Revision Gore-Tex Medialization Laryngoplasty

Safety and Adverse Events of Medialization Thyroplasty: A Systematic Review

INTRODUCTION

Unilateral vocal fold paralysis or paresis (UVFP) is a condition that causes significant morbidity due to dysphonia, dysphagia, and aspiration. Type I medialization thyroplasty (MT) is the current mainstay surgical treatment for UVFP. Though widely considered a safe procedure, concerns exist over possible airway complications which can lead to overnight observation. Herein, we report a systematic review of the safety and adverse events of MT to aid in determining the safety of same-day discharge.

DATA SOURCES

PubMed and Embase databases.

REVIEW METHODS

Our search identified studies investigating complications associated with MT. Articles were selected if published between January 1, 1989 and March 15, 2023. Abstracts were screened, and data were extracted from included studies. Only Type I MT procedures were included; case reports were excluded. Participant characteristics, intervention details, results, and adverse events were extracted.

RESULTS

The database query identified 751 abstracts, of which 46 studies met eligibility criteria. A total of 2426 patients underwent MT. The most common implant was Silastic (n = 898, 37.0%) followed by Gore-Tex (n = 664, 27.4%). There were 254 (10.5%) total complications reported; 110 (4.5%) were considered major. The most common complication was nonobstructive hematoma (n = 59, 2.4%) followed by hemorrhage (n = 36, 1.5%). Implant extrusion (n = 24, 0.99%) or displacement (n = 15, 0.62%) occurred mostly in Silastic and Gore-Tex implants. Same-day discharge occurred with 429 patients and was not associated with adverse events.

CONCLUSIONS

UVFP can be reliably improved by MT with a low risk of complications. Outpatient MT is a promising treatment with a favorable safety profile. Laryngoscope, 134:1994-2004, 2024.

An Integrated Experimental-Computational Study of Vocal Fold Vibration in Type I Thyroplasty

Subject-specific computational modeling of vocal fold (VF) vibration was integrated with an ex vivo animal experiment of type 1 thyroplasty to study the effect of the implant on the vocal fold vibration. In the experiment, a rabbit larynx was used to simulate type 1 thyroplasty, where one side of the vocal fold was medialized with a trans-muscular suture while the other side was medialized with a silastic implant. Vocal fold vibration was then achieved by flowing air through the larynx and was filmed with a high-speed camera. The three-dimensional computational model was built upon the pre-operative scan of the laryngeal anatomy. This subject-specific model was used to simulate the vocal fold medialization and then the fluid-structure interaction (FSI) of the vocal fold. Model validation was done by comparing the vocal fold displacement with postoperative scan (for medialization), and by comparing the vibratory characteristics with the high-speed images (for vibration). These comparisons showed the computational model successfully captured the effect of the implant and thus has the potential for presurgical planning.

Long-term Outcome of Autologous Lipoinjection Medialization Laryngoplasty versus Type I Thyroplasty

Glottic insufficiency is incomplete or soft closure of the true vocal folds during phonation and is a common cause of dysphonia. Treatment includes voice therapy, type I thyroplasty, vocal fold injection augmentation (with materials such as autologous fat), arytenoid cartilage repositioning, or a combination of treatment modalities. The present study aimed to compare long-term outcomes of lipoinjection medialization with type I thyroplasty for patients with glottic insufficiency.

METHODS

Adult voice center patients who had undergone surgical vocal fold medialization with autologous lipoinjection or with type I thyroplasty for glottic insufficiency were included in this retrospective study. The primary outcome measures were the need for further medialization surgery and improvement in the glottic gap.

