The assistance of coblation in arytenoidectomy for vocal cord paralysis

Background: There are many causes for vocal cord paralysis, which can cause difficulty in breathing in serious cases. The common surgical methods for solving vocal cord paralysis include laryngeal splitting or laser surgery, but there are limitations. Plasma radiofrequency ablation is a new treatment with good achievements in clinical applications.

Objective: To investigate the effect of coblation-assisted arytenoidectomy (CSA) in the treatment of bilateral vocal cord paralysis (BVCP).

Methods: All patients had undergone preoperative electrolaryngoscopic examination of the glottidis rima; electronic laryngoscopy can assess the width of the glottis. The purpose of preoperative electronic laryngoscopic evaluation is to assess the width of the glottis, and arytenoid cartilage movement. Unilateral arytenoid cartilage and a section of the vocal cords were removed in all cases.

Results: Of the 14 patients, 13 were successfully extubated after CSA; 1 patient could not be extubated and underwent a second CSA of the contralateral arytenoid cartilage, after which extubation was achieved. All patients were continuously followed up (6 months to 2 years), and all achieved satisfactory results.

Conclusions and significance: CSA can effectively relieve post-CSA dyspnea in patients with BVCP. More patients underwent tracheal cannula extubation after tracheotomy compared with other surgeries.     

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。     

Laser arytenoidectomy for bilateral vocal fold paralysis

Laser arytenoidectomy can be performed via an intralaryngeal approach which preserves airway and voice quality without aspiration. Laser arytenoidectomy is minimally invasive surgery, and a useful surgical procedure for bilateral vocal fold paralysis. CO2 laser arytenoidectomy was performed for 12 cases of bilateral vocal fold paralysis. Recommended methods for this surgical procedure are: 1) Submucous laser arytenoidectomy should be done. 2) To widen the posterior glottis, not only the arytenoid cartilage but also the posterior part of the thyroarytenoid muscle should be removed. 3) Membranous portions of the vocal folds should not be vaporized. 4) The wound should be covered with mucosa with fibrin glue.     

Submucosal cordectomy for laryngeal stenosis

Submucosal cordectomy, an old procedure first described for the treatment of bilateral abductor vocal cord paralysis, was used to relieve glottic or minimal subglottic stenosis in four patients. Three attained adequate airways with no further procedures; one required subsequent dilations for granulation tissue after which decannulation was successfully effected. Although airway restoration has been successful, the resultant voice has been poor, poorer than that usually achieved with arytenoidectomy. When cricoarytenoid scarring precludes arytenoidectomy and lateral vocal cord fixation, an adequate laryngeal lumen can be restored with submucosal cordectomy if sufficient laryngeal cartilage support remains.     

CO2 laser endoscopic subtotal arytenoidectomy for bilateral median vocal cord paralysis]

OBJECTIVE: To delineate the surgical procedures and correlated techniques for endoscopic subtotal arytenoidectomy, as well as to discuss their applications and clinical outcomes. METHODS: CO2 Laser endoscopic unilateral arytenoidectomy was performed in eight cases of bilateral median vocal cord paralysis combined with one stage of mucosal micro-anastomosis. All patients suffered from dyspnea in some extent, of which 5 had the history of thyroidectomy and 2 had traumatic causes following esophagectomy and tracheal surgery respectively. One of patient had unknown cause. Six patients had undergone tracheotomy prior to operation or before their referral to our hospital. The airway was evaluated via fibro-optic laryngoscopy, and the voice quality was assessed subjectively by the patients and the surgeon before and after surgery. RESULTS: Following 5-43 months after the surgery, in all cases the function of airway as well as the acceptable voice quality was successfully restored. The tracheotomy done before operation in six patients was decannulated within the mean time of 44.2 days post-operation. CONCLUSION: The endoscopic approach for CO2 laser unilateral arytenoidectomy may lead to better restoration of an adequate airway and satisfying phonation without postoperative aspiration. Mucosal micro-anastomosis can prevent the formation of granulation or scar tissue thus promotes the healing processes. This procedure is simpler than other ordinary surgical methods, and could be a satisfactory alternation of treatment for bilateral median vocal cord paralysis.     

Impact of vocal cord paralysis on cricoarytenoid joint

To demonstrate structural changes in the cricoarytenoid joint after recurrent laryngeal nerve paralysis, we performed a laboratory investigation of fixed arytenoid cartilages from adult humans obtained during laser surgical arytenoidectomy in cases of bilateral vocal fold paralysis, analyzing the articular cartilage, the joint capsule, and the attached laryngeal musculature. Ten arytenoid cartilages from adult humans were studied by means of histology, as well as scanning and transmission electron microscopy. After long-standing denervation (>6 months), all arytenoid cartilages showed degenerative changes in their joint surface structure at various levels of intensity. The articular surface revealed fibrillation in some places, demasking of collagen fibrils next to the joint surface, and formation of chondrocyte clusters near the joint surface. All specimens also showed muscle atrophy. We conclude that long-standing recurrent laryngeal nerve paralysis does not result in ankylosis of the cricoarytenoid joint, as assumed, but the articular cartilage undergoes structural changes comparable to those in osteoarthritis. Structural changes in the articular cartilage and in the surrounding musculature hamper efforts at joint function recovery, as do procedures aiming solely at either medialization or lateralization of the vocal fold.     

