Bilateral Vocal Fold Immobility Research Articles

Radiofrequency Versus CO2 Laser in Posterior Cordotomy for Managing Bilateral Abductor Vocal Fold Immobility

PurposeThis study aimed to assess the outcomes of posterior cordotomy in cases with Bilateral abductor vocal fold immobility (BAVFI), either by radiofrequency or CO2 laser. MethodsThis prospective comparative randomized study included 80 patients with BAVFI of different etiologies. They were divided randomly into two groups. Group A included 44 patients for whom radiofrequency was used for posterior cordotomy, while the other group (Group B) included 36 patients managed by CO2 laser-assisted posterior cordotomy. ResultsThe postoperative respiratory chink improved significantly in both groups, with a significant improvement in the dyspnea, especially in group B. The postoperative voice handicapped index (VHI-10) scores showed significant deterioration in both groups. ConclusionsCO2 laser and radiofrequency assisted posterior cordotomy were effective and safe for managing cases with BAVFI. Moreover, the CO2 laser has the upper hand regarding breathing and exercise tolerance outcomes, significantly impacting the quality of life.

Airway and Voice Outcomes After Thyroarytenoid Myomectomy for Bilateral Vocal Fold Immobility.

Type 4 posterior glottic stenosis and bilateral vocal fold paralysis are clinically challenging causes of bilateral vocal fold immobility (BVFI) that result in glottic airway obstruction. Established procedures for BVFI typically worsen dysphonia. We hypothesize the use of thyroarytenoid myomectomy (TAM) in the setting of BVFI will improve dyspnea with decreased detriment to voice. Eleven unilateral TAM procedures were performed between April 2021 and June 2023 at a single institution. Pre- and postoperative patient reported outcomes were compared. Representative images of maximal glottic opening were analyzed in ImageJ to calculate ipsilateral bowing index (BI), total BI, maximum glottic surface area (MGSA), and maximum opening angle (MOA). Statistical comparisons were performed with paired t-tests when normality was confirmed with Shapiro-Wilk test and otherwise with Wilcoxon signed-rank tests, with threshold for significance of α = 0.05. Interrater reliability for objective glottal measures was compared with intraclass correlation coefficient (ICC). Dyspnea Index improved from mean (standard error) of 24.1 (3.8) to 9.1 (3.3), p = 0.004. Voice Handicap Index-10 improved from 20.0 (4) to 10.3 (3.8), p = 0.011. Glottal Function Index improved from 9.6 (1.4) to 6.3 (1.3), p = 0.017. There was no significant difference in ipsilateral BI, total BI, MOA, and median MGSA. There was good to excellent ICCs for all comparisons (0.83-0.95). TAM demonstrated significant improvement in symptoms from BVFI while not significantly altering glottal structure. These data suggest TAM improves dyspnea in patients with BVFI without significantly impairing voice. 4 Laryngoscope, 2024.

Impact of BMI on Dyspnea and Need for Surgical Intervention in Bilateral Vocal Fold Immobility.

Bilateral vocal fold paralysis (BVFP) and posterior glottic stenosis (PGS) are causes of bilateral vocal fold immobility (BVFI) and may cause shortness of breath, stridor, and need for surgical intervention. Although increased body mass index (BMI) is associated with restrictive breathing patterns in patients with normal upper airways, it is unclear how BMI impacts dyspnea and need for surgical intervention in BVFI patients. Retrospective cohort study. Three tertiary academic centers in the United States. Demographics, BMI, Dyspnea Index (DI), etiology, presence of tracheostomy and surgical intervention (dilation, tracheostomy, cordotomy, arytenoidectomy, open reconstruction) were collected. Primary outcomes included dyspnea measured by DI and need for surgery to improve airway. Linear regressions were performed to assess continuous outcomes. Mann-Whitney U-test was utilized to assess categorical outcomes. Among 121 patients, 52 presented with BVFP and 69 with PGS. Previous neck surgery was the most common cause of BVFI (40.2%). 44.3% of patients received a tracheostomy. Through multivariate linear regression, increased BMI was significantly associated with increased DI in the entire cohort (β = .43, P = .016). Increased BMI was also associated with need for any surgical intervention (odds ratio [OR] = 1.07, 95% confidence interval [CI] = [1.01-1.13]) in the overall cohort. When stratifying our data, BMI was only significantly associated with DI in BVFP (β = .496) and need for surgical intervention in PGS (OR = 1.11, 95% CI = [1.01-1.21]), although a positive trend was seen in all analyses. Increased BMI may correlate with worsening dyspnea symptoms and need for surgical intervention in patients with BVFI. Weight-loss-related counseling may benefit symptom management.

