Underwent Medialization Thyroplasty Research Articles

446. VOCAL FOLD AUGMENTATION REDUCES PNEUMONIA INCIDENCE IN PATIENTS WITH IATROGENIC RECURRENT LARYNGEAL NERVE PALSY AFTER ESOPHAGECTOMY

Abstract Background Recurrent laryngeal nerve (RLN) palsy is a significant complication associated with esophagectomy, resulting in a high incidence of pneumonia and a poor quality of life. Vocal fold augmentation (VFA) can help alleviate the associated symptoms of dysphonia. We aimed to investigate the impact of VFA on pneumonia incidence in patients suffering from RLN palsy after esophagectomy. Methods This is a retrospective cohort study. Patients who underwent esophagectomy at our center from 2003 to 2022, and experienced right, left or bilateral RLN palsy postoperatively were selected from a prospectively managed database. VFA consisted of medialisation thyroplasty, injection laryngoplasty, arytenoid adduction or a combination of these procedures. Pneumonia was defined as lung changes on chest x-ray, along with clinical evidence of infection within six months after esophagectomy. Pearson’s chi-squared test was used to assess the difference in pneumonia rates. Univariate and multivariate logistic regression analyses were used to identify associations between variables and the outcome of pneumonia. Results A total of 107 esophagectomy patients with RLN palsy were included. The overall palsy rate was 14.5%. 41 patients (38.3%) underwent VFA. Of the patients who underwent VFA, 13 (31.7%) underwent medialization thyroplasty, 26 (63.4%) underwent injection laryngoplasty, 1 (2.4%) underwent injection laryngoplasty and medialization thyroplasty, and 1 (2.4%) underwent injection laryngoplasty and arytenoid adduction. Pneumonia rate (14.6%) for patients who underwent VFA was significantly lower than that of patients without VFA (47.0%, P < 0.001). On univariate and multivariate analyses, patients who underwent VFA were less likely to suffer from pneumonia compared to those without VFA (OR = 0.194, P = 0.001). Conclusion Vocal fold augmentation reduces pneumonia incidence in patients with recurrent laryngeal nerve palsy after esophagectomy.

Anesthetic Technique and Functional Outcomes in Modified Montgomery Thyroplasty.

Montgomery thyroplasty type I is a surgical technique indicated in vocal cord paralysis which consists of the paralyzed cord medialization, improving the voice quality. The objective of the study is to describe in detail the anesthetic method to obtain optimal post-medialization voice results. Retrospective case series study including patients who underwent medialization thyroplasty using the modified Montgomery technique at the General University Hospital of Valencia between 2011 and 2021. The anesthetic technique consisted of general anesthesia with neuromuscular relaxation and a laryngeal mask. Pre- and post-surgical vocal functional data of maximum phonation times (MPT), G score, and Voice Handicap Index-30 (VHI-30) were evaluated. All the patients presented an improvement in voice results, increasing MPT after surgery and a decrease in VHI-30 and G score postoperatively, with statistically significant differences between the pre- and post-surgical results (p-value < 0.05). There were no complications related to anesthesia or surgery. The use of general anesthesia with muscle relaxation in modified Montgomery thyroplasty may be a good option to consider. The use of a laryngeal mask for ventilation combined with a fiberoptic check allows direct visualization of the vocal cords intraoperatively, providing good functional voice results.

Arytenoid vertical height discrepancy in predicting outcomes after unilateral vocal cord medialization.

