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Adduction arytenopexy, hypopharyngoplasty, medialization laryngoplasty, and cricothyroid subluxation for the treatment of paralytic dysphonia and dysphagia
Operative Techniques in Otolaryngology (2012) 23, 164-172
Adduction arytenopexy, hypopharyngoplasty, medialization laryngoplasty, and cricothyroid subluxation for the treatment of paralytic dysphonia and dysphagia Ramon A. Franco Jr, MD From the Division of Laryngology, Department of Otology and Laryngology, Harvard Medical School, Voice and Speech Laboratory, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. KEYWORDS Vocal fold paralysis; Dysphagia; Dysphonia; Adduction arytenopexy; Hypopharyngoplasty
Vocal fold paralysis is a common disorder of variable etiology. The resultant dysphonia and dysphagia can result in significant morbidity and decreased quality of life for the afflicted patient. Numerous surgical procedures have been developed to improve voice and swallowing, each with its own set of advantages and disadvantages. Selection of the most appropriate procedure is determined in part an assessment of the position of the arytenoid cartilage, as proper realignment of vocal fold height and length may be critical to restoration of phonatory function. While arytenoid adduction has been employed traditionally to address arytenoid position, adduction arytenopexy coupled with cricothyroid subluxation may provide enhanced aerodynamic efficiency compared to arytenoid adduction. Hypopharyngoplasty can be easily performed concurrently, which through plication of the flaccid and non-functional ipsilateral pyriform sinus, can provide significant improvement in the salivary pooling and dysphagia which often accompanies recurrent laryngeal nerve dysfunction. This paper will address the indications, advantages, and surgical technique of adduction arytenopexy, cricothyroid subluxation, and hypopharyngoplasty. © 2012 Elsevier Inc. All rights reserved.
Glottal incompetence from unilateral vocal fold movement impairment can lead to severely disabling social, economical, and personal consequences. The inability to tightly close the glottis leads to a persistent pressure leak into the airway that can make swallowing more difficult and can increase the risk of aspiration, reducing the efficacy of the protective laryngeal sphincter. This same pressure leak leads to a reduction in vocal power, an increase in vocal effort, and a reduction in vocal stamina that can make already vocally demanding professions (teaching, medicine, law, singing, or acting) nearly impossible to perform. The vocal volume reduction can also
Address reprint requests and correspondence: Ramon A. Franco Jr, MD, Division of Laryngology Department of Otology and Laryngology, Harvard Medical School, Voice and Speech Laboratory, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.otot.2012.06.004
lead to social isolation and depression because the afflicted shuns social events where there is sufficient ambient noise, such as in restaurants, bars, or outdoor venues to make conversing difficult. Unilateral vocal fold mobility impairment leading to glottal incompetence can be because of a myriad of causes, including autoimmune (rheumatoid arthritis), metabolic, neoplastic (paragangliomas, tumors affecting the course of the recurrent laryngeal nerve in the neck and chest, brain tumors), infectious (viral neuronitis, syphilis), mechanical trauma (to the musculomembranous vocal fold, thyroid, arytenoid, or cricoid cartilages or the cricoarytenoid joint), and neural (neuronitis, iatrogenic injury, tumor). Of these, the most common causes are iatrogenic injury to the recurrent laryngeal nerve at the time of neck or chest surgery, viral neuronitis, and tumors affecting the nerve. Consistent use of precise common terminology when describing vocal fold movement is vital for proper commu-
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nication between providers. The term paralysis should be reserved for those cases when there is no volitional movement and the nerve is known to not function, such as after en-bloc resection of the recurrent laryngeal nerve during thyroid cancer surgery. The term paralysis implies the condition is permanent. Paresis can be used to describe a limitation in vocal fold motion that is due to injury to the nerve. This injury can be reversible or could be stable with no evidence of improvement with time. Because the process of synkinesis influences the final resting position and function of the vocal fold, the most accurate method is to describe the range and velocity of arytenoid motion during adduction and abduction, the vertical position of the vocal process, the tone of the musculomembranous vocal fold, and the amount of ventricular fold compression/laxity. Complete loss of unilateral recurrent laryngeal nerve function leads to an anterior, lateral, and inferiorly placed vocal fold and arytenoid complex compared with the normally innervated side. The arytenoid cartilage is perched atop the cricoid cartilage that is shaped like a signet ring, considerably taller posterior where the cricoarytenoid joints are located than anterior. As the arytenoid cartilage falls from the top of the cricoid, it falls anterior and lateral, losing height as it goes forward resulting in the anterior, lateral, and inferior displacement. To make matters worse, there is an ipsilateral sensory deficit from the glottis to the upper trachea that makes it more difficult to protect from aspiration. Medialization of the vocal fold, regardless of the technique or material used (polytetrafluoroethylene [Gore-Tex; W.L. Gore & Associates, Inc, Flagstaff, AZ] vs silastic block vs titanium or silicone prosthesis), is not sufficient to close the large glottal gap that results from an anterior, lateral, and inferiorly displaced arytenoid cartilage. When there is a height discrepancy between the vocal processes, a procedure that specifically addresses the position of the arytenoid is required to achieve satisfactory voice results. Simple medialization cannot bring the “fallen” arytenoid to its phonatory position: posterior, superior, and medial. In fact, the widely used technique of overclosure of the membranous region through thyroplasty type I can lead to a reduction in the vibratory ability of the true vocal fold mucosa that degrades vocal quality. Plus, there remains a significant cartilaginous region gap that reduces vocal volume and increases the work of vocalizing. Currently, there are 2 well-recognized ways to control the arytenoid cartilage via an open approach, the arytenoid adduction and the adduction arytenopexy. A quick review of the arytenoid adduction will serve to highlight the differences between the 2 techniques. It is important to recognize that excellent results can be obtained with either technique in the proper hands, but there are some theoretical differences that should be highlighted. The arytenoid adduction was described by Isshiki et al1,2 as a procedure that involves passing a suture through the muscular process of the arytenoid and pulling the two suture limbs anterior, lateral, and inferior to simulate the action of the lateral cricoarytenoid muscle (LCA) (Figure 1) that normally works to whip the vocal processes medially in
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Figure 1 Arytenoid adduction suture. The vector force of the arytenoid adduction suture is anterior, pulling the muscular process of the arytenoid forward, rotating the vocal process medially. In the process, the entire unstable arytenoid body also tends to go forward, and therefore, inferior and somewhat lateral as it goes down the cricoid. The solid arrow line is the final vector force. (Figure 7A from Miller FR, Bryant GL, Netterville JL: Arytenoid adduction in vocal fold paralysis. Oper Tech Otolaryngol Head Neck Surg 10:36-41, 1999.)