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.     

Laser surgical microlaryngoscopic glottis dilatation in the treatment of recurrent bilateral nerve paralysis. Surgical technique and results

In addition to conventional endoscopic operation procedures for vocal fold lateralisation, laser surgery has been used to perform endolaryngeal arytenoidectomy by individual laryngologists during the past few years. With respect to a regular swallowing function, the endoscopic technique presented in this paper preserves the arytenoid cartilage. Instead, a submucosal cordectomy is performed and the mucosal flap is glued onto the endolaryngeal wound. Tracheostomy is usually not required with this technique. 15 own cases are described, 14 of whom showed a sufficient respiratory result. Indications for endoscopic laser surgery in the treatment of bilateral vocal cord paralysis are discussed.     

CO2激光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CO2 激光单侧杓状软骨次全切除术治疗双侧外展性声带麻痹手术的适应证及临床意义。方法　支撑喉镜下对 8例双侧外展性声带麻痹伴呼吸困难的患者实施了CO2 激光单侧杓状软骨次全切除术和手术创面黏膜吻合术。其中 ,继发于双侧甲状腺切除术 5例 ,外伤所致双侧外展性声带麻痹 2例 ,原因不明 1例。术前接受气管造口术 5例 ,气管切开术 1例。术后通过纤维喉镜检查患者新建声门裂的通气情况 ,发音质量主观评估由患者本人和医疗小组共同完成。结果8例患者术后均恢复了满意的呼吸功能 ,发音质量均无明显下降 ,平均气管套管拔除时间为 44 2d。术后随访 5～ 43个月 ,没有出现误吸和再狭窄等并发症。结论　支撑喉镜下CO2 激光单侧杓状软骨次全切除术和创面黏膜吻合术简单易行 ,创面小 ,术后愈合快 ,可避免肉芽组织增生和瘢痕形成所导致的声门区再狭窄 ,患者的呼吸和发音功能均得到了满意的恢复和保留     

支撑喉镜下CO2激光杓状软骨切除术治疗双声带外展麻痹

目的 探讨支撑喉镜下ＣＯ２激光显微杓状软骨切除术治疗双声带外展麻痹的手术方法、疗效和适应证。方法１９９４￣１９９８年收治双声带外展麻痹患者８例,其中３例曾在外院经颈外进路手术失败,全部术前行气管切开术。参照并改良Ｏｓｓｏｆｆ窥镜下杓状软骨切除术,汽化杓状软骨前部,包括声带突和部分肌突,一小部分室带及声带后端,保留粘软骨膜并缝合切口,以消灭创面,双侧分次手术。结果 术后无肉芽滋生,无误吸,保留发音功     

支撑喉镜下CO2激光杓状软骨切除术治疗双声带外展麻痹

目的　探讨支撑喉镜下CO2 激光显微杓状软骨切除术治疗双声带外展麻痹的手术方法、疗效和适应证。方法　 1994～ 1998年收治双声带外展麻痹患者 8例 ,其中 3例曾在外院经颈外进路手术失败 ,全部术前行气管切开术。参照并改良Ossoff窥镜下杓状软骨切除术 ,汽化杓状软骨前部 ,包括声带突和部分肌突 ,一小部分室带及声带后端 ,保留粘软骨膜并缝合切口 ,以消灭创面 ,双侧分次手术。结果　术后无肉芽滋生 ,无误吸 ,保留发音功能。 5例拔管 ,2例日间堵管、因睡眠时喉鸣未予拔管 ,1例等待对侧手术。随诊 6个月～ 3 5年。结论　本方式弥补了单纯窥镜及外科手术不足 ,如粘膜出血、水肿、操作困难等 ,而具备显微外科精细、准确的特点。术后反应轻微 ,保留发音功能。并可作为杓状软骨切除术或神经再支配手术失败后的补充手术     

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。     

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。     

Extraluminal arytenoid reconstruction: laryngeal framework surgery applied to a pediatric problem

Laryngeal framework surgery has proved to be an important alternative in the treatment of vocal cord paralysis in adults. We have modified one of these operations in order to manage debilitating aspiration in a 14-year-old boy. His laryngeal incompetence resulted from a severe neurologic injury and laryngeal scarring from a unilateral arytenoidectomy and multiple Teflon injections. To help him, we studied a series of pediatric larynges and devised an operation that succeeded in rebuilding the bulk of his excised arytenoid cartilage and markedly reducing aspiration.     

闭合性喉外伤伴杓区损伤的临床特征和内镜下治疗

目的:探讨闭合性喉外伤伴杓区损伤的临床特征、内镜下手术治疗及疗效。方法:回顾性研究2007年4月至2018年12月因明显声音嘶哑就诊于首都医科大学附属北京同仁医院耳鼻咽喉头颈外科的闭合性喉外伤伴杓区损伤患者12例,其中男10例,女2例,年龄7~48岁,中位年龄21岁,患者均在全身麻醉和支撑喉镜下行喉显微修复手术。评估其...     

