Thyroplasty in the functional rehabilitation of neurotologic skull base surgery patients

Safety and Adverse Events of Medialization Thyroplasty: A Systematic Review

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.

Cortical-Basal Ganglia-Cerebellar Networks in Unilateral Vocal Fold Paralysis: A Pilot Study

OBJECTIVES/HYPOTHESIS

To evaluate differences in cortical-basal ganglia-cerebellar functional connectivity between treated unilateral vocal fold paralysis (UVFP) and healthy control cohorts using resting-state functional magnetic resonance imaging (RS-fMRI).

STUDY DESIGN

Cross-sectional.

METHODS

Ten UVFP study patients treated by type I thyroplasty and 12 control subjects underwent RS-fMRI on a 3-Tesla scanner to evaluate differences in functional connectivity of whole-brain networks. Spontaneous RS-fMRI data were collected using a gradient echo planar pulse sequence, preprocessed, and analyzed to compare seed-to-voxel maps between the two cohorts. Seeds were placed in the caudate, putamen, and globus pallidus divisions of the basal ganglia in both hemispheres. Group contrasts were tested for statistical significance using two-tailed unpaired t tests corrected for multiple comparisons with a cluster false discovery rate threshold of P < .05.

RESULTS

UVFP patients demonstrated increased connectivity between both caudate nuclei and the precuneus, a node of the default mode network, compared to healthy controls. Both caudate nuclei also showed decreased connectivity with the left cerebellar hemisphere. The putamen and globus pallidus divisions of the basal ganglia were not abnormally connected to other brain structures.

CONCLUSIONS

UVFP patients treated by type I thyroplasty exhibited long-term alterations of cortical-basal ganglia-cerebellar networks thought to be important for self-referential voice quality awareness and learning processes that compensate for changes to the paralyzed hemilarynx. This pilot study on relatively small cohorts adds to growing evidence for persistent central nervous system changes in treated UVFP. Replication studies with larger numbers of subjects will be essential to validate and extend findings.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:460-464, 2020.

Lateral skull base surgery: the otology group experience

Lateral skull base surgery has remained the surgical frontier of new developments in the treatment of lesions heretofore difficult to access. Examination of surgical results stimulates technical innovation and provides an intervention risk-benefit ratio assessment for particular lesions useful in management planning. With this in mind, we report the updated collective experience with lateral skull base surgery at the Otology Group over the past 20 years. Two hundred ninety-eight patients underwent surgical intervention for lateral skull base lesions. In 81 patients these lesions were malignant; in 217, benign. Of the benign lesions, 165 were glomus tumors: 139 glomus jugulare, 19 glomus vagale, and 7 glomus tympanicum. The remainder comprised 21 menigniomas, 14 neuromas, two neurofibromas, and a small group of much rarer entities. The philosophy of surgical approach, results, and follow-up are discussed.

Cricothyroid approximation for voice and swallowing rehabilitation of high vagal paralysis secondary to skull base neoplasms

This study documents the speech and swallowing outcomes of isolated ipsilateral cricothyroid approximation (aka tensioning thyroplasty; Type IV thyroplasty) for the treatment of high vagal paralysis (combined superior laryngeal nerve and recurrent laryngeal nerve paralysis). This is a pilot study of five cases with high vagal paralysis consequent to skull base neoplasms. Unilateral cricothyroid tensioning sutures were used. In all cases, vocal fold tensioning and vertical realignment of lax vocal folds were achieved. A partial, but acceptable medialization of vocal cord position was achieved. In all cases, aspiration was minimized and normal swallow function was restored by 6 weeks. The voice outcome was excellent in four cases and acceptable in one. Cricothyroid approximation restores vocal fold tension; in addition, it restores vertical vocal fold position and partially restores horizontal vocal fold position. Good voice and swallowing outcomes have been achieved. The procedure is quick, safe, and convenient when combined with a skull-base excision procedure. Further evaluation is merited.

Laryngeal framework surgery for the management of aspiration

BACKGROUND

During the past decade, laryngeal framework surgery has become the treatment of choice for the management of adductor paralysis of the vocal fold. The primary impetus for the use of this technique has been on the rehabilitation of voice. The purpose of this study was to ascertain the effectiveness of laryngeal framework surgery, including medialization laryngoplasty with silicone (MLS), with or without arytenoid adduction (AA), on eliminating aspiration, improving diet, and aiding in the subsequent decannulation of individuals with glottic insufficiency secondary to vocal fold palsy.

METHODS

A retrospective chart review was performed on all patients initially seen with vocal cord paralysis who were treated with laryngeal framework surgery from June 1992 to April 1996. The study comprised 70 patients, including 31 women and 39 men, with a median age of 57 years. Clinical information was obtained regarding the etiology of the lesion, characteristics of the vocal cord deficit, history of aspiration, the presence of other neurologic deficits or concurrent pulmonary disease, treatment, and outcome. To determine the effectiveness of MLS, with or without AA, we assessed the final outcome regarding the presence and degree of aspiration, diet, history of aspiration pneumonia, and decannulation.

RESULTS

Seventy patients underwent 77 MLS (three bilateral, four revisions), and 21 AA. Decreased aspiration was obtained in 96% of our patients. Seventy-five percent of those patients who had required a tracheotomy were decannulated.

CONCLUSIONS

These results support the use of laryngeal framework surgery for the effective treatment of aspiration in selected patients initially seen with deficits of the glottic closure secondary to vocal fold paralysis or paresis.