preparation for voicing. The net result of this procedure is rotation of the arytenoid cartilage3 to bring the vocal process medial, while also pulling the unsupported arytenoid complex further forward and inferior. Remember that in the pathologic state, the arytenoid has a tendency to fall anterior, lateral, and inferior: the vector of the arytenoid adduction sutures pulls it further anterior, inferior, and lateral, potentially making the height discrepancy worse (the more anterior it is pulled, the more inferior it will rest) while rotating the arytenoid causing the arytenoid bodies to not sit flush against each other during voicing and potentially leaving a persistent cartilaginous keyhole aperture. Normally, the action of the LCA is opposed by the simultaneous action of the posterior cricoarytenoid muscle (PCA), interarytenoid muscle, and the thyroarytenoid muscle to maintain proper vocal fold tension and arytenoid position. The adduction arytenopexy4 attempts to address paralytic arytenoid malposition by pulling the arytenoid up the cricoarytenoid facet (posterior) and suturing it in its normal phonatory position (medial), flush against the opposite arytenoid. Theoretically, the medial and posterior vector forces will result in an arytenoid in a “phonatory friendly” place with the membranous vocal fold at the proper height, in a medial position and of similar length (and tension) to the working vocal fold. Because the arytenoid bodies are able to rest flush with each other during phonation, there is no persistent cartilaginous chink from rotation of the
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Figure 4 Curved mayo scissors are used to cut through the cricothyroid joint. This allows further anterior rotation of the thyroid cartilage and access to the pyriform sinus mucosa, posterior cricoarytenoid muscle (PCA), and the arytenoid cartilage. The asterisk (*) represents the tip of the inferior cornu of the thyroid cartilage. The “1” denotes the posterior border of the thyroid. cartilage. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
Figure 2 A natural skin crease at the level of the lower border of the thyroid cartilage/cricothyroid membrane is selected as the proposed incision line. (Courtesy of Ramon Franco Jr, MD.)
arytenoid, and therefore, no excessive air leakage. A 2009 report by Franco and Andrus5 on a cohort of 28 patients who had undergone adduction arytenopexy with complete preop and postop aerodynamic and acoustic testing revealed statistically significant increases in the mean maximum phonation time and vocal intensity with a statistically significant decrease in mean glottal airflow.
These results validate the premise that adduction arytenopexy, when combined with medialization laryngoplasty, can help to statically correct the glottal deficiency seen when the arytenoid is malpositioned. In 2008, McNamar et al6 compared adduction arytenopexy with arytenoid adduction in an ex vivo experimental set-up. They found that after adduction arytenopexy, they needed only 80% of the phonation threshold pressures necessary for arytenoid adduction. This implies that the adduction arytenopexy is more aerodynamically efficient when compared with arytenoid adduction. Despite the fact that there is data to support the theoretical advantage of the adduction arytenopexy over the arytenoid adduction, many cases of unilateral vocal fold immobility do not need a procedure to address arytenoid position because of synkinesis. After nerve injury, there is aberrant neural healing that can result in a more medial and posterior location of the arytenoid than would have been predicted given the injury and
Figure 3 Double skin hooks are used to retract the posterior thyroid lamina to transect the inferior constrictor muscles. (Figure 3B from Zeitels SM: Adduction arytenopexy with medialization laryngoplasty and cricothyroid subluxation: a new approach to paralytic dysphonia. Oper Tech Otolaryngol Head Neck Surg 10:9-16, 1999.)
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Figure 5 The posterolateral laryngeal anatomy that is normally hidden beneath the inferior constrictors and thyroid cartilage has been uncovered by retracting the thyroid cartilage (5) medially. The arytenoid cartilage (1) has been disarticulated from the cricoid (immediately caudal to the arytenoid—the white of the cricoarytenoid joint surface can be appreciated) with the cut end of the PCA (2) used to manipulate the arytenoid. The recurrent laryngeal nerve (3) is seen entering the larynx between the cricoarytenoid and cricothyroid (6) joints. The pyriform sinus mucosa (4) is retracted posteriorly after it has been dissected away from the PCA muscle. The posterior margin of the thyroid cartilage (5) is retracted medially with sharp double-prong skin hooks. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
the position immediately after the injury. There is an abundance of adductory fibers in the recurrent laryngeal nerve (about 70%), so aberrant healing is more likely to stimulate adductors rather than abductors, resulting in better glottal competence leading to a stronger, less disordered voice and im-
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proved laryngeal protective sphincteric action during swallowing. Before considering an adduction arytenopexy, the position of the arytenoid must be carefully determined. If the immobile arytenoid is laterally and anteriorly displaced resulting in a caudally placed vocal process (and vocal fold) then an arytenopexy should be considered. It is important to appreciate that if there is any volitional motion from the impaired side, an adduction arytenopexy will permanently sacrifice this motion. The most important factor before considering an adduction arytenopexy is whether there is normal range of motion (lateral excursion) of the “normal” arytenoid to allow adequate glottal airflow after the adduction arytenopexy. This assessment should be performed in the clinic when deciding the proper treatment for the patient and repeated in the operating room before giving the patient any sedatives or injecting local anesthesia in the neck.
Adduction arytenopexy surgical procedure The patient is placed in the supine position with the head elevated above the body in reverse Trendelenburg position to decrease venous congestion and laryngeal edema. The side of the nose that will be used to introduce the flexible nasolaryngoscope is packed with neuropledgets soaked in 4% cocaine to vasoconstrict and decongest. It is vital to speak to the nursing and anesthesia teams before the surgery to ensure the intravenous infusion catheter is promptly placed when the patient is brought into the holding area so steroids (12 mg of Decadron or the equivalent) can be
Figure 6 (A) The adduction arytenopexy suture. A 4-0 prolene suture is used to reposition the arytenoid in a posterior, medial, and superior position. The suture is passed from the posterior-lateral cricoid to the posterior-medial quadrant of the cricoarytenoid joint. This same suture is passed from the undersurface of the arytenoid (central location) to exit the superior surface. The suture is finalized by passing it from the inner cricoid cortex to the outer cricoid cortex, exiting anterior to the initial insertion point. (B) Closer view of adduction arytenopexy stitch. (Courtesy of Ramon Franco Jr, MD.)
