Revision Thyroplasty Research Articles

Strap Muscle Type I Thyroplasty After Gore‐Tex Implant Extrusion: Case Report and Literature Review

To discuss the presentation and management techniques of implant extrusion following type I thyroplasty and to illustrate the potential of strap muscle for augmentation following implant removal. We report a unique case of a patient with late Gore-Tex implant extrusion after type I thyroplasty treated with removal and autologous strap muscle graft for augmentation. A 41-year-old female nearly 3.5 years status post Gore-Tex type I thyroplasty for left vocal fold paralysis presented for evaluation of dysphonia. Upon flexible laryngoscopy, erythema, edema, and granulation tissue were identified at the left vocal fold and ventricle. The patient subsequently underwent removal of her implant. Intraoperatively, a free portion of sternothyroid muscle was dissected free and placed into the paraglottic space. One month following surgery, the patient reported an improvement in her Voice Handicap Index (VHI) score from 40 to 0. In addition, no major complications were observed and complete glottic closure was achieved. Nine months postsurgery, she continued to function well with a VHI score of 0. At 50 months postop, the patient still reports a VHI score of 0. Implant extrusion is a rare complication of type I thyroplasty usually occurring in the first few months after surgery and more commonly presenting in females. Current management options consist of observation or augmentation with autologous fat or vocal fold injection following implant removal. This is the first report of a successful strap muscle free graft revision thyroplasty following implant extrusion. The patient's excellent long-term outcome highlights the potential of strap muscle augmentation as a feasible management option for implant extrusion.

Long-term Voice Outcomes of Early Thyroplasty for Unilateral Vocal Fold Paralysis Following Aortic Arch Surgery.

To describe this institution's experience with and the long-term outcomes of early type 1 thyroplasty for unilateral vocal fold paralysis (UVFP) following surgery on the aortic arch. Retrospective chart review with telephone questionnaire. Academic tertiary care center. Three hundred forty-eight patients with UVFP following surgery on the aortic arch since 1999 were identified; 40 were available for follow-up. The number of revision procedures following initial thyroplasty was ascertained, and the Voice Handicap Index (VHI) was administered by telephone. The hypothesis that early thyroplasty produced voice outcomes and revision rates comparable to injection laryngoplasty was established prior to the initiation of data collection. Six out of the 40 patients (15%) required revision thyroplasty following their initial procedure. Mean VHI of all patients was 36.0 (SD, 27.2). Mean VHI was significantly different in the 18 to 39 age group (13.1) when compared to the 40 to 59 (51.8) and 60+ (37.7) age groups (P = .013). Mean follow-up since initial thyroplasty was 46.5 months (SD, 42.2). In the setting of aortic arch surgery with injury to the recurrent laryngeal nerve, early thyroplasty produces voice outcomes comparable to those achieved in the literature with repeated injection and delayed thyroplasty and can be considered in select populations.

A novel anaesthetic technique for complex revision thyroplasty: the sedated, phonating patient

SummaryThyroplasty surgery challenges both anaesthetic and ear, nose and throat (ENT) practice; ideal surgical conditions demand intra‐operative vocal cord assessment of the phonating patient.The activity of the thyro‐arytenoid muscle is mimicked by placing an implant lateral to the defective vocal cord to medialise the mid‐membranous vocal cord. The awake patient method has the advantage of providing visual confirmation of vocal cord closure and immediate assessment of voice quality.We describe the provision of these surgical conditions during revision thyroplasty in a sedated spontaneously breathing, ASA physical status 3 patient with central obesity using a continuous infusion of remifentanil, dexmedetomidine and propofol. In our routine practice we limit depth of sedation to minimise patient disorientation and airway compromise. This newer combined sedation technique proved to be mutually beneficial from both anaesthetic and surgical perspectives.We further propose a novel technique for maintaining ideal airway conditions for thyroplasty surgery using THRIVE (Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange) high flow nasal oxygen.

Displacement of Residual Gore‐Tex Thyroplasty Implant Presenting as a True Vocal Fold Mass

Objectives:Describe the unique presentation and management of a patient with an ipsilateral true vocal fold mass following revision thyroplasty that was identified to have migration of residual Gore-Tex thyroplasty implant into the superficial lamina propria of the anterior true vocal fold.Methods:A single case of a patient who underwent revision type I thyroplasty after an unsuccessful attempt elsewhere using a Gore-Tex implant is reported. At the time of revision surgery, it was thought that all prior implant material was extricated, and the patient underwent revision type I thyroplasty using a carved silastic Netterville Implant with arytenoid adduction.Results:After initial improvement following the revision type I thyroplasty, the patient experienced deterioration of her voice. Indirect laryngeal examination revealed fullness on the superior surface of the right true vocal fold affecting mucosal wave and glottic closure. Microdirect laryngoscopy with endoscopic evaluation revealed migration of residu...

