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Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Address reprint requests and correspondence: Johnathan D. McGinn, MD, Otolaryngology–Head and Neck Surgery, H091, Penn State Milton S. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033-0850.
Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Bilateral vocal fold impairment is a potentially life threatening condition. The otolaryngologist must be able to quickly identify its etiology and select the appropriate surgical procedure to treat the airway obstruction while attempting to maintain phonation and deglutition. Multiple techniques, both endoscopic and open, are available to the surgeon in treating this clinical problem. Endoscopic procedures covered in this article are: arytenoidectomy; including laser and laser medical arytenoidectomy; suture lateralization; and partial posterior laser cordectomy or transverse cordotomy. Posterior lateral extralaryngeal arytenoidectomy and laryngeal reinnervaiton are discussed in regard to open techniques.
Bilateral vocal fold impairment is a potentially life-threatening condition. The otolaryngologist must be able to quickly identify its etiology and select the appropriate surgical procedure to treat the airway obstruction while attempting to maintain phonation and deglutition. Although tracheotomy remains the mainstay of treatment, especially regarding acute airway compromise, current surgical options for bilateral vocal fold impairment are divided into 3 categories: procedures involving removal of vocal fold and/or arytenoid tissue, vocal fold lateralization, and laryngeal reinnervation; the first 2 being the primary methods. Procedures can be further categorized as endoscopic or open. Endoscopic procedures covered in this article are arytenoidectomy, including laser and laser medial arytenoidectomy; suture lateralization; and partial posterior laser cordectomy or transverse cordotomy. Posterior lateral extralaryngeal arytenoidectomy and laryngeal reinnervation will be discussed in regard to open techniques. The challenges of surgery with bilateral vocal fold immobility are centered on the balance between airway maintenance and vocal quality as further lateralization of the vocal fold leads to a better airway but poorer phonation.
Innervation to the intrinsic muscles of the larynx is primarily from the recurrent laryngeal branch of the vagus nerve. The primary action of these muscles is adduction of the vocal folds. These muscles include the posterior and lateral cricoarytenoids, the thyroarytenoid, and the interarytenoid muscles; the posterior cricoarytenoid being the only abductor muscle. The cricothyroid muscle is the only laryngeal muscle innervated by the superior laryngeal nerve and serves to modify the tension and length of the vocal fold, resulting in vocal pitch changes.
Patients with bilateral vocal fold impairment primarily present with airway obstruction secondary to loss of vocal fold abduction. The vocal quality may remain relatively preserved secondary to the near midline position of the vocal folds. In contrast, loss of adduction leads to an unobstructed airway with a breathy voice. Unilateral vocal fold impairment leads primarily to loss of vocal quality, rather than airway compromise; therefore, its treatment will not be covered in this chapter. The objective of this chapter is the management of airway obstruction seen more often in bilateral vocal fold impairment.
The etiology of vocal fold impairment is diverse, ranging from neurologic deficits to local mechanical issues. These issues may arise secondary to extrinsic injury to the larynx or recurrent laryngeal nerve, central nervous system insult, local endolaryngeal injuries such as prolonged endotracheal intubation or iatrogenic scarring, neoplasm, or even inflammatory disorders of the cartilaginous framework of the larynx. Further etiologies of bilateral vocal fold impairment are listed in Table 1. Iatrogenic injuries remain the primary cause of bilateral vocal fold impairment. Vocal fold paralysis or paresis can result from thyroidectomy, anterior approaches to the cervical discs, esophageal surgery, carotid endarterectomy, and any other surgery that may put the recurrent laryngeal nerve at risk for injuries. Prolonged intubation can also lead to fibrosis of the interarytenoid muscles and cricoarytenoid joint ankylosis. Infiltrative disorders such as amyloidosis, tuberculosis, and sarcoidosis may lead to bilateral vocal fold motion impairment, whereas neoplasms most often present with a unilateral impairment. Rheumatoid arthritis should also be considered in cricoarytenoid or cricothyroid joint ankylosis.
