I. GENERAL CONSIDERATIONS

A. Indications

1. Symptomatic laryngeal paralysis

a. Dysphonia

b. Dysphagia

c. Poor cough

2. Glottic incompetence associated with incomplete vocal fold approximation

B. Contraindications

1. Abnormalities (eg, infection) of neck skin and underlying tissue precluding safe external approach to larynx

2. Anticipated recovery from laryngeal paralysis or glottic incompetence (see Gelfoam injection protocol )

II. PREOPERATIVE PREPARATION

A. Evaluation

1. Essential for most cases

a. Speech pathology assessment (see Laryngeal diagnostics protocol)

b. Videolaryngoscopy with voice recording (see Videostroboscopy protocol)

2. Consider for selected cases

a. Trial of voice therapy

b. Laryngeal electromyography (see Laryngeal EMG protocol)

B. Consent

1. Description: “Numb your neck and nostrils, examine your vocal cords with fiber optic scope through your nose as the vocal cord position is manipulated through a neck incision. Through this neck incision, a small window of cartilage is removed next to your vocal cord. Through this window, an implant (Gore-Tex) is placed to secure your vocal cord in a more medial position.”

a. Mention “fine-tuning” the voice during the procedure with overcorrection to make voice pressed in the early postoperative period.

b. Describe the use of a rotating drill and placement of an implant.

2. Potential complications

a. Bleeding, infection, reaction to the anesthesia

b. Damage to adjacent structures (rare)

(1) Worse voice

(2) Problems breathing

(3) Potential need for revision

III. NURSING CONSIDERATIONS

A. Room Setup

See Basic Soft Tissue Room Setup

1. Audio-visual unit

2. Olympus light source

3. Mayo stand x 2

4. Gown table x 2 (for “clean” setup for rhino-laryngo fiberscope)

B. Instrumentation and Equipment

1. Standard

a. Minor instrument tray, Otolaryngology

b. Bien otologic electric drill tray

c. Rongeur small tray

d. Bipolar forceps tray

e. Nasal prep tray

f. Rhino-laryngo fiberscope, Olympus Model

2. Special

a. News tracheotomy hook x 2

b. Richards adjustable double fork retractor

c. Syringe, Luer Lock, 20 cc

d. FRED (fog reduction elimination device), or anti-fog

e. ePTFE patch: 0.6 mm cardiovascular patch (Gore-Tex)

C. Medications (specific to nursing)

1. Bupivacaine injection, 0.25%, for preoperative injection

2. 1% lidocaine with 1:100,000 epinephrine

3. Oxymetazoline HCL nasal spray, 0.05%

4. Tetracaine hydrochloride, 2%, to mix with the oxymetazoline HCL

5. Bacitracin 50,000 units to soak Gore-Tex

D. Prep and Drape

1. Standard prep, 10% providone iodine

a. Do a betadine solo prep from lips to clavicles; lateral extension to trapezius muscles.

b. Leave the top of head and face unprepped to permit nonsterile placement and removal of flexible fiber optic laryngoscope from this approach during case.

2. Drape

a. Square off with towels the anterior neck inferiorly to clavicles

b. Place a narrow (rolled) towel over the chin to separate the mouth from the sterile field interior.

c. Split sheet: cover eyes with wet 4 x 4 in. cotton pads. Patient will be awake and asked to speak during the procedure.

E. Drains and Dressings

1. Fluffs

2. Adaptic, small

3. Penrose drain, 1/4 in

4. Burn netting

F. Special Considerations

1. Nose will be packed preoperatively with topical vasoconstrictor and anesthetic agent.

2. Have bupivacaine 0.25% plain on the field.

3. Soak Gore-Tex in bacitracin 50,000 Units.

4. Patch: Cardiovascular Gore-Tex patch graft 0.6 mm.

5. Soak 1/2 in x 3 in cottonoids in pontocaine 2% and oxymetazoline HCL nasal spray 1:1.

6. Procedure is done under local anesthesia.

7. Have all equipment needed for arytenoid adduction available; it may be necessary to supplement the thyroplasty with an arytenoid adduction.

V. ANESTHETIC CONSIDERATIONS

A. Intravenous Conscious Sedation

1. Although general anesthesia may be used in selected cases (eg, anticipated poor patient compliance), local anesthesia is preferred to permit voice assessment intraoperatively and avoid laryngeal distortion due to the presence of endotracheal tube.

2. Oxygen by nasal prongs to both nostrils (consider CO₂ monitor) permits topical anesthesia to the nose and placement of the flexible fiber optic laryngoscope adjacent the prongs.

