Thyroplasty under general anesthesia using a laryngeal mask airway and fibreoptic bronchoscope

Purpose

To report the management of a patient, with unilateral vocal cord paralysis, undergoing thyroplasty, under general anesthesia.

Clinical Features

A 25-yr-old man developed hoarseness and occasional episodes of pulmonary aspiration, caused by unilateral vocal cord paralysis. He was scheduled for thyroplasty, in an attempt to ease phonation and to decrease or prevent further episodes of pulmonary aspiration. He refused local anesthesia with sedation and it was therefore decided to attempt the procedure under general anesthesia. The paralysed vocal cord was displaced inwards by a wedge inserted through a window in the thyroid cartilage. We assessed the ideal position of the wedge by using a fibreoptic bronchoscope and laryngeal mask airway during general anesthesia, instead of phonation.

Conclusion

We describe the successful use of a general anesthetic for a thyroplasty, a procedure normally done under local anesthesia with or without sedation, in a patient who was keen to have surgery, but who refused local anesthesia with sedation.     

Bilateral vocal cord palsy during carotid endarterectomy under cervical plexus block

We describe a case of vocal cord palsy leading to respiratory obstruction during carotid endarterectomy under cervical plexus block in a patient who had preexisting contralateral vocal cord paralysis subsequent to a previous thyroidectomy. The patient required immediate tracheal intubation and subsequent tracheostomy to maintain the airway postoperatively. Care must be given to avoid contralateral vocal cord paralysis in the presence of a preexisting vocal cord palsy.     

Bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion in a case of whiplash cervical spine injury: a case report

BACKGROUND

Bilateral vocal cord paralysis is a risk of anterior cervical discoidectomy and fusion. We discuss the mechanism of vocal cord paralysis and the precautions necessary to avoid this catastrophic complication. A rare case of bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion (ACD/F) is reported.

CASE DESCRIPTION

The patient, a 37-year-old male, was paraplegic, had bilateral intrinsic hand muscle weakness and sphincter involvement following a whiplash cervical spinal injury. A C5-C6 ACD/F for traumatic C5-C6 disc prolapse was performed. On the third postoperative day, he developed difficulty in coughing and a husky voice. Otolaryngological evaluation revealed bilateral vocal cord paralysis. He later required a tracheostomy that partially alleviated his major symptoms.

CONCLUSION

In patients undergoing ACD/F, a mandatory preoperative evaluation of the vocal cords should be performed. An appropriate modification in surgical planning should be made if vocal cord palsy is diagnosed preoperatively to prevent bilateral vocal cord paralysis. Proper and judicious use of Cloward retractors is advocated.     

Therapeutic management of postoperatively diagnosed bilateral recurrent laryngeal nerve paralysis

Bilateral vocal cord paralysis is a rare but potentially dangerous postoperative complication in thyroid gland surgery. There is a controversial discussion about therapeutic management of postoperative bilateral vocal cord paralysis. METHODS: We analysed the frequency of bilateral nerve palsy in 985 operations. The disease of thyroid gland, the operative procedure, the exposure of laryngeal nerve, the mobility of vocal cord detected by an otolaryngologist, clinical symptoms and therapy of patients with bilateral paralysis were analysed. All patients were examined immediately postoperatively and 5 days, 14 days, 6 and 12 months after resection. RESULTS: The overall transient bilateral palsy rate was 0.7%, the permanent 0.3%. The palsy rate depended on the disease of thyroid gland. After resection of simple goitre we found a 0.2% transient injury rate (0.1% permanent), after operation of thyroid cancer 2.0% transient (1.0% permanent) and in cases of recurrent goitre 5.9% transient (1.9% permanent) palsies. The immediate postoperative symptoms are also very different. There are patients suffering from stridor and dyspnoea, patients with dysphonia without dyspnoea and those without any symptoms. These different clinical symptoms are due to the different grade of laryngeal nerve damage and the resulting position of vocal cords. The bilateral paralysis was completely temporary in 4 cases. 12 months later 4 patients suffered from dysphonia. Only in 3 patients with thyroid cancer and a preoperative unilateral vocal cord paralysis tracheostomy was necessary after operation. The vocal cord mobility did not recover in these 3 cases after 12 months and the patients are not decannulated. DISCUSSION: Bilateral paralysis is only relevant in thyroid cancer and recurrent goitre. The symptoms varies and no patient should leave the hospital without examination of the vocal cords by an otolaryngologist. Because vocal cord paralysis is temporary in most cases an emergency tracheostomy is seldom indicated.     

