Medialization

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Medialization laryngoplasty

Information for patients considering a medialization procedure or implant into their vocal folds

The following is typical for my patients. There certainly are regional and individual surgeon variations in style.

Definition

Medialization laryngoplasty is a procedure that provides support to a vocal fold that lacks either the bulk, the mobility or both, that it once had. Most commonly it is used to try and correct a neurologic injury or problem that prevents full closure of the vocal fold or folds. It is also frequently called a thyroplasty since the procedure is performed through a hole in the thyroid cartilage (not to be confused with the thyroid gland).

Indications

The vocal cord may require support if it is paralyzed. Two things happen with a paralysis. The vocal cord is basically a muscle with a mucous membrane (the type of skin you would find inside your mouth) covering. When a muscle is no longer hooked up to a nerve, it atrophies or shrinks. Therefore, the paralyzed vocal cord would be small in size and probably bowed. Additionally, depending on the type of paralysis, the vocal cord may not be moving close enough to the middle for the other vocal cord to come together and meet it. If they cannot come together, it is difficult to make a sound or at least a loud sound. So, in some types of vocal cord paralysis, the implant can rebulk up the atrophied vocal cord and move it toward the opposite vocal cord so that they can come together again for speaking.

A medialization implant could also be used to just provide bulk for a vocal cord that is bowed and atrophied or thin. This might occur with aging or a disorder such as Parkinsons where under use causes the vocal cord to atrophy.

In any case, the implant is a relatively permanent solution for the problem. Though it can be removed, it requires a surgery to remove it. For a temporary solution see injection medialization.

Presurgery

Before the surgery, a PARQ conference is held with you. This is an acronym for Procedures, Alternatives, Risks and Questions. It means that your surgeon has discussed with you in full detail the reasons for going to surgery and that you are satisfied with those reasons. The surgeon generally needs to see you within a week or two prior to surgery since your problem may have changed, especially if there has been a long interval. There is nothing quite like going to sleep, not needing surgery and getting charged a few thousand dollars for that brief sleep - I don’t think you even get a good dream out of it. You can go over any questions during this visit as well as again on the morning before surgery in the pre-surgery waiting area.

Risks

The main risks of the procedure are anesthesia, a less-than-expected beneficial outcome, bleedinginfection or breathing difficulties.

  • Anesthesia
    • The risk of anesthesia is that you would have a major life threatening reaction to some medication.  This is very uncommon and I would compare it to getting in your car and driving some distance with the risk of an accident and dying. Even though the risk is serious, it is apparently, acceptably small, as most of us continue to drive. In the case of surgery, you even have the added benefit of life support equipment and trained personnel standing by. I prefer to perform this procedure under local anesthesia or local anesthesia with sedation so the risk is even less than with general anesthesia.
  • Less-than-expected beneficial outcome
    • Unfortunately, your body is not a car and we cannot go to the body shop and just put on a brand new fender. The surgeon’s skills, your body’s healing capabilities, tendency to swell, scar and the type of disease present all enter into the equation of that attempted perfect result. Therefore, while everyone: surgeon, anesthesiologist, nurses and other staff strive to provide excellent care, in all likelihood perfection is tempered by the human condition. Still many results are excellent, some are good and rarely the outcome is poor. Your surgeon will likely temper your expectations based on the type of disease being treated as that has a major effect on the expected outcome.
  • Bleeding
    • Bleeding is a potential risk anytime a cut is made. If you are on any medication that may thin the blood, that would increase the risk. Examples of medications that might prolong bleeding include Coumadin, aspirin or even vitamin E. You should go over all medications that you take with your physician before surgery. I use a very conservative sized incision and that probably helps decrease the risk somewhat. I do not leave a drain in the skin for blood or fluid to come out, though some surgeons may do so.
  • Infection
    • Any time a skin incision is made, that becomes a route for bacteria to enter into the body. In this case we are also placing an implant into the body which increases the chance that an infection would require another surgery to remove an infected implant. That is why the procedure is performed under sterile conditions and I typically give an antibiotic in the operating room before I place the implant.
  • Breathing difficulties
    • This has occurred to a mild extent in my experience, but less than it would seem based on logic. The voice box and wind pipe are of a limited size since this procedure frequently moves one vocal fold to the midline, it may decrease the room to breathe by half. At times I place implants in both sides which only moves the front half of the vocal folds together. Breathing room remains at the back of the voice box. Then there is almost always some swelling after working on the voicebox. Your surgeon will ususally be able to predict the risk based on how much surgery is being done. Medications, particularly steroids, are often given to help decrease swelling.
  • Other risks
    • I have not had one of my implants dislodge or come out. However, I have revised some other implants that were not in the correct position. They may not have been in a great position from the start or they may have moved - I don't know. One person gave a good story for an initial good result that changed months later after an intubation for another surgery. I found the implant still in the original opening but it was pushing on the false vocal cord rather than the true vocal cord. It was corrected with a different implant.
    • I do ask patients to avoid heavy lifting for two weeks. I haven't seen a problem, but it seems possible to me that straining might move the implant. After about two weeks, the scar tissue is tight and should hold the implant in place.
    • I have revised about 10% of my implants. The typical story is the person has a much better voice after surgery, then it fades a little and they would like to get back to their immediate post-operative voice volume and quality. I usually have to go back and put a slightly larger implant or on occasion add the arytenoid adduction procedure. The initial swelling during and after the surgery makes the voice seem very good and then when the swelling goes away the voice weakens a bit. Consequently, I do aim to make the voice a little tight initially and anticipate some strain or hoarseness in the first week and then a better voice after that.

