Laryngoplasty for the Treatment of Vocal Cord Paralysis in an Amateur Singer Warren
Rothman,
have performed a medialization laryngoplasty on a schoolteacher who was also an amateur singer. Medialization laryngoplasty has been slow to gain acceptance but offers many advantages over Teflon injection because it is a reversible procedure and can be utilized early in vocal cord paralysis instead of waiting 9 months. Postoperatively, the patient can vocalize more than two octaves with good volume. Objective measurement of results is needed in judging the success of these procedures. (Arch Otolaryngol Head Neck Surg. 1992;118:209-210) \s=b\ We
vocal cord
paralysis frequently Unilateral hoarse, breathy voice, occasionally aspiration.
causes a
and To the singer or professional speaker this condition is a disaster for which there has been no effective treatment. The treatment of unilateral vocal cord paralysis has been confined to the restoration of the speaking voice. We have recently had the opportunity to care for a patient with vocal cord paralysis who was an amateur singer. He un¬ derwent a medialization laryngoplasty 1 year after the onset of a left vocal cord paralysis. The patient's remark¬ able recovery was documented by videostroboscopy and by a pitch and intensity recorder (Visi Pitch recordings). METHODS AND MATERIALS Medialization laryngoplasty is generally performed under local anesthesia with little discomfort to the patient. The technique in¬ volves the creation of a window into the larynx. The size of the win¬ dow is determined using a formula developed by Koufman. ' Height of Window, mm (Height of Thyroid Cartilage, mm 4)/4 Width of Window, mm= (Width ofThyroid Cartilage, mm —4)/2 The win¬ dow is centered over the thyroid alar. Measurement of the external laryngeal framework is taken using calipers and a flexible ruler (Fig 1). A rectangular window is cut with a No. 11 knife blade or with a microsagittal saw if the thyroid cartilage has calcified. The inner layer of perichondrium around the window is elevated with a Penfield elevator (Fig 2). The cartilage is pushed inward and held in place with a piece of carved Silastic (Fig 3). The size and shape of the implant is usually 1 by 0.5 cm. The average height of the flange is =
MD
about 3 mm. The size and placement of the Silastic is determined by trial and error while asking the patient to phonate. A final inspection of the larynx is performed with a flexible nasolaryngoscope. The voice was analyzed by a speech pathologist using a pitch and in¬ tensity recorder (Visi Pitch Model 6087) with Visi Pitch/IBM interface (Kay Elemetrics Corp, Pine Brook, NJ). The vocal cord appearance was videorecorded on a recorder (Panasonic AG 2400) with a stro¬ boscope (Bruel and Kjaer Rhino-Larynx Stroboscope type 4914).
REPORT OF A CASE A 64-year-old schoolteacher and amateur singer was well until
February 1986 when he developed the sudden onset of hoarse¬ ness after a cold. His vocal intensity was reduced to a whisper. He denied aspiration and weight loss. He discontinued cigarette smoking in 1981 after the successful resection of a left upper lobe large-cell undifferentiated carcinoma. Physical examination re¬ vealed a paralyzed left vocal cord in the paramedian position. Chest roentgenogram, computed tomography, and videoesophagogram were normal. A thorough search for a tumor by esophagoscopy, direct laryngoscopy, and fiberoptic laryngoscopy was also negative. In March 1987 he underwent medialization laryn¬ goplasty using the Isshiki technique with a good return of both the speaking and singing voice. He is now 3 years post-vocal cord paralysis with no evidence of recurrent lung cancer, and he has
been followed up for the past 21 months since medialization laryngoplasty with maintenance of his good voice.
RESULTS Most patients can expect an excellent improvement in voice quality and pitch range. This patient was able to achieve a range (fundamental frequency) from 59 (low C) to 332 Hz (high E) as determined by (Visi Pitch) for a total of 2.25
—
Accepted for publication June 27, 1991. From the Department of Otolaryngology\p=n-\Headand Neck Surgery, The Johns Hopkins University, Baltimore, Md. Presented at the Southern Sectional Meeting of the Triologic Society, White Sulfur Springs, WVa, January 12, 1990. Reprint requests
21204 (Dr
to 7505 Osier
Rothman).
Drive, Suite 306, Baltimore,
MD
Fig t.—Approximate size of window and implant.
