Endoscopic posterior cordotomy for treatment of dyspnea due to vocal fold immobility (original) (raw)
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Bilateral vocal fold immobility (BVFI) is a challenging clinical entity for laryngologists. The voice may be nearly normal, but mostly there is a severe inspiratory deficiency. The patients may need surgical interventions primarily for life-threatening dyspnea. While treating the dyspnea, dysphonia appears to be a problem to a certain extent. It is necessary to maintain a balance between providing a serviceable voice and prevention from further surgery for relapsing dyspnea. In the literature, there are various techniques which have been introduced for the surgical management of BVFI. In this report we present a modified approach performed on a BVFI patient, targeting to balance between dyspnea and dysphonia.
Posterior cordotomy in bilateral vocal cord paralysis
Journal of Otolaryngology-ENT Research, 2022
To determine the rate of resolution of inspiratory dyspnea or decannulation in patients with bilateral cord paralysis in adduction, treated with posterior cordotomy and partial arytenoidectomy. Design Descriptive and retrospective. Methods The electronic medical records of patients who consulted for inspiratory dyspnea or had a tracheostomy due to upper airway obstruction caused by bilateral cord paralysis in adduction between March 2004 and December 2018 were analyzed.
Vocal cord dysfunction treated with long-term tracheostomy: 2 case studies
Annals of Allergy, Asthma & Immunology, 2007
Background: Vocal cord dysfunction (VCD) is an increasingly recognized condition that affects the upper airway, which can be difficult to discriminate from asthma. Speech therapy and psychological cognitive therapy are the mainstays of treatment, but other modalities have been used when response is unsatisfactory.
ORL, 2013
Background/Aims: Rehabilitation of the bilaterally paralyzed human larynx remains a complex clinical problem. Conventional treatment generally involves surgical enlargement of the compromised airway, but often with resultant dysphonia and risk of aspiration. In this retrospective study, we compared one such treatment, posterior cordotomy, with unilateral laryngeal pacing: reanimation of vocal fold opening by functional electrical stimulation of the posterior cricoarytenoid muscle. Methods: Postoperative peak inspiratory flow (PIF) values and overall voice grade ratings were compared between the two surgical groups, and pre-and postoperative PIF were compared within the pacing group. Results: There were 5 patients in the unilateral pacing group and 12 patients in the unilateral cordotomy group. Within the pacing group, postoperative PIF values were significantly improved from preoperative PIF values (p = 0.04) without a significant effect on voice (grade; p = 0.62). Within the pacing group, the mean postoperative PIF value was significantly higher than that in the cordotomy group (p = 0.05). Also, the mean postoperative overall voice grade values in the pacing group were significantly lower (better) than those of the cordotomy group (p = 0.03). Conclusion: Unilateral pacing appears to be an effective treatment superior to pos terior cordotomy with respect to postoperative ventilation and voice outcome measures.
Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation
JAMA Otolaryngology–Head & Neck Surgery
and mechanical ventilation are life-saving treatments for acute respiratory failure but are complicated by significant rates of dyspnea and dysphonia after extubation. Unilateral vocal fold immobility (UVFI) after extubation can alter respiration and phonation, but its incidence, risk factors, and pathophysiology remain unclear. OBJECTIVES To determine the incidence of UVFI after prolonged (>12 hours) mechanical ventilation in a medical intensive care unit and investigate associated clinical risk factors for UVFI after prolonged mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS This subgroup analysis of a prospective cohort study was conducted in a single-center medical intensive care unit from August 17, 2017, through May 31, 2018, among 100 consecutive adult patients who were intubated for more than 12 hours. Patients were identified within 36 hours of extubation and recruited for study enrollment. Those with an established tracheostomy prior to mechanical ventilation, known laryngeal or tracheal pathologic characteristics, or a history of head and neck radiotherapy were excluded. EXPOSURE Invasive mechanical ventilation via an endotracheal tube. MAIN OUTCOMES AND MEASURES The incidence of UVFI as determined by flexible nasolaryngoscopy. RESULTS One hundred patients (62 men [62%]; median age, 58.5 years [range, 19.0-87.0 years]) underwent endoscopic evaluation after extubation. Seven patients had UVFI, of which 6 cases (86%) were left sided. Patients with hypotension while intubated (odds ratio [OR], 10.8; 95% CI, 1.6 to ϱ), patients requiring vasopressors while intubated (OR, 16.7; 95% CI, 2.4 to ϱ), and patients with a preadmission diagnosis of peripheral vascular disease (OR, 6.2; 95% CI, 1.2-31.9) or coronary artery disease (OR, 5.1; 95% CI, 1.0-25.5) were more likely to develop UVFI. CONCLUSIONS AND RELEVANCE Unilateral vocal fold immobility occurred in 7 of 100 patients in the medical intensive care unit who were intubated for more than 12 hours. Unilateral vocal fold immobility was associated with inpatient hypotension and preadmission vascular disease, suggesting that ischemia of the recurrent laryngeal nerve may play a role in disease pathogenesis.