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infused about 45 minutes before the incision. This delays the onset of meaningful edema later in the case when the paraglottic space is disturbed during the medialization laryngoplasty. It is vital that the patient not receive sedation before the nasolaryngoscopic examination because this can impair the mobility of the mobile vocal fold. An adduction arytenopexy should only be attempted if the mobile vocal fold can adequately abduct so as not to precipitate an airway crisis when the immobile fold is medialized. A marking pen is used to delineate the level of the cricoid, the lower border of the thyroid cartilage, and the hyoid bone. A natural skin crease overlying the cricothyroid membrane is marked from about 1 cm beyond midline to approximately the anterior border of the sternocleidomastoid muscle on the ipsilateral side (Figure 2). The incision will be longer and extend further posterior compared with a simple medialization laryngoplasty incision because access is required to the posterior border of the thyroid cartilage. A solution of 2% lidocaine with 1:200,000 epinephrine and 0.75% bupivacaine with 1:100,000 epinephrine combined one-to-one (final concentration of 1% lidocaine, 0.375%
bupivacaine with 1:150,000 epinephrine) is injected under and around the proposed incision, deep to the strap muscles and adjacent to the thyroid cartilage, with special emphasis paid to the inferior constrictor muscles around the posterior border. The neck is then prepped and draped in the standard way for an open neck procedure. After creating a 3- to 5-cm skin incision and carrying it down through the platysma layer, subplatysmal flaps are created. The ipsilateral strap muscles are transected to gain access to the posterior thyroid ala where double skin hooks are used to rotate the posterior border of the thyroid cartilage and expose the inferior constrictor muscles (Figure 3). Using a needle-tipped electrocautery, the constrictors are freed from the thyroid cartilage. It is important to stay on the lateral aspect of the thyroid cartilage and not wander posterior because the thin pyriform sinus mucosa could be inadvertently injured, potentially leading to a fistula. Once the constrictors are removed, a curved mayo scissors is used to separate the cricothyroid joint (Figure 4), further mobilizing the thyroid cartilage, allowing it to rotate medial (anterior). The pyriform sinus mucosa is bluntly swept out
Figure 7 This figure is a close-up of the open left cricoarytenoid joint. Both articulating surfaces of the cricoarytenoid joint can be seen (the superior surface of the cricoid and the undersurface of the arytenoid), and each has been divided into quadrants. The asterisk (*) represents the entry point for the adduction arytenopexy suture. There is a tremendous amount of variability to the final resting position of the arytenoid because there are many places to exit the cricoarytenoid surface and the arytenoid. To achieve a posterior and medial repositioning of the arytenoid, it is ideal to have the initial suture exit the cricoarytenoid joint surface within quadrant 1 (medial and posterior). The suture then needs to pass into the arytenoid. A good starting position is in the direct center (1) or within quadrant 4, depending on how much it needs to come posterior and medial. (Courtesy of Ramon Franco Jr, MD.)
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of the way in a caudal to cephalad direction using a Penfield #2 elevator, exposing the underlying PCA (Figure 5). The recurrent laryngeal nerve can be seen along the caudal border of the PCA muscle and should be separated and preserved. The PCA muscle is transected leaving a “tail” that leads to the muscular process of the arytenoid and allows direct manipulation of the arytenoid. While elevating the cut PCA muscle, a Penfield #2 elevator is used to widely incise the lateral capsule of the cricoarytenoid joint (Figure 5). In preparation for manipulating the arytenoid and resetting its position, a Stevens scissors is used to transect the LCA fibers as they insert anteriorly onto the muscular process. Any cricoarytenoid joint capsule fibrous tissue that seems to limit the motion of the arytenoid is transected. The arytenoid is now ready for the adduction arytenopexy suture (Figure 6A, 6B). A 4-0 prolene (monofilament) (Ethicon, Sommerville, NJ) suture with a P-3 reverse cutting needle is inserted through the lateral and posterior cricoid, just below the cricoarytenoid joint, and is passed out of the medial and posterior joint facet. The final resting place of the arytenoid is greatly influenced by the location this suture exits the joint; it is ideal to place the suture in the posterior and medial quadrant (Figure 7). The suture is then passed through the body of the arytenoid from the center of the articulating surface (undersurface) to exit the cephalad surface. The final position of the arytenoid can be further manipulated through careful placement of the arytenoid suture (Figure 8). If you want the arytenoid cartilage to rest more posterior, the suture needs to go through the anterior part of the arytenoid. If a more medial position is desired, the suture should be placed more lateral (Figure 8). A good starting position is in the direct center of the articulating surface or offset a bit lateral and anterior (to give it a medial and posterior final resting position). The suture is then passed from the medial to lateral cortex of the cricoid under the cricoarytenoid joint, anterior to the initial suture insertion (Figure 6B). The suture is temporarily tightened to allow visual inspection of the arytenoid with the flexible nasolaryngoscope
Figure 8 One of the surgical advantages of the adduction arytenopexy suture is the direct control the surgeon has on the final resting position of the arytenoid cartilage with respect to the cricoarytenoid joint. The final effect of suture placement is opposite with the arytenoid than it is with the cricoid. Placing the suture anteriorly in the arytenoid results in a posteriorly placed arytenoid. Lateral sutures through the arytenoid will result in a medial position. In the cricoid, the suture needs to be in the posterior and medial position to effect a posterior and medial final resting place. The figure labels refer to the quadrants (same labeling as in Figure 7) the suture exits the cricoid with a hyphen separating it from the arytenoid quadrant. One can see that a suture exiting the cricoid in quadrant 1 coupled with an arytenoid stitch in position 1 (1-1) or quadrant 2 (1-2) results in an arytenoid that is posterior and medial, with 1-2 being the ideal. One to three (1-3)s medial but anterior, whereas 1-4 is posterior but lateral. One to five (1-5) is both anterior and lateral. Of course, there are many other combinations, but as we can see with 4-5 (anterior and lateral), one must be careful to not stray too far from quadrant 1 (cricoid) and position 1 or quadrant 2 (arytenoid) to not cause glottal incompetence at the arytenoid level. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
Figure 9 The dilated pyriform sinus is pulled laterally into the open jaws of the stapling device to remove the excess tissue and decrease the volume of the pyriform sinus. The stapler lays down 2 layers of staples, making it a watertight seal, vital when operating on the pyriform sinus. The thyroid cartilage is pulled medially to allow access to this posterior laryngeal region. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
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Figure 10 A standard type I thyroplasty (medialization laryngoplasty) is performed using either a solid implant, such as a preformed silastic implant, as depicted on the left side of the image, or Gore-tex, as is seen on the right. Regardless of the implant that is used, the idea is to get good paraglottic space support to allow the patient to develop higher subglottic pressure that translates into a louder voice. (Courtesy of Ramon Franco Jr, MD.)