Table 1Etiologies of bilateral vocal fold impairment
The cornerstone of office laryngeal examination is indirect mirror or direct laryngoscopy with flexible fiberoptic endoscopy. Visualization of the vocal fold movement during phonation and inspiration can reveal a wealth of information to provide adequate diagnosis and guide management for the impaired vocal folds, although more invasive, endoscopic palpation of the cricoarytenoid joint can help differentiate paralysis from fixation. Besides this, laryngeal electromyography can help distinguish between neurologic and structural causes of immobility and may aid to predict recovery. Flow volume loop spirometry is also a useful adjunct to quantify respiratory flow limitations. There are 2 main patterns seen in bilateral vocal fold impairment that give information regarding the site of obstruction, as well as the severity of the airway obstruction. Inspiratory flow rate is mostly affected in a variable extrathoracic obstruction pattern, while the expiratory flow rate remains normal. This pattern is seen in laryngeal paralysis, cricoarytenoid ankylosis, interarytenoid fibrosis, and posterior glottic scarring. In contrast, patients with infiltrative lesions present with a flow rate limited on both inspiration and expiration, referred to as a fixed obstruction. In general, a midvital capacity inspiratory flow rate of less than 1.5 L per second for an adult is considered severe enough to warrant surgical intervention.
Surgical techniques
Before 1922, the treatment for bilateral vocal fold impairment was the tracheotomy. In 1922, Chevalier Jackson
introduced the cordectomy and the ventriculocordectomy to expand the airway, but unfortunately patients were left with poor vocal quality and scarring. Surgeons began to search for ways to lateralize the vocal folds but still preserve functional phonation. In 1932, Hoover
published his technique of extralaryngeal arytenoidectomy in which the ipsilateral arytenoid cartilage was sutured to the anterior belly of the omohyoid muscle. Scarring produced further lateralization of the vocal folds. The technique underwent further modification by Kelly
further modified the arytenoidectomy in 1946, using a posterolateral approach that spared the thyroid cartilage. With the advent of endoscopic arytenoidectomy by Thornell
in 1948, surgeons were able to decrease the complications and morbidity related to open procedures, but the new procedure was technically challenging and not immune to scarring. In the 1970s, authors such as Kirchner
advocated a more conservative approach using suture lateralization. This was especially attractive for patients who might have needed a reversible procedure for temporary bilateral vocal fold immobility. With the introduction of the CO2 laser in endolaryngeal surgery, laser arytenoidectomy techniques followed, as described by Ossoff and others.
in 1948, was the first endoscopic technique for vocal fold lateralization. After a tracheotomy is performed, the patient is suspended with an operative laryngoscope to obtain an adequate endoscopic view of the posterior arytenoids. The vocal folds and aryepiglottic folds are injected with an anesthetic solution, and a 1-cm incision is made over the arytenoid cartilage, with extension into the aryepiglottic fold (Figure 1). The cartilage is grasped and separated from its attachments with a sharp laryngeal knife. The site is then electrocauterized to stimulate scar tissue formation, leading to lateralization. The anterior half of the incision is closed using chromic suture, while the posterior half remains open to facilitate drainage. This technique saves the patient from an open procedure but may be complicated by postoperative formation of posterior commissure webs.
Figure 1Endoscopic arytenoidectomy. (A) An incision is made over the arytenoid cartilage. (B) The arytenoid cartilage is grasped and removed. (C) Needlepoint electrocoagulation applied to the arytenoid bed. (D) Vocal fold lateralization after scar contraction.
in 1984, a CO2 laser is used to ablate the arytenoid cartilage, including the vocal and muscular processes, as well as an area lateral to the vocalis muscle. The result is a lateralization of the posterior third of the vocal fold and thus better vocal quality than other techniques. After a tracheotomy is performed, a laryngoscope is suspended, providing exposure to the posterior commissure and interarytenoid cleft. A CO2 laser (repeat mode 0.1 second at 1,990 W/cm2) then vaporizes the mucoperichondrium above the corniculate cartilage, which is then ablated to expose the apex of the arytenoids (Figure 2). The mucoperichondrium of the arytenoids is then vaporized. With the laser on continuous mode at 3,185 W/cm2, the upper body of the arytenoids is ablated. The laser is then changed back to 1,990 W/cm2 to vaporize the mucoperichondrium of the lower body arytenoids and the lower body itself. The lateral ligament is cut. The vocal process and its connecting vocalis muscle are ablated, without including the attachment of the arytenoideus muscle or the interarytenoid cleft mucosa. A small area lateral to the vocalis muscle is vaporized to allow for further lateralization as the wound heals. In 1996, Remacle et al
described subtotal CO2 laser arytenoidectomy as a derivation of Ossoff’s technique, with the addition of 0.5 mL of slow-setting fibrin glue to the resected area of the arytenoids to decrease the chance of granuloma formation, bleeding, and crusting. A CO2 laser at 7 to 8 W on continuous superpulse mode was employed, and a posterior cartilage shell was preserved for stability of the arytenoids region. Complications of laser arytenoidectomy can include posterior laryngeal webs, especially if the interarytenoid cleft is disturbed, but most patients can be decannulated. Other potential complications include granuloma, arytenoids perichondritis, and endotracheal or tracheal tube fires. Application of fibrin glue can cause additional complications such as aspiration of the glue. The advantage of this procedure over others is improved patient voice, as well as minimal postoperative edema.
