Highlights

Key Glossary Terms

Laryngeal Framework Surgery
Surgical modification of the cartilage framework of the voice box so vocal folds can close better or have more tension, which allows vocal folds to vibrate better for sound production

Laryngeal Framework
Cartilages of voice box: thyroid cartilage, left and right arytenoid cartilages, cricothyroid cartilage

Types of Laryngeal Framework Surgical Procedures

1. Medialization thyroplasty/laryngoplasty (implant medialization)
2. Arytenoid repositioning (arytenoid adduction or adduction arytenopexy)
3. Crico-thyroid repositioning (approximation or subluxation)

Glossary

Laryngeal framework surgery improves the voice by altering the laryngeal framework so that vocal fold position and/or tension is adjusted. In the most common framework procedures, the vocal folds are moved towards the midline so that vocal fold closure during voice production is enhanced.

Common Terminology: Laryngeal Framework Surgery		Laryngeal Framework Surgery or Laryngoplastic Phonosurgery "Open" neck procedure (i.e., reconstructive surgical procedures of the larynx that are done through a small incision in the neck) Laryngeal cartilage framework is altered to reposition the vocal-fold soft tissues to achieve enhanced closure Typically done with local anesthesia and intravenous sedation to allow the patient to talk during the procedure for fine-tuning adjustments during the procedure
Laryngeal Refers to voice box or larynx	Framework Voice box cartilages that are the support structures of the voice box muscles – hence "framework"
Phonosurgical Terminology: Laryngoplastic Phonosurgery
Laryngoplastic Laryngeal reconstruction	Phonosurgery Surgery to improve or restore voice

To obtain the best results, the surgeon listens to the voice with varied tissue repositioning and examines the vocal folds with a fiberoptic laryngoscope.

It is advantageous for the surgeon to be familiar with the different procedures of laryngeal framework surgery.

Key Information

Better Detection Methods Have Led to Increased Diagnosis

Better methods of detection and evaluation of the larynx have identified advanced laryngeal cancer as the cause of death much more frequently than in previous decades and centuries, when doctors could not evaluate the throat and vocal folds visually.

• Implant Medialization or Medialization Thyroplasty

  Most commonly used.

  A small window is made in the thyroid cartilage on the outside-side of the vocal fold tissues so that an implant can be placed through the window to "push-over" the affected vocal fold closer to the middle.

• Combination of Procedures Can Achieve Better Voice Results

  In certain cases, combination of procedures may be recommended, such as:

  • Implant medialization + crico-thyroid subluxation
  • Implant medialization + crico-thyroid subluxation + arytenoid repositioning

Laryngeal framework surgery is a group of procedures that modify the different framework cartilages of the voice box. Procedures can be complex and require meticulous precision.

Laryngeal framework surgery is performed with local anesthesia as well as intravenous sedation

An incision is typically made in a natural neck crease and the muscles and soft tissues are separated to expose the cartilage framework of the larynx.

Since adjustments are made to soft tissues of the larynx, the position of the vocal folds and their ability to close are visualized through the fiberoptic laryngoscope.

The surgeon will be making adjustments to the vocal fold(s) and listening to the voice quality and improvement during the procedure. Therefore the patient will be in varied states of awareness as the procedure happens.

Most importantly, swelling can impair the airway. Additionally, swelling during the procedure may cause inaccurate judgements regarding implant size and placement during a medialization thyroplasty/laryngoplasty or implant medialization procedure.

The laryngologist, often working in concert with a speech pathologist and/or the voice care team, will recommend laryngeal framework surgery to patients with voice disorders caused by poor vocal fold closure which can be caused by different problems in the cartilage and/or soft tissue.

(For more information, see Voice Care Team.)

Examples of voice disorders that could benefit from laryngeal framework surgery are listed below.

Common

• Vocal fold paralysis
• Vocal fold paresis
• Tissue defects after cancer resection
• Blunt and penetrating laryngeal trauma

Less common

• Sulcus vocalis
• Voice problems associated with Parkinson's disease
• Abductor spasmodic dysphonias
• Vocal fold scarring (to some extent)

As with any treatment strategy, the most important factor in achieving the optimal outcome of laryngeal framework surgery is in making the proper diagnosis. This typically requires laryngeal videostroboscopy to carefully assess character and severity of the vibration abnormality. Often, laryngeal electromyography is helpful in determining why a vocal fold is not moving and assessing the chances of spontaneous recovery of function.

