Introduction
Unilateral vocal fold paralysis reduces a patient's quality of life by inducing severe dysphonia and aspiration. However, laryngeal framework surgery can significantly improve the symptoms of unilateral vocal fold paralysis. Laryngeal framework surgery comprises medialisation laryngoplasty and arytenoid adduction procedures. Since their introduction, these procedures have become common treatments for vocal fold paralysis and glottal incompetence. However, not all procedures provide satisfactory long-term phonological results. In some cases, symptoms have recurred, requiring revision surgery.Reference Young, Zullo and Rosen1, Reference Andrews, Van Daele, Karnell, McCulloch, Graham and Hoffman2 In our experience, revision medialisation laryngoplasty is easy to perform, but revision arytenoid adduction is more difficult because the surgical field is severely scarred after primary arytenoid adduction. Several important anatomical structures such as the pyriform sinus mucosa and carotid artery can be affected. Thus, revision arytenoid adduction requires a different approach from primary arytenoid adduction.
A method involving directly pulling the lateral cricoarytenoid muscle was first reported by Iwamura and Kurita.Reference Iwamura and Kurita3 Tokashiki and colleagues modified the procedure using a fenestration approach and obtained good phonological results in combination with medialisation laryngoplasty.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4, Reference Tokashiki, Hiramatsu, Shinada, Motohashi, Nomoto and Toyomura5 This approach is simple and enables arytenoid adduction to be performed through a window made in the posterior lower thyroid alar cartilage to enable pulling of the lateral cricoarytenoid muscle or the muscle process of the arytenoid cartilage.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4, Reference Tokashiki, Hiramatsu, Shinada, Motohashi, Nomoto and Toyomura5 The approach differs from the original Isshiki method, in which the thyroid alar cartilage is extended outward and the pyriform sinus mucosa is dissected to reach the cricoarytenoid joint (using a posterior approach).Reference Isshiki, Tanabe and Sawada6 We recently performed medialisation laryngoplasty and arytenoid adduction using the lateral cricoarytenoid muscle pull method as revision surgery in a patient who had previously undergone medialisation laryngoplasty and arytenoid adduction using the original posterior approach.
Case report
A 69-year-old woman had breathy hoarseness and severe aspiration after mediastinal surgery to remove a metastatic breast cancer tumour. Laryngoscopy revealed that the left vocal fold was fixed in a lateral position, with vocal fold bowing. The maximum phonation time was 3 seconds and the mean flow rate was greater than 1000 ml/s. Shimmer or jitter could not be measured. Upon phonation, a wide posterior glottal chink was observed. Thus, arytenoid adduction combined with medialisation laryngoplasty (i.e. combined surgery) was required to improve these measures (Table I). First, combined surgery was performed in accordance with descriptions in previous reports.Reference Kanazawa, Watanabe, Hara, Shinnabe, Kusaka and Murayama7 After creating a cervical incision, the thyroid cartilage was skeletonised. The inferior pharyngeal constrictor muscle was then removed from the thyroid cartilage to expose the posterior portion of the lamina. After forming a window for medialisation laryngoplasty, the thyroid cartilage was twisted and the surgical field was reached using a posterior approach (Figure 1a). The pyriform sinus mucosa was elevated from the underside of the thyroid cartilage to expose the muscular process of the arytenoid cartilage. The muscular process was then stitched with nylon suture and pulled to contract the lateral cricoarytenoid muscle. After arytenoid adduction, a strip of Gore-Tex (W. L. Gore, Flagstaff, Arizona, USA) was packed into the subperichondrial pocket of the medialisation laryngoplasty window. After the first surgery, phonological results were obviously improved. The maximum phonation time was 15 seconds and the mean flow rate was 149 ml/s. Shimmer and jitter values were 3.7 per cent and 0.4 per cent, respectively (Table I).
