Bilateral Vocal Fold Paralysis Treatment

Dr. Erami M.D.ENT Resident

Department Of ENTShahid Sadoghi Hospital

Yazd Iran

•The Paralysis:• a complete denervation of the vocal fold with no motor

activity, as proven by EMG.

•The Paresis :• there is some residual nerve function, as is most often the case.

•Vocal fold immobility :• a broad term encompasses impaired motion from either a neurogenic or

a rare mechanical cause such as:

• arytenoid dislocation

• joint fixation

• web formation.

•Evaluation of Bilateral Vocal Cord Immobility

• It is a sign of disease and not a diagnosis

• common problem found in the practice of Otolaryngology

• Bilateral vocal cord immobility can be :• life threatening for some patients

• Others, who have an open glottic chink, may have :• breathy dysphonia• intermittent dyspnea• Stridor

•Evaluation of Bilateral Vocal Cord Immobility

• weakness or paradoxical motion of the vocal cords mimics paralysis (similar signs and symptoms) that include :

• central nervous system diseases

• neuromuscular disorders

• Laryngospasm

• cricoarytenoid joint immobility or interarytenoid scar

• psychogenic disorders

The causes of vocal fold paresis :

Trauma

Idiopathic

Tumor

neurologic

medical diseases

Surgical/Traumatic: (20% cases)

Thyroidectomy

Pneumonectomy

CABG

Penetrating neck or chest trauma

Post intubation

Whiplash injuries

Posterior fossa surgery

•RECURRENT LARYNGEAL NERVE• Rt. Recurrent laryngeal nerve

arises from the Vagus nerve at the level of Subclavian artery, hooks round it & then ascends between the trachea & oesophagus.

• The Lt. Recurrent laryngeal nerve arises from the Vagus in the Mediastinum at the level of Arch of aorta, loops round it & then ascends into the neck in the tracheo-oesophageal groove.

• Thus, Lt. Recurrent Laryngeal Nerve has a much longer course which makes it more prone to paralysis as compared to the right one.

•Unilateral Recurrent Laryngeal Nerve Injury

Nonfunction of the intrinsic muscles of the larynx on the affected side

loss of abduction with intact adduction by cricothyroid

the vocal cord to assume a paramedian position

The voice is breathy but compensation occurs, though rarely back to normal

The airway is adequate and may become compromised only with exertion.

•Bilateral Recurrent Laryngeal Nerve Injury :

Usually result of damage to both RLN.

Cords lie in paramedian position

Variable degree of stridor

Position of vocal cords :

All the intrinsic muscles of larynx are

paralysed, vocal cords lie in median or

paramedian position due to unopposed

action of cricothyroid muscles.

Action of cricothyroid muscleslengthening (increasing tention) of vocal ligaments

Ext. superior laryngeal N.

•Managemen Bilateral Abductor Paralysis :

Preservation of airway is most important goal

Patients exhibit lack of abduction during inspiration

but good phonation

ExpirationInspiration

• Treatment Bilateral Abductor Paralysis :

Usually 6 months is an adequate time to wait for any spontaneous recovery

Tracheostomy Golden standard Most adult will require this (In acute stridor ) Speaking valves aid in phonation

Laser cordectomy

Laser cordotomy

Vocal cord lateralisation through endoscope

Thyroplasty type II

arytenoidectomy

Phrenic to Posterior Cricoarytenoid anastomosis Allows abduction during inspiration

Electrical Pacing Timed to inspiration with electrode placed on posterior cricoarytenoid Long-term efficacy not yet shown

• Reinnervation at the level of the RLN trunk can provide improvement in laryngeal muscle tone and mass.

• Because of the difficulty in obtaining cyclical motion of the vocal folds in coordination with respiration, reinnervation at the level of the nerve trunk has not gained wide acceptance as a clinical modality in bilateral vocal cord paralysis.

• The two most common reinnervation techniques:• neuromuscular pedicle (NMP)• ansa cervicalis to RLN (ansa-RLN) anastomosis/transfer.

• The neuromuscular pedicle (NMP) technique:• transfer a nerve with a portion of its motor units intact to a

denervated muscle.• The NMP can be considered for any patient with bilateral vocal

fold paralysis that has persisted for 6 months to 1 year.

