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A Transthyroidal Method for Arytenoid Adduction: A Basic Anatomical Study
A Transthyroidal Method for Arytenoid Adduction: A Basic Anatomical Study *G. Friedrich, *M. Gugatschka, *K. Kiesler, *L. Pertl, *C. Gerstenberger, †A. Weiglein, and ‡C. Storck, *yGraz, Austria, and zBasel, Switzerland
Summary: Introduction. Arytenoid adduction is a very effective procedure for medializing the posterior part of the vocal fold in vocal fold paralysis. Major drawback of the method is the technically sometimes-difficult access to the arytenoid with increased postoperative morbidity. Aim of this study was to provide basic anatomical data regarding the accessibility of the arytenoid cartilage through a thyroplasty window. Furthermore, to investigate the feasibility of an arytenoid adduction by fixation of a surgical screw to the arytenoid cartilage by using this approach. Materials and methods. 10 cadaver larynges, six female and four male, were dissected and measured for our points of interest. A standard manufacture-made surgical screw attached to a suture was anchored to the fovea oblonga of the arytenoid cartilage. Results. Our anatomical measurements proved a mean distance from the posterior edge of the thyroid window to the arytenoid of about 8–9 mm in male larynges and 7–8 mm in female larynges. The distances did not differ significantly between the sexes. Pulling the anchored surgical screw medializes the posterior part of the vocal fold. Discussion. Our data showed that there is a very constant morphometric relation between the thyroplasty window and the arytenoid cartilage. It is known that gender-related differences result in a veritable laryngeal dimorphism in nearly all absolute laryngeal dimensions. These differences appear to a much lesser extend in the distances from the surface to the depth, as was confirmed in our series. Using these findings led us to identification of the fovea oblonga near the muscular process as the most favorable point for fixation of a surgical screw through a conventional thyroplasty window. Pulling the attached suture medializes the arytenoid cartilage. Key Words: Arytenoid adduction–Transthyroidal access–Surgical anatomy of larynx. INTRODUCTION In patients with unilateral vocal fold paralysis, dysphonia is the main symptom.1 The severity of voice disorder depends on the position of the paralyzed vocal fold determining the degree of glottic insufficiency. According to the position of the paralyzed vocal fold, various surgical techniques are in use, all targeting on repositioning the paralyzed vocal fold in a median position with proper tension at the same level as the nonaffected vocal fold. The most common phonosurgical procedures used today are: injection augmentation, medialization thyroplasty, and arytenoid adduction (AA).2,3 When using an external approach through the thyroid cartilage as in medialization thyroplasty, only the anterior membranous part of the vocal fold can be medialized.4,5 To close the posterior glottis and/or correct level differences of the vocal folds, an AA can be performed together with medialization thyroplasty. AA simulates the action of the lateral cricoarytenoid muscle (LCA) by rotating the arytenoid cartilage, thus medializing the posterior part of the paralyzed vocal fold. The major drawback is the difficult accessibility of the muscular process deserving a demanding surgical procedure with significant increased morbidity including
Accepted for publication July 21, 2011. From the *Department of Phoniatrics, ENT University Hospital Graz, Medical University Graz, Graz, Austria; yInstitute of Anatomy Graz, Medical University Graz, Graz, Austria; and the zDepartment of Otorhinolaryngology, Head and Neck Surgery, University Hospital Basel, Switzerland. Address correspondence and reprint requests to Markus Gugatschka, Department of Phoniatrics, ENT University Hospital Graz, Medical University Graz, Auenbruggerplatz 26, A-8036 Graz, Austria. E-mail: [email protected] Journal of Voice, Vol. 26, No. 4, pp. 526-529 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2011.07.007
