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D. Costello et al.
a
b
Fig. 6.1 Paralysed left vocal fold sitting in a median position, hence with good glottic closure, seen on inspiration (a) and on phonation (b). Good
glottic closure on phonation results in a good voice
• Medialization injection (injection laryngoplasty) in clinic.
This technique, using local anaesthetic, is now seen as the
primary option and should be undertaken as soon as it is
practically possible. A detailed description appears below.
Similarly, under general anaesthetic, suspension microlaryngoscopy can be used in clinic and the paralysed
vocal fold can be injected trans-orally.
• Isshiki type 1 thyroplasty (medialization laryngoplasty) .
This procedure is described in detail below.
• Arytenoid repositioning procedures. In most cases, a
medialization injection or a thyroplasty will achieve adequate glottic closure and result in signicant voice
improvement. Occasionally, the arytenoid sits in an
unfavourable position and may need to be repositioned [2,
3]. However, voice outcomes are not demonstrably better
when an arytenoid procedure is performed at the same
time as thyroplasty, suggesting that thyroplasty alone is
usually sufcient [4]. In the procedure of arytenoid
adduction, the arytenoid cartilage is rotated: Having dissected around the posterior border of the thyroid lamina,
the muscular process of the arytenoid is located, and a
suture is placed through it and then pulled forwards and
secured anteriorly to rotate the arytenoid medially, mimicking the action of the lateral cricoarytenoid (LCA) muscle. In adduction arytenopexy, the whole arytenoid is
moved: The inferior constrictor is detached from the thyroid lamina, the cricothyroid joint is disarticulated, the
superior thyroid ligament is divided, and the posterior
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a
b
71
Fig. 6.2 Paralysed left vocal fold sitting in a very lateral position, hence with a high degree of glottic incompetence on inspiration (a) and on
attempted phonation (b). The large gap on phonation results in a very breathy voice
border of the thyroid lamina is retracted anteriorly. The
pyriform fossa mucosa is swept away. Inferior to this, the
posterior cricoarytenoid muscle (PCA) is identied and
followed superiorly to its insertion into the arytenoid. The
PCA is then divided at the cricoarytenoid joint and the
joint is entered with scissors. After division of the posterior joint capsule bres, the body of the arytenoid is then
sutured posteromedial onto the cricoid facet.
• Re-innervation. This emerging technique aims to restore
tone to the vocal fold. A detailed description appears
below.
6.2 Surgical Techniques
6.2.1 Vocal Fold Medialization Injection
(Injection Laryngoplasty)
Vocal fold medialization injection (injection laryngoplasty)
is relatively easy to perform under local anaesthetic in the
clinic setting. Equipment requirements are minimal: a distal
chip endoscopic system is essential, along with local anaesthetic and the injection material. The injecting surgeon is
assisted by a colleague who passes the endoscope.
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6.2.1.1 Indications
It is increasingly recognised that early medialization (within
weeks) following the onset of the UVFP improves long-term
outcomes: A series of studies have demonstrated that the longer the delay in performing a medialization procedure, the
more likely it is that the patient will require a thyroplasty in
the future [5–8]. There is therefore little justication for
“watchful waiting,” and clinical practice amongst laryngologists is being radically altered.
As an alternative to injection under local anaesthetic, it is
certainly possible to perform injection medialization under
general anaesthetic, but this has some disadvantages: Many
of the patients in this cohort have multiple comorbidities, so a
general anaesthetic may be contraindicated. Patients having a
palliative procedure will frequently not wish to have a daycase procedure, or may be too unwell to do so. There are further advantages to performing injections in the clinic setting:
• The degree of medialization achieved can be judged in
real time, allowing for precision in assessing the amount
of material needed. If the injection is performed under
general anaesthetic, there is no way of judging how much
should be injected.
• The improvement in voice can be assessed by asking the
patient to phonate during the procedure. More injection
material can then be injected if required.
6.2.1.2 Materials
Various materials can be used; following are the most
common:
• Calcium hydroxylapatite (Radiesse™ Voice, Prolaryn™
Plus, Renú® Voice) is easy to handle and requires no specic preparation. It has a typical duration of action of
about 12–18months.
• Hyaluronic acid (HA) (various proprietary preparations,
including Restylane®) typically lasts about 4months. It is
therefore ideally suitable for those patients in whom a
resolution of the UVFP is anticipated; it restores the voice
for the intervening recovery period.
