The Laryngoscope

C 2015 The American Laryngological,

V

Rhinological and Otological Society, Inc.

Systematic Review

A Comparison of Outcomes in Interventions for Unilateral Vocal Fold

Paralysis: A Systematic Review
Jennifer Siu, HBSc; Samantha Tam, MD; Kevin Fung, MD, FRCSC
Objectives/Hypothesis: To critically review current literature comparing interventional approaches for unilateral vocal
fold paralysis.
Study Design: Systematic review of the literature.
Methods: All English-language literature published in the PubMed database was eligible for inclusion. Inclusion criteria
were: 1) the major topic must be a direct comparison of outcomes in interventions for unilateral vocal fold paralysis, 2) the
subjects were 18 years or older, and 3) it was original research. Studies involving treatment of bilateral vocal fold paralysis
and nonprocedural interventions were excluded. Included studies were categorized according to level of evidence. Outcomes
analyzed were acoustic and aerodynamic measures, auditory perceptive evaluation, laryngoscopic findings, and complications.
Results: Of the 504 studies retrieved from the search strategy, 17 studies met inclusion and exclusion criteria. Overall,
four interventional approaches were used for treatment of unilateral vocal fold paralysis: medialization thyroplasty, injection
laryngoplasty, arytenoid adduction, and laryngeal reinnervation. Aside from some select improvements in single outcome
parameters, overall, the majority of studies show no difference in improvement of outcomes between techniques.
Conclusions: Four surgical interventions for unilateral vocal fold paralysis are available for treatment of unilateral vocal
cord paralysis. Multiple studies show favorable outcomes, but no significant differences between treatment arms based on
perceptual, acoustic, quality of life, and laryngoscopic outcomes.
Key Words: Unilateral vocal fold paralysis, medialization thyroplasty, injection laryngoplasty, laryngeal reinnervation,
arytenoid adduction.
Level of Evidence: NA
Laryngoscope, 00:000000, 2015

INTRODUCTION
Unilateral vocal fold paralysis (UVFP) is a common
condition presenting to the otolaryngologisthead and
neck surgeon. The most common cause includes damage
to the recurrent laryngeal nerve (RLN) either iatrogenically or from a neoplasm. Patients with UVFP typically
present with voice changes, hoarseness, or aspiration.
Examination on laryngoscopy shows impaired vocal fold
motion, bowing of the fold, and incomplete glottic closure. Recovery from UVFP depends on the degree of
RLN damage, which can range from temporary neuropraxia to complete neural disruption. Some patients may
recover spontaneously over weeks to months with conservative management with voice therapy. However, fur-

From the School of Medicine (J.S.), Queens University, Kingston,

Ontario, Canada; Department of OtolaryngologyHead and Neck
Surgery (S.T., K.F.), Schulich School of Medicine and Dentistry, Western
University, London, Ontario, Canada.
Editors Note: This Manuscript was accepted for publication
September 22, 2015.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Kevin Fung, MD, 800 Commissioners
Road East, Suite B3-427, London, Ontario, Canada N6G 5G1.
E-mail: kevin.fung@lhsc.on.ca
DOI: 10.1002/lary.25739

Laryngoscope 00: Month 2015

ther interventions may be necessary for patients who do

not recover spontaneously, who have known iatrogenic
nerve transection, or who experience debilitating voice
dysfunction or aspiration.1
A wide variety of interventional options are available in the otolaryngologists armamentarium for treatment of nonresolving UVFP including medialization
thyroplasty, injection laryngoplasty, arytenoid adduction,
and laryngeal reinnervation. However, none of these procedures has been shown to be definitely superior over
the others. The purpose of this study was to systematically review current literature comparing the interventional treatment approaches for unilateral vocal fold
paralysis.

