Medialization thyroplasty using autologous nasal septal cartilage for treating unilateral vocal fold paralysis

Active and Passive Bioimplants for Vocal Fold Paralysis

Vocal fold paralysis is one of the diseases that particularly affect quality of life. While unilateral paralysis leads to glottis closure insufficiency and hoarseness, bilateral paralysis compromises respiration and limits the exercise tolerance. Bioimplants have been used to treat persistent paralysis for over 100 years. The spectrum ranges from autologous tissue transfer and resorbable or permanent injection materials to composite thyroplasty implants and active electrical implants for neurostimulation of the larynx. If bioimplants are used in accordance with the recommendations, the quality of life of affected patients can be significantly improved today.

The Utility of Strap Muscle in Complex Type I Thyroplasties

INTRODUCTION

Type I thyroplasty is a common procedure used to improve dysphonia secondary to glottic insufficiency caused by vocal fold paralysis, paresis, or bowing. Revision often involves more complex procedures that can be complicated by mucosal violation, hemorrhage, infection, and shifted or extruded implants. Intraoperative challenges can be managed successfully using autologous strap muscle rotation flaps.

OBJECTIVES

Review vocal fold medialization with strap muscle as a viable option for thyroplasty, particularly operations with inadvertent mucosal disruption.

METHODS

All operative records of the senior author's 30-year experience were queried for modified, complex, or revision type I thyroplasties. Each of these was reviewed, and only those utilizing autologous strap muscle rotation flaps for vocal fold medialization were included. Changes in voice quality were assessed using strobovideolaryngoscopic assessment of glottic closure and Voice Handicap Index-10 (VHI-10) scores when available.

RESULTS

Seven patients were found to have undergone eight type I thyroplasty using autologous strap muscle flaps. Improved glottic closure was seen in all patients except one. This patient, complicated by a laryngeal fracture of unknown origin discovered at the time of surgery, had worse voice with strap muscle implantation intraoperatively; therefore, the patient's fracture was reduced, and medialization was postponed. All other patients reported improved voice quality both intra- and postoperatively. Pre- and postoperative VHI-10 scores were available for two of the seven cases with successfully implanted strap muscles. A decrease in VHI-10 was observed in both cases (mean = 11). No postoperative complications occurred in any patient.

CONCLUSION

Although revision thyroplasties are relatively rare, they can be challenging. The seven cases presented herein illustrate the successful and safe use of autologous strap muscle rotation flaps for complex, revision type I thyroplasty procedures. They are particularly helpful in cases requiring additional soft tissue between the thyroid cartilage and mucosa in preparation for possible future medialization after Gore-Tex or Silastic implants, and for inadvertent mucosal disruption in which using a foreign implant might pose a risk of infection. Future studies should be performed with larger populations and longer follow-up to confirm the efficacy and safety of this procedure.

Autologous thyroid cartilage graft implantation in medialization laryngoplasty: a modified approach for treating unilateral vocal fold paralysis

Medialization laryngoplasty is the standard surgical treatment for unilateral vocal fold paralysis. This study presents a modified approach in which a thyroid cartilage graft is implanted in medialization laryngoplasty. 22 patients who underwent this approach were included in the study. The results revealed that glottal incompetence and vocal performance were markedly improved following surgery, and the follow-up period ranged from 6 to 74 months (mean, 21.4 months). Acoustic analysis revealed significant improvements in the maximum phonation time (from 3.51 to 7.89 seconds, p < 0.001), F0 (from 221.7 to 171.0 Hertz, p = 0.025), and jitter (from 7.68 to 3.19, p < 0.001). Perceptual assessment revealed a significant decrease in voice grading (from 2.59 to 1.41, p < 0.001), roughness (from 1.82 to 1.23, p = 0.004), and voice breathiness (from 2.55 to 1.23, p < 0.001). None of the patients exhibited severe wound infection, tissue rejection, or other complications attributed to the surgical procedure. In conclusion, autologous thyroid cartilage implantation in medialization laryngoplasty medializes the vocal cord, minimizes the glottal gap, and improves the voice of patients with vocal fold paralysis. This procedure is characterized by simplicity, safety, and acceptable results.

Vocal fold medialization with tragal cartilage and perichondrium in high vagal paralysis

The goal of this pilot study was to test vocal fold medialization using autologous tragal cartilage and perichondrium by direct approach for treating high vagal paralysis. Five patients with the skull base tumors with involvement of the vagus nerve underwent concurrent vocal fold medialization with surgical excision. The patients were evaluated preoperatively, and at 14, 60 days, and 6 months later. Complete medialization with horizontal and vertical realignment was achieved. Improvement of voice and breathiness was correlated with the increase of closed quotient; the contact area of the vocal fold mucosa has increased. This advancement reduces breathiness and induced an improvement in subglottic pressure with aerodynamic parameters improvement, which led to stabilization of the vocal fold oscillation and a better voice quality recovery. This method can be considered a safe, quick, and efficient phonosurgical procedure combined with a skull-base surgical procedure.