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Medialization thyroplasty using Gor-Tex

Dr T Balasubramanian

Introduction:

Vocal cord paralysis is a rather common problem causing speech problems tothe patient. If the other cord doesnt compensate adequately these patientsmay have troublesome aspiration also. Aspiration happens to be the most

dreaded complication of vocal fold paralysis. Management of these patients ispossible only by performing Medialization thyroplasty (Ishiki type Ithyroplasty). Various graft materials have been used in this procedure.Presently lot of interest has been generated in Gor-Tex medicalizationthyroplasty.

Advantages of Gor-Tex:

Gor-Tex is expanded polytetrafluroethylene has obvious advantages as animplant material in Medialization thyroplasty procedures.

1. It is malleable2. Its position can easily be adjusted within the thyroid cartilage window3. Only a small fenestration is necessary in the lamina of thyroid cartilage tointroduce this material4. This procedure is reversible and has very few complications5. Creates less oedema when compared to that of silastic and hence overcorrection is not possible6. Resultant quality of voice is really good

History:Hoffman and McCullouch reported the first case of medialization thyroplastyusing Gor-Tex in May 1996.

Indications of Gor-Tex Medialization thyroplasty:

1. Unilateral vocal fold immobility due to paralysis, paresis, atrophy2. Unilateral vocal fold scarring / soft tissue loss

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3. In select cases of Parkinsons disease with vocal fold atrophy

Contraindications of Gor-Tex thyroplasty:

1. Previous history of irradiation2. Malignant lesions involving larynx3. Poor abduction of contralateral vocal fold as this would cause impairment ofairway

Procedure:This procedure is ideally performed under local infiltration anesthesia using2% xylocaine mixed with 1 in 100,000 units adrenaline.

Incision:

Horizontal skin crease incision beginning at the mid portion of the thyroidcartilage extending to the paralyzed side.The strap muscles are separated away from midline and held apart from theoperating field using umbilical tape.

A tracheal hook is used at the level of laryngeal prominence and pulledmedially. This helps in mobilizing the cartilage better.The thyroid cartilage perichondrium is incised in the midline and extendedlaterally towards the paralyzed side. The thyroid lamina on the paralyzed sideis skeletonized up to the level of cricothyroid membrane. Strips of cricothyoid

muscle that come in the way are excised.

Dimensions of cartilage cuts:

Appropriate size of cartilage window is about 5mm x 10mm. The lower borderof the window should be about 3mm above cricothyroid membrane. Thisensures that the lower strut of thyroid lamina doesnt fracture when window isbeing created. Anterior border of the window is about 8mm posterior tomidline. If thyroid cartilage is calcified then fissure burr can be used to create

the window.The inner perichondrium is elevated from the under surface of thyroid laminausing scissors. The inner perichondrium incised posteriorly and inferiorly. It isnot incised anteriorly. Now the cricothyroid membrane is incised in order toseparate it from the lower border of thyroid cartilage. A septal elevator isintroduced through the inferior margin of thyroid lamina and the paraglotticspace is compressed medially while the voice of the patient is assessed. If theresult is acceptable then 1 cm wide Gor-Tex strips dipped in bacitracinsolution is introduced via the inferior margin of thyroid lamina and deliveredvia the window. The amount of Gor-Tex insertion is dependent on theimprovement of quality of voice.

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If necessary use prolene sutures passing via the inferior strut of thyroid lamina to stabilize

Gor-Tex. Wound is closed in layers after keeping a penrose drain.

It is very important to perform pre operative and post operative video laryngeal examination.