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November 2020Introduction
Laryngeal framework surgery, contrived by Isshiki and colleagues (Acta Otolaryngol. 1974;78:451-457) has proven to be effective in adjusting the position and tension of the vocal folds by manipulating the laryngeal cartilages. Type I thyroplasty (TPI) moves the vocal folds inward, and arytenoid adduction (AA) adducts the vocal folds (Arch Otolaryngol. 1978;104:555-558). Both surgical methods have improved glottal insufficiency caused by incomplete closure of the vocal folds seen in unilateral vocal fold palsy.
A variety of implants are used to fix the vocal folds medially during TPI (Ann Otol Rhinol Laryngol Suppl. 1997;170:1-16. Otol Rhinol Laryngol. 1998;107:427-432. Ann Otol Rhinol Laryngol. 1999;108:79-86. Pract Otol. 2015;143:68-74). The present author has developed the “titanium medialization laryngoplasty implant” (TMLI) (patent number in Japan: 6434921) and reported on its usability (Nihon Jibiinkoka Gakkai Kaiho. 2015;118:1027-1036). Further, a number of modifications to AA, along with the surgical indications, have also been reported (Laryngoscope. 2007;117:1882-1887. J Voice. 2015;29:236-240. Laryngoscope. 2019;129:1876-1881). The present author also developed and proved the clinical utility of the “all muscles preserved method” (AMPM) (Clin Otolaryngol. 2019;44:1186-1189).
This study aims to present and discuss the results associated with a combined surgical approach of the above-mentioned methods to treat patients with severe breathy hoarseness.
Titanium medialization laryngoplasty implant. (Left side: scheme). The adjustment to achieve medialization is performed by molding the implant at a suitable site. (i) Handle. (ii) Medialization part. (a) This place adjusts the medialization of the vocal fold anteriorly and carries out compensation of the work of the thyroarytenoid muscle. (b) Adjusting the width and distance that carries out the medialization of the vocal fold here reforms the vibratory portion of the vocal fold. When the implant bends along the line imprinted on it, the medialization part is at a 15° incline to the handle. The implant is bent according to the position of the palsied vocal fold.
Method
All 10 patients underwent TPI using a TMLI combined with AA via the AMPM under general anesthesia. Owing to the requirement for a large incision and surgical manipulations around the arytenoid cartilage, a laryngeal mask was used for ventilation. Desflurane was administered for inhalation anesthesia; dexmedetomidine, flurbiprofen axetil, and fentanyl for intravenous anesthesia; and lidocaine and levobupivacaine for local infiltration.
AA was performed first, followed by TPI, during which time the patient was awakened and extubated to examine the effect of the medialization and to adjust positioning of the plate by listening to the voice of the patient.
However, pre- and postoperative vocal rehabilitation were not performed to exclusively evaluate the effect of the surgery. The examinations of vocal functions, including measuring the maximum phonation time (MPT), mean airflow rate (MFR), speaking fundamental frequency (SFF), pitch range (PR), and voice handicap index (VHI) (Jpn J Logop Phoniatr. 2014;55:291-298); performing an acoustic analysis of sustained vowel sounds using a multidimensional voice program (Pentax Medical, Montvale, NJ); and capturing video recordings of the laryngeal findings were performed before as well as one year following the surgery. In each case, the stability and fixation of the TMLI was examined using computed tomography (CT).
Postoperatively, there were significant improvements in the maximum phonation time, mean airflow rate, and voice handicap index.
Results
The patients’ average age was 67.9 years (range, 44-83 years). Postoperatively, there were significant improvements in the MPT, MFR, and VHI. Pre- and postoperative comparisons of SFF, PR, and acoustic parameters were not possible in most patients because they had difficulty producing sustained vowel sounds and had a very short MPT.
The mean postoperative SFF and PR were 145.7 Hz (range B2-G3) and 21.7 ± 4.5 semitones (mean ± standard deviation), respectively. The results of the postoperative acoustic analysis of the jitter %, shimmer %, and harmonic-to-noise ratio were 0.53 ± 0.18%, 2.54 ± 1.06%, and 0.12 ± 0.02, respectively. Almost all postoperative test results were in the normal range for elderly adult males. In the postoperative CT neck images, no implant migration, deformation, or fractures were identified.
View the results associated with the pre- and postoperative endoscopic laryngeal findings of the 10 patients in the video at https://players.brightcove.net/656326989001/default_default/index.html?videoId=6166961476001.