ARTICLE IN PRESS

A Novel Surgical Technique for Bilateral Vocal Fold Paralysis:

Microlaryngeal Posterior Glottoplasty
*_ _ _
Ismail Ilter  lu, and †Engin Başer, *yIzmir,
Denizog Turkey
Summary: Objectives/hypothesis. Bilateral vocal fold paralysis (BVFP) is a clinical condition that may
require emergency intervention that is characterized by airway obstruction. The main aspect to be taken under
consideration in treatment is to preserve the vocal functions as much as possible while also ensuring an open air-
way. This study aims to present the preliminary results of a novel surgical method that we refer to as “posterior
glottoplasty,” which has been performed on BVFP patients to minimize phonation disorder and achieve a better
respiratory function.
Methods. Five female patients who developed BVFP-related respiratory distress following total thyroidectomy
surgery and underwent “posterior glottoplasty” between 2017 and 2019 were included in our study. Preoperative and
postoperative aspiration-swallowing, respiration, and phonation functions were separately evaluated in all patients.
Results. Five subjects were included in the study. All patients were female and between 31 and 67 years of age
(mean 47). The mean duration of dyspnea was 58.4 months (range: 6-120). Mean postoperative follow-up time
was 11.6 months (range: 6-18). All patients experienced respiratory relief in the postoperative period. Acoustic
voice analysis showed minimal to no phonation loss. Minimal aspiration was observed in the early postoperative
period which was supposed to be related to the Botulinum effect and it resolved in 2-4 weeks.
Conclusions. The posterior glottoplasty technique aims to increase the posterior (respiratory) glottic space for a
better inhalation while keeping the membranous (phonatory) glottic gap to preserve phonation by redirecting the
residual or synkinetic muscular vectors. It does not carry major morbidity risks in terms of phonation and aspira-
tion and validates potential spontaneous recovery of the vocal fold paralysis since it preserves the integrity of the
cricoarytenoid joints.
Key Words: Voice quality−Vocal cord paralysis−Phonation−Airway obstruction−Thyroid surgery complications.

INTRODUCTION The main aspect to be taken under consideration in treat-

Bilateral vocal fold paralysis (BVFP) is a clinical condition
characterized by airway obstruction that frequently occurs
as a result of bilateral injury of the recurrent laryngeal nerve
during thyroid surgery and may require emergency interven-
tion.1 The severity of dyspnea depends on the position of the
vocal folds after paralysis,2 which is related to the type of
the laryngeal nerve injury, cricothyroid muscle function,
fibrosis of the denervated muscle structures, the degree of
ankylosis in the cricoarytenoid joint, and the anastomoses
of the anterior and posterior branches of the recurrent laryn-
geal nerve with the superior laryngeal nerve.3 Laryngeal syn-
kinesis has been defined as the state of abnormal laryngeal
innervation that may occur following injury to the recurrent
laryngeal nerve.4 This is the main cause of the intrinsic laryn-
geal muscular tonus to some extent, rather than muscular
atony after nerve injury.
Accepted for publication May 27, 2020.
Informed consent: “Informed consent was obtained from all individual participants
included in the study.”
Conflict of Interest: The authors declare that they have no conflict of interest.
Financial Disclosure: No financial disclosure.
From the *Otorhinolaryngology, Head&Neck Surgery Department, Izmir _ Medical
_
Park Hospital, Izmir, Turkey; and the yOtorhinolaryngology, Head&Neck Surgery
Department., University of Health Sciences, Izmir Tepecik Training and Research
_
Hospital, Izmir, Turkey.
