Tailored Treatments: The right approach to vocal fold paralysis depends on the patient, panelists say

“Anyone who does framework surgery really needs to appreciate the three-dimensional movement of the laryngeal structures,” she said. “This is not a two-dimensional organ, so you need to look at the movement of the cricoarytenoid joint.”

She said she prefers her patients to be “quite awake” during the procedure, for best results. “It is incredibly important to have visual and auditory feedback,” she said.

When placing the window for the procedure, “the idea is to keep that window as low as possible in the cartilage,” while keeping in mind the difference between a male larynx and a female larynx.

“We still do a lot of hand carving of our implants,” Dr. Garrett said. “The implant is fit to the patient, not the window.”

Reinnervation

Randy Paniello, MD, associate professor of otolaryngology-head and neck surgery at Washington University in St. Louis, Mo., said that, while reinnervation is done only in a minority of his vocal fold paralysis cases, it is an important and effective option to consider. “I use reinnervation in cases where I think it’s potentially going to give patients a better voice,” he said.

About 12 papers involving about 300 patients, have all concluded that the procedure works well, but there is still a lot of skepticism about reinnervation, Dr. Paniello said.

“I still hear people saying things like, ‘I heard it doesn’t work that well,’ things like that,” he said. “And I just don’t understand why they don’t accept the data that’s put before them.”

In a randomized trial of 24 patients at nine centers, Dr. Paniello compared reinnervation to medialization. Both procedures were found to have worked well.

In that study, which Dr. Paniello said is expected to be published later this year, researchers examined patient characteristics, such as gender and smoking history, to see whether one procedure worked better over the other in those groups. Age was the only factor that seemed to make a difference. “There was a natural break in the data at plus or minus age 52,” Dr. Paniello said.

Only the under-52 reinnervation group reached the “normal” range in voice as rated by untrained listeners. That group also reached the normal range in quality of life scores and had perfect scores on the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale of roughness, breathiness and other voice qualities.

“Reinnervation should really be considered,” Dr. Paniello said, “especially for the younger patients.”