Downloaded From: http://archotol.jamanetwork.com/ by a Georgetown University Medical Center User on 05/22/2015
using a small Silastic implant placed laterally to the perichondrium through a laterally placed thyroid window. cases
COMMENT The mainstay of treatment even until today remains in¬ jection of the paralyzed cord with Teflon. In experienced hands this procedure usually gives a satisfactory speaking voice. Unfortunately, this therapy adds rigid bulk to the vocal cord in a somewhat unpredictable fashion. Rein-
Fig 2. —Plane
of dissection.
nervation techniques remain controversial and are not widely used as yet.8 Teflon injection has inherent disad¬ vantages. It is somewhat uncomfortable for the patient. The amount of Teflon injected and the location of the ma¬ terial are critical to the success of the procedure. Inad¬ vertent injection into the false cord may cause diplophonia.9 Reinjection is needed in approximately 20% of cases. Overinjection may necessitate tracheostomy in 1% of the cases. Excess Teflon is difficult to remove and vocal results tend to be poor. Most surgeons prefer to wait at least 9 months before injecting Teflon. Should vocal cord func¬ tion return, Teflon may diffuse leading to a stony hard vocal cord and a poor-quality voice.
Laryngoplasty offers advantages over Teflon injection speaking and the singing voice can be The medialization improved. technique is reversible and can be performed much sooner if necessary. Medializa¬ tion laryngoplasty may also be used in patients with con¬ genital atrophy of the vocal cords and in patients with surgical or traumatic cord defects. Medialization laryngoplasty offers a useful addition in the treatment of vocal cord paralysis and an alternative to Teflon injection. Its main appeal is improved voice qual¬ ity and vocal range as well as reversibility. It may, there¬ fore, be used early in the treatment of aspiration. It may in that both the
Fig 3.—Seating
of implant.
octaves. This compares favorably with an average range of 2.50+ octaves in the trained voice. Continuous vowel pro¬
duction was 25 seconds, voiceless phoneme Isi 33 seconds, and voiced phoneme Izl 20 seconds, which are all in the nor¬ mal range. The maximum intensity reached was 65 db for 4 seconds. He is now able to sing again and has returned to full-time work without use of a microphone.
HISTORICAL PERSPECTIVE Phonatory surgery has been slow to gain recognition, but considerable progress has been made in recent years. In 1915 Payr2 was the first to report a "U-" shaped flap for the treat¬ ment of vocal cord paralysis. Meurman3 presented an article to the Swedish Medical Society demonstrating a medializa¬ tion technique involving the use of costal cartilage. Opheim4 reported a medialization procedure using a piece of thyroid ala cartilage through a midline split. In 1968 Sawashima et al5 described 20 cases with a 90% to 95% success rate using thy¬ roid cartilage placed through a midline incision. Isshiki et al6-7 described an experiment in 10 dogs using
variety of phonosurgical techniques. The following year they reported several cases of medialization laryngoplasty through a rectangular window in the thyroid cartilage using a wedge of cartilage taken from the opposite thyroid ala. Their work has helped to popularize this procedure around the world. Koufman1 further modified this technique. He reported 11 a
also be used in those conditions where the cords are mo¬ bile. It may offer hope to the singer who suffers vocal cord paralysis. As additional cases are collected and studied objectively, this question shall eventually be answered. I thank David Miller for the original drawings of the larynx, Kath¬ rin Mattox for the German translation, and Cara Erskine for the voice recordings and analysis.
References Laryngoplasty for vocal cord medialization: an alternative to Teflon. Laryngoscope. 1986;96:726-731. 2. Payr. Plastik am Schildknorpel zur Behebung der Folgen einseitiger Stimmbandl\l=a"\hmung.Dtsch Med Wochenschr. 1915;43:1265-1270. 3. Meurman Y. Operative mediofixation of the vocal cord in complete unilateral paralysis. Arch Otolaryngol Head Neck 1. Koufman JA.
Surg. 1952;55:544-553.
4. Opheim O. Unilateral paralysis of the vocal cord. Acta Otolaryngol. 1955;45:226-230. 5. Sawashima M, Totsuka G, Kobayashi T, Hirose H. Surgery for hoarseness due to unilateral vocal cord paralysis. Arch Otolaryngol. 1968;87:289-293. 6. Isshiki N, Morita H, Okamura H, Hiramoto M. Thyroplasty as a new phonosurgical technique. Acta Otolaryngol.
1974;78:451-457. 7. Isshiki N, Okamura H, Ishikawa T.
