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Valley ZA, Karp A, Garber D. Safety and Adverse Events of Medialization Thyroplasty: A Systematic Review. Laryngoscope 2024; 134:1994-2004. [PMID: 37916789 DOI: 10.1002/lary.31141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Unilateral vocal fold paralysis or paresis (UVFP) is a condition that causes significant morbidity due to dysphonia, dysphagia, and aspiration. Type I medialization thyroplasty (MT) is the current mainstay surgical treatment for UVFP. Though widely considered a safe procedure, concerns exist over possible airway complications which can lead to overnight observation. Herein, we report a systematic review of the safety and adverse events of MT to aid in determining the safety of same-day discharge. DATA SOURCES PubMed and Embase databases. REVIEW METHODS Our search identified studies investigating complications associated with MT. Articles were selected if published between January 1, 1989 and March 15, 2023. Abstracts were screened, and data were extracted from included studies. Only Type I MT procedures were included; case reports were excluded. Participant characteristics, intervention details, results, and adverse events were extracted. RESULTS The database query identified 751 abstracts, of which 46 studies met eligibility criteria. A total of 2426 patients underwent MT. The most common implant was Silastic (n = 898, 37.0%) followed by Gore-Tex (n = 664, 27.4%). There were 254 (10.5%) total complications reported; 110 (4.5%) were considered major. The most common complication was nonobstructive hematoma (n = 59, 2.4%) followed by hemorrhage (n = 36, 1.5%). Implant extrusion (n = 24, 0.99%) or displacement (n = 15, 0.62%) occurred mostly in Silastic and Gore-Tex implants. Same-day discharge occurred with 429 patients and was not associated with adverse events. CONCLUSIONS UVFP can be reliably improved by MT with a low risk of complications. Outpatient MT is a promising treatment with a favorable safety profile. Laryngoscope, 134:1994-2004, 2024.
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Affiliation(s)
- Zachary A Valley
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Avrohom Karp
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - David Garber
- Department of Otolaryngology-Head and Neck Surgery, Westchester Medical Center, Valhalla, New York, USA
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Torrecillas VF, Hoffman MR, Schiffer B, Keefe K, Smith ME. Long-Term Outcomes and Revision Rates in Laryngeal Reinnervation. Laryngoscope 2024. [PMID: 38279973 DOI: 10.1002/lary.31297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 11/26/2023] [Accepted: 12/29/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVES Nonselective laryngeal reinnervation is an effective procedure to improve voice quality after unilateral vocal fold paralysis. Few studies have captured long-term outcome data, and the revision rate for this operation is currently unknown. The objective of this study is to describe the long-term outcomes and revision rates of unilateral, nonselective reinnervation in pediatric and adult patients. METHODS Patients who underwent laryngeal reinnervation from 2000 to 2022 with a single surgeon were identified for inclusion. Patients who underwent bilateral, super selective, deinnervation and reinnervation, and/or concurrent arytenoid adduction procedures were excluded. Outcome measures included maximum phonation time [MPT], voice handicap index score [VHI], patient-reported percent normal voice, revision procedures, and complications. Data were compiled and analyzed using paired t-tests, repeated measures analysis of covariance, and binary logistic regression analysis. RESULTS One hundred thirty-two patients underwent unilateral, nonselective ansa-recurrent laryngeal nerve [RLN] laryngeal reinnervation. Reinnervation significantly improved MPT and patient-reported percentage of normal voice and significantly decreased VHI. Eleven patients underwent revision procedures, corresponding to a revision rate of 8.3%. Additional procedures included medialization laryngoplasty [n = 3], medialization laryngoplasty with arytenoid adduction [n = 3] and injection augmentation greater than 1 year after reinnervation [n = 5]. The only factor associated with the need for additional surgery was time lapse from nerve injury to reinnervation. The overall complication rate was 6.8%; no patient required reintubation or tracheostomy. CONCLUSION Unilateral, nonselective laryngeal reinnervation can provide reliable improvement in vocal symptoms after recurrent laryngeal nerve injury. The revision rate after laryngeal reinnervation is favorable and comparable to framework surgery. LEVEL OF EVIDENCE Level IV Laryngoscope, 2024.