Unilateral vocal fold paralysis is a structural abnormality that often occurs secondary to dysfunction of the recurrent laryngeal nerve and typically presents as a breathy voice. Medialization laryngoplasty is a constellation of procedures that improves apposition of the vocal cords. Many patients, however, fail to experience sufficient improvement in vocal quality postoperatively despite apparent glottic closure on stroboscopy. This suggests that asymmetry in other cord characteristics may also have acoustic consequences. Our hypothesis is that arytenoid height symmetry may play a significant role in vocal quality. To our knowledge there are no human observational studies examining this topic. We therefore aimed to correlate asymmetry in arytenoid height and patient-reported satisfaction in voice quality after thyroplasty. Retrospective cohort analysis. A retrospective review of prospectively collected data on consecutive patients who underwent medialization thyroplasty at a tertiary Sydney, Australia hospital was performed. Data collected included age, sex, onset of symptoms, as well as well as preoperative and 3-month postoperative maximum phonation time and Voice Handicap Index (VHI). Preoperative computed tomography scans were assessed for discrepancy of arytenoid vertical height discrepancy. Twenty-three patients (56.5% female) with mean age of 52.4 ± 14.9 years were included. Most patients underwent injection thyroplasty (78.3%, n = 5), whereas the remaining underwent an open approach. A statistically significant inverse correlation was found between increasing height discrepancy and VHI improvement (r = -0.6, P = .003.) Revision surgery was associated with increased height discrepancy. Findings of this study may affect future recommendations to address height discrepancy in surgery to treat unilateral vocal cord paralysis. 3 Laryngoscope, 130:418-422, 2020.

Medialization thyroplasty versus injection laryngoplasty: a cost minimization analysis

BackgroundMedialization thyroplasty and injection laryngoplasty are widely accepted treatment options for unilateral vocal fold paralysis. Although both procedures result in similar clinical outcomes, little is known about the corresponding medical care costs. Medialization thyroplasty requires expensive operating room resources while injection laryngoplasty utilizes outpatient resources but may require repeated procedures. The purpose of this study, therefore, is to quantify the cost differences in adult patients with unilateral vocal fold paralysis undergoing medialization thyroplasty versus injection laryngoplasty.Study designCost minimization analysis conducted using a decision tree model.MethodsA decision tree model was constructed to capture clinical scenarios for medialization thyroplasty and injection laryngoplasty. Probabilities for various events were obtained from a retrospective cohort from the London Health Sciences Centre, Canada. Costs were derived from the published literature and the London Health Science Centre. All costs were reported in 2014 Canadian dollars. Time horizon was 5 years. The study was conducted from an academic hospital perspective in Canada. Various sensitivity analyses were conducted to assess differences in procedure-specific costs and probabilities of key events.ResultsSixty-three patients underwent medialization thyroplasty and 41 underwent injection laryngoplasty. Cost of medialization thyroplasty was C$2499.10 per patient whereas those treated with injection laryngoplasty cost C$943.19. Results showed that cost savings with IL were C$1555.91. Deterministic and probabilistic sensitivity analyses suggested cost savings ranged from C$596 to C$3626.ConclusionsTreatment with injection laryngoplasty results in cost savings of C$1555.91 per patient. Our extensive sensitivity analyses suggest that switching from medialization thyroplasty to injection laryngoplasty will lead to a minimum cost savings of C$596 per patient. Considering the significant cost savings and similar effectiveness, injection laryngoplasty should be strongly considered as a preferred treatment option for patients diagnosed with unilateral vocal fold paralysis.

Medialization Thyroplasty Using the Pocket and Silicone Implant Technique

Objective: To describe a new method of medialization thyroplasty using a modified preformed nasal silicone implant.&#x0D; Methods: &#x0D; Design: Surgical Innovation&#x0D; Setting: Tertiary Private Hospital&#x0D; Participants: Four patients underwent medialization thyroplasty using a pocket and nasal implant technique performed by the senior co-author. The indication for medialization thyroplasty for these patients was hoarseness secondary to unilateral vocal fold paralysis of more than 6 months duration, and documented by flexible fiberoptic laryngoscopy. The outcomes were described with comparison of pre- and post-operative subjective voice assessment.&#x0D; Results: Operative time was 15–30 minutes. Post-operative subjective improvement of voice quality was evident. Scars were minimal and aesthetically acceptable. The procedure could be done on an outpatient basis. &#x0D; Conclusion: Medialization thyroplasty via a pocket and silicone implant technique is initially effective and may be a worthwhile alternative to the usual window technique.&#x0D; Keywords: unilateral vocal cord paralysis; medialization thyroplasty; Isshiki thyroplasty; silicone implant&#x0D;