Consent

I will ask you to sign an informed consent form before going to surgery.

Surgery

Anesthesia

You may request as little or as much sedation as you like. I like to have you wide awake when I am actually placing the implant so that I can appreciate the effect on your voice. Before that time, you can be fully awake, fully asleep or in between as is your preference. Please discuss your preferences with the anesthesiologist.

Preanesthesia room

In the pre-anesthesia area, you get to wear that famous "open back" gown. You will be there for about an hour answering many questions for the tenth or perhaps the twentieth time. You learn that you actually lead a very interesting life judging from the thickness of the stack of papers representing you in the medical record. From there you leave your family and ride on your back, staring at the ceiling, to the operating room.

The operating room

The operating room table is often pre-chilled (I warned you). The surgery is done with you in a lying down position. A roll may be placed under your shoulders to extend your neck. You can be put to sleep with medicine through a vein at the beginning while I inject numbing medication or local anesthesia into your neck and spray some numbing medication into your nose. A nasopharyngoscope is passed through your nose to the back of your throat until your vocal folds are visible on a video monitor. This should be very similar to the exam you experienced in clinic.

Your neck is prepped to be made sterile. Usually a solution of iodine is used unless you are allergic to iodine. Drapes are placed to keep the neck area sterile. This usually precludes you from seeing much of the surgery, but you can visit with the anesthesiologist.

The procedure

About a one inch incision is placed in your neck over the voice box. It is placed in or parallel to a skin crease to aid in hiding it later on. Several layers of muscle are pulled aside and the thyroid cartilage is exposed. The thyroid cartilage is the front of the voice box, the Adam’s apple. Several measurements are made and a window is drilled through the thyroid cartilage just underneath the vocal fold.

The implant

I like to use Gore-tex or Silastic for an implant. There are other alternatives in use, including several pre-fashioned implants of various sizes and shapes. I like the Gore-tex because I can adjust how much material I put in and where I put it. I like the Silastic because I can carve it to a specific size and shape. I watch the video monitor in surgery, to see what is happening on the inside and I have the patient talk to hear the results of the implant on the voice.

Arytenoid adduction

There may be times when an implant alone is not capable of completely correcting a paralysis. An addition to the implant, one may make a stitch passed through the joint (arytenoid) that moves the vocal fold toward the center of the voice box. When this stitch is placed and tightened, it can move the joint to a new and perhaps better position.

Pain

Typically there is mild pain after surgery. Since pain varies from person to person, I typically prescribe Vicodin. Vicodin is essentially Tylenol and a narcotic, hydrocodone. For some, this is a less nauseating option than codeine. This may be used for either throat pain or for a throat tickle or cough. Sometimes the sensation of the need to cough can persist for several weeks. Many find that Tylenol is sufficient for the pain. An over the counter option for cough is Dextromethorphan. It is the DM in medications such as Robitussin DM. There are extensive options for management of pain.

Recovery

You wake up (or more likely you are already awake) in the operating room and travel on your back again to the recovery room. You stay in the recovery room until the nurses and anesthesiologist are certain the majority of the anesthetic is gone from your system. You then return to the day surgery area where you started. If you had no anesthetic, you are probably ready to go when the paperwork is done. If you had much medication, when you can stand steadily, keep liquids down without nausea or vomiting and can go to the bathroom (essential human activities), you may go home. The whole process takes up a good part of the day.

Instructions during healing

These are my particular inclinations. Expect a wide variation in recommendations by other physicians.

  • First 3 days
    • Feel free to drink plenty of fluids to keep secretions thin. There are no restrictions on soft or normal talking. You should not yell or scream and should try to avoid coughing or straining very hard. If you are constipated, take a stool softener. Do not lift more than ten pounds. Theoretically, the implant could move some with enough force, until it is scarred in over several weeks. On the afternoon of the surgery, you voice will be pretty good, almost certainly better than before surgery. Then, swelling sets in since your vocal folds are bruised and your voice will sound deep, rough and laryngitis-like. It will require some extra effort to talk. Frequently steroids are given in surgery, such as Decadron that slow the amount of swelling. You may go home with additional steroids such as Prednisone or a Medrol Dose-pak.
  • The next day
    • If you are from out of town, I will ask you to stay overnight in town. If there are concerns, I will see you back in the office the next day. We can have a look at your vocal folds to assess how much swelling there is. They will usually look puffy and bruised and you will often say your voice was better after surgery than it is now.
  • 1 week
    • There may be a suture in your neck that you may remove by cutting one end off and pulling on the other. If you are uncomfortable removing it, you may make an appointment.  The suture material may also be self-absorbing and does not need to be removed.
  • After 2 - 6 weeks
    • Return for a follow up visit to see if you are healed. Swelling should be completely gone at this point. Feel free to use your voice as much as you want. In many instances, I will prescribe a voice building regimen to strengthen the remaining voice muscles.
  • Six months
    • Mid-term evaluation
  • One year
    • Long-term evaluation of your surgery.