty and does not discuss the different implants or the design of the shape of the implant, given that these are very personal choices for each surgeon and that medialization laryngoplasty can be done successfully with any of the aforementioned implant materials.

If the patient’s dysphonia and/or dysphagia is related to a severe posterior glottic insufficiency, arytenoid adduction should be strongly considered because it is the only operation that consistently corrects glottic insufficiency in the posterior aspect of the glottis. Neither injection laryngoplasty nor medialization laryngoplasty can address clinical issues related to posterior glottic insufficiency. Arytenoid adduction simulates the contraction of the lateral cricoarytenoid muscle by placing a suture in the muscular process of the arytenoid to rotate the arytenoid cartilage. This helps to medialize the posterior portion of the vocal fold, lengthen the vocal fold, close the posterior glottic gap, and change the height mismatch of vocal folds.

Key Operative Learning Points

  • Identification of the entire aspect of the muscular tubercle located on the inferior border of the thyroid cartilage ala

  • Slight overmedialization should be done during medialization laryngoplasty to account for intraoperative edema of the vocal fold and prevent undermedialization of the vocal fold postoperatively.

  • Adjustment of implant based on findings of voice quality, vocal fold appearance, and vocal fold closure pattern. Intraoperative end results should include a slightly strained voice, medial augmentation of vocal fold, and complete glottal closure.

Preoperative Period

History

  • 1.

    History of presenting illness

    • Acute or gradual onset of hoarseness

    • Precipitating events such as surgery, endotracheal intubation, or upper respiratory infection

    • Voice quality weak, breathy, and effortful

    • Dyspnea with speaking

    • Coughing and choking, especially with drinking liquids

    • History of aspiration pneumonia

  • 2.

    Pertinent past medical history

    • History of neck surgery (e.g., thyroid, parathyroid, carotid), cervical spine surgery, or thoracic/mediastinal surgery

    • History of malignancy (e.g., head and neck, thyroid, esophagus, lung)

    • History of cerebrovascular accidents

    • Underlying pulmonary disease (e.g., chronic obstructive pulmonary disease [COPD])—These patients have a smaller pulmonary reserve and thus will require more urgent intervention for vocal fold paralysis.

Physical Examination

  • Complete examination of the head and neck

  • Examination of the cranial nerves

  • Transnasal flexible laryngoscopy to evaluate vocal fold motion, including mobility of the contralateral vocal fold, and overall airway status

  • Stroboscopy to assess glottic closure pattern and vocal fold levels

Imaging

  • Computed tomography (CT) or magnetic resonance imaging (MRI) scan from skull base to aortic arch (along the course of the recurrent laryngeal nerve) with contrast in vocal fold paralysis with no clear precipitating events

Indications

  • Symptomatic glottic insufficiency (dysphonia, dyspnea on phonation, aspiration), especially if there is little or no chance of return of vocal fold motion

Contraindications

  • Coagulopathy (relative)

  • Malignancy involving the laryngotracheal complex

  • Poor abduction of the contralateral vocal fold due to airway concern

  • Presence of vocal fold lesions

  • Intact vocal fold mobility (for arytenoid adduction)

Preoperative Preparation

  • Review the patient’s laryngeal examination.

  • Counsel patients to stop anticoagulation agents, such as nonsteroidal anti-inflammatory medications (e.g., ibuprofen), Coumadin, antiplatelet agents (e.g., clopidogrel), and factor Xa inhibitors (e.g., rivaroxaban, apixaban, dabigatran). Management of patient’s anticoagulants may be coordinated with his/her cardiologists and/or hematologists.

  • Discuss with the patient regarding the environment in the operating room, given that the patient will be awake and only slightly sedated. It is best to prepare patients psychologically while they are awake for having surgery on their neck.

  • Counsel the patient that there may be a need for a bilateral procedure and the addition of an arytenoid adduction procedure pending the intraoperative results of the medialization laryngoplasty. Often with experience, surgeons can determine preoperatively, based on the laryngeal examination and the patient’s voice quality, whether he or she will require a unilateral or bilateral medialization laryngoplasty. However, certain situations do occur intraoperatively in which voice quality is only marginally improved with a medialization laryngoplasty, and it is determined that the patient would benefit significantly from a simultaneous arytenoid adduction.

Operative Period

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