Fig. 1 (a) Diagram showing differences between the lateral cricoarytenoid muscle (LCA) pull method and the original arytenoid adduction method using a posterior approach. The curved arrow indicates the direction of the original arytenoid adduction using the posterior approach. The dashed arrows represent sutures passed through the fenestration (F) to pull and fix the lateral cricoarytenoid muscle. The window (W) used for medialisation laryngoplasty is shown. The figure is modified from Tokashiki et al.9 (reprinted with permission). (b) Intra-operative image, showing a fenestration (F) in the upper rear of the medialisation laryngoplasty window (W) in the thyroid cartilage
Table I Voice evaluation before and after surgery
MPT = maximum phonation time; s = seconds; MFR = mean flow rate
However, 18 months after the primary surgery, the patient again experienced breathy hoarseness and aspiration, and the results of acoustic analysis were worse. The maximum phonation time decreased to 4 seconds and the mean flow rate increased to 766 ml/s. Shimmer and jitter values were 15.4 per cent and 7.0 per cent, respectively (Table I). Laryngoscopy revealed that the position of the Gore-Tex was unchanged; however, a posterior glottal chink was observed. Revision surgery was therefore performed to correct latent arytenoid adduction failure was thought to have occurred. The portion dissected in the first surgery was cicatrised, but it was difficult to identify the cricoarytenoid joint using a similar approach to the one used in the first surgery. Thus, to perform revision arytenoid adduction, a fenestration approach was used to pull the lateral cricoarytenoid muscle (Figure 1a). A fenestration was created at the upper rear of the medialisation laryngoplasty window in the thyroid cartilage (Figure 1b). Intra-operative laryngoscopy revealed that the paralysed side of the vocal process was located at a higher point than the normal side (Figure 2a). The lateral cricoarytenoid muscle was identified through the fenestration and pulled anteriorly using a 4-0 gauge nylon thread. The paralysed side of the vocal process was pulled down to a lower point than the normal side of the vocal process using the lateral cricoarytenoid muscle pull method (Figure 2b). The adductive effect of the lateral cricoarytenoid muscle pull method was similar to that of the original arytenoid adduction, as previously reported.Reference Kanazawa, Watanabe, Hara, Shinnabe, Kusaka and Murayama7 Medialisation laryngoplasty was then performed in the same way as the primary operation. The maximum phonation time improved to 11 seconds, and the mean flow rate decreased to 173 ml/s. Shimmer and jitter values were 4.9 per cent and 1.4 per cent, respectively, after the operation. These values were all within the normal ranges, and the patient's voice recovered to normal in terms of perceptual impression. Her post-operative course was uneventful for 10 months after the revision surgery.
Fig. 2 Positions of the paralysed side (VP-p) and normal side (VP-n) of the vocal process during surgery, as indicated by circles. (a) The VP-p was initially located at a higher point than the VP-n. (b) The VP-p was pulled down to a lower point than the VP-n using the lateral cricoarytenoid muscle pull method
Ethical standards
All procedures were performed in compliance with the ethical standards of the relevant national and institutional guidelines on human experimentation (Shinn-Oyama City Hospital) and with the Helsinki Declaration of 1975, as revised in 2008.
Discussion
Laryngeal framework surgery is a well-known surgical procedure for treating unilateral vocal fold paralysis. Medialisation laryngoplasty and/or arytenoid adduction can be performed, depending on the severity of hoarseness. In the case of severe unilateral vocal fold paralysis, arytenoid adduction combined with medialisation laryngoplasty (i.e. combined surgery) is needed to obtain acceptable results.Reference Franco and Andrus8 Although good vocal outcomes after laryngeal framework surgery have been described, they can be variable and may change over time. When adequate phonological results are not achieved, a revision procedure may be indicated. Young et al. described revision surgery following laryngeal framework surgery in 6 per cent of cases.Reference Young, Zullo and Rosen1 Common revision surgeries involved replacement with a larger (in 37 per cent of all medialisation laryngoplasty revisions) or smaller (in 8 per cent of cases) implant, and repositioning of the implant (in 24 per cent of cases).Reference Young, Zullo and Rosen1 Arytenoid adduction and vocal fold injection augmentation were performed in 10.3 per cent and 19.7 per cent of surgeries, respectively.Reference Young, Zullo and Rosen1 However, there are no reports of revision surgery for arytenoid adduction itself. This may be because arytenoid adduction is a stable surgical procedure, with little chance of failure. Alternatively, the surgical field following primary arytenoid adduction may contain severe scarring that might cause pyriform sinus mucosal damage, leading to difficulties in revision surgery.
