Bilateral Recurrent Laryngeal Nerve Paralysis Research Articles

Acute respiratory failure after deep cervical plexus block for carotid endarterectomy as a result of bilateral recurrent laryngeal nerve paralysis

We report about a case of acute respiratory distress (73-year-old female), which occurred minutes after a deep cervical plexus block (40 ml ropivacaine 0.5%) for carotid endarterectomy (CEA) and required immediate endotracheal intubation of the patient's trachea and consecutive mechanical ventilation. Subsequently, CEA was performed under general anaesthesia (TIVA) with continuous monitoring by somatosensory-evoked potentials. After a period of 14 hours, the endotracheal tube could be removed, the patient being in fair respiratory, cardiocirculatory and neurological conditions. Retrospectively, acute respiratory distress was caused by a combination of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral recurrent laryngeal nerve (RLN) paralysis confirmed by a postoperative ENT-check and related to previous thyroid surgery more than 50 years ago. RLN paralysis, often being asymptomatic, represents a typical complication of thyroid and other neck surgery with reported incidences of 0.5-3%. Therefore, a thorough preoperative airway check is advisable in all patients scheduled for a cervical plexus block. Particularly in cases with a history of respiratory disorders or previous neck surgery a vocal cord examination is recommended, and the use of a superficial cervical plexus block may lower the risk of respiratory complications. This may prevent a possibly life-threatening coincidence of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral RLN paralysis.

両側性反回神経麻痺症例の臨床的観察

We clinically investigated 19 cases of bilateral recurrent laryngeal nerve paralysis that were referred to our clinic over the 8-year period of 1993 to 2000. Eleven males and 8 females were studied. Laryngeal nerve paralysis was often seen in the 4th and 6th decades of life for males and in the 6th decade of life for females. Thyroid surgery was the most frequent cause, and the most common complaint was dyspnea.If the patient suffers dyspnea at rest, then a tracheostomy should be performed initially. For the next step, we need to strategize the best course of treatment for the bilateral recurrent laryngeal nerve paralysis according to the patient's needs in order to keep the quality of voice or to provide relief from dyspnea.There were two cases of paralysis following endotracheal intubation whose vocal cord movement recovered in 2 months.We performed laser cordectomies on 6 patients and as well as Woodman's operation on 4 patients to widen the airway. There were 2 cases that suffered dyspnea from stenosis of the airway after receiving laser cordectomey due to the granulation generated from the wound after vaporizaton of the posterior half of the glottis. It appears that Woodman's operation was more reliable than laser cordectomy in keeping the widened airway in good condition for a long time after surgery.

Causes of recurrent laryngeal nerve paralysis

Objective: Persistent hoarseness due to recurrent laryngeal nerve paralysis (RLNP) reduces the quality of life unless it is adequately treated. This study examined the indications for phonosurgical intervention in patients with RLNP. Materials and methods: The medical records of the Ehime University Hospital, Ehime, Japan, from October 1976 until December 1997 were reviewed retrospectively to identify patients with RLNP. The data collected included age, gender, paralyzed side, and cause of paralysis. Results: Four hundred and sixty-six patients with RLNP were identified: 262 males and 204 females. Unilateral RLNP was present in 422 patients, while 44 presented with bilateral RLNP. The incidence was relatively high in the 7th and 8th decades, and was twice as high in male patients as in female patients. The 466 patients were divided into 2 groups: Group 1 included 225 patients seen before January 1987, and Group 2 included 241 patients seen after this date. The number of patients with postoperative RLNP was significantly higher in Group 2 (124 of 239 patients) than in Group 1 (65 of 227 patients) ( P<0.05). Surgery for cardiovascular disease, esophageal cancer, and skull base and thyroid gland tumors contributed to this increased incidence of postoperative RLNP. Conclusions: Patients with persistent unilateral RLNP require appropriate treatment for hoarseness, regardless of its cause. Since the incidence of RLNP related to surgery was significantly increased in Group 2, phonosurgery has become more important for improving the quality of life of these patients.

Localization and reoperation results for persistent and recurrent parathyroid carcinoma.

