Ann Otol Rhinal Laryngo199:1990


The laryngeal framework-Silastic implant technique has become an increasingly attractive alternative to Teflon injection, particularly when there is fixation of the cricoarytenoid joint or the defect to be corrected is larger than usual; but it does not restore ability to change tension in the vocal fold. Unilateral vocal fold reinnervation can overcome this drawback and, when used in conjunction with surgical medialization, may offer return of function very close to normal. Twenty-nine patients with unrecovered unilateral vocal fold paralysis and/or fixation of the cricoarytenoid joint have been managed by use of a Silastic implant combined with unilateral vocal fold reinnervation with no complications. Voice improvement has been assessedon preoperative and postoperative voice recordings. The combined surgical techniques for reinnervation and a modification of Silastic implantation via the laryngeal framework approach are reported. KEY WORDS -

laryngeal framework surgery, Silastic implant, vocal fold reinnervation.

For many otolaryngologists Teflon injection remains the procedure of choice for unrecovered and poorly compensated unilateral vocal fold paralysis. Because voice improvement after Teflon injection is less reliable 1) when there is fixation of the cricoarytenoid joint, 2) when combined superior and recurrent laryngeal nerve paralyses result in large gaps at the posterior commissure, and 3) because Teflon can be removed only with difficulty, 1 interest in surgical medialization via the laryngeal framework surgery approach has been increasing.?:" Although this is an open surgical procedure, it can be carried out under local anesthesia, does not require routine overnight stay, and has provided very satisfactory voice results with a low incidence of complications. The other advantages of this approach are outlined in the Table.


Twenty-nine candidates were selected from among 70 consecutive patients with unilateral vocal fold immobility seen in the author's practice between January 1, 1987, and December 31, 1989. Each was judged to be a less than optimal candidate for Teflon injection because of fixation of the cricoarytenoid joint, combined superior and recurrent laryngeal nerve paralyses, and/or severe wasting of vocal fold musculature. Preoperative and postoperative voice recordings were obtained in all cases, and videostroboscopy in the more recent ones. The relative advantages and disadvantages of the various approaches to rehabilitation of voice were discussed and the patients each volunteered to undergo combined Silastic implant medialization and reinnervation. All operations were carried out under combined topical and local infiltration anesthesia. Pontocaine 0.5 % was sprayed between the vocal folds to diminish coughing and swallowing, and Xylocaine 10/0 with epinephrine 1:100,000 was injected into the skin and perilaryngeal tissues on the side of paralysis to achieve surgical anesthesia. Only a few of the patients required intravenous sedation with Valium or Versed during the procedure. After sterile skin preparation and draping, a skin

Although excellent vocal fold medialization with improved loudness and sustainability of voice may be achieved by either Teflon injection or a Silastic implant, unrestored motor innervation may yet be responsible for diplophonia and poor voice quality, since neither of these techniques can restore tonus, muscle turgor, or ability to tense the vocal fold. The only technique now available that can restore these functions is reinnervation, S.6 which has succeeded as the sole means of rehabilitation for unilateral vocal fold paralysis, but which imposes a delay of up to 6 months between the operation and beginning return of function. Since the surgical approach for nerve-muscle pedicle reinnervation is virtually identical to that for medialization by a Silastic implant, a combination of the two procedures was undertaken in hopes of providing a prompt increase in loudness secondary to the implant and later improvement in vocal quality and pitch control due to the reinnervation.

COMPARISON OF LARYNGEAL FRAMEWORK SURGERY AND TEFLON INJECTION Laryngeal Framework Surgery With Silastic Implant Teflon Injection of Vocal FoldY

Outpatient procedure Local anesthesia Any size defect Can medialize fixed arytenoid Easily removed Can reinnervate

Outpatient procedure Topical anesthesia 2- to 4-mm defect Cannot medialize fixed arytenoid Removed with difficulty Cannot reinnervate

From the Department of Otolaryngology and Communicative Disorders, The Cleveland Clinic Foundation, Cleveland, Ohio. Presented at the meeting of the American Laryngological Association, Palm Beach, Florida, April 28-29, 1990. REPRINTS - Harvey M. Tucker, MD, Dept of Otolaryngology and Communicative Disorders, The Cleveland Clinic Foundation, Desk A-71, 9500 Euclid Ave, Cleveland, OH 44195.