Displacement of Residual Gore‐Tex Thyroplasty Implant Presenting as a True Vocal Fold Mass

Objectives: Describe the unique presentation and management of a patient with an ipsilateral true vocal fold mass following revision thyroplasty that was identified to have migration of residual Gore-Tex thyroplasty implant into the superficial lamina propria of the anterior true vocal fold. Methods: A single case of a patient who underwent revision type I thyroplasty after an unsuccessful attempt elsewhere using a Gore-Tex implant is reported. At the time of revision surgery, it was thought that all prior implant material was extricated, and the patient underwent revision type I thyroplasty using a carved silastic Netterville Implant with arytenoid adduction. Results: After initial improvement following the revision type I thyroplasty, the patient experienced deterioration of her voice. Indirect laryngeal examination revealed fullness on the superior surface of the right true vocal fold affecting mucosal wave and glottic closure. Microdirect laryngoscopy with endoscopic evaluation revealed migration of residual implant material into the superficial lamina propria. Using microflap technique, excision of the residual Gore-Tex thyroplasty implant was successfully performed with a combination of carbon dioxide laser and cold-dissection techniques. Conclusions: This case report describes the unique presentation of a displaced, non-extruded residual Gore-Tex thyroplasty implant, which presented as new onset dysphonia and mass involving the superior surface of the true vocal fold. This case demonstrates that displaced or migrated Gore-Tex thyroplasty implant material can be successfully removed endoscopically using a modified microflap technique.

The Management of Postintubation Phonatory Insufficiency

Prolonged intubation may lead to medial arytenoid cartilage erosion and cricoarytenoid joint scarring with subsequent glottic insufficiency. This has been referred to as postintubation phonatory insufficiency (PIPI). Reports on treatment outcomes for this condition are lacking. A single institution retrospective chart review from January 2007 to present was preformed for PIPI diagnosis. Data were collected for intubation, symptoms, diagnosis, interventions, and outcomes. Five patients with PIPI underwent treatment to improve voice. Patient 1 underwent thyroplasty with adduction arytenopexy. Patient 2 had a revision thyroplasty and subsequently two injections of the posterior defect and true vocal fold. Patient 3 underwent injection of the medial arytenoid defect. Patient 4 had injection augmentation of the anatomic deficiency and the ipsilateral true vocal fold. Patient 5 underwent thyroplasty with adduction arytenopexy. Limited to no phonatory improvement was achieved in any case. The management of patients with PIPI is difficult. Currently, no reliable means are available to restore cartilaginous defects in the respiratory glottis. Patients with this condition should be counseled as to the difficult nature of treatment.

S198 – Muscle Pedicle Thyroplasty for Difficult or Revision Cases

Objectives 1) Describe a modification of the type I thyroplasty procedure of Isshiki, incorporating a pedicled muscle flap which is rotated through the thyroid cartilage window into a pocket lateral to the thyroarytenoid muscle. The muscle flap is used to replace or augment an alloplastic implant. 2) Be able to understand the applications and indications for this procedure. Methods Our series describes 6 patients undergoing primary or revision thyroplasty since January 2006. In primary cases, the muscle pedicle was utilized after initial dissection resulted in an injury to the endolaryngeal mucosa, or to augment an implant that did not produce adequate medialization. In the revision cases, the muscle pedicle was utilized to replace a Silastic implant at the time of removal. Pre-operative and postoperative videostroboscopy was performed on all patients. Results Postoperative videostroboscopy revealed satisfactory glottic closure in all 6 patients between 1 and 3 months after their operations. Conclusions The procedure of muscle pedicle thyroplasty provides adequate glottic closure in cases of revision thyroplasty and in cases where it was used to augment another implant. It represents an alternative medialization technique in difficult and unusual cases, or when an alloplastic implant is contraindicated. Long-term durability of the medialization is not assessed in this series.

Complications after type one thyroplasty: is day-case surgery feasible?

Isshiki type one medialisation thyroplasty is an accepted treatment for a unilateral immobile vocal fold. It can also be performed simultaneously as a bilateral procedure in patients with severe bowing of the vocal folds (e.g. presbyphonia). The objectives of this study were to assess the incidence and timing of post-operative complications, and to evaluate whether patients undergoing this operation could, in future, be treated as day cases. A retrospective analysis was undertaken of 57 consecutive patients who had undergone a type one thyroplasty (52 unilateral and five bilateral) at a tertiary referral centre between April 2003 and April 2006. Post-operative improvement in the voice (measured subjectively, perceptually and quantitatively) was considered to constitute a successful outcome. Any complications were documented. Fifty-seven patients who had undergone laryngeal framework surgery were recruited from the study database. All of these patients had undergone either unilateral or bilateral type one medialisation thyroplasty but no arytenoid surgery. Thirty-seven were male (65 per cent) and 20 female (35 per cent), and there was left-sided predominance (74 per cent). All patients were discharged the morning following afternoon surgery (i.e. within 24 hours). Complications occurred in four patients (7 per cent). One patient, who was taking warfarin, developed a post-operative haematoma which resolved with conservative treatment. Two patients (both of whom had undergone revision thyroplasty) developed a wound infection three days post-operatively, which resolved with antibiotics. One patient returned with hoarseness five months post-operatively, after an initially successful result. This patient had previously received radiotherapy for early glottic carcinoma, and the Silastic implant was eroding through the mucosa. This was subsequently removed under general anaesthesia. No patients developed complications leading to airway compromise. The only complications in this series were in patients taking anticoagulation medication, undergoing revision surgery, or in whom the laryngeal tissue was atrophic or absent. Careful patient selection to exclude any of the above should reduce the risk of complications. The authors would therefore advocate type one thyroplasty for unilateral or bilateral vocal fold paralysis as a suitable procedure for day-case surgery within our department.