hypopharyngeal perforation, postoperative respiratory distress, and tracheotomy.3,5 To overcome these difficulties, several modifications of the AA procedure have been proposed, for example, the resection of the posterior rim of the thyroid plate or pulling on the LCA muscle through a thyroid window.6,7 Based on our former anatomical studies it should be possible to get access to the muscular process of the arytenoid cartilage through a standard medialization thyroplasty window.8 This might allow a very atraumatic method of AA by using the same approach as in medialization thyroplasty. The aim of this study was to provide basic anatomical data regarding the accessibility of the arytenoid cartilage via a thyroplasty window, and to present the feasibility of a new method of AA by using a standard manufacture made surgical screw. MATERIALS AND METHODS Measurements were taken from 10 cadaver larynges, six female and four male. The specimens were provided by the Institute of Anatomy, Medical University of Graz. Soft tissues were removed from the specimens, and a standardized medialization thyroplasty window as for a titanium vocal fold medializing implant procedure was created (Figures 1 and 2).8 Briefly after exposition of the thyroid cartilage, a reference line is drawn parallel to the inferior margin of the thyroid cartilage, starting at the midpoint between the superior and inferior thyroid notches. This line corresponds to the free margin of the vocal fold in the endolarynx. The cartilage window should be placed caudal to the reference line and the inferior-posterior corner of the window near the oblique line.8 The transverse measurements of distances were taken from the posterior edge of the thyroplasty window to (1) the muscular
G. Friedrich, et al
A Transthyroidal Method for Arytenoid Adduction
527
FIGURE 3. Schematic picture of a right arytenoid cartilage from lateral (a: processus muscularis, b: fovea oblonga, c: processus vocalis).
FIGURE 1. Left hemilarynx from lateral. Thyroplasty window was created and posterior part of the thyroid cartilage was resected. Needle was inserted through the window, marking the way to the arytenoid. process (muscular process distance), (2) fovea oblonga (fovea oblonga distance), and (3) the vocal process of the arytenoid (vocal process distance) (Figures 3–5). All distances were measured with a rule. This was done on either side, so in all 20 measurements were performed. All angles were measured toward a sagittal line through the midline. Measurements of the required angles were done with a triangle. Abbreviations of the angles are analog to the distances (muscular process angle [MPA], fovea oblonga angle, and vocal process angle [VPA]). To guarantee reproducibility of our measurements, we used a reference line that was defined in a previous study.9 One reference point was set at the posterior end of the thyroid plate and one at the midpoint of the sagittal diameter. The
height at which measurements were taken was the posterior rim of the thyroplasty window. The fovea oblonga of the arytenoid cartilage proved to be the most favorable point for fixation of a standard manufacturemade orthopedic surgical screw as it is relatively easy to reach and offers a suitable area of space (Small Bone FASTak Suture Anchor with 2-0 FiberWire, 2.4 mm 3 7.5 mm; Arthrex, Inc., Naples, FL). Noteworthy of mention, the suture anchor did not penetrate the arytenoid’s far side. Data collection was performed with Microsoft Excel (version 2003, Microsoft Inc, Redmond, WA) and statistical analysis was done with SPSS (version 17.0, SPSS Inc, Chicago, IL). When normal distribution was given, differences between the means were tested with student t test and the level of significance was set at 0.05.
RESULTS Tables show mean distances and angles from cadaver larynges. Mean distance from the posterior edge of the thyroid window to either position was about 8–9 mm in male larynges and 7–8 mm in female larynges. The distances did not differ significantly between the two sexes (P always >0.05) (Table 1). A similar picture could be observed with the measured angles where MPA was 40 –45 , FOA was 55 –58 , and VPA was 80 . Here again, no statistically significant differences could be observed between the sexes. The same distances and angles were confirmed by measurements performed in sections from an aforementioned
FIGURE 2. Left hemilarynx after resection of the upper part of the thyroid cartilage from above. Needle was inserted through the thyroplasty window, marking way to the muscular process. Filled shape: thyroid cartilage and empty shape: arytenoid cartilage.
FIGURE 4. Schematic picture of all distances and angles in a horizontal slide. MPD, muscular process distance; FOD, fovea oblonga distance; VPD, vocal process distance; FOA, fovea oblonga angle.
