Flexible Laryngoscopy Research Articles

Should an Involved but Functioning Recurrent Laryngeal Nerve be Shaved or Resected in a Locally Advanced Papillary Thyroid Carcinoma?

The issue of whether an involved but functioning recurrent laryngeal nerve (RLN) should be shaved or resected in locally advanced papillary thyroid carcinoma (PTC) remains controversial. Our study aimed to compare the early and late outcomes between those who underwent shaving and those who underwent resection and also to identify independent prognostic factors in this subset of patients. Of the 77 patients with 1 RLN involved by PTC, 39 (50.6%) underwent RLN preservation (group I) while 38 (49.4%) underwent RLN resection (group II). Early and late vocal cord function (as assessed by flexible laryngoscopy) and disease status were compared between the 2 groups. A multivariate Cox proportional hazards model was carried out to identify independent factors. Baseline characteristics were comparable between the 2 groups. Although temporary vocal cord palsy rate was similar between the 2 groups (p=0.532), 5 patients in group II (13.2%) suffered temporary bilateral vocal cord palsies with 1 requiring a tracheostomy lasting for 1 month. After a median follow-up of 113.8 months, 1 patient from each group developed new onset vocal cord palsy. Presence of distant metastases (hazard ratio [HR]=5.892, 95% CI=1.971-17.604, p=0.001) and incomplete surgical resection in non-RLN concomitant sites (HR=2.491, 95% CI=1.181-5.476, p=0.024) were the 2 independent predictors for a poor cancer-specific survival. Our data suggested that shaving could preserve the normal functionality in most of the involved RLNs (>90%) in the short to medium term. In the presence of distant metastases or incomplete resection in other non-RLN concomitant sites, the argument for shaving over resection appears even stronger.

Propranolol in the Treatment of Upper Airway Hemangiomas

Airway hemangiomas (AHs), which are common in infant airways, often cause significant upper airway obstruction. The various therapies used for AH have limitations and complications. Propranolol may have a potential role in its treatment, since it leads to regression or stabilization of cutaneous infantile hemangiomas. To date, only 4 previous case reports (7 patients) in which propranolol was used for AH have been published. Based on encouraging preliminary data on propranolol use for AH treatment, our goal was to further investigate propranolol as an effective initial treatment of upper AHs that cause significant obstruction symptoms. In this retrospective case series, we reviewed the medical records of 5 consecutive pediatric patients with AH (glottic and subglottic) treated with propranolol at a tertiary care children's hospital. All 5 patients were 2 months of age at the time of hemangioma diagnosis and had stridor and physical signs of severe upper airway obstruction. Hemangioma was diagnosed by flexible laryngoscopy or flexible bronchoscopy. All patients received propranolol 2 mg/kg/day and showed significant relief of obstruction symptoms within 24 hours of treatment initiation. All patients tolerated propranolol without significant cardiovascular complications. Outcomes from this case series, in conjunction with available case reports in the literature, suggest that propranolol is a safe initial treatment for symptomatic upper AH.

Causes of Dysphagia in a Tertiary-Care Swallowing Center

Dysphagia can be caused by a myriad of disease processes, and it has significant impacts on patients' quality of life, life expectancy, and economic burden. To date, the most common causes of dysphagia in outpatient tertiary-care swallowing centers are unknown. We undertook this study to determine these prevalences. We also describe the diagnostic techniques utilized to establish the diagnosis. The electronic charts of 100 consecutive patients who presented to an outpatient tertiary-care university swallowing center between January 2010 and April 2011 were retrospectively reviewed. Information regarding patient demographics, validated symptom surveys, diagnostic workups, and ultimate diagnoses was abstracted and tabulated into a central database. Descriptive statistics were used to evaluate the association between patient symptoms and diagnoses. The mean age of the entire cohort was 62 +/- 13.5 years, and 58% of the cohort was male. The most common identified causes of dysphagia were reflux (27%), postirradiation dysphagia (14%), and cricopharyngeus muscle dysfunction (11%). In 13% of cases, the cause of dysphagia was undetermined. The diagnostic tests utilized included flexible laryngoscopy (71%; 17% with endoscopic swallow evaluation), modified barium swallow study (45%), esophagoscopy (35%), barium esophagography (21%), manometry (10%), and ambulatory pH testing (2%). The most common causes of dysphagia in a tertiary-care swallowing center are reflux, postirradiation dysphagia, and cricopharyngeus muscle dysfunction. A precise cause for the symptom could not be identified in 13% of our cohort. Endoscopic visualization (laryngoscopy, flexible endoscopic evaluation of swallowing, and transnasal esophagoscopy) and fluoroscopic swallow studies were the investigations most often utilized. These techniques can be used to arrive at a diagnosis in 80% of cases.