Severe stridor and marked respiratory difficulty after right-sided supraclavicular brachial plexus block

Brachial plexus block is commonly used for upper limb surgery. Although the procedure is safe, it may be associated with some life-threatening complications. We performed right-sided supraclavicular brachial plexus block for below-elbow amputation in a 45-year-old female. At completion of the block the patient developed marked respiratory difficulty with audible inspiratory stridor. Although SpO₂ decreased to 82% initially, it was increased to 100% by continuous positive airway pressure with a face mask. On conventional direct laryngoscopy, the left vocal cord was found to be in the midline position and the right vocal cord was in the paramedian position. The trachea was intubated and surgery proceeded without any other complication. Postoperative indirect laryngoscopy revealed that the left vocal cord was fixed, whereas the right vocal cord was mobile, and diagnosis of pre-existing incomplete left vocal cord paralysis was made. This clinical report is to emphasize the importance of thorough pre-operative evaluation of the vocal cord in patients who have undergone any surgical procedure or radiation treatment of the neck before planning for brachial plexus block. If such an evaluation cannot be obtained, an alternative technique, for example axillary approach, should be preferred.     

Anaesthesia for thyroplasty

The purpose of this report is to describe the anaesthetic considerations for layngoplastic procedures. Thyroplasty is a procedure which restores the voice in unilateral vocal cord paralysis. The procedure employs an external approach via a window cut at the appropriate level in the thyroid ala. A wedge of silastic is inserted against the inner perichondrium, thereby displacing the vocal cord medially and permitting voice production. Correct placement of the implant is assessed by asking the patient to phonate; patient cooperation is therefore necessary at certain times during the procedure. We describe our management of a patient undergoing thyroplasty. The use of a benzodiazepine agonist-antagonist combination provided both optimal operating conditions and patient comfort.     

Is dysphonia permanent or temporary after anterior cervical approach?

The rate, causes and prognosis of dysphonia after anterior cervical approach (ACA) were investigated in our clinical series. During a 10-year interval, 235 consecutive patients with cervical disc disease underwent surgical treatment using anterior approach. Retrospective chart reviews showed recurrent laryngeal nerve (RLN) injury in 3 (1.27%) patients. All three patients were men and only one patient had multilevel surgery. These patients had RLN injury after virgin surgery. Laryngoscopic examination demonstrated unilateral vocal cord paralysis in all patients who had postoperative dysphonia. No permanent dysphonia was observed in our series and patients recovered after a mean of 2 months (range 1–3 months) duration. Dysphonia after ACA was a rare complication in our clinical series. Pressure on RLN or retraction may result in temporary dysphonia.     

Palliative surgery for neoplastic unilateral vocal cord paralysis

Background: Locally advanced, recurrent or metastatic neoplasms are the commonest causes of unilateral vocal cord paralysis (UVCP). The aim of the present study was to evaluate both survival and results of treatment of vocal cord medialization procedures in this group of patients. Methods: Fifty‐seven patients (36 male, 21 female) with UVCP considered to be due to advanced malignancy who underwent medialization (Teflon injection or type I thyroplasty) between January 1994 and July 2000 were retrospectively reviewed. Results: The malignancy responsible for UVCP was non‐small‐cell lung carcinoma (NSCLC) in 43 patients, small‐cell lung car­cinoma (SCLC) in four patients, thyroid carcinoma in three patients and metastatic lower cervical lymph nodes in seven patients. All patients complained of dysphonia and 29 patients had symptoms of aspiration. Teflon injection was performed in 44 patients and thyroplasty in 13. Improvement in voice occurred in 51 patients (89%) and resolution of aspiration in 28 patients (97%) after 2 months. The median time from onset of symptoms of UVCP to death in NSCLC was 170 days; SCLC, 69 days; thyroid carcinoma, 783 days; and metastatic lower cervical lymph nodes, 304 days. Conclusion: Surgical treatment of neoplastic UVCP provides satisfactory palliation of symptoms, and management decisions should be based on patient survival expectations.     

