History of presenting illness

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  Acute or gradual onset of hoarseness

  
  
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  Precipitating events such as surgery, endotracheal intubation, or upper respiratory infection

  
  
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  Voice quality weak, breathy, and effortful

  
  
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  Dyspnea with speaking

  
  
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  Coughing and choking, especially with drinking liquids

  
  
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  History of aspiration pneumonia

Pertinent past medical history

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  History of neck surgery (e.g., thyroid, parathyroid, carotid), cervical spine surgery, or thoracic/mediastinal surgery

  
  
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  History of malignancy (e.g., head and neck, thyroid, esophagus, lung)

  
  
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  History of cerebrovascular accidents

  
  
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  Underlying pulmonary disease (e.g., chronic obstructive pulmonary disease [COPD])—These patients have a smaller pulmonary reserve and thus will require more urgent intervention for vocal fold paralysis.

Complete examination of the head and neck

Examination of the cranial nerves

Transnasal flexible laryngoscopy to evaluate vocal fold motion, including mobility of the contralateral vocal fold, and overall airway status

Stroboscopy to assess glottic closure pattern and vocal fold levels

Computed tomography (CT) or magnetic resonance imaging (MRI) scan from skull base to aortic arch (along the course of the recurrent laryngeal nerve) with contrast in vocal fold paralysis with no clear precipitating events

Symptomatic glottic insufficiency (dysphonia, dyspnea on phonation, aspiration), especially if there is little or no chance of return of vocal fold motion

Coagulopathy (relative)

Malignancy involving the laryngotracheal complex

Poor abduction of the contralateral vocal fold due to airway concern

Presence of vocal fold lesions

Intact vocal fold mobility (for arytenoid adduction)

Review the patient’s laryngeal examination.

Counsel patients to stop anticoagulation agents, such as nonsteroidal anti-inflammatory medications (e.g., ibuprofen), Coumadin, antiplatelet agents (e.g., clopidogrel), and factor Xa inhibitors (e.g., rivaroxaban, apixaban, dabigatran). Management of patient’s anticoagulants may be coordinated with his/her cardiologists and/or hematologists.

Discuss with the patient regarding the environment in the operating room, given that the patient will be awake and only slightly sedated. It is best to prepare patients psychologically while they are awake for having surgery on their neck.

Counsel the patient that there may be a need for a bilateral procedure and the addition of an arytenoid adduction procedure pending the intraoperative results of the medialization laryngoplasty. Often with experience, surgeons can determine preoperatively, based on the laryngeal examination and the patient’s voice quality, whether he or she will require a unilateral or bilateral medialization laryngoplasty. However, certain situations do occur intraoperatively in which voice quality is only marginally improved with a medialization laryngoplasty, and it is determined that the patient would benefit significantly from a simultaneous arytenoid adduction.

Before the patient comes into the operating room, nebulization of a 50:50 mixture of 4% lidocaine (2 mg/kg) and 1% tetracaine (0.5 mg/kg) is performed to provide topical anesthesia to the upper aerodigestive tract, which facilitates the patient tolerating the flexible laryngoscopy during the procedure.

Robinul, an anticholinergic medication, should be administered, unless medically contraindicated, to minimize laryngeal secretions during the procedure.

The patient will then undergo the procedure under monitored anesthesia care (MAC), which includes local anesthesia with sedation and analgesia.

Once in the operating room, the patient is placed in a supine position with a conservative shoulder roll to provide extension of the neck. Care should be taken to ensure that the patient is comfortable.

A prophylactic dose of intravenous antibiotics is given approximately 30 to 45 minutes before the skin incision, as per surgical prophylaxis guidelines.

One dose of dexamethasone (10 mg) is given to minimize airway edema.

The patient will be monitored by the anesthesia health care provider as per standard of practice.

Standard head and neck soft tissue set

Cottle or Freer elevator

Measuring caliper

Drill with a 1- to 2-mm cutting burr

Flexible laryngoscope

C-mount camera with video tower/monitor

Surgeon’s preferred implant material

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  For Gore-Tex implants, select middle ear instruments (e.g., middle ear alligator, annulus elevator, middle ear curette), Woodson elevator, Kerrison rongeus (1- to 3-mm tips)

  
  
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  For Silastic implants, Netterville medialization set (Medtronic ENT, Jacksonville, FL), Silastic block

For arytenoid adduction, 4-0 monofilament permanent suture (e.g., Mersilene by Ethicon, Medline Industries. Inc, Northfield, IL) and Kitner dissector (peanut)

Medialization laryngoplasty

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  Inferior border of the thyroid cartilage

  
  
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  The entire aspect of the muscular tubercle located on the inferior border of the thyroid cartilage ala because the angulation of this process can cause incorrect orientation of the medialization window

Arytenoid adduction

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  Posterior border of the thyroid cartilage

  
  
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  Posterior lamina of the cricoid cartilage

  
  
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  Cricopharyngeus muscle

  
  
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  Posterior cricoarytenoid (PCA) muscle

  
  
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  Muscular process of the arytenoid, seen as “a grain of rice”

Good understanding of laryngotracheal anatomy

Basic soft tissue handling skills

Infection

Bleeding/neck hematoma

Violation of the pyriform sinus (arytenoid adduction)

Implant migration

Implant extrusion

Airway obstruction

Persistent dysphonia after surgery requiring revision surgery. Reasons for suboptimal results include persistent posterior glottic gap, undermedialization, implant malposition (anteriorly and/or superiorly), vocal fold height mismatch.