return to: Laryngeal Surgery (Benign Disease) Protocols

see also: Case example Thyroplasty with arytenoid adduction under General Anesthesia; Complication from Arytenoid Adduction Combined with Medialization Laryngoplasty (Gore-tex thyroplasty); ARD- Arytenoid Repositioning Device

GENERAL CONSIDERATIONS

1. Indications
   1. Symptomatic laryngeal paralysis
      1. Dysphonia
         1. Wide posterior glottic chink
         2. Level difference between the vocal folds
      2. Dysphagia
   2. Cricoarytenoid joint fixation is a relative contraindication that may require more extensive mobilization of the arytenoid - more likely addressed with other treatment
      1. Arthritis
      2. Joint capsule scarring
   3. Phonatory instability of arytenoid
   4. Poor prognosis for spontaneous return of laryngeal function
   5. We most commonly limit arytenoid adduction to its use combined with medialization laryngoplasty (thyroplasty). Arytenoid adduction is designed to improve closure of the posterior glottis during phonation by positioning the vocal process into a more natural phonatory position by:
      1. Rotating the vocal process medially
      2. Positioning the vocal process at a lower level
   6. Controversy persists regarding the need to supplement thyroplasty with arytenoid adduction. The best glottic closure and best vocal quality appear more consistently in the group of patients we have treated with combined thyroplasty and arytenoid adduction. This adds time to the operative procedure, requires more dissection, and may diminish the glottic airway (during inspiration) to a greater degree than thyroplasty alone. Cases need to be evaluated on an individual basis to determine whether arytenoid adduction is a valuable adjunct to thyroplasty.
2. Contraindications
   1. Abnormalities (eg, infection) of neck skin and underlying tissue precluding safe external approach to larynx
   2. Anticipated recovery from laryngeal paralysis (see Gelfoam injection protocol) 
   3. Joint fixation (see above)

PREOPERATIVE PREPARATION

1. Evaluation
   1. Essential for most cases
      1. Speech pathology assessment (see Laryngeal diagnostics protocol)
      2. Videolaryngoscopy with voice recording (see Videostroboscopy protocol)
   2. Consider for selected cases
      1. Trial of voice therapy
      2. Laryngeal electromyography (see Laryngeal EMG (Electromyography) protocol)
2. Consent
   1. Description: "Numb your neck and nostrils, examine your vocal cords with fiberoptic scope through your nose as the vocal cord position is manipulated through a neck incision. Through this neck incision, a small window of cartilage is removed next to your vocal cord. Through this window, an implant (Gore-Tex) is placed to secure your vocal cord in a more medial position. Dissection is extended to remove a segment of the back portion of the thyroid cartilage to place a suture to mimic the pull of two of the muscles that are paralyzed (arytenoid adduction)" (see Medialization laryngoplasty protocol).
      1. Mention "fine-tuning" the voice during the procedure with over-correction to make the voice pressed in the early postoperative period
      2. Describe the use of a rotating drill and placement of an implant
      3. Use of a model or drawing to demonstrate the anatomy and surgical technique is helpful
   2. Note that we now perform arytenoid adduction more commonly under general anesthesia - see: Case example Thyroplasty with arytenoid adduction under General Anesthesia
   3. Potential complications
      1. Bleeding, infection, reaction to the anesthesia
      2. Damage to adjacent structures (rare)
         1. Worse voice
         2. Problems breathing
         3. Potential need for revision
         4. Potential for salivary leak (from pyriform sinus manipulation)

