Medialization Laryngoplasty- Type I Thyroplasty with ePTFE (Gore-Tex)

last modified on: Mon, 03/04/2024 - 08:46

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see operative notes and images with videos: Type I Thyroplasty (Gore-tex) case examples

GENERAL CONSIDERATIONS

Thyroplasty types:
1. Type I: medialization of vocal cord
2. Type II: lateralization of vocal cord
3. Type III: shortening or relaxation of vocal cord
4. Type IV: elongation or tensioning of the vocal cord
Indications
1. Symptomatic laryngeal paralysis:glottic incompetence associated with incomplete vocal fold approximation
  1. Dysphonia
  2. Dysphagia
  3. Poor cough
  4. Vocal fatigue
  5. Odynophonia
    1. A publication (Kupfer et al. 2015) identified in select cases associated with impaired vocal fold motion, medialization laryngoplasty my relieve pain related to voice use, even in the absence of hoarseness
2. Among the many options for management of symptomatic unilateral laryngeal paralysis, injection laryngoplasty has become the most common in our practice due to the ease of its performance in an outpatient clinic. Medialization laryngoplasty via gore-tex thyroplasty requires performance in an operating room with a neck incision, placement of drain and overnight stay. Despite these shortcomings, thyroplasty (with or without arytenoid adduction) is preferred by some as an initial choice, especially among those:
  1. with contraindications to in-clinic laryngeal injection with collagen (ie. allergy to injection materials; autoimmune or collagen vascular disease precluding in-clinic collagen injection)
  2. desire for a longer lasting medialization ("nothing is permanent")
  3. patients on Plavix/Coumadin or other 'blood thinners' who increase their stroke/MI/embolic risk with repeated withdrawal from anticoagulation. Injection laryngoplasty with collagen in the clinic setting in our practice usually requires a series of injections. Those who are better served with a longer lasting medialization may chose to avoid this program in favor of a more definitive medialization.
Contraindications
1. Abnormalities (eg, infection or radiation changes) of neck skin and underlying tissue precluding safe external approach to larynx
2. Anticipated recovery from laryngeal paralysis or glottic incompetence (see Injectable substances for injection laryngoplasty protocol )
3. Poor abduction of the contralateral vocal cord

PREOPERATIVE PREPARATION

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)
3. For patients with posterior glottic incompetency, arytenoid adduction as an adjunct to thyroplasty should be considered
  1. Type I thyroplasty alone may not effectively treat posterior glottic incompetency because the posterior glottis and arytenoids reside outside the paraglottic space manipulated by implant materials (see citation g). Younger, healthier patients who would better tolerate longer anesthetic time associated with combined approach may benefit from longer lasting voice results
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."
  1. Mention "fine-tuning" the voice during the procedure with overcorrection to make voice pressed in the early postoperative period.
  2. Describe the use of a rotating drill and placement of an implant.
2. Potential complications
  1. Bleeding, infection, reaction to the anesthesia
  2. Chondritis
  3. Wound infection
  4. Penetration of endolaryngeal mucosa
  5. Implant extrusion or migration (increased risk if endolaryngeal mucosa is violated during procedure)
  6. Airway obstruction (increased risk when thyroplasty is done in conjunction with arytenoid adduction)
  7. Damage to adjacent structures (rare)
    1. Worsening voice
    2. Problems breathing
    3. Potential need for revision
  8. The overall complication rate is low if persistent dysphonia from incomplete glottic or irregular glottic closure is excluded from consideration. Relapse (good early result followed by vocal deterioration) is common and has been attributed to better voicing occuring from vocal fold medialization from edema at the time of surgery - with resolution of the edema attended by dysphonia. A study of elderly patients treated with thyroplasty for vocal cord paralysis were offered revision at a high rate at their 6 weeks followup (Bowen 2017).
  9. Revision may be done with a repeated open procedure but, in our hands, is more commonly done as a supplemental injection augmentation (see: Injection Laryngoplasty for Vocal Fold Paralysis and Glottic Incompetence)