Medialization thyroplasty for voice restoration after transoral cordectomy

Fourteen dysphonic patients who had previously undergone total or extended cordectomy underwent medialization thyroplasty. A minimum delay of 6 months was respected to allow the spontaneous "neocord" formation, to evaluate the voice recovery achieved by speech therapy alone and to avoid an undiagnosed early recurrence. Surgery was performed under general anaesthesia, using a laryngeal mask, because undermining the fibrous tissue at the inner side of the thyroid ala is a prolonged and difficult procedure. This step was essential to ensure an easy placement of the implant and to avoid tearing the fibrous tissue, with subsequent risk of implant extrusion. Visual control of the implant implementation was obtained by flexible videoendoscopy. The Montgomery(®) implant system (Boston, Westborough, MA) was used for the majority of the cases. Hand-made modified Montgomery implants or Gore-tex(®) were used in case of extended scarring or peculiar anatomic defect. The voice assessment showed a decrease of the VHI score from 50.5 to 39.4; a decrease of G from 2.4 to 2; an increase of maximum phonation time (MPT) from 6.2 to 7.3 s; a decrease of the maximum fundamental frequency (Fo-high) from 338.7 to 242.4 Hz and a decrease of the phonation quotient from 1,144.9 to 544.9 ml/s. The lower intensity (I-low) remained unchanged, from 60 to 58 dB. Statistically significant improvement was noted only for VHI and G grading. A decrease of the voice efforts and fatigue were noticed by all the patients.

Long-term results after external vocal fold medialization thyroplasty with titanium vocal fold medialization implant (TVFMI)

Since its introduction in 1999 by Friedrich, the titanium vocal fold medialization implant (TVFMI) is widely used for medialization thyroplasty in glottal closure insufficiency. The purpose of this study was to investigate the long-term functional outcome after medialization thyroplasty using TVFMI. Between 1999 and 2009 123 patients (mean age 55.3 years, 76 male and 47 female) underwent medialization thyroplasty with the TVFMI (96 left, 27 right). For purpose of long-term follow-up, 33 patients could be examined. Prior to surgery, about 8 weeks and at least 1 year after surgery perceptual, acoustic, aerodynamic and videolaryngostroboscopic examinations have been performed. The interval between surgery and long-term follow-up was on average 57 (23-120) months. None of the 123 patients presented early major postoperative complications (e.g. implant dislocation, dyspnoea with need of tracheostomy, wound infection, postoperative bleeding). In three patients the TVFMI had to be removed 2-6 months after surgery due to granulation tissue formation. In one patient a subepithelial localization of the implant could be seen without necessity of removal. Perceptual and acoustic parameters were significantly improved after surgery with long-lasting effect even years after surgery. Airway resistance (R(aw)) showed an increase over time without a relevant negative impact on the peak expiratory flow (PEF). Medialization thyroplasty using TVFMI allows precise and save positioning of the implant with stable perceptual and acoustic improvement. The only postoperative complication was the development of endolaryngeal granulation tissue resulting in removal of the implant.

Novel Approach of Medialization Thyroplasty with Arytenoid Adduction Performed under General Anesthesia with a Laryngeal Mask

To objectively assess the voice outcomes of patients with unilateral vocal fold paralysis treated with medialization thyroplasty and arytenoid adduction suture. Case series of patients who underwent medialization thyroplasty and arytenoid adduction suture. Preoperative and postoperative voice testing was performed and the data were compared by statistical analysis. Tertiary referral teaching hospital in Sydney, Australia. All patients had a unilateral vocal fold paralysis, with a large posterior glottic gap and vocal symptoms affecting their quality of life. Thirteen patients with a diagnosis of a unilateral vocal fold paralysis with a large posterior glottic gap, vocal symptoms, and total denervation of the vocal fold underwent medialization thyroplasty and arytenoid adduction suture. The surgery was performed in a novel method under a general anesthetic using a laryngeal mask and with direct intraoperative endoscopic feedback. Preoperative and postoperative measures of voice performance were compared, including acoustic analysis (fundamental frequency, speech intensity against quiet and loud background noise, speech rate) and aerodynamic assessment (airflow, maximum phonation time). Medialization thyroplasty with arytenoid adduction suture significantly improved aerodynamic assessment and phonation duration for both male and female subjects overall. There were 2 of 13 treatment failures. Median follow-up time was 6 months. Preliminary results indicate that in selected patients with vocal fold paralysis, medialization thyroplasty with arytenoid adduction suture leads to significant improvements in objective voice measures. Longer follow-up data are required to further quantify the voice outcomes after this procedure.

