A Modified Laryngeal Stent for Glotto-Subglottic Stenosis: A Novel Stent for Better Outcomes.

Management of laryngotracheal stenosis is challenging and laryngotracheal stenosis is generally managed with laryngotracheal reconstruction. Stents are often used as part of the reconstructive surgery. Although most stents adequately stabilize the reconstruction during healing, they often do a poor job of mimicking glottic anatomy, particularly the anterior glottis. Here, we present a modified suprastomal stent designed to stabilize reconstruction after laryngotracheal reconstruction while also improving postoperative glottic anatomy and function. The case of a 15-year-old tracheostomy-dependent patient with glotto-subglottic stenosis who underwent laryngotracheal reconstruction using this modified stent is described. The patient had an excellent outcome with decannulation of her tracheostomy and significant improvement in voice.

Predictors of Increased Surgical Drain Output following Type I Thyroplasty for Glottic Insufficiency.

OBJECTIVE: To determine predictors of increased drain output following type I thyroplasty for glottic insufficiency. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective review was conducted for patients who underwent type I thyroplasty for glottic insufficiency from 2014-2019. The primary outcome was 24-hour drain output. Increased drain output was defined as >50th percentile for the sample. Univariate logistic regression models and linear regression models were used. RESULTS: There were 84 patients with a mean age of 58.9 (SD 16.9) years. Twenty-four-hour drain output ranged from 0 to 29 mL with a mean of 9.47 (SD 6.49) mL. Patients with a history of tobacco use (OR 3.33; 95% CI, 1.24-8.95; P = .017) and prior neck surgery (OR 3.52; 95% CI, 1.26 to 9.83; P = .016) were significantly more likely to have increased drain output following surgery; these patients had a mean increase in 24-hour drain output of 3.51 mL (95% CI, 0.52 to 6.51; P = .022) and 1.74 mL (95% CI, -1.41 to 4.89; P = .274), respectively. Type of implant (Gore-Tex vs. Silastic; P = .425) and operative technique (unilateral vs. bilateral; P = .506) were not significantly associated with drain output. CONCLUSION: History of tobacco use and prior surgery of the neck predict increased drain output following type I thyroplasty surgery. These patients may derive the most benefit from surgical drain placement. More research is needed to confirm these findings and elucidate potential mechanisms. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1557-1560, 2021.

Three-dimensional vocal fold structural change due to implant insertion in medialization laryngoplasty.

Glottal insufficiency due to vocal fold paralysis, paresis, or atrophy often leads to degraded voice quality. One of the primary surgical intervention procedures to treat glottal insufficiency is medialization laryngoplasty, in which an implant is inserted through a lateral window on the thyroid cartilage to medialize the vocal folds. While the goal of medialization is to modify the vocal fold structure to restore normal phonation, few studies have attempted to quantify such structural changes of the vocal folds. The goal of this study is to quantify the three-dimensional structural changes of the vocal folds due to implant insertion in medialization laryngoplasty, and evaluate its potential effect on voice production. Medialization laryngoplasty were performed in excised human larynges using implants of different stiffness. Magnetic resonance images of the larynges were obtained with and without implant insertion. The results showed that implant insertion significantly changed the original body-cover structure of the vocal folds, with the implant taking over the large space used to be occupied by the original body layer and the vocal fold being stretched into a thin layer wrapped around the implant. The medial-lateral dimension of the vocal fold was significantly reduced from about 4 mm to 1 mm, and the vocal fold was stretched in the coronal plane by about 70%. It is hypothesized that use of implants with stiffness comparable to that of the vocal folds is beneficial because the degree of medialization can be adjusted without much negative effects on phonation frequency, phonation threshold pressure, or vibration amplitude.

Precision treatment of post pneumonectomy unilateral laryngeal paralysis due to cancer.

Aim: The aim of this study is to assess the efficacy of external laryngeal medialization acquired through a Gore-Tex implant in a 45 patients affected by unilateral vocal fold paralysis in abduction after pneumonectomy. Method: The cohort of patients was made up of 30 male (73.1%) and 11 female patients (26.9%) with an average age of 66.7 years in a range between 46 and 78 years. Results: The results were analyzed with the objective and subjective analysis of voicing and swallowing. In 95.2% of cases, voice and swallow improvement with statistically significant evidences. Conclusion: We can conclude that Gore-Tex implantation is a simple, reproducible and minimally invasive procedure for management of selected cases of vocal fold unilateral paralysis in the abductory position.

