The fate of medialized cartilage in thyroplasty type I

Evaluation of thyroplasty with cartilage implant in young children

OBJECTIVE

To evaluate thyroplasty with autologous cartilage implant in young children.

METHODS

This retrospective study included all patients aged <10 years who underwent thyroplasty, in a tertiary care center, between 1999 and 2019 and had a postoperative follow-up at least one year later. Morphological evaluation was based on fiberoptic laryngoscopy and laryngeal ultrasound. Functional outcomes included parental evaluation of laryngeal signs by visual analogue scale and dysphonia ratings on the Grade, Roughness, Breathiness, Asthenia, and Strain scale. These assessments were performed at postoperative months 1, 6, and 12, and then annually.

RESULTS

Participants were 11 patients with a median age of 26 months (8-115 months). Their median duration of progression of paralysis before surgical management was 17 months. No intra or postoperative complications were observed. Postoperative evaluation showed virtual disappearance of aspiration and chronic congestion. Voice evaluation revealed significant improvements in all patients. The long-term trend, over a median of 77 months, showed stable results in 10 cases. One patient had late-onset deterioration requiring an additional vocal fold injection. Ultrasound follow-up showed no resorption of the cartilage implant and no deformation of the thyroid ala.

CONCLUSION

Pediatric thyroplasty requires technical adaptations. Use of a cartilage implant allows observation of medialization stability during the growth. These findings are particularly relevant of contraindication or failure of nonselective reinnervation.

Larynx: implants and stents

In the human larynx, implants a primarily used for the correction of glottis insufficiency. In a broader sense laryngeal stents may be considered as implants as well. Laryngeal implants can be differentiated into injectable and solid. The most important representatives of both groups are discussed in detail along with the respective technique of application. Laryngeal stents are primarily used perioperatively. Different types and their use are presented.

Continuous cervical epidural analgesia for Isshiki type - I thyroplasty

Thyroplasty is an operation on the upper airway to improve voice quality in patients with unilateral vocal cord paralysis. It is a difficult anaesthetic procedure that requires sharing the airway with the surgeon. We describe a good anaesthetic technique, which provides a safe airway with excellent operating conditions, using continuous cervical epidural anaesthesia and postoperative analgesia in three patients. The use of a regional anaesthetic technique provides excellent anaesthesia and analgesia while allowing the patient to phonate at the request of the surgeon intraoperatively.

[Unilateral extended medialization thyroplasty. Treatment for total aspiration after laser surgery and radiotherapy of laryngeal cancer]

BACKGROUND

Total aspiration is a rare complication after extended laser surgery for laryngeal cancer with adjuvant radiotherapy.

PATIENTS AND METHODS

Two patients with long-standing total aspiration after laser surgery with radiotherapy despite intensified swallowing therapy were treated with an extended medialization thyroplasty.

RESULTS

Postoperatively, both patients were able to swallow food and liquids without aspiration. One patient no longer has a gastrostomy tube and has been free from aspiration with normal oral food intake for 3 years. The second patient, with a tiny mucosal scar perforation, developed an abscess 2 months after surgery and needed revision surgery, with a subsequent return of aspiration.

DISCUSSION

The second patient's complication stresses the significance of an intact endolaryngeal scar because of the well-known prolonged healing of mucosa in the irradiated larynx. In our opinion, the potential benefits of medialization thyroplasty outweigh the risk of significant complications, especially after irradiation.

Bipedicled Strap Muscle Transposition for Vocal Fold Deficit after Laser Cordectomy in Early Glottic Cancer Patients

OBJECTIVE

In treating early glottic carcinomas, the outcomes of endoscopic laser cordectomy have been proven to be valuable in local control, survival, and vocal function preservation. In some extended cases, however, laser cordectomy may leave patients with poor vocal function because of vocal fold deficit. This work assesses the vocal outcome of medialization laryngoplasty with bipedicled strap muscle transposition for vocal fold deficit resulting from laser cordectomy in early glottic cancer patients.

STUDY DESIGN

A prospective clinical series.

METHODS

Thirteen early glottic cancer patients who had vocal fold deficit caused by previous laser cordectomy underwent medialization laryngoplasty with bipedicled strap muscle transposition. The thyroid lamina on the cordectomy side was paramedially separated. The inner perichondrium was circumspectly raised from the overlying thyroid cartilage. After separating the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally. A bipedicled strap muscle flap was then transposed into the area between the lamina and the paraglottic soft tissue. The thyroid cartilages were carefully sutured back in position. All patients received pre- and postoperative voice assessments comprising laryngostroboscopy and vocal function studies.

