MANAGEMENT OFMANAGEMENT OF B/L Vocal Cord B/L Vocal Cord Paralysis

DR.ROOHIADR.ROOHIA

Various surgical Various surgical interventions for interventions for BVFPBVFP classified into classified into many waysmany ways

Major Major characteristics characteristics structural changes structural changes at glottic level.at glottic level.

Another important Another important feature is surgical feature is surgical approach approach

TYPES OF BVFP:TYPES OF BVFP: 1.B/L Abductor paralysis1.B/L Abductor paralysis 2.B/L Adductor paralysis2.B/L Adductor paralysis The final position of cord depends onThe final position of cord depends on Function of cricothyroid(SLN)Function of cricothyroid(SLN) Fibrosis of denervated muscleFibrosis of denervated muscle Ankylosis of cricoarytnoid jointAnkylosis of cricoarytnoid joint Tension of conus elasticusTension of conus elasticus Weight of vocal cordWeight of vocal cord

Indications:symptomatic airway obstructionsymptomatic airway obstruction

Contraindication:1-Rapidly progressive neurologic disorder2-Unrealistic patient expectations (improvement in bothairway and voice)

Relative contraindications to treatment include:■ Presence of aspiration■ Compromised pulmonary status■ Diabetes (more true for open procedures than endoscopic)■ Previous radiation therapy to the neck/larynx

Treatment options for BVFP include:Treatment options for BVFP include: In the early 1900s, the only treatment option for bilateral vocalIn the early 1900s, the only treatment option for bilateral vocal cord palsy was tracheostomycord palsy was tracheostomy B/L Abductor paralysisB/L Abductor paralysis:: Extra laryngeal:Extra laryngeal: ARYTENOIDECTOMYARYTENOIDECTOMY

-----KING’ s-----KING’ s - woodmanns - woodmanns -Kelly’s-Kelly’s -Orton’s-Orton’s - Downie’s- Downie’s - Montgomery’s - Montgomery’s -McCall &Gardner-McCall &Gardner - type 2 thyroplasty- type 2 thyroplasty

intralaryngealintralaryngeal ■ ■ Microlaryngoscopy with laser Microlaryngoscopy with laser

posterior transverse posterior transverse cordotomycordotomy ■ ■ Microlaryngoscopy with laser Microlaryngoscopy with laser

medial arytenoidectomymedial arytenoidectomy ■ ■ Microlaryngoscopy with laser Microlaryngoscopy with laser

total arytenoidectomytotal arytenoidectomy ■ ■ Endoscopic suture lateralizationEndoscopic suture lateralization

B/L Adductor paralysisB/L Adductor paralysis:: Permanent tracheostomyPermanent tracheostomy Nasogastric tube for feedingNasogastric tube for feeding Epiglottopexy can be done where Epiglottopexy can be done where

subsequent neurological subsequent neurological improvement may occurimprovement may occur

Open ArytenoidectomyOpen Arytenoidectomy

An anterior laryngofissure or a lateral approach

reserved for cases where endoscopic techniques have failed or are impossible due to anatomic limitations, and thus is rarely required.

In 1939 King’s first In 1939 King’s first described the extra described the extra laryngeal procedure laryngeal procedure for abduction of for abduction of arytenoids.arytenoids.

Arytenoids and Arytenoids and paralysed cord paralysed cord mobilised and fixed mobilised and fixed in lateral position & in lateral position & attached to severed attached to severed omohyoid & thyroid omohyoid & thyroid ala.ala.

KELLY’S Operation:KELLY’S Operation: This technique developed to avoid difficulty This technique developed to avoid difficulty

approach to arytenoid.approach to arytenoid. Thyroid muscle elevated frm side of thyroid Thyroid muscle elevated frm side of thyroid

ala &window of 1.5cmm in post portion of ala &window of 1.5cmm in post portion of ala.ala.