Surgical Impact of the Montgomery Implant System on Arytenoid Cartilage and the Paralyzed Vocal Fold.

OBJECTIVES/HYPOTHESIS: Medialization thyroplasty (MT) has become a prominent method for treating glottal insufficiency. This study aimed to visualize the biomechanical influence of a medialization implant on arytenoid cartilage, particularly on the length and level of paralyzation in the vocal fold, in patients with unilateral vocal fold paralysis. STUDY DESIGN: Prospective study. METHODS: We recruited 15 patients (10 men, 5 women) with unilateral vocal fold paralysis that underwent MT with a Montgomery® thyroplasty implant. We performed high-resolution computed tomography of the arytenoid cartilage before and after MT and analyzed the three-dimensional images. To visualize the movement of the arytenoid and to measure the lengthening of the vocal fold, we superimposed pre- and postoperative 3D images with MIMICS software. RESULTS: On the affected side, the implant pushed the arytenoid backwards. In addition, the vocal process of the arytenoid was inwardly rotated. These movements resulted in an elongated, augmented vocal fold on the affected side. CONCLUSION: MT led to an elongated, medialized vocal fold on the treated side. After the intervention, the vocal folds on both sides were the same length in the phonatory position.

Anesthetic Management for Medialization Laryngoplasty Performed Under Concurrent Dexmedetomidine, Remifentanil, and Propofol Infusions.

INTRODUCTION: Type I thyroplasty, or medialization larygoplasty (ML), is a procedure which improves the voice by medializing a vocal fold with a permanent implant. Anesthetic management of these cases is challenging because patients can require periods of deep sedation followed by fully awake moments for phonation to assess the implant size. We present our experience of ML with or without arytenoid adduction (AA) using a multimodal anesthetic regimen consisting of concurrent infusions of dexmedetomidine, remifentanil, and propofol. METHODS: This is a retrospective case series of patients anesthetized using this protocol from June 1, 2015 through June 30, 2017. RESULTS: Seventy-five consecutive ML with or without AA patients anesthetized with dexmedetomidine and remifentanil infusions were identified, of which 74 (98.7%) also received concurrent propofol infusions. Mean duration of sedation was 190.9 ± 36.9 minutes and surgery was 139 ± 35.3 minutes. Transient hypopnea treated with supplemental oxygen complicated 18 (24%) cases and bradycardia requiring pharmacologic treatment complicated 3 (4%) cases. There were no other adverse anesthetic complications. One patient required surgical re-exploration due to postsurgical bleeding after the initial hospital discharge. CONCLUSION: In this cohort, a combination of remifentanil, dexmedetomidine and propofol infusions was well tolerated without serious adverse perioperative events.

Pre- and intraoperative acoustic and functional assessment of the novel APrevent® VOIS implant during routine medialization thyroplasty.

PURPOSE: Persistent unilateral vocal fold paralysis (UFVP) with glottal insufficiency often requires type I medialization thyroplasty (MT). Previous implants cannot be adjusted postoperatively if necessary. The newly developed APrevent® VOIS implant (VOIS) can provide postoperative re-adjustment to avoid revision MT. The objective of this pilot study is to evaluate the VOIS intraoperatively concerning voice improvement, surgical feasibility and device handling. METHODS: During routine MT, VOIS was applied short time in eight patients before the regular implantation of the Titanium Vocal Fold Medialization Implant (TVFMI™). In all patients, perceptual voice sound analysis using R(oughness)-B(reathiness)-H(oarseness)-scale, measurement of M(aximum)-P(honation)-T(ime) and glottal closure in videolaryngoscopy were performed before and after implanting VOIS/TVFMI™. Acoustic analyses of voice recordings were performed using freeware praat. Surgical feasibility, operative handling and device fitting of VOIS and TVFMI™ were assessed by the surgeon using V(isual)-A(nalog)-S(cale). Data were statistically analyzed with paired t test. RESULT: All patients showed significant improvement of voice sound parameters after VOIS/TVFMI™ implantation. The mean RBH-scale improved from preoperative R = 2.1, B = 2.3, H = 2.5 to R = 0.6, B = 0.3, H = 0.8 after VOIS and R = 0.5, B = 0.3, H = 0.8 after TVFMI™ implantation. The mean MPT increased from preoperative 7.9 to 14.6 s after VOIS and 13.8 s after TVFMI™ implantation. VOIS/TVFMI™ achieved complete glottal closure in 7/8 patients. The satisfaction with intraoperative device fitting and device handling of VOIS was as good as that of TVFMI™. CONCLUSION: The novel APrevent® VOIS implant showed similar intraoperative voice improvement compared to routinely used TVFMI™ without adverse device events and with safe device fitting.