Figure 2Endoscopic laser arytenoidectomy. Successive views of the vocal folds after layered ablation with CO2 laser. (A) Endoscopic view of the paralyzed vocal folds. (B) Mucoperichondrium overlying the corniculate cartilage ablated. (C) After ablation down to the cricoid cartilage. Note the medial muscular processes. (D) Final view with remnant of muscular process and attached arytenoideus muscle with ablation lateral to the vocalis muscle to facilitate lateralization. (E) Final third-week postoperative view.
proposed the laser medial arytenoidectomy. This method is based on the concept that the posterior one third of the vocal fold functions as the “respiratory glottis” and the anterior two thirds as the “phonatory glottis”; therefore, a widening of the medial portion of the arytenoid would lead to an increase in the posterior glottis and thus a relief of airway impairment while maintaining adequate phonation (Figure 3). Tracheotomy is not a requirement before the procedure. With a CO2 laser set at 10 to 20 W on a spot size of 0.8 mm, the superior and medial portions of the mucosa are vaporized and the body of the arytenoid cartilage is saucerized. The tip of the laryngeal suction is used to palpate the area that is located between the vocal process and the posterior edge of the arytenoids. The goal is to produce a concavity at the medial edge of the arytenoid body without injuring the cricoarytenoid. The procedure affords 1 to 2 mm of posterior glottic airway. The process can be repeated on the contralateral side 3 months afterward if needed. Aspiration and scar banding can be a problem if arytenoid resection is too aggressive, but otherwise the procedure is usually well tolerated, with minimal phonatory loss.
Figure 3Endoscopic laser medial arytenoidectomy. (A) The areas of the phonatory and respiratory glottis. (B) CO2 laser excision of the arytenoid cartilage and saucerization leading to concavity not involving the cricoarytenoid.
in 1979 as another conservative approach to bilateral abductor paralysis of the vocal folds. In this technique, the most medially positioned vocal fold is selected. After exposure of the larynx endoscopically, the vocal ligament is palpated for cricoarytenoid fixation or ankylosis. The thyroarytenoid muscle is exposed and excised as a wedge paralleling the vocal ligament using the microcautery. This leads to lateralization of the vocal fold. Lichtenberger describes using a CO2 laser to make a longitudinal incision 2 mm from the anterior commissure ending near the vocal process. The vocal process is then lifted with a hook and medialized to expose the thyroarytenoid muscle, which is then removed submucosally with the laser (Figure 4). Hemostasis is obtained with electrocautery. To lateralize the vocal fold, sutures are introduced through two 18-gauge needles placed transcutaneously and through the thyroid cartilage, one above and the other below the level of the vocal folds. The sutures are then pulled out through the laryngoscope, tied together, and then brought back to the level of the vocal folds. The suture ends at the surface of the neck are tensed to create a lateralizing force to the folds and then secured with fishing lead sinkers. If the vocal process projects too far, the cartilage can then be removed with a cup forceps. Lichtenberger’s technique utilizes a 2-0 polypropylene stitch placed transcutaneously using a special endoextralaryngeal needle carrier (Richard Wolf Medical Instruments, Knitlingen, Germany) below the posterior one third of the vocal fold.