RESULTS

Vocal enhancement was present in 92% (12/13) of patients after medialization laryngoplasty with strap muscle transposition. The glottal closure and maximal phonation time were noticeably improved by surgery. No dyspnea or other significant complications were observed in any patients.

CONCLUSION

The outcomes show that bipedicled strap muscle transposition is a prosthesis-free, safe, and valuable laryngoplastic technique for correcting glottal incompetence caused by endoscopic laser cordectomy in early glottic cancer patients.

Autologous elastic cartilage for laryngoplasty: histologic evaluation in a rabbit model

A wide range of materials have been used to achieve medialization of the paralyzed vocal fold. Recently, medialization techniques using autologous cartilage have been described, but little information is available on cartilage integration and viability in this situation. In this prospective, experimental, controlled study, right vocal fold paralysis was surgically induced in 30 New Zealand rabbits. An autologous auricular cartilage transplant was inserted in the vocal fold in 15 animals. In the control group, only the laryngeal nerve was sectioned. Each group was divided into two groups with follow-ups of 6 weeks and 6 months, respectively. Histologic studies revealed no inflammatory reaction against the cartilage transplants. There were no differences in the transplant surfaces in the 6-week and 6-month groups. The results show tissue integration and a low level of initial transplant resorption that stabilizes with time. Autologous auricular cartilage appears to be an appropriate material for type I thyroplasty procedures because of the low absorption rate.

Mechanical and Dynamic Aspects of Voice Production as Related to Voice Therapy and Phonosurgery

Laryngeal framework surgery can change the position and tension of the vocal folds safely without direct surgical intervention in the vocal fold proper. Some 23 years of experience with phonosurgery have proved its usefulness in treating dysphonia related to unilateral vocal fold paralysis, vocal fold atrophy, and pitch-related dysphonias. Meanwhile, much information about the mechanism of voice production has been obtained through intraoperative findings of voice and fiberscopic examination of the larynx. Based on such knowledge together with information obtained through model experiments, the human vocal organ was reconsidered mainly from the mechanical view point, and the roles of voice therapy and singing pedagogy were discussed in relation to phonosurgery. The vocal organ may not be an ideal musical organ and is rather vulnerable, but its potential is enormous.

Progress in laryngeal framework surgery

This paper reviews progress in laryngeal framework surgery since it was first reported about 25 years ago. The success of this type of surgery requires both a basic knowledge of the physiology of phonation, in order to make decisions about the surgical procedure, and surgical skill, in order to accomplish the intended procedure successfully. The main reason for hoarseness is imperfect closure of the glottis, but the second most important reason for hoarseness, increased stiffness of the vocal fold, cannot be corrected by mere medialization of the vocal fold. Laryngeal framework surgery is different in concept from conventional surgery, which is intended to remove the lesion. Controversial points discussed here regarding type I thyroplasty include: (i) whether the cartilage window should be removed; (ii) materials for fixation of the window; and (iii) comparison of type I thyroplasty with arytenoid adduction. A new surgical treatment for spasmodic dysphonia and its results in three patients are described briefly. Surgery for raising the vocal pitch requires further improvement. In the future, laryngeal framework surgery will have wider application in treatment of dysphonias, such as asthenic voice due to atrophy in professional singers or aging, pitch problems in females and gender identity disorder and spasmodic dysphonia.

Thyroplasty under general anesthesia using a laryngeal mask airway and fibreoptic bronchoscope

PURPOSE

To report the management of a patient, with unilateral vocal cord paralysis, undergoing thyroplasty, under general anesthesia.

CLINICAL FEATURES

A 25-yr-old man developed hoarseness and occasional episodes of pulmonary aspiration, caused by unilateral vocal cord paralysis. He was scheduled for thyroplasty, in an attempt to ease phonation and to decrease or prevent further episodes of pulmonary aspiration. He refused local anesthesia with sedation and it was therefore decided to attempt the procedure under general anesthesia. The paralysed vocal cord was displaced inwards by a wedge inserted through a window in the thyroid cartilage. We assessed the ideal position of the wedge by using a fibreoptic bronchoscope and laryngeal mask airway during general anesthesia, instead of phonation.

CONCLUSION

We describe the successful use of a general anesthetic for a thyroplasty, a procedure normally done under local anesthesia with or without sedation, in a patient who was keen to have surgery, but who refused local anesthesia with sedation.