RESULTS

There were 172 subjects included in this study: 100 subjects underwent type I thyroplasty and 72 subjects underwent autologous lipoinjection medialization. Neither age nor gender differed significantly between thyroplasty and lipoinjection groups. The rate of further medialization surgery did not differ significantly between thyroplasty and lipoinjection groups, but further medialization surgery was performed longer after the initial operation in the thyroplasty group Baseline glottic gap did not differ significantly between thyroplasty and lipoinjection groups. When improvement from baseline was compared between thyroplasty and lipoinjection subjects, the improvement from baseline was similar for both groups at 6 months and at 12 months. Voice handicap index scores improved significantly after thyroplasty or after lipoinjection, and the improvement from baseline was similar in both cohorts.

CONCLUSION

Both autologous lipoinjection medialization and type I thyroplasty provide effective medialization for patients with glottic insufficiency. Both techniques yield similar reoperation rates, and the benefit of surgery appears to last for at least 1 year for most patients.

Subject-Specific Modeling of Implant Placement for Type I Thyroplasty Surgery

Type I thyroplasty is widely used to improve voice production in patients affected by unilateral vocal fold paralysis. Almost two-thirds of laryngologists report using Silastic® implants to medialize the vocal fold, with implant size, shape, and location determined experientially. However, post-surgical complications arising from this procedure (extrusion, migration, resizing) necessitate revision in 4.5-16% of patients. To improve initial surgical outcomes, we have developed a subject-specific modeling tool, PhonoSim, which uses model reconstruction from MRI scans to predict the optimal implantation location. Eleven vocal fold sample sides from eight larynges of New Zealand white rabbits were randomized to two groups: PhonoSim informed (n = 6), and control (no model guidance, n = 5). Larynges were scanned ex vivo in the abducted configuration using a vertical-bore 11.7 T microimaging system, and images were used for subject-specific modeling. The PhonoSim tool simulated vocal fold adduction for multiple implant location placements to evaluate vocal fold adduction at the medial surface. The best implant placement coordinates were output for the 6 samples in the PhonoSim group. Control placements were determined by the same surgeon based on anatomical landmarks. Post-surgical MRI scans were performed for all samples to evaluate medialization in implanted vocal folds. Results show that PhonoSim-guided implantation achieved higher vocal fold medialization relative to controls (28 to 55% vs. - 29 to 39% respectively, in the glottal area reduction), suggesting that this tool has the potential to improve outcomes and revision rates for type I thyroplasty.

Options for treatment of a small glottic gap

Background

Glottic insufficiency, or glottic gap as it is commonly called, is a common cause of dysphonia, producing symptoms of soft voice, decreased projection, and vocal fatigue. The etiology of glottic gap can occur from issues related to muscle atrophy, neurologic impairment, structural abnormalities, and trauma related causes. Treatment of glottic gap can include surgical and behavioral therapies or a combination of the two. When surgery is chosen, closure of the glottic gap is the primary goal. Options for surgical management include injection medialization, thyroplasty, and other methods of medializing the vocal folds.

Methods

This manuscript reviews the current literature regarding the options for treatment of glottic gap.

Discussion

This manuscript discusses options for treatment of glottic gap, including the indications for temporary and permanent treatment modalities; the differences between the available materials for injection medialization laryngoplasty and how they affect the vibratory function of the vocal folds and vocal outcome; and the evidence that supports an algorithm for treatment of glottic gap.

Level of Evidence

3a-Systematic review of case-control studies.

Treatment of relapsing functional and organic dysphonia: a narrative literature review

Information about failure and relapses is critical in deciding whether and how to treat a given condition, as well as during patient counselling before therapy. This paper aims to perform a non-systematic review of relapses and failure of dysphonia treatment in the adult population. Studies on failure and relapses after treatment of benign vocal fold lesions, functional dysphonia and neurogenic dysphonia were analysed. The frequency and the duration of follow-up were heterogeneous, and the management of relapses was reported in only a portion of the studies. Relapses after surgical treatment of benign vocal fold lesions ranged between 1% and 58% of cases, and their management was mainly surgical. Rates of relapse after voice therapy for functional dysphonia and spasmodic dysphonia were 12%-88% and 8%-63%, respectively. Rates of relapse after surgical treatment for unilateral and bilateral vocal fold paralysis were 10%-39% and 6%-25%, respectively; treatment was mainly represented by surgical revision. In conclusion, failure and relapses of functional and organic dysphonias after therapy are not rare, but treatment modalities are seldomly reported. The data from this non-systematic review stresses the need for further research in this area.

