eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Vocal Fold Paralysis, Bilateral: Follow-up

Author: Joel A Ernster, MD, Active Staff, Penrose-St Francis Healthcare System; Active Staff, Memorial Health System; Clinical Instructor, University of Colorado Health Sciences Center
Coauthor(s): Arturo Avila Chavez, MD, Assistant Professor, Department of Otolaryngology and Head and Neck Surgery, Instituto Nacional De Enfermedades Respiratorias of Mexico City; Douglas Skarada, MD, Consulting Staff, Department of Otolaryngology, Salem Hospital
Contributor Information and Disclosures

Updated: Sep 9, 2008

Outcome and Prognosis

Spontaneous recovery can be expected in 55% of patients; almost half of patients who recover do so within the first year. Recovery may occur as late as 11 years after initial diagnosis.

All 6 patients treated by Dennis and Kashima with a posterior cordotomy achieved a functional airway without a tracheostomy.9 In 10 of 11 patients in Ossoff et al, a functional airway without tracheostomy was created after complete arytenoidectomy with an endoscopic carbon dioxide laser.11 Remacle et al had the same result in 40 of 41 patients with endoscopic partial arytenoidectomy.16 Eckel et al compared the results of patients treated with posterior cordotomy with those of a group of patients treated with complete arytenoidectomy.12 Both techniques were equally effective for achieving a functional airway, but patients treated with complete arytenoidectomy had more subclinical aspiration.

The plethora of etiologies in bilateral vocal fold (cord) paralysis (BVFP) and the multiple interventions do not allow easy comparison of techniques. Most series involving surgical techniques are small, and the findings generally support the authors' biases. Nonetheless, creative surgeons have a number of options that eventually should allow creation of a decannulated and safe airway in most patients.

Future and Controversies

Several techniques and approaches for the restoration of glottic competence in patients with bilateral vocal fold (cord) immobility (BVFI) are experimental but are promising. They include PCA muscle reinnervation, electrical stimulation of the laryngeal muscles, and use of the Cummings mechanical device.

PCA muscle reinnervation

Most efforts at laryngeal reinnervation have been focused on patients with unilateral vocal fold paralysis (UVFP). Chhetri et al has recently reported results with a combined procedure in which arytenoid adduction was performed with ansa cervicalis anastomosis to the RLN in a group of patients with UVFP.17 The reinnervation group had no benefit.

A group in the Netherlands selectively reinnervated the feline PCA muscle by using the phrenic nerve.18 Reinnervation was confirmed in 10 of 11 cats, but significant abductor function was restored in only 4 of 11. The authors' explanation was gradual ankylosis of the cricoarytenoid (CA) joint that limited the effects of improved abductor muscle function. This approach might be useful in patients with bilateral vocal fold (cord) paralysis (BVFP) and significant airway obstruction. The role of reinnervation in patients with BVFP remains undefined.

Electrical stimulation of the laryngeal muscles

Electrical muscle stimulation has been studied for more than 20 years. Current technology permits the creation of implanted laryngeal stimulators. Laryngeal stimulators send a stimulus that can be administered as a continuous current, an intermittent current, or a triggered (preferably by respiratory effort) pacing current. MedTronic has manufactured a number of prototype devices for this purpose, and they are still being researched.

In patients with BVFP, laryngeal pacing involves the use of an external apparatus that senses inspiration and reanimates the paralyzed larynx of the patient. Stimuli are delivered through a needle electrode to locate and pace the abductor muscle and through an electrode implanted in the PCA muscle or RLN branch that extends to the PCA muscle. Challenges include imprecise and excessive electrical stimulation, scar formation, bulky power sources, muscle fatigue with continuous stimulation, and difficulty in synchronizing the pacing with the respiratory effort in a convenient way. Researchers express optimism, but technical problems with the electrodes at the muscle site prevent widespread adoption of this technology.

Use of the Cummings mechanical device

Cummings has reported the use of an implantable device placed into the larynx through a thyroplasty window. This device engages the soft tissues of the larynx (including the TA muscle) with a screw. The screw then is rotated to pull the tissue laterally. Cummings et al conducted the investigation in sheep, with favorable results. Human studies are pending.