Glottic airway gain after ‘suture arytenoid laterofixation’ in bilateral vocal cord paralysis
Acta Oto-laryngologica, 2015
Conclusion: This method is an easy, non-expensive, and effective technique in bilateral vocal cord paralysis to improve glottic airway and clinical performance. Objective: To evaluate the effectiveness of 'suture arytenoid laterofixation' surgery in bilateral vocal cord paralysis. Materials and methods: A retrospective analysis of patients' medical history undergoing 'suture arytenoid laterofixation' surgery for bilateral vocal cord paralysis. This technique was applied under general anesthesia with both microlaryngoscopy and video-monitoring. Two 16 g needles and one 1/0 nylon thread were used for the procedure with 1 cm skin incision; no tracheotomy or tissue excision was required. Pre-post-operative photographs of the glottic region were taken from the endoscopic records, and the areas of rima glottis openings were calculated with the Image-J programme. Results: Forty-seven patients were analyzed. The mean pre-post-operative rima glottis areas were 1.11 ± 0.56 and 2.24 ± 0.93 mm 2 , respectively (p < 0.001). Five patients with previous tracheotomy were decannulated within a few days after the operation. In three patients, mild complications developed in the early post-operative period (two laryngeal edemas, one submucosal hematoma). Tracheotomy was performed to only one pregnant patient in the post-operative first day. None of the patients had granulation formation or synechia.
Outcomes of CO2 laser-assisted posterior cordectomy in bilateral vocal cord paralysis in 132 cases
Lasers in Medical Science
The purpose of the study was to assess the role of laser-assisted posterior cordectomy in the management of patients with bilateral vocal cord paralysis. We aimed an analysis of 132 consecutive patients treated by CO 2 laser posterior cordectomy, aged 38-91, 31% tracheotomized on admission. Cordectomy was performed under microlaryngoscopy using CO 2 laser (Lumenis AcuPulse 40 CO 2 laser, wavelength 10.6 μm, Lumenis Ltd., Yokneam, Israel). We looked at the number of laser glottic procedures necessary to achieve decannulation in tracheotomized patients and to achieve respiratory comfort in non-tracheotomized subjects and we evaluated the two groups for differences in patient characteristics. In tracheotomized patients, we also assessed factors affecting the success of decannulation and we evaluated the impact of tracheotomy on patients' lives. Decannulation was performed in 63% of tracheotomized patients. In terms of the number of procedures, 54% (14), 19% (5), and 27% (7) tracheotomized vs. 74% (61), 24% (20), and 2% (2) non-tracheotomized subjects underwent one, two, or three procedures, respectively. In the group of tracheotomized patients who were successfully decannulated, the number of multiple laser-assisted procedures was significantly higher than in the group of non-tracheotomized subjects with respiratory comfort after treatment (p = 0.04). Advanced age (> 66 years), comorbidities (diabetes, gastroesophageal reflux disease (GERD)), multiple thyroid surgeries, and tracheotomy below the cricoid cartilage were found to decrease the likelihood of successful decannulation. Posterior cordectomy is a simple method allowing for airway improvement and decannulation in patients with bilateral vocal cord paralysis. It is less effective in tracheotomized subjects with diabetes or GERD, older than 66 years old, after two or more thyroidectomies.