Intraoperative computed tomography imaging for laryngoplasty

OBJECTIVES

Intraoperative cone beam computed tomography (CBCT) imaging has the potential to facilitate the surgical procedure. The current preliminary retrospective chart review investigated the benefits of intraoperative CBCT during laryngoplasty.

METHOD

This study examined 26 cases that underwent intraoperative CBCT imaging during laryngoplasty, with one patient who counted twice due to first and revision surgery. The visual quality of structures of interest (glottal shape, thyroid cartilage, arytenoid cartilage, and implants) was determined using intraoperative CBCT during laryngoplasty. Each patient also underwent an aerodynamic assessment.

RESULTS

CBCT provided unique information, such as surgical landmarks in severe scarring, the subglottal shape, and the rotation angle of the arytenoid cartilage during arytenoid adduction. Nonetheless, 26.9% (7 of 26) of cases were affected by motion artifact, due to the long acquisition time. When motion artifact-negative cases were evaluated, 100% of glottal shape and more than 89% of thyroid cartilage were well visualized. All arytenoids were well-visualized in patients ≥ 50 years of age and without motion artifact, while CBCT failed to visualize the arytenoids in 2 of 4 patients who were < 50 years, due to the lack of calcifications. After medialization surgery, the yields of improved maximal phonation times (MPTs) in the motion artifact-negative and -positive groups were 8.7 sec and 3.4 sec, respectively (p = 0.032; Welch's t test). This comparison indicates intraoperative CBCT would contribute in MPT improvement, if CBCT is taken in measurable quality.

CONCLUSION

The potential benefits of intraoperative CBCT during laryngoplasty were demonstrated. A corollary, prospective study is warranted to further confirmation.

Medialization Laryngoplasty: A Review for Speech-Language Pathologists

Purpose The purpose of this study is to familiarize speech-language-pathologists with the current state of the science regarding medialization laryngoplasty in the treatment of voice disorders, with emphasis on current evidence-based practice, voice outcomes, and future directions for research. Method A literature review was performed in PubMed and Embase using the keywords vocal fold/cord and laryngoplasty, thyroplasty, augmentation, or laryngeal framework. Articles published between 2010 and 2020 were reviewed for data about clinical applications, technical approach, voice-related outcomes, and basic science or clinical innovations with the potential to improve patient care. A synthesis of data was performed from articles meeting the outlined search criteria. Conclusions As key members in the multidisciplinary care of voice disorders, speech-language pathologists need to be informed of current research in medialization laryngoplasty, a procedure commonly used for patients with glottic insufficiency. Advances in anesthetic technique, office-based procedures, and the development of materials with increased bio-tolerability over the past decade have led to innovations in treatment and improved patient outcomes. Recent applications of computational and bioengineering approaches have the potential to provide new directions in the refinement of currently available techniques and the improvement of patient-based treatment outcomes.

Numerical and experimental investigations on vocal fold approximation in healthy and simulated unilateral vocal fold paralysis

We have developed a novel surgical/computational model for the investigation of unilateral vocal fold paralysis (UVFP) which will be used to inform future in silico approaches to improve surgical outcomes in type I thyroplasty. Healthy phonation (HP) was achieved using cricothyroid suture approximation on both sides of the larynx to generate symmetrical vocal fold closure. Following high-speed videoendoscopy (HSV) capture, sutures on the right side of the larynx were removed, partially releasing tension unilaterally and generating asymmetric vocal fold closure characteristic of UVFP (sUVFP condition). HSV revealed symmetric vibration in HP, while in sUVFP the sutured side demonstrated a higher frequency (10 - 11%). For the computational model, ex vivo magnetic resonance imaging (MRI) scans were captured at three configurations: non-approximated (NA), HP, and sUVFP. A finite-element method (FEM) model was built, in which cartilage displacements from the MRI images were used to prescribe the adduction and the vocal fold deformation was simulated before the eigenmode calculation. The results showed that the frequency comparison between the two sides were consistent with observations from HSV. This alignment between the surgical and computational models supports the future application of these methods for the investigation of treatment for UVFP.

