Involving family members in a thyroplasty procedure - Case Commentary

AORN Journal, Feb, 2003 by Rebecca T. Ferguson

Thyroplasty is a surgical procedure performed to restore vocal quality to those patients affected by vocal cord paralysis. This is achieved through medialization or the repositioning of the paralyzed cord to the midline, which allows the nonparalyzed cord to meet the paralyzed cord on phonation. Paralysis can be caused by several factors, including injuring the recurrent laryngeal nerve during a procedure, such as carotid endarterectomy or thyroidectomy, or injuring the vocal cord itself during a difficult intubation. The symptoms of unilateral vocal cord paralysis include a weak, breathy voice and/or a change in pitch. The change in pitch is caused by the cord's inability to become taut. Aspiration and choking also may occur. Generally, unless paralysis persists for six months or more, no interventions are attempted because paralysis usually resolves spontaneously.

Several techniques can be used to perform thyroplasty. The most common are

* carving and implanting a wedge of silastic block to achieve medialization of the affected cord;

* injecting polytetraflouethylene paste, absorbable gelatin film, collagen, fat, or donated human tissue that has been processed for use as a minimally invasive tissue graft into the affected cord; or

* using a prefabricated thyroplasty implant.

The premade thyroplasty implant system consists of sizing kits and precut silicone implants, as well as a set of insertion instruments. The insertion instruments include calipers, curved hooks, dull hooks, 3-mm and 5-mm duckbill elevators, chisels, and implant inserters.

THE PROCEDURE

Preoperatively, staff members from surgery, anesthesia, and nursing see patients in the preoperative center. Any needed laboratory work is completed, a history is taken, and a physical examination is performed. Preoperative education is provided at this time. The anesthesia care provider explains to the patient that he or she will need to be awake during the procedure to allow the surgeon to test the implant and the voice achieved with it. The surgeon or perioperative nurse explains that the surgeon will have the patient repeat phrases and sounds throughout the procedure, such as "eeeee" or "1-2-3." It is important that the patient understand the surgeon's expectations during the procedure so that he or she will be prepared to participate and follow instructions. Other preoperative education includes an explanation of the use of the nasolaryngoscope and of monitored anesthesia care and local anesthesia.

On the day of surgery, the patient is admitted through the one-day surgery department and subsequently transferred to the preoperative holding area. In the preoperative holding area, the preoperative nurse, circulating nurse, anesthesia care provider, and surgeon interview the patient. The anesthesia care provider starts the necessary IVs.

The circulating nurse and scrub person prepare the OR by opening the sterile field and gathering all the needed equipment and instruments. Equipment needed includes a nasolaryngoscope, bipolar forceps, suction, and a power source for the saw. Surgical instruments needed include the thyroplasty instrument set, a small oscillating saw, and a plastic instrument set consisting of

* small iris scissors,

* small tenotomy scissors,

* a freer elevator,

* hemostats,

* mosquitoes,

* Webster needle holders, and

* other soft tissue instruments.

The anesthesia care provider and circulating nurse transfer the patient from the preoperative holding area to the OR and help him or her move onto the OR bed. The patient is positioned supine with both arms tucked at his or her sides. The anesthesia care provider sedates the patient to achieve an appropriate monitored anesthesia care level. After the patient is resting comfortably, the surgeon injects 1% lidocaine with epinephrine 1:100,000 into the region of the thyroid cartilage. The circulating nurse applies an electrosurgical grounding pad and preps the patient with povidone-iodine scrub and paint. The patient then is draped with four towels and a split sheet. The patient's face remains exposed with an anesthesia barrier up.

The surgeon identifies the anatomical landmarks (ie, thyroid notch, cricothyroid membrane, inferior margin of the cricoid cartilage) and marks them. He or she then makes the incision, exposing the thyroid cartilage. A window is cut into the thyroid cartilage, measuring approximately 5 mm by 10 mm. The window then is pried out using a sharp hook and a duckbill elevator or a freer elevator, and the sizers are inserted into the window.

The surgeon asks the patient to clear his or her throat, cough, and say "1-2-3, 1-2-3." While the patient is speaking, the anesthesia care provider views the vocal cords with the nasolaryngoscope to determine whether medialization of the paralyzed cord has been achieved. The surgeon also views the cords through the nasolaryngoscope. Various sizers are used until good phonation and projection are achieved with good medialization of the paralyzed cord. When the appropriate size implant is chosen, the surgeon places it in the window and sews it over with fascia. The surgical wound then is closed and dressed with self-adhesive wound approximating strips.