We directly pulled the lateral cricoarytenoid muscle using a fenestration approach and observed a good phonological outcome. The fenestration approach was first proposed by Iwamura and KuritaReference Iwamura and Kurita3 in the Japanese literature and was later modified by Tokashiki et al.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4, Reference Tokashiki, Hiramatsu, Shinada, Motohashi, Nomoto and Toyomura5 Of course, this procedure is also useful as a primary surgery, and its advantages in this context have been reported.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4, Reference Tokashiki, Hiramatsu, Shinada, Motohashi, Nomoto and Toyomura5, Reference Tokashiki, Hiramatu, Tsukahara, Kanebayashi, Nakamura and Motohashi9, Reference Tsukahara, Tokashiki, Hiramatsu and Suzuki10 Both fenestration and posterior approaches can be used to perform arytenoid adduction and medialisation laryngoplasty procedures.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4, Reference Kraus, Orlikoff, Rizk and Rosenberg11 The difference between these methods is that the fenestration approach does not remove the posterior border of the thyroid cartilage. Maragos reported that 6.8 per cent of his patients receiving arytenoid adduction by a posterior approach needed post-operative tracheostomy, and that airway narrowing induced by removal of the posterior portion caused airway obstruction.Reference Maragos12 To avoid this complication, he recommended stabilising the elevated pyriform sinus mucosa to the thyroid cartilage.Reference Su, Tsai, Chuang and Chiu13 He considered preservation of the posterior portion of the thyroid cartilage, as in the fenestration approach, to be useful because the pyriform attaches to the cartilage. Another difference is the direction of suture pulling in arytenoid adduction. The simultaneous performance of arytenoid adduction and medialisation laryngoplasty procedures has been reported. In all reports, the suture was fixed to the anterior–inferior part of the thyroid cartilage, as in Isshiki and colleague's original approach.Reference Isshiki, Tanabe and Sawada6 In these procedures, the suture runs across medialisation laryngoplasty window, and may therefore interfere with medialisation laryngoplasty.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4, Reference Tokashiki, Hiramatsu, Shinada, Motohashi, Nomoto and Toyomura5 In the present procedure, the suture was pulled in the contractile direction of the lateral cricoarytenoid muscle and fixed it to the lower edge of the thyroid cartilage. This procedure has the advantages of not interrupting the medialisation laryngoplasty surgical field and of reproducing the natural adduction of the arytenoid cartilage.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4 The lateral cricoarytenoid muscle plays the most important role in vocal fold adduction. Su et al. demonstrated that arytenoid adduction with a suture attachment to the cricoid cartilage along the longitudinal axis of the lateral cricoarytenoid muscle is more physiological and effective than suture attachment to the anterolateral part of the thyroid ala.Reference Tokashiki, Hiramatsu, Tsukahara, Kanebayashi, Nakamura and Motohashi4, Reference Su, Tsai, Chuang and Chiu13
• Poor vocal outcomes after laryngeal framework surgery may require revision surgery
• A good phonological outcome was observed after directly pulling the lateral cricoarytenoid muscle using a fenestration approach
• This approach has several advantages for both primary and revision surgery
Furthermore, laryngeal framework surgery is usually performed under local anaesthesia, but some patients require general anaesthesia because of their poor physical condition. A laryngeal mask airway device is a good tool for laryngeal framework surgery under general anaesthesia.Reference Kanazawa, Watanabe, Hara, Shinnabe, Kusaka and Murayama7, Reference Tokashiki, Hiramatu, Tsukahara, Kanebayashi, Nakamura and Motohashi9 However, the pyriform sinus mucosa is extended outward from the bulge caused by the device, thus making it difficult to expose the muscular process using the posterior approach. The fenestration approach avoids this problem, and makes it convenient to perform adduction under general anaesthesia using a laryngeal mask airway device.Reference Tokashiki, Hiramatu, Tsukahara, Kanebayashi, Nakamura and Motohashi9
Although it is unclear why a thread from the arytenoid adduction had loosened, this problem was successfully resolved following revision arytenoid adduction surgery using a fenestration approach. To the best of our knowledge, this is the first case report of revision arytenoid adduction performed using the lateral cricoarytenoid muscle pull method. This method has several advantages not only for primary surgery but also for revision surgery, and deserves consideration as a new fenestration approach.
Open access