Lower Cranial Nerve Function Following Jugular Foramen Tumor Resection

Objective: Describe the presentation, tumor characteristics, and postoperative lower cranial nerve function following surgery for jugular foramen tumors. Method: Thirty jugular foramen tumor resections performed between 1989 and 2009 were reviewed. The mean age was 48.2 years (range, 18.6-77.7 years) at time of presentation. Surgical approaches included infratemporal fossa (70%), retrosigmoid (23%), transtemporal (20%), transcondylar (17%), and transcervical (17%). The mean follow-up was 4.6 years. Results: Combined surgical approaches were used in over 50% of the cases, and 60% underwent preoperative tumor embolization. Tinnitus was the most common presenting symptom, and middle ear or neck mass was the most common presenting sign. The most common diagnosis was paraganglioma. Six patients required tracheotomy, and 8 had feeding tubes at discharge. Fifty-seven percent of patients underwent speech or swallow therapy, 43% were treated with vocal cord injections, and 17% underwent medialization thyroplasty. Cerebrospinal fluid leak was uncommon (13%), and meningitis occurred in 1 patient. Normal or near-normal facial nerve function was maintained in 89% of patients. Conclusion: Resection of jugular foramen tumors carries a significant risk of lower cranial nerve dysfunction; however, long-term speech, airway, and swallowing morbidity can be minimized with contemporary ancillary surgical procedures.

Hydroxyapatite versus titanium implant: Comparison of the functional outcome after vocal fold medialization in unilateral recurrent nerve paralysis

Results of medialization thyroplasty for treatment of unilateral vocal fold paralysis are often unsatisfactory. This study compares glottal closure and voice quality after use of 2 different medialization implant types: VoCoM and TVFMI. In all, 26 patients with unilateral vocal fold paralysis following thoracic surgery underwent medialization thyroplasty. In 11 patients (group I), a hydroxyapatite implant (VoCoM) was used. In 15 patients (group II), a titanium implant (TVFMI) was used. Preoperative and postoperative glottal closure and voice function were assessed with videostroboscopy, perceptual and objective voice measures, and the Voice Dysfunction Index (VDI). Group II showed a higher rate of complete glottal closure and greater improvement in perceived hoarseness, maximal phonation time, and maximal voice intensity than those in group I. With the individually adjustable titanium implant, better glottal closure and better functional outcome (phonation time and voice quality) were achieved.

Medialization thyroplasty: vocal outcome of silicone and titanium implant

Unilateral vocal fold paralysis can result in incomplete glottic closure, compromising the vocal efficiency and increasing the risk of aspiration. The glottic gap can be reduced by medialization thyroplasty. Both silicone and titanium implants have been described to be efficient in the improvement of the vocal outcome. The aim of this study was to assess the vocal outcome after medialization thyroplasty using silicone and titanium implants and to compare the results of the two implanted materials using prospective sequential cohort study. 24 patients underwent medialization thyroplasty, performed under local anaesthesia with intravenous sedation: 10 patients were included in the silicone cohort and 14 in the titanium cohort. All patients underwent vocal assessment preoperatively and postoperatively, using the Voice Handicap Index, the GRBASI scale, maximum phonation time and the Dysphonia Severity Index. Postoperative analysis of the entire population showed statistically significant improvement for the Voice Handicap Index, maximum phonation time, Dysphonia Severity Index and the parameters G, B and A of the GRBASI scale (83% follow up). Subgroup analysis showed a statistically significant greater improvement of Voice Handicap Index of the titanium cohort compared with the silicone cohort. Improvement of maximum phonation time, Dysphonia Severity Index and GRBASI scale of the titanium cohort was greater than improvement of the silicone cohort, but this difference was not statistically significant. Both silicone and titanium medialization implants showed improvement of vocal outcome, the results of the titanium implant being superior.