MATERIALS AND METHODS

Due to the broad variety of outcome measures utilized in literature, study results were unable to be combined for metaanalysis. Therefore, a systematic review of the literature was performed. All literature published in the PubMed database up to
November 2014 were eligible for inclusion. Search terms were
vocal cord paralysis, vocal fold paralysis, voice disorders,
dysphonia, aphonia, hoarseness, vocal cord dysfunction,
vocal fold dysfunction, laryngeal nerve injuries, recurrent
laryngeal nerve injuries, adult, human, nerve regeneration,
prosthesis and implants, absorbable implants, electrodes,

Siu et al.: Comparison of Interventions for UVFP

implanted, electrodes, laryngoplasty, reinnervation, injection laryngoplasty, medialization thyroplasty, arytenoid

adduction, cricothyroid subluxation, Isshiki type 1, vocal
fold augmentation, and vocal cord augmentation. The following
search terms were excluded: bilateral, pediatric, animals,
and Teflon.
Inclusion criteria were 1) major topic must be a direct
comparison of outcomes between at least two different intervention techniques for unilateral vocal fold paralysis in human subjects; 2) subjects 18 years or older; and 3) original research
including cohort studies, case control studies, case series with N
> 10, and retrospective observational studies. Articles were
excluded if they involved 1) outcomes from a single type of
intervention rather than a comparison of two techniques, 2)
treatment for bilateral vocal fold paralysis, 3) conservative or
nonprocedural management of vocal fold paralysis, 4) outcomes
in subjects less than 18 years of age, 5) outcomes in nonhuman
subjects, and 5) nonEnglish-language articles.
All abstracts retrieved were reviewed by two blinded
investigators for inclusion in the study. If consensus was unable
to be reached by the two investigators, a third investigator
would determine inclusion or exclusion. Level of evidence of all
included studies was determined by the Oxford Centre for
Evidence-Based Medicine Level of Evidence.2

RESULTS
A total of 504 studies were retrieved utilizing the
search strategy. Seventeen studies met all the inclusion
criteria. All studies were published between 1998 and
2014. Six studies made comparisons between injection
laryngoplasty and medialization thyroplasty (Table I).38
Six studies investigated arytenoid adduction alone or
with another procedure (Table II).6,913 Six studies had
laryngeal reinnervation as a main comparator of outcomes (Table III).1419 One study was a randomized controlled trial.16 Six studies were level 3 evidence, and 10
studies were level 4 evidence.
Four major categories of outcomes were found.
Acoustic and aerodynamic measures included acoustic
analysis for jitter, shimmer, harmonic-to-noise ratio,
maximum phonation time, glottic airflow, and subglottic
pressure. Subjective evaluation included perceptual evaluation and ratings on disability or quality of life. Perceptual scales used included the Grade, Roughness,
Breathiness, Asthenia, Strain scale and the Consensus
Auditory-Perceptual Evaluation of Voice, and selfreported instruments included the Voice Handicap Index
(VHI) and the Voice-Related Quality of Life scale. Laryngoscopic findings were utilized to characterize postoperative edema, degree of glottic closure, symmetry of
glottic closure, periodicity of glottic closure, and mucosal
wave. Last, other outcome measures included complication rates following each intervention.

DISCUSSION
Medialization Thyroplasty
Medialization thyroplasty, first described by Isshiki,
involves the creation of a window in the thyroid cartilage
and insertion of a permanent alloplastic implant to medialize the vocal fold.20 It has been considered the gold
standard approach to treatment of UVFP, and its benefiLaryngoscope 00: Month 2015

cial effects on long-term voice outcomes have been well

established in the literature.8 Commonly used alloplastic
materials include Silastic polymeric silicone, polytetrafluoroethylene (Gore-Tex), titanium, and Montgomery
implants.21 Advantages of this technique include low
cost, ability to adjust the implant intraoperatively, and
reversibility of the procedure.22 Rare complications
include edema, wound complications, extrusion, and need
for tracheotomy.21
In this review, 14 out of 17 studies retrieved involve
medialization thyroplasty as a direct comparator of outcomes to other techniques when used alone or in combination with other procedures. An analysis of these
comparisons will be discussed below within the context
of each approach.