A retrospective analysis of revision framework surgeries for unilateral vocal fold paralysis

INTRODUCTION

Revision framework surgeries might be required for unilateral vocal fold paralyses. However, outcomes and indications of revision surgeries have not been adequately documented. For a better understanding of indications for the procedure and to help in achieving better vocal outcomes, we performed a retrospective chart review of patients who underwent revision framework surgeries for unilateral vocal fold paralysis.

OBJECTIVES

This study aimed to present clinical features of patients who underwent revision framework surgeries for the treatment of unilateral vocal fold paralysis.

METHODS

Of the 149 framework surgeries performed between October 2004 and October 2019, 21 revision framework surgeries were performed in 19 patients. Self-assessments by patients using the voice handicap index-10 questionnaire, and objective aerodynamic and acoustic assessments performed pre- and post-operatively were analyzed using the Wilcoxon's signed-rank test for paired comparisons.

RESULTS

Undercorrection was indicated as reasons for revision surgeries in all cases. The revision techniques included type I thyroplasty, type IV thyroplasty, and arytenoid adduction, and revision surgeries were completed without any severe complication in all cases. Pre- and post-operative voice handicap index-10 scores were obtained in 12 cases, and other parameters were evaluated in 18 cases. Significant improvements were observed in voice handicap index-10 scores, maximum phonation time, mean flow rate, Current/Direct Current ratio, and pitch perturbation quotient.

CONCLUSION

Undercorrection was observed in all patients who underwent revision framework surgeries for unilateral vocal fold paralysis, and the initial assessment and planning are thought to be important in order to avoid revision surgeries. Revision surgeries were performed safely in all cases, and significantly improved vocal outcomes were observed, even after multiple procedures. Revision surgery should be considered for patients with unsatisfactory vocal functions after primary framework surgeries for unilateral vocal fold paralysis.

Gore-Tex implant extrusion following revision medialization thyroplasty: Case report and review of the literature

OBJECTIVE

To review current literature and experience with Gore-TexⓇ implant extrusion following medialization thyroplasty, as well as to report the unique case of Gore-TexⓇ implant extrusion following revision medialization thyroplasty.

METHODS

Review of existing literature and description of personal experience with unique case of Gore-TexⓇ implant extrusion following revision medialization thyroplasty.

RESULTS

Review of existing literature found no prior reported cases of Gore-TexⓇ implant extrusion following revision medialization thyroplasty. Risk factors for implant extrusion include the pressure of the implant on insertion and the inability to secure the implant. Cases of implant extrusion can be managed operatively via an endoscopic or via an external open approach.

CONCLUSION

This is the first reported case of Gore-TexⓇ implant extrusion following revision medialization thyroplasty. Careful consideration should be given in revision medialization thyroplasty as additional implant material may cause increased pressure, a risk factor for implant extrusion.

Strap Muscle Type I Thyroplasty After Gore-Tex Implant Extrusion: Case Report and Literature Review

OBJECTIVES

To discuss the presentation and management techniques of implant extrusion following type I thyroplasty and to illustrate the potential of strap muscle for augmentation following implant removal.

METHODS

We report a unique case of a patient with late Gore-Tex implant extrusion after type I thyroplasty treated with removal and autologous strap muscle graft for augmentation.