Address correspondence and reprint requests to Engin Başer, Otorhinolaryngology,
Head&Neck Surgery Department, University of Health Sciences, Izmir Tepecik
Training and Research Hospital, Yenisehir, Gaziler street, No:468. Konak, Izmir, _
Turkey. E-mail: dr.enginbaser@hotmail.com
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.05.023
ment is the preservation of phonation as much as possible
while also ensuring a better airway. In other words, ade-
quate vocal output must be balanced by sufficient airway.5
The most definitive and radical surgical method to correct
this clinical condition is tracheotomy. However, tracheot-
omy is an unfavorable method in regards to psychosocial/
cosmetic aspects, as well as reduced quality of life,6,7 except
in the management of dyspnea under emergency condi-
tions.8 Functional treatment of bilateral abductor paralysis
was historically introduced in 1922 by Chevalier Jackson
who described ventriculocordectomy, consisting of com-
plete excision of the entire vocal fold and ventricle.9
Despite creating an excellent airway, the procedure
resulted in a breathy voice. Since then, corrective surgery
has reverted to external techniques such as arytenoidopexy
and arytenoidectomy or endoscopic techniques including
arytenoidectomy combined with electrocoagulation, aryte-
noidectomy combined with submucous cordectomy, exci-
sion of the vocalis muscle, lateralization of the vocal fold,
and laser posterior cordectomy/cordotomy.7,10 However,
none of these treatment options offer a completely success-
ful functional outcome. Technical difficulties, complica-
tions, and severe dysphonia have led ENT surgeons in
pursuit of new techniques.6
This study aims to present the preliminary results of a
novel surgical method that we refer to as “posterior glotto-
plasty,” which has been performed on BVFP patients to
minimize phonation disorder and achieve a better respira-
tory function.
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2020
MATERIAL AND METHODS
Five female patients who developed BVFP-related respira-
tory distress following total thyroidectomy surgery and who
underwent “posterior glottoplasty” between 2017 and 2019
were included in our study. Following routine preoperative
ENT examination, all patients underwent endoscopic laryn-
geal examination and laryngeal electromyography to confirm
paralysis of both vocal folds. None of the cases required
tracheostomy after the thyroidectomy procedure or before
posterior glottoplasty.
In order to secure the airway, especially in the postoper-
ative early period, Botulinum-A injection was performed
unilaterally into the lateral cricoarytenoid (LCA) muscle
1 week prior to surgery. Due to limited glottic width, bilat-
eral injection was avoided. The same injection was
repeated peroperatively into the contralateral LCA mus-
cle. Therefore, both arytenoids were also avoided during
the tissue healing process.
Suspension laryngoscopy (direct laryngoscopy) was per-
formed in all patients under general anesthesia using a
laryngoscope (Karl Storz 8590J), after intubation with No
5 spiral endotracheal tube. The tube was retracted anteri-
orly by the laryngoscope to access to the interarytenoid
(IA) region.
Description and application of the technique
1. One week prior to the operation, 5 IU botulinum toxin
type A is unilaterally administered to the LCA muscle
via transcricothyroid membrane injection.
2. Under general anesthesia, direct laryngoscopy is car-
ried out, a vertical dissection is performed on the glot-
tic face of the IA region.
3. The IA muscle is located and totally dissected until the
cricoid cartilage is visible (Figure 1).
4. Mobilization of both cricoarytenoid joints is tested,
mobilization is secured if immobile.
FIGURE 1. (a, b) Respectively, interarytenoid muscle and its dissection schematic representation.
5. The incision line is horizontally sutured with 8/0 vicryl
(Figure 2).
6. 5 UI Botulinum toxin type A is unilaterally adminis-
tered to the contralateral LCA.
Immobility due to neural damage may result in different
degrees of joint fixation after a certain duration. As the
weak muscles are supposed to be used by their residual
tonus, it is important to secure the lateral movement of the
arytenoid bodies. Therefore, the arytenoids were forced to
move laterally and medially to prevent any resistance to
posterior cricoarytenoid (PCA) muscles after the operation.
Mobilization of the cricoarytenoid joints were tested by
pushing the arytenoids to lateral-medial directions by a
blunt instrument peroperatively.
The patients were kept under surveillance by the surgical
and anesthesia team for 4 hours in the postoperative intensive
care unit after surgery. In case of potential dyspnea, appro-
priate conditions for intubation and subsequent tracheotomy
were provided. No antibiotic medication was applied.
