Allograft (Alloderm) and Autograft (Temporalis Fascia) Implantation for Glottic Insufficiency: A Novel Approach

Objective

Traditionally, glottic insufficiency because of scar, atrophy, and sulcus has been treated by injection or medialization laryngoplasty. These procedures do not reestablish the vertical height of the vocal fold margin. We propose soft tissue augmentation laryngoplasty with allograft (sheet Alloderm; LifeCell Corporation, Branchburg, NJ) or autograft (temporalis fascia) via a minithyrotomy or a transoral approach.

Study Design

A retrospective case series analysis of 21 patients treated by sheet Alloderm or temporalis fascia for correction of glottic insufficiency.

Methods

Twenty-one patients with glottic insufficiency secondary to scar, atrophy, or sulcus were treated. Ten failed prior techniques. Seventeen had minithyrotomy by a small fenestration in the thyroid cartilage. Exploration of scar or lamina propria through the fenestration allowed for the creation of a pocket for Alloderm implantation within the intermediate layer of the lamina propria. Four patients underwent a transoral approach by cordotomy with either Alloderm or temporalis fascia implantation, which also allowed for exploration of scar but required repair using sutures. These implantation approaches allowed for both restoration of the layered structure and augmentation of the middle third of the musculomembranous vocal fold. Preoperative and postoperative videostroboscopic examinations were reviewed with review of clinical outcome.

Results

With a median follow-up time of 12 months, patients demonstrated excellent long-term vocal fold augmentation and minimal absorption of the implant in 19 out of 21 patients. There is improved pliability of the vocal fold with good oscillation in scar patients.

Conclusion

Minithyrotomy with soft tissue augmentation is a novel approach for soft tissue augmentation of glottic insufficiency. It has the advantage of augmentation of the medial edge of the vocal fold with a soft tissue implant that has long-term viability. Its role should be explored further in patients with atrophy and scar.     

Bacterial Cellulose as Laryngeal Medialization Material: An Experimental Study

Hypothesis

The use of a material made of bacterial cellulose with the aim of obtaining vocal fold medialization has not hitherto been fully investigated. Although the material has been tested in other animal models, the evaluation did not include the larynx; hence, situations, such as tissue reaction, material absorption, and extrusion, need to be addressed to evaluate its usefulness as a material for laryngeal reconstruction.

Objective

To evaluate the medialization, tissue response, and healing of rabbit vocal folds, after the implantation of a membrane of bacterial cellulose.

Study Design

Experimental study.

Methods

A total of 32 rabbits were used, two of which were used to check out the adequacy of the implant location. The animals were followed for 4 months and grouped according to follow-up times of 2, 4, and 16 weeks. All test animals received an implant of bacterial cellulose in one vocal fold and the injection of distilled water in the other, both performed by videoendoscopic cervicotomy. At the end of the follow-up, the presence of inflammatory and medial displacement was evaluated.

Results

No statistically significant difference in the inflammatory parameters between the study and control vocal folds or among follow-up times was found. All animals receiving cellulose presented medial displacement of vocal folds, and all retained this material at the implant site up to study endpoint.

Conclusion

Bacterial cellulose is a useful material for laryngeal medialization, showing no signs of rejection or absorption.     

Long-term preservation of voice improvement following surgical medialization and reinnervation for unilateral vocal fold paralysis

In June of 1996, we reported improved functional voice results when reinnervation was combined with surgical medialization for unilateral vocal fold paralysis. In addition, it was noted that further wasting of the reinnervated vocal fold was prevented in 96% of these patients beyond 2 years' follow-up. The study reported here compares the long-term preservation of voice improvement achieved by surgical medialization alone with that resulting from combined medialization and nerve-muscle pedicle reinnervation. Further significant wasting of the paralyzed vocal fold with voice deterioration from that achieved by surgical medialization alone was noted between 6 months and 2 years postoperatively in 28% of patients, while only 4% of those undergoing combined reinnervation demonstrated this finding at a minimum of 2 years' follow-up.     