Injection Laryngoplasty
Medialization of a unilateral paralyzed vocal fold
can be achieved by injection of filler material into the
paraglottic space. Br
unings was the first to describe
injection laryngoplasty in 1911 using paraffin.23 Since
then, the technique has been refined, and a variety of
injected materials have been used including autologous
fat, calcium hydroxylapatite microspheres, bovine collagen, and methylcellulose.21 Seven of the 17 articles
reviewed discussed injection laryngoplasty as a comparator to other techniques (Table I).
Injection laryngoplasty and objective voice outcomes. Five articles focused on acoustics and aerodynamics as primary outcome measures.36,9 All studies
showed improvements in postoperative voice outcomes
regardless of intervention type. Two studies found no difference in postoperative outcomes between injection laryngoplasty and medialization thyroplasty.6,9 However,
the effect of injection laryngoplasty was not permanent
with 10 of 16 subjects, requiring multiple injections in
one study.6 Three studies found improved outcomes with
injection laryngoplasty. Cantillo-Ba~
nos et al. found that
harmonic-to-noise ratio was significantly improved in
the injection laryngoplasty group at 24 months compared to the medialization thyroplasty group.3 Two studies by Umeno et al. showed significantly greater
improvement in maximum phonation time, mean frequency range, and acoustic variables in the injection laryngoplasty group compared to medialization thyroplasty
alone or in combination with arytenoid adduction.4,5
These results were attributed to heterogeneity between
the groups prior to surgical intervention, as there was a
higher degree of premorbid respiratory disability (e.g.,
UVPF due to lung resection) and a greater vertical glottis height difference in the laryngeal framework group
compared to the injection laryngoplasty group.
Injection laryngoplasty and subjective voice
outcomes. All three studies that focused on subjective
voice outcomes as a primary outcome show postoperative
improvement in subjective voice outcomes.3,7,8 CantilloBa~
nos et al. found that aside from higher postoperative
VHI scores in medialization thyroplasty compared to
injection laryngoplasty, there were no differences in subjective voice outcomes including jitter, shimmer, and
Siu et al.: Comparison of Interventions for UVFP

Laryngoscope 00: Month 2015

Siu et al.: Comparison of Interventions for UVFP

LoE

Comparison

Andrews et al.6

Mortensen et al.9

Umeno et al.5

Vinson et al.8

Vinson et al.8

IL vs. MT

IL vs. MT

IL vs. MT

IL vs. MT

IL vs. MT

IL vs. LF
(AA/MT/MT 1 AA)

IL vs. MT vs.
(AA 1 MT)

IL vs. MT

IL vs. MT

Glottic closure,
symmetry,amplitude,
periodicity

Symmetry, amplitude,
periodicity,closure
patterns, glottic
closure

CAPE-V, VHI

CAPE-V, VHI

VHI

MPT, MFR

Jitter, shimmer, HNR,

MPT, MFR

MPT

MPT, MFR, acoustic

variables

Jitter, shimmer, HNR

Outcome Measure

124 months

19 months

124 months

19 months

6 and 24 months

12 months 3 years

3 months

817 months

12 months4 years

6 and 24 months

Follow-up

In all outcome
measures

In all outcome
measures

Stats not
available

In all outcome
measures, but
not significantly
different

In all outcome
measures

In all outcome
measures

In all outcome
measures

In all outcome
measures

In all outcome
measures

IL had no
improvement
in shimmer

Postoperative
Improvement?*

No difference

No difference

No difference

No difference

MT had better VHI outcome

at 6 and 24 months
(P < .05)

IL had greater improvement

in all outcomes compared
to laryngeal framework
(P < .05)

No difference

No difference

IL had better change in MPT

and MFR (P < .001)

IL had better HNR score

compared to MT at 24
months (P < .05), but not
6 months

Comparison of Interventions

Both have comparable

outcomes

Both have comparable

outcomes

Both have comparable

outcomes

Both have comparable

outcomes

Both show postoperative

improvement, but MT
shows better improvement
in VHI compared to IL over
short and long term

Both effective at voice

improvements over 24month period; improvement
in HNR better sustained in
IL compared to MT
Difference may be due to
preoperative differences in
respiratory function (UVFP
due to lung resection)
IL and MT both effective
options for revision, but IL
is temporary and may
require repeat procedures
(10/16 needed reinjection)
No difference in improvement
of outcomes between
groups
Difference seen with IL may
be due to preoperative differences in glottal level
height

Conclusions/Additional
Information

*Postoperative improvement with P < .05

AA 5 arytenoid adduction; CAPE-V 5 Consensus Auditory Perceptual Evaluation-Voice; HNR 5 harmonics to noise ratio; IL 5 injection laryngoplasty; LoE 5 level of evidence; MFR 5 mean airflow rate;
MPT 5 maximum phonation time; MT 5 medialization thyroplasty; VHI 5 Voice Handicap Index.

