Spasmodic Dysphonia : A New Surgical Treatment
Nobuhiko Isshiki, M.D.
April 5th ,1998, revised May 14, 2000
A 40-year-old house-wife visited our clinic (Isshiki Voice Lab.) , complaining of phonation difficulty and a characteristic spasmodic voice of one and a half years duration.
Larygofiberscopy revealed an excessively tight closure of the anterior glottis ,with false vocal folds touching each other at the midline completely covering the vocal folds. No conservative treatments such as voice therapy and psychotherapy produced any change in her voice.
In an attempt to eliminate the excessive tight glottal closure , she was operated upon on June 10th , 1997 , displacing the vocal folds laterally at the anterior commissure. The surgery was done under local anesthesia so that the extent of lateralization could be adjusted to the voice produced.
Surgical Procedure (Midline Type 2 Thyroplasty , Isshiki)
The thyroid cartilage was incised at the midline and the incised edges were pulled apart laterally. The voice improved remarkably but not sufficient. A tiny perforation was then made at the anterior commissure to achieve wider separation of the vocal folds , which was closed by a free perichondro-chondrium graft and further covered by the strap muscle flap. The incised cartilage edges were maintained in adequate separation by placing tiny silicone shims in between at the inferior and superior margins of the thyroid cartilage.( Making perforation at the anterior commissure may not be necessary , if the separation of the cartilage edges alone was found sufficient to produce a normal voice.)
Postoperative course was uneventful and the voice has been restored to normal to her satisfaction , with no sign of recurrence at all so far nearly 10 months postoperative , though further follow-up is necessary.
This technique seems preferable to the current Botulinum Toxin Injection treatment in that repeated procedures are unnecessary and no deprivation of normal laryngeal function , partial or temporary, is involved. Should recurrence occur ,though quite unlikely if the separation is adequate , it is rather easy to treat ; just to replace the shims with wider ones.
In Brazil , Dr. Domingos H. Tsuji, our colleague , has already reported( Phonosurgery Workshop ,Amsterdam 2/14,1998 )two successful cases , using the surgical procedure based on the same concept ,but slightly different in actual technique to lateralize the anterior vocal folds.
This successful surgical treatment was reported at the Phonosurgery Workshops , at Mayo Clinic October 24-26,1997 ,and at University Hospital VU Amsterdam, February 12-14,1998 .
A manuscript containing the detail of this surgical technique and result was sent at the end of November,1997 to Annals of Otology, Rhinology , and Laryngology for possible publication.
PS . It has been published in February issue,2000 of the Journal.
Isshiki N, Tsuji DH, Yamamoto Y, Iizuka Y :Midline lateralization thyroplasty for adductor spasmodic dysphonia. Annals of Otology, Rhinology , and Laryngology 2000;109:187-93.
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Laryngeal and Intraoperative Findings 1. Preoperative laryngeal findings 2. Preoperative findings during 3. Intraoperative scene showing 4. the sternohyoid muscle flap 5. One month postoperative 6. Three month postoperative |
Addition(revision) I have done the surgery, thyroplasty type 2 on 6 patients with adductor spasmodic dysphonia so far , including the one whose surgery was demonstrated live in Amsterdam. The outcomes were complete restoration of normal voice in 5, and no significant improvement in one due to severe accompanied dystonia (neck muscles and cricopharyngeal muscle ?), which caused retention of saliva over the vocal folds, and the consequent dysphonia. Without dysphagia or mucous retention over the vocal folds, the thyroplasty type 2 ,we are confident , will cure the SD voice. Now , sligtht modification, or simplification, has been made in lateralyzing the vocal folds; just to separate the incised edges of the thyroid cartilage at the midline , say 3_4 mm apart, without making perforation, as shown by the figures. Dr. Domingos Tsuji , at Sao Paulo , Brazil , also has some experiences with the type 2 thyroplasty. | |||||
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An Additional Latest Report
(2001.5.20) Thyroplasty type 2 or Lateralization thyroplasty has been applied so far on 23 patients with adductor spasmodic dysphonia. Except one patient with SD who had other focal dystonias accompanied, such as spasmodic torticollis, blephalospasmus, and probably that of the cricopharyngeal muscle, all of the other 8 patients have restored normal or almost normal voice without recurrence for 4 years at the longest. Recently, 3 patients complained of occasional slight strain felt on voice production, but the voices are still much better than preoperative ones. It seems extremely important how to maintain the lateralization(usually about 4 mm) of the mid-line split thyroid cartilages and consequently the vocal folds. |
Spasmodic Dysphonia Case-Movie | ||
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