B. Preoperative Systemic Medications

1. Glycopyrrolate 0.1 to 0.2 mg intramuscular on call to operating room

2. Decadron 8 to 10 mg intravenous as soon as IV started

3. Antibiotics (as soon as IV started) (see Antibiotic protocol)

C. Positioning

1. Head of table toward the door with anesthesia equipment at patient’s side

2. Audiovisual equipment (television monitor) and flexible fiber optic laryngoscope at the patient's head

3. Head of bed elevated 30°; neck extended with shoulder roll placed

VI. OPERATIVE PROCEDURE

A. Incision is made over midportion of thyroid cartilage canted to side of paralysis.

B. Separate strap muscles in midline.

C. Supplement injection to deeper tissue with 1% lidocaine with 1:100,000 epinephrine as the dissection continues.

D. Placement of a heavy suture or tracheotomy hook through the laryngeal prominence permits medial traction on the larynx with improved exposure.

E. Incise the thyroid cartilage perichondrium in the midline and elevate it progressively in a lateral direction on the side of the paralysis.

F. Ensure the ipsilateral thyroid cartilage is exposed inferiorly to the cricothyroid membrane and posteriorly to lateral edge of thyroid cartilage. Limiting dissection to oblique line is adequate for placement of the prosthesis but restricts exposure and orientation.

1. It is necessary to detach slips of the cricothyroid muscle inserting on the lateral border of muscular process (inferior tubercle) of thyroid cartilage.

2. Inject 1% with 1:100,000 epinephrine into the cricothyroid membrane immediately below lower border of thyroid cartilage.

G. Mark proposed cartilage cuts on thyroid cartilage with electrocautery.

1. Dimensions of window: approximately 5 mm x 10 mm (for Gore-Tex thyroplasty; larger if silastic used)

2. Lower border of window 3 mm above cricothyroid membrane (as low as possible without danger of fracturing inferior strut)

3. Anterior border of window 7 to 10 mm posterior to midline

H. Elevate inner perichondrium through window from undersurface of thyroid cartilage employing Penfield elevators.

1. Incise inner perichondrium posteriorly, inferiorly, and superiorly if needed; do not incise anteriorly.

2. Incise cricothyroid membrane to separate it from lower border of thyroid cartilage.

3. From inferior approach, place Woodson elevator under lower border of thyroid cartilage and into the window to depress the contents of the paraglottic space medially while assessing phonation.

I. Fashion a 1-cm-wide continuous strip of Gore-Tex from a square patch

1. Soak the Gore-Tex implant in bacitracin solution.

2. Place the Gore-Tex strip into thyroid cartilage window from inferior approach and pull out through window.

J. Secure the Gore-Tex strip into position, placing the vocal fold in ideal location as determined by phonatory assessment and examination with fiber optic laryngoscope.

1. The strip is secured primarily by wedging it between the contents of the paraglottic space (perichondrium and LCA/TA muscle group) and the overlying thyroid cartilage.

2. Ensure that medialization is approximately 2 mm greater than desirable in anticipation of gradual resolution of edema.

3. Place a 4-0 prolene suture around lower strut of window from an inferior approach through the Gore-Tex and tie it on itself. Leave the needle attached.

4. Employing same needle with the suture still attached, place the needle through unossified thyroid cartilage (or if ossified, place drill hole) above the window and tie it again on itself to help secure Gore-Tex implant.

K. Consider supplementing vocal fold medialization with arytenoid adduction if needed (see arytenoid adduction protocol).

L. Loosely approximate strap muscles in midline with 3-0 vicryl after placing Penrose drain deep to them.

M. Close platysma with 4-0 vicryl.

N. Close skin with 5-0 nylon.

VII. POSTOPERATIVE CARE

A. Observe overnight in-hospital (23-hour observation).

B. Begin oral feedings when alert.

C. Continue oral antibiotics for 5 to 7 days.

D. Use topical wound care (see Nursing wound care protocol).

E. Voice rest

1. Absolute for 48 hours.

2. Relative for 2 weeks: employ “arm’s length rule” wherein the patient does not address a person unless they are within arm’s length.

F. Remove drain postoperative day 1 with examination of larynx.

G. Follow-up is at postoperative day 6 for suture removal.

H. Videostroboscopic exam with speech path assessment at 6 weeks, 3 months, 6 months and 1 year.

I. Consider voice therapy after 6 weeks if modification of voicing behavior is indicated based on speech path assessment and the patient desire.

VIII. CPT CODING

31588, Laryngoplasty, not otherwise specified; Note: We employ the same code 31588 for thyroplasty alone, arytenoid adduction alone, or the combination of thyroplasty with arytenoid adduction.

IX. SUGGESTED READING

A. Hoffman HT, McCulloch TM, Victoria L. Laryngeal paralysis. In: Gates G, ed. Current Therapy in Otolaryngology. 6^th ed. St Louis, MO: Mosby; 1998:446-452.

B. Hoffman HT, McCulloch TM. Anatomic considerations in the surgical treatment of unilateral laryngeal paralysis. Head Neck. 1996;18:174-187.

C. McCulloch TM, Hoffman HT. Medialization laryngoplasty with expanded polytetrafluoroethylene. Ann Otol Rhinol Laryngol. 1997;107:427-432.