528
Journal of Voice, Vol. 26, No. 4, 2012
FIGURE 5. Schematic picture of all distances and angles from a lateral view. VP, vocal process; MP, muscular process; FO, fovea oblonga. anatomical study.9 The findings from the cadaveric dissections led us to the identification of the fovea oblonga of the arytenoid cartilage as the most favorable point for fixation of the surgical screw. Pictures show the screw in loco, in rest as well as after pulling the suture (Figures 6 and 7). DISCUSSION Recent publications show that localization of anatomical landmarks and especially of the arytenoid muscular process is still of high interest in surgical laryngology.10–12 Based on our previous anatomical studies dealing with surgical anatomy of the larynx, this study aimed to provide basic morphometric data regarding the accessibility of the arytenoid cartilage via a thyroplasty window.9 Our data let us to assume that there is a very constant morphometric relation between the thyroplasty window and the vocal and the muscular process of the arytenoid. It is well known that gender-related differences result in a veritable laryngeal dimorphism in nearly all absolute laryngeal dimensions, what makes it often difficult in laryngeal framework surgery.9 Noteworthy of mention, these differences appear to a much lesser extend in the distances from the surface to the depth,9 what has been the case also the in our series. Our points of
FIGURE 6. Right hemilarynx after resection of the upper part of the thyroid cartilage and of the LCA muscle from above. Screw fixed to the fovea oblonga of the arytenoid cartilage. ‘‘*’’ ¼ muscular process of the arytenoid cartilage.
interests were to be found in distances between 7 and 8 mm in female and 8–9 mm in male larynges. We found the same results concerning the angles, which did not differ between the two sexes. We are very well aware of the relatively small number of specimens. Furthermore, we cannot rule out that the measurements have not been affected by the preservation technique. However, our data are in concordance with previous results from the aforementioned anatomical study where we made the same measurements again in horizontal slides.9
TABLE 1. Distances and Angles Taken From Cadaver Larynges Divided by Sex Sex
MPD (SD) [Range]
FOD (SD) [Range]
VPD (SD) [Range]
MPA (SD) [Range]
FOA (SD) [Range]
VPA (SD) [Range]
Male (n ¼ 4) 8.1 (±0.8) [7–9] 8 (±1.7) [6–10] 8.5 (±2.3) [6–11] 45.6 (±8) [42–59] 58.3 (±8) [46–69] 79 (±4) [78–84] Female (n ¼ 6) 7.1 (±1.6) [5–9] 7.2 (±1.7) [5–10] 7.9 (±2.1) [5–10] 41.8 (±8) [25–49] 58 (±6) [45–65] 79.3 (±8) [55–84] Total
7.5 (±1.4) [6–9] 7.6 (±1.7) [5–10] 8.2 (±2.2) [5–11]
43 (±8) [25–59]
58 (±7) [45–69]
79 (±7) [55–84]
Abbreviations: MPD, muscular process distance; SD, standard deviation; FOD, fovea oblonga distance; VPD, vocal process distance; FOA, fovea oblonga angle. All distances are given in mean mm, all angles in mean degrees.
G. Friedrich, et al
A Transthyroidal Method for Arytenoid Adduction
529
REFERENCES
FIGURE 7. Right hemilarynx from lateral after resection of the upper part of the thyroid cartilage. Screw fixed to the fovea oblonga of the arytenoid cartilage. ‘‘*’’ ¼ vocal process of the arytenoid cartilage.
Our study demonstrates the good accessibility of the arytenoid cartilage via a standard thyroplasty window. Depth and angle of the access are very constant morphometric findings independent of sex. As a rule, one can state that the arytenoid cartilage can be found in a depth of about 8 mm from the thyroplasty window. Using these findings allows a very atraumatic method of arytenoid adduction as demonstrated with the presented new technique. The fovea oblonga near the muscular process of the arytenoid proved to be the best point for a relatively easy fixation of the surgical screw. Pulling the attached sutures of the screw medializes the posterior part of the vocal fold.