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Affiliation(s)
- Vanessa F Torrecillas
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - Matthew R Hoffman
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, U.S.A
| | - Breanne Schiffer
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Katherine Keefe
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Marshall E Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
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Heaton JT, Kobler JB, Otten DM, Tynan MA, Petrillo RH, Ottensmeyer MP, Slate AR, Hillman RE, Zeitels SM. Electrical Stimulation of Vocal Fold Adduction Triggered by Laryngeal Electromyography Using a Custom Implant. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2023; 66:4812-4827. [PMID: 37971489 DOI: 10.1044/2023_jslhr-23-00377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE Medialization procedures for unilateral vocal fold (VF) paralysis generally improve voice but do not fully replace dynamic VF adduction. Paralyzed VFs typically experience synkinetic reinnervation, which makes it feasible to elicit movement through electrical stimulation. We tested a novel laryngeal pacing implant capable of providing closed-loop (automatic) stimulation of a VF triggered by electromyography (EMG) potentials from the contralateral VF. METHOD A custom, battery-powered, microprocessor-based stimulator was tested in eight dogs with bipolar electrodes implanted for recording EMG from the left VF and stimulating adduction of the right VF. A cuff electrode on the left recurrent laryngeal nerve (RLN) stimulated unilateral VF adduction, modeling voluntary control in anesthetized animals. Closed-loop stimulation was tested in both acute and chronic experiments. Synkinetic reinnervation was created in two animals by right RLN transection and suture repair to model unilateral VF paralysis. RESULTS In all animals, left VF activation through RLN stimulation generated a robust EMG response that rapidly triggered stimulation of contralateral thyroarytenoid and lateral cricoarytenoid muscles, causing nearly simultaneous bilateral adduction. Optimal triggering of VF stimulation from elicited EMG was achieved using independent onset and offset thresholds. Real-time artifact blanking allowed closed-loop stimulation without self-perpetuating feedback, despite the proximity of recording and stimulation electrodes. CONCLUSIONS Using a custom implant system, we demonstrated real-time closed-loop stimulation of one VF triggered by the activation of the contralateral VF. This approach could potentially restore dynamic glottic closure for reflexive behaviors or phonation in cases of unilateral VF paralysis with synkinetic reinnervation. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.24492133.
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Affiliation(s)
- James T Heaton
- Department of Surgery, Harvard Medical School, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - James B Kobler
- Department of Surgery, Harvard Medical School, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - David M Otten
- Laboratory for Electromagnetic and Electronic Systems, Massachusetts Institute of Technology, Cambridge
| | - Monica A Tynan
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Robert H Petrillo
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | | | - Andrea R Slate
- Center for Comparative Medicine, Massachusetts General Hospital, Boston
| | - Robert E Hillman
- Department of Surgery, Harvard Medical School, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
| | - Steven M Zeitels
- Department of Surgery, Harvard Medical School, Boston, MA
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston
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Müller A. Active and Passive Bioimplants for Vocal Fold Paralysis. Laryngorhinootologie 2022; 101:S144-S159. [PMID: 35605617 DOI: 10.1055/a-1708-2881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Vocal fold paralysis is one of the diseases that particularly affect quality of life. While unilateral paralysis leads to glottis closure insufficiency and hoarseness, bilateral paralysis compromises respiration and limits the exercise tolerance. Bioimplants have been used to treat persistent paralysis for over 100 years. The spectrum ranges from autologous tissue transfer and resorbable or permanent injection materials to composite thyroplasty implants and active electrical implants for neurostimulation of the larynx. If bioimplants are used in accordance with the recommendations, the quality of life of affected patients can be significantly improved today.