Slit in internal perichondrium,through Slit in internal perichondrium,through thyroarytenoid ,arytenoid approachedthyroarytenoid ,arytenoid approached

Vocal process to be lateralised suturd to Vocal process to be lateralised suturd to xternal perichondrium at margins of windowxternal perichondrium at margins of window

Woodmanns ‘s :1946 Woodmanns ‘s :1946 TracheostomyTracheostomy Insicion along ant. Border of Insicion along ant. Border of SCM,retracted.SCM,retracted. Cut constrictor on back of thy lamina,rotate Cut constrictor on back of thy lamina,rotate

larynx.larynx. Visualise cricothyroid joint disarticulated,pull Visualise cricothyroid joint disarticulated,pull

thy.cart forward &rotate cricoid to see PCA.thy.cart forward &rotate cricoid to see PCA. Access to arytenoid disarticulate Access to arytenoid disarticulate

submucosally,identify vocal process suture submucosally,identify vocal process suture it to inf horn of thy to lateralise cord.it to inf horn of thy to lateralise cord.

ORTON’SORTON’S After skin and subcutaneous incisionAfter skin and subcutaneous incision Vertical incision ant. To post. Border Vertical incision ant. To post. Border

of thyroid ala through the muscles of thyroid ala through the muscles and external perichondrium is and external perichondrium is dessected frm post.border. Incision dessected frm post.border. Incision internal perichondrium reach internal perichondrium reach arytenoid,vocal process sutured to arytenoid,vocal process sutured to thyroid ala&outer perichondriumthyroid ala&outer perichondrium

McCall &Garener’sMcCall &Garener’s Same as kelly’s here brightly lit Same as kelly’s here brightly lit

laryngosope used to press laryngosope used to press arytenoid laterally against arytenoid laterally against ala ,then it can b identified by ala ,then it can b identified by transilluminationtransillumination

Downe’s Downe’s ArytenoidectomyArytenoidectomy Collar incision at level of thy Collar incision at level of thy

cartilagecartilage Upper&lower flaps elevateUpper&lower flaps elevate Cut vertivally in midline of thyroid Cut vertivally in midline of thyroid

cartcart Retract each lamina Retract each lamina Remove one arytenoid by incising Remove one arytenoid by incising

frm apex to vocal rocess and frm apex to vocal rocess and removedremoved

Expose one side of outer surface Expose one side of outer surface of thy cartilage of thy cartilage

Needle of 24G Pass through Needle of 24G Pass through cartilage emerge in laryngeal cartilage emerge in laryngeal lumen immediately inf.to post end lumen immediately inf.to post end of vocal cord.of vocal cord.

Pass out through the ventricle Pass out through the ventricle immediately superior to posterior immediately superior to posterior edge of vc now again emerges edge of vc now again emerges outside thyroid cartilage.outside thyroid cartilage.

Tighten ends of wire to drawn vc Tighten ends of wire to drawn vc laterally.laterally.

Montgomery’sMontgomery’s Specially designed pins & Specially designed pins &

pinholders used to lateralised pinholders used to lateralised arytenoid.arytenoid.

Pin placed through the body of Pin placed through the body of arytenoid cartilage entering joint arytenoid cartilage entering joint space, ushed through rostrum of space, ushed through rostrum of cricoid posterior lamina.cricoid posterior lamina.

The CO2 laser was first used for The CO2 laser was first used for arytenoidectomy by Eskew and Bailey in 1983,arytenoidectomy by Eskew and Bailey in 1983,

adapted for patients with bilateral vocal cord adapted for patients with bilateral vocal cord palsy by Ossoff with good results.palsy by Ossoff with good results.

In 1989, Dennis and Kashima introduced the In 1989, Dennis and Kashima introduced the posteriorcordectomy technique, which entails posteriorcordectomy technique, which entails excision of the posterior part of the vocal cord excision of the posterior part of the vocal cord with the CO2 laser without arytenoidectomywith the CO2 laser without arytenoidectomy

Eckel et al. compared laser arytenoidectomy Eckel et al. compared laser arytenoidectomy and laser cordectomy and found them both to and laser cordectomy and found them both to have a more than 90% success rate.have a more than 90% success rate.

Laser cordotomyLaser cordotomy

Incision is started just anterior to vocal process, being careful not to expose the cartilage, to avoid granulation tissue postoperatively.

