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Bilateral Vocal Fold Paralysis Treatment & Management

  • Author: Joel A Ernster, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Dec 17, 2015
 

Medical Therapy

Medical management of the inflammatory conditions of the cricoarytenoid (CA) joint (eg, gout) and the laryngeal mucosa (eg, syphilis, tuberculosis) that result in mechanical fixation may improve the patient's airway. Corticosteroids may be effective in several conditions (eg, Wegener granulomatosis, sarcoidosis, polychondritis). Glucose management may help neuropathy due to diabetes mellitus. Reflux management may be helpful in patients with bilateral vocal fold (cord) immobility (BVFI) due to laryngopharyngeal reflux.

Daniel and Cardona reported on the successful use of onabotulinumtoxinA in children with bilateral abductor vocal fold paralysis. The toxin was injected into the cricothyroid muscles of six pediatric patients, five of whom were consequently able to avoid a tracheostomy, with the sixth patient able to undergo decannulation.[11]

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Surgical Therapy

Procedures for bilateral vocal fold immobility (BVFI) due to IA scarring with or without CA ankylosis:

  • Tracheostomy
  • Functional procedures
    • Microflap trapdoor techniques
    • Laryngofissure with posterior cricoidotomy with cartilage grafting and stent placement (or only stent placement)
    • Local mucosal flap reconstruction
    • Excision of the scar and mucosal or skin grafting
  • Static procedures
    • Posterior cordotomy (unilateral or bilateral)
    • Arytenoidectomy (endoscopic or external, partial or complete)
    • Suture lateralization

Procedures for bilateral vocal fold (cord) paralysis (BVFP)

  • Tracheostomy
  • Reinnervation techniques (experimental) [12]
  • Electrical pacing (experimental) [13]
  • Permanent procedures
    • Posterior cordotomy (unilateral or bilateral)
    • Arytenoidectomy (endoscopic or external, partial or complete)
    • Cordopexy, lateralization of the vocal cord
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Intraoperative Details

Procedures for BVFI

This discussion does not specifically address surgical management of glottic fixation other than to warn of the difficulty in differentiating between fixation and paralysis in some patients.

Procedures for BVFP - General algorithm

A general algorithm for the treatment of patients with BVFP is the following: If the patient does not require a tracheotomy for a significantly compromised airway, the first procedure can be unilateral posterior cordotomy. The patient is told that this may not provide a sufficient airway, but it has the least adverse effects on his or her voice. The results may need to be revised, or a medial arytenoidectomy may be considered as the next step. Total arytenoidectomy can be performed if necessary.

Suture lateralization is a newer procedure, and its role has yet to be defined. Laryngofissure with arytenoidectomy is reserved for major reconstructive surgery in patients with a severely compromised airway. Decisions of the appropriate surgical procedure must be based on individual clinical parameters. Four techniques are discussed in further detail: posterior cordotomy or cordectomy, endoscopic limited or complete arytenoidectomy, suture lateralization (Ejnell procedure), and laryngofissure with arytenoidectomy.

Posterior cordotomy or cordectomy

Kashima and Dennis proposed these procedures in 1989.[14] Complications are rare. The procedures are effective and easily repeatable in cases of recurrence. Laccourreye recently reported a 92% decannulation rate with this approach in 25 patients.[15] The procedure is performed as follows:

  • Perform suspension laryngoscopy with any laryngoscope that provides satisfactory glottic exposure and allows use of a carbon dioxide laser with an attached microscope with a 400-mm lens.
  • Ventilate the patient with a laser-resistant tracheotomy tube (ie, jet ventilation) or a small (eg, 6-mm–outside diameter [OD]) laser-resistant endotracheal (ET) tube positioned in the IA region.
  • Use cottonoids soaked in a vasoconstrictor (eg, oxymetazoline) to protect the ET tube and cuff.
  • Set the carbon dioxide laser for continuous delivery at 2-5 W. Use of higher power settings and the superpulse mode also have been described.
  • Make an incision in the posterior true vocal fold (TVF) at the vocal process. This results in a wedge-shaped defect. Extending the incision anteriorly along the ventricle, as some have proposed, is not advised because this leads to deleterious and irreversible effects on the voice.
    Direct laryngoscopic view of larynx after left pos Direct laryngoscopic view of larynx after left posterior cordotomy

Endoscopic limited or complete arytenoidectomy

Ossoff et al first described complete arytenoidectomy via an endoscopic approach in 1984.[16] Subsequent findings from both dog models and patient series suggest that a complete arytenoidectomy is unnecessary to achieve a high decannulation rate. Eckel et al, however, compared arytenoidectomy with posterior cordectomy and found no difference in effectiveness, but the chance for subclinical aspiration in patients who underwent complete arytenoidectomy was increased.[17] The procedure is performed as follows:

  • Expose the larynx with a suspension device that provides a satisfactory view of the posterior glottis. Use a microscope with a 400-mm lens and a laser attachment.
  • Vaporize the mucosa overlying the arytenoid and corniculate cartilage.
  • Vaporize the bulk of the arytenoid without the vocal or muscular process. Preserving the posterior portion of the muscular process attached to the IA muscle reduces the likelihood of posterior commissure scarring.

