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The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at The Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.
Medialization
Thyroplasty
Vocal fold medialization can be accomplished by injection techniques (Teflon, gelfoam, collagen, fat), surgical implantation of various materials, or arytenoid adduction. Teflon injection was the procedure of choice for management of unrecovered unilateral vocal fold paralysis for many years, but by now has been largely replaced by open surgical techniques. The advantages of the latter include its relatively inexpensiveness, the fact that it can actually be done under topical anesthesia, it gives immediate voice improvement, and it provides a satisfactory voice in most cases. Its disadvantages are that it does not restore vocal fold tensioning capability or prevent further wasting of the vocal fold muscle because it does not restore reinnervation. It is unreliable at overcoming larger glottal gaps especially at the posterior commissure. Extrusion, displacement, and granuloma formation can occur, and it is difficult to remove. Teflon should be considered permanent and should never be used in a moving or innervated vocal fold because of the likelihood of displacement (usually subglottically where it can obstruct the airway), extrusion, and granuloma formation. Surgical medialization has become the medialization procedure of choice for unrecovered unilateral vocal fold paralysis or fixation in recent years. The term thyroplasty was introduced by Isshiki to describe a series of operations in which the thyroid cartilage is surgically modified to produce changes in the voice. Conceptually, thyroplasty changes the dimensions, tension, and position of the vocal folds by altering the anatomical relationships of the thyroid cartilage. This results in changes in vocal fold characteristics, vibratory activity, and voice. Terminology for discussing
thyroplasty has been set forth by the Academy, which followed those
terms proposed by Isshiki, but which are more descriptive. The work of Isshiki, Koufman, Tucker, Wanamaker and associates, and others has demonstrated that various implants and techniques can be effective in repositioning the paralyzed fold for improved voice and glottic competancy. The theoretical advantage of thyroplasty is that the vocal fold can be medialized without disrupting the histological integrity of the soft tissues. Its advantages over teflon injection include that any size defect can be overcome, the implant is easily removed, fixation of the cricorytenoid joint can be corrected, and simultaneous reinnervation is possible. Disadvantages and complications are few. These include the need for an open procedure, although done under local anesthesia, the fact that medialization can restore vocal strength and durability but not voice quality and that it cannot prevent vocal fold wasting unless combined with reinnervation prodecure, and the occasional extrusion of the implant. Medialization thyroplasty is the most widely used of the thyroplasty techniques. It is the treatment of choice for most cases of glottic insufficiency. Medialization thyroplasy is indicated in the management of small to moderate degrees of glottic insufficiency when one or both vocal folds can be medialized without compromise of the airway. Indications include: 1) vocal fold paralysis or paresis, 2) immobile vocal fold for causes other than laryngeal cancer, 3) presbylaryngis or other causes of bowed vocal folds, 4)sulcus vocalis (adjunctive measure) and related deformities, and 5) scarred or absent vocal folds. It is often possible to predict
the outcome of medialization thyroplasty by performing a manuel compression
test. When the thyroid lamina are compressed together, the vocal folds
are forced together. This enhances vocal fold vibration and phonation
in patients with glottic insufficiency whose vocal folds are intact.
This test is less reliable when the folds are scarred or the cartilage
heavily calcified. If properly done, the compression test is usually
uncomfortable for the patient, but when the test is properly done and
a good voice obtained, the prognosis of medialization thyroplasty is
good. Gardner and Parnes investigated
the impact of Teflon injection and Type 1 thyroplasty on two parameters
essential to voice production. Vocal fold vibratory characteristics
and mucosal wave were preserved in those patients who underwent thyroplasty
Case Presentation The patient is a 31-year old male who was status post stab wound to left neck after drinking heavily the night prior to admission. He allegedly fell from his porch while holding a knife, subsequently, impaling himself. He sustained a stab wound to the left neck at the border of zones I and II requiring emergent neck exploration by the General Surgery service for massive bleeding. There was no injury to the carotid sheath; however, the left subclavian artery was lacerated requiring ligation and a synthetic graft repair. The patient was extubated in the fourth postoperative day with complaints of hoarseness, weak cough. He denied dyshagia and choking while eating or drinking. Computed tomography of the head revealed a left midbrain infarct. Past Medical History: gastroesophageal
reflux disease. Physical exam demonstrated a left true vocal cord paralysis with significant bowing of the affected cord. There was moderate pooling of secretions and no mucosal lesions. The head and neck exam was otherwise unremarkable. His recovery was unremarkable and he underwent medialization thyroplasty on the 16th hospital day. He tolerated this procedure well and was discharged home on the first postoperative day. Flexible laryngoscopy at two months revealed good cord approximation, strong voice, and no clinical evidence of aspiration.
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©2001,
The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences,
Baylor College of Medicine
One Baylor Plaza, NA102, Houston, TX 77030 oto@bcm.tmc.edu
URL: http://www.bcm.tmc.edu/oto (Modified: 10/032/01)