Botulinum toxin injection in the treatment of vocal fold paralysis associated with multiple sclerosis: A case report

Botulinum toxin has been demonstrated clinically to be an effective treatment for a variety of laryngeal problems, most notably spasmodic dysphonia. As in other movement disorders, the theory behind the injection of this substance in the larynx has been a weakening of the vocal fold musculature to relieve uncoordinated and spasmodic movement of the vocal folds, presumably rebalancing the forces within the intralaryngeal musculature. Recently, this concept was applied to help reposition the arytenoid cartilage in acute and longstanding anteromedial cricoarytenoid dislocations. This same concept may apply to the paralyzed vocal fold. In support of this idea, a number of investigators have shown that immobile, clinically paralyzed vocal folds may still have partial voluntary motor unit activity. This voluntary activation may not produce clinically evident movement but may be sufficient to produce tone within the fold. If the voluntary motor units in the abductor musculature of the paralyzed fold are weakened with botulinum toxin, the continued pull of the functioning adductor musculature may be sufficient to medialize the paralyzed fold. This idea has been supported by animal experiments, which have shown that botulinum toxin may affect the ability of the fold to rebalance itself. With this evidence in mind, a patient with fold immobility secondary to multiple sclerosis was treated in an attempt at laryngeal rebalancing, using botulinum toxin to medialize the fold. However, instead of simply having the fold return fixed to the midline, the patient regained normal laryngeal mobility and voice. While it is unclear whether the botulinum toxin alone was responsible, the coincidence of this occurrence certainly requires reporting. This paper is a report of the first successful treatment of vocal fold paralysis using botulinum toxin to treat vocal fold fixation in a patient with multiple sclerosis.     

Differences Between Flexible and Rigid Endoscopy in Assessing the Posterior Glottic Chink

Objective

To determine whether different modalities of laryngeal examination produce differences in the assessment of the posterior glottic chink (PGC), and whether the prevalence of PGC differs by gender.

Introduction

The PGC has been described as a triangular laryngeal space between the posterior laryngeal wall and the vocal processes during glottic closure found commonly in human females, but less often in males. The purpose of this study was not only to identify whether there are gender differences in prevalence of posterior glottic but also to determine whether there is a difference in detection of this configuration dependent on the modality of laryngeal imaging, specifically flexible nasopharyngolaryngoscopy (FNPL) versus rigid laryngoscopy (RL).

Methods

A review of 104 consecutive initial laryngeal examinations was performed. All patients underwent both flexible laryngoscopy (FL) and RL performed under stroboscopic light. Patients with immobile vocal folds, masses causing glottic gaps, atrophy, or severe muscle tension dysphonia causing an inability to fully visualize the entire length of the vocal fold were excluded. In the remaining patients, the posterior glottic configuration showing a posterior chink in relation to the vocal process was graded on a 0–4 scale (called the Posterior Glottic Closure Score [PGCS]); 0 was used to indicate a closed glottis and 4 the most open configuration without creating a complete glottic gap. PGCSs for males were compared with those of females, and the PGCSs obtained by flexible nasopharyngolaryngoscopy was compared with RL.

Results

Fifty-two patients were included in the study. Twenty-four of the patients were male, and 28 were female. The average age of the patients was 48.4 years (SD ± 17.35), and the range was 15–81 years. On RL, eight males had a PGCS 1–4, that is, evidence of PGC, and 23 females had a PGCS 1–4. On flexible nasopharyngolaryngoscopy, only four males had a PGCS 1–4 and 24 females had PGCS 1–4. Twenty-two females had a PGC detected by both modalities, and the PGCS was significantly higher using RL (2.73 ± 0.70 vs 2.14 ± 0.834) than FL. For the four males in which PGC was detected by both modalities, there was no statistical significance when comparing the PGCS between RL and FL (1.75 ± 0.96 vs 1.75 ± 0.5, P < 0.05). When comparing only males and females who had a PGC (PGCS 1–4), females had a higher PGCS (2.65 ± 0.78) than males (1.75 ± 0.71, P < 0.05) on RL, indicating a more open posterior glottis in females. On flexible examination, there was no difference detected in the average PGCS, 2.08 ± 0.83 for females and males 1.75 ± 0.50. PGCs were more common in younger (age 43 years) than older (age 54–56 years) subjects for both laryngoscopic modalities.

