eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Vocal Fold Paralysis, Bilateral: Treatment

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

Treatment

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.

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)
  • Electrical pacing (experimental)
  • Permanent procedures
    • Posterior cordotomy (unilateral or bilateral)
    • Arytenoidectomy (endoscopic or external, partial or complete)
    • Cordopexy, lateralization of the vocal cord

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 1989.9 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.10 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.

Endoscopic limited or complete arytenoidectomy

Ossoff et al first described complete arytenoidectomy via an endoscopic approach in 1984.11 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.12 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.

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 adults13,14 ) provides a superior decannulation rate (84%) compared with that of endoscopic laser arytenoidectomy (56%).15 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

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.

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.

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
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Further Reading

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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

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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

 
 
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