 


More on Vocal Fold Paralysis, Bilateral

Overview: Vocal Fold Paralysis, Bilateral
Workup: Vocal Fold Paralysis, Bilateral
Treatment: Vocal Fold Paralysis, Bilateral
Follow-up: Vocal Fold Paralysis, Bilateral
Multimedia: Vocal Fold Paralysis, Bilateral
References
[ CLOSE WINDOW ]

References

  1. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal fold immobility. Laryngoscope. Sep 1998;108(9):1346-50. [Medline].

  2. Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg. Nov-Dec 1980;88(6):765-72. [Medline].

  3. Gellad ZF, Hampton D, Tebbit CL, et al. Bilateral vocal cord paralysis following stent placement for proximal esophageal stricture. Endoscopy. Jul 16 2008;[Medline].

  4. Jung A, Schramm J, Lehnerdt K, et al. Recurrent laryngeal nerve palsy during anterior cervical spine surgery: a prospective study. J Neurosurg Spine. Feb 2005;2(2):123-7. [Medline].

  5. Jin YH, Jeong TO, Lee JB. Isolated bilateral vocal cord paralysis with intermediate syndrome after organophosphate poisoning. Clin Toxicol (Phila). Jun 2008;46(5):482-4. [Medline].

  6. Rosin DF, Handler SD, Potsic WP, et al. Vocal cord paralysis in children. Laryngoscope. Nov 1990;100(11):1174-9. [Medline].

  7. Gacek RR. Hereditary abductor vocal cord paralysis. Ann Otol Rhinol Laryngol. Jan-Feb 1976;85(1 Pt 1):90-3. [Medline].

  8. Munin MC, Murry T, Rosen CA. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. Aug 2000;33(4):759-70. [Medline].

  9. Dennis DP, Kashima H. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol. Dec 1989;98(12 Pt 1):930-4. [Medline].

  10. Laccourreye O, Paz Escovar MI, Gerhardt J, et al. CO2 laser endoscopic posterior partial transverse cordotomy for bilateral paralysis of the vocal fold. Laryngoscope. Mar 1999;109(3):415-8. [Medline].

  11. Ossoff RH, Sisson GA, Duncavage JA, et al. Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis. Laryngoscope. Oct 1984;94(10):1293-7. [Medline].

  12. Eckel HE, Thumfart M, Wassermann K, et al. Cordectomy versus arytenoidectomy in the management of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol. Nov 1994;103(11):852-7. [Medline].

  13. Helmus C. Microsurgical thyrotomy and arytenoidectomy for bilateral recurrent laryngeal nerve paralysis. Laryngoscope. Mar 1972;82(3):491-503. [Medline].

  14. Singer MI, Hamaker RC, Miller SM. Restoration of the airway following bilateral recurrent laryngeal nerve paralysis. Laryngoscope. Oct 1985;95(10):1204-7. [Medline].

  15. Bower CM, Choi SS, Cotton RT. Arytenoidectomy in children. Ann Otol Rhinol Laryngol. Apr 1994;103(4 Pt 1):271-8. [Medline].

  16. Remacle M, Lawson G, Mayne A, et al. Subtotal carbon dioxide laser arytenoidectomy by endoscopic approach for treatment of bilateral cord immobility in adduction. Ann Otol Rhinol Laryngol. Jun 1996;105(6):438-45. [Medline].

  17. Chhetri DK, Gerratt BR, Kreiman J, et al. Combined arytenoid adduction and laryngeal reinnervation in the treatment of vocal fold paralysis. Laryngoscope. Dec 1999;109(12):1928-36. [Medline].

  18. van Lith-Bijl JT, Stolk RJ, Tonnaer JA, et al. Laryngeal abductor reinnervation with a phrenic nerve transfer after a 9-month delay. Arch Otolaryngol Head Neck Surg. Apr 1998;124(4):393-8. [Medline].

  19. Bower CM, Choi SS, Cotton RT. Arytenoidectomy in children. Ann Otol Rhinol Laryngol. Apr 1994;103(4 Pt 1):271-8. [Medline].

  20. Cavo JW Jr. True vocal cord paralysis following intubation. Laryngoscope. Nov 1985;95(11):1352-9. [Medline].

  21. Coffey CS, Vallejo SL, Farrar EK, et al. Sarcoidosis Presenting as Bilateral Vocal Cord Paralysis From Bilateral Compression of the Recurrent Laryngeal Nerves From Thoracic Adenopathy. J Voice. May 9 2008;[Medline].