(For more information, see Laryngoscopy/Stroboscopy and LEMG.)

It is very important to carefully assess the mobility of the uninvolved (or normal) vocal fold and mucosal surfaces of both sides. All of these factors are important for restoration and improvement of voice function.

The experience and skills of the operating surgeon are central to the success of laryngoplastic phonosurgery.

In many ways the principles of laryngoplastic phonosurgery are the same as the basic principles of surgery.

• Airway safety: The mobility of the normal vocal fold should be carefully assessed since altering the cartilage and the vocal fold will often narrow the airway.
• Patient communication: Care should be taken to prepare patients for the events that will take place during the operation. It is helpful to use medications to help calm anxious patients and to limit unnecessary conversation in the operating room.
• Preservation of normal tissue: Tissues must be handled gently to minimize damage to normal tissues and to minimize swelling. This allows for a more accurate soft tissue adjustment for tuning the voice.
• Control of bleeding: Bleeding should be minimized since it can lead to swelling and delayed healing. This can be accomplished by skillful use of cautery, careful dissection, and avoiding operating on patients who are taking anticoagulant medications.

Successful laryngeal framework surgery is based on an accurate assessment of the vibration problems of the vocal folds. Currently, vocal fold vibration is best studied by laryngeal stroboscopy wherein the laryngologist studies the two key elements of vocal fold vibration for sound production.

1. How well do both vocal folds meet in the middle? (vocal fold "closure")
2. How flaccid is the muscle of the vocal fold?
3. How supple or pliable are the vocal folds? (vocal fold pliability)

(For more information, see Laryngoscopy/Stroboscopy and Anatomy & Physiology of Voice Production.)

The airway should be carefully evaluated in the context of the patient's specific aerodynamic needs (e.g., younger active patients, athletes, singers).

• The choice of procedure(s) is based on the preoperative assessment as well as the familiarity of the surgeon with various procedural options.

  (For more information, see How to Find a Voice Physician.)

• The procedure(s) that optimizes the voice and is within the surgeons' skill sets while adjusting to the patient's airway needs should be selected.

Red Flag

If vocal fold closure is achieved and hoarseness persists, there may be:

1. Overclosure anteriorly
2. Substantial height difference between the vocal folds
3. Mucosal stiffness or scarring that had not been appreciated
4. Unrecognized neurological, behavioral, or psychological problems

The results of laryngeal framework surgery can be improved or impaired by the patient.

• For example, if a patient has backflow of stomach fluids to the voice box (laryngopharyngeal reflux), the patient should carefully follow physician recommendations for aggressive treatment of the reflux, especially during the perioperative period. (For more information, see Reflux Laryngitis.)
• Another example, if the mechanical problem has been corrected by surgery, the patient must correct problematic voice behaviors to optimize the result. This is especially true for older patients who have had the problem for a long time (e.g., vocal fold paralysis for more than six months) since they often develop inappropriate voice habits to compensate for the vocal fold paralysis. (For more information, see Voice Therapy.)
• The patient must also address other factors that worsen voice problems, such as allergies, smoking, and other environmental factors, to ensure the best outcome.

• Patients should design a plan for postoperative voice care with their surgeon and/or speech pathologist before the surgery.
• In some instances, patients may be instructed to perform certain exercises that will help eliminate bad voice habits after the surgery, thus promoting proper healing.

Voice rest is seldom needed, however guidance for use by a speech language pathologist is helpful.

Key Information

• Patients might need to spend some time with a speech pathologist after surgery until they collaboratively believe that voice function has been optimized.
• Patients should not expect immediate results from many types of phonosurgical procedures because it may take some time for swelling to subside and healing to occur.
• Patients must follow the voice care team's specific recommendations for voice rest, vocal hygiene, and postoperative vocal tasks to optimize the outcome of surgery. (For more information, see Voice Therapy and Prevention of Voice Disorders.)

Highlights