Thyroplasty type I (latdysphonia due to vocal cord paralysis or atrophy. Acta Otolaryngol. 1975;80:465-473. 8. Crumley RL, Krzysztof I, McMicken B. Nerve transfer versus Teflon injection for vocal cord paralysis: a comparison. Laryngoscope. 1988;98:1200-1204. 9. Lewy RB. Experience with vocal cord injection. Ann Otol Rhinol Laryngol. 1976;85:440-450. eral
compression)
for
Downloaded From: http://archotol.jamanetwork.com/ by a Georgetown University Medical Center User on 05/22/2015
Rothman,
have performed a medialization laryngoplasty on a schoolteacher who was also an amateur singer. Medialization laryngoplasty has been slow to gain acceptance but offers many advantages over Teflon injection because it is a reversible procedure and can be utilized early in vocal cord paralysis instead of waiting 9 months. Postoperatively, the patient can vocalize more than two octaves with good volume. Objective measurement of results is needed in judging the success of these procedures. (Arch Otolaryngol Head Neck Surg. 1992;118:209-210) \s=b\ We
vocal cord
paralysis frequently Unilateral hoarse, breathy voice, occasionally aspiration.
causes a
and To the singer or professional speaker this condition is a disaster for which there has been no effective treatment. The treatment of unilateral vocal cord paralysis has been confined to the restoration of the speaking voice. We have recently had the opportunity to care for a patient with vocal cord paralysis who was an amateur singer. He un¬ derwent a medialization laryngoplasty 1 year after the onset of a left vocal cord paralysis. The patient's remark¬ able recovery was documented by videostroboscopy and by a pitch and intensity recorder (Visi Pitch recordings). METHODS AND MATERIALS Medialization laryngoplasty is generally performed under local anesthesia with little discomfort to the patient. The technique in¬ volves the creation of a window into the larynx. The size of the win¬ dow is determined using a formula developed by Koufman. ' Height of Window, mm (Height of Thyroid Cartilage, mm 4)/4 Width of Window, mm= (Width ofThyroid Cartilage, mm —4)/2 The win¬ dow is centered over the thyroid alar. Measurement of the external laryngeal framework is taken using calipers and a flexible ruler (Fig 1). A rectangular window is cut with a No. 11 knife blade or with a microsagittal saw if the thyroid cartilage has calcified. The inner layer of perichondrium around the window is elevated with a Penfield elevator (Fig 2). The cartilage is pushed inward and held in place with a piece of carved Silastic (Fig 3). The size and shape of the implant is usually 1 by 0.5 cm. The average height of the flange is =
MD
about 3 mm. The size and placement of the Silastic is determined by trial and error while asking the patient to phonate. A final inspection of the larynx is performed with a flexible nasolaryngoscope. The voice was analyzed by a speech pathologist using a pitch and in¬ tensity recorder (Visi Pitch Model 6087) with Visi Pitch/IBM interface (Kay Elemetrics Corp, Pine Brook, NJ). The vocal cord appearance was videorecorded on a recorder (Panasonic AG 2400) with a stro¬ boscope (Bruel and Kjaer Rhino-Larynx Stroboscope type 4914).
REPORT OF A CASE A 64-year-old schoolteacher and amateur singer was well until
February 1986 when he developed the sudden onset of hoarse¬ ness after a cold. His vocal intensity was reduced to a whisper. He denied aspiration and weight loss. He discontinued cigarette smoking in 1981 after the successful resection of a left upper lobe large-cell undifferentiated carcinoma. Physical examination re¬ vealed a paralyzed left vocal cord in the paramedian position. Chest roentgenogram, computed tomography, and videoesophagogram were normal. A thorough search for a tumor by esophagoscopy, direct laryngoscopy, and fiberoptic laryngoscopy was also negative. In March 1987 he underwent medialization laryn¬ goplasty using the Isshiki technique with a good return of both the speaking and singing voice. He is now 3 years post-vocal cord paralysis with no evidence of recurrent lung cancer, and he has
been followed up for the past 21 months since medialization laryngoplasty with maintenance of his good voice.
RESULTS Most patients can expect an excellent improvement in voice quality and pitch range. This patient was able to achieve a range (fundamental frequency) from 59 (low C) to 332 Hz (high E) as determined by (Visi Pitch) for a total of 2.25
—
Accepted for publication June 27, 1991. From the Department of Otolaryngology\p=n-\Headand Neck Surgery, The Johns Hopkins University, Baltimore, Md. Presented at the Southern Sectional Meeting of the Triologic Society, White Sulfur Springs, WVa, January 12, 1990. Reprint requests
21204 (Dr
to 7505 Osier
Rothman).
Drive, Suite 306, Baltimore,
MD
Fig t.—Approximate size of window and implant.
