Suture lateralization of vocal cord treating paradoxical vocal cord movement: a case report

Paradoxical vocal cord movement (PVCM) causes inspiratory stridor and extra-thoracic airway obstruction through inappropriate adduction of the vocal cords during the respiratory cycle. We report on a patient with severe PVCM necessitating tracheostomy insertion. Using the technique of endoscopic suture lateralization of a vocal cord, we succeeded in decannulation 22 years after tracheostomy. PVCM of this severity is rare and its management remains unclear. Successful treatment in this manner has not been documented previously. A brief review of current management options for this condition is included.     

Paradoxical vocal cord movement in newborn and congenital idiopathic vocal cord paralysis: two of a kind?

The second most common cause of stridor reported in the newborn is bilateral vocal cord paralysis (BVCP) and one-third of the cases have been categorized as idiopathic. During the last year four children with stridor since birth were referred to our department for examination. Videotaped flexible laryngoscopy, carried out with the patient awake or under general anaesthesia with a spontanous respiration, revealed instead of abduction of the vocal cords during inspiration, rather an active adductory movement. Consequently instead of BVCP, we made the diagnosis paradoxical vocal cord movement (PVCM). One of the twins required a tracheostomy, the three other patients have been observed without the need of further treatment. No previous publications have described PVCM in newborn. However, our observations and video recordings clearly show that the stridor in our four patients is due to PVCM. This is possibly the same condition as earlier reported as congenital, idiopathic BVCP where incoordinated vocal cord movement or dyskinesia has been a part of the laryngoscopic findings. The mechanism behind PVCM in this age group or site of lesion is unclear.     

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     

Reversible lateralization of the paralyzed vocal cord without tracheostomy.

The initial management of bilateral abductor vocal cord paralysis is usually tracheostomy. It is proposed that a reversible endoscopic vocal cord lateral fixation would avoid this morbid procedure. The operation is performed by laryngoscopy utilizing the endo-extralaryngeal suture technique of Lichtenberger. Two polypropylene sutures are looped over one of the paralyzed vocal cords and brought out through the neck skin. A small incision is made, and the sutures are secured in the sternohyoid muscle. If movement of one or both vocal cords returns, the sutures are removed. Sixty-one of 63 cases were successful. In 53 cases, the airway became stable, without return of function. In 8 cases, one or both of the vocal cords became mobile 3 to 4 months after the operation. The reversible endo-extralaryngeal lateralization of the vocal cord using the above suture technique ensures a stable airway immediately. This technique avoids the need for tracheostomy in cases of bilateral abductor vocal cord paralysis.     

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     

Parálisis bilateral de cuerdas vocales en pediatría: nuestra experiencia

Bilateral vocal cord paralysis (BVCP) is the second most common cause of neonatal stridor. The aim of this study was to describe the demographic features, aetiology, comorbidities, and management of our patients with BVCP.

Endoscopic laterofixation in bilateral vocal cords paralysis in children

Introduction

Vocal cords paralysis is the second most frequent cause of laryngeal stridor in children. Symptoms of congenital vocal cords paralysis can occur shortly after birth or later. Vocal cords paralysis can be unilateral or bilateral. Symptoms of unilateral paralysis include hoarse weeping or stridor during a deep inhalation. In children unilateral vocal cords paralysis often retreats spontaneously or can be completely compensated. Children with bilateral vocal cords paralysis present mainly breathing disorders while phonation is normal. Symptoms are different, starting from complete occlusion of respiratory tracts and ending on small symptoms connected with the lack of effort tolerance. When symptoms are severe, patients from this group require a tracheotomy. The lack of restoration of normal function of vocal cords or lack of complete compensation and maintenance of symptoms are an indication for surgical treatment.

Objective

The aim of this study is to present results of the treatment of bilateral vocal cords paralysis in children using the endoscopic method of laterofixation of vocal cords.

Material and methods

In the Pediatric ENT Department between 1998 and 2009 sixty four children with dyspnoea and/or phonation disorders caused by vocal cords paralysis were treated.

Results

In ten cases laterofixation of vocal cords was performed, in most cases with good result. In this article the authors present the method of endoscopic laterofixation and achieved results.