1. Brunner E, Friedrich G, Kiesler K, Chibidziura-Priesching J, Gugatschka M. Subjective breathing impairment in unilateral vocal fold paralysis. Folia Phoniatr Logop. 2010;63:142–146. 2. Friedrich G, Remacle M, Birchall M, Marie JP, Arens C. Defining phonosurgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society (ELS). Eur Arch Otorhinolaryngol. 2007;264:1191–1200. 3. Mortensen M, Carroll L, Woo P. Arytenoid adduction with medialization laryngoplasty versus injection or medialization laryngoplasty: the role of the arytenoidopexy. Laryngoscope. 2009;119:827–831. 4. Isshiki N. Progress in laryngeal framework surgery. Acta Otolaryngol. 2000;120:120–127. 5. Friedrich G, de Jong FI, Mahieu HF, Benninger MS, Isshiki N. Laryngeal framework surgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society. Eur Arch Otorhinolaryngol. 2001;258:389–396. 6. Maragos NE. Pyriform sinus mucosa stabilization for prevention of postoperative airway obstruction in arytenoid adduction. Ann Otol Rhinol Laryngol. 2006;115:171–174. 7. Iwamura S, Kurita N. A newer arytenoids adduction technique for one vocal fold paralysis: a direct pull of the lateral cricothyroid muscle. Head Neck Surg Jpn 1996;1–10. [Article in Japanese]. 8. Friedrich G. Titanium vocal fold medializing implant: introducing a novel implant system for external vocal fold medialization. Ann Otol Rhinol Laryngol. 1999;108:79–86. 9. Friedrich G, Lichtenegger R. Surgical anatomy of the larynx. J Voice. 1997; 11:345–355. 10. Mitchell JR, McRae BR, Halum SL. Localization of the muscular process for arytenoid adduction surgery. Laryngoscope. 2009;119:631–634. 11. Storck C, Gugatschka M, Friedrich G, et al. Developing a 3D model of the laryngeal cartilages using HRCT data and MIMICS’s segmentation software. Logoped Phoniatr Vocol. 2010;35:19–23. 12. Storck C, Juergens P, Fischer C, et al. Three-dimensional imaging of the larynx for pre-operative planning of laryngeal framework surgery. Eur Arch Otorhinolaryngol. 2010;267:557–563.
Summary: Introduction. Arytenoid adduction is a very effective procedure for medializing the posterior part of the vocal fold in vocal fold paralysis. Major drawback of the method is the technically sometimes-difficult access to the arytenoid with increased postoperative morbidity. Aim of this study was to provide basic anatomical data regarding the accessibility of the arytenoid cartilage through a thyroplasty window. Furthermore, to investigate the feasibility of an arytenoid adduction by fixation of a surgical screw to the arytenoid cartilage by using this approach. Materials and methods. 10 cadaver larynges, six female and four male, were dissected and measured for our points of interest. A standard manufacture-made surgical screw attached to a suture was anchored to the fovea oblonga of the arytenoid cartilage. Results. Our anatomical measurements proved a mean distance from the posterior edge of the thyroid window to the arytenoid of about 8–9 mm in male larynges and 7–8 mm in female larynges. The distances did not differ significantly between the sexes. Pulling the anchored surgical screw medializes the posterior part of the vocal fold. Discussion. Our data showed that there is a very constant morphometric relation between the thyroplasty window and the arytenoid cartilage. It is known that gender-related differences result in a veritable laryngeal dimorphism in nearly all absolute laryngeal dimensions. These differences appear to a much lesser extend in the distances from the surface to the depth, as was confirmed in our series. Using these findings led us to identification of the fovea oblonga near the muscular process as the most favorable point for fixation of a surgical screw through a conventional thyroplasty window. Pulling the attached suture medializes the arytenoid cartilage. Key Words: Arytenoid adduction–Transthyroidal access–Surgical anatomy of larynx. INTRODUCTION In patients with unilateral vocal fold paralysis, dysphonia is the main symptom.1 The severity of voice disorder depends on the position of the paralyzed vocal fold determining the degree of glottic insufficiency. According to the position of the paralyzed vocal fold, various surgical techniques are in use, all targeting on repositioning the paralyzed vocal fold in a median position with proper tension at the same level as the nonaffected vocal fold. The most common phonosurgical procedures used today are: injection augmentation, medialization thyroplasty, and arytenoid adduction (AA).2,3 When using an external approach through the thyroid cartilage as in medialization thyroplasty, only the anterior membranous part of the vocal fold can be medialized.4,5 To close the posterior glottis and/or correct level differences of the vocal folds, an AA can be performed together with medialization thyroplasty. AA simulates the action of the lateral cricoarytenoid muscle (LCA) by rotating the arytenoid cartilage, thus medializing the posterior part of the paralyzed vocal fold. The major drawback is the difficult accessibility of the muscular process deserving a demanding surgical procedure with significant increased morbidity including
