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Management of iatrogenic bilateral vocal cord paralysis by endoscopic transoral CO2 laser surgery
The document discusses the management of iatrogenic bilateral vocal cord paralysis through endoscopic transoral CO2 laser surgery, highlighting two successful case reports. It details the surgical technique, benefits of using CO2 laser for cordectomy, and the patients' improvements post-surgery. This minimally invasive approach is noted for its precision, reduced morbidity, and favorable outcomes in restoring airway function while maintaining voice quality.
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Management of iatrogenic bilateral vocal cord paralysis by endoscopic transoral CO2 laser surgery
- 1. Management of iatrogenicbilateral 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
- 2. Case Report Management ofiatrogenic bilateral vocal cord paralysis by endoscopic transoral CO2 laser surgery 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 6 e4 8 http://dx.doi.org/10.1016/j.apme.2014.02.001 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
- 3. 2. Case report Thefirst 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 AcubladeÒ, 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 along with posterior third of true cord was excised. The medial 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 6 e4 8 47
- 4. permanent surgical treatmentshould 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 was modified 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 vocal fold immobility. Laryngoscope. Sep 1998;108(9):1346e1350. 2. Jackson C. Ventriculocordectomy. A new operation for the cure of goitrous glottic stenosis. Arch Surg. 1922;4:257e274. 3. Hoover WB. Bilateral abductor paralysis, operative treatment of submucous resection of the vocal cord. Arch Otolaryngol. 1932;15:337e355. 4. King BT. A new and function restoring operation for bilateral abductor cord paralysis. JAMA. 1939;112:814e823. 5. Kelly JD. Surgical treatment of bilateral paralysis of the abductor muscles. Arch Otolaryngol. 1941;33:293e304. 6. Thornell WC. Intralaryngeal approach for arytenoidectomy in bilateral abductor vocal cord paralysis. Arch Otolaryngol. 1948;47:505e508. 7. Dennis DP, Kashima H. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol. 1989;98:930e934. 8. Plouin-Gaudon I, Lawson G, Jamart J, Remacle M. Subtotal carbon dioxide laser arytenoidectomy for the treatment of bilateral vocal fold immobility: long term results. Ann Otol Rhinol Laryngol. 2005;114:115e121. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 4 6 e4 848
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