Highlights

Key Glossary Terms

Laryngeal Framework Surgery
Surgical modification of the cartilage framework of the voice box so that vocal folds can close better or have more tension, in order 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 or implant medialization
2. arytenoid repositioning (adduction or arytenopexy)
3. cricothyroid repositioning (approximation or subluxation)

Glossary

Laryngeal framework surgery or laryngoplastic phonosurgery is a key surgical treatment for certain voice disorders.

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 the neck skin 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-tune 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: a. the surgeon listens to the voice with varied tissue repositioning b. the surgeon 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:

  1. implant medialization + cricothyroid subluxation
  2. implant medialization + cricothyroid subluxation + adduction arytenopexy
  3. etc.

Laryngeal framework surgery is a group of procedures which modify the different framework cartilages of the voice box. Procedures can be complex and require meticulous precision. Generally, medialization thyroplasty or implant medialization is a fairly easy procedure to do, but in some cases can be complex and more difficult.

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. Therefore the patient will be in varied states of awareness during the procedure.

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

A few examples of voice disorders that could benefit from laryngeal framework surgery are:

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

2. 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 best surgical result 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 necessary as well.

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

It is very important to carefully assess the function of 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.
• Control of Swelling: Steroids are often used since they will prevent some degree of swelling.
• Patient Communication: Care should be taken to keep anxious patients calm during the procedure with medications and with conversation since they will often be awake listening to surgeons' verbal comments and hearing a variety of sounds in the operating room.
• Preserve Normal Tissue: Tissues must be handled gently to minimize damage to normal structures to minimize swelling which 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.

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 both vocal folds meet in the middle (vocal fold "closure")
2. how supple or pliable the vocal folds are (vocal fold pliability)

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

The airway should be carefully evaluated in the context of the patient's specific aerodynamic needs; i.e. 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) should be selected that optimizes the voice and are within the surgeons' skill sets, while adjusting to the patient's airway needs.

Red Flag

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

• a. overclosure anteriorly
• b. substantial height difference between the vocal folds
• c. mucosal stiffness or scarring that had not been appreciated

The results of laryngeal framework surgery can be improved by the patient  but also decreased 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 the aggressive treatment of the reflux, especially during the perioperative period. (For more information, see Reflux Laryngitis.)
• For 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 6 months  since they often develop peculiar 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, in order 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 should 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 in order to optimize the outcome of surgery. (For more information, see Voice Therapy and Prevention

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