Medialization thyroplasty under intubation anesthesia to restore the voice after cordectomy

Medialization thyroplasty is performed to improve the voice and swallowing ability in patients with unilateral laryngeal palsy. Some clinicians have used the procedure to improve the voice following cordectomy. In such cases, the extent of fibrosis of the surgical bed necessitates wide dissection of the paraglottic space to introduce the prosthesis. This surgical step is uncomfortable for the patient when it is performed under local anesthesia. Sedation is required, especially if a fibrolaryngoscope is used to monitor glottal changes. We have studied voice changes associated with sedation. In our experience, voice testing during surgical procedures performed under local anesthesia is not an accurate means by which to choose the size of the prosthesis, because both sedation and pressure exerted on the larynx by the metering device can influence phonation. Therefore, we prefer to use general anesthesia when monitoring glottal changes during surgical procedures. Herein we describe our surgical method of voice restoration after cordectomy in four patients. We performed medialization thyroplasty under intubation anesthesia. A set of metering devices that we previously designed and described was used to locate the cartilage window in a location suitable for filling the glottal defect. Direct examination was performed using direct (microsuspension) laryngoscopy. To our knowledge, this is the first report of glottal restoration via thyroplasty under general anesthesia with intubation to allow observation of the larynx through a surgical microscope. MATERIALS AND METHODS We performed surgery on four patients with glottal defects caused by prior cordectomy. Patient 1 (female) had undergone type III cordectomy; patient 2 (female) had undergone type IV cordectomy, patient 3 (male) had undergone type IV cordectomy, and patient 4 (male) had undergone type V cordectomy. All patients had severe dysphonia 1 year after treatment and selfassessed their voice quality as inadequate, even after speech therapy. A fibrolaryngoscopic examination revealed glottal defects with small anterior synechiae in patients 1 and 2, a deeper anterior defect with a small anterior synechia in patient 3, and a wide glottal defect with an extended synechia in patient 4. A single speech therapist, blinded to the planned surgical procedure, scored the patients using the Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale, maximum phonation time (MPT), Voice Handicap Index (VHI), and acoustic voice analysis (AVA) (Praat software version 5.3.39, Amsterdam the Netherlands) (Table I). All surgical procedures were performed by the same surgeon (E.Z.) with the patients under intubation anesthesia. The glottis was monitored using a microscope focused through a conventional laryngoscope. The location of the thyroid cartilage window was determined using our described method and set of measurement devices. After exposing the thyroid cartilage, the four points of the standard window recommended by Montgomery were marked via electrocautery. However, rather than constructing the entire cartilage window, we drilled a 5-mm-long, 2-mm-high line between these points, which afforded sufficient space for our measuring devices (Fig. 1). We used a new set of metering devices that were narrower and thinner than the originals (Fig. 2). After drilling the line, we positioned the laryngoscope to monitor the glottis. From this time until the end of the procedure, the surgeon performed the operation in a seated position. Our measurement devices were inserted through the cartilage hole. The point at which the device pushed the endolarynx could be seen on the monitor; the microscope was focused on the glottis and afforded an excellent magnified image. The surgeon could monitor changes in the glottis produced by the metering devices, which reproduced the angulated posterior shape of the prosthesis, but were narrower and thinner than the silicone meters provided by BMP (Westborough, MA) (Fig. 2). The angulated shape of the metering device is an advantage when compared with a straight device such as a needle. It protrudes posteriorly where the definitive prosthesis would protrude. Therefore, we can predict not only the vertical location of the prosthesis, but also the horizontal one. This enables us to customize the window location by drilling as required. From the ENT Department, University General Hospital, Valencia Medical School, Valencia, Spain. Editor’s Note: This Manuscript was accepted for publication July 29, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Natsuki Oishi, MD, University General Hospital, Avda. Tres Cruces, 46014 Valencia, Spain. E-mail: dramiriamoishi@gmail.com