Patients received daily 8 mg IV dexamethasone during the
operation and in the hospital for 2 days postoperatively. IA
dissection and Botulinum A injection separately may also
result in additional aspiration and difficulty swallowing.
Swallowing therapy (anteflexion of the head and effortful
swallowing exercise for postural compensation) was contin-
ued 4 weeks postoperatively. After the prominent effects of
botulinum injection resolved spontaneously (in 2-4 weeks),
voice therapy was initiated. Weekly endoscopic laryngeal
examinations were performed in the first month after surgery
to evaluate glottic space and function, and postoperative
complications such as edema and granulation.
Preoperative and postoperative aspiration-swallowing,
respiration, and phonation were separately evaluated in all
patients. Pearson’s scale was used to evaluate aspiration
and swallowing9 (0, none; 1, occasional cough but no clini-
cal problem; 2, constant cough worsening with meals or
 ARTICLE IN PRESS
_
Ismail _
Ilter  lu and Engin Başer
Denizog Microlaryngeal Posterior Glottoplasty
FIGURE 2. (a, b, c) Respectively, interarytenoid muscle dissection, saturation, and end-of-surgery view.
swallowing; 3, pulmonary complications). The subjective
“exercise tolerance test” (ETT)7 was used to evaluate
respiratory functions (very good: can climb 4-5 flights of
stairs; good: can climb 2-3 flights of stairs; bad: can climb
no more than one flight of stairs or dyspnea at rest). For
the objective assessment of respiratory function, the same
technician performed a pulmonary function test with a
flow-sensing dry spirometer (Super Spiro V 2.0, UK) to
evaluate peak expiratory flow. Dr. Speech software was
used for acoustic analysis; mean fundamental frequency
(f0), jitter %, shimmer %, and harmonics to noise ratio
were objectively measured and recorded. The validated
Turkish version of the Voice Handicap Index (VHI-10)
was used for subjective self-reporting of severity of vocal
symptoms.11 Pre- and postoperative comparison of VHI-
10 evaluation was made simultaneously at the late post-
operative period. All assessments were done at least 6
months postoperatively (this is necessary for the disap-
pearance of intraoperatively applied botulinum effect)
and recorded separately (only postoperative values were
available for peak expiratory flow).
Informed written consent was obtained from all patients.
The study was approved by the regional scientific ethics
committee (No. 2019/14-5; Date: 10/09/2019).
Statistical analysis
SPSS version 21.0 program was used for the statistical
analysis of the data. Descriptive statistics were assessed
with Wilcoxon signed rank test. The value of P < 0.05 was
considered statistically significant.
FIGURE 3. (a, b) Respectively, preoperative and postoperative visualization of posterior glottal space of a patient with BVFP.
3
RESULTS
Five females were included in the study. Patient age ranged
from 31 to 67 years and mean patient age was 47 years. The
mean duration of dyspnea was 58.4 months (range: 6-120).
Mean postoperative follow-up time was 11.6 months (range:
6-18). Patients were evaluated separately in terms of respira-
tion, phonation, swallowing, and aspiration. In the first
4 weeks, when the effect of botulinum toxin was most promi-
nent, breathy phonation and mild aspiration problems were
observed in all patients. Both conditions completely resolved
without any serious clinical situation by the sixth week. Major
complications such as aspiration pneumonia were not
observed in any of the patients and there was no need for tra-
cheotomy. IA edema, which we can express as a minor compli-
cation, was observed mildly (without causing dyspnea) in all of
our patients and all recovered within 2 weeks. All patients
expressed that the stridor sound during sleep was disappeared
postoperatively. Laryngeal assessment of the patients showed
an increased opening of the posterior glottic region (Figure 3).
Respiration
All patients experienced respiratory relief in the postopera-
tive period. According to ETT, three patients had a good
postoperative respiratory assessment, and two patients had
a very good response (Table 1).