NURSING CONSIDERATIONS

Room Setup
See Basic Soft Tissue Room Setup---see specific setup for thyroplasty under local anesthesia
1. Audio-visual unit
2. Olympus light source
3. Mayo stand x 2
4. Gown table x 2 (for "clean" - not sterile - setup for rhino-laryngo fiberscope)
Instrumentation and Equipment
1. Standard
2. Special
  1. News tracheotomy hook x 2
  2. Richards adjustable double fork retractor (modified Richards retractors)
  3. Syringe, Luer Lock, 20 cc
  4. FRED (fog reduction elimination device), or anti-fog
  5. An FDA approved 'device' is was available as a ribbon of ePTFE (Gore-Tex) 0.6 mm thick that is approved as a laryngeal implant. If it is not available, a square cardiovascular patch graft (also 0.6 mm thick) can be cut into a similarly shaped ribbon for use.
Medications (specific to nursing)
1. Bupivacaine injection, 0.25%, for preoperative injection
2. 1% lidocaine with 1:100,000 epinephrine
3. Oxymetazoline HCL nasal spray, 0.05%
4. Tetracaine hydrochloride, 2%, to mix with the oxymetazoline HCL
5. Bacitracin 50,000 units to soak Gore-Tex
Prep and Drape
1. Standard prep, 10% providone iodine
  1. Do a betadine solo prep from lips to clavicles; lateral extension to trapezius muscles.
  2. Leave the top of head and face unprepped to permit non-sterile placement and removal of flexible fiberoptic laryngoscope from this approach during case.
2. Drape
  1. Square off with towels the anterior neck inferiorly to clavicles.
  2. Place a narrow (rolled) towel over the chin to separate the mouth from the sterile field interior.
  3. Split sheet: cover eyes with wet 4 x 4 in. cotton pads. Patient will be awake and asked to speak during the procedure.
Drains and Dressings
1. Fluffs
2. Adaptic, small
3. Penrose drain, 1/4 in
4. Burn netting
Special Considerations
1. Nose may be packed preoperatively with topical vasoconstrictor and anesthetic agent.
2. Have bupivacaine 0.25% plain on the field.
3. Soak Gore-Tex in bacitracin 50,000 Units.
4. Patch: Cardiovascular Gore-Tex patch graft 0.6 mm.
5. Soak 1/2 in x 3 in cottonoids in pontocaine 2% and oxymetazoline HCL nasal spray 1:1.
6. Procedure is done under local anesthesia.
7. Throughout the case, surgeon should take special care to avoid inadvertent dragging of suture material, instruments etc. across unsterile part of operative field
8. Have all equipment needed for arytenoid adduction available; it may be necessary to supplement the thyroplasty with an arytenoid adduction.

ANESTHETIC CONSIDERATIONS

Intravenous Conscious Sedation
1. Although general anesthesia may be used in selected cases (eg, anticipated poor patient compliance), local anesthesia is preferred to permit voice assessment intraoperatively and avoid laryngeal distortion due to the presence of endotracheal tube.
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 to the prongs.
Preoperative Systemic Medications
1. Glycopyrrolate 0.1 to 0.2 mg intramuscular on call to operating room
2. Decadron 8 to 10 mg intravenous as soon as IV started
3. Antibiotics (as soon as IV started) (see Antibiotic protocol)
Positioning
1. Head of table with anesthesia at patients side (obliquely to permit surgeons to stand on either side of the neck).
2. Audiovisual equipment (television monitor) and flexible fiberoptic laryngoscope at the patient's head.
3. Head of bed elevated 30° and neck extended (shoulder roll usually not needed if patient positioned appropriately on bed).