• the most common contraindication for NMP procedure :

• Fixation or limitation of the cricoarytenoid joint (1/3)

•prior to proceeding with the NMP procedure :• Direct laryngoscopy and palpation of the arytenoids is

recommended(Mechanical fixation and neurogenic paralysis are differentiated )

• ansa-RLN anastomosis/transfer :• The ansa cervicalis nerve and its insertion into the appropriate

strap muscle must be available for this technique. In practice, only half of patients are suitable candidates.

•Ansa-RLN transfer is Absolute contraindication in bilateral vocal fold paralysis.

• Laser Posterior Cordotomy: Is it a Good Choice in Treating Bilateral Vocal Fold Abductor Paralysis?

Mahmoud A. Khalil and Hazem M. Abdel Tawab (May 27, 2014 )

A prospective study was done on 18 patients with bilateral abductor vocal fold paralysis.

• RESULTS:

• All patients showed improvement of dyspnea

• most of the patients suffered from mild to moderate dyspnea in the immediate post-operative period

• two patients needed another intervention to solve it.

• All the patients had satisfactory results of their voice after the operation

• one patient only suffered from temporary aspiration.

•CONCLUSION:

•Unilateral CO₂ laser posterior cordotomy is an easy and effective procedure to solve the dyspnea after bilateral vocal fold abductor paralysis without :

•Aspiration

• significant voice alteration.

•Management of Bilateral Vocal Fold Paralysis: Experience at the University of Athens

During the last 5 years, we have treated 20 patients (8 men and 12 women)

patients are treated with:

a partial posterior cordectomy of one or both true and false vocal folds with the CO2 laser (15 patients) and the KTP-532 laser (5 patients)

An elective tracheotomy was done before the cordotomy.

Complications were minimal (such as infection, stridor, or dyspnea)

Although no objective voice analysis was performed :

all patients were able to communicate without any phonation devicwere satisfied with the result of the surgery.

the advantages offered by the posterior cordectomy included : rapidity and simplicity in concept reliability of outcome short hospitalization low risk of complications the possibility for revision when necessary (posterior cordectomy)

From the successful postsurgical results of this study, it can be concluded that : the posterior cordectomy is a reliable treatment option,

for the management of patients withbilateral vocal fold paralysis.

• ARYTENOIDCORDECTOMY FOR BILATERAL VOCAL CORD PARALYSIS: PRIMARY AND REVISION PROCEDURE (Ivan et al. 2015)

• Methods:• Four adult patients with bilateral recurrent nerve paralysis were

subjected to submucosal arytenoidcordectomy through a thyreofissure approach with ventricular folds transposition and long-term translaryngeal stenting.

• Follow-up ranged from 8 to 28 months• Results: • In all patients tracheostomy closure was achieved. Midterm follow-

up revealed stable airway,adequate for the patients’ routine physical activities.

• Postoperatively patients phonated with the ventricular folds and the resulting voice quality was good.

• We describe a novel approach for management of impaired airway because of bilateral recurrent nerve paralysis and/or stenosis.

• It comprises intralaryngeal soft tissue resection, enlargement of the cartilaginous framework of the larynx and long-term translaryngeal stenting.

• The surgical approach described here proved to be successful both in patients with simple bilateral vocal fold motion impairment and in those, who have been already unsuccessfully treated with other surgery.

• Nevertheless the technique should be regarded as an option

only in complicated revision cases, rather than a primary intervention in bilateral vocal fold paralysis.

Translaryngeal stenting with a rigid

T-Tube. The upper end lies just above the

ventricular

folds. The horizontal limb passes between

the thyroid laminae

• In three patients the stent was left in place for 3 months and an other patient (with multiple operations in the neck and thorax and 3 endoscopic CO2 laser cordotomies) the stent was left in place for 6 months.

• Stent removal was done under local anesthesia

•No suturing of the wound was done.

• this second incision closed spontaneously within a week.