  22. Cohen SR. Pseudolaryngeal paralysis: a postintubation complications. Ann Otol Rhinol Laryngol. Sep-Oct 1981;90(5 Pt 1):483-8. [Medline].

  23. Correa AJ, Reinisch L, Sanders DL, et al. Inhibition of subglottic stenosis with mitomycin-C in the canine model. Ann Otol Rhinol Laryngol. Nov 1999;108(11 Pt 1):1053-60. [Medline].

  24. Cummings CW, Redd EE, Westra WH, et al. Minimally invasive device to effect vocal fold lateralization. Ann Otol Rhinol Laryngol. Sep 1999;108(9):833-6. [Medline].

  25. Daya H, Hosni A, Bejar-Solar I, et al. Pediatric vocal fold paralysis: a long-term retrospective study. Arch Otolaryngol Head Neck Surg. Jan 2000;126(1):21-5. [Medline].

  26. Dedo DD, Dedo HH. Vocal Cord Paralysis. Otolaryngology. 1980;3:2489-2503.

  27. Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or micro-trapdoor flap. Laryngoscope. Apr 1984;94(4):445-50. [Medline].

  28. Downey WC, Keenan WG. Laryngofissure approach for bilateral abductor paralysis. Arch Otolaryngol. 1968;88:513-17.

  29. Dray TG, Robinson LR, Hillel AD. Idiopathic bilateral vocal fold weakness. Laryngoscope. Jun 1999;109(6):995-1002. [Medline].

  30. Endo K, Okabe Y, Maruyama Y, et al. Bilateral vocal cord paralysis caused by laryngeal mask airway. Am J Otolaryngol. Mar-Apr 2007;28(2):126-9. [Medline].

  31. Fukuda H, Kitani M, Imaoka K. [A case of hereditary motor and sensory neuropathy with vocal cords palsy and diaphragmatic weakness]. Rinsho Shinkeigaku. Feb 1993;33(2):175-81. [Medline].

  32. Gardner GM. Posterior glottic stenosis and bilateral vocal fold immobility: diagnosis and treatment. Otolaryngol Clin North Am. Aug 2000;33(4):855-78. [Medline].

  33. Goodwin WJ Jr, Isaacson G, Kirchner JC, et al. Vocal cord mobilization by posterior laryngoplasty. Laryngoscope. Aug 1988;98(8 Pt 1):846-8. [Medline].

  34. Grahne B, Poppius H, Viljanen AA, et al. Surgical treatment of chronic laryngeal stenosis secondary to vocal cord paralysis: pre and postoperative evaluation of ventilatory function. Laryngoscope. Feb 1983;93(2):163-7. [Medline].

  35. Gray SD, Kelly SM, Dove H. Arytenoid separation for impaired pediatric vocal fold mobility. Ann Otol Rhinol Laryngol. Jul 1994;103(7):510-5. [Medline].

  36. Hartl DM, Brasnu D. [Recurrent laryngeal nerve paralysis: current knowledge and treatment]. Ann Otolaryngol Chir Cervicofac. Mar 2000;117(2):60-84. [Medline].

  37. Hillel AD, Benninger M, Blitzer A, et al. Evaluation and management of bilateral vocal cord immobility. Otolaryngol Head Neck Surg. Dec 1999;121(6):760-5. [Medline].

  38. Holinger LD, Holinger PC, Holinger PH. Etiology of bilateral abductor vocal cord paralysis: a review of 389 cases. Ann Otol Rhinol Laryngol. Jul-Aug 1976;85(4 Pt 1):428-36. [Medline].

  39. Inomata S, Nishikawa T, Suga A, et al. Transient bilateral vocal cord paralysis after insertion of a laryngeal mask airway. Anesthesiology. Mar 1995;82(3):787-8. [Medline].

  40. Isaacson G, Moya F. Hereditary congenital laryngeal abductor paralysis. Ann Otol Rhinol Laryngol. Nov-Dec 1987;96(6):701-4. [Medline].

  41. Jackson C. Ventriculocordectomy. Arch Surg. 1922;4:257-74.

  42. Kashima HK. Bilateral vocal fold motion impairment: pathophysiology and management by transverse cordotomy. Ann Otol Rhinol Laryngol. Sep 1991;100(9 Pt 1):717-21. [Medline].