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Garber D, Wandell GM, Gobillot TA, Merati A, Bhatt NK, Giliberto JP. Safety and Predictors of 30-Day Adverse Events of Laryngeal Framework Surgery: An Analysis of ACS-NSQIP data. Laryngoscope 2021; 132:1414-1420. [PMID: 34726793 DOI: 10.1002/lary.29921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To characterize and identify predictors of 30-day adverse events in patients undergoing laryngeal framework surgery (LFS). STUDY DESIGN This study is a retrospective analysis of the National Surgical Quality Improvement dataset. METHODS LFS cases were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2008 to 2018. Demographic variables, patient comorbidities, and perioperative outcomes (any adverse event, 30-day readmission, 30-day reoperation, and unplanned intubation) were extracted. Patient-specific and surgery-specific factors associated with perioperative adverse events were examined using descriptive statistics and univariate logistic regression (LR). RESULTS Of 283 patients who underwent LFS, 225 underwent laryngoplasty medialization, 56 underwent laryngoplasty medialization with arytenoidectomy or arytenoidopexy via an external approach, and 2 underwent local myocutaneous or fasciocutaneous advancement flap along with laryngoplasty. Medical comorbidities were present in 33.6% of patients and 57.9% were American Society of Anesthesiologists (ASA) Class III/IV (57.9%). LFS was performed as same-day surgery in 30.7% of cases. Fourteen patients (4.9%) suffered an adverse condition within 30 days following surgery. In univariate LR, ASA Class III or IV (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.2-30.1) was the only predictor associated with any adverse event. Arytenoid adduction (AA) was associated with increased risk of reoperation within 30 days of the initial surgery (OR 6.4, 95% CI 1.0-49). CONCLUSIONS LFS is a generally safe procedure with infrequent perioperative adverse events. In the ACS-NSQIP database, ASA classification of III or IV was associated with a higher risk for any 30-day adverse event and AA was associated with a higher risk for 30-day reoperation. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- David Garber
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Grace M Wandell
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Theodore A Gobillot
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Al Merati
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - Neel K Bhatt
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
| | - John Paul Giliberto
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington Medical Center, Seattle, Washington, U.S.A
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Yılmaz T, Özer F. Unilateral Vocal Fold Paralysis With Large Posterior Glottic Gap: Is Arytenoid Procedure Necessary? Ann Otol Rhinol Laryngol 2021; 131:859-867. [PMID: 34535066 DOI: 10.1177/00034894211045637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES For unilateral vocal fold paralysis (UVFP) with large posterior glottic gap medialization laryngoplasty (ML) + arytenoid adduction (AA), ML + adduction arytenopexy (AApexy), and ML alone using prosthesis with posterior extension are possible solutions. This study was carried out to elucidate the controversy among these solution options. METHODS Retrospective cohort. Tertiary referral center. One hundred forty patients with UVFP with large posterior glottic gap. Group 1 had 30 patients with ML + AA; Group 2 had 25 patients with ML + AApexy; Group 3 had 29 patients with ML using Isshiki prosthesis; Group 4 had 26 patients with ML using Montgomery prosthesis; Group 5 had 30 patients with ML using prosthesis with large posterior extension. Glottic closure using videolaryngostroboscopy, GRBAS, VHI-30, EAT-10, acoustic and aerodynamic analysis was carried out pre- and 1-year-postoperatively. RESULTS Preoperatively there was no significant difference in any parameters studied among all study groups (P > .05). Except F0, speaking F0 and EAT-10, all other parameters in acoustic and aerodynamic analysis, glottic closure, GRBAS, and VHI-30 scores were significantly better postoperatively in Groups 1 and 2 compared to Groups 3 to 5 (P < .05). CONCLUSIONS In patients with UVFP and large posterior glottic gap, ML + AA and ML + AApexy seem to do better subjectively and objectively, acoustically and aerodynamically, when compared to ML using prosthesis with and without large posterior extension. ML alone does not appear to close posterior glottic gap. Therefore, it is a better and more reasonable option to perform arytenoid procedure when there is large posterior glottic gap in UVFP.