RESULTS

A 41-year-old female nearly 3.5 years status post Gore-Tex type I thyroplasty for left vocal fold paralysis presented for evaluation of dysphonia. Upon flexible laryngoscopy, erythema, edema, and granulation tissue were identified at the left vocal fold and ventricle. The patient subsequently underwent removal of her implant. Intraoperatively, a free portion of sternothyroid muscle was dissected free and placed into the paraglottic space. One month following surgery, the patient reported an improvement in her Voice Handicap Index (VHI) score from 40 to 0. In addition, no major complications were observed and complete glottic closure was achieved. Nine months postsurgery, she continued to function well with a VHI score of 0. At 50 months postop, the patient still reports a VHI score of 0.

CONCLUSIONS

Implant extrusion is a rare complication of type I thyroplasty usually occurring in the first few months after surgery and more commonly presenting in females. Current management options consist of observation or augmentation with autologous fat or vocal fold injection following implant removal. This is the first report of a successful strap muscle free graft revision thyroplasty following implant extrusion. The patient's excellent long-term outcome highlights the potential of strap muscle augmentation as a feasible management option for implant extrusion.

Revision Transcervical Medialization Laryngoplasty for Unilateral Vocal Fold Paralysis

Objective

To identify patterns of failure following transcervical medialization laryngoplasty for unilateral vocal fold paralysis and describe indications and revision techniques for optimal vocal outcomes.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

Thirty-nine consecutive patients between January 2005 and April 2014 undergoing transcervical revision of failed primary medialization laryngoplasty were identified. Demographics, etiology, stroboscopic assessment, and surgical techniques were recorded. Patient self-assessment using the Voice-Related Quality-of-Life (VRQOL) questionnaire and objective acoustic and aerodynamic assessments performed pre- and postoperatively were analyzed using t tests for paired comparisons.

Results

Thirty-nine patients underwent 48 transcervical revision surgeries. Median follow-up was 14.6 months from time of final revision surgery. Indications included anterior glottic incompetence (38/48, 79%), posterior glottic incompetence (20/48, 42%), glottic overclosure (8/48, 17%), and/or decreased phonatory pliability (12/48, 25%). A combination of findings was present in 21 (44%) surgeries. Revision techniques included either anterior augmentation, arytenopexy, and cricothyroid subluxation (alone or in combination) in 46 of 48 (96%) patients or partial implant removal alone in 2 patients. Seven patients (18%) required multiple revisions. A complete set of voice parameters was available for 22 patients, and statistically significant improvements included VRQOL scores, fundamental frequency in females, jitter, noise-to-harmonic ratio, and mean airflow rate.

Conclusion

Patterns of failure in patients with suboptimal phonatory function after transcervical medialization laryngoplasty included persistent glottic incompetence, glottic overclosure, and decreased vocal fold pliability. Revision transcervical medialization surgery, guided by individualized consideration of vocal fold position and surface pliability, can improve phonatory outcomes.

Computed tomographic assessment of the causal factors of unsuccessful medialization thyroplasty

CONCLUSION

The present results demonstrate that a small implant size, undercorrection of the vocal fold, antero-posterior implant malposition, and the use of expanded polytetrafluoroethylene (ePTFE) are the primary factors that cause a poor outcome of medialization thyroplasty (MT).

OBJECTIVES

To assess the postoperative laryngeal condition using computed tomography (CT) in patients with unilateral vocal fold paralysis who underwent MT alone, and to identify the primary causal factors in terms of the surgical procedures that affect the outcomes of MT.

METHODS

Twenty-two patients who underwent MT alone were divided into two groups based on either the maximal phonation time or the perceived vocal breathiness. Two laryngologists assessed the postoperative laryngeal CT images during sustained vowel phonation and judged whether there were abnormalities of the arytenoid cartilage position, window position, implant size, and implant position, as well as the degree of correction of the vocal fold. As implant material, a silicone block, ePTFE, and hydroxyapatite had been inserted in 2, 9, and 11 patients, respectively. Comparisons of the prevalence of abnormalities in the abovementioned factors between the different outcomes and between the types of material used for the implant were performed.