Morgan et al.7

Laryngoscopic outcomes

Morgan et al.7

Subjective voice outcomes

~ os et al.3
Cantillo- Ban
4

Umeno et al.4

Acoustic and aerodynamic outcomes

4
IL vs. MT
Cantillo-Banos et al.3

Article

TABLE I.
Outcome Measures Comparing Injection Laryngoplasty With Other Interventions.

Laryngoscope 00: Month 2015

Siu et al.: Comparison of Interventions for UVFP

LoE

Comparison

Sonoda et al.11

Murata et al.10

eAA vs. (eAA 1 MT)

vs. (eAA 1 IL)

(AA 1 MT) vs. MT

(AA 1 MT) vs. MT

(AA 1 MT) vs. MT

(AA 1 MT)vs. IL

(AA/lateral traction)
vs. (AA 1 MT)

(eAA 1 IL) vs.

(eAA 1 MT)

Complication rates

Complication rates

Glottic gap

Glottic gap

GRBAS

MPT

Jitter, shimmer, HNR,

MPT, MFR

Jitter, shimmer, HNR,

MPT, MFR

Outcome Measure

6 months1 year

NA

NA

9 weeks

817 months

NA

6 months1 year

3 months

Follow-up

NA

NA

NA

NA

In all outcome
measures

In all outcome
measures

In all outcome
measures

In all outcome
measures

Postoperative
Improvement

Two minor complications in

endoscopic AA patients

Increased mean time

of surgery and hospital
stay for AA 1 MT;
increased wound
complications,
risk of tracheotomy,
edema with AA 1 MT

(AA 1 MT) had better

posterior glottic gap
closure (P 5 .0054)

No difference

No difference

No difference

Significant improvement
in degree of change of
acoustic and aerodynamic
parameters for AA 1 MT
No difference

Comparison of Interventions

Endoscopic AA a safe option for

UVFP and can be used in
combination with MT and IL

Increased complication rate

with MT 1 AA

Improved closure of the posterior

glottis with addition of AA

Usefulness of AA for large glottis

gaps and vertical height
discrepancies may not be
warranted

No difference in improvement of
outcomes between groups

No difference in improvement of
outcomes between groups

No difference in improvement of
outcomes between groups

AA 1 MT may correct the physiology

of the incompetent larynx better
than MT or IL alone

Conclusions

AA 5 arytenoid adduction; eAA 5 endoscopic arytenoid adduction; GRBAS 5 Grade, Roughness, Breathiness, Asthenia, Strain; HNR 5 harmonic to noise ratio; IL 5 injection laryngoplasty; LoE 5 level
of evidence; MFR 5 mean airflow rate; MPT 5 mean phonation time; MT 5 medialization thyroplasty; NA 5 not available; UVFP 5 unilateral vocal fold paralysis.

Abraham et al.13

Complications
Abraham et al.13

Li et al.12

Laryngoscopic outcomes

Subjective voice outcomes

3
Andrews et al.6

Murata et al.10

Acoustic and aerodynamic outcomes

4
(AA 1 MT) vs.
Mortensen et al.9
IL vs. MT

Article

TABLE II.
Outcome Measures Comparing Arytenoid Adduction With Other Interventions.

Laryngoscope 00: Month 2015

Siu et al.: Comparison of Interventions for UVFP

LoE

Comparison

Hassan et al.15

Paniello et al.16

Havas and
Priestley17

Tucker18

Paniello et al.16

(LR/NMP 1 AA) vs. AA

(LR 1 AA) vs. AA

LR vs. (MT 6 AA)

(NMP 1 MT) vs. MT

LR vs. IL vs. MT

(NMP 1 AA) vs.

