return to: Medialization Laryngoplasty- Type I Thyroplasty with ePTFE (Gore-Tex); Setup for thyroplasty (medialization laryngoplasty)

Unilateral Laryngeal Paralysis or Vocal Cord Paralysis; Case example Thyroplasty with arytenoid adduction under General Anesthesia; Complication from Arytenoid Adduction Combined with Medialization Laryngoplasty (Gore-tex thyroplasty)

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 endoscope was used to confirm adequate visualization of the larynx during the procedure as well as laterality and persistence of the left vocal cord paralysis. The patient was then prepped and draped in standard sterile fashion, leaving the face above the lips unsterile, allowing for intraoperative placement transnasal flexible laryngoscopy (see images for room set-up below). 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 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 reapproximated using 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.