RESULTS

Twelve patients with a poor outcome and 10 with a good outcome showed 36 and 18 abnormal findings identified by either of the two laryngologists, respectively. In the poor outcome group, a smaller implant size and undercorrection of the vocal fold showed both high kappa values and a significantly higher prevalence than those in the good outcome group (p < 0.001 and p < 0.05), respectively. The comparison between material types demonstrated that the sheet-like material (ePTFE) group exhibited a significantly higher prevalence of undercorrection than the block-like material group (p < 0.05).

Voice Outcome after Gore-Tex Medialization Thyroplasty

Introduction Although medialization thyroplasty utilizing Gore-Tex (Gore and Associates, Newark, Delaware, United States) has been discussed in the literature, few reports have assessed voice quality afterward, and they did not use a full assessment protocol.

Objective To assess the improvement in voice quality after medialization thyroplasty utilizing Gore-Tex in patients with glottic insufficiency of variable etiology.

Methods Eleven patients with glottic insufficiency of different etiologies that failed compensation were operated by type 1 thyroplasty utilizing Gore-Tex. Pre- and postoperative (1 week, 3 months, and 6 months) voice assessment was done and statistical analysis was performed on the results.

Results In all postoperative assessments, there was significant improvement in the grade of dysphonia (p < 0.004) and highly significant reduction in the size of glottic gap and prolongation of maximum phonation time (p < 0.0001). The difference in voice parameters in the early (1 week) and the late (3 and 6 months) postoperative period was not significant. None of the patients developed stridor or shortness of breath necessitating tracheotomy, and there was no implant extrusion in any patient during the study period.

Conclusion Gore-Tex medialization provides reliable results for both subjective and objective voice parameters. It leads to a satisfactory restoration of voice whatever the etiology of glottic incompetence is. This technique is relatively easy and does not lead to major complications. Further studies with larger number of patients and more extended periods of follow-up are still required to assess the long-term results of the technique regarding voice quality and implant extrusion.

Lack of Adverse Events after Medialization Laryngoplasty with the Montgomery Thyroplasty Implant in Patients with Unilateral Laryngeal Nerve Paralysis

Objectives:

We sought to document the incidence of and risk factors for adverse events after medialization laryngoplasty with Montgomery implant insertion in patients with unilateral laryngeal nerve paralysis.

Methods:

We studied a retrospective series of 191 patients consecutively managed at a university teaching hospital.

Results:

No adverse events were noted in 79.8% of the patients. Intraoperative, immediate, and late postoperative adverse events were noted in 8.3%, 8.9%, and 4.1% of the patients, respectively. The various adverse events noted were failure to insert the implant (3.6%), difficulties in stabilizing the implant (4.8%), misplacement of the implant (2.1%), dyspnea (2.7%), hematoma (4.8%), extrusion (1.6%), persistent morphological laryngeal alterations (1.6%), and keloid scars (1.1%). Tracheotomy, procedure-related death, and infection at the insertion site were not encountered. No significant statistical relationship was noted between the various adverse events encountered and the variables under analysis.

Conclusions:

Our data demonstrate that medialization laryngoplasty with Montgomery implant insertion in patients with unilateral laryngeal nerve paralysis from various causes is a relatively safe, reliable, and reproducible procedure with a short learning curve.

Laryngoscopy of vocal fold paralysis: evaluation of consistency of clinical findings

OBJECTIVES/HYPOTHESIS

Laryngoscopy is the principal tool for the clinical assessment of vocal fold paralysis (VFP). Yet no consistent, unified vocabulary to describe laryngoscopic findings exists, compromising the evaluation and comparison of cases, outcomes, and treatment. The goal of this investigation was to evaluate laryngoscopic findings in VFP for inter- and intra-rater consistency.

STUDY DESIGN

Prospective survey-based study.

METHODS

Half-minute excerpts from stroboscopic exams of 22 patients with VFP were mailed to 22 fellowship-trained laryngologists. Each reviewer was sent exams in randomized order, with three random repeats included to determine intra-rater reliability. Twelve laryngoscopic criteria were assessed and recorded on preprinted sheets. Eleven criteria were binary in nature (yes/no); glottic insufficiency was rated on a four-point scale (none/mild/moderate/severe). Raters were blinded to clinical history, each other's ratings, and to their own previous ratings. Inter-rater agreement was calculated by Fleiss' kappa.

RESULTS

Twenty reviewers (91%) replied. Intra-rater reliability by reviewer ranged from 66% to 100% and by laryngoscopic criterion from 77% to 100%. Of the laryngoscopic criteria used, glottic insufficiency (kappa = 0.55), vocal fold bowing (kappa = 0.49), and salivary pooling (kappa = 0.45) showed moderate agreement between reviewers. Arytenoid stability (kappa = 0.1), arytenoid position (kappa = 0.12), and vocal fold height mismatch (kappa = 0.12) showed poor agreement. The remainder showed slight to fair agreement.

CONCLUSIONS

Inter-rater agreement on commonly used laryngoscopic criteria is generally fair to poor. Glottic insufficiency, vocal fold bowing, and salivary pooling demonstrated the most agreement among responding laryngologists. These findings suggest a need for a standardized descriptive scheme for laryngoscopic findings in VFP.

Office-based injection laryngoplasty in the irradiated larynx

OBJECTIVES/HYPOTHESIS

To review the clinical results of office-based injection laryngoplasty with two different therapeutic materials in patients with vocal fold paralysis and history of radiation therapy to the larynx.

STUDY DESIGN

Retrospective study.

METHODS

Chart review of 11 patients who underwent office-based injection laryngoplasty with calcium hydroxylapatite or micronized Alloderm. All patients had a history of radiation therapy to the neck, with the larynx included in the radiation field. Voice analyses, clinical outcomes, and complications were reviewed. Efficacy of the procedure was evaluated by comparing pre- and postinjection mean phonation time (MPT) results from voice analysis data.

RESULTS

A total of 15 injections were performed in 11 patients with vocal fold paralysis (one females, 10 males, mean age 62 years). Data from voice analyses before and after the procedure were available for nine injections. The MPT was significantly increased among patients undergoing the procedure (P < .05). All procedures were successful, and only one self-limited complication was reported.

CONCLUSIONS

Office-based injection laryngoplasty is a safe procedure with acceptable clinical results in patients with vocal fold paralysis who have a history of radiation therapy to the larynx.

Evaluation of open approach and injection laryngoplasty inrevision thyroplasty procedures

INTRODUCTION: Vocal outcomes after medialization laryngoplasty are variable and may change over time. A revision procedure via open approach or an injection laryngoplasty may be necessary to improve vocal outcomes.

METHODS: A retrospective chart review was performed.

RESULTS: Twenty-nine subjects were identified and stratified into group 1A (n = 9) if the allograft was repositioned/replaced, group 1B (n = 4) if the allograft was removed, and group 2 (n = 16) if an injection laryngoplasty was performed. Statistically significant differences were found between all data prerevision to postrevision ( P ≤ 0.05) for group 1A and group 2 when multiple paired-sample t tests were calculated for patient-reported voice severity ratings and voice impact ratings as well as clinician-reported voice ratings of grade, roughness, and breathiness. Results of group 2 were often temporary, with 10 of 16 (62.5%) subjects receiving multiple injections.

CONCLUSION: Both open revision laryngoplasty and injection laryngoplasty are successful at providing improved vocal outcomes. Results are often temporary after injection laryngoplasty and often require multiple procedures.

