Type I Thyroplasty with Gore-Tex
This is a procedure performed in the operating room under sedation or local anesthesia in which the vocal fold is medialized through an external approach. Transnasal flexible laryngoscopy and real-time patient phonatory feedback are used to guide correct placement of the implant.
Indications/Contraindications
Glottic insufficiency from vocal fold paralysis, paresis, scar, age-related changes, cancer defects, and trauma.
Prior radiation and autoimmune disease are relative contraindications to the procedure as there is an increased risk of implant rejection/extrusion. Any known allergy to Gore-Tex is a contraindication.
In the Clinical Setting
Key Points
The procedure can be performed to improve both voice and swallowing problems attributable to a gap between the vocal folds.
An advantage of Gore-Tex is its physical malle-ability, which permits tailored insertion into the paraglottic space to account for glottic defects of varying shapes and sizes.
Gore-Tex may also be inserted through smaller thyroplasty windows compared with other implants.
The patient can be sedated until the thyroplasty window(s) is/are completed. Lightening of sedation is required at that point so that the patient can phonate, which is essential in establishing the desired phonatory result.
Even with bilateral thyroplasty, airway compromise is rare. Care must be taken in cases where a paralyzed vocal fold is medialized but the contralateral vocal fold exhibits limited abduction.
If there is overdissection or bleeding in the paraglottic space, then edema will quickly set in, creating a pseudomedialization of the vocal fold. This may lead the surgeon to put in an implant that is too small for good final outcome since the combination of the excess transient edema and the implant may produce an adequate phonatory outcome intraoperatively, but once the edema subsides, undermedialization may be encountered.
Pitfalls
If too large an insertion pocket is created, the implant is more prone to movement, increasing the chance of migration away from the intended location.
Placement of the implant too anteriorly will uniformly create a strained, effortful voice quality.
Aggressive superior placement of the implant may predispose to violation of the laryngeal ventricle and implant extrusion.
Aggressive posterior placement may dissect the piriform sinus and not produce any medialization of the musculomembranous segment of the vocal fold.
Both the medial and infraglottic edges of the vocal fold must be medialized for optimal phonatory outcome. Inferior placement of the implant near the lower border of the thyroid cartilage is essential in assisting in this outcome.
From a Technical Perspective
Key Points
Accurate placement of the thyroplasty window is essential.
Implant placement can be simulated by pressing on the paraglottic space musculature with a blunt instrument through the thyroplasty window. This maneuver will help the surgeon to develop three-dimensional familiarity with the anatomy as well.
Mobilization of the inner perichondrium along the inferior strut of the thyroid cartilage will allow the implant to be placed for adequate medialization of the infraglottic edge of the vocal fold.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