Transverse Cordotomy with Thyroarytenoid Myectomy for Bilateral Vocal Fold Immobility.

We propose a modification of the transverse cordotomy procedure which improves the predictable airway outcome and allows for better voice. Laryngoscope, 134:2790-2792, 2024.

Quantitative Analysis of Unilateral and Bilateral Vocal Fold Immobility

To analyze the correlation between clinical and video laryngoscopy findings for 89 patients with bilateral vocal fold immobility (BVFI), unilateral vocal fold immobility (UVFI), and healthy controls by quantitative analysis of normalized laryngeal outlet (NLO), bowing index (BI), and supraglottic compression (SGC). Laryngoscope pictures were taken by two reviewers, and all pictures were standardized by scaling and calibrating to the same width and height in Image J. Three reviewers used quantitative measures to calculate BI, NLO, and SGC in Image J. We assessed reliability for each measurement by two-factor analysis of variance (ANOVA) without replication to calculate the interclass correlation coefficient. Analysis was broken down for each measurement in each group of interest by using a one-way test. The total glottic area was obtained by calculating the normalized glottal gap area from each image of maximum glottal closure during phonation. Overall reliability of all the measurements was 0.69 (IQ 0.58-0.83). Mean NLO from UVFI, BVFI, and control groups differed significantly. There was no significant difference between control and BVFI. The total glottic area did not consistently predict normalized laryngeal outlet values. Mean normalized laryngeal outlet values of UVFI and BVFI were significantly smaller in the BVFI groups compared with controls and UVFI. BI values consistently predicted total glottic area in the BVFI group. Static SGC measurement did not predict a difference between groups. This is a reliable novel technique, which can be utilized in clinical settings. These measurements have clinical relevance for managing voice disorders. NLO is the most accurate measurement correlating with glottal incompetence. BI findings are sufficiently specific to identify between UVFI and BVFI.

Revision Endoscopic Posterior Costal Cartilage Grafting: Is It Feasible?

The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty-one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p > .05). There was no difference between groups with respect to decannulation rate (85% primary vs100% revision, p = .32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients.

Arytenoidectomy for the Treatment of Bilateral Vocal Folds Immobility

Arytenoidectomy, or the partial removal of the arytenoid cartilage, is a surgical procedure performed to treat bilateral vocal fold immobility. It can widen the posterior glottis, which is important as an airway, and maintain the voice quality more effectively than vocal fold lateralization. In addition, it is expected to have a permanent effect without the possibility of relapse due to the breakage of traction threads or subsequent infection. When the opening of the glottis is insufficient after arytenoidectomy for posterior glottic stenosis, vocal fold lateralization should be additionally performed.

Predictive Outcomes of Deep Learning Measurement of the Anterior Glottic Angle in Bilateral Vocal Fold Immobility.

(1) To compare maximum glottic opening angle (anterior glottic angle, AGA) in patients with bilateral vocal fold immobility (BVFI), unilateral vocal fold immobility (UVFI) and normal larynges (NL), and (2) to correlate maximum AGA with patient-reported outcome measures. Patients wisth BVFI, UVFI, and NL were retrospectively studied. An open-source deep learning-based computer vision tool for vocal fold tracking was used to analyze videolaryngoscopy. Minimum and maximum AGA were calculated and correlated with three patient-reported outcomes measures. Two hundred and fourteen patients were included. Mean maximum AGA was 29.91° (14.40° SD), 42.59° (12.37° SD), and 57.08° (11.14° SD) in BVFI (N=70), UVFI (N=70), and NL (N=72) groups, respectively (p < 0.001). Patients requiring operative airway intervention for BVFI had an average maximum AGA of 24.94° (10.66° SD), statistically different from those not requiring intervention (p=0.0001). There was moderate negative correlation between Dyspnea Index scores and AGA (Spearman r=-0.345, p=0.0003). Maximum AGA demonstrated high discriminatory ability for BVFI diagnosis (AUC 0.92, 95% CI 0.81-0.97, p < 0.001) and moderate ability to predict need for operative airway intervention (AUC 0.77, 95% CI 0.64-0.89, p < 0.001). A computer vision tool for quantitative assessment of the AGA from videolaryngoscopy demonstrated ability to discriminate between patients with BVFI, UVFI, and normal controls and predict need for operative airway intervention. This tool may be useful for assessment of other neurological laryngeal conditions and may help guide decision-making in laryngeal surgery. III Laryngoscope, 133:2285-2291, 2023.