Pin-up Glottoplasty: Feasibility Study of a Novel Approach Medializing or Lateralizing Immobile Vocal Folds.

Principles in medializing and lateralizing vocal folds have not changed a lot within the last decades (Isshiki et al, 1974; Bruenings, 1911). We present a feasibility study for a completely new approach to perform medialization and lateralization of immobile vocal folds. The method was tested on 20 human larynges by inserting a 21G needle into the vocal fold, medializing (or, in other cases, lateralizing) the vocal cord and fixing the needle at the cricoid cartilage posteriorly. The anterior and posterior fixation points of the needle allow for a stable positioning of the needle, which we consider necessary in both cases of medialization or lateralization. The needle position was examined visually as well as three-dimensionally via cone beam computed tomography.

Evaluation of a prototype dynamic laryngoplasty system in vitro with an equine vacuum airflow system.

OBJECTIVE: To evaluate a prototype dynamic laryngoplasty system (DLPS) in a static airflow model. STUDY DESIGN: Experimental. SAMPLE POPULATION: Ten equine larynges. METHODS: The right arytenoid was fixed in abduction in all specimens. A left-sided laryngoplasty was performed with No. 2 Fiberwire and a FASTakII anchor. Each larynx was tested in a static airflow model. The system was adjusted to a flow rate of 55 L/s and prelaryngeal pressure of 12 mm Hg prior to testing in maximal arytenoid abduction. In phase 1, the left suture was loosened, shortened, and tested in 3-mm steps from 0 to 30 mm. In phase 2, the suture was tied with the DLPS in position at a target left-to-right quotient angle (LRQ) of 0.5. The DLPS was activated to target psi of 0, 25, and 50 for testing. Translaryngeal impedance (TLI), LRQ, cross-sectional areas (CSA), and resultant change in LRQ and CSA between, before, and during airflow testing were calculated. RESULTS: In phase 1, TLI was reduced by suture shortening up to 6 mm (P = .001) but not by additional shortening (P > .05). In phase 2, activation of the DLPS reduced the TLI from 0 psi (0.43 ± 0.08 mm Hg/L/s) to 25 psi (0.16 ± 0.04 mm Hg/L/s, P < .001), but no further reduction was detected at maximal psi (P = .10). CONCLUSION: Activation of the DLPS effectively reduced TLI. CLINICAL SIGNIFICANCE: These results justify further investigation of the DLPS to assess its clinical applicability.

Operative Procedure of Anterior Commissure for Type II Thyroplasty.

OBJECTIVE: We reviewed the clinical anatomy of the anterior commissure and examined the effectiveness of a specialized spreader developed for optimal, efficient spreading of the thyroid cartilage in type II thyroplasty. STUDY DESIGN AND METHODS: The present study was a multicenter retrospective study of patients with spasmodic dysphonia who underwent a primary operation either before or after the introduction of a specialized spreader (in 2008 or 2014, respectively). In these patients, we examined the size of the titanium bridge used, the presence of perforation of the mucosa directly superior to the anterior commissure, and postoperative glottic findings. RESULTS: The sample comprised 39 and 40 patients who underwent surgery in 2008 and 2014, respectively. The mean size of the titanium bridge used during surgery was significantly smaller in 2014 (2.9 mm) than in 2008 (3.81 mm). Perforation of the laryngeal mucosa occurred in 13 patients in 2008 but occurred in only one patient in 2014. Based on glottic findings, spreading the thyroid cartilage using the specialized spreader was deemed to yield an effective glottic gap. CONCLUSIONS: In type II thyroplasty, the handling of the anterior commissure is the most important point. It is necessary to split the tendon and to spread the glottis while the tendon is joined with the cartilage. For this purpose, a specialized spreader was made. The use of a specialized spreader renders separation around the anterior commissure unnecessary, enabling minimally invasive spreading of the thyroid cartilage and thereby improving phonation.

