Explain medialization of the vocal cord by an otolaryngologist (ENT).

Vocal Cord Medialization by ENT

Vocal cord medialization is a surgical procedure performed by otolaryngologists to reposition a paralyzed or weakened vocal fold toward the midline of the larynx, thereby closing the glottic gap to restore voice quality, improve swallowing safety, and enhance airway protection. 1

Indications and Pathophysiology

• Glottic insufficiency is the primary indication, characterized by incomplete closure of the vocal folds during phonation. 1
• This condition results from impaired vocal fold mobility (paralysis or paresis), vocal fold bowing, or soft tissue defects. 1
• Patients typically present with weak, breathy dysphonia, poor cough, dyspnea, and dysphagia due to inadequate glottic closure. 1
• The procedure works by reducing the glottic opening during phonatory tasks to improve vocal efficiency. 1

Surgical Techniques

Injection Medialization (Injection Laryngoplasty)

• Injection of bulking agents into the affected vocal fold provides temporary medialization and can be performed in the office under local anesthesia or in the operating room under general anesthesia. 1
• Both settings provide comparable improvement in voice outcomes. 1
• Resorbable, temporary injectable implants (collagen, hyaluronic acid gel, or lyophilized dermis) are preferred while allowing time for neural recovery. 1
• Early intervention (within 6 months) with injection laryngoplasty decreases the need for more invasive long-term therapy including transcervical vocal fold medialization. 1, 2
• Collagen or lyophilized dermis injections can provide adequate vocal rehabilitation in pediatric patients. 1

External Medialization (Laryngeal Framework Surgery/Medialization Thyroplasty)

• Open surgical procedure that creates a window in the thyroid cartilage and positions an implant to push the vocal fold medially. 3
• Unlike injection, this technique does not increase the "bulk" of the atrophic vocal fold but merely brings it closer to its unaffected partner. 3
• Can be performed under local or general anesthesia, allowing for intraoperative voice assessment when done awake. 3
• Materials used include silicone, expanded polytetrafluoroethylene (ePTFE), and adjustable implants. 4, 5

Critical Contraindications and Warnings

• Polytetrafluoroethylene (Teflon) as a permanent injectable implant is NOT recommended due to its association with foreign body granulomas that can result in voice deterioration and airway compromise. 1
• This produces stiffness of the vocal fold with loss of the "mucosal wave" and concomitantly poor vocal function. 4

Outcomes and Benefits

• Improved voice quality and voice-related quality of life are the primary benefits. 1
• Observational studies show comparable objective and subjective improvement in voice between injection laryngoplasty and laryngeal framework surgery. 1
• Prospective trials demonstrate significant improvement in validated voice QOL measures in 94% to 100% of patients without significant complications after six-month follow-up. 1
• Early medialization creates a more favorable vocal fold position for phonation that can be maintained by synkinetic reinnervation, in contrast to the final position of a lateralized vocal fold being determined solely by reinnervation. 1

Risks and Complications

• Dysphagia, airway obstruction, and breathy voice are potential complications. 1
• The benefits-harm assessment shows a preponderance of benefit over harm. 1
• Current injectables are largely resorbable, leaving no long-term effect on vocal fold function if motion returns. 1

Special Considerations

Arytenoid Adduction

• When there is a posterior glottal gap or vertical mismatch between vocal folds, medialization thyroplasty alone may be insufficient. 6, 3
• The slipping and prolapse forward of the arytenoid cartilage due to muscle atrophy causes a vertical drop that may require arytenoid adduction in addition to medialization. 3

Bilateral Medialization

• Medialization techniques can be performed unilaterally or bilaterally depending on the clinical scenario. 1

Clinical Pearls

• Office-based injection is cost-effective, shows good patient tolerance, minimal complications, and successful outcomes compared to operating room procedures. 1
• Patients with unrecovered vocal fold paralysis who had temporary injection medialization were statistically less likely to ultimately require permanent surgical intervention compared to those initially treated only with conservative management. 1
• The procedure is especially indicated when the paralyzed vocal fold is in a lateralized position, but may be less effective when there is significant vertical height mismatch. 6