Repairing Glottic Insufficiency (Vocal Cord Gap)
For adults with a gap between the vocal cords, injection medialization with temporary resorbable materials (collagen, hyaluronic acid gel, or lyophilized dermis) is the first-line surgical intervention, ideally performed within six months of onset to reduce the need for more invasive permanent procedures. 1
Treatment Algorithm
Initial Management: Voice Therapy
- Voice therapy should be the first-line treatment for glottic insufficiency, including presbylarynx and vocal fold paralysis, before considering surgical intervention 2
- Voice therapy can be combined with surgical approaches to optimize outcomes, including pre- and post-operative therapy 2
- Surgery is reserved for cases where satisfactory voice results cannot be achieved with conservative management alone 2
Surgical Intervention: Injection Medialization (First-Line)
Timing & Materials:
- Early intervention within six months of onset significantly decreases the need for permanent transcervical medialization procedures 1
- Use temporary, resorbable injectable implants (collagen, hyaluronic acid gel, or lyophilized dermis) as they allow time for potential neural recovery while avoiding permanent tissue alteration 1
- These materials leave no lasting adverse effect on vocal fold function if native motion returns 1
Procedure Setting:
- Can be performed in the office under local anesthesia or in the operating room under general anesthesia with comparable voice outcomes 1
- Office-based injection is cost-effective, well-tolerated, associated with minimal complications, and yields outcomes comparable to operating-room procedures 1
Expected Outcomes:
- Prospective trials demonstrate significant improvement in validated voice quality-of-life measures in 94%–100% of patients with no major complications at six-month follow-up 1
- Observational studies show comparable objective and subjective voice improvement between injection laryngoplasty and laryngeal framework surgery 1
- Patients receiving temporary injection medialization are statistically less likely to require permanent surgical intervention compared to those managed conservatively 1
Surgical Intervention: Laryngeal Framework Surgery (Second-Line)
Indications:
- Reserved for cases where injection medialization fails to achieve adequate closure or when permanent medialization is required 2, 3
- Particularly useful for large glottic gaps that cannot be closed completely with injection alone 3
- Can be combined with other phonosurgical procedures and is reversible and revisable 3
Technique:
- External vocal fold medialization (thyroplasty) using implants to move the vocal fold to midline 3
- Modified techniques using titanium sheets or glass ionomer cement implants have been developed 3
- Significantly reduces the degree of glottic insufficiency, though complete closure of large gaps may not always be achievable 3
Critical Contraindication
Never use polytetrafluoroethylene (Teflon) as a permanent injectable implant—it causes foreign-body granulomas leading to voice deterioration, airway compromise, loss of mucosal wave, and poor vocal function 1
Common Pitfalls to Avoid
- Delaying intervention beyond six months: Early medialization establishes favorable vocal fold positioning that can be maintained by synkinetic reinnervation, whereas delayed treatment may result in lateralized fold position dependent solely on later reinnervation 1
- Using permanent materials prematurely: Temporary materials should be preferred initially to allow for potential neural recovery 1
- Skipping voice therapy: Even when surgery is planned, voice therapy should be integrated as it addresses behavioral and muscular issues contributing to dysphonia 2
Potential Complications
- Dysphagia, airway obstruction, and breathy voice are possible complications 1
- The overall benefit-harm assessment shows a clear preponderance of benefit over harm with current techniques 1
- Current resorbable injectable agents minimize long-term complications 1