Injection laryngoplasty through a transoral approach using the Guedel oral airway.

Injection laryngoplasty has gained popularity as a treatment modality for glottal insufficiency. Several approaches have been described, specifically transcutaneous, transoral and transnasal. The authors describe a novel technique performed successfully on three subjects, namely endoscopic injection laryngoplasty using the modified Guedel oral airway. There was marked improvement in dysphonia, maximum phonation time and closed quotient in all three subjects with a decrease in the Voice Handicap Index-10 score. This new approach is a viable approach for the treatment of glottal insufficiency.

Current trends of balloon laryngoplasty in Thailand.

OBJECTIVE: To describe the current trend in balloon laryngoplasty usage and experience by practicing otolaryngologists in Thailand. STUDY DESIGN: Anonymous 11 question online and paper survey of otolaryngologists on their current balloon laryngoplasty practices. SUBJECTS AND METHODS: Current practices and experience in balloon laryngoplasty were queried with multiple choice and open-ended questions. RESULTS: Laser use is the most commonly utilized instrument to treat airway stenosis in Thailand. 86% of respondents do not have experience with balloon dilatation; yet, almost half (47.6%) report they perform a minimum of five airway surgeries per year. Most respondents had been in practice for less than 6 years (41%) and reported that they did not have exposure to balloon use during residency training. The largest barrier reported for the use of balloon instrumentation in the airway is inexperience (44.4%) followed by cost (38.3%), yet most feel that treatment in airway stenosis could benefit by usage of balloons (95.5%). CONCLUSIONS: Most otolaryngologists in Thailand do not have experience with the use of balloon dilatation and lack of exposure remains the largest barrier to its use. Otolaryngologists in Thailand feel that increased usage of balloons in the airway could improve airway stenosis treatment in the country.

Shape of Thyroid Cartilage Influences Outcome of Montgomery Medialization Thyroplasty: A Gender Issue.

OBJECTIVE: This study aimed to determine whether the shape of the thyroid cartilage and gender influence voice outcomes after a Montgomery thyroplasty implant system (MTIS). METHODS: A retrospective cohort study was performed on 20 consecutive patients who underwent MTIS. Voice outcome variables were the relative decrease in Voice Handicap Index (%) and the absolute increase in maximum phonation time (MPT) (in seconds). Material variables were the angle between the thyroid cartilage laminae (α-angle), the size of the prosthesis, and a combination of both (the α-ratio). Continuous variables were analyzed using medians and were compared between groups using the Mann-Whitney U test. Factors associated with the outcome variables were assessed by multivariable linear regression. A Pearson coefficient was calculated between material variables. RESULTS: The absolute increase in MPT between the pre- and postoperative period was significantly different between men and women, with a median absolute increase of 11.0 seconds for men and of 1.3 seconds for women (P < 0.001). A strong inverse correlation between the α-ratio and the absolute increase in MPT is observed in all patients, with a Pearson correlation coefficient R = -0.769 (P < 0.001). No factors were significantly associated with the relative Voice Handicap Index decrease in univariable or multivariable analyses. A better Pearson coefficient between the α-angle and the prosthesis size was found for females (0.8 vs 0.71). CONCLUSION: The MTIS is a good thyroplasty modality for male patients, but inadequate design of MTIS female implants leads to poor MPT outcomes. This represents a gender issue that needs to be further studied and eventually tackled.

Longitudinal Voice Outcomes After Type I Gore-tex Thyroplasty for Nonparalytic Glottic Incompetence.