Coblation Cordotomy for the Management of Bilateral Vocal Fold Immobility

Bilateral vocal fold immobility (BVFI) has an impact on both the voice and breathing. Many procedures have been developed to manage BVFI including the use of a coblator to perform a unilateral posterior cordotomy. This study evaluated the use of unilateral coblator cordotomy for BVFI. Retrospective chart review. Ninety-four patients having undergone coblation cordotomies for BVFI performed by surgeons at two different institutions. Parameters evaluated were etiology of BVFI, prior tracheotomy, the number of revision procedures, postoperative decannulations, breathing outcomes as measured by Dyspnea Index, and voice outcomes as measured by the Voice Handicap Index. The main causes of immobility were thyroidectomy and prolonged endotracheal intubation. Twenty-one procedures were performed in patients who had a tracheotomy already in place, two required concurrent tracheotomy with cordotomy, and two underwent tracheotomy some time after cordotomy. The mean follow up was 16 months (1-38 months). Of the 25 patients who had a tracheotomy tube placed before or during the course of their care, we were unable to decannulate four of them after initial or revision cordotomy. Twenty of our 94 patients required a secondary revision unilateral cordotomy, usually on the previously un-operated vocal fold. This was more common in bilateral fixation than in paralysis. In 44 patients where Voice Handicap Index data was known both pre- and postoperatively, the median VHI scores improved from 62.2 to 37.4, while the VHI worsened in only four patients. Eight patients had a Dyspnea index performed both pre- and post-operatively and the median score dropped from 18.3 to 12.5. Coblation cordotomy is a reasonable option for vocal fold lateralization in BVFI. In our study, this method allowed for decannulation in 21 of 25 patients who had a tracheotomy. The initial coblator cordotomy was sufficient for the majority of patients, with 22% (20/94) requiring a revision procedure. Interestingly, our study also showed promising voice outcomes with improvements in VHI in all but four patients.

Etiology and Management of Bilateral Vocal Fold Paralysis: a Retrospective Cohort Study

<h2>Summary</h2><h3>Objectives</h3> Bilateral vocal fold immobility can occur secondary to bilateral nerve injuries, resulting in paralysis of both vocal folds, known as bilateral vocal fold paralysis (BVFP). BVFP can cause airway obstruction and is associated with significant morbidity. Treatment options include tracheotomy, cordotomy, and arytenoidectomy, which are designed to increase the caliber of the upper airway. In the largest BVFP study to date, we set out to review cases of BVFP to better understand the etiologies of paralysis and subsequent surgical interventions. <h3>Methods/Study Design</h3> A retrospective review of patients with BVFP over a 17-year period within a single institution was performed. For each patient included in the study, the etiology of paralysis, simultaneous vs sequential onset of paralysis, subsequent surgeries, and spontaneous recovery were reviewed. Logistic regression was performed to determine whether patient factors predicted tracheotomy or recovery of vocal fold motion. <h3>Results</h3> 86 patients with BVFP followed for greater than 180 days were included in this retrospective cohort study. The majority of patients (84.9%) did not recover any vocal fold motion, while 13 patients (15.1%) recovered motion in at least one vocal fold. Iatrogenic injury was the most common etiology of paralysis. Sixty-seven patients (77.9%) underwent a tracheotomy placement, the most commonly performed procedure. Age, gender, or paralysis progression did not predict whether patients underwent tracheotomy or experienced spontaneous vocal fold motion recovery. <h3>Conclusions</h3> The most common etiology of BVFP was iatrogenic injury during thyroid surgery. A greater number of patients developed simultaneous paralysis of both vocal folds compared to sequential unilateral paralysis. Tracheotomy was the most commonly performed surgery, and the minority of patients were successfully decannulated. This study helps define the etiologies and treatments of patients with BVFP to better describe the patient-related morbidity associated with this condition.

