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Vocal Fold Medialization by Surgical Augmentation Versus Arytenoid Adduction in the in Vivo Canine Model

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Vocal Fold Medialization by Surgical Augmentation Versus Arytenoid Adduction in the in Vivo Canine Model Ann Otol Rhinol Laryngol100:1991 VOCAL FOLD MEDIALIZATION BY SURGICAL AUGMENTATION VERSUS ARYTENOID ADDUCTION IN THE IN VIVO CANINE MODEL DAVID C. GREEN, MD GERALD S. BERKE, MD PAUL H. WARD, MD Los ANGELES, CALIFORNIA There are a variety of methods for treating unilateral vocal cord paralysis, but to date there have been few studies that compare these phonosurgical techniques by using objective measures of voice improvement. Vocal efficiency is an objective voice measure that is defined as the ratio of the acoustic power produced by the larynx to the subglottic air power. Vocal efficiency has been found to decrease with glot­ tic disorders such as vocal cord paralysis and carcinoma. This study compared the effects of vocal fold medialization by surgical augmenta­ tion to those of arytenoid adduction on the vocal efficiency, videostroboscopy, and acoustics (jitter, shimmer, and signal-to-noise ratio) of a simulated unilateral vocal cord paralysis in an in vivo canine model. Arytenoid adduction was superior to surgical augmentation in vocal efficiency, traveling wave motion, and acoustics. KEYWORDS - flaccid laryngeal paralysis, laryngoplasty, phonosurgery, recurrent laryngeal nerve, stroboscopy, vocal efficiency. INTRODUCTION noid muscle contraction plays a greater role in in­ There are a variety of methods for treating uni­ tensity control during normal phonation than later­ lateral vocal cord paralysis. These include Teflon al cricoarytenoid contraction by changing cord stiffness and shape, while lateral cricoarytenoid injection;' thyroplasty, 2 arytenoid adduction," and contraction plays a greater role in pathologic cases nerve" and nerve-muscle pedicle transfer. 5 Most of these methods have been reported to improve the with incomplete glottic closure by enhancing cordal voice. However, recently, a theoretical paper com­ adduction. Clinically, vocal efficiency has been paring effects of the above treatment modalities on shown to decrease with some forms of laryngeal dis­ laryngeal vibration found significant differences ease, such as invasive carcinoma and vocal cord pa­ among them." Unfortunately, to date there have ralysis.t"" been few studies that compare these phonosurgical techniques by using objective measures of voice im­ Although vocal efficiency is a useful objective provement. Most authors simply describe the voice measure of voice, it does have its shortcomings. This as improved over the paralyzed state. measure may not correspond with vocal quality. The voice may be quite harsh with a normal vocal Vocal efficiency is an objective measure of the efficiency. Also, vocal efficiency does not indicate voice that was first studied by van den Berg" in the degree of control the patient has over the glottis. 1956. He defined the efficiency of the voice as the Typically, vocal efficiency increases with intensity, ratio of the acoustic power of the voice to the sub­ and an early vocal abuser may have a higher vocal glottic power. The subglottic air power can be esti­ efficiency despite actively abusing his or her voice. 9 mated as the product of the mean glottic airflow rate and the mean subglottic pressure. The physio- A number of acoustic measures of voice quality logic control of vocal efficiency has been studied by have been used clinically. These include jitter, shim- several investigators. Koyama et al," using an in vi- mer, and signal-to-noise ratio. Jitter is defined as vo canine model, found higher levels of vocal effi- the fluctuation in the time interval between succes- ciency when cricothyroid contraction was added to sive peaks of the fundamental frequency. Shimmer recurrent laryngeal nerve stimulation. Tanaka and is the cycle-to-cycle variation in the amplitudes of Tanabe," also using an in vivo canine model, found the peaks. Signal-to-noise ratio is the ratio of the that increased contraction of the thyroarytenoid or sound energy in the acoustic signal to the noise in cricothyroid muscle increased glottic resistance (the the voice signal. 12.13 Lieberman':' was the first to re- ratio of glottic airflow to subglottic pressure), while port an increased jitter in pathologic phonation. vocal efficiency remained constant. They further Lieberman':' and Koike et al 15 found, using high- observed that contraction of the lateral cricoaryte- speed cinematography, that pitch perturbations re- noid muscle increased both glottic resistance and fleeted variations in the glottic area and periodicity. vocal efficiency. They postulated that thyroaryte- Koike et aIlS and Zyski et al 16 found increased jitter From the Division of Head and Neck Surgery, University of California-Los Angeles, and the Department of Head and Neck Surgery, West Los Angeles Veterans Administration Medical Center, Los Angeles, California. This study was performed in accordance with the PHS Policy on Humane Care and Use of Laboratory Animals, the NIH Guide for the Care and Useof Laboratory Animals, and the Animal Welfare Act (7 U.S.C. et seq.): the animal use protocol was approved by the Institutional Animal Care and Use Committee (IACUC) of the University of California. Presented at the meeting of the American Laryngological Association, Palm Beach, F1orida, April 28-29, 1990. REPRINTS - Gerald S. Berke, MD, Division of Head and Neck Surgery, UCLA, 10833 Le Conte Ave, Los Angeles, CA 90024. 