Arytenoid adduction combined with medialization thyroplasty: an evidence-based review.

OBJECTIVE: Medialization thyroplasty (MT) and arytenoid adduction (AA) are effective treatments for medializing the paralyzed vocal cord, but indications and benefits of each procedure are controversial. We performed a formal evidence-based review to answer this question: In patients with unilateral vocal cord paralysis, does AA combined with MT significantly improve subjective and objective voice outcomes compared with MT alone?Study design We performed a MEDLINE literature search using specific search terms to identify pertinent articles, which were reviewed and graded according to the evidence quality. RESULTS: We identified 219 potentially pertinent articles; detailed review yielded 10 studies for further analysis. Only 3 studies directly compared MT with AA plus MT: overall, there was no clear benefit in subjective or objective outcomes for AA plus MT. CONCLUSIONS: Very limited grade C evidence indicates no clear benefit, or lack of benefit, in subjective or objective outcomes if AA is added to MT, compared with MT alone.     

Medialization thyroplasty for cancer-related unilateral vocal fold paralysis.

OBJECTIVE: To justify the application of medialization thyroplasty in Chinese patients with symptomatic cancer-related unilateral vocal fold paralysis (UVFP). STUDY DESIGN AND SETTING: Retrospective chart review from February 2000 to March 2006. RESULTS: Eighty-seven Chinese patients undergoing medialization thyroplasty for UVFP were included; there were no significant differences between the cancer-related and benign groups in terms of the speech and swallowing rehabilitation outcome and the perioperative complication rate (P > 0.05). The median survival time of cancer-related UVFP patients from the date of medialization to death was 129 days. Age more than 65 years was identified as the only factor for a shorter survival period after medialization (P = 0.040). CONCLUSION: Medialization thyroplasty restores satisfactory speech and swallowing and has a low perioperative complication rate in Chinese patients with cancer-related UVFP. Postmedialization survival period was also reasonable. SIGNIFICANCE: Medialization thyroplasty is a justifiable treatment option for cancer-related UVFP.     

Vocal cord paralysis associated with anterior cervical fusion: considerations for prevention and treatment

In a series of 375 patients with anterior cervical fusions, long-term follow-up results complete with laryngeal examination were obtained in 102 patients. One patient was found to have an inferior laryngeal nerve palsy, and one had a superior laryngeal nerve palsy. Both deficits were thought to be the result of surgical trauma. Measures to minimize the incidence of vocal cord paralysis include careful surgical technique and knowledge of the surgical anatomy of the laryngeal nerves. Suggestions are given for the assessment of postoperative hoarseness, and for the management of vocal cord paralysis.     

Acute respiratory failure after deep cervical plexus block for carotid endarterectomy as a result of bilateral recurrent laryngeal nerve paralysis

We report about a case of acute respiratory distress (73-year-old female), which occurred minutes after a deep cervical plexus block (40 ml ropivacaine 0.5%) for carotid endarterectomy (CEA) and required immediate endotracheal intubation of the patient's trachea and consecutive mechanical ventilation. Subsequently, CEA was performed under general anaesthesia (TIVA) with continuous monitoring by somatosensory-evoked potentials. After a period of 14 hours, the endotracheal tube could be removed, the patient being in fair respiratory, cardiocirculatory and neurological conditions. Retrospectively, acute respiratory distress was caused by a combination of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral recurrent laryngeal nerve (RLN) paralysis confirmed by a postoperative ENT-check and related to previous thyroid surgery more than 50 years ago. RLN paralysis, often being asymptomatic, represents a typical complication of thyroid and other neck surgery with reported incidences of 0.5-3%. Therefore, a thorough preoperative airway check is advisable in all patients scheduled for a cervical plexus block. Particularly in cases with a history of respiratory disorders or previous neck surgery a vocal cord examination is recommended, and the use of a superficial cervical plexus block may lower the risk of respiratory complications. This may prevent a possibly life-threatening coincidence of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral RLN paralysis.     