(AA 1 MT)

LR vs. (MT 6 AA)

(NMP 1 AA) vs.

(AA 1 MT)

(LR 1 AA) vs. AA

Degree peak edema

postoperatively

Glottic closure, mucosal

wave, glottic symmetry

GRBAS, VRQOL

Perceptual voice ratings

Voice outcomes scale

GRBAS (G and B only)

MPT, CPP

Jitter, shimmer,
HNR, MPT

Laryngeal air flow,

subglottic pressure

Outcome Measure

Postoperative
day 3

NA

12 months

6 months
and 2 years

2 months8 years

3, 12, and
24 months

6, 12 months

3, 12, 24 months

NA

Follow-up

Postoperative
improvement

In all outcome
measures

In all outcome
measures

Stats not
available

Stats not
available

In all outcome
measures

In all outcome
measures

In all outcome
measures

In all outcome
measures

Postoperative
Improvement

No difference

No difference

No difference

(NMP 1 MT) had

improvement at 2 years,
and MT had
deterioration (NS)

(NMP 1 AA) had better G

(P < .05) and B (P < .01)
scores at 24 months
Stats not available

(MT 6 AA) had better

improvement in MPT
compared to LR at
6 months, (P < .009);
LR had better CPP
score than (MT 1 AA)
at 12 months (P < .05)

(AA 1 NMP) had greater

improvement in MPT
compared to (AA 1 MT)
at 12 and 24 months

No difference

Comparison of
Interventions

LR 1 AA and AA provide significant improvement in laryngoscopic findings but no

differences in improvement
between groups
No difference in postoperative
edema between groups

Both LR and (MT 6 AA) effective

in improving both GRBAS and
VRQOL; younger subjects in
both groups had better results
(P 5 .048)

Long-term improvement in (NMP

1 MT) compared to MT

(AA 1 NMP) may provide longterm benefit over (AA 1 MT) in

perceptual voice outcomes
Multiple effective options for
treatment of UVFP; successful
rehabilitations requires consideration of patient
characteristics

Delayed onset of improved MPT

in LR group; better maintenance of cepstral peak in LR
group compared to (MT 6 AA)

AA 1 NMP may provide longerterm benefits in acoustic voice

parameters

LR 1 AA and AA both effective

in improving voice outcomes,
with no difference in outcome
between groups.

Conclusions

AA 5 arytenoid adduction; CPP 5 cepstral peak prominence; GRBAS 5 Grade, Roughness, Breathiness, Asthenia, Strain; HNR 5 harmonics to noise ratio; IL 5 injection laryngoplasty; LoE 5 level of evidence; LR 5 laryngeal reinnervation; MPT 5 maximum phonation time; MT 5 medialization thyroplasty; NA 5 not available; NMP 5 neuromuscular pedicle; NS 5 not significant; UVFP 5 unilateral vocal fold
paralysis; VRQOL 5 voice-related quality of life.

Narajos et al.19

Laryngoscopic outcomes
Chhetri et al.14
3

Hassan et al.15

Subjective voice outcomes

Chhetri et al.14

Acoustic and aerodynamic outcomes

Article

TABLE III.
Outcome Measures Comparing Laryngeal Reinnervation With Other Interventions.

harmonic-to-noise parameters between these two interventions.3 Similarly, two other studies reported no difference in subjective voice outcome parameters when
injection laryngoplasty was compared to medialization
thyroplasty.7,8
Laryngoscopy. The two studies that used glottic
closure, symmetry, and amplitude periodicity on laryngoscopic examination as primary outcome measures both
showed no difference in outcomes between injection laryngoplasty and medialization thyroplasty.7,8

