Permanent medialization of the paralyzed vocal fold utilizing botulinum toxin and gelfoam

The clinical picture of a paralyzed vocal fold often has the same appearance as a subluxated arytenoid, with anterior and medial displacement of the arytenoid and a foreshortened and lax vocal fold. Previous work by the authors has shown that a subluxated arytenoid may be permanently repositioned by reduction and selective injection of the intrinsic laryngeal musculature with botulinum toxin. The injection changes the forces within the larynx, allowing the arytenoid to be brought back to proper position on the cricoid cartilage. This concept has been extended to the paralyzed vocal fold. It has been noted that even a clinically paralyzed vocal fold has voluntary motor units that may still act on the arytenoid through residual action from the interarytenoid and synkinesis. These forces are significant enough to manipulate the arytenoid and, thus, the vocal fold, into its correct, adducted position. In this paper, the arytenoid is mobilized to free any fibrosis. The thyroarytenoid and lateral cricoarytenoid muscles are then injected to prevent any forward synkinetic pull on the arytenoid. Next, a Gelfoam injection medializes the vocal fold to create glottic closure. This rebalancing sufficiently positions the arytenoid, so that valvular function is permanently restored. In the ten patients studied for over I year, there was a 90% success rate as measured by videostroboscopy, phonation time, and V-RQOL analysis. There were no untoward complications. All the materials used are nonpermanent. The procedure does not limit other techniques from being performed at a later time.