Anatomic study for posterior medialization thyroplasty

To attain posterior medialization by thyroplasty type I, we simulated the surgery using 3 cadaveric larynges. Two approaches were applied to adduct the arytenoid cartilage: one involved compression of the vocal process, and the other, compression of the muscular process inward. The inner perichondrium was incised to reach the arytenoid cartilage from the framework. To compress the vocal process, a large silicone plug was required. In this method, there was some difficulty in compressing the vocal process precisely, and there was the risk of postoperative extrusion of the large plug. In contrast, the muscular process was more superficial relative to the framework, and it could be precisely compressed, resulting in sufficient posterior glottal closure. The silicone plug required for this procedure has a shallow depth that may provide the advantage of preventing postoperative extrusion. In conclusion, the compression of the muscular process is preferable for safely achieving posterior glottal closure.

Titanium vocal fold medializing implant: introducing a novel implant system for external vocal fold medialization

With the increasing worldwide spread of the Isshiki technique for external vocal fold medialization, some disadvantages and limitations have also emerged. and an increasing demand for a ready-made and standardized implant system can be observed. For this reason. I started experimental and clinical investigations with the goal of replacing the silicone with a safer material, and also simplifying and standardizing the surgical procedure. In particular, the danger of implant dislocation should be excluded with greater certainty. As a result, I have developed an implant made of medical-grade titanium. My surgical experiences in 20 patients with this newly developed titanium vocal fold medializing implant revealed that vocal fold medialization could be performed easily and that no perioperative complications occurred in any case. The major advantage was a significant reduction of operative time due to the preformed implant. This is not only more convenient for both the surgeon and the patient, but is also critical for obtaining optimal results due to the reduced intralaryngeal swelling and hematoma. The reduction of the glottic gap by the operation was statistically significant. Significant improvement of all voice parameters was achieved and demonstrated by a statistically significant reduction of the voice dysfunction index. Compared to the current techniques and implant systems, I see the following additional advantages: 1) titanium is a relatively safe implant material with excellent biocompatibility: 2) the design of the implant ensures optimal fixation and stabilization: 3) the implantation technique and handling is simple and time-saving; 4) the titanium sheet is easy to shape and adapt to the individual situation: and 5) only 2 sizes of implants, and no expensive instruments, are required.

Vocal mechanics as the basis for phonosurgery

OBJECTIVE

A number of modifications in laryngoplastic phonosurgery have recently been proposed. This report is intended to clarify the concept on which the surgery should be based, vocal mechanics, for further rational development of the surgery.

STUDY DESIGN

The results of various previous surgeries were compared. In an attempt to elucidate what makes the difference in the results, simulation of voice production was conducted with the use of excised larynges.

METHODS

Excised larynges were mounted on a tube so as to be blown from below. Experimental variables in the model included the glottal area initially set, stiffness of the vocal folds, and subglottal pressure. The conditions under which the voice became hoarse were examined.

RESULTS

The voice became hoarse under the following major conditions: 1) the initial glottal area exceeded a certain value, 2) stiffness was too high, and 3) the glottis was too tightly closed. Clinical representation for each condition was made, particularly for excessively tight glottal closure such as in spasmodic dysphonia. A new type of surgical treatment for spasmodic dysphonia, lateralization thyroplasty, was briefly reported, which restored the voice to normal without recurrence for 1 year at the time of this writing.

CONCLUSIONS

A potential new type of laryngoplastic phonosurgery should be conformed to the mechanics of voice production. In treating dysphonia, it is often necessary to switch from etiologic or radical treatment, if infertile, to symptomatic treatment instead, at the level of mechanics.

Mechanical and dynamic aspects of voice production as related to voice therapy and phonosurgery

Laryngeal framework surgery can change the position and tension of the vocal folds safely without direct surgical intervention in the vocal fold proper. Some 23 years of experience with phonosurgery have proved its usefulness in treating dysphonia related to unilateral vocal fold paralysis, vocal fold atrophy, and pitch-related dysphonias . Meanwhile, much information about the mechanism of voice production has been obtained through intraoperative findings of voice and fiberscopic examination of the larynx . Based on such knowledge together with information obtained through model experiments, the human vocal organ was reconsidered mainly from the mechanical view point, and the roles of voice therapy and singing pedagogy were discussed in relation to phonosurgery. The vocal organ may not be an ideal musical organ and is rather vulnerable, but its potential is enormous.