Conclusions

Endoscopic laterofixation of vocal cords in children is a safe and an easy method of surgical treatment of bilateral vocal cords paralysis. This method can be used as a first and often as a one stage treatment of vocal cords paralysis. In some cases this procedure is insufficient and has to be completed with other methods.     

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.     

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.     

Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change

ObjectiveTo analyze the safety of a standardized pediatric tracheostomy care protocol in the immediate postoperative period and its impact on tracheostomy related complications.Study designRetrospective case series.SubjectsPediatric patients undergoing tracheotomy from February 2010–February 2014.MethodsIn 2012, a standardized protocol was established regarding postoperative pediatric tracheostomy care. This protocol included securing newly placed tracheostomy tubes using a foam strap with hook and loop fastener rather than twill ties, placing a fresh drain sponge around the tracheostomy tube daily, and performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome measures included rate of skin breakdown and presence of a mature stoma allowing for a safe first tracheostomy tube change. Two types of tracheotomy were performed based on patient age: standard pediatric tracheotomy and adult-style tracheotomy with a Bjork flap. Patients were analyzed separately based on age and the type of tracheotomy performed.ResultsThirty-seven patients in the pre-protocol group and 35 in the post-protocol group were analyzed. The rate of skin breakdown was significantly lower in the post-protocol group (standard: p = 0.0048; Bjork flap: p = 0.0003). In the post-protocol group, all tube changes were safely accomplished on postoperative day three or four, and the stomas were deemed to be adequately matured to do so in all cases.ConclusionA standardized postoperative pediatric tracheostomy care protocol resulted in decreased rates of skin breakdown and demonstrated that pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.     

Inspiratory activation of the vocal cord adductor, part I: human study in patients with restricted abduction of the vocal cords

OBJECTIVES/HYPOTHESIS: In patients with restricted abduction of the vocal cords, it has generally been accepted that glottis narrowing with laryngeal stridor during inspiration is attributed to static and passive obstruction of the glottis. However, active glottis narrowing can also be contributory. We tested the hypothesis that the vocal cord adductor is activated during inspiration in patients with restricted abduction of the vocal cords. STUDY DESIGN: Electromyographic evaluation of vocal cord adductor activity in patients with restricted abduction of the vocal cords. METHODS: Five patients with restricted abduction of the vocal cords who had stridor with mild to severe dyspnea during wakefulness were anesthetized with propofol. We recorded the adductor muscle electromyogram during breathing through a laryngeal mask airway while observing the vocal cord movement endoscopically. In three patients who had undergone tracheostomy, we also recorded adductor firing patterns not only while closing but also while opening the tracheostoma. RESULTS: The adductor was activated during inspiration, and the glottis was narrowed in accordance with inspiratory stridor. This adductor inspiratory activity was abolished by opening the tracheostoma in the tracheostomized patients. CONCLUSION: Not only static or passive glottis narrowing but also active narrowing may contribute to inspiratory flow limitation in patients with restricted abduction of the vocal cords. This active glottis narrowing is probably induced by an airway reflex.     

Familial vocal cord dysfunction associated with digital anomalies

Familial vocal cord dysfunction is a rare condition that has been reported in only a few instances. This is a report of identical male twins, both of whom had congenital bilateral abductor vocal cord paresis associated with finger deformities. The vocal cord paresis progressed to paralysis that required tracheotomy, then returned to a slowly resolving paresis during which the vocal cords had uncoordinated motion generally known as synkinesis. Another male sibling and the mother had a history of stridor during infancy and finger deformities. Several other relatives had digital abnormalities, and an infant first cousin with finger abnormalities required a tracheotomy for vocal cord paralysis.     

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.     

Laryngeal gout

A review of the literature reveals only 12 reported cases of laryngeal gout. We describe three further cases of laryngeal gout, the largest series ever published. The first case is previously undescribed acute gouty cricoarytenoiditis resulting in acute airway embarrassment requiring tracheotomy, and then we describe two cases of chronic tophaceous involvement of the thyroid lamina with computed tomography (CT) images of this process. The paucity of literature on this subject may not only be due to rarity but also lack of clinical awareness. Gouty involvement of the larynx must be considered in any patient with a history of gout who presents with hoarseness, odynophagia, dysphagia, stridor or neck lump. Acute airway compromise may require tracheotomy, whereas chronic airway problems may necessitate endoscopic tophi removal, lateralization procedures or even permanent tracheostomy.     