Endoscopic posterior laryngotracheoplasty

Posterior glottic stenosis and bilateral vocal fold immobility can be challenging conditions to manage. However, the introduction of endoscopic posterior cricoid expansion with costal cartilage grafting nearly 20 years ago has been revolutionary, resulting in shorter hospital stays, decreased morbidity, and improved vocal outcomes after surgery. Further advances have been made through the development of single-stage protocols, the use of non-traditional grafting materials, and the application of transoral robotic approaches to improve access and visualization. This review highlights the key features for safe and effective endoscopic posterior cricoid expansion and provides an overview of recent developments designed to decrease morbidity. Posterior glottic stenosis and bilateral vocal fold immobility can be challenging conditions to manage. However, the introduction of endoscopic posterior cricoid expansion with costal cartilage grafting nearly 20 years ago has been revolutionary, resulting in shorter hospital stays, decreased morbidity, and improved vocal outcomes after surgery. Further advances have been made through the development of single-stage protocols, the use of non-traditional grafting materials, and the application of transoral robotic approaches to improve access and visualization. This review highlights the key features for safe and effective endoscopic posterior cricoid expansion and provides an overview of recent developments designed to decrease morbidity.

Laryngeal electromyography, a useful tool in difficult cases of pediatric laryngeal mobility disorders

IntroductionPediatric laryngeal mobility disorders constitute a challenge in terms of diagnosis and treatment, especially in small children and those complex patients with prior history of prolonged intubation or surgery. Laryngeal electromyography (L-EMG) may help to distinguish vocal fold paralysis from fixation. Material and methodsTen children with laryngeal mobility disorders (including bilateral vocal fold immobility (BVFI) or unilateral vocal fold immobility (UVFI) with contralateral hypomobility) underwent suspension laryngoscopy and L-EMG between July 2019 and March 2021. The EMG data were acquired simultaneously in both thyroarytenoid muscles. Anesthesia was lightened until volitional activity appeared like cough, cry or spontaneous Valsalva maneuver. ResultsWe found secondary airway lesions in 2 patients and 3 vocal fold fixation. L-EMG recordings were pathologic in 4 patients (3 moderate and 1 severe nerve lesion). No recurrent laryngeal nerve injury was found in congenital BVFI cases. The data from both suspension laryngoscopy and L-EMG recordings influenced clinical decision-making. ConclusionsL-EMG adds value to suspension laryngoscopy in the management of pediatric patients with laryngeal mobility disorders. Selected cases such as patients with iatrogenic BVFI, UVFI with associated contralateral hypomobility or patients with combined pathologies may obtain the greatest benefit.

Isolated Laryngeal Syphilis with Bilateral Vocal Fold Immobility: A Rare Clinical Presentation

Isolated Laryngeal Syphilis with Bilateral Vocal Fold Immobility: A Rare Clinical Presentation

Unilateral Cordotomy: A Systematic Review of Efficacy and Outcomes.

Glottic obstruction may arise secondary to bilateral vocal fold immobility (BVFI). Treatment options include a tracheostomy to bypass the site of obstruction as well as unilateral transverse cordotomy to alleviate the obstruction. The objective of this review is to determine the efficacy, adverse event profile, and long-term outcomes, including the need for tracheostomy, in patients undergoing unilateral cordotomy. The Preferred Reporting Systems for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed for this systematic review. A literature search of unilateral cordotomy was performed by searching PubMed, Cochrane Library, and Embase. Articles presenting cases of BVFI treated with unilateral cordotomy were included. Review articles, animal studies, non-English-language articles, and abstracts were excluded. Articles presenting cases of bilateral cordotomy or cordotomy with arytenoidectomy were excluded. We identified 14 studies and 291 patients undergoing unilateral cordotomy. Sixty-eight patients had a prior tracheostomy in place at the time of cordotomy. The most common post-operative complication was granulation tissue formation (n=39). Thirty-one patients developed glottic edema with subsequent dyspnea. Three patients developed scarring of the primary cordotomy site with the return to an obstructed airway. Nine patients required a post-cordotomy tracheostomy due to these complications. Five patients required a long-term tracheostomy and were unable to be decannulated. Unilateral cordotomy is an effective treatment for glottic obstruction with high post-operative decannulation rates. Adverse events including worsening glottic obstruction are uncommon, although edema and granulation tissue may develop in the post-operative period and necessitate close post-operative monitoring. Laryngoscope, 133:6-14, 2023.

