The combined endoscopic CO2 laser posterior cordectomy and total arytenoidectomy for treatment of bilateral vocal cord paralysis

The combined endoscopic CO₂ laser posterior cordectomy and total arytenoidectomy for treatment of bilateral vocal cord paralysis Upper airway obstruction, because of bilateral vocal cord paralysis, presents a serious challenge to the Otolaryngologist. Various surgical techniques have been advocated for the management of patients with vocal cord paralysis. Among these techniques, the individual use of laser CO₂ arytenoidectomy and posterior cordotomy has gained wide acceptance. In this report, we describe our experience in the management of bilateral vocal cord paralysis by combining posterior partial cordotomy as described by Dennis and Kashima, with total arytenoidectomy as described by Ossoff et al. We report the long‐term results in the management of 18 patients treated in our department during the last 8 years.     

The combined endoscopic CO(2) laser posterior cordectomy and total arytenoidectomy for treatment of bilateral vocal cord paralysis

Upper airway obstruction, because of bilateral vocal cord paralysis, presents a serious challenge to the Otolaryngologist. Various surgical techniques have been advocated for the management of patients with vocal cord paralysis. Among these techniques, the individual use of laser CO(2) arytenoidectomy and posterior cordotomy has gained wide acceptance. In this report, we describe our experience in the management of bilateral vocal cord paralysis by combining posterior partial cordotomy as described by Dennis and Kashima, with total arytenoidectomy as described by Ossoff et al. We report the long-term results in the management of 18 patients treated in our department during the last 8 years.     

低温等离子单侧声带离断并同侧杓状软骨切除术治疗双侧声带外展麻痹

目的 探讨在内镜支撑喉镜辅助下, 采用低温等离子消融刀头行单侧声带离断加同侧杓状软骨切除术治疗双侧声带外展麻痹的疗效。方法 对双侧声带外展麻痹的患者19例, 采用低温等离子消融术行单侧声带离断加同侧杓状软骨切除术进行治疗, 术后随访6～42个月, 分析评估该术式的临床效果。结果 19例术后呼吸功能恢复满意, 术后1个月内安全拔管18例, 其中术前已行气管切开8例。术后瘢痕挛缩喉腔狭窄未能拔管者1例, 经再次手术行对侧杓状软骨切除后成功拔管。嗓音评估发声效果满意14例, 轻微下降但患者能接受4例, 行2次手术者声嘶较前明显加重1例。结论 低温等离子单侧声带离断及同侧杓状软骨切除术治疗双侧声带外展麻痹, 术后呼吸困难完全缓解, 拔管率高, 发声功能保留良好。此术式创伤小, 术后愈合快, 安全、有效、微创。     

CO2激光杓状软骨声带突切除与肌腱切断治疗双侧声带外展麻痹

目的：探讨CO2激光杓状软骨声带突切除与肌腱切断治疗双侧声带外展麻痹的应用价值。方法：回顾性分析18例因甲状腺切除术后双侧声带外展麻痹的临床资料,术前预防性气管切开后,行CO2激光杓状软骨声带突切除与肌腱切断术。结果：18例患者术后即可经口鼻呼吸,其中15例于术后8周内拔管;3例于术后4～6周因局部肉芽组织增生再次激光手术后拔管;所有患者随访1．6～2．3年,无呼吸困难及误吸,对发声满意。结论：CO2激光杓状软骨声带突切除与肌腱切断,可有效改善双侧声带外展麻痹造成的呼吸困难,并取得较满意的发声,以及避免误吸。     

Emergency endoscopic vocal cord lateralization as an alternative to tracheotomy for patients with bilateral abductor vocal cord paralysis