Suture lateralization (Ejnell procedure)

This technique may be performed alone or with posterior cordectomy, limited arytenoidectomy, or submucosal partial cordectomy. The suture may be placed with the needle inserted from the skin into larynx. This technique is a technically demanding and requires appropriate positioning of the needles and passage of the suture through the needles. The Lichtenberger needle greatly facilitates this approach. This technique may be a reasonable for revision in cases in which additional lateralization of the TVF is desired. The procedure is performed as follows:

  • Position the laryngoscope to allow satisfactory visualization of the entire glottis. Use a microscope with a 400-mm lens and laser attachment.
  • Via the laryngoscope, introduce the laryngeal needle holder.
  • Insert a curved needle while holding a 2-0 polypropylene suture in the distal end of the curved shaft with the plunger within the shaft retracted.
  • Place the shaft into the supraglottic larynx in the middle of the false vocal fold (FVF). Direct the shaft laterally and engage the plunger, directing the needle from the shaft through the mucosa, cartilage, and neck skin. At this point, retrieve the needle.
  • Repeat the procedure in the subglottic larynx by using the same suture.
    Direct laryngoscopic view of a lateralized left tr Direct laryngoscopic view of a lateralized left true vocal fold (TVF) is shown. Use of a Lichtenberger needle holder facilitates vocal fold lateralization. Posterior cordotomy or submucous resection of the vocal fold precedes suturing.

A study by Su et al of a simplified endoscopic suture lateralization procedure indicated that the surgery is effective in patients with bilateral vocal fold paralysis (BVFP). The operation, performed in 20 patients, resulted in adequate respiration in the 19 patients who did not have an artificial airway. In addition, 19 patients had acceptable voice quality, with preoperative voice quality maintained in 14 patients. Eighteen patients suffered mild postoperative aspiration, but only for the first few days.[18]

A cadaveric study by Sztano et al indicated that in cases of posterior glottic stenosis, endoscopic arytenoid abduction lateropexy creates a greater amount of space in the posterior glottic area than does classic vocal cord laterofixation, transverse cordotomy, or arytenoidectomy.[19]

Laryngofissure with arytenoidectomy

A surgical procedure is warranted for patients in whom vocal fold paralysis persists for several years and who are tracheostomy dependent. Bower et al showed that an external arytenoidectomy via a laryngofissure (originally described by Helmus and later by Singer et al in adults[20, 21] ) provides a superior decannulation rate (84%) compared with that of endoscopic laser arytenoidectomy (56%).[22] The procedure is performed as follows:

  • Expose the larynx with a previous tracheotomy by making a curvilinear transverse neck incision through skin and platysma.
  • Create a midline thyrotomy through thyroid cartilage and cricoid cartilage.
  • Visualize the posterior larynx, and inject 1% Xylocaine with 1:100,000 epinephrine into the mucosa over the arytenoids.
  • Make a transverse incision through the mucosa to free the arytenoids from the cricoid and muscles.
  • Achieve hemostasis with bipolar cautery, and close the mucosa with a chromic suture.
  • Place polypropylene lateralization sutures around the TVF, exiting the thyroid lamina and overlying skin.
  • Close the thyrotomy in layers. Close the skin and place a drain.
  • Perform laryngoscopy to confirm positioning of the lateralization sutures.
  • Perform endoscopy after 4 weeks to plan decannulation
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Postoperative Details

Adults

The use of systemic corticosteroids and systemic antibiotics generally are recommended in each of the described endoscopic procedures. Topical fibrin glue may decrease scarring and hasten improved healing at the surgical site.

Children

After a laryngofissure is created with arytenoidectomy, perform periodic endoscopy to determine the need for decannulation or downsizing the tracheostomy tube.

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Complications

The goal of all the described procedures is to restore a glottic airway despite compromised abductor and adductor function. Altered vocal quality and loss of airway protection resulting in poor cough and aspiration are possible consequences of each of these static procedures. All voice parameters are negatively affected as the airway is improved. Once the voice is affected, returning it to its previous condition often is impossible.

These complications develop with varying probabilities based on the degree of airway opening achieved with a specific technique, amount of residual abductor and adductor function, and laryngeal sensation.

Specific complications of posterior cordotomy and endoscopic partial or complete arytenoidectomy include granuloma formation, chondritis of arytenoids, carbon dioxide laser–related fire, IA scar formation, possible aspiration, and a breathy voice.

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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.[14] 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.[16] Remacle et al had the same result in 40 of 41 patients with endoscopic partial arytenoidectomy.[23] Eckel et al compared the results of patients treated with posterior cordotomy with those of a group of patients treated with complete arytenoidectomy.[17] 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.

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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 reported results from the use of a combined procedure in which arytenoid adduction was performed with ansa cervicalis anastomosis to the RLN in a group of patients with UVFP.[24] The patients obtained no benefit from the surgery. Nonetheless, a literature review by Marina et al reported that several promising surgical procedures exist for laryngeal innervation in BVFP.[12] Such techniques, however, remain experimental.

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.

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Contributor Information and Disclosures
Author

Joel A Ernster, MD Active Staff, Chief of Medical Staff, Penrose-St Francis Health System; Medical Director, Penrose Cancer Center; 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, Triological Society, American College of Surgeons, American Head and Neck Society, American Rhinologic Society, Colorado Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Head and Neck Society, American Rhinologic Society, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Clark A Rosen, MD Director, University of Pittsburgh Voice Center; 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, Pennsylvania Medical Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Merz North America Inc<br/>Received consulting fee from Merz North America Inc for consulting; Received consulting fee from Merz North America Inc for speaking and teaching.

Acknowledgements

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.

References
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Direct laryngoscopic view of the larynx in a patient who with bilateral vocal fold immobility (BVFI) is shown. Palpation of the arytenoids revealed cricoarytenoid (CA) joint ankylosis. Close inspection of the interarytenoid space demonstrated interarytenoid scar. This condition is posterior glottic stenosis (PGS).
Direct laryngoscopic view of larynx after left posterior cordotomy
Direct laryngoscopic view of a lateralized left true vocal fold (TVF) is shown. Use of a Lichtenberger needle holder facilitates vocal fold lateralization. Posterior cordotomy or submucous resection of the vocal fold precedes suturing.
 
 
 
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