Clinical Predictors of Postintubation Bilateral Vocal Fold Immobility.

Introduction Iatrogenic bilateral vocal fold immobility (BVFI) often arises from posterior glottic stenosis (PGS) after endotracheal intubation, whereby posterior commissure mucosal disruption leads to fibrosis and ankylosis of the cricoarytenoid joints. Sequelae can be devastating, resulting in dyspnea, stridor, and death due to asphyxiation. Objectives We sought to review features associated with PGS to better understand how to prevent this condition. A secondary aim is to analyze factors correlating to tracheostomy dependence. Methods Charts from January 2010 to November 2020 were retrospectively reviewed, and adult patients with the diagnosis of BVFI after intubation were included. Data on comorbidities, duration of intubation, laryngoscopy, and decannulation status was analyzed. Results Out of the 68 patients included in the present study, 60.3% were male, and the mean duration of intubation 14.3 ± 8.5 days. A total of 94% of the patients were intubated for at least 7 days, diabetic, and/or obese. Although association with prolonged intubation >7 days was not significant ( p = 0.064), complete BVFI on fiberoptic exam ( n = 47) was significantly associated with tracheostomy dependence both in the entire cohort ( p = 0.036) and in the 56 patients with tracheostomy ( p = 0.0086). Patients without cardiovascular disease (CVD) were less likely to be tracheostomy dependent compared with those with CVD (odds ratio [OR]: 0.23 [0.053-0.79]; p = 0.028). Conclusions We identified duration of intubation, DM, and obesity as potential risk factors for PGS. Complete immobility and CVD were significantly associated with tracheostomy dependence. Our findings may have important implications for earlier tracheostomy in high-risk intubated patients, as well as for closer monitoring of disease progression and earlier intervention in those predisposed to tracheostomy dependence.

Partial arytenoidectomy with transoral vocal fold lateralisation in treating airway obstruction secondary to bilateral vocal fold immobility.

To report the outcome of 18 patients with a tracheostomy secondary to bilateral vocal fold immobility, who were managed using reconstructive transoral laser microsurgical techniques. A retrospective review was conducted of the surgical outcome of 18 patients with bilateral vocal fold immobility and a tracheostomy resulting from different aetiologies. Follow-up duration ranged from one to five years. A total of 18 patients had a tracheostomy at presentation because of bilateral true vocal fold immobility and stridor. All cases were treated using reconstructive transoral laser microsurgery with arytenoidectomy and vocal fold lateralisation. All patients were successfully decannulated by eight weeks after surgery. Reconstructive transoral laser microsurgery using partial arytenoidectomy with vocal fold lateralisation is minimally invasive, feasible, safe and effective for airway reconstruction in patients who present with stridor due to bilateral true vocal fold immobility.

Partial Arytenoidectomy with transoral Vocal Fold Lateralization in Treating Airway Obstruction Secondary to Bilateral Vocal Fold Immobility.

Partial Arytenoidectomy with transoral Vocal Fold Lateralization in Treating Airway Obstruction Secondary to Bilateral Vocal Fold Immobility.

Balloon-Assisted Rib Graft Placement in Endoscopic Posterior Cricoid Split Procedure.

View Video S1 Laryngoscope, 132:212–214, 2022

Surgical Treatment for Bilateral Vocal Fold Immobility

Surgical Treatment for Bilateral Vocal Fold Immobility

Pediatric Bilateral Vocal Fold Paralysis

Pediatric bilateral vocal fold paralysis (BVFP) is a rare but impactful diagnosis. Stridor and respiratory distress are common presenting symptoms, often requiring airway intervention. Historically, tracheostomy has been the mainstay of management of BVFP in children, but alternative interventions have more recently been described in an attempt to avoid or minimize the morbidity associated with pediatric tracheostomy. This review aims to summarize current knowledge surrounding etiology, workup, and management options for children with bilateral vocal fold immobility. The past several years have seen an increase in the understanding of, and range of, surgical options for pediatric patients with BVFP. Early studies have demonstrated that endoscopic interventions, including anterior-posterior cricoid split and suture lateralization, may be effective means of airway management in this population. Further studies are needed on the topic, but alternative surgical techniques may aid in reducing the frequency of tracheostomy for pediatric patients with BVFP.