Phonation
Acoustic voice analysis (after the sixth week of operation)
showed minimal or no dysphonia. Statistical analysis revealed
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2020

TABLE 1.
Respiratory Parameters of Patients
Preop ETT Postop ETT Postop PEF %
Patient 1 Poor Very good
Patient 2 Poor Good
Patient 3 Poor Good
Patient 4 Poor Very good
Patient 5 Poor Very good
increased fundamental frequency and VHI-10 values (P ˂
0.05). Jitter, shimmer, and harmonics to noise ratio did not
show statistically significant change (P > 0.05). The results of
preoperative and postoperative acoustic analyses and the
VHI-10 evaluations are presented in Table 2.
Swallowing and aspiration
Mild to moderate aspiration and/or swallowing problems
were observed in the early postoperative period due to bilat-
eral Botulinum A injection. No symptoms continued after 6
weeks postoperatively (Table 3).
DISCUSSION
The purpose of BVFP treatment is to provide a reliable and
adequate airway while also preserving voice quality and pre-
venting aspiration. Despite the number of various surgical
techniques, none have been regarded as optimal. BVFP still
remains a surgical challenge and the outcome is additionally
affected by the skills and experience of the treating clinicians
as well as by glottic position.8
Extralaryngeal approaches present manipulation difficul-
ties and prolonged postoperative follow-up time, leading to
the development of endolaryngeal approaches.8 Laser pos-
terior cordectomy/cordotomy is currently one of the most
commonly performed endolaryngeal surgical procedures.
The technique is fast and easy to apply, less affected by sur-
gical experience, and has a low risk of postoperative compli-
cations. However, in the long term, granulation tissue that
forms in the surgical site and closure of the opening formed
as a result of fibrosis cause recurrence of dyspnea com-
plaints which require revision surgeries or more aggressive
surgical treatments.10,12 The literature reports the respira-
52 tory success rate of posterior cordotomy as 50%-68% in the
37 first procedure, and 90%-100% in the second procedure.13
44 True paralysis of the larynx is a misconception, due to its
58 complex neural network; the term synkinesis seems to be
31 more appropriate.4 Therefore, the nerve damage differs in
comparison to other body muscles in both tonus and move-
ments of laryngeal muscles. For these reasons, this physio-
logical fact should be considered when choosing the surgical
technique for BVFP treatment. Posterior glottoplasty aims
to alter the laryngeal muscle vectors affecting the body of
the arytenoid for a better laryngeal functioning. Keeping in
mind that synkinesis and collateral reinnervation affect
postparalysis laryngeal posture, the arytenoid bodies can be
repositioned by decreasing the adductory muscular tonus of
the IA muscle. Posterior glottoplasty method aims to
increase the posterior glottic space, also known as the respi-
ratory or cartilaginous glottis, by relieving the arytenoid
bodies from the IA muscle pull. In this way, the residual or
synkinetic muscular force of the PCA muscles will have a
better mechanical abductor effect on the arytenoids. On the
other hand, the membraneous glottis, or the phonatory glot-
tis, will still be kept closer because the lateral cricoarytenoid
and thyroarytenoid muscles are intact to affect the vocal
processes and vocal fold mass for mucosal vibration.
The main function of the IA muscle is the medialization
of the posterior body of the arytenoid cartilage. Its effect on
the vocal process is comparatively less than the LCA. The
vector of the IA muscle works opposite to the PCA muscle,
which is responsible for the opening of the posterior glottic
triangle.14 The IA is the only muscle bilaterally innervated
by the recurrent laryngeal nerve. Aberrant reinnervation of
laryngeal muscles results in a synkinetic larynx where
adductor muscle fibers are a majority and therefore the par-
amedian position of the vocal folds tends to be the most
usual result. While this is an advantage in UVFP, it presents
a handicap for respiration in BVFP.15 Through this mecha-
nism, posterior glottoplasty may be differentiated from the

TABLE 2.