Evaluation of open approach and injection laryngoplasty in revision thyroplasty procedures

Vocal outcomes after medialization laryngoplasty are variable and may change over time. A revision procedure via open approach or an injection laryngoplasty may be necessary to improve vocal outcomes. A retrospective chart review was performed. Twenty-nine subjects were identified and stratified into group 1A (n = 9) if the allograft was repositioned/replaced, group 1B (n = 4) if the allograft was removed, and group 2 (n = 16) if an injection laryngoplasty was performed. Statistically significant differences were found between all data prerevision to postrevision (P < or = 0.05) for group 1A and group 2 when multiple paired-sample t tests were calculated for patient-reported voice severity ratings and voice impact ratings as well as clinician-reported voice ratings of grade, roughness, and breathiness. Results of group 2 were often temporary, with 10 of 16 (62.5%) subjects receiving multiple injections. Both open revision laryngoplasty and injection laryngoplasty are successful at providing improved vocal outcomes. Results are often temporary after injection laryngoplasty and often require multiple procedures.

Revision thyroplasty.

To document surgical techniques for performing a revision thyroplasty operation and to describe the subjective and objective results of these operations. I undertook a retrospective review of all patients who have undergone thyroplasty in my practice. I identified patients who required revision of a previous thyroplasty and evaluated preoperative and postoperative video and audio analyses of the voice. I identified the surgical steps necessary for successful completion of a revision operation and noted any special findings made at surgery. Charts were reviewed and tabulated for reasons for failure of the first operation, efficacy of the second surgical approach, specific anatomic findings made at revision surgery, and types of surgery available for revision. Of 625 total thyroplasties in 331 patients, revision operations accounted for 61 operations in 48 patients. All thyroplasty operations were found to be revisable or reversible. Objective voice analysis for 35 operations in 32 patients revealed a statistically significant improvement in shimmer in women, and in harmonics-to-noise ratio in all patients. Subjective voice improvement occurred in 80% of patients after revision surgery. I conclude that revision thyroplasty is possible with all thyroplasty types, giving significant improvement in both shimmer (women) and harmonics-to-noise ratio (all patients). Although most voices are still abnormal on postoperative objective voice analysis, 80% of patients are subjectively improved.

Concomitant type I thyroplasty and thoracic operations for lung cancer: Preventing respiratory complications associated with vagus or recurrent laryngeal nerve injury

Objectives: We sought to prevent postoperative swallowing disorder, aspiration, and sputum retention in cases of recurrent laryngeal or vagus nerve section occuring during lung cancer resection. Methods: In 14 of 25 consecutive patients, type I thyroplasty and thoracic operations were performed during the same period of anesthesia. All patients had a preoperative laryngeal computed tomographic scan providing us with indispensable measurements for vocal fold medialization under general anesthesia (ie, without intraoperative phonatory control). Nine remaining patients had a type I thyroplasty delayed from thoracic operations because of intraoperative doubt about laryngeal innervation injury, and 2 did not need a laryngeal operation. Main postoperative records consisted of swallowing ability, respiratory complications, and quality of voice. Results: No swallowing disorder, aspiration, or sputum retention occurred in cases of concomitant laryngeal and thoracic operations. Of these 14 patients, a single case (7%) of major complication (vocal fold overmedialization) occurred and required an early and successful revision thyroplasty; one case of cervical hematoma that did not require surgical drainage was considered a minor complication (7%). Twelve (86%) patients who underwent the concomitant association of both operations were fully satisfied with their quality of voice. Conclusions: Type I thyroplasty and thoracic operation can be advantageously associated in case of injury to laryngeal motor innervation to prevent postoperative swallowing disability and dramatic respiratory complications. (J Thorac Cardiovasc Surg 2001;121:642-8)

Magnetic resonance imaging (MRI) assessment of vocal fold medialization surgery

Historically, clinicians have used subjective assessment and perceptual judgments, supplemented with acoustic measures, aerodynamic studies, and videostroboscopy, to determine the effects of phonosurgery. When phonosurgical results are poor, magnetic resonance imaging (MRI) can be useful in determining how the surgical modifications contributed to the anatomical and functional status of the vocal folds. The authors present examples of MRI following vocal fold medialization by injection, thyroplasty, and arytenoid adduction. Findings reveal that the superior contrast resolution of MRI can precisely identify placement and persistence of injected implants and is particularly helpful in showing effects of the size and shape of alloplastic prostheses on vocal fold displacement. Such information is useful in troubleshooting suboptimal results and in planning revision thyroplasty by defining modification in the design of prostheses and the placement of cartilaginous windows in medialization thyroplasty. MRI can also aid in confirming indications for and limitations of certain procedures.