with simultaneous aural assessment of the voice. The voice should have more power behind it but will not typically sound normal because the vocal fold is not yet supported laterally. If adjustments are needed, the suture is pulled through and the adduction arytenopexy suture is reinserted. If the arytenoid position is ideal, the suture is finalized. If there is a history of associated dysphagia with retained secretions within the dilated/paralyzed pyriform sinus, a hypopharyngoplasty can be performed.7,8 The pyriform sinus is pulled taut while an articulating tip gastrointestinal anastomosis (GIA) stapler is used to lay down 2 layers of staples and decrease the volume of the nonfunctional pyriform sinus (Figure 9). Speech language pathologists teach these patients to turn the head to the affected side and tuck the chin during swallowing to obliterate the dilated pyriform sinus. The hypopharyngoplasty acts as a surgical “head turn” and “chin tuck” maneuver by permanently decreasing the size of the pyriform sinus. SURGICEL (Ethicon, Sommerville, NJ) is placed over the remnant pyriform sinus mucosa before rotating the thyroid cartilage back to the neutral position for the type I thyroplasty. A standard type I (medialization) thyroplasty is performed (Figure 10). It is important to be careful to keep the window and all dissection into the paraglottic space inferior to the level of the ventricle. The Penfield #2 elevator is used to elevate the inner perichondrium inferiorly and posteriorly if polytetrafluoroethylene is used. Directions for placement of solid implants should be followed carefully. Cricothyroid subluxation is performed after adduction arytenopexy and medialization laryngoplasty to impart tension to the flaccid, but medialized ipsilateral vocal fold (Figure 11). A 2-0 prolene suture is wrapped around the inferior cornu of the thyroid cartilage and tightened, leaving 2 ends of near equal length. The suture is then passed around the arch of the cricoid and approximated to a varying degree, increasing and decreasing the tension while asking the patient to speak until the optimal amount of tension is discovered. The suture is finalized in that position.
Although audition is used to ensure the voice sounds normal, nasolaryngoscopic inspection is performed to ensure there is no extrusion of Gore-tex from the ventricle, no tears in the mucosa from paraglottic space manipulation, no concerning laryngeal edema that could compromise breathing, and that the arytenoid and vocal fold are adequately medialized and supported (Figure 12A-12C). Elderly pa-
Figure 11 To establish tension within the flaccid vocal fold, a 2-0 prolene suture is tied around the inferior cornu of the thyroid cartilage. The suture is then wrapped around the anterior arch of the cricoid. Varying amounts of tension are applied to the suture limbs while the patient phonates to determine the optimal tension to achieve a good voice. (Courtesy of Ramon Franco Jr, MD.)
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Figure 13 Horizontal mattress sutures are used to bring the skin edges together with minimal tension and maximum eversion. The goal of all skin suturing is wound eversion in a tension-free environment to allow for proper healing. Because the mattress sutures are excellent anchors, only 2 or 3 separate sutures are needed to close the wound, minimizing the potential for foreign body reactions to the sutures. Adequate amounts of tissue are required for effective eversion of the wound edges, meaning the suture should pierce the skin 15-25 mm back from the wound edge. The base of the suture (distance between the 2 suture limbs) should also be between 15 and 25 mm to not strangulate the tissue at the base. Although the raised wound looks unusual, the long-term result is excellent cosmesis. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
Figure 12 (A) Preoperative rigid televideostroboscopic examination reveals an immobile left true vocal fold and pooling of secretions within the left pyriform sinus. Closer evaluation reveals the left vocal process is caudal and anterior to the right vocal process (loss of height). The vocal fold is positioned off of midline. (B) Postoperative rigid televideostroboscopic examination reveals the left arytenoid body is midline, flush with the mobile right side. The body of the arytenoid is also aligned with the membranous vocal fold in the midline. (C) The adequacy of closure can be appreciated in this still image from the rigid stroboscopic examination. There is complete closure of the musculomembranous region, with a normal persistent posterior cartilaginous chink as can be seen on rigid examination. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
tients and those with a long history of dysphonia may not be able to immediately achieve their best voice while in the operating room because of hyperfunction. Voice therapy for these patients is essential in the postoperative period. In
these hyperfunction cases, visual inspection is vital to know when enough medialization has been performed. The wound is closed in layers over a quarter inch Penrose drain with a compression dressing. The subcutaneous tissue and skin are brought together using 2 or 3 wide horizontal mattress sutures (4-0 prolene) to achieve maximal woundedge eversion with tension-free skin edge healing (Figure 13). The use of wide horizontal mattress sutures also minimizes the number of sutures piercing the skin and potentially causing a foreign body reaction, further degrading cosmesis. Patients are observed overnight to monitor oxygen saturation and evidence for bleeding. They are placed on IV Decadron, 12 mg, every 8 hours with appropriate antibiotic coverage. They are placed on voice rest during the time of maximal paraglottic space edema and vocal fold ecchymosis (7-14 days) but are started on a soft to regular diet immediately after surgery. Nasolaryngoscopic airway inspection at this time reveals edema and ecchymosis that will resolve over the course of a few weeks. The next morning, the wound is inspected, and if there is no evidence for bleeding, the Penrose drain is removed. The patient is discharged with a prescription for a Medrol dose pack and is scheduled to return to the outpatient clinic 1 week after surgery for a wound check and suture removal. The initial postoperative voice therapy visit is scheduled after the physician assessment and the suture removal.
Conclusions Adduction arytenopexy with cricothyroid subluxation affords a reliable method of surgical repositioning of the paralyzed vocal fold. By replicating the medial and poste-
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rior vector forces applied to the arytenoid during phonation, the membranous vocal fold is returned to its proper height, medial position and length. Complete posterior arytenoid contact ensures there is no persistent cartilaginous chink from malrotation of the arytenoid, and therefore, no excessive air leakage. Adduction arytenopexy increases the mean maximum phonation time and vocal intensity while decreasing mean glottal airflow, resulting in improved phonatory function. Hypopharyngoplasty can be easily performed concurrently, addressing the dysphagia commonly seen in association with unilateral vocal fold paralysis.