• Dissolvable gels (Renú® Gel, Radiesse™ Voice Gel,
Prolaryn™ Gel) are synthetic products that have a similarly short duration of action (typically a few months) as
HA and are used in similar situations.
6.2.1.3 Techniques Under Local Anaesthetic
Injection medializations can be performed percutaneously or
per-orally. Percutaneous injection medialization can use a
trans-thyrohyoid approach (Figs. 6.3 and 6.4), a transcricothyroid approach (Figs.6.5 and 6.6), or a trans-thyroid
cartilage approach (Fig.6.7).
Fig. 6.3 Vocal fold
medialization injection
(injection laryngoplasty)
using a trans-thyrohyoid
approach. Under endoscopic
guidance, local anaesthetic is
injected into the skin and into
the airway via the thyrohyoid
membrane. The injection
needle is introduced into the
skin just above the thyroid
notch and is then aimed
downwards towards the
laryngeal introitus. The
needle often needs to be bent
into a curve to achieve the
correct trajectory
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a
b
73
Fig. 6.4 Trans-thyrohyoid approach. (a) The needle is seen entering the upper surface of the (paralysed) right vocal fold, taking care to direct the
needle lateral to the vocal ligament (hence into the thyroarytenoid muscle). (b) The right vocal fold is lled with injection material
In the per-oral approach (Fig.6.8), a long, rigid needle is
6.2.2 Medialization Thyroplasty
curved to pass over the tongue base towards the larynx. A
disadvantage of this technique is the “dead space” in the relatively long needle, so some material is lost.
All of these local anaesthetic techniques take just a few
minutes to perform, and the patient will typically leave the
clinic a few minutes after it is completed. Some clinicians
advocate voice rest in order to allow the injection points to
epithelialize, and thus to avoid extrusion of injection
material.
6.2.2.1 Indications
Medialization thyroplasty, also called type 1 thyroplasty
(referring to Isshiki’s classication) [9, 10], represents a
standard treatment for paralyzed vocal fold in abduction [11,
12].
It represents the treatment of choice for large glottic gaps
during phonation and when permanent treatment is sought
[13, 14]. The importance of this glottis gap is mostly appreci-
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ab
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Fig. 6.5 Vocal fold medialization injection (injection laryngoplasty)
using a trans- cricothyroid approach. Under endoscopic guidance, local
anaesthetic is injected into the airway via the cricothyroid membrane.
Fig. 6.6 (a) The needle is seen entering the airway under the (paralysed) right vocal fold. (b) The right vocal fold is lled with injection
material
The injection needle appears in the subglottis and is aimed
upwards towards the undersurface of the paralysed vocal fold.
(a) before, (b) after
ated through video-laryngoscopic examination and aerodynamic measurement of glottic leakage such as the mean
airow rate, measured with a pneumotachygraph, or the
Phonation Quotient, the vital capacity (in cc) divided by the
maximum phonation time (in seconds) [15].
tration created in the lateral ala of the thyroid cartilage. The
medialized vocal fold is held in an adductive position by
interposition of a material that is left in place at the end of
surgery. By maintaining the paralyzed vocal fold in adduction, surgeons restore a subglottic vault and thus achieve
glottis closure during phonation, which allows a build-up
6.2.2.2 Materials
The basic principle of medialization thyroplasty consists of
pushing the paralyzed vocal fold inwards through a fenes-
of subglottic pressure and subsequent oscillation of the
vocal fold mucosa, two conditions required for proper
phonation.
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Fig. 6.7 Vocal fold medialization injection (injection laryngoplasty)
using a trans-thyroid cartilage approach. In this approach, the airway is
not entered, but the injection needle is passed through the thyroid cartilage into the paraglottic space. This technique can be more difcult if
there is calcication of the cartilage
75
Many materials have been proposed over the years since
the rst interposition of cartilage performed by Mr. Payr in
1915 [16]. Table6.1 summarizes the different main materials
used around the world. Some materials require larger or
smaller cartilage fenestrations. Some are pre-moulded and
provided by the industry; others are self-carved perioperatively by the surgeon. Some are self-anchored; others
need stitches in order to be stabilized. Reports reveal good
results for all of the materials listed, showing a rather low
rate of re-interventions.
