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“Dropping Acid” Blog

Voice Rehabilitation Surgery

Koufman JA, Rees CJ, Halum SL, Blalock D. Treatment of adductor-type spasmodic dysphonia by surgical myectomy. Ann Otol Rhinol Laryngol 115: 97-102, 2006.

Spasmodic dysphonia (SD) of the adductor type is characterized by a “strain-strangled” voice in which vocal fluency is greatly impaired, making some SD sufferers’ speech virtually unintelligible.  Fortunately, injections of botulinum toxin (Botox) into the vocal cords are highly effective in restoring the voice for a few months (with each set of injections). Dr. Koufman’s surgical technique reported here is done under local anesthesia so that excessive vocal cord muscle is not removed. The effectiveness of this operation is based upon removal of muscle, rather like a “permanent Botox injection.” The disadvantages of the technique are; (1) only one side can be done at a time, (2) a small neck incision is required, and (3) the technique is not good for SD patients with vocal tremor. Nevertheless, surgical myectomy is an excellent therapeutic option for some SD patients.  Click to see full article

Koufman JA. Laryngoplasty for vocal fold medialization: An alternative to Teflon. Laryngoscope 96:726, 1986.

In the 1960s, injection of Teflon paste was popularized by Arnold for the treatment of paralytic dysphonia (voice loss due to vocal cord paralysis). The idea was to move the paralyzed vocal cold back into the midline so that the good contralateral (opposite side) vocal cord could achieve closure. Unfortunately, the voice results with this technique were unpredictable, and many patients subsequently (years later) developed airway obstruction due to “Teflon granuloma,” a condition in which the injected vocal cord blew up in reaction to the Teflon, obstructing the breathing by the sheer mass.

In 1915, a German surgeon named Payr had the idea to reposition the vocal fold by externally modifying the voice box (“thyroid”) cartilage. This was the first “laryngeal framework surgery.” Subsequently in the 1940s and 1960s variations of Payr’s technique were reported; however, it was not until 1975, when a Japanese surgeon named Isshiki modified the technique using a surgical-grade, soft-plastic (silastic), to reposition the paralyzed vocal cord that the results were really good.

In 1983, Dr. Jamie Koufman learned Isshiki’s method of medialization laryngoplasty (repositioning the vocal cord toward the midline by reconfiguring the thyroid cartilage) and was the first U.S. surgeon to perform an “Ishiki thyroplasty.” She refined and popularized the procedure and coined the term “laryngoplastic phonosurgery.” This paper is the first paper on laryngoplasty in an American medical journal; it is the landmark paper, after which the techniques of laryngeal framework surgery became popular in the United States. Click to see full article

Postma GN, Blalock PD, Koufman JA. Bilateral medialization laryngoplasty. Laryngoscope 108:1429-1434, 1998.

This is one of the first papers describing Dr. Koufman’s technique of bilateral (both sides) medialization laryngoplasty for vocal fold (cord) bowing due to atrophy, presbylaryngis (aging voice), and vocal fold paresis (partial paralysis). This was an important paper that established that the techniques were safe and effective in patients who did not have  paralysis. The idea that both vocal ccrds could be “straightened” at the same time with the patient awake and speaking/singing comfortably. Dr. Koufman has described her technique, “like tuning piano strings.” The results reported were excellent. Dr. Koufman remains the most experienced laryngoplastic phonsurgeon the the world, having performed over 2,000 laryngoplastic procedures.  Click to see full article

Amin MR, Koufman JA.  Hemicricoidectomy for voice rehabilitation following hemilaryngectomy. Ann Otol Rhinol Laryngol 110:514-518, 2001.

After partial laryngectomy for laryngeal cancer, the patients’ voices are often weak and breathy. This novel technique of collapsing the ipsilateral (same side) cricoid cartilage to restore vocal cord closure is technically difficult but a highly effective voice rehabilitation procure that targets an otherwise an almost unfixable problem. Click to see full article

Halum SL, Postma GN, Koufman JA.  Endoscopic Management of Extruding Medialization Laryngoplasty Implants.  Laryngoscope 115:1051-54, 2005.

This article is mostly of interest to other surgeons. The main message here is that when laryngoplasty implants go bad, they can be removed endoscopically (through the mouth) — that re-operation on the outside of the neck is not necessary. Click to see full article