Arytenoid Adduction
First described by Isshiki et al. in 1978, arytenoid
adduction involves medialization of the posterior vocal
fold by placement of a suture in the muscular portion of
the arytenoid, thereby simulating contraction of the lateral cricoarytenoid muscle.24 Theoretically, this results
in an improvement in posterior glottic gap closure.
Although arytenoid adduction offers several advantages
over other procedures, it is a technically challenging procedure that involves significant laryngeal manipulation
of the cricoarytenoid joint. Compared to medialization
thyroplasty, it is associated with an increase in overall
complications including airway obstruction due to laryngeal edema, dysphagia, and increased operating time.13
Addition of arytenoid adduction to medialization thyroplasty or injection laryngoplasty. Arytenoid adduction is often performed in combination with
medialization thyroplasty or injection laryngoplasty.
Andrews et al. found no difference between subjective
voice outcomes between arytenoid adduction with medialization thyroplasty compared to injection laryngoplasty. Mortensen et al. found that there was an added
benefit of arytenoid adduction to acoustic or aerodynamic outcome measures including jitter, shimmer,
harmonic-to-noise ratio, mean phonation time, mean
phonatory flow, or subglottic pressure, but this did not
reach statistical significance. Multivariate analysis
showed a statistically greater degree of change of acoustic and aerodynamic parameters in this group.9
Two studies investigated laryngoscopic outcomes.
Abraham et al. conducted the largest study with 194
patients: 98 underwent medialization thyroplasty alone
compared with 96 who underwent medialization thyroplasty combined with arytenoid adduction. In this study,
the addition of arytenoid adduction to medialization thyroplasty resulted in significantly improved closure of the
posterior glottis on laryngoscopy, with no statistical difference in complication rates.13 This improvement in
glottic closure was not reproducible in a study by Li
et al. However, this was a much smaller-scale study
involving 10 patients who had medialization thyroplasty
and arytenoid adduction compared to 35 patients who
had medialization thyroplasty alone.12 Differences in
results between these two studies may also be due to
variability between groups in terms of preoperative
comorbidities, glottic closure patterns, and vertical
height discrepancies.
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Arytenoid adduction and technique modifications. To address the increased complication rates associated with the increased technical difficulty of
arytenoid adduction, two studies introduced modified
arytenoid adduction methods in attempt to reduce complication rates.10,11 Murata et al. found that endoscopicassisted arytenoid adduction surgery yielded similar
postoperative acoustic and aerodynamic results, with no
significant added complication rates when performed
alone and in combination with medialization thyroplasty
or injection laryngoplasty.10 Sonoda et al. introduced a
modified open arytenoid adduction technique to avoid
dissection of the posterior edge of the thyroid cartilage
and damage to the surrounding tissues. Lateral traction
is applied to the cricoarytenoid muscle using nylon
sutures pulled anterocaudally.11 This modified open technique was found to have similar results as compared to
arytenoid adduction and medialization thyroplasty in
achieving successful voice outcomes as measured by
maximum phonation time of more than 10 seconds.
Arytenoid adduction summary. Arytenoid adduction can be performed either alone or in combination
with other techniques. The hypothesis that this technique results in an improvement in posterior glottic gap
was demonstrated in one study, but not in another.12,13
Mortensen et al. also demonstrated no statistically significant added benefit of arytenoid adduction to medialization thyroplasty on acoustic and aerodynamic voice
outcomes.9 Modified arytenoid adduction techniques
have been developed to improve complication rates associated with the traditional approach. Further research is
necessary to improve comparisons between approaches.

Laryngeal Reinnervation
Laryngeal reinnervation was introduced as a technique to prevent long-term atrophy and decreased stiffness of a paralyzed vocal fold, which can occur with
medialization thyroplasty. Vocal fold bulk, stiffness, and
tension are maintained by providing nerve supply to the
thyroarytenoid adductor muscles. It is the resultant
medialization of the vocal fold, rather than complete restoration of dynamic vocal fold movement, that leads to
voice improvements with this technique. Functional restoration of the vocal fold is limited by disorganized axon
regrowth, resulting in synkinesis.
There are a variety of approaches to reinnervation
including primary anastomosis of the transected recurrent laryngeal, nerve-muscle pedicle transfer to the thyroarytenoid muscle, direct ansa cervicalis nerve
implantation onto the thyroarytenoid muscle, and anastomosis between a donor nerve (usually the hypoglossal,
phrenic, or ansa cervicalis) and the recurrent laryngeal
nerve.25
Laryngeal reinnervation alone. Paniello et al.
conducted the most robust study directly comparing
laryngeal reinnervation with medialization thyroplasty
in a multicenter randomized control trial with 12 subjects in each arm.16 Results from the study suggest a
delayed onset of improved outcomes with reinnervation.
Minimal differences in auditory and perceptual voice
Siu et al.: Comparison of Interventions for UVFP