This study aimed at evaluating the results of emergent endoscopic permanent vocal cord lateralization instead of tracheotomy in patients with bilateral vocal cord paralysis who were admitted to the emergency service. Retrospective analysis was done of 13 patients with bilateral vocal cord paralysis admitted to emergency service with severe dyspnea. Patient information, paralysis etiology, operation times and follow-up data were reviewed. All 13 patients who underwent this procedure were females and the ages were ranging from 38 to 69 (average 52). Bilateral vocal cord paralysis was a result of thyroid surgery in all. Thyroid surgery was performed 8?months to 10?years (mean 41?months) before being admitted to the emergency service. The duration of procedure from intubation to closing skin incision ranged from 20 to 50?min (average 34?min). Patients were followed for a duration of 3?months to 10?years (average 24?months). In 12 of the patients adequate glottis chink was obtained and recovery from general anesthesia was uneventful without a need for tracheotomy. In one case, catheter placement was done with difficulty and a tracheotomy was performed as a temporary measure. Endoscopic vocal cord lateralization with submucosal cordectomy is a reliable alternative to tracheotomy even in emergency conditions for bilateral abductor vocal cord paralysis. Adequate air can be obtained in majority of cases and long term patency is satisfactory.     

Human laryngeal reinnervation: the Northwestern experience

Recent publications have reported impressive success with laryngeal reinnervation utilizing a nerve-muscle pedicle. This innovative surgical procedure is claimed to be useful for unilateral and bilateral vocal cord paralysis. Although the surgical results reported by Tucker have been good, they have lacked corroboration from other centers. We have performed six laryngeal reinnervation procedures at Northwestern University Medical School. Four patients presented with bilateral vocal cord paralysis and two patients with unilateral paralysis. All six operations were successful in restoring vocal cord function. The technique, problems, and results are discussed. Our experience supports the initial reports of success with this new operation.     

单侧声带横断与声带部分切除术治疗双侧声带外展麻痹

目的探讨用单侧声带横断与声带部分切除术治疗双侧声带外展麻痹的疗效与临床应用价值。方法对9例继发性双侧声带外展麻痹的患者,采用支撑喉镜下单侧声带横断与声带部分切除术进行治疗,通过术后的观察随访,对该术式的临床效果进行分析与评估。结果8例患者气管切开后行单侧声带横断与声带部分切除术,其中7例患者术后2个月安全拔管,1例不能拔管的患者经过再次手术2个月后安全拔管;另1例I度呼吸困难患者经口气管内插管后行声带手术。所有患者行单侧声带横断与声带部分切除术后随访半年以上呼吸困难完全缓解;术后声嘶程度均较前加重,但不影响日常的生活交流。结论单侧声带横断与声带部分切除术治疗双侧声带外展麻痹的方法,不需要昂贵器械,简单实用,临床疗效良好,并发症少,值得在基层医院中推广应用。     

Obstructive sleep apnea syndrome and snoring in patients with bilateral vocal cord paralysis

The analysis of the correlation between bilateral vocal cord paralysis and the occurrence of obstructive sleep apnea syndrome and snoring is presented. The aim of the study was to establish whether the decrease of the air flow in the upper airway in patients with bilateral vocal cord paralysis involves OSAS and/or snoring occurrence and whether arytenoidectomy affects an improvement of breathing parameters measured during sleep. Fourteen patients with bilateral vocal cord paralysis underwent Poly-MESAM examination before and 3 months after arytenoidectomy. They had never complained of snoring before. The Epworth sleepiness scale was used to quantify excessive daytime somnolence. The RDI, DI, mean saturation and percentage of snoring, loud snoring and sleep without snoring were estimated and compared pre- and postoperatively. The results were compared by the Student's t-test for dependent values. No significant differences were shown between the Epworth scores before and after the treatment. The RDI, DI and mean saturation were normal before and after the operation. The percentage of loud snoring decreased and the percentage of sleep without snoring increased significantly after arytenoidectomy in both cases. The mechanism of snoring in patients with vocal cord paralysis seems to be similar to OSAS. The difference consists in the level of flow limitation. On the basis of the results there is no reason to diagnose OSAS and UARS in patients with bilateral vocal cord paralysis. On the other hand, the intensive snoring that occurs after paralysis was significantly reduced as a result of arytenoidectomy.     