Nine-month outcomes of tracheostomy in patients with COVID-19: A retrospective study

PurposeThe outcome of performing a tracheostomy in patients with coronavirus disease (COVID-19) seems promising based on the reported 30-day survival rate. However, long-term outcomes are still lacking. Therefore, our aim in this study was to evaluate the long-term outcomes of tracheostomy performed in critically ill COVID-19 patients.MethodsThis was a retrospective analysis of 27 COVID-19 patients on whom tracheostomy was performed between February 28, 2020, and April 7, 2020, at Tongji Hospital (Wuhan, China). Patients' clinical characteristics, complications, and outcomes were analyzed.ResultsAll patients underwent successful bedside tracheostomy. Thirteen patients (48.1%) were successfully weaned off ventilation within 1 month. The survival rate at one, three, and nine months after tracheostomy were 63.0%, 37.0%, and 29.6%, respectively. At nine months after tracheostomy, 8/27 patients had survived, with five (62.5%) being discharged home while the remaining were dependent on nursing care.ConclusionThe survival rate of COVID-19 patients who underwent tracheotomy decreased markedly from 1 to 3 months after tracheotomy, remaining stable between 3 and 9 months. Medical support is much needed for COVID-19 patients over the first 90 days after tracheotomy.     

Comparison of endoscopic glottis-dilating operations

Endoscopic glottis-dilating operations were first utilized in 1948 by Thornell, who performed an endolaryngeal arytenoidectomy. The real breakthrough in these operations was reported by Kleinsasser in 1968. There have been many modifications of the endoscopic glottis dilating operations by other authors over the past 30 years or more. These methods have brought great progress in relieving airway obstruction. However, some disadvantages have reduced the effectiveness of these operations. This study will compare the advantages and disadvantages of the previous methods and compare them to the methods based on the endo-extralaryngeal suture technique by Lichtenberger in the hope that some of the previous ineffectiveness of glottis-dilating operations can be eliminated. These recent endo-extralaryngeal suture techniques consist of two operations. The first operation performed on patients whose vocal cords were paralyzed is an irreversible operation. This was performed with and without arytenoidectomy. These operations were successful in 89 out of 94 patients. The second operation was reversible endo-extralaryngeal lateralization, which was carried out in 37 patients; of these operations, 35 were successful. The operation was performed, and, if the cords remained paralyzed, the suture was not removed. If there was evidence of a return of vocal cord function, the suture was removed, eliminating the need for further dilating operations. The author feels that these two operations are quite successful, because the medial mucous membrane of the vocal cord is preserved, and this avoids the scar and granuloma formation that are characteristic of most other glottic dilating operations.     

Aerosol-generating procedure; percutaneous versus surgical tracheostomy

PurposeThis study aims to compare percutaneous tracheostomy (PCT) and surgical tracheostomy's aerosol and droplet scattering by using a particle counter.Materials and methodsThis study was carried out with 35 patients between October 2020 and June 2021. All personal protective equipment was provided to protect healthcare workers. Measurements were made in the 5 s period before the tracheal incision and the 5 s period after the tracheal incision.ResultsThe mean age of the 15 female and 20 male patients in this study was 68.88 ± 13.48 years old (range: 33–95 years old). Patients were intubated for an average of 22 days. Particle amounts were found to be significantly higher at 5 μm (p = 0.003) and 10 μm (p = 0.012) during PCT. In surgical tracheostomy, there was no significant increase in the number of particles. When the particle measurement values of both methods were compared with each other, there was a significantly more particle scattering in PCT than in surgical tracheotomy at 0.3 μm (p = 0.034), 5 μm (p = 0.001), and 10 μm (p = 0.003).ConclusionAccording to the data in our study, a surgical tracheotomy was not identified as an aerosol-generating procedure. Considering the risk of airborne transmission may increase due to viral mutations, we have shown that surgical tracheostomy may be more appropriate in patients who need a tracheostomy. Of course, the use of personal protective equipment during these processes is very important.     