References 1. Isshiki N, Morita H, Okamura H, et al: Thyroplasty as a new phonosurgical technique. Acta Otolaryngol 78:451-457, 1974
2. Isshiki N, Okamura H, Ishikawa T: Thyroplasty type I (lateral compression) for dysphonia due to vocal cord paralysis or atrophy. Acta Otolaryngol 80:465-473, 1975 3. Miller FR, Bryant GL, Netterville JL: Arytenoid adduction in vocal fold paralysis. Oper Tech Otolaryngol Head Neck Surg 10:36-41, 1999 4. Zeitels S: Adduction arytenopexy with medialization laryngoplasty and cricothyroid subluxation: a new approach to paralytic dysphonia. Oper Tech Otolaryngol Head Neck Surg 10:9-16, 1999 5. Franco RA Jr, Andrus JG: Aerodynamic and acoustic characteristics of voice before and after adduction arytenopexy and medialization laryngoplasty with Gore-Tex in patients with unilateral vocal fold immobility. J Voice 23:261-267, 2009 6. McNamar J, Montequin DW, Welham NV, et al: Aerodynamic, acoustic, and vibratory comparison of arytenoid adduction and adduction arytenopexy. Laryngoscope 118:552-558, 2008 7. Mok P, Woo P, Schaefer-Mojica J: Hypopharyngeal pharyngoplasty in the management of pharyngeal paralysis: a new procedure. Ann Otol Rhinol Laryngol 112:844-852, 2003 8. Richer SL, Yelken K, Cunningham MJ, et al: Hypopharyngeal pharyngoplasty for the management of piriform fossa sinus. Laryngoscope 120:500-503, 2010
Adduction arytenopexy, hypopharyngoplasty, medialization laryngoplasty, and cricothyroid subluxation for the treatment of paralytic dysphonia and dysphagia Ramon A. Franco Jr, MD From the Division of Laryngology, Department of Otology and Laryngology, Harvard Medical School, Voice and Speech Laboratory, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. KEYWORDS Vocal fold paralysis; Dysphagia; Dysphonia; Adduction arytenopexy; Hypopharyngoplasty
Vocal fold paralysis is a common disorder of variable etiology. The resultant dysphonia and dysphagia can result in significant morbidity and decreased quality of life for the afflicted patient. Numerous surgical procedures have been developed to improve voice and swallowing, each with its own set of advantages and disadvantages. Selection of the most appropriate procedure is determined in part an assessment of the position of the arytenoid cartilage, as proper realignment of vocal fold height and length may be critical to restoration of phonatory function. While arytenoid adduction has been employed traditionally to address arytenoid position, adduction arytenopexy coupled with cricothyroid subluxation may provide enhanced aerodynamic efficiency compared to arytenoid adduction. Hypopharyngoplasty can be easily performed concurrently, which through plication of the flaccid and non-functional ipsilateral pyriform sinus, can provide significant improvement in the salivary pooling and dysphagia which often accompanies recurrent laryngeal nerve dysfunction. This paper will address the indications, advantages, and surgical technique of adduction arytenopexy, cricothyroid subluxation, and hypopharyngoplasty. © 2012 Elsevier Inc. All rights reserved.
Glottal incompetence from unilateral vocal fold movement impairment can lead to severely disabling social, economical, and personal consequences. The inability to tightly close the glottis leads to a persistent pressure leak into the airway that can make swallowing more difficult and can increase the risk of aspiration, reducing the efficacy of the protective laryngeal sphincter. This same pressure leak leads to a reduction in vocal power, an increase in vocal effort, and a reduction in vocal stamina that can make already vocally demanding professions (teaching, medicine, law, singing, or acting) nearly impossible to perform. The vocal volume reduction can also
Address reprint requests and correspondence: Ramon A. Franco Jr, MD, Division of Laryngology Department of Otology and Laryngology, Harvard Medical School, Voice and Speech Laboratory, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.otot.2012.06.004
lead to social isolation and depression because the afflicted shuns social events where there is sufficient ambient noise, such as in restaurants, bars, or outdoor venues to make conversing difficult. Unilateral vocal fold mobility impairment leading to glottal incompetence can be because of a myriad of causes, including autoimmune (rheumatoid arthritis), metabolic, neoplastic (paragangliomas, tumors affecting the course of the recurrent laryngeal nerve in the neck and chest, brain tumors), infectious (viral neuronitis, syphilis), mechanical trauma (to the musculomembranous vocal fold, thyroid, arytenoid, or cricoid cartilages or the cricoarytenoid joint), and neural (neuronitis, iatrogenic injury, tumor). Of these, the most common causes are iatrogenic injury to the recurrent laryngeal nerve at the time of neck or chest surgery, viral neuronitis, and tumors affecting the nerve. Consistent use of precise common terminology when describing vocal fold movement is vital for proper commu-
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nication between providers. The term paralysis should be reserved for those cases when there is no volitional movement and the nerve is known to not function, such as after en-bloc resection of the recurrent laryngeal nerve during thyroid cancer surgery. The term paralysis implies the condition is permanent. Paresis can be used to describe a limitation in vocal fold motion that is due to injury to the nerve. This injury can be reversible or could be stable with no evidence of improvement with time. Because the process of synkinesis influences the final resting position and function of the vocal fold, the most accurate method is to describe the range and velocity of arytenoid motion during adduction and abduction, the vertical position of the vocal process, the tone of the musculomembranous vocal fold, and the amount of ventricular fold compression/laxity. Complete loss of unilateral recurrent laryngeal nerve function leads to an anterior, lateral, and inferiorly placed vocal fold and arytenoid complex compared with the normally innervated side. The arytenoid cartilage is perched atop the cricoid cartilage that is shaped like a signet ring, considerably taller posterior where the cricoarytenoid joints are located than anterior. As the arytenoid cartilage falls from the top of the cricoid, it falls anterior and lateral, losing height as it goes forward resulting in the anterior, lateral, and inferior displacement. To make matters worse, there is an ipsilateral sensory deficit from the glottis to the upper trachea that makes it more difficult to protect from aspiration. Medialization of the vocal fold, regardless of the technique or material used (polytetrafluoroethylene [Gore-Tex; W.L. Gore & Associates, Inc, Flagstaff, AZ] vs silastic block vs titanium or silicone prosthesis), is not sufficient to close the large glottal gap that results from an anterior, lateral, and inferiorly displaced arytenoid cartilage. When there is a height discrepancy between the vocal processes, a procedure that specifically addresses the position of the arytenoid is required to achieve satisfactory voice results. Simple medialization cannot bring the “fallen” arytenoid to its phonatory position: posterior, superior, and medial. In fact, the widely used technique of overclosure of the membranous region through thyroplasty type I can lead to a reduction in the vibratory ability of the true vocal fold mucosa that degrades vocal quality. Plus, there remains a significant cartilaginous region gap that reduces vocal volume and increases the work of vocalizing. Currently, there are 2 well-recognized ways to control the arytenoid cartilage via an open approach, the arytenoid adduction and the adduction arytenopexy. A quick review of the arytenoid adduction will serve to highlight the differences between the 2 techniques. It is important to recognize that excellent results can be obtained with either technique in the proper hands, but there are some theoretical differences that should be highlighted. The arytenoid adduction was described by Isshiki et al1,2 as a procedure that involves passing a suture through the muscular process of the arytenoid and pulling the two suture limbs anterior, lateral, and inferior to simulate the action of the lateral cricoarytenoid muscle (LCA) (Figure 1) that normally works to whip the vocal processes medially in
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Figure 1 Arytenoid adduction suture. The vector force of the arytenoid adduction suture is anterior, pulling the muscular process of the arytenoid forward, rotating the vocal process medially. In the process, the entire unstable arytenoid body also tends to go forward, and therefore, inferior and somewhat lateral as it goes down the cricoid. The solid arrow line is the final vector force. (Figure 7A from Miller FR, Bryant GL, Netterville JL: Arytenoid adduction in vocal fold paralysis. Oper Tech Otolaryngol Head Neck Surg 10:36-41, 1999.)