Thyroplasty with simultaneously use of silastic and Gore-Tex implants

Introduction: Type I thyroplasty for unilateral vocal fold paralysis restores voice. In medialization thyroplasty carved sailastic, prefabricated, dense hydroxyapatite and Gore-Tex implants are routinely used. Materials and Methods: In this prospectively study thyroplasty performed with simultaneously use of carved sailastic and Gore-Tex implants. Nine patients with true vocal fold paralysis due to complication of cardiac surgery, thyroidectomy and idiopatic, underwent medialization thyroplasty by this method. In six patients, just sailastic implant was used and results compared together. Results: Mean duration of follow was 9 months. 5 patients had excellent voice improvement. The voice improvement in four patients was good. In patients with only sailastic implant, just one patient had excellent voice improvement and 5 patients had dysphonia. Conclusion: In this method carved silastic is placed in thyroid cartilage window just one time and additional medialization is performed by insertion of Gore –Tex strips between cartilage and silastic implant. Resulting decreased manipulation of surgical field and surgical time, paralyzed true vocal fold edema is reduced and judgment of voice improvement was exact.

Long-term results of different treatment modalities for glottic insufficiency

Purpose The purpose of this study was to investigate the early and long-term functional results of thyroplasty type-I and injection laryngoplasty using fat or calcium hydroxylapatite. Materials and methods Thirty patients with glottic insufficiency were included and followed up between 1-7 years. Patients with glottic bowing or sulcus vocalis were selected for injection augmentation of the vocal folds, while those with unilateral vocal fold immobility underwent medialization thyroplasty. Perceptual and acoustic analysis of voice, and videolaryngostroboscopy were performed before and after surgery. Results After the surgery, GRBAS scale of all patients demonstrated significant change in grade of severity, roughness, and breathiness. Acoustic analysis demonstrated significant change in Fo, jitter, shimmer, noise to harmonic ratio, and maximum phonation time (MPT) in thyroplasty group, while those demonstrated significant change in Fo (lowest) and jitter, and MPT in injection augmentation group. Conclusions Medialization thyroplasty is the gold standard for the management of glottic insufficiency, regardless of the severity of glottic gap. However, injection augmentation of the vocal folds may be considered as an alternative in the treatment of patients with small glottic gap. Further studies with larger groups and long follow-up periods are required to figure out the proper material for injection laryngoplasty.

Thyroplasty under total intravenous anaesthesia with intermittent positive pressure ventilation

Medialization thyroplasty is a surgical technique for improving voice quality, cough effort and laryngeal competence in patients with unilateral vocal fold paralysis. Precision surgery is enabled by operating under total intravenous anaesthesia with controlled ventilation and by using a laryngoscopic video-assisted technique. The anaesthetic challenge is to manage the shared airway with the surgeon, provide a stable operative field and ensure patient safety throughout the procedure. The objective of this case series was to evaluate the use of a modified general anaesthetic technique using the laryngeal mask airway, total intravenous anaesthesia with controlled ventilation. In all, 29 patients underwent medialization thyroplasty using a disposable laryngeal mask airway, total intravenous anaesthesia and controlled ventilation. Standard anaesthetic monitoring including capnography was used intraoperatively. Total intravenous anaesthesia was achieved using effect site target-controlled infusions of propofol and remifentanil. The technique proved safe with stable haemodynamic observations and only two minor complications. It also provided the surgeon with stable view of the vocal folds in order to perform this precision surgery under an operating microscope.

Impact of laryngeal paralysis and its treatment on the glottic aperture and upper airway flow characteristics during exercise

Patients with unilateral vocal fold paralysis occasionally report shortness of breath during exercise. This symptom may persist in some patients after medialization thyroplasty. A review of the literature revealed no study that objectively evaluated laryngeal dynamics or airway flow characteristics during exercise after medialization thyroplasty for unilateral laryngeal paralysis. This study evaluates glottic aperture size and configuration as well as upper airway flow characteristics during exercise in 16 subjects. Six patients who underwent medialization thyroplasty for unilateral vocal fold paralysis were compared with 10 healthy control subjects. During a standardized exercise protocol on an incremental ergometer (bicycle type), real-time videolaryngoscopy was obtained and correlated in a synchronized fashion with maximum-effort respiratory efforts at the beginning, midpoint, and end of the exercise period. Direct calculations of glottic size during various phases of the exercise period were performed from digitized images. These data were correlated with inspiratory flow data for each patient. Patients with laryngeal paralysis demonstrated smaller mean glottic areas and lower peak inspiratory flow rates than controls both at rest and during all phases of the exercise period. This study suggests that after treatment of unilateral laryngeal paralysis with medialization thyroplasty, inspiratory flow rate and glottic area are significantly less than in normal controls. (Otolaryngol Head Neck Surg 1999;120:819-23.)