新生儿双侧声带麻痹临床特点及预后分析

目的 探讨新生儿双侧声带麻痹的病因、临床特点、治疗及预后转归。 方法 对新生儿中心在2016年1月至2020年12月期间收治的双侧声带麻痹患儿进行回顾性分析,记录患儿的基本资料、病因、治疗情况及预后情况,并对患儿进行门诊及电话随访。 结果 共纳入28例患儿,男18例,女10例,年龄1~24 d,中位年龄3.5 d。92.9%(26/28)的患儿为足月儿,53.6%(15/28)的患儿为剖宫产。患儿首发症状主要为吸气性喉鸣及呼吸困难,占比高达78.6%(22/28),其次为呛奶及呕吐,占比为14.3%(4/28)。先天性双侧声带麻痹23例(82.1%,23/28),其中合并中枢神经系统病变7例(23.8%),先天性心脏病6例(21.4%),喉气管疾病6例(21.4%),胃食管反流疾病2例(7.1%);后天获得性声带麻痹5例(17.9%,5/28),获得性因素中多发于食管、气管疾病术后(80%,4/5)。全部患儿中8例(28.6%)行气管切开。所有患儿随访时间1个月~4年,死亡4例。气管切开患儿8例中,1例12个月时顺利拔管,1例堵管中,余5例目前随访16~47个月声带仍无恢复。观察等待20例患儿中,11例(64.7%)在后期随访的1~38个月内痊愈,声带活动恢复,6例(35.3%)在后期随访的5~17个月内声带活动改善,活动后喉鸣。 结论 新生儿双侧声带麻痹病因以先天性多见,共患病因素多,临床多表现为喉鸣及呼吸困难,部分有吞咽困难。气管切开术在新生儿双侧声带麻痹中并不是普遍必要的,多数先天性双侧声带麻痹患儿可自行恢复,预后较好,不要过早行外科手术干预。     

Reversible immediate and definitive lateralization of paralyzed vocal cords

The author reports on glottis dilation operations based on the endoextralaryngeal suture technique he has developed. In all, 101 patients were operated on for bilateral recurrent nerve paralysis using different variations of the above method, of which 73 have had more than 1 year of follow-up. Dilation was performed in 52 patients following tracheostomy, whereas no tracheostomy was performed in 21 patients. In 9 cases irreversible laterofixation without tracheostomy was performed with good results. In 12 patients a reversible glottis dilating operation was carried out without tracheostomy not long after the development of bilateral paramedian position of the vocal cords. Tracheostomy was necessary in 1 of 12 patients, who underwent reversible glottis dilating operations. In this case later reoperation, using a definitive endoscopic glottis dilating operation, was performed with success. Three patients required reoperation using open surgical procedures after irreversible endoscopic laterofixation methods. Received: 26 September 1998 / Accepted: 7 April 1999     

Simple method of vocal cord lateralization in bilateral abductor cord paralysis in paediatric patients

OBJECTIVE: To simplify the procedure of suture lateralization of a vocal cord in children with bilateral abductor cord palsy and to evaluate its results. METHODS: Ten tracheostomised infants and children with bilateral abductor cord palsy where there was either minimal or no recovery of vocal cord movement even after 2 years' observation were taken up for suture lateralization of one vocal cord. In this simplified procedure needles were passed twice through the larynx from one side of neck to the other. The aim was to reduce the microlaryngoscopic or telescopic manipulation inside the small larynx. Two techniques (1 and 2) were used to carry out this procedure. In technique 1 the needle used was one with a slit in the eye situated at its tail end whereas in technique 2 it was a lumbar puncture needle. Patient follow-up ranged from 6 months to 5 years. RESULTS: Intraoperative manipulation inside the larynx was considerably reduced. The technique 2 was even simpler and faster than technique 1. With both techniques the placement of suture was accurate without any knot inside the larynx. All the patients could be decanulated with only minimal stridor on exertion in two and an acceptable voice in all. CONCLUSIONS: Suture lateralization of one vocal cord using technique 2 can be tried as the first line of management in cases of bilateral abductor cord palsy requiring lateralization.