NURSING CONSIDERATIONS

1. Room Setup
   See Basic Soft Tissue Room Setup
   1. Audio-visual unit
   2. Olympus light source
   3. Donut head support
2. Instrumentation and Equipment
   1. Standard
      1. Minor Instrument Tray, Otolaryngology
      2. Rongeur Tray, Small (for Kerrison rongeurs)
      3. Bien Otologic Electric Drill Tray
      4. Bipolar Forceps Trays
      5. Rhino-Laryngo Fiberscope, Olympus Model
      6. Trach hook
   2. Special
      1. Penfield dissectors; woodson elevator
      2. Large double-pronged skin hooks
      3. Richards double forked retractors
3. Medications (specific to nursing)
   1. Bupivacaine injection, 0.25%, for preoperative injection and throughout the procedure
   2. Dyclone solution, 0.5%, topical for local
   3. 1% lidocaine injection with 1:100,000 epinephrine
   4. Oxymetazoline HCL nasal spray, 0.05%
   5. Tetracaine hydrochloride, 2%, to mix with the oxymetazoline HCL
   6. Antibiotic ointment to suture line
   7. Bacitracin 50,000 (to soak thyroplasty devise)
4. Prep and Drape
   1. Standard prep, 10% providone iodine from lips to clavicles; lateral extension to trapezius muscles
   2. Drape
      1. Leave the top of head unprepped to permit non-sterile placement and removal of flexible fiberoptic laryngoscope (or esophagoscope maintenance under general anesthesia) from this approach during case.
      2. Drape with a folded towel over chin to leave mouth and nose exposed; square off the anterior neck with towels inferiorly to clavicles.
      3. Split sheet
5. Drains and Dressings
   1. Antibiotic ointment to suture line
   2. Adaptic, small
   3. Fluffs
   4. Burn netting
6. Special Considerations
   1. If cartilage is fractured, order the KLS oto trauma implant/instrument tray and the KLS locking reconstruction threadlock instrument tray.
   2. The surgeon will use a 4-0 prolene to pass through the arytenoid cartilage.
   3. Patch: cardiovascular Gore-Tex patch graft 0.6 mm and will soak in the bacitracin 50,000 Units.

ANESTHESIA CONSIDERATIONS

1. Intravenous Conscious Sedation
   1. General anesthesia is now more commonly used in our hands.
   2. Local anesthesia in the past was preferred to permit voice assessment intraoperatively and avoid laryngeal distortion due to the presence of endotracheal tube.
      1. Sedate heavily for first 30 minutes of case; thereafter the patient should be comfortable, but still able to respond verbally to questions.
      2. Oxygen by nasal prongs to both nostrils (consider CO2 monitor) permits topical anesthesia to the nose and placement of the flexible fiberoptic laryngoscope adjacent the prongs.
2. Preoperative Systemic Medications
   1. Decadron 8 to 10 mg intravenous as soon as IV started
   2. Antibiotics (as soon as IV started) (see Antibiotic protocol)
3. Positioning
   1. Head of table rotated 90 degrees with anesthesia at the patient's right side.
   2. Audio-visual equipment (television monitor) and flexible fiberoptic laryngoscope at the patient's head.
   3. Head of bed elevated 30°; neck extended +/- shoulder roll placed (if positioned appropriately on the table, don't need shoulder roll).