outcomes at 6 months were found; however, subjects

undergoing laryngeal reinnervation had continued
improvement and better maintenance of results at 12
months. Subgroup age analysis showed that subjects
aged less than 52 years had better outcomes with laryngeal reinnervation compared to medialization thyroplasty at any age, and significantly better outcomes
than subjects greater than 52 years old with laryngeal
reinnervation, suggesting that younger patients may
have more benefit from laryngeal reinnervation and
older patients better outcomes with medialization thyroplasty. However, Havas and Priestley reported less successful voice outcomes with only four out of 12 subjects
undergoing reinnervation achieving satisfactory voice
results.17
Laryngeal reinnervation in combination with
other techniques. Three studies evaluated the added
effect of laryngeal reinnervation with a laryngeal framework procedure.14,15,18 These included the combination of
neuromuscular pedicle with either medialization thyroplasty or arytenoid adduction, and ansa-RLN in combination with arytenoid adduction. In one study, significant
improvements in acoustic and aerodynamic parameters
persisted up to 2 years postoperatively following a neuromuscular pedicle and medialization thyroplasty combination procedure.15 Furthermore, this study found that
perceptual voice outcomes improved in those undergoing
the combined procedure, whereas voice deterioration was
seen in those undergoing medialization thyroplasty
alone.18 Hassan et al. also found that the combination of
neuromuscular pedicle with arytenoid adduction resulted
in significantly greater improvements in maximum phonation time that persisted up to 2 years.15 Together, these
results suggest that the addition of a neuromuscular pedicle to medialization thyroplasty not only prevents the
voice deterioration that occurs with medialization thyroplasty alone, but also results in improved long-term voice
outcomes due to the increased bulk and vocal fold mass
provided by the reinnervation.18
Unfortunately, similar results were not found when
ansa cervicalis anastomosis reinnervation was combined
with arytenoid adduction. Chhetri et al. found no added
benefit of ansa cervicalis anastomosis to arytenoid
adduction in aerodynamic parameter outcomes, auditory
and perceptual outcomes, or laryngoscopic outcomes.14
However, in this study, a significant portion of patients
were lost to follow-up, and patients had variable postoperative follow-up intervals, which may explain in variability in the results.
Laryngeal reinnervation complications. Importantly, in comparison to framework surgery alone, laryngeal reinnervation procedures were shown to be safe
when performed alone or in combination with arytenoid
adduction. Blumin and Merati found no difference in
minor or major complication rates between laryngeal
reinnervation and other laryngeal framework procedures.26 Narajos et al. added evidence to the safety profile of laryngeal reinnervation by demonstrating no
difference in degree of edema in different subsites of the
larynx following arytenoid adduction with or without
laryngeal reinnervation.19
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Laryngeal reinnervation summary. Overall,

when employed alone or in combination with laryngeal
framework procedures, reinnervation is associated with
improved subjective and objective voice outcomes preand postintervention without the expense of increased
complications. Patients who have undergone laryngeal
reinnervation have been shown to have a delayed benefit
in voice outcome, with maximal benefit reached several
months after surgery, whereas results from medialization thyroplasty are achieved almost immediately.
Results from studies in this review suggest that the
marginal benefits compared to other medialization techniques may not outweigh the technical challenges that
microneural surgery presents.

Overall Observations
A wide variety of effective procedural interventions
are available for patients with UVFP. Each of these techniques may be performed in isolation or in combination
with other techniques. Each technique has relative
strengths and weaknesses. Patient selection, etiology of
the paralysis, and preoperative laryngoscopic findings
are all necessary considerations when considering an
optimal, individualized approach. Table IV summarizes
the overall observations of each technique according the
findings of this study.