Treatment of bilateral vocal cord paralysis following permanent recurrent laryngeal nerve injury

Bilateral vocal cord paralysis is a serious illness requiring emergency intervention to resolve the potentially life-threatening respiratory distress. Several surgical procedures were proposed to help improve the airway and to eliminate the tracheostoma in those patients with permanent paralysis. All the procedures have their own advantages and disadvantages. We conducted a retrospective study of 30 patients affected by bilateral vocal cord paralysis following total thyroidectomy. All the patients underwent total thyroidectomy for benign thyroid pathology. In 26 patients (86.6%), cord paralysis occurred during the perioperative stage; and in the remaining 4 cases (13.3%), it occurred within the following 6 months. We treated all these bilateral recurrent laryngeal nerve paralysis patients with arytenoidectomy alone in 5 patients and arytenoidectomy with concomitant true and false posterior cordectomy in the remaining 25 patients. Twenty-four of the 25 patients who underwent the combined procedures (96%) reported subjective respiratory improvement and were decannulated within 60 days, being able to return to their normal daily activities. This study demonstrates that arytenoidectomy associated with posterior cordectomy is a satisfactory surgical treatment of bilateral vocal cord paralysis because it leads to a considerable and stable enlargement of the breathing space.     

Vincristine-induced recurrent laryngeal nerve paralysis.

Vincristine-sulfate-related vocal cord paralysis has been reported infrequently in the literature. The neurotoxicity of the vinca alkaloids is well-known; however, the potential for cranial nerve involvement is not widely recognized. Given the complexity of the typical patient receiving such a chemotherapeutic agent, the potential for misdiagnosis is high. Many patients have primary tumors or metastatic lesions in sites that could cause the clinician to overlook this reversible cause of neurologic dysfunction. This study describes the first three reported pediatric cases of vincristine-induced vocal cord paralysis. Two patients developed increasing stridor secondary to bilateral vocal cord paralysis; the third developed a unilateral vocal cord paralysis. All resolved spontaneously upon withdrawal of the vincristine. Vinca-alkaloid-induced vocal cord paralysis is a potentially dangerous but reversible lesion. Otolaryngologists should be aware of the association between these agents and cranial nerve neuropathies.     

声带后端切开术

目的 探讨声带后端切开术治疗双侧声带麻痹的疗效.方法 2009年1月～2010年6月共5例双侧声带麻痹患者在我院住院行声带后端切开术治疗.单侧声带后端切开术3例,双侧声带后端切开术2例.女性4例,男性1例,年龄30～68岁,甲状腺手术后双侧声带麻痹4例,颈部外伤后双侧声带麻痹1例.入院前已行气管切开3例,要求拔管而人院...     

Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis

Most patients with bilateral vocal cord paralysis have a fairly satisfactory voice, but their airway is usually compromised. The management of such patients presents a challenge to the otolaryngologist-head and neck surgeon. Numerous surgical procedures have been developed in an attempt to improve the patients's airway insufficiency without leaving him with a breathy, weak voice. Arytenoidectomy is currently the most reliable method of treating patients with bilateral vocal cord paralysis. Although both endoscopic and external approaches have been described for performing an arytenoidectomy, the endoscopic technique is more desirable since it requires no incision and theoretically allows for the immediate assessment of airway size. The addition of the CO2 laser to the surgical armamentarium offers certain refinements to the technique of endoscopic arytenoidectomy. Eleven patients with bilateral vocal cord paralysis of the larynx have been treated by endoscopic laser arytenoidectomy by the authors utilizing a technique developed by the two senior authors and subsequently taught to over 200 participants of the CO2 laser workshops sponsored by the Department of Otolaryngology-Head and Neck Surgery at Northwestern University Medical School; 10 of the 11 patients have been successfully decannulated. The technique and problems of this operation will be discussed.     