两种手术方法治疗双侧声带神经麻痹

目的 通过观察经喉外进路及经支撑喉镜下行CO2激光手术切除杓状软骨治疗双侧声带神经麻痹的疗效,对比两种手术方法的优缺点,择优选取合适的术式。方法 对双侧喉返神经致喉狭窄的13例术后患者进行随访,其中7例行喉外进路杓状软骨切除术声带外展固定,6例行经支撑喉镜下行CO2激光手术切除杓状软骨,13例术前均已行气管切开,术后随访6个月至2年。结果 采用喉外进路杓状软骨切除术声带外展固定7例,术后1次拔管3例,2次拔管2例;采用经支撑喉镜下行CO2激光手术切除杓状软骨6例,术后1次拔管4例,2次拔管1例。结论 两种手术方法各有优缺点。     

Bilateral vocal cord paralysis associated with laryngeal myxedema

For managing dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy in the acute postoperative period, reversible vocal cord lateralisation is performed at the authors’ departments. However, in the later postoperative period of thyroidectomy when there is no chance for recovery of the recurrent laryngeal nerves, they perform irreversible procedure. Applying these operative techniques satisfactory breathing can be achieved in about 95% of cases avoiding tracheostomy. In 5% of cases there are other comorbidities in the background of unsuccessful operative results which can cause potential dyspnea as well. From these complications the authors emphasize the role of laryngeal obstruction and myxedema as a consequence of hypothyroidism developed after thyroidectomy. Management of severe dyspnea caused by association of these two complications of thyroidectomy means a great therapeutic challenge. Between 01 Jan 1989 and 30 Nov 2008 the authors performed 161 reversible and 135 irreversible vocal cord lateralisations to manage dyspnea caused by bilateral vocal cord paralysis as a complication of thyroidectomy. From these cases four patients had further obstruction due to laryngeal myxedema. By performing endoscopic laryngeal surgeries and applying levothyroxine replacement therapy sufficiently wide glottic chink has been achieved in all the cases. According to the experience of the authors dyspnea caused by bilateral vocal cord paralysis after thyroidectomy needs complex, interdisciplinary therapeutic approach beside glottis widening operations.     

Endoscopic laser medial arytenoidectomy for treatment of bilateral vocal fold paralysis

Endoscopic laser medial arytenoidectomy for bilateral vocal fold paralysis has the advantage of preserving the structure and the position of the vocal fold, contrary to a transverse cordotomy or total arytenoidectomy. Our objective was to evaluate the functional results of this procedure. This is a prospective non-randomized study. Twenty patients were included: five patients had a tracheotomy preoperatively and 15 patients had dyspnea on exertion. Acoustic voice measurements, spirometric parameters and the voice handicap index 120 (VHI), were evaluated 1 week before surgery and 3 months after. All the five patients with tracheotomy were successfully decannulated. Acoustic records and VHI were available for eight patients. Jitter and shimmer were worse (p = 0.0078), whereas the VHI was not significantly different after surgery. Spirometric records, available for six patients, were not modified. Endoscopic laser medial arytenoidectomy allowed decannulation and subjective improvement of quality of life in patients with bilateral vocal fold paralysis.     

Late results of laterofixation in the treatment of bilateral abductor paralysis of the vocal cords: a clinical study with long-term follow-up.

Thirty-four patients with bilateral vocal cord abductor paralysis were treated surgically during the period from 1960 to 1979. The main cause of paralysis was thyroid surgery (85%). Woodman's external laterofixation was performed in 31 patients, 1 had laterofixation by laryngofissure and 2 had endoscopic arytenoidectomy. In Woodman's procedure the body of the arytenoid cartilage was removed in 10 cases and mobilized from the cricoarytenoid joint in 21 cases. Thirteen of the 34 patients needed further surgery. Including previously performed procedures in 6 patients, altogether 68 operations were performed and 17 patients (50%) were operated on more than once. The immediate failure rate of laterofixation was 22% but the need for reoperation increased with time and the total failure rate of the method was 44%. Endoscopic arytenoidectomy was successful in 1 of 2 cases as a primary operation and in 3 of 3 cases as secondary operation. Follow-up time ranged from 2 months to 29 years 8 months (mean 15 years 10 months).     

Bilateral vocal cord palsy: the alternative to tracheostomy.

Bilateral abductor vocal cord paralysis remains a difficult management problem for otolaryngologists. The techniques currently used fall into four main types: arytenoidectomy, cordectomy, cord lateralization and laryngeal re-innervation. These techniques invariably require a tracheostomy either prior to or at the time of the main procedure. A technique for managing patients without performing a tracheostomy which is as effective as the previously mentioned procedures and with no greater morbidity in terms of voice production was initially described by Ejnell, et al (1984). The results in three patients using this technique which involves vocal cord lateralization under endoscopic control confirms its ease and efficacy. All three patients were relieved of their presenting dyspnea and had satisfactory postoperative voice production. This appears to be an effective technique for the treatment of patients with bilateral abductor laryngeal paralysis which obviates the need for tracheostomy and its attendant complications.