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Tucker, Combined Medialization & Reinnervation




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Procedure. A) Cartilage window is removed for access to lateral thyroarytenoid muscle and as template for Silastic block. B) Pocket is dissected between inner surface of thyroid cartilage and perichondrium. C) Previously prepared nerve-muscle pedicle is sutured to outer surface of lateral thyroarytenoid muscle. D) Wedge-shaped implant is carved from block of Silastic, with cartilage window used as template. E) Implant is placed into pocket with corner removed to accommodate nerve-muscle pedicle and medialize vocal fold.

crease incision was made at the level of the lower border of the thyroid cartilage, beginning at the midline and extending posteriorly to just behind the anterior border of the sternocleidomastoid muscle. This incision was carried through skin, superficial fascia, and platysma muscle, permitting the development of flaps in the subplatysmal plane. The sternocleidomastoid muscle was mobilized posteriorly and the jugular vein identified. A nerve-muscle pedicle was developed, most often from the branch of the ansa hypoglossi to the anterior belly of the omohyoid muscle, although other strap muscle branches were used on occasion." A nerve stimulator was used to help identify the nerve, which responded to electrical stimulation at 1 to 1.5 mA in spite of the use of local anesthetic. The pedicle was laid aside and the lateral aspect of the thyroid cartilage was exposed by retraction of the overlying strap muscles. A scalpel incision or saw cut was made (depending upon the degree of calcification of the thyroid ala) parallel to the vocal fold and judged to be at or slightly below its upper surface. Most often this level was at the midpoint between the thyroid notch and the lower border of the thyroid cartilage when measured at the midline. Additional cuts were made at right angles to describe an oblong window in the lower half of the thyroid ala, with care taken to leave intact cartilage struts of 3 or 4 mm anteriorly, inferiorly, and posteriorly (see Figure, A). The cartilage window was removed intact by dissecting it free from its underly-

ing inner perichondrium and the thyroarytenoid muscle. The inner perichondrium was further dissected in all directions from the edges of the window to create a generous pocket (see Figure, B). Posterior dissection permitted mobilization of the arytenoid cartilage toward the midline if it was ankylosed. The inner perichondrium was removed from the area of the window to expose the underlying muscle, and the previously prepared nerve-muscle pedicle was sutured to the surface with two stitches of 5-0 monofilament nylon (see Figure, C). A block of Silastic was carved to create a wedge of appropriate size. The cartilage block removed from the window was used as a template, with 2 to 3 mm of Silastic allowed to protrude beyond it on all four sides. It was also used to position and measure a "key" or lateral extension of Silastic on the lateral surface of the carved wedge to fix the block in the pocket (see Figure, D). A posterior corner was cut away from the Silastic wedge to allow for the entry of the nerve-muscle pedicle. The wedge was then compressed and inserted into the pocket through the window and positioned so that the lateral "key" was locked into the window (see Figure, E). The resulting voice and airway were then assessed. On the two occasions that the airway seemed to be compromised by the implant, the Silastic was removed, trimmed, and reinserted. On one occasion it was clear that voice improvement was inade-

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Tucker, Combined Medialization & Reinnervation


quate. The block was removed and a new, slightly larger one was carved and inserted. The wound was closed over a small Penrose or rubber band drain. Broad spectrum antibiotics were given for 48 to 72 hours. Patients who underwent any type of laryngeal framework operation":" were initially kept in the hospital overnight, but after the first 50 consecutive patients (not all included in this study) suffered no complications in the first 24 hours they were thereafter permitted to go home on the night of the operation. Postoperative voice assessment was carried out 2 weeks, 3 months, and 6 months after the operation. RESULTS

All patients developed marked improvement in vocal strength and ability to sustain speech, varying from immediately on the operating table to 3 weeks postoperatively. Not infrequently, what was an initially excellent voice result at operation would deteriorate for various periods of time before gradually restabilizing at improved levels. All of these patients have sustained the improvement to the present. All of the 29 patients had successful medialization of the vocal fold with significant improvement in the voice, and 19 of the 29 (66%) had further improvements in quality and pitch control 2 to 6 months later. There were no immediate complications. Airway obstruction occurred in one patient 72 hours after the operation (48 hours after discharge). A tracheotomy tube was inserted, and it was successfully removed without further incident 1 week later. The patient's voice result was excellent. There was extrusion of one of the Silastic implants 9 months after the operation. The patient coughed up the implant, but her voice improvement has been sustained despite loss of the Silastic. All of the patients have been followed up for at least 6 months, beyond which time no patient in our previous experience has shown onset of motor activity after attempted reinnervation." Nineteen of the 29 patients are judged to show evidence of successful reinnervation (66 % ), as evidenced by visible tensing, increased muscle volume, and improved turgor of the vocal fold. There has been subjective and objective improvement in voice over that which was achieved by mechanical medialization alone in all of these cases, but not in the patients who showed no evidence of successful reinnervation.