Downloaded From: http://archotol.jamanetwork.com/ by a Georgetown University Medical Center User on 05/22/2015
using a small Silastic implant placed laterally to the perichondrium through a laterally placed thyroid window. cases
COMMENT The mainstay of treatment even until today remains in¬ jection of the paralyzed cord with Teflon. In experienced hands this procedure usually gives a satisfactory speaking voice. Unfortunately, this therapy adds rigid bulk to the vocal cord in a somewhat unpredictable fashion. Rein-
Fig 2. —Plane
of dissection.
nervation techniques remain controversial and are not widely used as yet.8 Teflon injection has inherent disad¬ vantages. It is somewhat uncomfortable for the patient. The amount of Teflon injected and the location of the ma¬ terial are critical to the success of the procedure. Inad¬ vertent injection into the false cord may cause diplophonia.9 Reinjection is needed in approximately 20% of cases. Overinjection may necessitate tracheostomy in 1% of the cases. Excess Teflon is difficult to remove and vocal results tend to be poor. Most surgeons prefer to wait at least 9 months before injecting Teflon. Should vocal cord func¬ tion return, Teflon may diffuse leading to a stony hard vocal cord and a poor-quality voice.
Laryngoplasty offers advantages over Teflon injection speaking and the singing voice can be The medialization improved. technique is reversible and can be performed much sooner if necessary. Medializa¬ tion laryngoplasty may also be used in patients with con¬ genital atrophy of the vocal cords and in patients with surgical or traumatic cord defects. Medialization laryngoplasty offers a useful addition in the treatment of vocal cord paralysis and an alternative to Teflon injection. Its main appeal is improved voice qual¬ ity and vocal range as well as reversibility. It may, there¬ fore, be used early in the treatment of aspiration. It may in that both the
Fig 3.—Seating
of implant.
octaves. This compares favorably with an average range of 2.50+ octaves in the trained voice. Continuous vowel pro¬
duction was 25 seconds, voiceless phoneme Isi 33 seconds, and voiced phoneme Izl 20 seconds, which are all in the nor¬ mal range. The maximum intensity reached was 65 db for 4 seconds. He is now able to sing again and has returned to full-time work without use of a microphone.
HISTORICAL PERSPECTIVE Phonatory surgery has been slow to gain recognition, but considerable progress has been made in recent years. In 1915 Payr2 was the first to report a "U-" shaped flap for the treat¬ ment of vocal cord paralysis. Meurman3 presented an article to the Swedish Medical Society demonstrating a medializa¬ tion technique involving the use of costal cartilage. Opheim4 reported a medialization procedure using a piece of thyroid ala cartilage through a midline split. In 1968 Sawashima et al5 described 20 cases with a 90% to 95% success rate using thy¬ roid cartilage placed through a midline incision. Isshiki et al6-7 described an experiment in 10 dogs using
variety of phonosurgical techniques. The following year they reported several cases of medialization laryngoplasty through a rectangular window in the thyroid cartilage using a wedge of cartilage taken from the opposite thyroid ala. Their work has helped to popularize this procedure around the world. Koufman1 further modified this technique. He reported 11 a
also be used in those conditions where the cords are mo¬ bile. It may offer hope to the singer who suffers vocal cord paralysis. As additional cases are collected and studied objectively, this question shall eventually be answered. I thank David Miller for the original drawings of the larynx, Kath¬ rin Mattox for the German translation, and Cara Erskine for the voice recordings and analysis.
References Laryngoplasty for vocal cord medialization: an alternative to Teflon. Laryngoscope. 1986;96:726-731. 2. Payr. Plastik am Schildknorpel zur Behebung der Folgen einseitiger Stimmbandl\l=a"\hmung.Dtsch Med Wochenschr. 1915;43:1265-1270. 3. Meurman Y. Operative mediofixation of the vocal cord in complete unilateral paralysis. Arch Otolaryngol Head Neck 1. Koufman JA.
Surg. 1952;55:544-553.
4. Opheim O. Unilateral paralysis of the vocal cord. Acta Otolaryngol. 1955;45:226-230. 5. Sawashima M, Totsuka G, Kobayashi T, Hirose H. Surgery for hoarseness due to unilateral vocal cord paralysis. Arch Otolaryngol. 1968;87:289-293. 6. Isshiki N, Morita H, Okamura H, Hiramoto M. Thyroplasty as a new phonosurgical technique. Acta Otolaryngol.
1974;78:451-457. 7. Isshiki N, Okamura H, Ishikawa T.
Thyroplasty type I (latdysphonia due to vocal cord paralysis or atrophy. Acta Otolaryngol. 1975;80:465-473. 8. Crumley RL, Krzysztof I, McMicken B. Nerve transfer versus Teflon injection for vocal cord paralysis: a comparison. Laryngoscope. 1988;98:1200-1204. 9. Lewy RB. Experience with vocal cord injection. Ann Otol Rhinol Laryngol. 1976;85:440-450. eral
compression)
for
Downloaded From: http://archotol.jamanetwork.com/ by a Georgetown University Medical Center User on 05/22/2015
