Invited Commentary

Abstract

Vocal cord paralysis after thoracic surgery remains an important problem worthy of further study. Vocal cord paralysis markedly impairs quality of life and leads to significant perioperative morbidity [1Schneider B. Bigenzahn W. End A. et al.External vocal fold medialization in patients with recurrent nerve paralysis following cardio-thoracic surgery.Eur J Cardiothorac Surg. 2003; 23: 477-483Crossref PubMed Scopus (38) Google Scholar]. Obviously the best treatment is prevention, which entails a detailed knowledge of the anatomy of the nerve, careful dissection when the nerve is in the field, judicious use electrocautery around the nerve, avoidance of traction injury on the nerve, and a weighing of the risk to benefit ratio when dissecting nodes out from the aortopulmonary window. Surgeons are slow at times to make this diagnosis postoperatively, perhaps because of a wish to avoid a painful discussion and acceptance of a technical problem with the procedure. Indeed prospective reports indicate this complication is underdiagnosed when a comparison is made with retrospective reports [2Filare M. Mom T. Laurent S. et al.Vocal cord dysfunction after left lung resection for cancer.Eur J Cardiothorac Surg. 2001; 20: 705-711Crossref PubMed Scopus (48) Google Scholar]. However, as this report indicates, ignoring this issue puts the patient at risk and is not recommended. Laccourreye and colleagues [3Laccourreye O. Malinvaud D. Delas B. et al.Early unilateral laryngeal paralysis after pulmonary resection with mediastinal dissection for cancer.Ann Thorac Surg. 2010; 90: 1075-1079Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar] reported 69 patients who had early recognition of vocal cord paralysis after lung cancer surgery. All patients had a poor voice quality and two thirds aspirated. Notably, 13% of patients recovered vocal cord function, which rose to 24% if the nerve was not reported to be cut in the operative note. As expected, 90% of the time the left vocal cord was involved due to the greater exposure of the left nerve to surgical injury. Vocal cord medialization was very effective at restoring voice quality and swallowing function. Early involvement of an ear nose and throat (ENT) surgeon and a speech therapist is prudent when confronted with a patient who likely has a vocal cord paralysis after thoracic surgery. Bedside inspection with a nasopharyngoscope can confirm the clinical suspicion of a vocal cord paralysis easily without any anesthesia. Bedside aspiration testing, which is usually followed by a modified barium swallow evaluation conducted by the speech therapist, completes the initial evaluation. Recent reports and my own preference is to have the ENT surgeon inject an absorbable substance in the vocal cord fold to medialize the cord in the early postoperative period. This can be done under local anesthesia at the bedside. The ENT surgeon can then follow the patient in the office to see if vocal cord function returns or not. My ENT surgeon waits at least 6 months (when it is not known if the nerve was irreversibly damaged) before recommending a medialization with a permanent implant, which seems prudent to me. This report indicates that the nerve did not recover function beyond 9 months, but does not elaborate on the pace of recovery of the recovered nerves, which would have been interesting to know. Repeat swallowing evaluation is typically done after any vocal cord intervention and periodically if function remains impaired. Early placement of a percutaneous gastrostomy tube is helpful to facilitate good nutrition in those patients with severe impairment of swallowing function. Most will regain adequate swallowing ability with time and swallowing therapy. Careful management of this sometimes unavoidable complication can prevent life-threatening aspiration and enhance the quality of the patient's life with vocal cord medialization procedures. Early Unilateral Laryngeal Paralysis After Pulmonary Resection With Mediastinal Dissection for CancerThe Annals of Thoracic SurgeryVol. 90Issue 4PreviewThe purpose of this study was to document the symptoms, evolution, management, and outcome in a large series of patients with an early unilateral laryngeal paralysis after mediastinal lymph node dissection and pulmonary resection for cancer. Full-Text PDF