Onset of perceived secondary improvement in voice varied from 2 months to 5 months after the operation. Detailed phonatory analysis of this group of patients will be the subject of a subsequent communication. DISCUSSION

Vocal fold medialization by Silastic or other implantation has long been known to afford good possibilities for voice improvement. Recent improvements in diagnosis, materials, technique, and documentation have permitted its employment in patients who are not likely to achieve reliably satisfactory results with Teflon injection. Since it is now clear that it can be done under local anesthesia and as an outpatient procedure, it may begin to replace Teflon injection for many patients, especially because it can be easily removed, whereas Teflon cannot. Nerve-muscle pedicle reinnervation has been shown to succeed in restoring not only adduction of the vocal fold, but also the ability to tense the muscles and thus to control pitch.":" Theoretically, at least, it should permit the closest possible return to "normal" function that can be achieved with present technology. It has suffered from the built-in delay of 2 to 6 months after the operation before any improvement may be noted. If it can be combined with Silastic implant medialization, the patient can have immediate voice improvement while awaiting the onset of further improvement in quality and pitch control. Although definitive voice analysis is not yet complete, it is clear that many of these patients have experienced further improvement in voice commencing some weeks or months after the initial postoperative results. Since no individual experienced any complication from the reinnervation process itself, it seems reasonable to continue to combine these two procedures for properly selected patients. CONCLUSIONS

Implantation of Silastic under local anesthesia for medialization of a unilateral immobile vocal fold is a relatively safe and effective way to restore vocal loudness and sustainability. It can be combined with nerve-muscle pedicle reinnervation as a single procedure under local anesthesia that can provide improved pitch control and voice quality in selected patients without increased cost or risk.

REFERENCES 1. Tucker HM. Management of the patient with an incompetent larynx. Am J OtolaryngoI1979;1:47-56.

paralyzed vocal cord with Silastic implant. Ann Otol Rhinol Laryngol 1988;97:234-8.

2. Isshiki N, Masahiro T, Sawada M. Arytenoid adduction for unilateral vocal cord paralysis. Arch OtolaryngoI1978;104:555-8.

5. Tucker HM, Rusnov M. Laryngeal reinnervation for unilateral vocal cord paralysis: long-term results. Ann Otol Rhinol LaryngoI1981;90:457-9.

3. Koufman JA. Laryngoplasty for vocal cord medialization: an alternative to Teflon. Laryngoscope 1986;96:726-31. 4. Escajadillo JR. Technique for external repositioning of the

6. Crumley RL, Izdebski K. Voice quality following laryngeal reinnervation by ansa hypoglossi transfer. Laryngoscope 1986;96:611-6.

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Tucker, Combined Medialization & Reinnervation 7. Tucker HM. Anterior commissure laryngoplasty for adjustment of vocal fold tension. Ann Otol Rhinol Laryngol 1985;94: 547-9.


8. Tucker HM. Laryngeal framework surgery in the management of spasmodic dysphonia. Preliminary report. Ann Otol Rhinol LaryngoI1989;98:52-4.

26TH POSTGRADUATE COURSE IN EAR SURGERY The 26th Postgraduate Course in Ear Surgery will be held from April 7-12, 1991, in Nijmegen, the Netherlands. For further information and registration form, please write to: Prof Dr P. van den Broek, University Hospital Nijmegen, Department of Otorhinolaryngology, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Telefax 80-540251.

CARE OF THE PROFESSIONAL VOICE The Voice Foundation's 20th Annual Anniversary Symposium on Care of the Professional Voice will be held July 14-19, 1991, at the Warwick Hotel in Philadelphia, Pennsylvania. For further information, contact The Voice Foundation, 1721 Pine Street, Philadelphia, PA 19103; (215) 735-7999.

OBJECTIVE VOICE MEASUREMENTS & STANDARDS A course entitled Objective Voice Measurements & Standards will be held July 22-23, 1991, at the Warwick Hotel in Philadelphia, Pennsylvania. For further information, contact The Voice Foundation, 1721 Pine Street, Philadelphia, PA 19103; (215) 735-7999.

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Combined laryngeal framework medialization and reinnervation for unilateral vocal fold paralysis.

The laryngeal framework-Silastic implant technique has become an increasingly attractive alternative to Teflon injection, particularly when there is f...
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