Conclusion

From this pilot study, we determined that there is a difference in male and female PGC prevalence and size. PGC is more common in females than males. Prevalence (or the detection rate) is about the same with RL and FL in females, but higher with RL than FL in males. The average score of the glottic opening, when present, was statistically significantly different between RL and FL in females but not in males. Furthermore, females had a larger PGCS on both modalities when compared with males, although this difference was only found to be statistically significant on RL; and complete glottic closure was more common in older than in younger subjects.     

Relationship among glottal area, static supraglottic compression, and laryngeal function studies in unilateral vocal fold paresis and paralysis

In this study, we evaluated the relationship between laryngeal function measures and glottal gap ratio and normalized measures of supraglottic behaviors in patients with unilateral vocal fold paresis (UVFP). Thirty-one patients were found to have unilateral vocal fold paresis by videoendoscopy and laryngeal electromyography, and 13 controls participated in this study. Patients with UVFP demonstrated significantly larger glottal gap ratios (p = 0.016) than control subjects. The nonparalyzed or contralateral vocal fold was associated with significantly more static false vocal fold compression (p = 0.03) compared with the paralyzed vocal fold or with the controls. Patients with unilateral vocal fold paresis were divided into subgroups: those with normal or abnormal maximum phonation time, flow, or pressure measures. Smaller glottal gap ratios were identified in patients with normal maximum phonation times and flow measures. Greater false vocal fold activity was identified in unilateral vocal fold paresis patients with normal laryngeal function measures than in unilateral vocal fold paresis patients with abnormal measures. These findings suggest that some patients with documented unilateral paresis and glottal incompetence can compensate for vocal fold weakness such that their acoustic and aerodynamic measures are normal.     

The Adjustable Laryngeal Implant

An adjustable laryngeal implant made of titanium has been developed for the treatment of unilateral vocal fold paralysis. The implant includes three parts: a plate that allows fixation to the thyroid cartilage, a block of titanium which includes the adjustable part, and a micrometric screw in the middle of the lateral side of the block, which moves the adjustable part. Precise medialization is accomplished by regulating the screw which also permits easy secondary adjustments, if needed in the future. This retrospective study assesses clinical outcomes of medialization laryngoplasty with the titanium adjustable implant, in patients with unilateral vocal fold paralysis. This study has the limitations of a retrospective study. However, preliminary results are encouraging. Analysis of subjective responses confirmed marked improvement in laryngeal function, speech, and swallowing. Objective voice analysis confirmed improvement in the aerodynamic measures. The adjustable laryngeal implant has many advantages including: precise medialization, ease of secondary adjustment, and preseveration of the mucosal wave. This implant is biocompatible, no migration is possible (it is fixed to the cartilage) and no extrusion of the implant has occurred. Titanium is magnetic resonance imaging (MRI)-safe.     

How I Do It: Miniplate Reconstruction of the Lateral Thyroid Lamina: One-Stage Restoration of Voice After Teflon Granuloma Resection

This case report describes a one-stage technique for long-term voice restoration and laryngeal reconstruction in the treatment of Teflon (Dupont, Wilmington, Delaware) granuloma. A patient who presented with severe dysphonia underwent resection of a Teflon granuloma via a lateral laryngotomy. A pedicled strap muscle flap was used to reconstruct the paraglottic space. The muscle flap was positioned through the lateral laryngotomy with direct endoscopic visualization of the endolarynx to ensure correct vertical positioning and medialization of the vocal fold. The muscle flap was secured in this position with suture fixation. The trapdoor piece of cartilage that was elevated to create the window in the lateral thyroid lamina was repositioned over the pedicled muscle flap and reinforced with a titanium miniplate, which was secured to the remaining thyroid cartilage. The patient had excellent voice results and has not required revision or augmentation. Reinforcement of the lateral thyroid lamina using titanium miniplate fixation helps to stabilize the muscle pedicle flap and the position of the vocal fold, in this case resulting in good long-term voice results after a single-stage reconstruction.     