Accepted for publication July 21, 2011. From the *Department of Phoniatrics, ENT University Hospital Graz, Medical University Graz, Graz, Austria; yInstitute of Anatomy Graz, Medical University Graz, Graz, Austria; and the zDepartment of Otorhinolaryngology, Head and Neck Surgery, University Hospital Basel, Switzerland. Address correspondence and reprint requests to Markus Gugatschka, Department of Phoniatrics, ENT University Hospital Graz, Medical University Graz, Auenbruggerplatz 26, A-8036 Graz, Austria. E-mail: [email protected] Journal of Voice, Vol. 26, No. 4, pp. 526-529 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2011.07.007
hypopharyngeal perforation, postoperative respiratory distress, and tracheotomy.3,5 To overcome these difficulties, several modifications of the AA procedure have been proposed, for example, the resection of the posterior rim of the thyroid plate or pulling on the LCA muscle through a thyroid window.6,7 Based on our former anatomical studies it should be possible to get access to the muscular process of the arytenoid cartilage through a standard medialization thyroplasty window.8 This might allow a very atraumatic method of AA by using the same approach as in medialization thyroplasty. The aim of this study was to provide basic anatomical data regarding the accessibility of the arytenoid cartilage via a thyroplasty window, and to present the feasibility of a new method of AA by using a standard manufacture made surgical screw. MATERIALS AND METHODS Measurements were taken from 10 cadaver larynges, six female and four male. The specimens were provided by the Institute of Anatomy, Medical University of Graz. Soft tissues were removed from the specimens, and a standardized medialization thyroplasty window as for a titanium vocal fold medializing implant procedure was created (Figures 1 and 2).8 Briefly after exposition of the thyroid cartilage, a reference line is drawn parallel to the inferior margin of the thyroid cartilage, starting at the midpoint between the superior and inferior thyroid notches. This line corresponds to the free margin of the vocal fold in the endolarynx. The cartilage window should be placed caudal to the reference line and the inferior-posterior corner of the window near the oblique line.8 The transverse measurements of distances were taken from the posterior edge of the thyroplasty window to (1) the muscular
G. Friedrich, et al
A Transthyroidal Method for Arytenoid Adduction
527
FIGURE 3. Schematic picture of a right arytenoid cartilage from lateral (a: processus muscularis, b: fovea oblonga, c: processus vocalis).
FIGURE 1. Left hemilarynx from lateral. Thyroplasty window was created and posterior part of the thyroid cartilage was resected. Needle was inserted through the window, marking the way to the arytenoid. process (muscular process distance), (2) fovea oblonga (fovea oblonga distance), and (3) the vocal process of the arytenoid (vocal process distance) (Figures 3–5). All distances were measured with a rule. This was done on either side, so in all 20 measurements were performed. All angles were measured toward a sagittal line through the midline. Measurements of the required angles were done with a triangle. Abbreviations of the angles are analog to the distances (muscular process angle [MPA], fovea oblonga angle, and vocal process angle [VPA]). To guarantee reproducibility of our measurements, we used a reference line that was defined in a previous study.9 One reference point was set at the posterior end of the thyroid plate and one at the midpoint of the sagittal diameter. The
height at which measurements were taken was the posterior rim of the thyroplasty window. The fovea oblonga of the arytenoid cartilage proved to be the most favorable point for fixation of a standard manufacturemade orthopedic surgical screw as it is relatively easy to reach and offers a suitable area of space (Small Bone FASTak Suture Anchor with 2-0 FiberWire, 2.4 mm 3 7.5 mm; Arthrex, Inc., Naples, FL). Noteworthy of mention, the suture anchor did not penetrate the arytenoid’s far side. Data collection was performed with Microsoft Excel (version 2003, Microsoft Inc, Redmond, WA) and statistical analysis was done with SPSS (version 17.0, SPSS Inc, Chicago, IL). When normal distribution was given, differences between the means were tested with student t test and the level of significance was set at 0.05.