Thyroplasty under total intravenous anaesthesia with intermittent positive pressure ventilation

BACKGROUND AND OBJECTIVES: Medialization thyroplasty is a surgical technique for improving voice quality, cough effort and laryngeal competence in patients with unilateral vocal fold paralysis. Precision surgery is enabled by operating under total intravenous anaesthesia with controlled ventilation and by using a laryngoscopic video-assisted technique. The anaesthetic challenge is to manage the shared airway with the surgeon, provide a stable operative field and ensure patient safety throughout the procedure. The objective of this case series was to evaluate the use of a modified general anaesthetic technique using the laryngeal mask airway, total intravenous anaesthesia with controlled ventilation. METHODS AND RESULTS: In all, 29 patients underwent medialization thyroplasty using a disposable laryngeal mask airway, total intravenous anaesthesia and controlled ventilation. Standard anaesthetic monitoring including capnography was used intraoperatively. Total intravenous anaesthesia was achieved using effect site target-controlled infusions of propofol and remifentanil. CONCLUSIONS: The technique proved safe with stable haemodynamic observations and only two minor complications. It also provided the surgeon with stable view of the vocal folds in order to perform this precision surgery under an operating microscope.     

Bilateral vocal cord paralysis in newborns with neuraxial malformations--two case reports--

Two neonates presented with inspiratory stridor due to bilateral vocal cord paralysis associated with occipital encephalocele, Chiari malformation, and hydrocephalus in one patient, and cervical meningomyelocele and Chiari malformation in the other patient. The clinical symptoms dramatically regressed after repair of the encephalocele or meningomyelocele with no requirement for craniovertebral decompressive procedures or shunts in the acute phase. Careful evaluation of neonatal stridor and recognition of vocal cord paralysis are important, as treatment of associated congenital central nervous system anomalies is likely to achieve satisfactory surgical results.     

Vocal cord paralysis after subtotal oesophagectomy

BACKGROUND: Although vocal cord paralysis is a well known complication of subtotal oesophagectomy, precise data concerning origin, incidence and associated morbidity are lacking. METHODS: A retrospective study was performed of 241 patients who underwent transhiatal oesophagectomy for carcinoma of the mid/distal oesophagus between 1994 and 1998. Preoperative and postoperative laryngoscopy results were available for 140 patients. RESULTS: There were 109 men and 31 women, of mean age 63 years. Thirty-one patients (22 per cent) with recurrent laryngeal nerve paralysis were identified, three with bilateral and 28 with unilateral dysfunction. Paralysis occurred ipsilateral to the side of the cervical incision in 22 of 28 patients. It was permanent in six patients. The associated morbidity was substantial: pulmonary complications were more common in patients with vocal cord paralysis (12 of 31 versus 26 (24 per cent) of 109), leading to significantly more reintubations, and a significantly prolonged ventilation time and stay in the intensive care unit. CONCLUSION: Although mostly transient, vocal cord paralysis is a frequent complication with significant associated morbidity. In an extended transthoracic resection (including a lymphadenectomy in the aortopulmonary window where the left recurrent laryngeal nerve is at risk) the cervical anastomosis should be made on the left side, to minimize the risk of bilateral vocal cord paralysis.     

Bilateral vocal cord paralysis in a patient with Parkinson's disease

Bilateral vocal cord paralysis in patients with Parkinson's disease is a life-threatening complication. The need for surgical treatment such as a tracheotomy or laser arytenoidectomy is determined by the severity of the patient's symptoms. A case of bilateral vocal cord paralysis in a patient with Parkinson's disease treated with an urgent tracheotomy is reported.     

Bilateral congenital vocal cord paralysis: a 16-year institutional review.