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Affiliation(s)
- Taner Yılmaz
- Department of Otolaryngology-Head and Neck Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Furkan Özer
- Department of Otolaryngology-Head and Neck Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Silvia N, Lim C, Aguirre A, Guisado G, Schneider GT. 3D Printed Cutting Rig for Creating Silicone Carving Templates for Medialization Laryngoplasty. Laryngoscope 2020; 131:E885-E889. [PMID: 32717110 DOI: 10.1002/lary.28899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/30/2020] [Accepted: 06/11/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Nathaniel Silvia
- University of Rochester Department of Biomedical Engineering, Rochester, New York, U.S.A
| | - Chantelle Lim
- University of Rochester Department of Biomedical Engineering, Rochester, New York, U.S.A
| | - Abril Aguirre
- University of Rochester Department of Biomedical Engineering, Rochester, New York, U.S.A
| | - Gabriel Guisado
- University of Rochester Department of Biomedical Engineering, Rochester, New York, U.S.A
| | - Glenn T Schneider
- University of Rochester Medical Center Department of Otolaryngology, Rochester, New York, U.S.A
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Pillutla P, Zhang Z, Chhetri DK. Effects of Arytenoid Adduction Suture Position on Voice Production and Quality. Laryngoscope 2020; 131:846-852. [PMID: 32710654 DOI: 10.1002/lary.28903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/17/2020] [Accepted: 06/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Arytenoid adduction (AA) is performed to treat unilateral vocal fold paralysis with a large posterior glottal gap. However, the voice effects of AA suture position remain unclear. This study aimed to evaluate voice production and quality as a function of AA suture position on the thyroid ala in a neuromuscularly intact in vivo larynx. STUDY DESIGN Animal model. METHODS Unilateral recurrent laryngeal nerve and vagal paralysis were modeled in two canines. AA suture position was varied across five equidistant positions on the anterior inferior thyroid ala, from a paramedian position anteriorly to the oblique line posteriorly. Phonation was performed over 8 × 8 graded level combinations of recurrent and superior laryngeal nerve stimulation per suture position. The primary outcome was percent successful phonatory conditions. Secondary outcomes included fundamental frequency (F0), phonation onset pressure (PTP), cepstral peak prominence (CPP), and laryngeal posture. RESULTS Anterior suture positions resulted in a greater percentage of successful phonatory conditions compared to posterior sutures. Suture position 2, located at the anterior inferior thyroid ala, resulted in the highest percentage of successful phonatory conditions, lowest PTP, and lower muscle activation levels to achieve higher CPP. Posterior sutures resulted in wider glottal gap and more effective F0 and vocal fold strain increase with cricothyroid muscle contraction, but with fewer successful phonatory conditions and higher PTP. Trends were consistent across both paralysis types. CONCLUSIONS AA suture placed in the anterior inferior thyroid ala resulted in the best acoustic, aerodynamic, and voice quality outcomes. This study provides scientific evidence for maintaining current clinical practice. LEVEL OF EVIDENCE NA Laryngoscope, 131:846-852, 2021.
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Affiliation(s)
- Pranati Pillutla
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, U.S.A
| | - Zhaoyan Zhang
- Department of Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
| | - Dinesh K Chhetri
- Department of Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
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Patel J, Boon M, Spiegel J, Huntley C. Safety of Outpatient Type 1 Thyroplasty. EAR, NOSE & THROAT JOURNAL 2020; 100:608S-613S. [PMID: 31903781 DOI: 10.1177/0145561319894414] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Type 1 thyroplasty is an established procedure for the treatment of vocal fold paralysis to improve voice and swallowing outcomes. At our institution, we commonly perform this procedure on an outpatient basis in medically stable patients. With this study, we assess the safety of outpatient thyroplasty by examining complication and readmission rates, need for revision surgery, and predictors of these outcome measures. METHODS We performed a retrospective review of patients undergoing outpatient type 1 thyroplasty for vocal fold paralysis between 2013 and 2018 at our institution. We documented the etiology of paralysis, comorbidities, and demographic data. Our primary outcome measures were complications, need for readmission, and need for revision surgery. RESULTS During the study period, 160 patients met our inclusion criteria. Mean age at time of surgery was 62.1 ± 13.9 years; there were 82 (51%) males and 78 (49%) females. Nine (5.6%) patients experienced major complications after surgery and 7 (4.4%) patients required unplanned readmission. Mean time to complication was 6.9 ± 9.7 days. There were no instances of postoperative airway compromise requiring intervention. There were no mortalities. Of those who underwent primary surgery, 22 (14%) patients required revision surgery. CONCLUSION Given that complications tend to occur in a delayed fashion rather than in the acute postoperative period, same-day discharge seems reasonable as compared to overnight observation in medically stable patients undergoing type 1 thyroplasty. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jena Patel
- Department of Otolaryngology-Head and Neck Surgery, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph Spiegel
- Department of Otolaryngology-Head and Neck Surgery, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, 6559Thomas Jefferson University, Philadelphia, PA, USA
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