OPERATIVE PROCEDURE

Incision is made over midportion of thyroid cartilage canted to side of paralysis.
Separate the strap muscles at midline and elevate straps along with perichondrium from ipsilateral thyroid ala.
Supplement injection to deeper tissue with 1% lidocaine with 1:100,000 epinephrine as the dissection continues.
Place heavy suture or tracheotomy hook through the laryngeal prominence permitting medial traction on the larynx with improved exposure.
Incise the thyroid cartilage perichondrium in the midline and elevate it progressively in a lateral direction on the side of the paralysis.
Ensure the ipsilateral thyroid cartilage is exposed inferiorly to the cricothyroid membrane and posteriorly to the lateral edge of thyroid cartilage. Limiting dissection to the oblique line is adequate for placement of the prosthesis, but restricts exposure and orientation.
1. It is necessary to detach slips of the cricothyroid muscle inserting on the lateral border of the muscular process (inferior tubercle) of thyroid cartilage.
2. Inject 1% lidocaine with 1:100,000 epinephrine into the cricothyroid membrane immediately below the lower border of thyroid cartilage.
3. Avoid doing an 'injection laryngoplasty' with the lidocaine epinephrine injection that may cause cord medicalization and complicate assessment of degree of medicalization needed
Mark proposed cartilage cuts on thyroid cartilage with electrocautery.
1. Dimensions of window: approximately 5 mm x 10 mm (for Gore-Tex thyroplasty; larger if silastic used)
  1. Lower border of window 3 mm above cricothyroid membrane leaving an inferior strut (as low as possible without danger of fracturing inferior strut)
2. Anterior border of window 7 to 10 mm posterior to midline
3. The superior aspect of the window is positioned at the level of the true vocal fold
  1. the halfway point between the anterior-inferior aspect of the thyroid cartilage and the thyroid notch defines the approximate level of the true fold
4. Use Bien drill if thyroid cartilage is calcified.
  1. A ~ 4 mm fluted bit is appropriate with care not to enter the deep soft tissue.
Elevate inner perichondrium through window from undersurface of thyroid cartilage employing Woodson and Penfield elevators.
1. Incise inner perichondrium posteriorly, inferiorly, and superiorly if needed; do not incise anteriorly.
2. Incise cricothyroid membrane to separate it from lower border of thyroid cartilage.
3. From inferior approach, place Woodson elevator under lower border of thyroid cartilage and into the window to depress the contents of the paraglottic space medially while assessing phonation.
Fashion a 1-cm wide continuous strip of Gore-Tex from a square patch.
1. Soak the Gore-Tex implant in bacitracin solution.
2. Place the Gore-Tex strip into thyroid cartilage window from inferior approach and pull out through window.
Secure the Gore-Tex strip into position, placing the vocal fold in an ideal location as determined by phonatory assessment and examination with fiberoptic laryngoscope. See good images: Type I Thyroplasty (Gore-tex) case examples Video: Intraoperative Manipulations Goretex Thyroplasty
1. The strip is secured primarily by wedging it between the contents of the paraglottic space (perichondrium and LCA/TA muscle group) and the overlying thyroid cartilage.
2. Ensure that medialization is approximately 2 mm greater than desirable in anticipation of gradual resolution of edema.
3. Place a 4-0 prolene suture around lower strut of window from an inferior approach through the Gore-Tex and tie it on itself. Leave the needle attached.
4. Employing same needle with the suture still attached, place the needle through unossified thyroid cartilage (or if ossified, place drill hole) above the window and tie it again on itself to help secure Gore-Tex implant.
Consider supplementing vocal fold medialization with arytenoid adduction if needed (see Arytenoid Adduction protocol).
Place Penrose drain deep to strap muscles; then loosely approximate them in the midline with 3-0 vicryl suture.
Close platysma with 4-0 vicryl.
Close skin with 5-0 nylon.

POSTOPERATIVE CARE

Observe overnight in-hospital (23-hour observation).
Begin oral feedings when alert.
Continue oral antibiotics for 5 to 7 days.
Use topical wound care (see Nursing wound care protocol).
Voice rest
1. Absolute for 48 hours
2. Relative 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.
Remove drain on postoperative day 1 with examination of larynx.
Follow-up is at postoperative day 6 for suture removal.
Videostroboscopic exam with speech pathology assessment at 6 weeks, 3 months, 6 months and 1 year.
Consider voice therapy after 6 weeks if modification of voicing behavior is indicated based on speech pathology assessment and the patient's desire.

Modified Operative Note

The patient was brought back to the operating room and laid supine with the table turned 120 degrees from anesthesia.

Oxygen was administered via nasal prongs with total IV sedation of 1 mg versed through case. Intravenous Unasyn and Decadron (10 mg) were administered. A multidisciplinary timeout was performed.

The patient's nose was decongested first with instillation of Afrin, then aerosolized 1% lidocaine with phenylephrine, and then - after initial transnasal flexible laryngoscopy, a pledget soaked in a 1:1 mixture of 4% lidocaine and Afrin was placed in one nostril.

The flexible laryngoscope was used to confirm adequate visualization of the larynx during the procedure as well as laterality and persistence of the left vocal cord paralysis.

Local anesthesia was administered in the form of 1% lidocaine with 1:100,000 epinephrine (11 cc) at the laryngeal prominence, on the face of the left aspect of the thyroid cartilage ala, and along the inferior border of the thyroid cartilage. We also infiltrated local anesthetic along our planned incision site within a relaxed skin tension line at about the mid portion of the thyroid cartilage on the left. Three mL of 0.25% Marcaine was also infiltrated along the planned incision site.