Reoperation is safe and benefits patients with persistent and recurrent parathyroid carcinoma. Retrospective study. The mean follow-up time was 8.1 years (median, 7 years; range, 1-23 years). A university tertiary referral center. Eighteen patients treated for parathyroid carcinoma from 1966 to 1999. The mean serum calcium level was 13.7 mg/dL (3.43 mmol/L), and the parathyroid hormone (PTH) level was 1.6 to 20 times the upper limit of normal. Fourteen of 18 patients had persistent or recurrent parathyroid carcinoma and underwent 54 reoperations (28 at our institution). Mean time to recurrence was 4.8 years (range, 1-20 years). Symptoms of hyperparathyroidism were relieved in 86% of patients who had reoperation (P<.05). Reoperation for parathyroid carcinoma (25 locoregional and 3 distant) significantly reduced and normalized the serum calcium and PTH levels in 75% and 62% of the cases, respectively (P<.001). The preoperative serum calcium level was a significant predictor of postreoperative normalization of the serum calcium level but not extent of initial resection, PTH level, time to recurrence, concordance of localization studies, or patient age and sex (P<.01). Surgical complications consisted of 5 unilateral and 1 bilateral permanent recurrent laryngeal nerve palsies (2 intentionally resected en bloc), 1 transient hypoparathyroidism, 1 wound seroma, and 1 tracheoesophageal fistula. The sensitivity rates of sestamibi scan (n = 14), magnetic resonance imaging (n = 15), computed tomographic scan (n = 6), ultrasound (n = 13), and selective venous catheterization with PTH measurement (n = 6) were 79%, 93%, 67%, 69%, and 83%, respectively. Recurrence is common in patients with parathyroid carcinoma. Patients with this disease should have frequent, lifelong follow-up to ensure early detection of recurrence. Although reoperation for persistent or recurrent parathyroid carcinoma provides significant symptomatic relief and normalizes serum calcium and PTH levels in most patients, it is associated with some morbidity. Localizing studies of parathyroid carcinoma are helpful but do not detect all tumor foci.

Airway complication after thyroid surgery: minimally invasive management of bilateral recurrent nerve injury.

After bilateral vocal cord paralysis, the consequent paramedian position usually necessitates tracheostomy for at least 6 months, when the paralysis is potentially reversible. In the present study a reversible endoscopic vocal cord laterofixation procedure was used instead of tracheotomy. Prospective study of 15 consecutive patients aged 33 to 73 years who suffered bilateral recurrent laryngeal nerve paralysis after thyroid surgery. The operation was performed endoscopically with a special endo-extralaryngeal needle carrier instrument. Two ends of a monofilament nonresorbable thread were passed above and under the posterior third of the vocal cord and knotted on the prelaryngeal muscles, permitting the creation of an abducted vocal cord position. If movement of one or both vocal cords recovered, the suture was removed. Regular spirometric measurements and radiological aspiration tests were conducted on the patients. During the follow-up period of 3 to 40 months, airway stability was demonstrated in all but one patient. After the repeated lateralization procedure, this patient's breathing improved. Partial or complete vocal cord recovery was observed in eight patients. In six patients further voice improvement was achieved when the threads were removed after vocal cord medialization or recovery. Mild postoperative aspirations ceased in the first postoperative days. This management approach offers an alternative to tracheostomy in the early period of paralysis, avoids terminal loss of voice quality, and provides a "one-stage" solution for permanent bilateral recurrent nerve injuries.

Overlooked impacted dentures and their unusual complications.

Two interesting and unusual cases of overlooked impacted dentures in oesophagus, one for 3 months and the other for 2 years are reported. We also report the complications of Bilateral Recurrent Laryngeal Nerve Paralysis and Oesophageal Diverticuli due to prolonged obstruction by denture.

Electromyography study and follow-up of bilateral recurrent laryngeal nerve paralysis after thyroid gland operations

Bilateral recurrent laryngeal nerve (RLN) palsies result in dyspnea and often require further surgery to secure an adequate airway for safe respiration. The present study was devised to determine a predictive value of laryngeal electromyography (LEMG) and if it has therapeutic consequences. In a retrospective study of 63 patients with bilateral recurrent laryngeal nerve palsies after thyroid gland surgery we compared the results of LEMG from the thyroarytenoid muscles with the spontaneous recovery rate of vocal cord mobility. A tracheostomy had to be performed in 18 patients because of unsafe dyspnea, while a unilateral lateral cord fixation had to be carried out in 20 patients. Primary thyroidectomies as treatment for benign goiters showed spontaneous normalization of unilateral or bilateral vocal cord mobility in 75% of cases versus 36% after revision thyroidectomies. Single LEMG correctly predicted prognosis in 78% of patients. In all, LEMG was found to be of value in the assessment of bilateral recurrent laryngeal nerve palsies. Findings also showed that a lateral cord fixation should be planned after a 9-month waiting period. When a patient refuses a tracheostomy lateral cord fixation can be performed at an earlier time, with the use of repeated LEMGs to predict whether or not a corrective surgery.

