Adduction Surgery Research Articles

Long-term voice evaluation after arytenoid adduction surgery in patients with unilateral vocal fold paralysis

PurposeLaryngeal framework surgery, including medialization laryngoplasty and arytenoid adduction (AA), is expected to have a lasting or permanent effect in patients with unilateral vocal fold paralysis (UVFP); however, there are few reports about the long-term outcomes of AA. This study aimed to evaluate the long-term postoperative effects of AA surgery and examine its stability and reliability.MethodsThis study collected the voice handicap index (VHI) questionnaire from patients with UVFP who underwent AA more than 2 years previously. The VHI values preoperatively and 3 months postoperatively (early postoperative evaluation) were retrospectively calculated, and VHI values more than 2 years after surgery (late postoperative evaluation) were collected by mailing a sheet to the patients and asking to fill and return it. Possible influenced subscales such as age, sex, causes of UVFP, affected side, and surgeons were also analyzed.ResultsA total of 77 patients with UVFP who underwent AA had significantly lower early and late postoperative evaluations than preoperative evaluations. In 38 patients with no missing values, there were no significant differences between early and late postoperative evaluations, measured at a median of approximately 5 years. There were also no significant differences between early and late postoperative evaluations in any of the subscale groups.ConclusionPatients with UVFP who underwent AA surgery achieved stable voice improvement in the long term after surgery.

Impact on swallowing functions of arytenoid adduction in patients with unilateral vocal fold paralysis

ObjectiveAlthough the pathophysiology of swallowing dysfunction in patients with unilateral vocal fold paralysis (UVFP) remains uncertain, glottal insufficiency is known to be a possible major cause, and other factors due to vagus nerve or recurrent laryngeal nerve damage may contribute to dysphagia or aspiration. This study aimed to evaluate the effect of arytenoid adduction (AA) surgery on the swallowing functions of UVFP patients and to investigate the important role of glottic closure during swallowing. MethodsWe prospectively analyzed the data of thirteen patients with UVFP who underwent AA in combination with medialization laryngoplasty (ML) for improving voice quality. The subjects received a series of examinations for not only voice function but also swallowing function and cough strength both preoperatively and approximately 6 months after surgery. The evaluations of voice function included the Voice Handicap Index and aerodynamic measures; the evaluations of swallowing function included the Eating Assessment Tool-10, liquid aspiration, a videofluorographic examination of swallowing study, and high-resolution manometry; and the evaluation of cough strength included the measurement of cough peak flow. All measurements before and after surgery were statistically compared and examined. ResultsConsiderable improvements in voice measures were observed after the procedure, as sufficient glottic closure was achieved during phonation and swallowing. In terms of swallowing evaluation, there were significant differences in the subjective assessment methods after the operation. Additionally, our intervention improved two cases of aspiration according to abnormal findings on the videofluorographic examination of swallowing. There was a significant difference in cough peak flow, with all participants having better values after surgery. High-resolution manometry revealed no significant differences between pre- and postsurgery in any parameters at the level of the mesopharynx or upper esophageal sphincter. ConclusionThe findings of our study suggest an important effect on the dysphagia of UVFP patients who undergo AA combined with ML. In addition, we revealed improvements in swallowing by strengthening incomplete glottic closure; thus, we consider that sufficient glottic closure must play an important role in swallowing function in patients with UVFP.

Arytenoid asymmetry: Is it the most predictive parameter for arytenoid adduction in unilateral vocal fold paralysis?

The aim of this study was to establish arytenoid asymmetry as a pre-operative predictive parameter for arytenoid adduction surgery in unilateral vocal fold paralysis and thereafter identify the most predictive parameter for arytenoid adduction among the established parameters. A retrospective comparative study was undertaken. The 'arytenoid asymmetry angle' formed between skewed 'glottic' and 'interarytenoid' axes (traced along the plane of closure of the membranous and cartilaginous glottis, respectively) was quantified in pre-operative laryngoscopic images of 85 adults with unilateral vocal fold paralysis who underwent either type 1 thyroplasty (group 1) or type 1 thyroplasty with arytenoid adduction (group 2). The need for arytenoid adduction was determined intra-operatively based on subjective voice improvement and laryngoscopic results. Arytenoid asymmetry (p < 0.0001), posterior phonatory gap (p = 0.001) and vertical level difference (p = 0.004) were significantly greater in group 2 (descending order of parameters). Arytenoid asymmetry angle showed a significant positive correlation with the latter two parameters. Arytenoid asymmetry is the most predictive parameter for arytenoid adduction. An arytenoid asymmetry angle of more than or equal to 33.9⁰ is an indication for arytenoid adduction. This aids in pre-operative planning of arytenoid adduction.

Outcomes in two patients with vocal fold palsy who underwent revision arytenoid adduction surgery.