The other end is placed above the posterior one third of the vocal fold. The ends are tied over a bent silicon tube at the external neck under tension to allow for appropriate lateralization of the vocal fold. A further stitch can be placed at the middle one third of the vocal fold if needed but may require placement of the stitch anterior to the vocal process to avoid the difficulty of placing a needle through the thyroid cartilage. The sutures are then removed in 2 to 3 weeks and the airway is reassessed for possible decannulation. The major advantage of suture lateralization is its reversibility, especially in light of patients with early bilateral vocal fold immobility. Complications include damage to the vocal fold mucosa, mild aspiration, and odynophagia; however, most patients are able to avoid tracheotomy with this procedure.
Figure 4Endoscopic suture lateralization. (A) An incision is made lateral and parallel to the vocal fold. (B) A wedge of thyroarytenoid muscle is removed, and the base is cauterized. (C) Placement of transcutaneous sutures. (D) The vocal fold is lateralized by a temporary suspension suture. (E) The site 6 weeks after sutures are removed.
In most patients, preprocedure tracheotomy is not required. After the posterior commissure is exposed using suspension microlaryngoscopy, a CO2 laser set to 10 W with a 0.1-second repeat mode is used to produce a C-shaped incision at the posterior membranous vocal fold just anterior to the vocal process of the arytenoids (Figure 5). The incision extends 4 mm laterally along the membranous cord. Care is taken not to expose the cartilage of the vocal process, and char is removed with a moistened pledget. The result is a 6- to 7-mm transverse opening at the posterior larynx as a result of retraction of the divided thyroarytenoid muscle. Eventually, the wedge assumes a rounded tear-shaped opening. Contracture occurs at the anterior portion of the divided thyroarytenoideus, thereby facilitating a midline position of the vocal folds and thus better phonation. A smaller cordectomy can be performed on the contralateral vocal fold after 6 to 8 weeks if the airway is still inadequate. Besides complications that befall laser use, complications to the procedure include granuloma, scarring, arytenoid perichondritis, and vocal fold edema that may necessitate revision or tracheotomy. The procedure is simple, produces predictable results, and does not require tracheotomy in most cases.
Further modifications include the application of topical mitomycin C and using rotational mucosal flaps to order to preserve the surgical airway.
Figure 5CO2 laser posterior partial cordectomy or transverse cordotomy. (A) A C-shaped incision is made anterior to the vocal process. (B) Initial posterior glottal enlargement is obtained with cordotomy. (C) Immediate view. (D) Final result after the healing process.
described this modification of extralaryngeal arytenoidectomy for bilateral abductor vocal fold paralysis in 1953. Formerly, arytenoidectomy was performed via a window through the thyroid cartilage
After tracheotomy is performed, an incision is placed at the anterior border of the sternocleidomastoid muscle at the level of the upper edge of the thyroid cartilage (Figure 6). Once the muscles are exposed, a perichondrial incision is then made along the posterior edge of the lateral thyroid cartilage and its inferior horn, releasing it from the attachments to the inferior constrictor muscle. The inferior horn of the thyroid cartilage is then separated from the cricoid cartilage, and the perichondrium is then incised to expose the cricoarytenoid joint. The majority of the cartilage is removed, except for the part associated with the vocal process. A chromic suture is passed around the remaining arytenoids cartilage, including some vocalis fibers and thyroarytenoid muscle, and tied to the inferior horn of the thyroid cartilage. Further reinforcement is done by anchoring the suture to the anterior edge of the sternocleidomastoid muscle. The larynx is then inspected with a laryngoscope to ensure proper vocal fold position. The layers are then approximated separately with a Penrose drain left in for 48 hours. Woodman’s
where visualization was limited to a small thyroid window.
Figure 6Posterior lateral extralaryngeal arytenoidectomy. (A) An incision is made at the anterior border of the sternocleidomastoid muscle. (B) Incision over the perichondrium lateral to the thyroid ala. (C) Separation of the inferior horn of the thyroid cartilage from the cricoid cartilage exposes the cricoarytenoid joint. (D) The posterior and lateral cricoarytenoid muscles are separated, and the cricoarytenoid joint is disarticulated. (E) The majority of the arytenoid cartilage is removed except for the part associated with the vocal process. (F) A suture is placed around the remaining arytenoid cartilage, including some vocalis fibers and thyroarytenoid muscle, and is tied to the inferior horn of the thyroid cartilage. (G) The larynx is visualized to ensure proper lateralization.
Figure 6Posterior lateral extralaryngeal arytenoidectomy. (A) An incision is made at the anterior border of the sternocleidomastoid muscle. (B) Incision over the perichondrium lateral to the thyroid ala. (C) Separation of the inferior horn of the thyroid cartilage from the cricoid cartilage exposes the cricoarytenoid joint. (D) The posterior and lateral cricoarytenoid muscles are separated, and the cricoarytenoid joint is disarticulated. (E) The majority of the arytenoid cartilage is removed except for the part associated with the vocal process. (F) A suture is placed around the remaining arytenoid cartilage, including some vocalis fibers and thyroarytenoid muscle, and is tied to the inferior horn of the thyroid cartilage. (G) The larynx is visualized to ensure proper lateralization.
introduced laryngeal reinnervation using a nerve-muscle pedicle technique that restored the airway without compromising vocal quality within 6 to 12 weeks, at an overall success rate of 89%. Patients must have had bilateral vocal fold paralysis for 6 months to a year. Cricoarytenoid fixation and central nervous system disease must be ruled out. A midline incision at the lower margin of the thyroid cartilage is placed, extending posteriorly to just beyond the anterior sternocleidomastoid muscle (Figure 7). The branch of the ansa hypoglossi is identified, innervating the anterior belly of the omohyoid muscle, along with its accompanying artery and vein. A small block of muscle not more than 2 to 3 mm is removed as the pedicle. After the inferior constrictor muscle is separated to reveal the fibers of the posterior cricoarytenoid muscles, a small incision is placed to “score” the fibers in preparation to receive the pedicle. The nerve-muscle pedicle is then sutured to the posterior cricoarytenoid muscle. A Penrose drain is placed as the layers are approximated. Despite the reported success with decannulation by the author, others have not been able to reproduce similar success rates, and the technique has not gained popularity compared with endoscopic methods.
Figure 7Neuromuscular pedicle transposition. (A) Stay sutures placed on either side of entry point of ansa hypoglossi to omohyoid muscle. (B) Detail of nerve traveling between muscle fibers before entering muscle. (C) Separation of inferior constrictor muscle. (D) Retraction of pyriform sinus and jugular vein. (E) Placement of a superficial incision and scoring over the posterior cricoarytenoid muscle (note the muscle fibers run perpendicular to the inferior constrictor fibers). (F) Securing of nerve-muscle pedicle onto the posterior cricoarytenoid muscle.
Figure 7Neuromuscular pedicle transposition. (A) Stay sutures placed on either side of entry point of ansa hypoglossi to omohyoid muscle. (B) Detail of nerve traveling between muscle fibers before entering muscle. (C) Separation of inferior constrictor muscle. (D) Retraction of pyriform sinus and jugular vein. (E) Placement of a superficial incision and scoring over the posterior cricoarytenoid muscle (note the muscle fibers run perpendicular to the inferior constrictor fibers). (F) Securing of nerve-muscle pedicle onto the posterior cricoarytenoid muscle.
Other techniques for bilateral vocal fold immobility include posterior laryngoplasty and the posterior commissure split with rib grafting or stenting, as described by Grahne et al
in 1988, respectively. These operations are designed primarily for patients with posterior glottic stenosis, mostly a complication of long-term endotracheal intubation, and will not be covered in this chapter. Another potential for treatment of bilateral vocal fold immobility still undergoing clinical trials is laryngeal pacing of the posterior cricoarytenoid muscle by an implanted electrical stimulator.
The treatment of bilateral vocal fold immobility still presents a surgical challenge to otolaryngologists. Surgical enlargement of the glottic airway can lead to poorer vocal quality and aspiration, although with newer minimally invasive techniques utilizing endoscopy and the CO2 laser, these issues are lessened and patients can often avoid tracheotomy. Endoscopic techniques to remove vocal fold mucosa or arytenoid tissue, along with lateralization of the intact vocal folds, are less invasive and as effective as open procedures but are not exempt from complications such as aspiration, scarring, and mucosal edema. The surgeon should choose a method within his or her expertise that produces reliable results and proves most beneficial to the patient.
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