Ronda Alexander, MD
Often in medicine, our ability to treat disease outpaces our reconstructive capacity. This was long the case in Otolaryngology which for years provided curative surgery but had little to offer patients who suffered cosmetic and functional defects after. The past century, however, served as a period of ‘catch-up’ and the larynx also finally garnered the attention it deserved. We now have options to improve the quality of life of patients whose illnesses or treatments have left them with vocal cord paralysis (VCP). VCP can result from myriad causes including viral illnesses, brain diseases, and surgical or traumatic injuries to the laryngeal nerves. For these patients, the inability to fully close the glottis can result in breathy, unpredictable voices as well as dysphagia and decreased cough strength. In order to achieve optimal function, patients require a team approach that gives them both the anatomic and technical tools to generate good voice.
The ideal surgical treatment would move the vocal fold margin medially so that the mobile one would meet it without interfering with phonatory vibration of either. In 1974, Dr Nobuhiko Isshiki of Kyoto, Japan, described several types of laryngoplasty including one that accomplished the medialization of the vocal fold and improved glottic closure. Over many decades, the technique has been refined and has emerged as an essential tool for surgical voice rehabilitation.
Medialization laryngoplasty involves exposing the larynx through an incision in the neck and creating a ‘window’ in the cartilage through which an implant can be placed while the larynx is observed with a flexible scope. Many different materials are used as implants including carved silastic or ceramic blocks, Gore-tex® strips, and silastic shims. The procedure is usually performed using a special anesthesia technique as there are periods when the patient must be comfortable enough to tolerate the operation but during the placement of the implant, s/he must be alert enough to respond to commands and speak so that the size can be customized. Patients are usually observed overnight in the hospital and discharged the following morning if there are no complications. Surgical risks include infection, bleeding and the possibility of an implant moving or extruding into the airway. They can also be made too small, too large and placed incorrectly. When done well, patients will experience an improvement in objective measures like loudness, maximum phonation time and noise-to-harmonic ratio as well as subjective improvements in breathiness, effort of phonation and vocal predictability. These changes are considered permanent and generally do not decline over time.
In addition to this surgical structural change, there are also injectable implants available. This option uses materials as diverse as fat, human dermis, cultured hyaluronic acid (a component of human joint fluid), and an engineered bone analogue. The advantage of this technique is that, with the right patient and material, it can be performed under local anesthesia with the patient awake in the office. This reduces both the cost and time spent on the procedure. For those who are too nervous for this, it can also be done under general anesthesia and remains quick and effective. There is mounting evidence that injections of fat and bone dust can last for many years and that the durability of the results is comparable with those from laryngoplasty. These injections do, however, require a skilled hand as they carry risks of bleeding and possibly permanent voice damage if one material is injected improperly.
Of course, neither of these treatments is complete without appropriate rehabilitation. The patients need training in the safe use of the new voice. Un-learning the compensatory maneuvers they used prior to surgical correction can be painstaking and requires a trained professional. In addition, there is often significant jitter and shimmer within the voice in the initial post-operative period; patients must be coached through the recovery as they discover their new voice. After several sessions of vocal rehabilitation therapy, they return to the surgeon for another examination and review of their progress. Good communication between the Speech Pathologist and Laryngologist is paramount and SLPs who do not perform stroboscopy should view those recorded by the surgeon when possible. With the right team in place, patients with unilateral vocal fold immobility have good options for recovering their voice as they face their other medical challenges. Let’s work together to help them be heard again!