Some surgeons combine the medialization thyroplasty
procedure with an arytenoid procedure such as arytenoid
Table 6.1 Various implant systems and materials for medialization
thyroplasty
Implant Material References
Self-carved hard
silicone (Silastic)
Netterville’s
Phonoform
Montgomery’s
Implant
Gore-tex® Implant Polytetrauoroethylene
Freiderich’s Implant®Titanium Schneider etal.
VoCom
®
®
®
Polysiloxane Benninger etal.
[17]
Polysiloxane Netterville etal.
[18]
Polysiloxane Montgomery
etal. [19]
Zeitels etal.
(PTFE)
Hydroxylapatite Cummings etal.
[20]
[21]
[22]
Fig. 6.8 Vocal fold
medialization injection
(injection laryngoplasty)
using a per-oral approach. A
long, rigid needle is curved to
pass over the tongue base
towards the larynx
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Cartilago thyroidea
cricothyroideus
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adduction or arytenopexy. These adjunctive procedures are
aimed at specically addressing the posterior part of the glottis. There is presently no evidence or consensus about the
circumstances in which these arytenoid procedures may be
necessary, and these adjunctive techniques are not described
in detail in this chapter. Readers can refer themselves to the
specic literature for more details [4, 23].
Unfortunately, the lack of standardized voice outcome
indicators impedes proper comparison between various
materials and techniques so that, to our best knowledge,
none of these can be declared to be superior to the others.
The choice of the technique and material to be used for a
medialization thyroplasty is left to the discretion of the surgeon, usually based on his or her own experience and
training.
6.2.2.3 Surgical Technique
To be concise, we will explain here only one technique and
material: the medialization thyroplasty technique known as
the Montgomery Thyroplasty Implant System™ (MTIS).
This technique and type of implant is widely used and available over the world. It is growing in popularity, reported to
have a short learning curve and excellent postoperative voice
outcomes. Although the MTIS provides not only a premoulded hard silicone implant but also a step-by-step operative procedure, the procedure has been recently questioned in
the literature. The procedure described here has been modied according to this recent literature [24, 25].
The procedure is performed under local anaesthesia and
light sedation. Particular attention is offered to overweight
and/or apnoeic patients, for whom sedation must be titrated
in order to avoid any tongue ptosis causing apnoea and desaturation. An anaesthesiologist is present within the OR during
the entire procedure. Oxygen and cardiopulmonary parame-
ters are monitored continuously. The patient is supine with a
neutral positioning of the head. Oxygen is administered
through a nasal probe xed with tape.
In our experience, we do not systematically use visual
feedback with the help of transnasal video-laryngoscopy.
The patient’s voice—the purpose of the procedure—is the
sole feedback indicator. Video-laryngoscopy is reserved for
difcult cases or when in doubt.
Local anaesthesia is performed by subcutaneous and
intramuscular inltration of noradrenaline-lidocaine 2% at
the level of the skin incision. The skin is prepped with a disinfectant from sternum to nose. Draping spares the mouth
and nose to avoid any claustrophobic sensation that could be
felt by the patient. Eyelid closure is secured by tape.
Light and sound intensity is carefully reduced to a minimum within the OR.
The surgeon regularly checks the patient’s vigilance by
engaging in conversation with him or her. A skin incision
4–5cm in length is performed at the level of the cricothyroid
membrane. Generally, the main cause of failure of this procedure is a tendency to create the cartilage window too superiorly. Placing the skin incision relatively low helps to
prevent a too-superior cartilage fenestration.
The platysma is divided and dissected. An orthostatic
retractor is placed to expose the eld and maintain cutaneomuscular platysma aps (Fig.6.9). The midline is dissected
and the sternohyoid and omohyoid muscles are reclined with
two retractors. On some occasions, an anterior jugular vein
needs to be ligated to allow proper retraction of the strap
muscles.
In the female patient, the thyroid cartilage is usually relatively at and the infrahyoid strap muscles do not need to be
divided. In male patients, the thyroid cartilage shape has a
sharper angle, and the sternohyoid muscle must be partially
Fig. 6.9 An orthostatic
retractor is placed to expose
the eld and maintain
cutaneomuscular platysma
aps
Musculus
Infrahyoid strap
muscles
Thyroid cart.