A complete cordotomy extends laterally 3–4 mm into the false vocal fold tissue/musculature

Frequently, a branch of the superior laryngeal arteryis encountered, and troublesome bleeding can occur. Suction and bipolar laryngeal cautery are effective in stopping the bleeding.

Laser Medial Laser Medial arytenoidectomyarytenoidectomy

obliterate the medial-most portionof the arytenoid cartilage for approximately 2–3mm in width.

The anterior–posterior dimensions of this area ofobliteration should be posterior to the tip of the vocal Process preserving all or most of the vocal process.

Posterior cordotomy Posterior cordotomy with partial with partial arytenoidectomyarytenoidectomy

Posterior Cordotomy Submucosa disection of arytenoid cartilage

Subtotal Arytenoidectomy Vaporization of the fibers of thyroidarytenoidmuscle

Bloody area covering with mucosa flap

the first endoscopic the first endoscopic arytenoidectomy, performed by arytenoidectomy, performed by Thornell , the arytenoid cartilage Thornell , the arytenoid cartilage was dissected after tracheostomy, was dissected after tracheostomy, with coagulation of the exposed with coagulation of the exposed area to promote scarring.area to promote scarring.

This method had a reported This method had a reported success rate of 80%success rate of 80%

Endoscopic Suture Endoscopic Suture LateralizationLateralization used as a temporizing measure in used as a temporizing measure in

patients with early symptomatic BVFP patients with early symptomatic BVFP who have an uncertain prognosis for who have an uncertain prognosis for recovery.recovery.

Or permanent with partial Or permanent with partial arytenoidectomyarytenoidectomy

should not be carried out if the should not be carried out if the patient has suffered recent trauma to patient has suffered recent trauma to the posterior glottis from an ETT or is the posterior glottis from an ETT or is currently intubatedcurrently intubated

Microtrapdoor flap Microtrapdoor flap technique technique The microtrapdoor flap The microtrapdoor flap

technique first described technique first described by Dedo & Sooy was used by Dedo & Sooy was used initially in eight patients initially in eight patients with posterior glottic with posterior glottic stenosisstenosis

incision is made on the incision is made on the superior surface of the superior surface of the stenosis, the submucosa is stenosis, the submucosa is dissected with CO2 laser to dissected with CO2 laser to create a bipediculated create a bipediculated lateral mucous flap, and lateral mucous flap, and the underlying scar tissue the underlying scar tissue is removed. is removed.

a vertical incision was made on a vertical incision was made on the vocal process on one side the vocal process on one side and extended through a and extended through a horizontal incision on the horizontal incision on the posterior interarytenoid surface posterior interarytenoid surface to the other side, thereby to the other side, thereby creating a crescent moon-creating a crescent moon-shaped unilaterally based shaped unilaterally based mucous flap. mucous flap.

The submucosal scar is easily The submucosal scar is easily vaporized by CO2 laser (0.25 vaporized by CO2 laser (0.25 mm microspot, superpulse mm microspot, superpulse mode, 5 watts). The mucous flap mode, 5 watts). The mucous flap is thinned and placed over the is thinned and placed over the open surface on one side and open surface on one side and fixed with fibrin gel on the site . fixed with fibrin gel on the site . This is the unilateral This is the unilateral microtrapdoor flap technique microtrapdoor flap technique

Treatment – Laryngeal Treatment – Laryngeal reinnervationreinnervation Goal: Increase bulk and toneGoal: Increase bulk and tone Indications: Poor chance of Indications: Poor chance of

spontaneous recoveryspontaneous recovery

TypesTypes

Phrenic to Posterior Phrenic to Posterior Cricoarytenoid anastamosisCricoarytenoid anastamosis– Allows abduction during Allows abduction during

inspirationinspiration– Preserves voice when Preserves voice when

successfulsuccessful Electrical PacingElectrical Pacing

– Timed to inspiration with Timed to inspiration with electrode placed on posterior electrode placed on posterior cricoarytenoidcricoarytenoid

– Long-term efficacy not yet Long-term efficacy not yet shownshown

ANSA-ANSA-NMP(tucker)1976NMP(tucker)1976

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