Medialization Laryngoplasty With Gore-Tex: An Animal Study

Vocal cord paralysis is a disease that can cause voice disability and aspiration problems. Expanded polytetrafluoroethylene (ePTFE; Gore-Tex) has been widely used in cardiovascular and plastic surgery; however, its biocompatibility and safety have not been established precisely in the larynx. In this study, the biocompatibility and safety of ePTFE used in vocal cord medialization in the rabbit larynx were assessed. Type 1 thyroplasty with Gore-Tex was performed on one side of the larynx in eight rabbits. A sham procedure was applied on the contralateral side of their larynx. The rabbits were sacrificed after 6 months, and macroscopic and microscopic evaluations and comparisons were performed. No significant inflammatory response to Gore-Tex or displacement of the implant was seen. There was only a tiny fibrotic capsule surrounding the material in each specimen. Intense eosinophilic cell infiltration was seen surrounding one rabbit specimen. Gore-Tex seems to be a biocompatible, stable, and reversible material that can be safely used in laryngeal framework surgery.

Histopathologic study of minced and injected expanded polytetrafluoroethylene (Gore-Tex) in quadriceps muscle of rats for injection laryngoplasty

OBJECTIVE

Gore-Tex has not yet been used as an injection material, and no animal study has been performed. The purpose of this study was to investigate the histopathological and volumetric changes of minced and injected expanded polytetrafluoroethylene (Gore-Tex) in the quadriceps muscle of rats to find out its possibility as an injection material in future injection laryngoplasty.

DESIGN

A prospective study was performed in 13 Wistar rats.

METHODS

The 50+/-5 mg Gore-Tex vascular graft was minced until it was fine enough to pass through a 16G injection cannula. To create viscosity in order to avoid precipitation, minced Gore-Tex was mixed with sodium hyaluronate (SH) gel. 0.5 ml of this mixture was injected into the middle part of the right quadriceps muscle of each subject. Then, pure SH (0.5 ml) was injected into the middle part of the left quadriceps muscle of each subject. To compare the volumetric and histopathological changes of the injection area occupied by the materials over the time, two rats were sacrificed 1 day after the procedure, four rats after 1 month, four rats after 3 months and three rats after 6 months.

RESULTS

In pure SH: SH was observed as an effusion in the muscle of one subject on the first day only. We did not detect SH in the muscle in the first, third and sixth months and, as a result, there was no augmentation. Inflammation and fibrosis was not detected in any of these applications of SH. In minced Gore-Tex+SH gel mixture: SH was again eliminated from the muscle in a very short period of time, but the remaining Gore-Tex created a 15.8% volumetric gain. Fibrosis and capsule formation began in the first month and, in the sixth month; we observed connective tissue surrounding the Gore-Tex material. Ingrowth of connective tissue into the Gore-Tex, though not present in the first month, occurred partially in the third and significantly in the sixth month. In addition, we observed foreign body granuloma formation after the third month.

CONCLUSIONS

Pure SH, though easily applicable, was immediately eliminated leaving no trace. In the relatively difficult applications of Gore-Tex mixed with SH, however, there was residual Gore-Tex present in all subjects throughout the study. Gore-Tex may be an applicable material for injection laryngoplasty.

Endoscopic Management of Extruding Medialization Laryngoplasty Implants

BACKGROUND

Medialization laryngoplasty (ML) is a commonly performed procedure for vocal fold motion impairment with glottic incompetence. Although implant extrusion is a well-known risk of ML, management of this complication is rarely mentioned in the literature. The aim of this study was to review our experience with endoscopic implant retrieval for a group of patients with extruding ML implants.

METHODS

All patients identified in our institution from January 1989 through August 2004 with a history of ML and extruded implants were identified. Case management was reviewed, including information on presentation, management techniques, and outcomes.

RESULTS

Five patients presented with extruding ML (Gore-Tex [n = 2] or silastic [n = 3]) implants. All patients presented with worsening dysphonia and evidence of fullness and/or granulation tissue at the extrusion site. Endoscopic removal was performed using either sharp dissection or CO2 laser dissection. After removal, four patients underwent vocal fold injection augmentation.

CONCLUSIONS

Endoscopic removal appears to be a safe, effective, and even preferred alternative to external transcervical removal in selected cases of extruding implants.