Severe functional laryngeal stenoses treated by endoscopic arytenoidectomy.

During the 15-year period from 1978 to 1993 we treated 17 cannulated patients suffering from dyspnea caused by bilateral recurrent laryngeal nerve palsies. The causes of palsy were struma surgery (13 cases), prolonged intubation (3 cases) and unknown (1 case). All cases were operated on by the classical endolaryngeal arytenoidectomy technique developed by Kleinsasser. All patients were able to be decanulated after arytenoidectomy: 14 cases within 1 month of surgery and 3 delayed. Four patients required replacements of their tracheotomies during the follow-up period, but this proved to be only temporary in 3 cases. After excisions of polypoid tissues or enlargement of an ipsilateral partial cordectomy, definitive closure of the tracheostome was possible. Among the retracheotomized patients, only 1 patient with multilocular stenoses has remained under treatment for the past 2 years. In all, 16 of 17 patients (93%) have remained permanently decannulated.

Postoperative interstitial pneumonia in primary lung cancer patients — Its causes and management: Miyamoto Y, Tsubota N, Yoshimura M, Murotani A, Matoba Y. Department of Thoracic Surgery, Hyogo Medical Center for Adults, Kobe. J Jpn Assoc Thorac Surg 1995;43:452–457

Eight patients who developed interstitial pneumonia after surgery for primary lung cancer were reviewed to investigate its causes and the key points in treatment. These patients accounted for 1.8% of 633 operated lung cancer patients at our institution over the last 9 years. Risk factors such as bilateral recurrent laryngeal nerve palsy, preoperative chemoradiotherapy, and extensive mediastinal involvement were present in all of them. Pneumonia developed on the nonoperated side in all patients between the 2nd and 45th postoperative day (mean: 18 days). In most of the patients, faint reticular shadows initially appeared in the lower lobe of the nonoperated lung, rapidly spread to the upper lobe, and finally affected the whole lung. Among these eight patients, the initial five patients died because steroids were only administered after the pneumonia had become widespread, whereas the last three patients received early steroid therapy and were saved. The findings that 1) this pneumonia originated from the lower lobe of the nonoperated lung where blood flow is highest postoperatively, 2) the eosinophil count increased just before the onset of pneumonia, and 3) early steroid therapy and immunosuppressive therapy were effective suggest that an allergic or autoimmune mechanism may play some role in its development. When characteristic reticular shadows appear in the lower lobe on the nonoperated side in a lung cancer patient, even if not associated with any symptoms, an early diagnosis of interstitial pneumonia and initiation of steroid therapy is mandatory to ensure survival.

Total thyroidectomy in the treatment of thyroid cancer

Considerable controversy exists about the most appropriate treatment for thyroid cancer. In this report the authors present their experience of 189 patients, all of whom had a total thyroidectomy between June 1980 and December 1993. The age of the patients ranged from 11 to 78 years (mean age: 42 years), there were 144 women and 45 men. Histological types were: 146 papillary, 16 medullary, 10 follicular, eight Hurtle, six insular and three undifferentiated. Coexistent lesions included: 22 thyroiditis, 17 adenomas, one Graves' disease and 22 benign goitre. Fifty-six (29.6%) patients had multifocal papillary cancer (bilateral in 45 cases). Surgical complications included 20 cases of transient recurrent laryngeal nerve palsy, 16 cases of transient and one of permanent hypoparathyroidism, and one respiratory obstruction due to bilateral recurrent laryngeal nerve palsy that required temporary tracheostomy. Two patients were reoperated on due to bleeding. Ninety per cent of patients were discharged within 3 days of thyroidectomy. One hundred and fifty patients were evaluated for 131I treatment by a standardized dosimetry procedure 4 weeks after surgery. Dosimetry was also used to calculate therapeutic 131I doses. Seventy-six patients did not show a 131I uptake above background levels, 56 underwent therapeutic 131I, while in the 18 patients who showed an abnormal uptake of 131I it was decided not to give the therapeutic dose. The authors conclude that total thyroidectomy can be performed with a minimum of permanent disability in patients with malignant thyroid tumours. The theoretical and practical advantages of this kind of surgical strategy make it the treatment of choice for thyroid cancer.

Completion thyroidectomy for differentiated thyroid carcinoma

Completion thyroidectomy is defined as the surgical removal of the remnant thyroid tissue following procedures less than total or near-total thyroidectomy. The extent of surgical management for differentiated thyroid carcinoma (DTC) is controversial. Although some authors advocate subtotal thyroidectomy with lower complication rates, total or near-total thyroidectomy and completion thyroidectomy have been defended by others because of the improved survival and lower morbidity that is comparable with subtotal thyroidectomy. In this study, the incidence of residual tumor and surgical complication rates in patients who underwent completion thyroidectomy were investigated. The medical records of 165 patients undergoing completion thyroidectomy for DTC were reviewed. Seventy-seven (46.6%) of these patients were found to have residual tumor in the remaining thyroid tissue. Anaplastic transformation developed in two of these patients. Permanent bilateral recurrent laryngeal nerve palsy occurred in three patients, and permanent hypoparathyroidism was seen in one patient. We recommend completion thyroidectomy as an efficient and safe method of surgical treatment with a low complication rate for DTC.

A RESECTED CASE OF ADENOSQUAMOUS CARCINOMA OF THE ESOPHAGUS

We report a resected case of adenosquamous carcinoma of the esophagus. A 60-year-old male was admitted to our hospital because of dysphagia. Roentgenogram and esophagoscopy revealed tumor and area of stenosis of the entire circumference in the middle of the intra-thoracic esophagus. The lesion was surrounded by an area which stained negative with iodine. The biopsy specimen showed squamous cell carcinoma. After subtotal esophagectomy and fundectomy with R3 lymph node dissection, esophagogas-trostomy was performed via the posterior sternum route. The intraoperative gross stage was Stage III A2N1Pl0M0, and curability was CIII. Histological examination of the resected specimen showed adenos-quamous carcinoma, and tumor invasion into adventitia (a2) with 101 lymph node metastasis. Bilateral recurrent laryngeal nerve paralysis and brain metastasis occurred during the postoperative course, and the patient died seven months after surgery.

Isolated bilateral recurrent laryngeal nerve paralysis: a delayed complication of organophosphorus poisoning.

Isolated bilateral recurrent laryngeal nerve paralysis: a delayed complication of organophosphorus poisoning.

両側反回神経麻ひ症例の臨床的検討

Twenty-three patients with bilateral recurrent laryngeal nerve paralysis treated at our clinic over the past 15 years were studied. The vocal cord was fixed in a paramedian position in twelve patients, in a median position in ten patients and in our intermediate position in one patient. No surgical treatment was performed in ten patients, while thirteen patients were surgically treated. Surgical procedures were undertaken as follows: tracheotomy in three patients, endoscopic lateralization of the vocal cord by Kirchner's method in two patients, widening of the anterior glottis combined with Woodman's operation in one patient, arytenoidectomy in five patients, thyroplasty type I (Isshiki's method) in one patient, glottic closure in one patient and laryngectomy in one patient. From our long term observations, we think that arytenoidectomy is the simplest and most reliable method for reducing the laryngeal obstruction in bilateral recurrent nerve paralysis.

両側性反回神経麻ひ症例の臨床的観察

A clinical study was conducted on 48 patients with bilateral recurrent laryngeal nerve paralysis, 29 females and 19 males. In 38 patients (79%), the paralysis was seen as surgical or post-operative. In a fairly large number of female patients it occurred after thyroid surgery and in males after surgery for esophageal cancer.This paralysis was often seen in males in the 6th and 7th decades of life, but in females seen from the 4th to 8th decades. Hoarseness was the most common symptom, followed by dyspnea, but dyspnea was never observed if there was more than 2 mm between the vocal folds. There was no significant correlation between the distance between the vocal folds and aspiration. There was also no instance of dyspnea becoming more serious, according to the answers to our questionnaire.

Intrathoracic stapled anastomosis after oesophagectomy for cancer.

Fifty consecutive oesophagectomies for cancer are reported which were performed using a two-stage technique with an intrathoracic stapled anastomosis. The oesophagus was resected through a right thoracotomy. Continuity was restored using orthotopic stomach, mobilized through an abdominal incision and anastomosed to the oesophagus at the apex of the thorax. No deaths occurred within 30 days, but two patients died without leaving hospital. Routine contrast study revealed no anastomotic leaks. Major complications were: chylothorax (one), transient bilateral recurrent laryngeal nerve palsy (one), anastomotic bleed (one), respiratory failure (one) and brain abscess (one). Four upper resection margins contained tumour (all in middle third tumours). With this technique, a reliable anastomosis can be made high in the chest. The amount of oesophagus removed is comparable with that obtained with the 'three-stage' or transhiatal procedures. The problem of occult submucosal spread in oesophageal tumours remains.