Imaginary curved
landmark
Outline instrument
W
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Fig. 6.10 A line is drawn through two points dened with the help of
a two-teeth fork provided by the Montgomery Surgical Set
divided to allow proper access to the lateral ala of the thyroid
cartilage. For both sexes, the anterior lower part of the thyrohyoid muscle must be divided in order to completely expose
the external perichondrium of the thyroid cartilage.
two landmarks are on the midline: the upper thyroid notch,
superiorly, and the lower midline edge of the thyroid cartilage, inferiorly. The third midline landmark consists of a
point located exactly mid-distance between the previous two
landmarks. This midpoint corresponds to the position of the
anterior commissure of the vocal folds. The fenestration
should never occur above (or superior to) this level.
of a two-teeth fork provided by the Montgomery Surgical Set
(Fig.6.10). These forkteeth are oriented perpendicular to the
lower margin of the thyroid cartilage. One will mark a point
anterior (a) to the inferior thyroid tubercle marking the end
of the oblique line, the second posterior (b) to the same
tubercle. An imaginary curved line will be drawn between a,
b, and the midpoint. This line represents the limit that the
Outline Instrument, which is the upper limit of the implant,
will never cross over. The same line will also determine the
orientation or angulation of the implant relative to the lower
limit of the cartilage.
Surgical Set, will glide and make a translation below the
imaginary line (Fig.6.11). In our experience, we try to locate
the window as low and as median as the patient’s cartilage
allows us to do. This is just to avoid any protrusion within the
Morgagni’s space superiorly and any interference with the
arytenoid cartilage posteriorly.
superior notch
Mid point
Inferior midline
line
Key
Point 1
Point 2
At this stage, fenestrations landmarks are made. The rst
A line is drawn through two points dened with the help
An outline instrument, also provided by the Montgomery
Key
landmark
Fig. 6.11 An outline instrument, also provided by the Montgomery
Surgical Set, will glide and make a translation below the imaginary line
SA
Fig. 6.12 Application of electrocauterization on the outline instrument
will mark the four corners of the fenestration rectangle
Usually, only 1–2mm of cartilage remains inferior to the
fenestration. If there is more, take a time-out and reconsider
the landmarks; you may be wrong. Likewise, the distance
between the anterior edges of the fenestration and the midline does not exceed 5mm. If it does, check your landmarks
before drilling the cartilage window. Application of electrocauterization on the outline instrument will mark the four
corners of the fenestration rectangle (Fig.6.12).
After removing the external perichondrium of the fenestration area, a time-out is required. During this time-out, the
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Cartilage
elevation
Measuring device
and translation
Squeeze of
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or dummy
2mm
2mm
window
Fig. 6.13 Removing of the cartilage window is performed with a cold
knife if the cartilage is soft, and with a three-tooth saw if it is calcied
surgeon will ask the assistant to release any traction on the
operative eld and will step back to make sure of the “overall
picture” of where the fenestration area lies and whether it
makes sense, considering the particular shape of the patient’s
thyroid cartilage. If the surgeon has any doubts, the landmark
points must be double-checked.
Removing of the cartilage window is performed with a
cold knife if the cartilage is soft, and with a three-tooth saw
if it is calcied. The cartilage window is elevated en bloc
with an elevator (Fig.6.13). To preserve the thyro-arytenoid
muscle, the inner perichondrium should preferably be preserved, although the insertion of measuring devices (or dummies) will mostly require its incision.
The measuring devices are gradually inserted in the fenestration whilst the patient is asked to phonate. The size of
the implant corresponds to the “dummy” that offers the best
voice. The implant is eventually inserted within the window
by squeezing the middle plate of the implant with the implant
inserter (Figs.6.14 and 6.15).
The implant is self-anchoring. The stability of the implant
is assessed by asking the patient to cough and swallow. When
in doubt regarding the stability of the implant, the surgeon
can secure the implant by stitching it to the cartilage with a
2.0 Prolene nylon. The wound is then closed in three layers,
leaving a small suction drain in place.
