THIS PAGE IS FOR THOSE PATIENTS WHO HAVE A PARALYSED VOCAL

CORD (FOLD)

For an effective voice the vocal folds must meet each other in the midline.
If one vocal fold is thinned out, bowed or paralysed AND if no recovery
occurs the only way is to push the weak one inwards. This is known as
“medialisation” In some cases only the floppy membranous part of the
cord needs to be corrected ---usually by an implant or injection

2. Open Laryngeal Surgery (or laryngeal framework surgery/laryngoplasty) is performed through

a small external cut to the skin to access the larynx. All these procedures manipulate the vocal
folds from the outside. They do not touch the interior of the larynx so trauma to the vocal folds
does not occur. If possible a local anaesthetic is used so the surgeon can test the voice during
the operation. The laryngeal cartilages can then be manipulated either to widen or to narrow the
airway, or to alter the position or tension of one or both vocal folds. Surgical grade materials such
as silastic or goretex are frequently inserted as an implant to maintain the desired improvement.

5. 6.
7.

Image 5 showing the normal cartilage of the larynx, with the side of the vocal cords
indicated by the dotted line. In image 6 a window in the laryngeal cartilage allows implant
insertion at the level of the vocal cords in a medialisation procedure. Image 7 shows the
implant insertion to medialise the paralysed left vocal cord.

Indications: This surgery is most often performed to push (medialise) one of the vocal folds
towards the midline in the case of a paralysed nerve (recurrent laryngeal nerve palsy). This can
occur following surgery to the chest or neck or from a tumour or a mass pressing on the nerve.
This nerve has a longer course on the left as it passes from the neck into the chest on that side
and is therefore more commonly injured than the right one.
Medialising the paralysed fold allows the functioning one to meet it in the midline and therefore
close the “gap” between them.

Is there another way to medialise the paralysed vocal fold?

Many years ago Teflon paste was injected into the vocal fold. Neville Wran for instance had this
carried out in the 70’s. The problem was that it often went into the wrong place, either too near
the surface or too deep (Subglottic). It is very hard to get out.
Another substance that is safe is the patients own fat, however up to 40% can be absorbed
making it difficult to judge the correct amount to inject.
There is now a new substance called “VOX” which is safer but it can still be injected into the
wrong spot.
I prefer the absorbable Hyaluronic acid, “Restylane” that is used for filling spaces between
wrinkles for facial cosmetic reasons. It is absorbable over 3-4 months, very safe and if it is helpful
then a permanent substance or medialisation can be used.
More recently an artificial substance called “Radiesse” is popular especially in Europe as it lasts
twice as long as Restylane ie. About a year

Recovery
Recovery from an implant insertion is usually quick, with little in the way of pain. Your surgeon will
be able to send you home the same day or after one day in hospital. You must ensure a
responsible adult is available to supervise you for 24 hours post surgery. A period of absolute
voice rest may be required after endoscopic surgery. Follow up appointments will be required to
assess the success of the procedure.
LARGE GAPS / POSTERIOR LARYNX (Vid. infra-closure of posterior gap)
The back of the larynx cannot be closed by a normal implant or injection so that
If the whole vocal cord is paralysed and lateral or on a different level; then the
back of the larynx (Arytenoid) needs to be fixed in the correct position by
procedures known as arytenopexy or arytenoid adduction. Tensioning of one
weak vocal fold requires a procedure to tilt the larynx back wards and pull the
“cord/s” tight (cricothyroid subluxation).

A suture is placed to stabilise or pull the cartilage inwards. This operation is more difficult
BUT IT CAN STILL BE DONE UNDER LOCAL ANAESTHETIC so that assessment of the
correct position and tension is carried out by inspecting using a fibreoptic telescope and
by testing the voice.
A small drain is inserted overnight but most patients go home after two days.
This procedure does give some discomfort postoperatively so that you will have trouble
swallowing for a few days after but within a week it is usually resolved.

THE CRICOTHYROID SUBLUXATION TO TENSION ONE VOCAL FOLD

THE ARYTENOID ADDUCTION AND ARYTENOPEXY PROCEDURES