双声带楔形切除术治疗双侧声带外展麻痹

目的：探讨治疗双侧声带外展麻痹的微创外科手术方式——显微支撑喉镜下CO2激光双声带楔形切除术的临床应用价值。方法：使用显微支撑喉镜激光手术系统,治疗4例双侧声带外展麻痹患者。结果：3例经过1次手术,1例经过2次手术,随访5-36个月,患者呼吸困难完全缓解,能耐受日常生活活动;4例均对自己的声音较为满意,能进行日常的生活交流。结论：显微支撑喉镜CO2激光双侧声带楔形切除术,不需气管切开,术后喉功能恢复快,并发症少。既能解决患者通气的要求,又能保证发声的质量,本方法治疗双侧声带外展麻痹有很好的临床推广使用价值。     

Neuralgic amyotrophy presenting with bilateral vocal cord paralysis in a child: a case report.

Acute stridor and bilateral vocal cord paralysis is not uncommon in the neonate but is unusual in the older child. We report the first case of bilateral vocal cord paralysis secondary to neuralgic amyotrophy, a peripheral polyneuropathy, in a 5-year-old child. An extensive workup revealed a paralyzed right hemidiaphragm, arm weakness and an EMG pattern consistent with neuralgic amyotrophy. Neuralgic amyotrophy is an uncommon disorder in pediatric patients which may involve cranial and peripheral nerves including the phrenic nerves and rarely the recurrent laryngeal nerves. We propose that the diagnosis be considered in children who present with bilateral vocal cord paralysis and other associated neurologic findings.     

Laryngeal synkinesis: its significance to the laryngologist

Basic research and surgical cases have shown that the injured recurrent laryngeal nerve (RLN) may regenerate axons to the larynx that inappropriately innervate both vocal cord adductors and abductors. Innervation of vocal cord adductor muscles by those axons that depolarize during inspiration is particularly devastating to laryngeal function, since it produces medial vocal cord movement during inspiration. Many patients thought to have clinical bilateral vocal cord paralysis can be found to have synkinesis on at least one side. This will make the glottic airway smaller, particularly during inspiration, than would true paralysis of all the intrinsic laryngeal muscles. Patients with bilateral vocal cord paralysis should undergo laryngeal electromyography. If inspiratory innervation of the adductor muscles is present, simple reinnervation of the posterior cricoarytenoid muscle will fail. The adductor muscles also must be denervated by transection of the adductor division of the regenerated RLN.     

Airway complication after thyroid surgery: minimally invasive management of bilateral recurrent nerve injury

OBJECTIVES: After bilateral vocal cord paralysis, the consequent paramedian position usually necessitates tracheostomy for at least 6 months, when the paralysis is potentially reversible. In the present study a reversible endoscopic vocal cord laterofixation procedure was used instead of tracheotomy. STUDY DESIGN: Prospective study of 15 consecutive patients aged 33 to 73 years who suffered bilateral recurrent laryngeal nerve paralysis after thyroid surgery. METHODS: The operation was performed endoscopically with a special endo-extralaryngeal needle carrier instrument. Two ends of a monofilament nonresorbable thread were passed above and under the posterior third of the vocal cord and knotted on the prelaryngeal muscles, permitting the creation of an abducted vocal cord position. If movement of one or both vocal cords recovered, the suture was removed. Regular spirometric measurements and radiological aspiration tests were conducted on the patients. RESULTS: During the follow-up period of 3 to 40 months, airway stability was demonstrated in all but one patient. After the repeated lateralization procedure, this patient's breathing improved. Partial or complete vocal cord recovery was observed in eight patients. In six patients further voice improvement was achieved when the threads were removed after vocal cord medialization or recovery. Mild postoperative aspirations ceased in the first postoperative days. CONCLUSIONS: This management approach offers an alternative to tracheostomy in the early period of paralysis, avoids terminal loss of voice quality, and provides a "one-stage" solution for permanent bilateral recurrent nerve injuries.     

