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return to: Medialization Laryngoplasty- Type I Thyroplasty with ePTFE (Gore-Tex); Type I Thyroplasty (Gore-tex) case examples
Intraoperative Manipulations Goretex Thyroplasty; Unilateral Laryngeal Paralysis or Vocal Cord Paralysis
Modified email sent to nursing, anesthesia and surgical team the day before:
__ yo with left vocal cord paralysis on for goretex thyroplasty with anesthesia for sedation and monitoring (don’t plan general for him)
Previous treatment in injection laryngoplasty done subsequent to his intubation for cardiac surgery 9 years previously with dysphonia since. Has mobile but bowed vocal cords with past temporary vocal improvement with injection laryngoplasty done elsewhere.
Left Gore-Tex thyroplasty with concurrent flexible nasal endoscopy for 1-1/2 hours local anesthesia with sedation.
Plan: start with table turned 90 from anesthesia – will begin with thyroplasty under local anesthesia with sedation (oxygen by nasal prongs) need gore-tex (note: need a 0.6 mm cardiovascular patch graft which I will trim to make an implant and soak in a liquid bacitracin 50,000 unit solution) before making incision. Also before incision ensure foot pedals for bipolar cautery and Bien drill are in place with both a small and a medium sized cutting burr selected.
Need nasal prep tray with neurosurgical cottonoids to place in nostril with lidocaine/afrin mixture. Need retractors (modified Richards); bipolar, unipolar cautery, 5-0 prolene. In the very unlikely event there are problems with local with sedation (very unlikely) should be prepared (see immediately below) to convert to general anesthesia. See very good protocol: Medialization Laryngoplasty- Type I Thyroplasty with ePTFE (Gore-Tex).
Note there are new (as of March 18 2019) flexible bronchoscopes in scope cabinet 1 (sterile core outside OR 24) has new flexible bronchosopes of smaller diameter - used with "Olympus GI Flex Tower"
BF-1TH190 Bronchoscope may be too large
BF-H190 Bronchoscope may be slightly smaller than the 180
BF-P190 Smaller caliber bronchoscope may be best for thyroplasty and possible KTP transnasal lasing (P= pediatric)
BF-XP190 Smallest caliber bronchoscope still possibly likely best for thyroplasty and possibly transnasal KTP lasing
Modified Procedure Details from similar case:
Written and informed consent was obtained. The patient was brought back to the Main operating room and laid supine on the table with the bed turned 120 degrees from Anesthesia and the back up at a 30-degree elevation. Oxygen was administered via nasal prongs with IV sedation (Propofol and Versed). A time-out was performed. The nose was instilled with Afrin and then aerosolized 4% lidocaine with phenylephrine. An initial transnasal fiberoptic laryngoscopy was performed to confirming again mobility to both vocal cords with glottic incompetence and most markedly bowed left vocal cord. After this, a pledget soaked in 1:1 mixture of 4% lidocaine and afrin were placed in the right nostril. Local anesthesia was administered in the form of 1% lidocaine with epinephrine 1:100,000, for a total of 10 mL 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 and also injected to our planned incision site within a relaxed skin tension line along the midportion of the thyroid cartilage on the left. A total of 0.5 cc of 0.25% Marcaine was also infiltrated along the planned incision site.
A 15 blade was then used to incise the skin and subcutaneous dissection continued past the platysma to the level of the strap muscles. The straps were identified at midline and lateralized and secured with two separate modified rich retractors. The thyroid cartilage was identified and a 15 blade used to make an incision along the midline with subperichondrial dissection used to expose the left aspect of the thyroid cartilage. A cricoid hook was placed into the laryngeal prominence to retract the larynx to the right. A Bien drill was then used to make a window that was approximately 1 cm x 5 mm and 3 mm above the inferior aspect of the thyroid cartilage. An incision along the lower border of the thyroid cartilage was used to separate the cricothyroid membrane from the thyroid cartilage and permit access to the paraglottic space. A blunt Woodson and Padgett (see photos) was then used to enter the paraglottic space along the inferior border of the thyroid cartilage.
The Woodson was then used to do vocal testing under direct visualization with the transnasal fiberoptic laryngoscope to determine which would be the best placement for our Gore-Tex implant. The Gore-Tex implant (which was previously fashioned from a 0.6mm cardiovascular patch graft and soaked in Bacitracin) under the inferior strut that was created from the window and brought out through the window. The implant was then positioned with the Woodson elevator to achieve optimal medialization with tucking of the edges of the implant under adjacent inner flange of the thyroid cartilage with continuous monitoring with the transnasal laryngoscope was used for inspection of the implant in regards to positioning and placement. Once ideal voicing was obtained, we did a slight overcorrection so the patient had a slightly pressed voice.
Two small drill holes were placed at the upper edge of the window and a 5-0 Prolene double ended suture was placed under in the inferior strut of the window, through the implant, into the window and then through the holes recently drilled in the thyroid cartilage above the window and tied on itself, securing the implant in place.
The wound was irrigated with saline and wound closure obtained by placing first a 3-0 Vicryl suture in an interrupted fashion to close the strap muscles placing a quarter-inch Penrose in the midline of the wound beneath the strap muscles, and reapproximating the skin with a 3-0 Vicryl for deep subcutaneous closure and 5-0 nylon for skin closure in an interrupted fashion. The Penrose was secured to the skin.
A final examination of the larynx with the transnasal laryngoscope confirmed a good airway with adequate medializaiton.
A fluff and burn netting were placed. The patient was then turned back to the Anesthesia Team for recovery and transferred back to the PACU.
Equipment includes:
