LARYNGOLOGY SEMINAR
Management of Bilateral Vocal Cord Immobility
R3 黃同村 2002-10-23
Introduction of vocal cord immobility (Hillel et al, 1999)
 Paralysis
 Synkinesis
 Cricoarytenoid joint fixation

Interarytenoid scar ( posterior glottic stenosis)
Etiology (Benninger et al, 1998)
 Henry Ford Hospital, 1985-1995: unilateral 280, bilateral 117
Evaluation
 Thorough history
 Complete head and neck examination (include larynx)
 Chest X-ray
 Neck CT [skull base to thoracic inlet (right) or aortic arch (left)]
 Larynx EMG (etiology, prognosis)
 Others: panendoscope, CT or MRI of chest or neck and head, barium swallowing,
metabolic study, palpation of arytenoids
Management
 Principle
1. Early intervention when specific causes or permanent injury
2. Wait 6-12 months for recovery
3. Balance of airway and voice quality
Goal: improve airway, avoid breathy voice or incompetent larynx

Endoscopic Surgery
External Procedure
Vocal cord laterization or arytenoidopexy
Arytenoidectomy: partial or total
Laser cordectomy or cordotomy


Arytenoidectomy
Reinnervation
Laryngeal electrical pacing
Tracheostomy: temporary or permanent (with speaking valve)
Medical or no treatment with regular observation
Arytenoidectomy
 Posterolateral extralaryngeal approach, vocal process left and sutured to thyroid
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ala (Woodman 1946)


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Endoscopic arytenoidectomy with electrocautery (Thornell 1948)
Endoscopic laser arytenoidectomy (Ossoff et al, 1983)
1. Vaporization of mucosa overlying arytenoids, arytenoids cartilage, a portion
of posterior membranous vocal fold
2. Potential Complication: formation of granuloma, posterior web, inadequate
airway, loss of adequate voice, cricoid perichondritis, tube ignition
3. 28 patients, 86% decannulation, 7% fail, 7% lost f/u (Ossoff et al, 1990)
Modification of Ossoff’s technique: varying portion preserved
1. Crumley 1993: only medial portion of one or both arytenoid bodies
2. Remacle et al, 1996: subtotal, preserve a shelf of posterior aspect
Laser cordectomy or cordotomy
 Posterior cordectomy, CO2 laser (Dennis & Kashima, 1989)
1.



c-shape of membranous vocal ford removed just anterior to vocal process,
unilateral , bilateral or stepwise manner
2. good voice, no swallowing impairment, no aspiration, no tracheostomy
Transverse cordotomy, CO2 laser (Kashima HK 1991)
posterior portion of vocal cord released from vocal process
Eckel et al, 1994: laser cordectomy versus laser arytenoidectomy
1. equally effective, both affect voice to unpredictable degree
2. cordectomy: faster and easier to perform, no subclinical aspiration
Segas et al, 2001: modification of Kashima’s cordotomy
1. Modification of Kashima’s cordotomy: posterior cordectomy of true & false
folds
2. Advantage: rapidity and simplicity, reliability of outcome, short
hospitalization, low risk of complication, possibility for revision
3. Complication: edema, granuloma, scar formation
4. Post-op antireflux therapy
5. Algorithm for bilateral vocal palsy (University of Athens, Greece)
Elective tracheostomy + posterior ventricular cordectomy → ok
↓
Revised + contralateral posterior cordectomy, limited→ ok
↓
Revised or medial arytenoidectomy
Vocal cord laterization or arytenoidopexy
 Ejnell et al, 1984: suture laterization of one immobile vocal fold
2

Alternative to tracheostomy, for case with favorable prognosis for recovery or


long term solution
Easy to perform, adjustable, reversible
Combined with endolaryngeal arytenoidectomy (Moustafa et al, 1992)
Reinnervation
 Reinnervation of PCA for RLN or VN paralysis
 Neuromuscular pedicle: ansa hypoglossi + omohyoid → PCA (Tucker 1976)


Tucker, 1989: 74% success in 202 patients
Direct nerve implant: phrenic nerve in animal model
Difficult technique
Laryngeal electrical pacing
 Implant a pacing device into PCA, trigger with inspiration


First in human larynx by Zealear et al, 1996
Experimental
Others
 Specific management for posterior glottic stenosis
1. Endoscopic lysis of web, scar with cold or laser ± keel + antireflux
2.
3.


Endoscopic postcricoid advancement flap for PGS (Goldberg, 2000)
Anterior laryngofissure for web or scar division/excision + flap ± stent
Botulinum toxin to adductor muscles in synkinesis
Laryngeal muscular tenotomy for bilateral midline vocal cord fixation
1. selective tenotomy of IA, TA
2. Rontal and Rontal, 1994: 100% success and excellent voice
Conclusion
 Choice determined by individual needs, diagnosis and surgeon’s preference
 Reserve irreversible procedures for permanent injuries or after sufficient time for
spontaneous resolution
Reference
1. Bailey: Head & Neck surgery-Otolaryngology, 3rd edition, 607-616, 2001
2. Bruce Benjamin: Endolaryngeal surgery, 125-141, 1998
3. Gardner GM: PGS and BVCI, diagnosis and treatment. Otolaryngol Clin North
Am, 33: 855-877, 2000
4. Hillel AD et al: Evaluation and management of BVCI. Otolaryngol Head Neck
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Surg, 121: 760-5, 1999
5. Benninger MS et al: changing etiology of VFI. Laryngoscope 108: 1346-50, 1998
6. Eckel HE et al: cordectomy versus arytenoidectomy in management of bilateral
vocal paralysis. Ann Otol 103: 852-7, 1994
7. Rontal MR, Rontal E: use of laryngeal muscular tenotomy for bilateral midline
vocal cord fixation. Ann 103: 583-9, 1994
8. Ossoff RH et al: endoscopic laser arytenoidectomy revised. Ann 99: 764-771,
1990
9. Dennis DP, Kashima H: CO2 posterior cordectomy for treatment of BVCP.
Ann 98: 930-4, 1989
10. Kashima HK: bilateral vocal fold motion impairment: pathophysiology and
management by transverse cordotomy. Ann 100, 717-721, 1991
11. Segas J, et al: management of BVFP: experience at university of Athens.
Otolaryngol Head Neck Surg, 124: 68-71, 2001
12. Hawthorn and Nunez: Bilateral vocal cord palsy: alternative to tracheostomy. J
Otolaryngol 21: 364-5, 1992
13. Lichtenbeeerger G: reversible laterization of the paralyzed VC without
tracheostomy. Ann 111: 21-5, 2002
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