Effects of Recurrent Laryngeal Nerve Transection and Vagotomy on Respiratory Contraction of the Cricothyroid Muscle

The cricothyroid muscle (CT) appears to be an accessory muscle of respiration. Phasic inspiratory contraction is stimulated by increasing respiratory demand. Reflex activation of the CT may be responsible for the paramedian position of the vocal folds, and hence airway obstruction, in patients with bilateral recurrent laryngeal nerve (RLN) paralysis. Previous research has demonstrated the influence of superior laryngeal nerve (SLN) afferents on CT activity. The present study addresses the effects of vagal and RLN afferents. Electromyographic activity of the CT and right posterior cricoarytenoid muscle was monitored in anesthetized cats during tracheotomy breathing and in response to tracheal or upper airway occlusion in the intact animal. This was repeated following left RLN transection, bilateral vagotomy, and bilateral SLN transection. Vagotomy abolished CT response to tracheal occlusion and markedly reduced the response to upper airway occlusion. Vocal fold position following RLN transection appeared to correlate with CT activity; however, observed changes were minor.

Functional electrical stimulation for the treatment of bilateral recurrent laryngeal nerve paralysis.

We have previously presented the concept of electrophysiologic pacing of bilaterally paralyzed vocal cord abductors as a solution to the difficult problem incurred in this clinical situation. Initially, we demonstrated that it was indeed feasible to electrophysiologically pace abduction of the vocal cords synchronously with respiration, employing the EMG activity of the diaphragm as a trigger stimulus. Further research has led us to evaluate other possible physiologic trigger stimuli to ascertain which of these will prove most suitable in long-term pacing studies. In this article, we will report our preliminary results, employing negative intrathoracic pressure occurring with respiration--as detected by an implanted pressure transducer as a trigger stimulus. This device was interfaced with a muscle stimulator attached to electrodes placed in the cricoarytenoid muscles in five canines whose recurrent laryngeal nerves had been sectioned bilaterally. In all animals, obvious physiologic synchrony of vocal cord abduction and a reduction of negative inspiratory intratracheal pressure was achieved during electrical pacing. This reinforces our initial findings that it is indeed feasible to pace vocal cord abduction in bilateral recurrent laryngeal nerve paralysis with resultant return of physiologic normality to the glottis. Thus, functional electrical stimulation offers an alternative approach to the difficult problems incurred in the patient with bilateral recurrent laryngeal nerve paralysis. It also demonstrates that physiologic negative intrathoracic pressure activity occurring with inspiration can be a trigger source.

こう頭運動障害の診断 治療方針の決定をめぐって

A total of 311 cases with recurrent laryngeal nerve (RLN) paralysis, comprising of unilateral and bilateral, are statistically analyzed to obtain the following results:1. The spontaneous recovery from RLN paralysis can occur as low as 20% of all the cases examined.2. Eighty per cent of the cases having shown eventual recovery from RLN paralysis demonstrated their recovery sign as early as before 3 months following the onset.3. The complete recovery from RLN paralysis occurred in 74% of the spontaneously recovered cases while incomplete recovery was seen in 26%.4. An intubation tube might ensure the highest recovery rate of 73% among other etiological factors.5. The right RLN paralysis tended to improve more greatly with a ratio of 38% than the left in 24% while the bilateral RLN paralysis spontaneously recovered only in 17%.6. The cases presenting both the median and the paramedian fixation of the vocal cord (s) improved in 29% while other cases with the intermediate fixation showed spontaneous recovery in 23%.7. The paralyzed vocal cord (s) with the straight appearance improved more greatly in 38% than the vocal cord with the bowed appearance in 21%.

Restoration of the airway following bilateral recurrent laryngeal nerve paralysis.

Bilateral recurrent laryngeal nerve paralysis has been treated by a number of ingenious techniques that include arytenoidectomies, vocal cord lateralizations, cordectomies, and, recently, reinnervation procedures and laser arytenoidectomies. An arytenoidectomy is recommended by a thyrotomy approach without lateralization of the vocal cord. The resulting airway is adequate for decannulation by expansion of the posterior glottic aperture, with preservation of the anterior glottis for phonation.