This study investigated the position of adduction thread attachment, pulling direction and fixation position in revision arytenoid adduction surgery performed in two patients with left vocal fold palsy in whom satisfactory speech improvement had not been obtained by arytenoid adduction and type 1 thyroplasty. Revision arytenoid adduction surgery was performed with the vocal fold in the midline position in both cases. A type 1 thyroplasty procedure was subsequently added in one case because of worsened quality of speech following arytenoid adduction. Although the arytenoid adduction procedure is conceptually well established, there is still room for debate concerning the actual surgical procedures used. The technique described in this report is effective, suggesting that it is worthy of recognition as an index procedure.

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

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. This was a retrospective 2:1 case matched study design; matched on age, sex, body mass index, AA, and surgical revision status. Data was obtained from the electronic medical record of a tertiary referral center. Cases underwent ML ± AA using DRP. Control subjects underwent surgery ML ± AA without DRP. 58 DRP cases (43.1% AA) were matched with 116 control patients (44.8% AA). DRP was associated with decreases in fentanyl dose (50 [25, 100] vs. 100 [50, 150] mcg; p < 0.01), incidence and dose of midazolam (4 [6.9%] vs. 70 [60.3%]; p < 0.01; 1 [1, 1] vs. 2 [2, 2]; p < 0.02), operative duration (131 ± 33 vs. 160 ± 50 min; p < 0.01), and anesthetic duration (182 ± 35 vs. 219 ± 60.3 min; p < 0.01). When adjusted for timeline, it was observed that case duration was declining prior to DRP introduction; this trend persisted after DRP introduction. Hypopnea was more common with DRP (14 [24.1%] vs. 7 [6.0%]; p < 0.01). DRP was associated with a substantial decrease in opioid and benzodiazepine administration. A reduction in procedural duration over time was also observed.

内視鏡下披裂軟骨内転術

内視鏡下披裂軟骨内転術

Outcomes of Arytenoid Adduction under Laryngeal Mask Mechanical Ventilation for Unilateral Vocal Fold Paralysis

Objectives: Arytenoid adduction surgery for the unilateral vocal fold paralysis is usually carried out under intravenous sedation because improvement of the voice evaluable during surgery. In patients preferred for surgery under general anesthesia due to their physical or mental condition, we selected general anesthesia using laryngeal mask mechanical ventilation, and we confirmed the location of the vocal fold during surgery using a flexible fiberscope. To evaluate this procedure of anesthesia, we compared outcomes of the adduction surgeries between intravenous sedation and general anesthesia. Methods: From September 2012 to August 2013, adduction surgeries were performed in 17 cases under intravenous sedation with spontaneous breathing, and in 5 cases under general anesthesia using laryngeal mask. Pre- and postoperative maximum phonation time (MPT), mean flow ratio (MFR), and voice handicap index-10 (VHI-10) were evaluated. Results: MPT, MFR, and VHI-10 were remarkably improved in all adduction surgery with intravenous sedation cases. In the general anesthesia group, improvement of the factors was also recognized in most cases, but not in all. Conclusions: Adduction surgery under general anesthesia with laryngeal mechanical mask ventilation is a useful tool for the unilateral vocal fold palsy patient. However, even though we checked the position of the vocal fold in surgery, the efficacy of the surgery is not guaranteed in a few cases because the actual voice cannot be evaluated in general anesthesia.

The Impact of Endoscopic-Assisted Arytenoid Adduction Surgery on Phonation Disorder Voice Handicap

The Impact of Endoscopic-Assisted Arytenoid Adduction Surgery on Phonation Disorder Voice Handicap

Endoscopic-assisted Arytenoid Adduction Surgery (EAAS) ^|^mdash;Practice with Extirpated Larynges and Skilled Surgical Technique^|^mdash;

Endoscopic-assisted Arytenoid Adduction Surgery (EAAS) ^|^mdash;Practice with Extirpated Larynges and Skilled Surgical Technique^|^mdash;

A New and Less Invasive Procedure for Arytenoid Adduction Surgery: Endoscopic-Assisted Arytenoid Adduction Surgery

A New and Less Invasive Procedure for Arytenoid Adduction Surgery: Endoscopic-Assisted Arytenoid Adduction Surgery

A new and less invasive procedure for arytenoid adduction surgery

Arytenoid adduction (AA) is the most effective procedure for improving voice function in patients affected by unilateral vocal fold paralysis (UVFP), but it is often associated with severe complications following airway obstruction. The aim of this study is to describe a new and less invasive AA surgical procedure termed endoscopic-assisted AA surgery (EAAS) and to evaluate its voice outcomes. We demonstrated this method using extirpated larynges from three laryngeal cancer patients. Ten patients with severe UVFP underwent EAAS alone or combined with type I thyroplasty or lipoinjection laryngoplasty. EAAS involves the placement of permanent adducting sutures around the muscular process (MP) of the arytenoid cartilage using two needles, a penetration needle and a loop needle, under endoscopic guidance. To define the anatomic position of the MP for safer needle insertion, the location of the MP was measured relative to three landmarks on computed tomography/X-ray images of the larynges and in resected larynges. For all patients with UVFP, the maximum phonation time, mean airflow rate, and three acoustic analysis parameters were measured before and after EAAS. The values of the three variables were similar in all cases. Most patients achieved a maximum phonation time of more than 10 seconds and a mean airflow rate of less than 200 mL/second. All three acoustic analysis parameters were significantly improved after surgery. EAAS is a simple and effective arytenoid rotation procedure.

