Vocal cord paralysis, synkinesis and vocal fold motion impairment

Felix Semon's 'laws' of vocal cord paralysis were conceived over a century ago, based on the simple concept that abductor function of the recurrent laryngeal nerve was more vulnerable than adductor function. It is now clear that the neuromuscular pathology of laryngeal innervation is much more complex. Whether the nerve has been cut, crushed, stretched, cauterized or otherwise injured, it is seldom completely transected. There might be no detectable vocal cord movement at laryngoscopy, yet, electromyography usually shows at least some activity because of incomplete denervation and/or developing synkinesis. Electrical silence hardly ever persists forever. Disordered vocal fold movement following nerve injury appears to depend on laryngeal synkinesis with disorganized neuromuscular function caused by misdirected regeneration and aberrant reinnervation, sometimes by adjacent nerves. The severity of the injury, abnormal random reinnervation, scar tissue formation and nerve growth-stimulating and inhibiting factors influence the final position of the vocal fold. For a better understanding of neurolaryngological disorders it is no longer sufficient to think merely in terms of 'vocal cord paralysis'.     

UNILATERAL VOCAL FOLD PARALYSIS: CAUSES,OPTIONS AND OUTCOMES

Background : This study presents the current aetiology of and management options for vocal fold paralysis. Methods : One hundred and eight patients with unilateral vocal fold paralysis, managed by The Sydney Voice Clinic from 1989 to 1996, are reviewed. Aetiology of the palsy was classified as iatrogenic (45 of 108), idiopathic (36 of 108) and other defined causes (27 of 108). Nineteen patients were observed with the rest being managed with speech therapy alone (38 of 108), surgery (24 of 108) or surgery with adjuvant speech therapy (27 of 108). Surgical techniques included vocal fold augmentation (n = 43), thyroplasty (n = 20) and laryngeal re-innervation (n = 12). Results : Overall 78 of 108 patients had restoration of near normal to normal voice with an additional 14 attaining a very good voice or better (voice outcome < 2). Conclusions : Early intervention for symptomatic patients was found to be rewarding and safe. Vocal fold augmentation with autologous fat was particularly successful in achieving sustained improvement of voice.     

Vocal cord paralysis following carotid endarterectomy: The paradox of return of function

In a series of 411 consecutive carotid endarterectomies 29 patients were identified with vocal cord paralysis. All patients were symptomatic, although in many these symptoms were subtle and rapidly resolved. There was a statistically significant predominance of left-sided paralysis. Excluding three patients who died during the initial year of follow-up return of normal voice was noted in 22 patients, but complete return of vocal cord function was present in only 15. Apposition of the contralateral vocal cord against a paralyzed vocal cord allowed for production of normal voice in five patients. Less than 1% of patients remained with symptoms at one year following endarterectomy. We conclude that vocal cord paralysis is a common complication of carotid endarterectomy; the voice becomes an unreliable guide as to its resolution. We recommend laryngoscopic examination of all patients who undergo bilateral carotid endarterectomy.Presented at the Thirteenth Annual Meeting of the New England Society for Vascular Surgery, Dixville Notch, New Hampshire, September 26, 1986.     

Laser tenotomy and vocal process resection for bilateral midline vocal fold fixation

Background: The present retrospective study presents the outcomes of a group of 21 patients with laryngeal obstruction caused by bilateral vocal fold fixation. All of these patients were treated by laser assisted muscle tenotomy and vocal process resection ? a modification of the technique described by Michael and Eugene Rontal in 1994. 1 Methods: Between January 1997 and March 2002 the senior author performed muscle tenotomy and vocal process resection for bilateral vocal fold fixation on 21 patients. Results: The mean follow‐up time was 2.3 years. The technique was successful in achieving an adequate airway and good voice with no aspiration in every case. Conclusions: Laser assisted muscle tenotomy and vocal process resection is a proven treatment for bilateral medial vocal fold fixation with the provision of a good airway, good voice and the avoidance of aspiration.     

Bilateral vocal cord paralysis

A case of bilateral vocal cord paralysis following anterior cervical fusion is described. Although previously documented, this complication does not appear to be widely recognised. An outline for the pathogenesis is suggested. Immediate postoperative vocal cord inspection by the anaesthetist is advocated.     

Autologous fat injection laryngoplasty for unilateral vocal fold paralysis

Background: Fat injection laryngoplasty has been used at the Sydney Voice Clinic for selected cases of unilateral vocal fold paralysis since 1989. Methods: Forty‐five consecutive cases deemed suitable for treatment by this technique are presented in this paper. Results: Mean follow up for this group of patients was 33 months. Over the period of follow up, 39 of the 45 patients achieved normal or near normal voice, with four patients requiring additional surgical intervention. Conclusion: Fat injection laryngoplasty is a quick, simple, inexpensive and reliable procedure, with few complications and good long‐term results in suitable selected cases of unilateral vocal fold paralysis.     