  43. Lacy PD, Hartley BE, Rutter MJ, et al. Familial bilateral vocal cord paralysis and Charcot-Marie-tooth disease type II-C. Arch Otolaryngol Head Neck Surg. Mar 2001;127(3):322-4. [Medline].

  44. Lichtenberger G, Toohill RJ. Technique of endo-extralaryngeal suture lateralization for bilateral abductor vocal cord paralysis. Laryngoscope. Sep 1997;107(9):1281-3. [Medline].

  45. Neuschaefer-Rube C, Haase G, Angerstein W, et al. [Unilateral recurrent nerve paralysis in suspected Lyme borreliosis]. HNO. Mar 1995;43(3):188-90. [Medline].

  46. Rahbar R, Valdez TA, Shapshay SM. Preliminary results of intraoperative mitomycin-C in the treatment and prevention of glottic and subglottic stenosis. J Voice. Jun 2000;14(2):282-6. [Medline].

  47. Reker U, Rudert H. [Modified posterior Dennis and Kashima cordectomy in treatment of bilateral recurrent nerve paralysis]. Laryngorhinootologie. Apr 1998;77(4):213-8. [Medline].

  48. Rimell FL, Dohar JE. Endoscopic management of pediatric posterior glottic stenosis. Ann Otol Rhinol Laryngol. Apr 1998;107(4):285-90. [Medline].

  49. Sanders I. Electrical stimulation of laryngeal muscle. Otolaryngol Clin North Am. Oct 1991;24(5):1253-74. [Medline].

  50. Sofferman RA, Haisch CE, Kirchner JA, et al. The nasogastric tube syndrome. Laryngoscope. Sep 1990;100(9):962-8. [Medline].

  51. Sommer DD, Freeman JL. Bilateral vocal cord paralysis associated with diabetes mellitus: case reports. J Otolaryngol. Jun 1994;23(3):169-71. [Medline].

  52. Strong MS, Healy GB, Vaughan CW, et al. Endoscopic management of laryngeal stenosis. Otolaryngol Clin North Am. Nov 1979;12(4):797-805. [Medline].

  53. Terris DJ, Arnstein DP, Nguyen HH. Contemporary evaluation of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg. Jul 1992;107(1):84-90. [Medline].

  54. Wani MK, Yarber R, Hengesteg A, et al. Endoscopic laser medial arytenoidectomy versus total arytenoidectomy in the management of bilateral vocal fold paralysis. Ann Otol Rhinol Laryngol. Nov 1996;105(11):857-62. [Medline].

  55. Whited RE. Posterior commissure stenosis post long-term intubation. Laryngoscope. Oct 1983;93(10):1314-8. [Medline].

  56. Woodson BT, McFadden EA, Toohill RJ. Clinical experience with the Lichtenberger endo-extralaryngeal needle carrier. Laryngoscope. Sep 1991;101(9):1019-23. [Medline].

  57. Zalzal GH. Posterior glottic fixation in children. Ann Otol Rhinol Laryngol. Sep 1993;102(9):680-6. [Medline].

  58. Zeitels SM. The evolution of the assessment and treatment of paralytic dysphonia. Otolaryngol Clin North Am. Aug 2000;33(4):803-16. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

vocal, vocal fold paralysis, vocal cords, vocal cord, bilateral vocal fold paralysis, bilateral vocal cord paralysis, bilateral vocal cord immobility, vocal cord paralysis, bilateral vocal fold immobility, BVFP, BVFI, recurrent laryngeal nerve, cricoarytenoid joint, bilateral vocal fold

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Joel A Ernster, MD, Active Staff, Penrose-St Francis Healthcare System; Active Staff, Memorial Health System; Clinical Instructor, University of Colorado Health Sciences Center
Joel A Ernster, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Rhinologic Society, Colorado Medical Society, and Triological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Arturo Avila Chavez, MD, Assistant Professor, Department of Otolaryngology and Head and Neck Surgery, Instituto Nacional De Enfermedades Respiratorias of Mexico City
Disclosure: Nothing to disclose.

Douglas Skarada, MD, Consulting Staff, Department of Otolaryngology, Salem Hospital
Disclosure: Nothing to disclose.

Medical Editor

Clark A Rosen, MD, Director, University of Pittsburgh Voice Center; Associate Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine
Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Pennsylvania Medical Society
Disclosure: Bioform Medical  Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York, Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society
Disclosure: GE Healthcare Honoraria Review panel membership

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.