Laryngeal function and vocal fatigue after prolonged reading in individuals with unilateral vocal fold paralysis

The purpose of the present study was to examine the effect of prolonged loud reading, intended to induce fatigue, on vocal function in adults with unilateral vocal fold paralysis (UVFP). Subjects were 20 adults, 37–60 years old, with UVFP secondary to recurrent laryngeal nerve paralysis. Subjective ratings and instrumental measures of vocal function were obtained before and after reading. Statistical analysis revealed subjects rated their vocal quality and physical effort for voicing more severely following prolonged loud reading, whereas expert raters did not detect a significant perceptual difference in vocal quality. Reading fundamental frequency (Fo) was significantly increased following prolonged loud reading, as were mean airflow rates at all pitch conditions. Maximum phonation times for comfort and low pitches significantly decreased during posttests. Multiple regression analyses revealed significant associations between ratings of posttest physical effort and select posttest measures. Interpretation of results indicates the prolonged loud reading task was successful in vocally fatiguing most of the UVFP subjects. Key physiologic correlates of vocal fatigue, in individuals with UVFP, include further reduction of glottic efficiency, resulting in decreased regulation of glottic airflow and a temporary destabilization of speaking fundamental frequency.     

MRI Anatomical and Morphological Differences in the Vocal Tract Between Dysphonic and Normal Adult Women

Objective

To analyze the vocal tract morphometry of women with vocal nodules (VN) compared with normal subjects by means of magnetic resonance imaging (MRI) at rest position.

Study Design

Prospective study.

Methods

The present research included 20 young adult women, aged 18–40 years: 10 dysphonic patients with VN and 10 normal subjects. All participants were tested using MRI; 12 measurements of the vocal tract were performed: nine in median sagittal section and three in axial section.

Results

The 12 measurements were smaller in the dysphonic group; statistical significance was obtained for three parameters: in the sagittal plane, the laryngeal vestibule area was significantly smaller in the dysphonic group, with P = 0.012∗ (∗ = statistical significance); in the axial section, the distance between the right and left vocal processes of the arytenoids’ cartilages and the distance between the anterior commissure of the glottis and the laryngeal posterior wall were also significantly lower in the dysphonic group, with P = 0.036∗ and 0.010∗, respectively. Significant differences in the vocal tract morphometry of individuals with VN were observed compared with normal subjects, at rest position.

Conclusions

Results obtained from this study suggest that patients with VN may present a constantly increased tension of the laryngeal muscles, even at rest; moreover, reduced anterior-posterior dimension of the larynx may be a morphological characteristic of patients with VN.     

Multiparametric Analysis of Vocal Fold Vibrations in Healthy and Disordered Voices in High-Speed Imaging

Objectives

The aim of this study was to look for visual subjective and objective parameters of vocal fold dynamics being capable of differentiating healthy from pathologic voices in daily clinical practice applying endoscopic high-speed digital imaging (HSI).

Study Design and Methods

Four hundred ninety-six datasets containing 80 healthy and 416 pathologic subjects (232 functional dysphonia (FD), 13 bilateral, and 171 unilateral vocal fold nerve paralysis) were analyzed retrospectively. Videos at 4000 Hz (256 × 256 pixel) were recorded during sustained phonation. Subjective parameters were visually evaluated and complemented by an analysis of objective parameters. Visual subjective parameters were mucosal wave, glottal closure type, glottal closure insufficiency (GI), asymmetries of the vocal folds, and phonovibrogram (PVG) symmetry. After image segmentation, objective parameters were computed: closed quotient, perturbation measures (PMs) of glottal area, and left-right asymmetry values.

Results

HSI evaluation enabled to distinguish healthy from pathologic voices. For visual subjective parameters, GI, symmetrical behavior, and PVG symmetry exhibited statistical significant differences. For 95% of the data, objective parameters could be computed. Among objective parameters, closed quotient, jitter, shimmer, harmonic-to-noise ratio, and signal-to-noise ratio for the glottal area function differentiated statistically significant normal from pathologic voices. Applying linear discriminant analysis by combining visual subjective and objective parameters, accurate classifications were made for 63.2% of the female and 87.5% of the male group for the three-class problem (healthy, FD, and unilateral vocal fold nerve paralysis).