红宝石激光同期杓状软骨内侧切除治疗双侧声带麻痹

目的 :探讨支撑喉镜下以红宝石激光同期切除双侧杓状软骨内侧治疗双侧声带麻痹的疗效。方法 :全部患者均行气管切开插管麻醉 ,以红宝石激光同期切除双侧杓状软骨的内侧。结果 :无手术并发症。全部患者随访 3～ 13个月 ,呼吸平稳 ,喉内无瘢痕粘连 ,发音明显好转 ,声门呼吸部较术前扩大≥ 4mm。结论 :以红宝石激光同期行双侧杓状软骨内侧切除治疗双侧声带麻痹是切实可行的。     

The influence of laser arytenoidectomy on ventilation parameters in patients with bilateral vocal cord paralysis

Bilateral vocal cord paralysis is a symptom that may lead to serious breathing problems. The treatment of patients with vocal cord paralysis presents a challenge to otolaryngologists. Many techniques have been developed in an attempt to improve the patient's airway insufficiency. The aim of the study was to evaluate the efficacy of the laser total unilateral arytenoidectomy with posterior cordectomy in patients with bilateral vocal cord paralysis. Thrity-six patients (33 females, 3 male) aged between 24 and 76 (mean 52) were treated by laser arytenoidectomy. The flow-volume loop and pletysmography were performed in all patients before and after the operation. Additionally, a group of 15 patients with unilateral vocal cord paralysis was introduced and analyzed as a special control. Based on the relative increase of the parameters after the surgery, the most useful of them were selected for the evaluation. Also, the character of the laryngeal obstruction was defined. Changes in the flow-volume loop before and after surgery were compared by planned comparison in univariate analysis ANOVA/MANOVA with an isolated control group. As the parameters AREA(EX), FEF50, FEF75, PEF and MMEF(75/25) increased most effectively, they appeared to be the most useful in the evaluation. FIV1/FEF1, FEF50/FIF50 and FEV1/FEV(0,5) allowed the definition of the obstruction as an extrathoracic dynamically variable quantity. The resistances measured during pletysmography diminished significantly after surgery. The introduction of the special control group with unilateral vocal cord paralysis showed that despite the significant improvement after surgery, the patients who had been operated on still had a laryngeal obstruction worse than that of patients from the control group. The laser arytenoidectomy is shown to be a useful and efficacious procedure for bilateral vocal cord paralysis.     

Long-term results with a simple surgical treatment of bilateral vocal cord paralysis

Since 1979, we have treated patients suffering from bilateral vocal cord paralysis with laterofixation of one vocal cord, a simple and comparatively atraumatic method. To evaluate the long-term results of this method of laterofixation, 11 consecutive patients were examined at least 5 years postoperatively regarding breathing capacity, voice function, and swallowing ability. Breathing capacity was assessed by determination of orolaryngeal (upper) airway resistance and spirometry. Voice function was judged by two listening panels. Swallowing ability was studied by barium contrast radiography. Postoperative improvement of breathing capacity was, in most cases, found to be long lasting. Furthermore, there was no deterioration of voice function, nor were there aspiration problems during the postoperative follow-up period. We suggest this method of laterofixation as the treatment of choice in patients suffering from breathing difficulties due to bilateral vocal cord paralysis.     

颈侧进路内镜下喉外单侧杓状软骨次全切除术治疗双侧外展性声带麻痹

目的：探讨提高治疗双侧外展性声带麻痹疗效的手术方法。方法：对13例双侧外展性声带麻痹伴呼吸困难的患者，行气管切开插管、全麻，经颈侧进路内镜下实施喉外单侧杓状软骨次全切除术。结果：手术过程均顺利，术后均未放置扩张子；呼吸和发声功能均恢复满意；拔管时间为8～15d，平均11．5d；术后随访6～36个月，未出现再狭窄、发声质量下降及呼吸困难等并发症。结论：该手术操作简单，术中对声门裂的可控性好，对喉黏膜无损伤，无需放置喉内扩张子；术后喉功能恢复快而满意，是治疗双侧外展性声带麻痹的较好术式。