This document provides an overview of laryngeal framework surgery techniques. It discusses the anatomy of the laryngeal cartilages and muscles involved in voice production. It then describes the history and types of thyroplasty procedures developed to improve voice, including type 1-4 thyroplasties. Type 1 involves medialization of the vocal fold while types 2-4 are used to expand, relax or increase tension on the vocal folds. Other techniques discussed include arytenoid adduction, thyroarytenoid myomectomy, cricothyroid approximation and femlar surgery. Complications and limitations of the procedures are also summarized.

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