Conclusion

Actual acoustically applied PMs can be transferred to clinical beneficial HSI analysis. Combining visual subjective and objective basic parameters succeeds in differentiating pathologic from healthy voices. The presented evaluation can easily be included into everyday clinical practice. However, further research is needed to broaden our understanding of the variability within and across healthy and pathologic vocal fold vibrations for diagnosing voice disorders and therapy control.     

Japanese version of voice handicap index for subjective evaluation of voice disorder

Recently, the Voice Handicap Index (VHI), developed in the United States, has been highlighted as a means to assess a patient's perceptions of the severity of his or her voice disorder. The VHI is based on a self-administered questionnaire that quantifies the degree of a patient's disability related to his/her voice disorder. The questionnaire was translated into Japanese and applied to Japanese patients with various kinds of disordered voice or dysphonia. The results were analyzed and the usefulness discussed. In this study, 546 patients (281 males and 265 females) were included. Mean VHI scores were 36.2/120 in males and 44.1/120 in females. In the male patients, VHI scores were the highest among teens. However, VHI scores did not vary with age in the female patients. Patients with vocal fold paralysis, functional dysphonia, psychological dysphonia, and spasmodic dysphonia showed relatively high VHI scores, whereas those with laryngeal granuloma and laryngopharyngeal reflux disease showed low scores. In most diseases, functional and physiological scores were higher than emotional scores. In any treated patients, those with vocal nodule, vocal polyp, polypoid vocal fold, and recurrent laryngeal nerve paralysis, VHI scores decreased after therapeutic intervention. These findings suggest that the Japanese VHI is a useful tool for monitoring a patient's psychological status, choosing appropriate treatment, and assessing the therapeutic outcome.     

Objective Vocal Quality in Children Using Cochlear Implants: A Multiparameter Approach

Objectives

The purpose of this study was to determine the objective vocal quality in 36 prelingually deaf children using cochlear implant (CI) with a mean age of 9 years. An additional purpose was to compare the objective vocal quality of these 36 CI users with 25 age-matched children with prelingual severe hearing loss using conventional hearing aids (HAs) and 25 normal hearing (NH) children.

Study Design

The design for this cross-sectional study was a multigroup posttest-only design.

Methods

The objective vocal quality was measured by means of the dysphonia severity index (DSI). Moreover, perceptual voice assessment using the GRBASI scale was performed.

Results

CI children have a vocal quality by means of the DSI of +1.8, corresponding with a DSI% of 68%, indicating a borderline vocal quality situated 2% above the limit of normality. The voice was perceptually characterized by the presence of a very slight grade of hoarseness, roughness, strained phonation, and higher pitch and intensity levels. No significant objective vocal quality differences were measured between the voices of the CI children, HA users, and NH children.

Conclusions

According to the results, one aspect of the vocal approach in children with CI and using HAs must be focused on the improvement of the strained vocal characteristic and the use of a lower pitch and intensity level.     

The Role of the Cricothyroid Joint Anatomy in Cricothyroid Approximation Surgery

Objectives/Hypothesis

Cricothyroid approximation (CTA) surgery aims at raising the voice pitch in male-to-female transsexuals. However, 30% of the patients are not satisfied with the result. The purpose of our study was to examine the cricothyroid joint (CTJ) biomechanics and to analyze if (and how) the CTJ anatomy influences the movement of the cricoid and, consequently, the elongation of the vocal fold and the voice pitch after CTA.

Methods

Twenty-four cadaver larynges were examined with high-resolution computerized tomography and MIMICS three-dimensional imaging software (Materialise Interactive Medical Image Control System, Leuven, Belgium). After superimposing the two scans taken in “neutral” and in “CTA” positions, vector geometrical analysis was used to determine the effective rotation axis of the CTJ and to calculate the elongation of the vocal folds after CTA.

Results

Our results showed that the cricoid rotates around an axis, the position of which depends on the anatomical structure of the CTJ. Based on the location of this effective rotation axis, we could distinguish three groups. In group I (N = 13), the rotation axis was located in the lower third; in group II (N = 5), it was located in the middle third; and in group III (N = 6), it was located in the upper third of the cricoid. The elongations of the vocal fold were 12%, 8%, and 3%, in groups I, II, and III, respectively.