280 Green et al, Vocal Fold Medialization 281 and shimmer in patients with laryngeal tumors and Surgery on the laryngeal framework as a treat­ unilateral vocal cord paralysis. Efforts have been ment for unilateral vocal cord paralysis began with made to use these measures as screening devices for Payer" and was later modified by Meurrnarr" and laryngeal disease;" but few studies have used these others. The first systematic study and classification measures to document the results of laryngeal sur­ of these procedures was by Isshiki et al," who coined gery.:" the term thyroplasty. There are four types of thyro­ plastic operations. Type I provides lateral compres­ An examination of current literature demonstrates sion to the paralyzed cord, narrowing the glottic that the optimal procedure for voice improvement chink. Type II creates lateral expansion of the glot­ in a patient with unilateral vocal cord paralysis is in tis. Type III shortens and relaxes the cord bilateral­ a state of flux. 19 Teflon injection has been very suc­ ly. Type IV lengthens and stretches the cords. Isshi­ 29 cessful in improving the voice and reducing aspira­ ki et al studied the results of these four types of tion since its introduction in 1962 by Arnold.' Ru­ thyroplasties in treating unilateral vocal cord paral­ bin 20 studied the histology of Teflon-injected vocal ysis in the canine larynx. In their study, the degree cords and showed, using high-speed cinematogra­ of voice improvement was evaluated subjectively as phy, improved vibration of the paralyzed cord, "improved" or "rough," and the mechanical effect which was placed in a more medial position after on the larynx was studied only with laryngoscopy. injection. Von Leden et al" found voice improve­ They recommended using a type I thyroplasty for a ment, postinjection, using both acoustic analysis unilateral recurrent laryngeal nerve paralysis and and laryngeal function studies. Rontal et al 22 also types I and IV together for a unilateral superior and demonstrated improvement in voice spectrograms recurrent laryngeal nerve paralysis. Clinically, postinjection. However, a number of concerns re­ there are four types of manual compression tests garding Teflon injection are emerging. that can be performed on the larynx to help decide if thyroplasty would be helpful. These are the later­ al compression test, the dorsal compression test, the The degree of improvement with Teflon injection cricothyroid approximation test, and combinations is sensitive to the amount and position of injection. 23 24 of the above. 30 Improvement in the voice during the Trapp et al found, in the dog, that overinjection lateral compression test helps indicate the degree of or underinjection of Teflon into the paralyzed cord improvement after type I thyroplasty. would result in a lack of two-mass (upper and lower margin) vibration. Crumley et al" found, in hu­ Koufrnarr" reported a series of 11 patients who mans, that Teflon-injected vocal cords lacked a mu­ underwent a modification of the type I thyroplasty cosal wave. They postulated that the early voice fa­ (medialization laryngoplasty) for treatment of uni­ tigue often seen after Teflon injection may be due to lateral vocal cord paralysis (both recurrent and va­ sound's being generated by only the noninjected gal). On a five-point scale, improvement was seen cord. Failure to achieve an improved voice has been in 10 of 11 patients. Escajadillo'" reported a modifi­ reported to occur in about 10% of cases." Acoustic cation of the type I thyroplasty performed in dogs 24 studies by Trapp et al using the in vivo canine and humans. This modification resulted in a "near model have shown that phonation after Teflon in­ normal" or "normal" voice in 4 of 5 patients. Kouf­ jection requires a high flow rate and has a high jit­ man found several advantages of medialization la­ 26 ter. Cormier et al measured forced inspiratory and ryngoplasty over Teflon injection. The medialization expiratory airflow before and after injections and is theoretically easily reversible, whereas Teflon in­ found a transient subclinical inspiratory airway ob­ jection is more difficult to reverse. The patient's dis­ struction at 24 hours after injection in all seven of comfort is less with this procedure under local anes­ the patients studied. This airway obstruction was thesia than with a direct laryngoscopy under topical thought to be due to postinjection inflammation of and local anesthesia. The surgeon can add to and the paralyzed cord, which resolved in approximate­ subtract from the degree of medialization to fine­ ly 10 days. Hublrr" demonstrated this inflammatory tune the voice, whereas the Teflon injection can on­ reaction histologically and warned that the voice ly add to the medialization.
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