Vocal Fold Medialization, Arytenoid Adduction, and Reinnervation

127 Restoration of vocal function with laryngeal framework surgery (laryngoplastic phonosurgery) was introduced at the beginning of the 20th century. Today, these procedures have emerged as the dominant surgical management approach for the treatment of the aerodynamic incompetence and acoustic deterioration associated with vocal fold paralysis/paresis. Other indications include cancer defects, vocal fold scar, sulcus vocalis, bowing associated with vocal fold atrophy, laryngeal trauma, and neuromuscular disorders including abductor spasmodic dysphonia and parkinsonism. Laryngeal framework surgery has also been employed to alter pitch for gender reassignment; however, this topic is not discussed here. Although medialization of the musculomembranous vocal fold by means of rearranging the laryngeal cartilage framework was described by Payr1 in 1915, and others in the mid–20th century,2,3 Isshiki et al4–6 championed the systematic analysis and laryngoplastic treatment of glottal incompetence in the 1970s. He designed his medialization procedure of the musculomembranous vocal fold with the use of a synthetic implant in 1974. In 1978, Isshiki et al5 designed the arytenoid adduction procedure to treat patients with large glottal gaps secondary to a malpositioned arytenoid. One of his outstanding contributions is that he taught surgeons that laryngeal framework procedures could be done with facility utilizing local anesthesia with sedation. The concept that the cricoarytenoid joint could be dissected and manipulated under local anesthesia to allow for phonatory feedback was revolutionary. Based on this seminal work, the adduction arytenopexy2,7–9 and cricothyroid subluxation7,8,10 procedures were introduced to further enhance phonatory reconstruction.