preparation for voicing. The net result of this procedure is rotation of the arytenoid cartilage3 to bring the vocal process medial, while also pulling the unsupported arytenoid complex further forward and inferior. Remember that in the pathologic state, the arytenoid has a tendency to fall anterior, lateral, and inferior: the vector of the arytenoid adduction sutures pulls it further anterior, inferior, and lateral, potentially making the height discrepancy worse (the more anterior it is pulled, the more inferior it will rest) while rotating the arytenoid causing the arytenoid bodies to not sit flush against each other during voicing and potentially leaving a persistent cartilaginous keyhole aperture. Normally, the action of the LCA is opposed by the simultaneous action of the posterior cricoarytenoid muscle (PCA), interarytenoid muscle, and the thyroarytenoid muscle to maintain proper vocal fold tension and arytenoid position. The adduction arytenopexy4 attempts to address paralytic arytenoid malposition by pulling the arytenoid up the cricoarytenoid facet (posterior) and suturing it in its normal phonatory position (medial), flush against the opposite arytenoid. Theoretically, the medial and posterior vector forces will result in an arytenoid in a “phonatory friendly” place with the membranous vocal fold at the proper height, in a medial position and of similar length (and tension) to the working vocal fold. Because the arytenoid bodies are able to rest flush with each other during phonation, there is no persistent cartilaginous chink from rotation of the
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Figure 4 Curved mayo scissors are used to cut through the cricothyroid joint. This allows further anterior rotation of the thyroid cartilage and access to the pyriform sinus mucosa, posterior cricoarytenoid muscle (PCA), and the arytenoid cartilage. The asterisk (*) represents the tip of the inferior cornu of the thyroid cartilage. The “1” denotes the posterior border of the thyroid. cartilage. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
Figure 2 A natural skin crease at the level of the lower border of the thyroid cartilage/cricothyroid membrane is selected as the proposed incision line. (Courtesy of Ramon Franco Jr, MD.)
arytenoid, and therefore, no excessive air leakage. A 2009 report by Franco and Andrus5 on a cohort of 28 patients who had undergone adduction arytenopexy with complete preop and postop aerodynamic and acoustic testing revealed statistically significant increases in the mean maximum phonation time and vocal intensity with a statistically significant decrease in mean glottal airflow.
These results validate the premise that adduction arytenopexy, when combined with medialization laryngoplasty, can help to statically correct the glottal deficiency seen when the arytenoid is malpositioned. In 2008, McNamar et al6 compared adduction arytenopexy with arytenoid adduction in an ex vivo experimental set-up. They found that after adduction arytenopexy, they needed only 80% of the phonation threshold pressures necessary for arytenoid adduction. This implies that the adduction arytenopexy is more aerodynamically efficient when compared with arytenoid adduction. Despite the fact that there is data to support the theoretical advantage of the adduction arytenopexy over the arytenoid adduction, many cases of unilateral vocal fold immobility do not need a procedure to address arytenoid position because of synkinesis. After nerve injury, there is aberrant neural healing that can result in a more medial and posterior location of the arytenoid than would have been predicted given the injury and
Figure 3 Double skin hooks are used to retract the posterior thyroid lamina to transect the inferior constrictor muscles. (Figure 3B from Zeitels SM: Adduction arytenopexy with medialization laryngoplasty and cricothyroid subluxation: a new approach to paralytic dysphonia. Oper Tech Otolaryngol Head Neck Surg 10:9-16, 1999.)
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Figure 5 The posterolateral laryngeal anatomy that is normally hidden beneath the inferior constrictors and thyroid cartilage has been uncovered by retracting the thyroid cartilage (5) medially. The arytenoid cartilage (1) has been disarticulated from the cricoid (immediately caudal to the arytenoid—the white of the cricoarytenoid joint surface can be appreciated) with the cut end of the PCA (2) used to manipulate the arytenoid. The recurrent laryngeal nerve (3) is seen entering the larynx between the cricoarytenoid and cricothyroid (6) joints. The pyriform sinus mucosa (4) is retracted posteriorly after it has been dissected away from the PCA muscle. The posterior margin of the thyroid cartilage (5) is retracted medially with sharp double-prong skin hooks. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
the position immediately after the injury. There is an abundance of adductory fibers in the recurrent laryngeal nerve (about 70%), so aberrant healing is more likely to stimulate adductors rather than abductors, resulting in better glottal competence leading to a stronger, less disordered voice and im-
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proved laryngeal protective sphincteric action during swallowing. Before considering an adduction arytenopexy, the position of the arytenoid must be carefully determined. If the immobile arytenoid is laterally and anteriorly displaced resulting in a caudally placed vocal process (and vocal fold) then an arytenopexy should be considered. It is important to appreciate that if there is any volitional motion from the impaired side, an adduction arytenopexy will permanently sacrifice this motion. The most important factor before considering an adduction arytenopexy is whether there is normal range of motion (lateral excursion) of the “normal” arytenoid to allow adequate glottal airflow after the adduction arytenopexy. This assessment should be performed in the clinic when deciding the proper treatment for the patient and repeated in the operating room before giving the patient any sedatives or injecting local anesthesia in the neck.
Adduction arytenopexy surgical procedure The patient is placed in the supine position with the head elevated above the body in reverse Trendelenburg position to decrease venous congestion and laryngeal edema. The side of the nose that will be used to introduce the flexible nasolaryngoscope is packed with neuropledgets soaked in 4% cocaine to vasoconstrict and decongest. It is vital to speak to the nursing and anesthesia teams before the surgery to ensure the intravenous infusion catheter is promptly placed when the patient is brought into the holding area so steroids (12 mg of Decadron or the equivalent) can be
Figure 6 (A) The adduction arytenopexy suture. A 4-0 prolene suture is used to reposition the arytenoid in a posterior, medial, and superior position. The suture is passed from the posterior-lateral cricoid to the posterior-medial quadrant of the cricoarytenoid joint. This same suture is passed from the undersurface of the arytenoid (central location) to exit the superior surface. The suture is finalized by passing it from the inner cricoid cortex to the outer cricoid cortex, exiting anterior to the initial insertion point. (B) Closer view of adduction arytenopexy stitch. (Courtesy of Ramon Franco Jr, MD.)