Acoustic Analysis and VHI-10 Values of Patients
Preop Postop Preop Postop Preop Postop Preop Postop Preop Postop
fo fo Jitter (%) Jitter (%) Shimmer (%) Shimmer (%) HNR (dB) HNR (dB) VHI-10 VHI-10
Values Values
Patient 1 220 225 0.64 0,52 3,86 3,72 19,6 15,68 39 20
Patient 2 211 276 0.35 0,51 2,34 3,13 26,46 19,12 15 12
Patient 3 198 230 0.33 0,14 2,58 1,17 21,22 29,55 35 18
Patient 4 158 195 0.54 0,71 0,13 6,95 17,15 12,8 28 19
Patient 5 204 215 0.28 0,34 2,18 3,68 25,89 19,7 5 4
Mean 198 228 0.42 0.44 2.21 3.73 22.06 19.37 24.4 14.6
P value 0.04 0.89 0.34 0.50 0.04
Mean values and statistically significant values are indicated in bold.
Abbreviations: fo, functional frequency; HNR, harmonics to noise ratio.
 ARTICLE IN PRESS
_
Ismail _
Ilter  lu and Engin Başer
Denizog Microlaryngeal Posterior Glottoplasty
TABLE 3.
Pearson Scale Values of Patients
Preop PS Postop PS
Patient 1 0 0
Patient 2 0 0
Patient 3 0 0
Patient 4 0 0
Patient 5 1 0
passive mass-elimination effect provided by arytenoidec-
tomy, and thus, may be regarded as an active/functional
intervention. As the adductive synkinesis effect of the LCA
and thyroarytenoid muscles on the vocal process remain,
the phonatory contribution of the membranous glottis is
less affected.
The mass-elimination effect of posterior glottoplasty is
the secondary expected respiratory-relieving mechanism.
Elimination of the IA muscle mass and vertical incision of
the mucosa with horizontal suturing decrease posterior
mass and tension, contributing to increased posterior glottic
opening. All patients reported that night stridor had disap-
peared in the early postoperative period. Due to increased
airflow rate through a larger space at the respiratory glottis,
the reverse vibration of the membranous vocal fold (espe-
cially during sleep without intentional control) diminishes
the stridor noise which sometimes a serious environmental
problem at night. All patients had significant improvement
in respiratory parameters (ETT). It is assumed that respira-
tory relief was an additional factor for the better VHI-10
results.
Long-term spontaneous neural recovery to some
extent, may not be predicted even by laryngeal EMG
(electromyography). With the possibility of a limited
spontaneous recovery of paralysis and aim at achieving
improved quality of life, the selection of surgical tech-
nique should cause less morbidity as possible and preserve
the anatomical-physiological features of the larynx. 8 In
the case of spontaneous partial recovery of vocal fold
motions, posterior glottoplasty seems to cause minimal
functional morbidity. It also enables second-line surger-
ies, eliminating the need for tracheotomy in the early
postoperative period with less complication risk.
The posterior glottoplasty is a less invasive procedure in
comparison to other surgical procedures providing early
respiratory relief and minimal loss of vocal output. The
integrity of the most important functional unit of the larynx,
the cricoarytenoid joint, is maintained in the procedure.
The number of patients is the most important limitation
of this study, multicentric prospective clinical studies with
an increased number of cases are needed to claim more
accurate efficacy results of the method. Also, a long-term
follow-up assessment of the patients will support the efficacy
of the method. Preoperative pulmonary function tests were
not performed in this case group. The pre- and postoperative
glottic area was also not calculated.
5
CONCLUSION
The posterior glottoplasty technique aims to increase the
posterior (respiratory) glottic space for a better inhalation
while keeping the membranous (phonatory) glottic gap to
preserve phonation by redirecting the residual or synkinetic
muscular vectors. It does not carry major morbidity risks in
terms of phonation and aspiration and validates potential
spontaneous recovery of the vocal fold paralysis since it
preserves the integrity of the cricoarytenoid joints.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
online at doi:10.1016/j.jvoice.2020.05.023.
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