Limitations
A wide breadth of literature has been published on
the topic of UVFP. This study was conducted in an
attempt to systematically review all head-to-head comparisons between interventions. This study, as a systemic review, is limited by the quality of the included
studies. Because it is a collection of findings from various other studies, it provides an overview of the direction of the literature, but is unable to show new
findings. This study is not a meta-analysis, and study
results have not been statistically combined for more
powerful results. As well, only English-language studies
were able to be included in this review.
Interpretation of the pooled dataset was particularly challenging due to a variety of factors. First, there
is significant variation across the studies in methodology
and study design. Lack of standardization in outcome
measures and differences in reporting outcome data
make generalizability between studies difficult. Furthermore, there was significant heterogeneity in preoperative patient population, length of postprocedural followup, and breadth of surgical combinations. All of these
factors could contribute to why there were no differences
seen in the outcome measures across interventions. Second, differences in surgical technique and preferred
materials are vast between institutions and surgeons.
Within each surgical technique, there is significant variability in the amount of material injected, durability of
the injected material, and type of injection or implant.
All of these factors make comparisons of the results
between institutions additionally challenging. Finally, as
with any comparison of surgical technique, surgeon
Siu et al.: Comparison of Interventions for UVFP

TABLE IV.
Summary of Interventions by Strengths and Weaknesses.
Technique

Strengths

Weakness

Medialization thyroplasty

Immediate result

May lack long-term effect due to continued vocal fold

atrophy when done alone

Injection laryngoplasty

Simple procedure
Can be completed in a clinic setting

Requires operating room time

May not be ideal for patients who cannot tolerate an
office-based procedure under local anesthesia or
general anesthetic
May require multiple injections

May be used as an effective temporizing

measure for UVFP
Arytenoid adduction

Laryngeal reinnervation

May be useful in correcting posterior glottic

gaps and vertical height discrepancies

Prevents vocal fold atrophy, resulting in

long-term results

Technically challenging
More manipulation of the larynx resulting in more
complications compared to medialization thyroplasty
Requires operating room time
Technically challenging
No immediate result when done alone
Requires operating room time

UVFP 5 unilateral vocal fold paralysis.

experience and institutional volume plays a large role in

patient outcomes. Reported outcomes in the literature
often represent institutions with large volumes. This
may limit the external validity of the findings. Therefore, individual experience and comfort with each technique should be taken into consideration when choosing
the best intervention for each patient scenario.

FUTURE DIRECTIONS
Overall, standardized study protocols outlining outcome measures, method of reporting measurements, and
follow-up intervals would facilitate future analysis of
data, including meta-analyses. In this review, only one
study attempted to investigate aspiration outcomes in a
systematic way. As aspiration is a major complication of
UVFP, further studies objectively investigating this outcome measure may direct decisions for intervention in
this subset of patients.

CONCLUSION
Based on this review, there is no definitive evidence
suggesting superiority of any one technique on acoustic
and aerodynamic parameters, perceptual voice outcomes,
and laryngoscopic findings. Current evidence suggests
that although voice outcomes are similar between medialization thyroplasty and injection laryngoplasty initially
following the procedures, long-term results may favor
the former. Furthermore, injection laryngoplasty may be
favored in patients who are unable to tolerate general
anesthetic and those who wish to have a more immediate short-term benefit. Laryngeal reinnervation techniques may be best used in combination with other
laryngeal framework techniques for longer-term benefit
and may be best reserved for younger patients. All procedures were shown to be safe, and not associated with
any significant perioperative morbidity.
Overall, a variety of procedures are available within
the otolaryngologists armamentarium for treating
Laryngoscope 00: Month 2015

patients with UVFP. Because of the variability in surgical

combinations, surgeon expertise, and inconsistencies in
techniques of assessment, it is difficult to generalize based
on this literature review as to which operative procedure
is superior. Multiple studies have shown no significant differences between treatment arms based on laryngoscopic,
perceptual, acoustic, and quality of life measures. Ultimately, patient preference and expectations, preoperative
laryngoscopy findings, procedural cost, onset, and duration of therapeutic effect, and surgeon preference are all
essential components in determining the most optimal
intervention for the patient with UVFP.

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