Arytenoid Adduction
Arytenoid adduction is a surgical procedure that repositions and stabilizes the paralyzed arytenoid, vocal process and posterior membranous vocal fold into the phonatory position. Successful arytenoid adduction restores glottic competence to improve vocal and swallowing function.
Indications/Contraindications
Hoarseness and glottal incompetence secondary to unilateral vocal fold paralysis (UVFP).
This procedure can be particularly useful in UVFP for dysphagia and/or ineffective cough.
A relative contraindication is poor abduction of the non-paralyzed vocal fold, since adduction might risk a narrow glottis, producing symptoms of airway stenosis.
From a Technical Perspective
Key Point
The anterior membranous vocal fold is not consistently medialized appropriately with arytenoid adduction alone, and may require thyroplasty to supplement the procedure.
This procedure is performed under local anesthesia with sedation. This approach allows for simultaneous monitoring of a patient′s voice during the procedure and permits visualization of the larynx with a transnasal flexible laryngoscope.
Pitfall
A risk of this procedure is airway compromise after the procedure.
From a Clinical Perspective
Key Points
Familiarity with the posterior larynx requires practice, making cadaveric dissection ideal for training.
Pitfalls
Perforation of the piriform sinus mucosa is possible and should be avoided.
Identification of the muscular process of the arytenoid is not obvious, since most of the muscular process is covered by the lateral and posterior cricoarytenoid muscles.
If fracture of the muscular process occurs when placing a needle through it, a “figure-of-8” suture can be used around the residual muscular process and its surrounding muscles to secure it, as recommended below, even if the muscular process is intact.
Stepwise Procedure
Mount a larynx for open dissection.
OR Pearl: In the live patient, a horizontal incision is made at the level of the thyroid cartilage. The strap muscles are lateralized, and the medial insertion of the sternothyroid muscle is lysed from the hyoid bone to assist in retraction However, in the cadaver, it is helpful to remove all the strap muscles to enhance the view.
The thyroid ala is exposed. The midline of the ala is identified and the perichondirum is sharply incised along the midline, superior and lateral borders of the thyroid ala.
An inferiorly based thyroid perichondrial flap is elevated in a subperichondrial plane ( Fig. 15.1 ).
The inferior constrictor muscle is identified and its attachment to the thyroid cartilage is cut ( Fig. 15.2 ).
The posterior aspect of the cartilage is identified. A hook is used to retract this laterally.
The perichondrium along the thyroid ala is elevated along the medial aspect of the thyroid cartilage. Care is taken to ensure the dissection takes place along the thyroid cartilage, avoiding the piriform sinus ( Fig. 15.3 ).
A rongeur is used to remove portions of cartilage from the posterior aspect of the thyroid lamina, with care to leave the attachment of the inferior cornu to the cricoid intact ( Fig. 15.4 ).
The fan-shaped posterior cricoarytenoid muscle is identified and traced supero-medially to its attachment to the muscular process of the arytenoid ( Fig. 15.5 ).
A suture is placed through the PCA muscle at its attachment to the muscular process. The two ends of the suture are placed under traction ( Fig. 15.6 ).
A second pass of the needle is made through the muscular process and a figure-of-eight suture is tied.
A thyroplasty window is created using a small cutting burr or oscillating saw ( Fig. 15.7 ).
A perichondrial flap is raised as shown.
The midline of the thyroid cartilage is identified and a mark is made 0.5 cm lateral from the midline and 0.5 cm above the lower border of the cartilage. A #2 cutting burr is used to make a fenestration through the cartilage at this point.
A slightly bent Keith needle is placed retrograde through the small anterior fenestration, visualized through the thyroplasty window, and positioned adjacent the muscular process.
The free end of the arytenoid adduction suture is threaded through the Keith needle. The needle is then pulled forward, delivering the suture through the fenestration ( Fig. 15.8 ).
The second end of the suture with the needle attached is placed dull end first through the thyroplasty window, and then sharp end first under the lower border of the thyroid cartilage through the cricothyroid membrane ( Fig. 15.9 ).
In this cadaveric specimen, the inferior constrictor muscles have been divided off the posterior border of the thyroid cartilage (left image). 
Further dissection with creation of a window in the thyroid cartilage (larger than the window used for thyroplasty) as well as further rotation of the larynx demonstrated the muscular process of the arytenoid (left image). Note the thin transparent mucosa of the piriform sinus permitting view of a Freer elevator placed into the apex of the left piriform sinus. The piriform sinus mucosa may overlap the muscular process (right image). TA, thyroarytenoid; LCA, lateral cricoarytenoid; PCA, posterior cricoarytenoid. 
Further dissection with removal of the posterior aspect of the thyroid cartilage (left image) demonstrates the branching of the RLN (recurrent laryngeal nerve) as it innervates the TA and LCA muscles (right image). 
Further rotation of the specimen permits view of the fibers of the PCA beginning as a broad base on the cricoid converging to the muscular process (right image). 
A nonabsorbable suture is placed through the muscular process or at its junction with the PCA muscle and placed on traction. 
In many specimens, a scalpel can be used to cut through the soft cartilage. The window is then removed. A window larger than that used for thyroplasty is used. 
There is no fenestration made in this specimen as the cartilage was nonossified. The suture is seen passing through the anterior thyroid cartilage. 
The other suture end has been passed through the cricothyroid membrane. 
The soft inferior strut of the thyroid cartilage fractured in this image. Folded cloth tape has been used in this example instead of Gore-Tex to save cost. The implant is folded into the paraglottic space to support the vocal fold. 
The sutures are placed under tension and a knot is tied to secure the sutures and arytenoid in place.
While pulling on the sutures, intermittently examine from above to confirm abduction and adduction of the vocal fold.
A strip of Gore-Tex is layered in the paraglottic space to medialize the vocal fold. The implant is placed lateral to the arytenoid adduction sutures ( Fig. 15.10 ).
The sutures are placed under tension and a knot is tied to secure the sutures and arytenoid in place ( Fig. 15.11 ).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