OBJECTIVE: Type I Gore-tex thyroplasty (GTP) for nonparalytic glottic incompetence (GI) results in significantly improved subjective and perceptual voice outcomes. We endeavored to investigate the longitudinal course of voice outcomes measuring the same patients across time points stratified by diagnostic subgroup. METHODS: Seventy-five patients with nonparalytic GI treated with GTP in the past 9 years were retrospectively reviewed and grouped according to their primary diagnoses (atrophy, scar, hypomobility, and paresis). Voice outcome measures, Voice-Related Quality of Life (VRQOL), Glottal Function Index (GFI), and GRBAS (grade, roughness, breathiness, asthenia, and strain) for each individual patient and diagnostic subgroup were grouped by time interval following surgery: 0 to 90 days, 3 to 9 months, 9 to 18 months, 18 to 36 months, 3 to 5 years, and 5 to 10 years. RESULTS: Across all diagnoses, statistically significant improvement in VRQOL was maintained at 3 to 5 years (P = .03) and GFI at 5 to 10 years (P = .02). The GRBAS showed statistically significant improvements out to 18 to 36 months (P = .02). In the subgroup analysis, hypomobility/paresis patients maintained significant improvement voice measures longer than patients with other diagnoses. As a group, scar patients did not show statistically significant postoperative improvement in VRQOL or GFI at any of the tested time points. CONCLUSIONS: Gore-tex thyroplasty provides durable improvement in subjective and perceptual voice outcomes for patients with nonparalytic GI. Patients treated for hypomobility/paresis have the most durable vocal outcomes followed by atrophy and lastly, scar.

[The long-term results of the application of the polypropylene mesh for the plastic correction of extensive laryngo-tracheostomas].

The objective of the present study was to estimate the long-term results of the closure of large laryngeal and tracheal stomas with the use of the polypropylene mesh. The study included 33 adult patients presenting with extensive laryngeal and tracheal stomas. A total of 34 surgical interventions were performed for alloplastic correction of these defects. The complete closure of the tracheal and laryngeal defects with the incorporation of the prosthesis and restoration of respiration was achieved in 88.2% of the alloplastic procedures. The long-term follow-up of the treated patients (median: 75 months) failed to reveal any signs of mesh rejection. Moreover, none of the patients reported an appreciable feeling of discomfort at the site of mesh localization. Thus, the results of the study indicate that the alloplastic correction of laryngeal and tracheal stomas with the implantation of the modern mesh prostheses from polypropylene monofilaments provides the safe and reliable alternative to autoplastic surgery. Low rigidity of the modern prosthetic meshes ensures good immediate results of implant survival in the absence of long-term complications associated with the durable presence of the polypropylene mesh on the neck.

Endoscopic vocal fold injection using a 25-gauge butterfly needle.

OBJECTIVE: To describe a useful technique for infiltrating a bulking agent using a butterfly needle, as part of a transoral endoscopic vocal fold medialisation procedure. METHODS: This paper describes the procedure of grasping the needle with phonosurgery forceps and administering the injectate to the vocal fold through careful application of the syringe plunger via a length of rubber tubing from outside the mouth. RESULTS: This procedure is performed routinely in our institution without complication. The advantages of this technique are discussed. CONCLUSION: This is a safe and easy method of injecting into a vocal fold.

Voice tuning with new instruments for type II thyroplasty in the treatment of adductor spasmodic dysphonia.

OBJECTIVE: Adductor spasmodic dysphonia is a rare voice disorder characterized by strained and strangled voice quality with intermittent phonatory breaks and adductory vocal fold spasms. Type II thyroplasty differs from previous treatments in that this surgery does not involve any surgical intervention into the laryngeal muscle, nerve or vocal folds. Type II thyroplasty intervenes in the thyroid cartilage, which is unrelated to the lesion. This procedure, conducted with the aim of achieving lateralization of the vocal folds, requires utmost surgical caution due to the extreme delicacy of the surgical site, critically sensitive adjustment, and difficult procedures to maintain the incised cartilages at a correct position. During surgery, the correct separation of the incised cartilage edges with voice monitoring is the most important factor determining surgical success and patient satisfaction. METHODS: We designed new surgical instruments: a thyroid cartilage elevator for undermining the thyroid cartilage, and spacer devices to gauge width while performing voice monitoring. These devices were designed to prevent surgical complications, and to aid in selecting the optimal size of titanium bridges while temporally maintaining a separation during voice monitoring. RESULTS: We designed new surgical instruments, including a thyroid cartilage elevator and spacer devices. Precise surgical procedures and performing voice tuning during surgery with the optimal separation width of the thyroid cartilage are key points for surgical success. CONCLUSION: We introduce the technique of voice tuning using these surgical tools in order to achieve a better outcome with minimal surgical complications.