Pathophysiology and indications for medialization thyroplasty in patients with dysphagia and aspiration

Medialization thyroplasty is generally considered a phonosurgical procedure for voice augmentation in patients with glottic insufficiency. This article addresses specifically the issue of dysphagia and aspiration in patients with laryngeal paralysis. A retrospective review of patients undergoing medialization thyroplasty is performed. From 1991 to 1995, 84 patients at The Johns Hopkins Medical Institutions underwent medialization thyroplasty for unilateral vocal fold motion impairment. At presentation 48 patients had isolated recurrent laryngeal nerve injury, 26 with combined superior laryngeal nerve/recurrent laryngeal nerve injury and 10 with idiopathic nerve injury. Sixty-one percent of patients had swallowing difficulties. The severity of symptoms is greater in the superior laryngeal nerve/recurrent laryngeal nerve group. Before surgery 13 patients were dependent on feeding tubes. Nine patients improved to the point at which all alimentation was taken by mouth and tube feedings were discontinued after medialization thyroplasty. One patient was subsequently converted to a full oral diet after cricopharyngeal myotomy. Three patients remained dependent on feeding tubes. The pathophysiology of dysphagia including clinical and experimental observations is reviewed. In addition, the nonsurgical and surgical approaches to treatment of patients with laryngeal paralysis are reviewed. (Otolaryngol Head Neck Surg 1997;116:349-54.)

Pathophysiology and indications for medialization thyroplasty in patients with dysphagia and aspiration.

Medialization thyroplasty is generally considered a phonosurgical procedure for voice augmentation in patients with glottic insufficiency. This article addresses specifically the issue of dysphagia and aspiration in patients with laryngeal paralysis. A retrospective review of patients undergoing medialization thyroplasty is performed. From 1991 to 1995, 84 patients at The Johns Hopkins Medical Institutions underwent medialization thyroplasty for unilateral vocal fold motion impairment. At presentation 48 patients had isolated recurrent laryngeal nerve injury, 26 with combined superior laryngeal nerve/recurrent laryngeal nerve injury and 10 with idiopathic nerve injury. Sixty-one percent of patients had swallowing difficulties. The severity of symptoms is greater in the superior laryngeal nerve/recurrent laryngeal nerve group. Before surgery 13 patients were dependent on feeding tubes. Nine patients improved to the point at which all alimentation was taken by mouth and tube feedings were discontinued after medialization thyroplasty. One patient was subsequently converted to a full oral diet after cricopharyngeal myotomy. Three patients remained dependent on feeding tubes. The pathophysiology of dysphagia including clinical and experimental observations is reviewed. In addition, the nonsurgical and surgical approaches to treatment of patients with laryngeal paralysis are reviewed.

Acoustic analysis of glottal gap measurement.

A simple, efficient, noninvasive method for defining the size of the glottic gap in patients with dysphonia would be highly desirable. Current methods for defining the degree of insufficiency involve aerodynamic and videostroboscopic analysis. PARCOR analysis of the glottal area was calculated utilizing DAT recorded data obtained at a 44.1-kHz sampling rate from 15 patients with dysphonia, 14 of which presented unilateral recurrent laryngeal nerve paralysis. Ten thousand data points were calculated for each voiced sample. PARCOR coefficients were obtained and used as a basis for determining the cross-section area of vocal tract, i.e., the glottal area ratio (GAR). GAR, which is a noninvasive technique, was utilized successfully in the verification of the reduction in glottal gap of 15 patients who underwent medialization thyroplasty for glottis insufficiency. Results demonstrate that GAR utilizing PARCOR analysis corresponds favorably with findings obtained using well-attested methods of aerodynamic and videolaryngoscopic analysis.