Sling arytenoid adduction

The purpose of this study was to describe a simplified arytenoid rotation technique and to test its applicability in excised human larynges. A non-absorbable monofilament thread is slung around the muscular process of the arytenoid cartilage through an external approach. During visual control through flexible endoscopy, two needles and a wire loop needle threader are the only instruments needed. Thread tensioning and fixation results in a stabilized arytenoid adduction. This technique avoids cricothyroid joint disarticulation and leaves the thyroid cartilage intact. The practicability of the technique was proven in five excised larynx experiments. In two clinical cases, the muscular process was slung and pulled with a monofilament thread. Tension in the vector direction parallel to the LCA muscle showed an effective and stable arytenoid rotation with complete closure of the posterior glottis. The rotational effect following sling arytenoid adduction (SAA) is similar to conventional arytenoid adduction surgery outcome. However, SAA is performed from an external approach and avoids dissection of cartilage. Challenging dissections to reach the muscular process are avoided. In some cases of unilateral vocal fold immobility, arytenoid rotation may be performed by using the SAA technique, which allows for an external and extralaryngeal approach. Further studies should assess the clinical value of this technique. In principal, the wire loop needle threader can also be employed for external vocal fold lateralization procedures.

Clinical Outcome of Phonosurgery with Endoscopic Arytenoid Adduction Surgery

Clinical Outcome of Phonosurgery with Endoscopic Arytenoid Adduction Surgery

Localization of the muscular process for arytenoid adduction surgery

Arytenoid adduction (AA) surgery can be technically challenging, potentially limiting its utilization in general practice. Because AA often serves as an adjunct to thyroplasty type I (TTI) in the management of unilateral vocal fold paralysis, this study sought to define the anatomic position of the muscular process (MP) of the arytenoid cartilage in relation to the TTI window and other key thyroid cartilage landmarks, thereby facilitating a more efficient surgical approach. Cadaveric anatomic dissections. Arytenoid MPs were identified bilaterally in eight cadavers for a total of 16 hemilarynges. The location of the MP was measured relative to the anteroinferior corner of the traditional TTI window and also relative to the roots of the superior and inferior cornua for comparison with other studies. : The muscular processes were located along an axial line extending posteriorly from the inferior border of the TTI window and parallel to the inferior border of the thyroid cartilage. In males, the mean distance to the MP was 26.9 mm from the anteroinferior corner of the window, whereas in females the mean distance was 18.9 mm. In all cases, the MP was inferior to the midpoint between the roots of the superior and inferior cornua (mean inferior offset = 2.7 mm). The TTI window can be used intraoperatively to help locate the arytenoid muscular process during arytenoid adduction surgery.

Localization of the Muscular Process for Arytenoid Adduction Surgery

The LaryngoscopeVolume 119, Issue S1 p. S99-S99 Triological Society Poster Presentation South/Middle Localization of the Muscular Process for Arytenoid Adduction Surgery Joshua R. Mitchell BA, Joshua R. Mitchell BASearch for more papers by this authorBryan R. McRae MD, Bryan R. McRae MDSearch for more papers by this authorStacey L. Halum MD, Stacey L. Halum MDSearch for more papers by this author Joshua R. Mitchell BA, Joshua R. Mitchell BASearch for more papers by this authorBryan R. McRae MD, Bryan R. McRae MDSearch for more papers by this authorStacey L. Halum MD, Stacey L. Halum MDSearch for more papers by this author First published: 30 March 2009 https://doi.org/10.1002/lary.20391AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume119, IssueS1Supplement: Triological Society Poster Presentations from the Eastern, Western, Southern and Middle Section Meetings2009Pages S99-S99 RelatedInformation

Arytenoid adduction to treat impaired adduction of the vocal fold due to rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting the synovial membrane and causing joint damage and bone destruction. The symptoms of cricoarytenoid joint (CJ) arthritis often include hoarseness, and a sense of pharyngeal fullness in the throat. Sometimes, in cases with bilateral CJ involvement, an urgent tracheostomy might be required for acute airway obstruction. In this report, we describe a woman suffering from aphonia due to hampered adduction of the vocal fold which was caused by RA with unilateral CJ involvement. Arytenoid adduction surgery on the affected side was performed. She retrieved a normal voice immediately after the surgery.