七氟醚与异氟醚麻醉用于支撑喉镜下声带息肉摘除术的比较

目的探讨七氟醚与异氟醚麻醉在支撑喉镜下声带息肉摘除术的临床效果。方法支撑喉镜下声带息肉摘除术患者40例,ASAⅠ～Ⅱ级,随机分为七氟醚组（S组）与异氟醚组（Ⅰ组）,每组20例。两组静注异丙酚2mg／kg、维库溴胺0．05mg／kg,随即S组吸入8％七氟醚或Ⅰ组吸入4．5％异氟醚2min后行气管插管术,术中分别以七氟醚或异氟醚维持麻醉。监测围术期血压、心率、心电图及脉搏氧饱和度等生命体征,记录术毕自主呼吸恢复、拔管及认知恢复的时间。结果麻醉诱导后,S组与Ⅰ组平均动脉压均明显降低,心率加快（P〈0．01）;气管插管后MAP、HR均升高（P〈0．05或P〈0．01）。七氟醚或异氟醚维持麻醉均满足手术要求,两组麻醉苏醒顺利,不良反应少,但S组自主呼吸恢复、拔管及认知恢复的时间均快于Ⅰ组（P〈0．01）。结论七氟醚或异氟醚全麻均适用于支撑喉镜下声带息肉摘除术,七氟醚的麻醉苏醒比异氟醚快。     

Risk factors and outcomes of vocal cord paralysis after lung transplantation – a retrospective cohort study

Vocal cord paralysis (VCP) may complicate thoracic surgery and is associated with increased morbidity and mortality. Among lung transplant (LTx) recipients, chronic pulmonary aspiration can contribute to chronic allograft dysfunction (CLAD). We herein assessed the unknown incidence and clinical impact of VCP in a large LTx cohort. All first‐time bilateral LTx recipients, transplanted between January 2010 and June 2015 were included in a single‐centre retrospective analysis. Bronchoscopy reports were assessed for VCP. Patients exhibiting VCP were compared to propensity score‐matched negative controls regarding CLAD onset and graft survival and secondary end‐points, including inpatient duration and complications; lower respiratory tract infections (LRTI) within 24 months. In total, 583/713 (82%) patients were included in the analysis. A total of 52 (8.9%) exhibited VCP, which was transient in 34/52 patients (65%), recovering after median 6 months (IQR 2–12). Compared to 268 controls, 3‐year graft survival and CLAD‐free survival were non‐inferior in VCP [HR 0.74 (95% CI 0.35–1.57), and HR 0.74 (95% CI 0.39–1.41)] respectively. Duration of hospitalization was similar and no differences in LRTI rates or airway complications were observed. Lower pre‐Tx BMI increased risk for VCP [HR 0.88 (95% CI 0.79–0.99)]. Overall, VCP did not adversely affect graft and CLAD‐free survival and secondary outcomes including LRTIs and hospitalizations.     

Vocal fold paralysis and progressive cricopharyngeal stenosis reversed by cricopharyngeal myotomy

Three infants with progressive upper esophageal stenosis had bilateral vocal fold paralysis. The patients were apparently normal at birth and without neurologic abnormality. Cricopharyngeal myotomy, followed by serial dilatations, relieved esophageal stenosis and restored the swallowing function. Vocal fold mobility, to the authors’ surprise, also recovered after myotomy in 2 patients. Vocal paralysis persisted in the first patient encountered, although this case was complicated by longstanding tracheostomy. Decannulation in this case was successful at 4 years only after arytenopexy and cricoid interposition grafting. Direct laryngoscopy findings showed weak abductive motion of 1 vocal fold at 14-year follow-up. Loss of vocal function secondary to constriction by a cricopharyngeal band has been previously undocumented. The potential reversibility of both vocal paralysis and esophageal stenosis by surgical cricopharyngeal myotomy is of significant clinical importance.     

Vincristine-induced vocal cord paralysis in an infant

We report the development of stridor and dysphagia in a 5-month-old-infant with acute lymphoblastic leukaemia after the administration of four weekly doses of vincristine during induction therapy. Because direct laryngoscopy revealed bilateral vocal cord paralysis, the patient underwent elective intubation. Extubation was performed 7 days later, after direct laryngoscopy confirmed recovery of vocal cord mobility. Vincristine-induced bilateral recurrent laryngeal nerve paralysis is a rare but potentially life-threatening complication. Therefore, it should be suspected when stridor is present, and clinicians should consider visualization of the airway to establish the cause of upper airway compromise in infants receiving vincristine.     

全麻支撑喉镜联合鼻内窥镜与单纯支撑喉镜下治疗声带息肉的疗效比较

目的对全麻支撑喉镜联合鼻内窥镜与单纯支撑喉镜下治疗声带息肉的疗效进行比较,探讨两种方法治疗声带息肉的优劣,为基层医院临床治疗寻求更好的治疗手段。方法选取2009-2013年我院收治的声带息肉患者60例,随机分成治疗组和对照组。治疗组在静脉复合麻醉下采用支撑喉镜联合鼻内窥镜行声带息肉摘除术,对照组则单纯采用支撑喉镜下行声带息肉摘除术,对两组患者手术结果进行评估。结果术后1个月随访,对鼻内窥镜复查结果结合患者的主观声嘶等症状改善情况进行比较,治疗组治愈率达93.3%,明显高于对照组73.3%,两组比较差异有统计学意义（x2=4.320,P〈0.05）。两组手术成功患者术后2-6个月随访均无复发。结论全麻支撑喉镜联合鼻内窥镜治疗声带息肉疗效确切,值得基层临床推广使用。