Laryngeal Morbidity and Quality of Tracheal Intubation
Anesthesiology, 2003
Background Vocal cord sequelae and postoperative hoarseness during general anesthesia are a significant source of morbidity for patients and a source of liability for anesthesiologists. Several risk factors leading to laryngeal injury have been identified in the past. However, whether the quality of tracheal intubation affects their incidence or severity is still unclear. Methods Eighty patients were randomized in two groups (n = 40 for each) to receive a propofol-fentanyl induction regimen with or without atracurium. Intubation conditions were evaluated with the Copenhagen Score; postoperative hoarseness was assessed at 24, 48, and 72 h by a standardized interview; and vocal cords were examined by stroboscopy before and 24 and 72 h after surgery. If postoperative hoarseness or vocal cord sequelae persisted, follow-up examination was performed until complete restitution. Results Without atracurium, postoperative hoarseness occurred more often (16 vs. 6 patients; P = 0.02). The numbe...
Tracheostomy in patients with long-term mechanical ventilation: A survey
Respiratory Medicine, 2010
Tracheostomy is increasingly performed in intensive care units (ICU), with many patients transferred to respiratory ICU (RICU). Indications/timing for closing tracheostomy are discussed.We report results of a one-year survey evaluating: 1) clinical characteristics, types of tracheostomy, complications in patients admitted to Italian RICU in 2006; 2) clinical criteria and systems for performing decannulation, and outcome of patients undergoing tracheostomy (number decannulated; number non-decannulated/non-ventilated; number non-decannulated/ventilated; dead/lost patients).22/32 RICUs replied. There were 846 admissions of 719 patients (Mean age 64,3 (±14.2) years, 489 (68%) males). Causes of admission were: acute respiratory failure with underlying chronic co-morbidities 176 (24.4%); exacerbation of Chronic Obstructive Pulmonary Disease 222 (34.4%); neuromuscular diseases 200 (27.8%); surgical patients 77 (10.7%); thoracic dysmorphism 28 (3.8%); obstructive sleep apnea syndrome 16 (2.2%). Percutaneous tracheostomies were 65.9%. Major complications after tracheostomy were 2%. 427 tracheostomies were evaluated for decannulation: 96 (22.5%) were closed; 175 patients (41%) were discharged with home mechanical ventilation; 114 patients (26.5%) maintained the tracheostomy despite weaning from mechanical ventilation and 42 patients (10%) died or lost.The clinical criteria chosen for decannulation were: stability of respiratory conditions, effective cough, underlying diseases and ability to swallow. The systems for evaluating feasibility of decannulation were: closure of tracheostomy tube; laryngo-tracheoscopy; use of tracheal button and down-sizing.There were few major complications of tracheostomy. A substantial proportion of patients maintain the tracheostomy despite not requiring mechanical ventilation. There was no agreement on indications and systems for closing tracheostomy.
Surgical management of bilateral vocal fold paralysis
Operative Techniques in Otolaryngology-Head and Neck Surgery, 1998
Bilateral vocal fold immobility presents a challenging problem for the otolaryngologist. Although some patients may be managed without intervention, most patients with bilateral true vocal fold immobility require airway management. The goals of such management are usually aimed at producing a safe tracheotomy-free airway, with preservation of deglutition and phonation. Two surgical treatment methods for bilateral true vocal fold immobility are presented: endoscopic submucosal arytenoidectomy with suture lateralization and endoscopic cordotomy with anterolateral arytenoidectomy. The two techniques with their indications, advantages, and complications are illustrated. These modified techniques have resulted in significantly lower rates of the troublesome complication of granuloma formation. Both methods yield a satisfactory glottic airway while maintaining both speech and swallowing.