Pyriform Sinus Mucosa Stabilization for Prevention of Postoperative Airway Obstruction in Arytenoid Adduction

The Isshiki arytenoid adduction procedure directly closes the open posterior glottis. Postoperative airway obstruction that necessitates emergent tracheotomy is an important complication in arytenoid adduction patients when the standard posterior thyroplasty window is used to approach the posterolateral larynx. Immediate postoperative fiberoptic laryngoscopy shows ipsilateral edema and/or hematoma of the arytenoid and supraglottic mucosa, with occasional obstructing inspiratory collapse. In this study, I sought to modify the posterior window approach during arytenoid adduction surgery, and thereby decrease the incidence of immediate postoperative airway obstruction. I performed a retrospective chart review of 246 arytenoid adduction patients, looking for immediate postoperative airway compromise. There were no episodes of postoperative airway obstruction that necessitated tracheotomy in the first 30 patients in whom I approached the posterolateral larynx using the classic Isshiki techniques. Nine of the succeeding 132 adduction patients required emergent tracheotomy when the standard posterior window technique was used instead of a classic Isshiki approach (6.8%). In the most recent 84 patients, I used one tacking suture to stabilize the elevated pyriform sinus mucosa to the upper margin of the posterior window cartilage at closure. Four of the 84 patients had audible postoperative airway turbulence that abated with medical treatment, and 1 patient required an emergent tracheotomy (1.2%; p = .0495). Suture stabilization of the pyriform sinus mucosa is effective and is recommended for prevention of posterior glottic airway obstruction after arytenoid adduction when the posterior window technique is used.

画像解析プログラムを用いた音声外科手術前後の声門面積の計測

Purpose : Thyroplasty type I and arytenoid adduction surgery are effective surgical treatments for dysphonic patients with unilateral vocal fold paralysis. Adduction of the vocal fold decreases the glottal gap during phonation and improves breathy voice. The decrease of glottal area during inspiration, however, may cause an increase in upper airway resistance. The purpose of this study is to quantify the glottal area during inspiration and to examine the relationship between glottal area and upper airway resistance in phonosurgical treatment.Materials and Methods : Eleven patients with unilateral vocal fold paralysis underwent multi-slice helical computerized tomography (MSHCT) before and after phonosurgical treatment. Seven of them underwent pulmonary function tests and FEV1.0/PEF ratio was calculated to evaluate upper airway obstruction. Six of them underwent body plethysmography to evaluate airway resistance. Image analysis software was developed to measure the glottal area during inspiration.Results : Glottal area during inspiration was significantly decreased after phonosurgical treatment. The mean glottal area decreased in size to 77.0% of that before phonosurgery. The FEV1.0/PEF ratio was not significantly increased after phonosurgery. The mean airway resistance was 114.4% of that before phonosurgery. A correlation between glottal area and airway resistance was not found.Conclusion : It is possible to measure glottal area by MSHCT, and upper airway resistance does not significantly increase after phonosurgical treatment.

Biomechanics of Arytenoid Adduction Surgery in an Ex Vivo Canine Model

The biomechanics of arytenoid adduction surgery are not well understood. An excised canine larynx model was used to study the effects of variable suture tension on glottal configuration and on vocal fold tension (at the midfold and the vocal process). Arytenoid adduction both medializes the vocal fold and closes a posterior glottal chink. Vocal fold tension at the midfold did not vary significantly with suture tension. As suture tension increased to approximately 100 g, vocal fold tension at the vocal process also increased. Beyond 100 g of suture tension, vocal fold tension at the vocal process did not increase. We conclude that the effects of suture tension on the resistance to lateral movement are different at the midfold compared to the vocal process. Procedures for surgical rehabilitation of vocal fold paralysis should address the biomechanical subunits of the larynx individually in order to achieve optimum results.

Changes in length and spatial orientation of the vocal fold with arytenoid adduction in cadaver larynges.

Videoendoscopy suggests that arytenoid adduction (AA) surgery not only medializes the paralyzed vocal fold, but increases the length of its membranous portion so that it more closely resembles the normal side. This could represent either real length change or out-of-plane rotation. Computed tomography scanning was performed on adult male cadaver larynges before and after the AA procedure to measure changes in length and spatial orientation of the vocal fold. Three-dimensional coordinates of radiopaque markers on the anterior commissure, posterior glottic midline, and vocal processes were determined. The distance between the vocal processes was 3.9 mm before, and 0.8 mm after AA. The mean vocal fold length was 12.4 mm before, and 13.4 mm after AA (p = .14). The vocal process moved consistently caudally, an average of 3.5 mm (p = .02). The data suggest that clinically apparent vocal fold length changes with AA could be an illusion due to vertical displacement of the vocal process, and not actual lengthening.