RESULTS Tables show mean distances and angles from cadaver larynges. Mean distance from the posterior edge of the thyroid window to either position was about 8–9 mm in male larynges and 7–8 mm in female larynges. The distances did not differ significantly between the two sexes (P always >0.05) (Table 1). A similar picture could be observed with the measured angles where MPA was 40 –45 , FOA was 55 –58 , and VPA was 80 . Here again, no statistically significant differences could be observed between the sexes. The same distances and angles were confirmed by measurements performed in sections from an aforementioned
FIGURE 2. Left hemilarynx after resection of the upper part of the thyroid cartilage from above. Needle was inserted through the thyroplasty window, marking way to the muscular process. Filled shape: thyroid cartilage and empty shape: arytenoid cartilage.
FIGURE 4. Schematic picture of all distances and angles in a horizontal slide. MPD, muscular process distance; FOD, fovea oblonga distance; VPD, vocal process distance; FOA, fovea oblonga angle.
528
Journal of Voice, Vol. 26, No. 4, 2012
FIGURE 5. Schematic picture of all distances and angles from a lateral view. VP, vocal process; MP, muscular process; FO, fovea oblonga. anatomical study.9 The findings from the cadaveric dissections led us to the identification of the fovea oblonga of the arytenoid cartilage as the most favorable point for fixation of the surgical screw. Pictures show the screw in loco, in rest as well as after pulling the suture (Figures 6 and 7). DISCUSSION Recent publications show that localization of anatomical landmarks and especially of the arytenoid muscular process is still of high interest in surgical laryngology.10–12 Based on our previous anatomical studies dealing with surgical anatomy of the larynx, this study aimed to provide basic morphometric data regarding the accessibility of the arytenoid cartilage via a thyroplasty window.9 Our data let us to assume that there is a very constant morphometric relation between the thyroplasty window and the vocal and the muscular process of the arytenoid. It is well known that gender-related differences result in a veritable laryngeal dimorphism in nearly all absolute laryngeal dimensions, what makes it often difficult in laryngeal framework surgery.9 Noteworthy of mention, these differences appear to a much lesser extend in the distances from the surface to the depth,9 what has been the case also the in our series. Our points of
FIGURE 6. Right hemilarynx after resection of the upper part of the thyroid cartilage and of the LCA muscle from above. Screw fixed to the fovea oblonga of the arytenoid cartilage. ‘‘*’’ ¼ muscular process of the arytenoid cartilage.