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infused about 45 minutes before the incision. This delays the onset of meaningful edema later in the case when the paraglottic space is disturbed during the medialization laryngoplasty. It is vital that the patient not receive sedation before the nasolaryngoscopic examination because this can impair the mobility of the mobile vocal fold. An adduction arytenopexy should only be attempted if the mobile vocal fold can adequately abduct so as not to precipitate an airway crisis when the immobile fold is medialized. A marking pen is used to delineate the level of the cricoid, the lower border of the thyroid cartilage, and the hyoid bone. A natural skin crease overlying the cricothyroid membrane is marked from about 1 cm beyond midline to approximately the anterior border of the sternocleidomastoid muscle on the ipsilateral side (Figure 2). The incision will be longer and extend further posterior compared with a simple medialization laryngoplasty incision because access is required to the posterior border of the thyroid cartilage. A solution of 2% lidocaine with 1:200,000 epinephrine and 0.75% bupivacaine with 1:100,000 epinephrine combined one-to-one (final concentration of 1% lidocaine, 0.375%
bupivacaine with 1:150,000 epinephrine) is injected under and around the proposed incision, deep to the strap muscles and adjacent to the thyroid cartilage, with special emphasis paid to the inferior constrictor muscles around the posterior border. The neck is then prepped and draped in the standard way for an open neck procedure. After creating a 3- to 5-cm skin incision and carrying it down through the platysma layer, subplatysmal flaps are created. The ipsilateral strap muscles are transected to gain access to the posterior thyroid ala where double skin hooks are used to rotate the posterior border of the thyroid cartilage and expose the inferior constrictor muscles (Figure 3). Using a needle-tipped electrocautery, the constrictors are freed from the thyroid cartilage. It is important to stay on the lateral aspect of the thyroid cartilage and not wander posterior because the thin pyriform sinus mucosa could be inadvertently injured, potentially leading to a fistula. Once the constrictors are removed, a curved mayo scissors is used to separate the cricothyroid joint (Figure 4), further mobilizing the thyroid cartilage, allowing it to rotate medial (anterior). The pyriform sinus mucosa is bluntly swept out
Figure 7 This figure is a close-up of the open left cricoarytenoid joint. Both articulating surfaces of the cricoarytenoid joint can be seen (the superior surface of the cricoid and the undersurface of the arytenoid), and each has been divided into quadrants. The asterisk (*) represents the entry point for the adduction arytenopexy suture. There is a tremendous amount of variability to the final resting position of the arytenoid because there are many places to exit the cricoarytenoid surface and the arytenoid. To achieve a posterior and medial repositioning of the arytenoid, it is ideal to have the initial suture exit the cricoarytenoid joint surface within quadrant 1 (medial and posterior). The suture then needs to pass into the arytenoid. A good starting position is in the direct center (1) or within quadrant 4, depending on how much it needs to come posterior and medial. (Courtesy of Ramon Franco Jr, MD.)
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of the way in a caudal to cephalad direction using a Penfield #2 elevator, exposing the underlying PCA (Figure 5). The recurrent laryngeal nerve can be seen along the caudal border of the PCA muscle and should be separated and preserved. The PCA muscle is transected leaving a “tail” that leads to the muscular process of the arytenoid and allows direct manipulation of the arytenoid. While elevating the cut PCA muscle, a Penfield #2 elevator is used to widely incise the lateral capsule of the cricoarytenoid joint (Figure 5). In preparation for manipulating the arytenoid and resetting its position, a Stevens scissors is used to transect the LCA fibers as they insert anteriorly onto the muscular process. Any cricoarytenoid joint capsule fibrous tissue that seems to limit the motion of the arytenoid is transected. The arytenoid is now ready for the adduction arytenopexy suture (Figure 6A, 6B). A 4-0 prolene (monofilament) (Ethicon, Sommerville, NJ) suture with a P-3 reverse cutting needle is inserted through the lateral and posterior cricoid, just below the cricoarytenoid joint, and is passed out of the medial and posterior joint facet. The final resting place of the arytenoid is greatly influenced by the location this suture exits the joint; it is ideal to place the suture in the posterior and medial quadrant (Figure 7). The suture is then passed through the body of the arytenoid from the center of the articulating surface (undersurface) to exit the cephalad surface. The final position of the arytenoid can be further manipulated through careful placement of the arytenoid suture (Figure 8). If you want the arytenoid cartilage to rest more posterior, the suture needs to go through the anterior part of the arytenoid. If a more medial position is desired, the suture should be placed more lateral (Figure 8). A good starting position is in the direct center of the articulating surface or offset a bit lateral and anterior (to give it a medial and posterior final resting position). The suture is then passed from the medial to lateral cortex of the cricoid under the cricoarytenoid joint, anterior to the initial suture insertion (Figure 6B). The suture is temporarily tightened to allow visual inspection of the arytenoid with the flexible nasolaryngoscope
Figure 8 One of the surgical advantages of the adduction arytenopexy suture is the direct control the surgeon has on the final resting position of the arytenoid cartilage with respect to the cricoarytenoid joint. The final effect of suture placement is opposite with the arytenoid than it is with the cricoid. Placing the suture anteriorly in the arytenoid results in a posteriorly placed arytenoid. Lateral sutures through the arytenoid will result in a medial position. In the cricoid, the suture needs to be in the posterior and medial position to effect a posterior and medial final resting place. The figure labels refer to the quadrants (same labeling as in Figure 7) the suture exits the cricoid with a hyphen separating it from the arytenoid quadrant. One can see that a suture exiting the cricoid in quadrant 1 coupled with an arytenoid stitch in position 1 (1-1) or quadrant 2 (1-2) results in an arytenoid that is posterior and medial, with 1-2 being the ideal. One to three (1-3)s medial but anterior, whereas 1-4 is posterior but lateral. One to five (1-5) is both anterior and lateral. Of course, there are many other combinations, but as we can see with 4-5 (anterior and lateral), one must be careful to not stray too far from quadrant 1 (cricoid) and position 1 or quadrant 2 (arytenoid) to not cause glottal incompetence at the arytenoid level. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
Figure 9 The dilated pyriform sinus is pulled laterally into the open jaws of the stapling device to remove the excess tissue and decrease the volume of the pyriform sinus. The stapler lays down 2 layers of staples, making it a watertight seal, vital when operating on the pyriform sinus. The thyroid cartilage is pulled medially to allow access to this posterior laryngeal region. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
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Figure 10 A standard type I thyroplasty (medialization laryngoplasty) is performed using either a solid implant, such as a preformed silastic implant, as depicted on the left side of the image, or Gore-tex, as is seen on the right. Regardless of the implant that is used, the idea is to get good paraglottic space support to allow the patient to develop higher subglottic pressure that translates into a louder voice. (Courtesy of Ramon Franco Jr, MD.)
with simultaneous aural assessment of the voice. The voice should have more power behind it but will not typically sound normal because the vocal fold is not yet supported laterally. If adjustments are needed, the suture is pulled through and the adduction arytenopexy suture is reinserted. If the arytenoid position is ideal, the suture is finalized. If there is a history of associated dysphagia with retained secretions within the dilated/paralyzed pyriform sinus, a hypopharyngoplasty can be performed.7,8 The pyriform sinus is pulled taut while an articulating tip gastrointestinal anastomosis (GIA) stapler is used to lay down 2 layers of staples and decrease the volume of the nonfunctional pyriform sinus (Figure 9). Speech language pathologists teach these patients to turn the head to the affected side and tuck the chin during swallowing to obliterate the dilated pyriform sinus. The hypopharyngoplasty acts as a surgical “head turn” and “chin tuck” maneuver by permanently decreasing the size of the pyriform sinus. SURGICEL (Ethicon, Sommerville, NJ) is placed over the remnant pyriform sinus mucosa before rotating the thyroid cartilage back to the neutral position for the type I thyroplasty. A standard type I (medialization) thyroplasty is performed (Figure 10). It is important to be careful to keep the window and all dissection into the paraglottic space inferior to the level of the ventricle. The Penfield #2 elevator is used to elevate the inner perichondrium inferiorly and posteriorly if polytetrafluoroethylene is used. Directions for placement of solid implants should be followed carefully. Cricothyroid subluxation is performed after adduction arytenopexy and medialization laryngoplasty to impart tension to the flaccid, but medialized ipsilateral vocal fold (Figure 11). A 2-0 prolene suture is wrapped around the inferior cornu of the thyroid cartilage and tightened, leaving 2 ends of near equal length. The suture is then passed around the arch of the cricoid and approximated to a varying degree, increasing and decreasing the tension while asking the patient to speak until the optimal amount of tension is discovered. The suture is finalized in that position.