OPERATIVE PROCEDURE

1. Incise over midportion of thyroid cartilage canted to side of paralysis extended laterally to anterior border of sternocleidomastoid muscle.
2. Separate strap muscles in midline.
3. Supplement injection to deeper tissue with 1% lidocaine with 1:100,000 epinephrine as the dissection continues.
4. Place heavy suture or tracheotomy hook through the laryngeal prominence permitting medial traction on the larynx with improved exposure.
5. Incise the thyroid cartilage perichondrium in the midline and elevate it progressively in a lateral direction on the side of the paralysis.
6. Create window in thyroid cartilage as described for Gore-Tex thyroplasty protocol.
7. Elevate perichondrium laterally to identify lateral border of thyroid cartilage.
   ##. Incise through perichondrium attached to lateral thyroid lamina (detaching constrictor muscles).
8. Employing Kerrison rongeurs, remove a 1 to 2 cm wide segment from lateral aspect of the thyroid cartilage making an effort to preserve the inferior thyroid cornu attachment to the cricoid cartilage. Care is also required to avoid injury to the underlying pyriform sinus and adjacent soft tissue.
9. Employing small Kittner, elevate pyriform sinus mucosa superiorly to permit exposure of the fibers of the posterior cricoarytenoid muscle.
10. The V-shaped fibers of the cricothyroid muscles converge from the broad base on the cricoid cartilage to insert on the muscular process of the arytenoid cartilage.
11. Place one 4-0 or 5-0 prolene suture through the tendon of the posterior cricoarytenoid muscle at its attachment to the muscular process drawing the muscular process laterally, allowing for placement of the same suture with a second pass through the process itself. (Note: It is occasionally difficult to place the sutures within the cartilaginous muscular process itself; may have to settle for suture placement immediately adjacent to the cartilage in the tendon).
12. Leave the needle attached to the 4-0 or 5-0 prolene as both ends are passed anteriorly along the undersurface of the thyroid cartilage and out the window created for thyroplasty.
13. The two ends of the arytenoid adduction suture are placed 0.5 cm posterior to the midline with one end immediately below the thyroid cartilage (through the cricothyroid membrane) and the other through the thyroid cartilage 0.5 cm superior to the inferior border of the thyroid cartilage.
14. Suture placement is accomplished by employing the needle (still attached to the prolene suture) to draw and drive the suture through the cricothyroid membrane. The other end of the arytenoid adduction suture (without the needle attached) is threaded through a Keith needle to place it through the thyroid cartilage 0.5 cm above its inferior border. If the cartilage at this location is ossified, then a small drill hole is created to accommodate placement of the suture.
15. The Gore-Tex is then placed as described in the medialization laryngoplasty (see Gore-Tex thyroplasty protocol).
16. The two ends to the arytenoid adduction suture are tied to one another once the Gore-Tex has been secured.
17. Manipulations of the glottic configuration are observed employing the flexible fiberoptic laryngoscope (or esophagoscope taped in place if general anesthesia is used) during the course of the procedure. 
18. Loosely approximate strap muscles in midline with 3-0 vicryl after placing a Penrose drain deep to them.
19. Close platysma with 4-0 vicryl.
20. Close skin with 5-0 nylon.

POSTOPERATIVE CARE

1. Observe overnight in-hospital (23-hour observation).
2. Begin oral feedings when alert.
3. Continue oral antibiotics for 5 to 7 days.
4. Continue topical wound care.
5. Voice rest: Relative voice rest for 2 weeks: Employ "arm's length rule" wherein the patient does not address a person unless they are within an arm's length away.
6. Remove drain postoperative day 1 with examination of larynx.
7. Follow-up at postoperative day 6 for suture removal.
8. Videostroboscopic exam with speech pathology assessment at 6 weeks, 3 months, 6 months and 1 year.
9. Consider voice therapy after 6 weeks if modification of voicing behavior is indicated based on speech pathology assessment and patient desire.

REFERENCES

Hoffman HT, McCulloch TM. Anatomic considerations in the surgical treatment of unilateral laryngeal paralysis. Head Neck. 1996;18:174-187.

Hoffman HT, McCulloch TM, Victoria L. Laryngeal Paralysis. In: Gates G, ed. Current Therapy in Otolaryngology. 6th ed. St Louis, MO: Mosby; 1998:446-452. 

Hoffman MR, Witt RE, Chapin WJ, McCulloch TM, Jiang JJ. Multiparameter comparison of injection laryngoplasty, medialization laryngoplasty, and arytenoid adduction in an excised larynx model. Laryngoscope. 2010 Apr;120(4):769-76.

Isshiki N, Tanabe M, Sawada M. Arytenoid adduction for unilateral vocal cord paralysis. Arch Otolaryngol. 1978 Oct;104(10):555-8.

Maragos NE. Pyriform sinus mucosa stabilization for prevention of postoperative airway obstruction in arytenoid adduction. Ann Otol Rhinol Laryngol. 2006 Mar;115(3):171-4.