types of thyroplasty

1. Laryngeal Framework
Surgery
DR SAFIKA ZAMAN
DEPT OF ENT & HNS
RKMSP, VIMS

2. Introduction
 Voice – identity of a person.
Production of voice
 Pulmonary reserve.
 Resonance created in the nose , PNS, oral cavity and pharynx.
 Movement of cord, shape , size and structural integrity of cord.

3. History
 1911- Brunnings , made the 1st attempt to
medialize vocal fold by injecting paraffin.
 1915- Payr – pedicle flap of cartilage.
 1974- Isshiki –proposed different type of
thyroplasty for different dysphonia.
http://www.entandaudiologynews.com/

4. Definition
 Surgical procedures performed on the laryngeal skeleton and the insertion
of muscles to correct vocal fold positioning and tension.
 Objective: improve the voice without directly intervening in the vocal folds.

5. Laryngeal framework
 Cartilages
 Ligaments
 Membranes
 Muscles

6. Cartilages

7. Thyroid cartilage
 Most prominent cartilage
 Two laminae
 Thyroid notch
 Superior and inferior cornua
 Vocal fold lies closer to the inferior
border of the thyroid cartilage

8. Muscles
 The intrinsic muscles- 1. adductors
2.abductors 3. tensor
 Adductors – lateral cricoarytenoid,
thyroarytenoid, interarytenoid.
 Abductor – posterior cricoarytenoid
 Tensor – cricothyroid

9. Type of Thyroplasty(Isshiki)

10. Europian laryngological society
classification
Approximation laryngoplasty Type 1 Thyroplasty with or without arytenoid
adduction
Expansion laryngoplasty Type 2 Thyroplasty
Relaxation laryngoplasty Type 3 Thyroplasty
Tensioning laryngoplasty Type 4 Thyroplasty

11. Approximation laryngoplasty / Type
1 thyroplasty
 Indications: - Symptomatic glottic insufficiency (dysphonia, aspiration).
 U/L vocal fold paralysis.
 Vocal fold atrophy, including age related atrophy.
 Vocal fold bowing due to ageing and cricothyroid joint fixation.
 Sulcus vocalis - Soft tissue defect resulting from excision of pathological masses.
Contraindications: -Malignant disease overlying laryngotracheal complex.
-Poor abduction of C/L vocal fold.
-h/o radiation therapy to larynx.

12. Manual compression test

14. Treatment options for unilateral VFP
 Observation
 Voice therapy
 Surgical intervention
 Injection augmentation
 Laryngeal frame work surgery
 Re-innervation

15. Procedure
 Positioning
 Anasthesia
 Thyroid cartilage is palpated
 Midline is also marked on the chin, neck and sternal
notch.
 Incision -horizontal with about 3-4 cm
 Thyroid cartilage widely exposed

16. Type 1 thyroplasty window

17. Implants

18. Titanium Implants

19. Cont..
Textbook of Laryngology – N K Narukar, A Roychoudhury

20. Complication
 Penetration of endo-laryngeal mucosa - assess air leak before placement
of implant in window.
 Wound infection – Chondritis.
 Airway obstruction – overnight monitoring is required.
 Implant extrusion-Can become displaced and even extrude into the airway.

21. Limitation
 Mechanical nature of the procedure.
 Imparts only static change to laryngeal framework with no effect on
dynamic function.
 No effect on vocal fold muscle mass, innervation and mobility.
 Closure of posterior glottis limited.
 No effect on vocal fold level in vertical plane.

22. Adduction of arytenoid
 Lower the vocal process
 Stabilize and medialize the vocal
process
 Suture mimics TA-LCA muscle complex .
Textbook of Laryngology – N
K Narukar, A Roychoudhury

23. Expansion laryngoplasty
Indication - adductor spasmotic dysphonia( involuntary muscle spasms in the
intrinsic muscles of larynx).
Treatment options – botulinum toxin injection , recurrent nerve avulsion and
expansion laryngoplasty

24. Type 2 thyroplasty – lateral approach
 purpose of this procedure is to increase
the transverse diameter of the thyroid
cartilage, extending the glottic space.
Catani GSA, Catani MEC, Kinasz LRS, et al. Laryngeal framework surgery. J Otolaryngol ENT Res.
2020;12(5):151‒154

25. Type 2 Thyroplasty – medial approach
 Thyroid cartilage is split in the midline.
 Split ala kept apart with the help of 3 mm sialastic shims or titanium
miniplate.
Catani GSA, Catani MEC, Kinasz LRS, et al. Laryngeal framework surgery. J Otolaryngol ENT Res.
2020;12(5):151‒154

26. Thyroarytenoid myomectomy
 Endoscopic or open approach
 Vocal cord abduction by suture method
 Partial arytenoidectomy

27. Advantage and disadvantage of type 2
Advantages: Optimal glottal closure can be adjusted and readjusted
- No damage of physiologic function
- Reversible
Disadvantages: Technically difficult
Shim displacement
Does not relieve cause of Spasmodic Dysphonia.

28. Relaxation laryngoplasty
 Tension of the vocal folds reduced by antero-posterior shortening of
thyroid ala.
 Lowers the pitch.

29. Relaxation laryngoplasty
 Indication – 1.Males with high pitch voice resistant to voice therapy.(
Puberphonia/ Mutational falsetto)
2. Stiff VF with high pitched breathy voice.
3. Spastic dysphonia

30. Cont …
Lateral approach : ( Type III) Thyroid ala is
incised at about junction of anterior and middle
one third, and 2-5 mm cartilage strip is excised.

31. Cont…
 Medial approach: ( Anterior
commissure retrusion) - Retrusion of
the middle portion of the thyroid
cartilage and leads to reduction in
the length of vocal folds.
 - Vertical incision was made either
side of the midline of the thyroid
cartilage.

32. Type 4 thyroplasty
 Increases the vocal pitch.
 It increases the distance between the vocal fold attachments and thus raise
the tension of vocal fold.
 Indications: Androphonia -Abnormally low pitched voice in female. -
Male to female trans-sexualism
- Abnormallly lax or bowed vocal folds (presbyphonia)

33. Cricothyroid approximation
 Cricothyroid Approximation : - increases vocal pitch
by simulating the contraction of cricothyroid muscle
with sutures.
 The cricoid and thyroid cartilage is approximated as
closely as possible.
 Non absorbable monophilic sutures are placed to
draw the cricoid and thyroid cartilages together.

34. Anterior commissure advancement
Potentially the comfortable speaking pitch is higher .
Catani GSA, Catani MEC, Kinasz LRS, et al. Laryngeal framework surgery. J Otolaryngol ENT Res.
2020;12(5):151‒154

35. Webbing of the ant vocal fold
 Microlaryngoscopy under general
anaesthesia.
 Vocal fold mucosa from ant half of
vocal fold removed, then sewn
together.
https://els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/c1e59191-23f6-4dfd-b306-
d6018364c3e1/gr1.jpg

36. Femlar
 Anterior 25% of false cords and 50% of true cords are removed
 Upper part of thyroid cartilage removed
 Larynx suspended high in the neck by sutureing to hyoid bone
 Advantage: physical size and location of the larynx in the neck is close
approximation of a female larynx.

37. FemLar
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38. Thank You