Although audition is used to ensure the voice sounds normal, nasolaryngoscopic inspection is performed to ensure there is no extrusion of Gore-tex from the ventricle, no tears in the mucosa from paraglottic space manipulation, no concerning laryngeal edema that could compromise breathing, and that the arytenoid and vocal fold are adequately medialized and supported (Figure 12A-12C). Elderly pa-
Figure 11 To establish tension within the flaccid vocal fold, a 2-0 prolene suture is tied around the inferior cornu of the thyroid cartilage. The suture is then wrapped around the anterior arch of the cricoid. Varying amounts of tension are applied to the suture limbs while the patient phonates to determine the optimal tension to achieve a good voice. (Courtesy of Ramon Franco Jr, MD.)
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Figure 13 Horizontal mattress sutures are used to bring the skin edges together with minimal tension and maximum eversion. The goal of all skin suturing is wound eversion in a tension-free environment to allow for proper healing. Because the mattress sutures are excellent anchors, only 2 or 3 separate sutures are needed to close the wound, minimizing the potential for foreign body reactions to the sutures. Adequate amounts of tissue are required for effective eversion of the wound edges, meaning the suture should pierce the skin 15-25 mm back from the wound edge. The base of the suture (distance between the 2 suture limbs) should also be between 15 and 25 mm to not strangulate the tissue at the base. Although the raised wound looks unusual, the long-term result is excellent cosmesis. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
Figure 12 (A) Preoperative rigid televideostroboscopic examination reveals an immobile left true vocal fold and pooling of secretions within the left pyriform sinus. Closer evaluation reveals the left vocal process is caudal and anterior to the right vocal process (loss of height). The vocal fold is positioned off of midline. (B) Postoperative rigid televideostroboscopic examination reveals the left arytenoid body is midline, flush with the mobile right side. The body of the arytenoid is also aligned with the membranous vocal fold in the midline. (C) The adequacy of closure can be appreciated in this still image from the rigid stroboscopic examination. There is complete closure of the musculomembranous region, with a normal persistent posterior cartilaginous chink as can be seen on rigid examination. (Courtesy of Ramon Franco Jr, MD.) (Color version of figure is available online.)
tients and those with a long history of dysphonia may not be able to immediately achieve their best voice while in the operating room because of hyperfunction. Voice therapy for these patients is essential in the postoperative period. In
these hyperfunction cases, visual inspection is vital to know when enough medialization has been performed. The wound is closed in layers over a quarter inch Penrose drain with a compression dressing. The subcutaneous tissue and skin are brought together using 2 or 3 wide horizontal mattress sutures (4-0 prolene) to achieve maximal woundedge eversion with tension-free skin edge healing (Figure 13). The use of wide horizontal mattress sutures also minimizes the number of sutures piercing the skin and potentially causing a foreign body reaction, further degrading cosmesis. Patients are observed overnight to monitor oxygen saturation and evidence for bleeding. They are placed on IV Decadron, 12 mg, every 8 hours with appropriate antibiotic coverage. They are placed on voice rest during the time of maximal paraglottic space edema and vocal fold ecchymosis (7-14 days) but are started on a soft to regular diet immediately after surgery. Nasolaryngoscopic airway inspection at this time reveals edema and ecchymosis that will resolve over the course of a few weeks. The next morning, the wound is inspected, and if there is no evidence for bleeding, the Penrose drain is removed. The patient is discharged with a prescription for a Medrol dose pack and is scheduled to return to the outpatient clinic 1 week after surgery for a wound check and suture removal. The initial postoperative voice therapy visit is scheduled after the physician assessment and the suture removal.
Conclusions Adduction arytenopexy with cricothyroid subluxation affords a reliable method of surgical repositioning of the paralyzed vocal fold. By replicating the medial and poste-
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rior vector forces applied to the arytenoid during phonation, the membranous vocal fold is returned to its proper height, medial position and length. Complete posterior arytenoid contact ensures there is no persistent cartilaginous chink from malrotation of the arytenoid, and therefore, no excessive air leakage. Adduction arytenopexy increases the mean maximum phonation time and vocal intensity while decreasing mean glottal airflow, resulting in improved phonatory function. Hypopharyngoplasty can be easily performed concurrently, addressing the dysphagia commonly seen in association with unilateral vocal fold paralysis.
References 1. Isshiki N, Morita H, Okamura H, et al: Thyroplasty as a new phonosurgical technique. Acta Otolaryngol 78:451-457, 1974
2. Isshiki N, Okamura H, Ishikawa T: Thyroplasty type I (lateral compression) for dysphonia due to vocal cord paralysis or atrophy. Acta Otolaryngol 80:465-473, 1975 3. Miller FR, Bryant GL, Netterville JL: Arytenoid adduction in vocal fold paralysis. Oper Tech Otolaryngol Head Neck Surg 10:36-41, 1999 4. Zeitels S: Adduction arytenopexy with medialization laryngoplasty and cricothyroid subluxation: a new approach to paralytic dysphonia. Oper Tech Otolaryngol Head Neck Surg 10:9-16, 1999 5. Franco RA Jr, Andrus JG: Aerodynamic and acoustic characteristics of voice before and after adduction arytenopexy and medialization laryngoplasty with Gore-Tex in patients with unilateral vocal fold immobility. J Voice 23:261-267, 2009 6. McNamar J, Montequin DW, Welham NV, et al: Aerodynamic, acoustic, and vibratory comparison of arytenoid adduction and adduction arytenopexy. Laryngoscope 118:552-558, 2008 7. Mok P, Woo P, Schaefer-Mojica J: Hypopharyngeal pharyngoplasty in the management of pharyngeal paralysis: a new procedure. Ann Otol Rhinol Laryngol 112:844-852, 2003 8. Richer SL, Yelken K, Cunningham MJ, et al: Hypopharyngeal pharyngoplasty for the management of piriform fossa sinus. Laryngoscope 120:500-503, 2010