Medialization Laryngoplasty: Revision Surgery

Medialization laryngoplasty has the potential for highly satisfactory results; however on occasion outcomes are subpar. Comprehensive evaluation of a patient with a less-than-satisfactory laryngoplasty outcome includes history, perceptual voice analysis, and examination emphasizing stroboscopy. Immediate failures may be due to undercorrection, overcorrection, failure to treat the contralateral vocal fold, or, most often, persistent posterior glottic insufficiency. Delayed failures may be caused by progressive atrophy of the vocal folds, progression of underlying disease, or implant displacement. Perceptual analysis and stroboscopy typically provide clues about the cause of a poor result - breathy voice, low volume, incongruously high pitch, persistent glottal gap, arytenoid instability, or ventricular hyperfunction suggest insufficiency, whereas a pressed voice quality, inspiratory stridor, contour abnormalities, or vocal fold stiffness indicate overcorrection. These clues become indispensable in the planning of additional therapeutic intervention. In patients with persistent insufficiency, injection augmentation can serve as a trial for revision laryngoplasty. Persistent posterior glottal gap or arytenoid instability with symptoms of insufficiency may be treated successfully with an arytenoid procedure. Patients who are overcorrected typically improve with implant downsizing. Other options for management include behavioral therapy alone, salvage framework surgery procedures such as cricothyroid subluxation, or laryngeal reinnervation. Although limited data exist, several studies report improvement in both subjective and objective measures following revision medialization laryngoplasty.