Conclusions

The anatomical structure of the CTJ influences directly (1) the position of the effective rotation axis and (2) the elongation of the vocal folds.     

Mild Vocal Fold Paresis: Understanding Clinical Presentation and Electromyographic Findings

The implications of mild vocal fold hypomobility are incompletely understood. This study describes the clinical, electromyographic, and probable etiologic findings in patients who presented with complaints of dysphonia and whose physical examination revealed vocal fold paresis as a factor possibly contributing to their voice complaints. A retrospective chart review of all patients who presented to a tertiary laryngology referral center over a 13-month period, who had a clinical diagnosis of mild vocal fold hypomobility and who underwent laryngeal electromyography, were included in the study. A total of 22 patients completed the medical evaluation of their voice complaint. Of these patients, 19 (86.4%) were found to have evidence of neuropathy on laryngeal electromyography. The clinical picture indicated the following probable origins for the vocal fold paresis: goiter/thyroiditis (7/22 or 31.8%), idiopathic (4/22 or 18.2%), viral neuritis (4/22 or 18.2%), trauma (3/22 or 13.6%), and Lyme's disease (1/22 or 4.5%). This article describes the clinical entity of mild vocal fold hypomobility and associated flexible laryngoscopic, rigid strobovideolaryngoscopic, and laryngeal electromyographic findings.     

Symptomatology of adductor spasmodic dysphonia: A physiologic model

Vocal symptomatology of adductor spasmodic dysphonia (SD) is reviewed critically from historical, epidemiologic, and clinical perspectives. A model of symptomatology of this disorder based on a large patient population, and clinical and physiologic observations is advanced. The model incorporates crucial symptomatic and asymptomatic phonatory and nonphonatory physiologic parameters of laryngeal behavior in these patients. These parameters include vocal fold contact area, vocal fold collision force, glottic compression, and subglottic air pressure. Inappropriate efferent discharges from brain-stem basal ganglia are hypothesized as causing overadduction of the vocal folds in phonation, generating the basic and fundamental vocal symptom of adductor SD—strained, strangled, overpressured voice quality. Cortical loops are implicated as accountable for compensatory vocal behavior, not as the primary site of the disorder. Symptom occurrence, variability, magnitude, effects, and failure of treatment approaches, as well as recurrence of symptoms after ablative or invasive procedures, are explained by this model. The model also predicts that symptomatology of adductor spasmodic dysphonia is unique to this disorder and that symptoms are phonotopically organized. The minimal diagnostic battery based on the model is presented, and it is shown how this battery aids in the differential diagnosis of adductor SD and other phonatory disorders that closely mimic the vocal symptoms of adductor spasmodic dysphonia, including tremor.     

Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective

Unilateral vocal fold paralysis is now considered a common disorder seen in the practice of otolaryngology and voice pathology. Concern first is for the accurate diagnosis of the associated etiology in an efficient and thorough fashion. When etiology has been determined the focus of treatment becomes the management of the presenting symptoms, which typically include dysphonia and dysphagia. A retrospective study was conducted reviewing the records of 117 patients with unilateral adductor vocal fold paralysis who presented to a large otolaryngology practice and clinical voice lab from 1995 to 1998. Demographic data reveal most patients to range in age from 16 to 91 with a dominant clustering for ages 50 to 70. Gender distribution reveals males slightly exceed females in this sample. Data regarding etiology type are collected in great detail, revealing that disease and surgery involving the chest contribute the greatest to the overall number in this study and that anterior approach to cervical spine surgery contributes as much as thyroid surgery. General outcomes of the patients are reviewed. A small group (n = 25) of patients who had pretreatment and posttreatment data available revealed statistically significant differences between voice outcomes for patients who were treated with medialization and for those treated with therapy. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.     

Too Much Fat, a Rare Complication of Injection Medialization Laryngoplasty: A Case Report

Vocal fold medialization with autologous fat is indicated in certain persons with glottic insufficiency. This article reports the first case, to our knowledge, of long-term (greater than 1 year) survival of too much fat after injection into the vocal folds.     

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 1 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.