A paralyzed true vocal fold (TVF) affects all the basic laryngeal functions, decreasing its ability to protect the tracheobronchial airways during swallowing, reducing the efficiency and strength of the cough, eliminating the natural positive pressure on expiration (that aids with inflation of the lungs), and causing varied degrees of dysphonia and vocal fatigue. In addition, a TVF palsy decreases the efficiency of a Valsalva maneuver; thus, patients may exhibit problems lifting significant weight or forcing a bowel movement. Medialization of a paralyzed cord does not restore all these functions, but it facilitates neuromuscular compensation by the unaffected contralateral side.

A medialization laryngoplasty or thyroplasty type I involves the medialization of a paralyzed or paretic TVF by the insertion of a paraglottic implant. Silicone and polytetrafluoroethylene (Gortex; W.L. Gore and Associates, Newark, DE) are the most commonly implanted, but others, such as titanium, hydroxyapatite, cartilage, fascia, acellular dermis, and an adjustable balloon, have been reported.

Most surgeons prefer to complete this procedure under local anesthesia and sedation to observe the function of the vocal fold (VF) and adjust the implant according to changes in the patient’s voice, cough, and airway. In select patients, however, such as those undergoing elective sacrifice due to oncologic surgery, or in patients who suffer iatrogenic or penetrating trauma to the neck with injury to the recurrent laryngeal or vagus nerve, an immediate thyroplasty (i.e., done at the same stage as the oncologic resection or exploratory surgery) may correct a potential glottic gap before symptoms arise.

A preoperative or intraoperative cervical examination ascertains the presence of masses, scars, or excessive subcutaneous adipose tissue, which may interfere with the exposure or alter the plan of surgery. In patients undergoing elective surgery, a preoperative flexible fiberoptic laryngoscopy offers unparalleled advantages to ascertain the functions of the larynx, namely, airway, swallowing, voice, and cough. Special consideration is taken to ascertain the position of the VFs and arytenoids (horizontal and vertical planes) during normal and forced ventilation, vocalization, and cough, as well as the VFs tone, bulk, and mucosal integrity. However, due
to the indications and nature of an immediate thyroplasty I, the surgeon cannot ascertain the functional position of the VF and arytenoid after the vagus or recurrent laryngeal nerve has been injured or sacrificed. Some patients, however, may have presented preoperative paresis associated with hoarseness, shortness of breath, or dysphagia. These symptoms should be assessed preoperatively as they are assumed to worsen postoperatively. A functional assessment of all cranial nerves is fundamental, as it has implications regarding the outcome of voice/speech and swallowing and possibly the extent of the resection.

A contraindication to an immediate thyroplasty is the presence, or suspicion, of glottic airway stenosis due to edema or abductor paralysis or paresis of the contralateral TVF. A relative contraindication is the presence of a coagulopathy, congenital or acquired. This situation, however, is rare in patients undergoing elective surgery, although it might be encountered in patients with trauma to the neck.

Whenever possible, an informed consent (from the patient or relatives) should be obtained clarifying goals, expectations, and risks. This is important, as an immediate thyroplasty is associated with a greater need for revision (for misplacement and under- or overcorrection).

An immediate thyroplasty type I requires no other preparation other than that indicated by the clinical examination and flexible fiberoptic laryngoscopy. I empirically use broad-spectrum perioperative prophylactic antibiotics and systemic corticosteroids.

Positioning of the neck and placement of the incision are often dictated by the requirements of the oncologic surgery and/or the need to control the great vessels of the neck. If possible, however, the neck is positioned in neutral or slightly extended position. Similarly, the best placement for the incision is a skin crease near the level of the inferior edge of the thyroid cartilage. In many instances, however, the thyroplasty type I is completed through the incision for the primary surgery or an extension.