Management of iatrogenic bilateral vocal cord

paralysis by endoscopic transoral CO2 laser

Management of iatrogenic bilateral vocal cord

paralysis by endoscopic transoral CO2 laser

surgery

Management of iatrogenic bilateral vocal cord

paralysis by endoscopic transoral CO2 laser

Case Report

Management of iatrogenic bilateral vocal cordparalysis by endoscopic transoral CO2 lasersurgery e Report of two cases

Shantanu Panja

Senior Consultant, ENT & Head and Neck Surgery Apollo Gleneagles Hospitals, Kolkata, India

a r t i c l e i n f o

Article history:

Received 4 February 2014

Accepted 5 February 2014

Available online 17 March 2014

Keywords:

Bilateral vocal cord paralysis

CO2 laser

Cordectomy

Thyroidectomy

a b s t r a c t

Bilateral vocal fold paralysis is a rare condition. The commonest cause identified is mostly

iatrogenic. It can be extremely debilitating for the patient who usually suffers from severe

breathlessness on slightest exertion. Many of them requires a tracheostomy to maintain

airway. The treatment of bilateral vocal cord palsy is a balance between phonation, airway

and swallowing. Several surgical modalities have been described for cases which doesn’t

improve with conservative management. However transoral CO2 laser endoscopic aryte-

noidectomy has become the standard of management today for this condition. CO2 laser is

arguably the most appropriate tool for cordectomy with the advantage of increased pre-

cision, better hemostasis and minimal tissue handling. We describe the procedure of

posterior cordectomy with partial arytenoidectomy using transoral CO2 laser in two pa-

tients who were successfully managed for this condition in our centre.

Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Bilateral vocal cord immobility is a rare condition and is

mostly iatrogenic in nature. It can be caused by surgical

trauma (mainly thyroid surgery), malignancies, endotracheal

intubation, neurologic disease and idiopathic causes.1 The

voice quality is not affected as the vocal cords are in adduction

with an inability to abduct. However the patients develop

respiratory distress and sometimes stridor with minimal

exertion which can be life threatening. Many a times the pa-

tients need to undergo tracheostomy as a life saving measure

(Figs. 1 and 2).

The goal of treatment for this condition is to achieve a

delicate balance between phonation, respiration and aspira-

tion. Since 19th century various surgical techniques have

evolved to give an adequate glottic opening to the patient

without compromising on the voice quality and/or causing

aspiration. At present CO2 laser is considered to be the most

appropriate tool for carrying out cordectomy to achieve this

goal because of better hemostasis, increased precision, less

morbidity and superior outcomes.

In this article I present two cases of bilateral vocal cord

palsy following thyroid surgery that were managed in our

centre successfully by laser posterior cordectomy with partial

arytenoidectomy.

E-mail addresses: shantanu.panja@gmail.com, dr_spanja@yahoo.co.in.

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier .com/locate /apme

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 4 6e4 8

http://dx.doi.org/10.1016/j.apme.2014.02.0010976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

2. Case report

The first patient was a 32-year-old female from Kolkata who

underwent thyroidectomy for a colloid goitre elsewhere about

one year back before she presented to us. The second patient

was a 45-year-old female from Pakistan who underwent thy-

roid surgery twice in her country for a benign thyroid disease

leaving both her vocal cords paralysed. Both the patients

presented with severe respiratory distress and stridor on

slightest exertion, whistling sound at night and disturbed

sleep. The voice was unaffected and there was no difficulty on

swallowing. Both the patients were misdiagnosed and

wrongly treated for asthma by local physicians for several

months before they came to us for treatment.

Both the patients were investigated with endoscopy, radi-

ology and pulmonary function test (PFT). Fibreoptic laryn-

goscopy and digital videostroboscopy was carried out to

evaluate the vocal cords and airway. The vocal cords were

found to be fixed in paramedian position with minimal glottic

chink. Notably the second patient had a very high TSH level of

30.4. However a normal free T4 and T3 allowed us to take the

risk of surgery.

3. Operative technique

The surgery was carried out under general anaesthesia with a

double-cuffed stainless steel laser safe endotracheal tube and

placing wet cottonoids in the endolarynx.

A suspension laryngoscope was used to get adequate

exposure, especially of the posterior glottis. Cricoarytenoid

mobility was checked using a probe.

A CO2 laser was used, coupled with Acublade�, an auto-

mated scanning device. This laser was coupled to an operating

microscope for surgery. Laryngeal microsurgical instruments

specially adapted for laser surgery with suction and cautery

attachments were used.

The surgery began by incising the vocal cord with laser just

anterior to the vocal process of arytenoids reaching upto the

paraglottic space thereby allowing the membranous vocal

cord to retract anteriorly. The vocal process of arytenoids

alongwith posterior third of true cordwas excised. Themedial

part of arytenoid was vaporised by using the laser in a scanner

mode leaving adequate posterior shell of arytenoids to pre-

vent aspiration. An adequate glottic chink of 5e6 mm was

created. Mitomycin-C soaked cottonoids were applied on the

operative bed for 2 min to prevent postoperative fibrosis. The

bed was then covered with fibrin glue to prevent any granu-

loma formation.

Postoperatively both the patients were extubated without

any complication. Antibiotics, steroids, mucolytic agents and

nebulisation were used in the postoperative period. Both the

patients had significant symptomatic improvement from the

very next day and started having normal diet without any

features of aspiration. Stridor and respiratory distress

completely disappeared. The initial dysphonia improved with

time as the neocord formation took place. The operative time

was about 45 min and the patients were discharged from the

hospital within 48 h.

4. Discussion

Surgical trauma is considered to be the commonest cause of

bilateral vocal fold immobility. Thyroid surgery by far ac-

counts for the maximum number of bilateral palsy. For pa-

tients with bilateral vocal fold paralysis (BVFP) due to

iatrogenic injury in which the recurrent laryngeal nerve (RLN)

or vagus nerve is injured (neurapraxia) but not severed,

Fig. 1 e Pre-operative bilateral abductor palsy.

Fig. 2 e Post-operative laser cordectomy.

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 4 6e4 8 47

permanent surgical treatment should be postponed for at

least 9 months after injury to allow spontaneous recovery.

Laryngeal electromyographic (EMG)monitoring can be helpful

in obtaining an index of potential recovery. Both the patients

in our case presented after one year and fortunately didn’t

undergo a tracheostomy to maintain airway.

Since 1922 surgical treatment of bilateral immobile cords

have evolved with time. Several surgical methods have been

designed to attain good respiration, phonation and swallow-

ing. The method adopted by Chevalier Jackson introduced of

ventriculocordectomy, where by the entire vocal cord and

ventricle was excised,2 creating an excellent airway but

resulted in breathy voice. Sub mucosal resection of vocal fold

proposed by Hoover resulted in excessive scarring and thus

leading to glottic stenosis and postoperative dysphonia.3

Procedures on arytenoids included extra laryngeal arytenoi-

dectomy4 in which arytenoid cartilage was freed from all its

muscular and ligamental attachments except the vocal mus-

cle. In lateralization procedure, the arytenoids are fixed

laterally to the thyroid ala. This wasmodified by fixation of the

corresponding vocal fold in order to conserve a good glottic

opening.5 Various techniques of endoscopic approach for the

treatment of bilateral vocal fold immobility have been pro-

posed and have been modified by various surgeons.6,7 The

laser surgical technique described in the article is considered

to be one of the best, minimally invasive techniques which

gives a satisfactory outcome.

The distinct advantages of laser cordectomy with partial

arytenoidectomy in managing bilateral cord immobility are

less surgical time, minimum morbidity, no surgical scar,

absence of laryngeal edema, good hemostasis, better post-

operative pulmonary function, less hospitalization, satisfac-

tory outcome and scope of revision surgery if need arises. The

posterior cartilaginous shelf preserved provides good stability

to the arytenoid region and prevents aspiration.8 Patient does

have some dysphonia, but this can be minimized by preser-

vation of as much as possible of the vibrating portion of the

vocal cord. The contraindications for the surgery includes

patients with concurrent pulmonary, neurological and ma-

lignant disease, a simultaneous lesion compromising the

airway like a subglottic stenosis and pediatric age group with

age less than 12 years.

5. Conclusion

CO2 laser cordectomy with partial arytenoidectomy by

Transoral endoscopic route is an excellent and less morbid

alternative modality to open procedure for managing bilateral

vocal cord paralysis. However precision needs to be exercised

to maintain the balance between airway, phonation and

swallowing and to avoid long term complications.

Conflicts of interest

The author has none to declare.

r e f e r e n c e s

1. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocalfold immobility. Laryngoscope. Sep 1998;108(9):1346e1350.

2. Jackson C. Ventriculocordectomy. A new operation for the cureof goitrous glottic stenosis. Arch Surg. 1922;4:257e274.

3. Hoover WB. Bilateral abductor paralysis, operative treatmentof submucous resection of the vocal cord. Arch Otolaryngol.1932;15:337e355.

4. King BT. A new and function restoring operation for bilateralabductor cord paralysis. JAMA. 1939;112:814e823.

5. Kelly JD. Surgical treatment of bilateral paralysis of theabductor muscles. Arch Otolaryngol. 1941;33:293e304.

6. Thornell WC. Intralaryngeal approach for arytenoidectomy inbilateral abductor vocal cord paralysis. Arch Otolaryngol.1948;47:505e508.

7. Dennis DP, Kashima H. Carbon dioxide laser posteriorcordectomy for treatment of bilateral vocal cord paralysis. AnnOtol Rhinol Laryngol. 1989;98:930e934.

8. Plouin-Gaudon I, Lawson G, Jamart J, Remacle M. Subtotalcarbon dioxide laser arytenoidectomy for the treatment ofbilateral vocal fold immobility: long term results. Ann OtolRhinol Laryngol. 2005;114:115e121.

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