•Bilateral vocal fold immobility: a 13 year review of etiologies, management and the utility of the empeyindex

• at St. Michael’s Hospital, University of Toronto, a tertiary referral centre for laryngology (Maria K. Brake and Jennifer Anderson 2015)

• A total of 48 patients with bilateral vocal fold immobility were identified

• Management depends on :

• respiratory performance

• airway patency

• vocal ability

• quality-of-life priorities

• Empey index (EI) and the Expiratory Disproportion Index (EDI) are evaluated as an objective monitoring tools for BVFI patients.

• Determining the need for surgery can be difficult (due to the variability in etiology, symptoms and limited BVFI patient population).

• Empey Index (EI) :The index is the ratio of forced expiratory volume in 1 s (FEV1) in milliliters to the peak expiratory flow rate (PEFR) in litres per minute.

• In the setting of upper airway stenosis, the ratio increases (greater than 10 and a mean of 14).

• In normal subjects and in patients with lung diseases (asthma, chronic bronchitis and others) the EI ratio was found to be less than 10 (ml/l/min).

• Conclusion:

• Adequate airway management using endoscopic cordotomies/arytenoidectomy can achieve :• symptom improvement and decannulation for the majorityof patients.

(Twenty-one patients underwent endoscopic arytenoidectomy/cordotomy).

• CPAP ventilation can be a useful adjunct for those patients who continue to experience upper airway obstruction while sleeping.

• The decision to treat is based on :• the severity of symptoms• Functionality• patient priorities.

• A Ten-Year Kuala Lumpur Review on Laser Posterior Cordectomy for Bilateral Vocal Fold Immobility

(Azman Mawaddah et al. 2016 )

• 31 patients with BVFI were referred for surgery.

• Tracheostomy remains the most effective management, especially in airway-compromised patients. However, it is not usually accepted by the patients as a long-term solution.

• Endolaryngeal laser posterior cordectomy is an alternative to tracheostomy, both as an emergent management for patients with airway compromise and a definitive management for tracheostomisedpatients for BVFI.

• The patients were divided into two groups and CO2 LASER was used in all cases :• tracheotomised (TT) 12 patients•nontracheotomised (NTT) 19 patients

•CO2 LASER was used to create a horizontal incision at the posterior third of the vocal cord • A triangular area posterior to the incision marked was

subsequently ablated • The patients were seen routinely at 1 month post

operatively, and then at 3 and 6 months depending on the outcome of the procedure.

A horizontal incision is performed at the posterior third of the vocal cord

A triangular shaped area posterior to the incision was ablated

Endoscopic view of the larynx intraoperatively showing the resultant airway created

• In the NTT group, laser cordectomy was 100% successful (19 out of 19 patients) in avoiding a tracheostomy.

• Out of the 12 patients of the TT group, 10 (83.3%) were successfully decannulated.

• Immediately after an event of paralysis :

• the vocal folds are in a cadaveric position, with poor closure during phonation.

• However, after a few months, the paralysed vocal folds tend to move medially with improved glottal closure and voice but increasing stridor.

•Clinical significance and novelty of this study

• Laser posterior cordectomy is an excellent and reliable procedure in relieving upper airway obstruction caused by BVFI.

• It results in a significant improvement of the post operative airway resistance obviating the need of tracheostomy

• The phonatory outcome is not predictable with either surgical outcome.

•Clinical significance and novelty of this study

• Endolaryngeal laser posterior cordotomy and arytenoidectomy are equally effective and reliable in the management of the restricted airway.

• Subclinical aspiration developed in the patients who had undergone arytenoidectomy. On the contrary, none of the patients in the cordectomy group experienced aspiration .

• Endolaryngeal laser cordectomy is advantageous compared to other procedures because of its

• rapidity and simplicity in concept. • It has a low risk of complications• there is always a possibility of revision when necessary.

• Bilateral posterior cordectomy is commonly performed as a revision procedure due to inadequate airway and insufficient respiration after a unilateral procedure

• unilateral posterior cordectomy was successful in 75% • bilateral (one-step procedure in 17 patients)reported excellent

results in improving respiratory function and preserving acceptable voice quality without causing aphonia.

• There is no absolute rule on whether to perform the bilateral procedure as a one step procedure or unilateral procedure as a two-step procedure.

• Therefore, a bilateral two-step procedure may be the preferred choice in :

•patients who have tracheostomy, which indicates they have a smaller glottic aperture compared to those who do not need tracheostomy.