Bilateral Vocal Fold Paralysis Treatment & Management

Updated: Oct 20, 2020
  • Author: Joel A Ernster, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

Medical management of inflammatory conditions of the cricoarytenoid (CA) joint (eg, gout, rheumatoid arthritis) 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). 

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

It is important to realize that patients with bilateral vocal fold (vocal cord) immobility (BVFI) may present with symptoms ranging from mild inspiratory noise of gradual onset (or no symptoms at all if mild enough) to urgent airway compromise requiring emergent intervention. The wide range in presentation and cause of BVFI makes a discussion of management difficult. Suffice it to say that management of a compromised airway is paramount and takes precedence over other considerations.

Occasionally, patients present with such mild findings and symptoms that watchful monitoring is an effective strategy.

Depending on the patient's presentation, surgical procedures for bilateral vocal fold (cord) paralysis (BVFP) include the following:

  • Tracheostomy
  • Permanent procedures such as posterior vocal fold cordotomy, or partial or complete arytenoidectomy, cordopexy lateralization, and arytenoid abduction lateropexy
  • Less frequent and experimental procedures include reinnervation techniques (experimental) [2]  and electrical pacing (experimental){ref3​}

Surgical procedures for bilateral vocal fold (cord) immobility (BVFI) or posterior glottic stenosis (PGS) due to interarytenoid (IA) scarring, with or without cricoarytenoid (CA) ankylosis, include the following:

  • Tracheostomy
  • Permanent procedures such as cordotomy or arytenoidectomy but that also include microflap removal of the interarytenoid scar, laryngofissure with arytenoidectomy, posterior cricoidotomy with stent and/or graft placement, and endoscopic lateralization techniques; there are also innovative techniques such as placement of a self-retaining interarytenoid spring and cricoarytenoid release

There is some overlap in the choice of these procedures. Recognize, however, that BVFP is a neurologic condition that is potentially reversible and leaves the structure of the larynx intact. Therefore, less destructive procedures are preferable for managing this disorder.

PGS, on the other hand, is caused by structural changes in the larynx; therefore, structurally altering the larynx is often the only way to address the problem.

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Intraoperative Details

A general approach for the treatment of patients with BVFI 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)
  • Laryngofissure with arytenoidectomy.

Posterior cordotomy or cordectomy

Kashima and Dennis proposed these procedures in 1989. [12] 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. [13] 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. [14] 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. [15] 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. [16]

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. [17]

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 [18, 19] ) provides a superior decannulation rate (84%) compared with that of endoscopic laser arytenoidectomy (56%). [20] 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

All 6 patients treated by Dennis and Kashima with a posterior cordotomy achieved a functional airway without a tracheostomy. [12] 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. [14] Remacle et al had the same result in 40 of 41 patients with endoscopic partial arytenoidectomy. [21] Eckel et al compared the results of patients treated with posterior cordotomy with those of a group of patients treated with complete arytenoidectomy. [15] Both techniques were equally effective for achieving a functional airway, but patients treated with complete arytenoidectomy had more subclinical aspiration.

A study by Scatolini et al of pediatric patients with bilateral vocal fold (cord) paralysis (BVFP) indicated that those with idiopathic paralysis were more likely to regain vocal fold mobility (62.5%) than were those whose condition was congenital (44%) or acquired (31%). [22]

The plethora of etiologies in BVFP and PGS and the multiple potential 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. [23] 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 bilateral vocal fold paralysis (BVFP). [2] 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 have prevented widespread adoption of this technology.

In a study of nine symptomatic persons with BVFP who underwent unilateral implantation of a laryngeal pacemaker, Mueller et al found that neurostimulation produced an immediate and stable improvement in peak expiratory flow. Moreover, voice quality and glottal closure during phonation were not negatively affected. [2]

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