The patient was prepped and draped in standard sterile fashion. A #15 blade was used to incise the skin and subcutaneous dissection with the #15 blade ensued. The strap muscles were identified at the midline and incised with left lateral retraction in a subperichondrial plan to expose the thyroid cartilage. Exposure of the left lateral thyroid ala was improved with use of the modified Richards retractors (x2) and placement of a trach (cricoid) hook into the laryngeal prominence to retract the larynx to the right.

The Bien drill was used to make the window of approximately 1 cm x 5 mm located 1 cm from the midline taking care to leave an inferior strut approximately 3 mm along the inferior aspect of the thyroid cartilage. An incision along the lower border of the thyroid cartilage (below the window) separated the cricothyroid membrane from the thyroid cartilage to permit access to the paraglottic space with the blunt end of the Woodson elevator. Before making this incision, additional 1% lidocaine was injected to the site and bipolar cautery used for hemostasis.

Vocal testing and inspection of vocal cord position (with the recently placed transnasal fiberoptic laryngoscope) then occurred with the Woodson elevator medializing the vocal cord from the inferior approach. A Gore-Tex implant (see video below) had been previously fashioned and had been soaking in bacitracin solution. The implant was placed from an inferior approach (under the inferior strut) and brought out through the window. The implant was then positioned (carefully using the sharp end of the Woodson elevator) to position it where previous testing suggested optimal medialization. Replacement of the transnasal flexible scope allowed for inspection as the implant was positioned - with ongoing phonatory assessment helping to direct its placement (wedged under adjacent thyroid cartilage with care to prevent uneven 'knuckling' of the implant). Once ideal voicing was obtained, purposeful slight overcorrection (resulting in a slightly pressed voice) was done to accommodate for expected slight resolution of edema. A 5-0 Prolene suture was placed under the inferior strut of the window and through the implant (after trimming the implant) and tied on itself. The suture was then placed in a 'hammock fashion' over the implant and then through the implant at its upper border before passing through a small drill hole placed in the thyroid cartilage immediately above the window. The suture was then tied on itself, securing the implant in place. The wound was thoroughly irrigated with saline and attention was turned to closure. The deeper layers of the wound were closed with 3-0 Vicryl suture.

A quarter-inch Penrose drain was placed in the midline of the wound. The skin was re-approximated using deep 3-0 vicryl and superficial 5-0 nylon suture and the Penrose drain was secured with to the skin. Bacitracin was applied along the incision line and burn netting and fluffs were placed. Final inspection with the transnasal flexible laryngoscope identified ideal positioning of the immobile vocal cord with a strong (slightly pressed) voice with a good airway. The patient was then turned back over to Anesthesiology and, ultimately, taken back to recovery in stable condition.

REFERENCES

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

McCulloch TM, Hoffman HT. Medialization laryngoplasty with expanded polytetrafluoroethylene. Ann Otol Rhinol Laryngol. 1997;107:427-432.

Murata T, Yasuoka Y, Shimada T, Shino M, Iida H, Takahashi K, Furuya N. A new and less invasive procedure for arytenoid adduction surgery: Endoscopic-Assisted Arytenoid Adduction Surgery. Laryngoscope. 2011 Jun;121(6):1274-80

Fakhry, C., Flint, PW., Cummings, CW. Medialization Thyroplasty. In Cummings CW, et al: Cummings - Otolaryngology - Head and Neck Surgery. 5th ed. Philadelphia, Mosby-Elsevier, 2010, pp. 904-11.

Rosen, C., Medialization Laryngoplasty and Arytenoid Adduction. In Myers, E et al. Operative Otolaryngology - Head and Neck Surgery. 2nd edition. Philadelphia, Suaders-Elsevier. 2008, chap 41

McCulloch TM, Hoffman HT, Andrews BT, Karnell MP.Arytenoid adduction combined with Gore-Tex medialization thyroplasty. Laryngoscope. 2000 Aug;110(8):1306-11.

Kupfer RA, Merati AL, and Sulica L: Medialization Laryngoplasty for Odynophonia JAMA Otolaryngol Head Neck Surg. 2015;141(6):556-561

Bowen AJ, Huang TL, Benninger MS, Bryson PC.Medialization Laryngoplasty in the Elderly: Outcomes and Expectations.Otolaryngol Head Neck Surg. 2017 Oct;157(4):664-669. doi: 10.1177/0194599817718783. Epub 2017 Jul 18

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