From the Departments of Communicative Disorders (Ms Gorham and Dr Crary) and Otolaryngology (Drs Avidano, Cotter, and Cassisi), University of Florida Health Science Center, Gainesville.
To describe the pattern of laryngeal recovery and its relationship to voice improvement following thyroplasty.
We used a 5-point scale to rate 5 laryngeal characteristics preoperatively and 1 day, 1 week, 1 month, and 3 months following thyroplasty.
A university-affiliated health center.
Forty-four patients who underwent thyroplasty to correct incomplete glottal closure.
Improved glottal closure and reduced supraglottic activity followed thyroplasty. Although evidence of postoperative irritation (erythema, edema, or hematoma) was present in many patients, it resolved within the first 1 to 4 weeks postoperatively in 22 (73%) of the 30 subjects available for follow-up at 3 months following thyroplasty.
Thyroplasty is an effective procedure in correcting incomplete glottal closure and works to reduce excessive supraglottic activity in some patients. Recovery from postoperative vocal-fold irritation occurs rapidly, typically between the first week to first month, depending on the type and severity of irritation. These findings may help explain variations in postoperative voice improvement.
TYPE I thyroplasty has become a primary choice of treatment in cases of unilateral vocal-fold paralysis1 and other conditions leading to incomplete glottal closure.2 This procedure has been shown to be quite successful in restoring voice,1,3- 5 with a high degree of patient satisfaction.6
Reports of voice improvement following thyroplasty indicate variation during the time following the procedure. Sasaki et al5 described improved voice function on the first postoperative day, with subsequent improvement at 1 and 3 postoperative months. Tucker7 also reported marked voice improvement up to 3 weeks postoperatively but noted that, in some cases, voice initially deteriorated compared with the intraoperative status before improving again. Netterville et al8 reported initial voice improvement intraoperatively, followed by a rapid deterioration. They attributed this deterioration in voice performance to the development of edema. Vocal quality improved within the first postoperative week, presumably corresponding to remission of edema.
Aside from the observations by Netterville et al8 of postoperative voice deterioration suspected to be associated with edema, few descriptions of laryngeal changes associated with thyroplasty have been discussed. Given the reported variability in postoperative vocal function, knowledge of laryngeal recovery after thyroplasty is warranted. Our purpose is to describe that pattern of laryngeal recovery.
The subject group consisted of 44 patients who had undergone a unilateral type I thyroplasty to correct glottic insufficiency. Diagnoses contributing to glottic insufficiency are given in the following tabulation:
Five of these patients required revision of the thyroplasty due to extrusion (n=3) or movement (n=2) of the implant. A sixth patient underwent a second thyroplasty in an attempt to provide additional voice improvement subsequent to the initial operation. Hence, 50 procedures performed on 44 patients provided the database for the laryngoscopic measures.
Sixteen of the patients were men; 28, women. They ranged in age from 22 to 84 years. Twenty-six of the patients underwent a left-sided thyroplasty, whereas 17 patients underwent a right-sided thyroplasty. One patient underwent bilateral medialization in an attempt to correct bilateral vocal-fold bowing. All patients underwent a type I thyroplasty as described by Cotter et al.9
Each procedure was performed by the attending physician (N.J.C.), who was assisted by an otolaryngology resident. Intraoperative videolaryngoscopy was performed by the speech pathologist (M.A.C.). Local anesthesia with intravenous sedation was used in all procedures.
A window was outlined on the desired side of the thyroid cartilage at the estimated level of the vocal fold, approximately halfway between the thyroid notch and the lower border of the thyroid cartilage at the midline. The window dimensions were altered individually, and in general were smaller for women and larger for men. The average size of the window was 4×10 mm. A knife was used to incise the cartilage window in most patients. A small diamond burr drill was then used to remove the remaining cartilage, and the inner perichondrium was left intact. A wedge-shaped implant with a lateral extension or key piece was then cut from a silastic block for each patient. The implant was inserted into the pocket under videolaryngoscopic guidance. The implant may have been removed and custom fit several times to achieve the ideal medialization. Occasionally, a separate small wedge of silastic was inserted adjacent to the implant to increase medialization. The incision was then closed with reapproximation of the infrahyoid and platysma muscles. Patients usually received prophylactic antibiotics for several days. They were observed for several hours in the recovery room, and then were discharged to a local hotel with an appointment for videolaryngoscopy the following morning. Some patients required hospital admission for preexisting medical conditions.
Laryngoscopic examinations were conducted at the following times relative to surgery: preoperatively, intraoperatively, and at 1 day, 1 week, 1 month, and 3 months postoperatively. All examinations were recorded on a videocassette recorder for subsequent analysis.
Five laryngeal characteristics were evaluated using an ordinal scale. These characteristics included the degree of glottal closure, the amount of supraglottic compression, and evidence of erythema, edema, and hematoma. Five-point ordinal scales were used to rate each of the parameters, as shown in the following tabulation:
All parameters were rated by 2 third-year otolaryngology residents on a consensus basis. Interrater reliability was established by having a third examiner independently rate 20 of the videos. Pearson product moment correlation (r) values ranged from 0.56 to 1.00 for individual parameters, with a correlation of 0.87 for all parameters combined.
Preoperative ratings showed that 20 of the patients received a rating of 3, whereas 9 others received a rating of 1. Hence, the most common glottal configurations observed preoperatively were large and small glottal gaps with no posterior extension.
As shown in Figure 1, a marked reduction in glottal opening occurred intraoperatively. This improved glottal closure was maintained at the 1-day and 1-week postoperative visits.