OBJECTIVE: To review the management and outcome of bilateral congenital true vocal cord paralysis in 22 patients treated over a 16-year period and to review the role of tracheostomy in these patients. DESIGN: Retrospective chart review. SETTING: Pediatric tertiary hospital. PATIENTS: Twenty-two pediatric patients diagnosed with bilateral congenital true vocal cord paralysis. INTERVENTIONS: Flexible or rigid diagnostic evaluation, tracheostomy, and vocal cord lateralization procedures. MAIN OUTCOMES MEASURES: Vocal cord recovery and decannulation. RESULTS: With a mean follow up of 50 months, 15 of 22 patients (68%) with bilateral vocal cord paralysis required tracheostomy for airway securement. Of the 15 tracheotomized patients, 10 were successfully decannulated (8 had spontaneous recovery, whereas 2 required lateralization procedures). Eleven of these patients with tracheostomy had comorbid factors, including neurologic abnormalities (midbrain/brainstem dysgenesis, Arnold-Chiari malformation, global hypotonia, and developmental delay). Of the 7 patients not requiring tracheostomy, 6 recovered vocal cord function (86%). CONCLUSION: In our series of 22 patients with bilateral vocal cord paralysis, 14 had spontaneous recovery of function. Patients managed with tracheostomy were noted to have a high incidence of comorbid factors. In this series, recovery rates were found to be higher in nontracheostomized patients than in tracheostomized patients. Patients can be carefully selected for observation versus tracheostomy at the time of diagnosis based on underlying medical conditions.     

General anaesthesia for thyroplasty

A new anaesthetic technique is described for thyroplasty. Thyroplasty was performed to restore the voice in unilateral vocal cord paralysis. After skin incision and dissection down to the larynx, a window was cut in the thyroid ala and a silastic wedge used to displace the vocal cord medially. The required size of this wedge was determined by pre-operative computerized tomography scanning of the larynx. At this point the patient had to be awake and cooperative to allow repeated phonation to facilitate correct displacement of the vocal cord.     

Impact of laryngeal paralysis and its treatment on the glottic aperture and upper airway flow characteristics during exercise

Patients with unilateral vocal fold paralysis occasionally report shortness of breath during exercise. This symptom may persist in some patients after medialization thyroplasty. A review of the literature revealed no study that objectively evaluated laryngeal dynamics or airway flow characteristics during exercise after medialization thyroplasty for unilateral laryngeal paralysis. This study evaluates glottic aperture size and configuration as well as upper airway flow characteristics during exercise in 16 subjects. Six patients who underwent medialization thyroplasty for unilateral vocal fold paralysis were compared with 10 healthy control subjects. During a standardized exercise protocol on an incremental ergometer (bicycle type), real-time videolaryngoscopy was obtained and correlated in a synchronized fashion with maximum-effort respiratory efforts at the beginning, midpoint, and end of the exercise period. Direct calculations of glottic size during various phases of the exercise period were performed from digitized images. These data were correlated with inspiratory flow data for each patient. Patients with laryngeal paralysis demonstrated smaller mean glottic areas and lower peak inspiratory flow rates than controls both at rest and during all phases of the exercise period. This study suggests that after treatment of unilateral laryngeal paralysis with medialization thyroplasty, inspiratory flow rate and glottic area are significantly less than in normal controls.     

Natural history of tracheostomy-dependent idiopathic congenital bilateral vocal fold paralysis.

OBJECTIVE: To identify the age at which spontaneous improvement in vocal fold function occurs that will allow decannulation to be performed in tracheostomy-dependent children with isolated idiopathic congenital bilateral vocal fold paralysis (BVFP). STUDY DESIGN AND SETTING: Retrospective chart review in tertiary pediatric center. RESULTS: Three children were identified who underwent tracheostomy between 13 and 45 days old. Two patients have been decannulated at age 5 years 11 months and 7 years 1 month, but both have persistent symptoms of upper airway obstruction. One patient remains tracheostomy-dependent at 4 years of age with only minimal vocal cord abduction. CONCLUSIONS: Spontaneous improvement in vocal fold function sufficient to allow decannulation appears to occur during the second quinquennium of life. SIGNIFICANCE: Conservative treatment could be considered as an alternative to surgery in severe idiopathic congenital BVFP.