interests were to be found in distances between 7 and 8 mm in female and 8–9 mm in male larynges. We found the same results concerning the angles, which did not differ between the two sexes. We are very well aware of the relatively small number of specimens. Furthermore, we cannot rule out that the measurements have not been affected by the preservation technique. However, our data are in concordance with previous results from the aforementioned anatomical study where we made the same measurements again in horizontal slides.9
TABLE 1. Distances and Angles Taken From Cadaver Larynges Divided by Sex Sex
MPD (SD) [Range]
FOD (SD) [Range]
VPD (SD) [Range]
MPA (SD) [Range]
FOA (SD) [Range]
VPA (SD) [Range]
Male (n ¼ 4) 8.1 (±0.8) [7–9] 8 (±1.7) [6–10] 8.5 (±2.3) [6–11] 45.6 (±8) [42–59] 58.3 (±8) [46–69] 79 (±4) [78–84] Female (n ¼ 6) 7.1 (±1.6) [5–9] 7.2 (±1.7) [5–10] 7.9 (±2.1) [5–10] 41.8 (±8) [25–49] 58 (±6) [45–65] 79.3 (±8) [55–84] Total
7.5 (±1.4) [6–9] 7.6 (±1.7) [5–10] 8.2 (±2.2) [5–11]
43 (±8) [25–59]
58 (±7) [45–69]
79 (±7) [55–84]
Abbreviations: MPD, muscular process distance; SD, standard deviation; FOD, fovea oblonga distance; VPD, vocal process distance; FOA, fovea oblonga angle. All distances are given in mean mm, all angles in mean degrees.
G. Friedrich, et al
A Transthyroidal Method for Arytenoid Adduction
529
REFERENCES
FIGURE 7. Right hemilarynx from lateral after resection of the upper part of the thyroid cartilage. Screw fixed to the fovea oblonga of the arytenoid cartilage. ‘‘*’’ ¼ vocal process of the arytenoid cartilage.
Our study demonstrates the good accessibility of the arytenoid cartilage via a standard thyroplasty window. Depth and angle of the access are very constant morphometric findings independent of sex. As a rule, one can state that the arytenoid cartilage can be found in a depth of about 8 mm from the thyroplasty window. Using these findings allows a very atraumatic method of arytenoid adduction as demonstrated with the presented new technique. The fovea oblonga near the muscular process of the arytenoid proved to be the best point for a relatively easy fixation of the surgical screw. Pulling the attached sutures of the screw medializes the posterior part of the vocal fold.
1. Brunner E, Friedrich G, Kiesler K, Chibidziura-Priesching J, Gugatschka M. Subjective breathing impairment in unilateral vocal fold paralysis. Folia Phoniatr Logop. 2010;63:142–146. 2. Friedrich G, Remacle M, Birchall M, Marie JP, Arens C. Defining phonosurgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society (ELS). Eur Arch Otorhinolaryngol. 2007;264:1191–1200. 3. Mortensen M, Carroll L, Woo P. Arytenoid adduction with medialization laryngoplasty versus injection or medialization laryngoplasty: the role of the arytenoidopexy. Laryngoscope. 2009;119:827–831. 4. Isshiki N. Progress in laryngeal framework surgery. Acta Otolaryngol. 2000;120:120–127. 5. Friedrich G, de Jong FI, Mahieu HF, Benninger MS, Isshiki N. Laryngeal framework surgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society. Eur Arch Otorhinolaryngol. 2001;258:389–396. 6. Maragos NE. Pyriform sinus mucosa stabilization for prevention of postoperative airway obstruction in arytenoid adduction. Ann Otol Rhinol Laryngol. 2006;115:171–174. 7. Iwamura S, Kurita N. A newer arytenoids adduction technique for one vocal fold paralysis: a direct pull of the lateral cricothyroid muscle. Head Neck Surg Jpn 1996;1–10. [Article in Japanese]. 8. Friedrich G. Titanium vocal fold medializing implant: introducing a novel implant system for external vocal fold medialization. Ann Otol Rhinol Laryngol. 1999;108:79–86. 9. Friedrich G, Lichtenegger R. Surgical anatomy of the larynx. J Voice. 1997; 11:345–355. 10. Mitchell JR, McRae BR, Halum SL. Localization of the muscular process for arytenoid adduction surgery. Laryngoscope. 2009;119:631–634. 11. Storck C, Gugatschka M, Friedrich G, et al. Developing a 3D model of the laryngeal cartilages using HRCT data and MIMICS’s segmentation software. Logoped Phoniatr Vocol. 2010;35:19–23. 12. Storck C, Juergens P, Fischer C, et al. Three-dimensional imaging of the larynx for pre-operative planning of laryngeal framework surgery. Eur Arch Otorhinolaryngol. 2010;267:557–563.