Fig. 6.14 The measuring devices are gradually inserted in the fenestration whilst the patient is asked to phonate
implant
Thumb pressure
Fig. 6.15 The implant is eventually inserted within the window by
squeezing the middle plate of the implant with the implant inserter
incision
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6.2.3 Non-selective Reinnervation Using
anAnsa Cervicalis Nerve Transfer
6.2.3.1 Indications
Non-selective reinnervation can be considered in cases of
persistent hoarseness or voice problems after paralysis of the
recurrent laryngeal nerve (RLN). Spontaneous nerve regeneration and reinnervation often occurs after nerve injury, but
not always with return of function [26–28]. A maximal delay
between the time of paralysis and the moment of reinnervation is generally taken to be 2 years, although there are
reports suggesting that reinnervation can still be feasible
after longer delays [29–31].
When RLN paralysis is due to injury to the nerve, such as
accidental cutting of the nerve or resection of part of the
nerve for oncological reasons, reanastomosis of the nerve in
the acute phase is an option, but non-selective reinnervation
such as reanastomosis or a nerve transfer with the ansa cervicalis or the hypogossal nerve to the distal stump of the RLN
will not lead to recovery of vocal fold motion. Nerve regeneration leads to synkinesis of adductor and abductor muscle
groups. In RLN–RLN reanastomosis, there is even a chance
of paradoxical or unfavourable movement resulting in voice
problems [26, 27]. Using the ansa cervicalis, this adverse
activity does not occur. Tonus and a medial position of the
formerly paralysed vocal fold (and possibly a more appropriate height of the vocal fold) may be achieved, resulting in
voice improvement [32]. If the ipsilateral ansa cervicalis is
not available, an anastomosis can be performed using the
contralateral ansa hypoglossi, provided there is enough
length.
Non-selective reinnervation using an ansa cervicalis nerve
transfer is a good option in children, for whom implants in a
growing larynx are markedly unfavourable, but re- innervation
takes several months before voice improvement is achieved
[29–33]. Temporary injection laryngoplasty with hyaluronic
acid or fat can ameliorate the waiting period.
A selective reinnervation procedure could also be considered for reinnervation of only the adductor muscles. Good
voice results have been reported using nerve muscle pedicle
technique [34] and later the muscle-nerve-muscle technique
[35, 36]. Excellent results also have been reported after
selective adductor re-innervation with the ansa cervicalis in
patients with spasmodic dysphonia [37, 38].
Electromyography (EMG) of the adductor muscles (and
preferably also of the abductor muscles) should be performed
bilaterally before surgery. If no activity is seen or denervation potentials are encountered, there is probably extensive
atrophy of the muscles and a re-innervation procedure is not
likely to result in their re-innervation, and the procedure
should not be performed. Instead, alternative treatment
options should be sought.
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Size of skin
Fig. 6.16 A horizontal incision is made at the lower border of the cricoid cartilage
6.2.3.2 Surgical Technique
As the ansa cervicalis is readily available, adverse effects of
using this nerve are limited, and good results have been
reported, the non-selective re-innervation procedure with the
ansa cervicalis is described here.
The patient is under general anaesthesia. A roll is placed
under the shoulders and the head is extended in a neutral
position. The surgical area is prepped and draped.
A horizontal incision is made at the level of the lower
border of the cricoid cartilage and extended about 5cm laterally along a horizontal skin crease (Figs.6.16 and 6.17).
The platysma is divided and the fascia is incised along the
anterior edge of the sternocleidomastoid muscle; the ansa
cervicalis may be crossing horizontally beneath it. The jugular vein is identied. The ansa is searched for; it can be found
traversing the jugular vein or along the posterior aspect of
the omohyoid muscle (Fig.6.18). When identied (by electrical stimulation), the ansa cervicalis is divided just proximal to the omohyoid branch.
The recurrent laryngeal nerve (RLN) is looked for next. A
hook is placed around the posterior aspect of the thyroid cartilage just superior to the cricothyroid (CT) joint. The hook
is pulled anteriorly, thereby rotating the larynx. The pharygeal
constrictor muscle is divided on the posterior edge of the
thyroid ala and the piriform sinus is retracted. The RLN is
found behind the CT joint and should be followed for several
centimetres inferiorly. The ansa cervicalis is divided just
proximal to the omohyoid branch.
The proximal stump is transferred to the oesophageal
laryngeal groove by forming a tunnel under the omohyoid
and sternothyroid muscles. After measuring the appropriate
length of the RLN, allowing a tension-free anastomosis, it is
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