Mean (SD) scores for the ratings of glottal opening. Ratings are described in the "Procedure" subsection of the "Subjects and Methods" section. Numbers indicate procedures for which patient was available for follow-up.
At the 1-month postoperative visit, 8 (27%) of the 30 patients available for follow-up demonstrated an increase in glottal opening. Three patients were found to have extrusion or movement of the implant and subsequently underwent a revision thyroplasty. Four others demonstrated a reduction in vocal-fold edema corresponding to the increase in glottal opening. The eighth patient exhibited a slight increase in glottal opening that could not be attributed to implant movement or remission of edema.
Continued improvement in glottal closure was maintained for the other 22 (73%) of 30 patients seen at the 3-month postoperative visit.
Excessive supraglottic compression has been viewed as a compensatory laryngeal mechanism in reaction to reduced glottal closure.10,11 Improved glottal closure following thyroplasty was reasoned to contribute to reduced supraglottic compression. Only those patients exhibiting supraglottic compression before surgery were therefore included for analysis.
Patients undergoing 34 (68%) of the 50 procedures demonstrated supraglottic compression preoperatively. Supraglottic compression decreased initially following medialization but increased at the 1- and 3-month postoperative visits (Figure 2). Possible explanations for the increase include subject attrition, implant extrusion, and/or remission of postoperative edema.
Mean (SD) scores for the ratings of supraglottic activity. Ratings are described in the "Procedure" subsection of the "Subjects and Methods" section. Numbers indicate procedures for which patient was available for follow-up.
The remaining 3 parameters—erythema, edema, and hematoma—were included as laryngoscopic evidence of irritation or trauma to the vocal folds secondary to surgery. Only those patients exhibiting evidence of vocal-fold irritation at the 1-day postoperative visit were included for the final analysis.
Erythema was noted following 34 (68%) of the 50 procedures at the 1-day postoperative visit. An initial increase was observed 1 day postoperatively, with a subsequent decline occurring 1 week to 3 months postoperatively (Figure 3).
Mean (SD) scores for the ratings of erythema. Ratings are described in the "Procedure" subsection of the "Subjects and Methods" section. Numbers indicate procedures for which patient was available for follow-up.
Edema was noted following 38 (76%) of the 50 procedures at the 1-day postoperative visit. As shown in Figure 4, edema increased intraoperatively and reached its highest level 1 day postoperatively. A marked reduction in edema was noted 1 week postoperatively, with further decline occurring at the 1- and 3-month postoperative visits.
Mean (SD) scores for the ratings of edema. Ratings are described in the "Procedure" subsection of the "Subjects and Methods" section. Numbers indicate procedures for which patient was available for follow-up.
Patients undergoing 14 (28%) of the 50 procedures demonstrated evidence of minor vocal-fold hematoma 1 day following surgery. Hematoma in most of these cases (n=12) was rated as mild or moderate. Only 2 of the 14 instances of hematoma were considered to be severe.
As shown in Figure 5, a marked reduction in the hematoma rating was observed 1 week postoperatively. Complete resolution of all hematomas occurred within 1 to 3 months.
Mean (SD) scores for the ratings of hematoma. All subjects received a rating of 0 at 1- and 3-month postoperative follow-up. Ratings are described in the "Procedure" subsection of the "Subjects and Methods" section. Numbers indicate procedures for which patient was available for follow-up.
Our data are consistent with those of previous studies1,2,4- 6,8 in demonstrating that type I thyroplasty is an effective treatment to improve glottal closure in patients with glottic insufficiency. Possible explanations for increases in glottal opening after 1 month may include shifting or extrusion of the implant, remission of edema, or even altered laryngeal mechanics.
The pattern of laryngeal recovery described herein may have important implications for voice improvement following thyroplasty and patient counseling. Although improved vocal quality is generally noted immediately following placement of the implant, the patient and voice clinician should be aware that marked deterioration in voice performance may occur in the initial postoperative stages. The development of erythema, edema, and/or hematoma immediately following surgery may result in less-than-optimum vocal quality. Resolution of these tissue changes, however, often occurs within the first postoperative week or month, allowing for improved vocal quality. This healing process may occur rapidly within the first postoperative week or may last up to 1 to 3 months, thus supporting the observation of Tucker et al12(p780) that improved vocal quality noted intraoperatively "would often deteriorate for various periods of time before gradually restabilizing at improved levels." Netterville et al8 also observed a similar trend relative to voice recovery. Specifically, they noted that "the initial voice improvement acquired on the operating table rapidly changes in the recovery room as perioperative edema develops. Although the voice is usually stronger, it is raspy for several days to weeks after surgery."8(p442)
Our results demonstrated that laryngeal recovery following thyroplasty generally occurs within the first postoperative month. Potential patients should be alerted to the possibility that optimum vocal quality may not be obtained for at least the first 1 to 3 months, if not longer, following medialization. Indeed, Netterville et al8 suggested that vocal samples obtained before 3 months may not be indicative of long-term voice quality. Lack of improved vocal quality immediately following surgery may indicate a prolonged period of healing, rather than surgical failure, for a particular patient.
Accepted for publication August 20, 1997.
Presented in part at the American Speech-Language-Hearing Association Convention, Anaheim, Calif, November 1993.
Reprints: Michael A. Crary, PhD, Department of Communicative Disorders, Box 100174, University of Florida Health Science Center, Gainesville, FL 32605 (e-mail: email@example.com).
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The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
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