Propranolol in the Treatment of Upper Airway Hemangiomas

Airway hemangiomas (AHs), which are common in infant airways, often cause significant upper airway obstruction. The various therapies used for AH have limitations and complications. Propranolol may have a potential role in its treatment, since it leads to regression or stabilization of cutaneous infantile hemangiomas. To date, only 4 previous case reports (7 patients) in which propranolol was used for AH have been published. Based on encouraging preliminary data on propranolol use for AH treatment, our goal was to further investigate propranolol as an effective initial treatment of upper AHs that cause significant obstruction symptoms. In this retrospective case series, we reviewed the medical records of 5 consecutive pediatric patients with AH (glottic and subglottic) treated with propranolol at a tertiary care children's hospital. All 5 patients were 2 months of age at the time of hemangioma diagnosis and had stridor and physical signs of severe upper airway obstruction. Hemangioma was diagnosed by flexible laryngoscopy or flexible bronchoscopy. All patients received propranolol 2 mg/kg/day and showed significant relief of obstruction symptoms within 24 hours of treatment initiation. All patients tolerated propranolol without significant cardiovascular complications. Outcomes from this case series, in conjunction with available case reports in the literature, suggest that propranolol is a safe initial treatment for symptomatic upper AH.

Airway obstruction due to unilateral vocal fold paralysis

Airway obstruction is an uncommon presentation of unilateral laryngeal paralysis. We have observed two mechanisms of obstruction: arytenoid prolapse and inappropriate adduction of the paralyzed vocal fold. We evaluated arytenoid abduction (AAb) and recurrent laryngeal nerve (RLN) reinnervation as treatments for airway obstruction in patients with unilateral laryngeal paralysis. Retrospective case series. Seven patients with airway obstruction secondary to unilateral laryngeal paralysis were evaluated with flexible laryngoscopy and direct laryngoscopy. Patients with flaccid paralysis and a prolapsing arytenoid were treated with AAb. Airway obstruction due to inspiratory vocal fold adduction was managed by RLN transection and ansa reinnervation of the distal stump. In all cases, paralysis resulted from RLN injury during surgery: thyroidectomy or cervical spine surgery. AAb was performed in four patients with arytenoid prolapse, and all had significant airway improvement, including decannulation of the two patients who had been tracheotomy dependent. RLN reinnervation was performed in five patients, two of whom had inappropriate adduction detected after AAb. The site of RLN injury was identified at surgery in all four patients. Inspiratory stridor and laryngospasm were abolished immediately after RLN transection. Arytenoid prolapse and/or inappropriate laryngeal adduction can cause airway obstruction in patients with unilateral laryngeal paralysis. Treatment of airway obstruction should address the underlying pathophysiology. AAb and RLN transection with ansa reinnervation can be effective in selected patients.

Transnasal endoscopic steroid injection: A practical and effective alternative treatment for benign vocal fold disorders

Emerging literature has documented the effectiveness of intralesional steroid injection as an alternative treatment for benign vocal fold disorders. However, clinical application is frequently limited by the associated technical demands for adequate anesthesia and precise needle placement. This study investigated the applicability and effectiveness of the more practical and less technically demanding method of transnasal endoscopic steroid injection (TESI). Prospective case series. This study recruited 30 patients with vocal nodules and polyps. Dexamethasone was injected into the Reinke's space under local anesthesia via the operating channel of a transnasal flexible laryngoscope in an office setting. Treatment outcome were measured before, 1 month after, and 3 months after the injection, using videolaryngostroboscopy (VLS), maximal phonation time (MPT), 10-item voice handicap index (VHI-10), acoustic analysis, and perceptual evaluation. VLS examinations at 3 months post-treatment demonstrated that vocal lesions of 10 and 19 patients were resolved or reduced, respectively. Objective measurements showed increased MPT and decreased VHI-10 (P < .05 and P < .01, respectively). Acoustic analysis revealed significant decrease in jitter and shimmer (P < .05). Perceptual evaluation using the GRB (grade, roughness, breathiness) scale also showed improved voice quality (P < .01). Treatment outcomes were similar between vocal nodules and polyps (P > .05). Mild vocal hematoma occurred in three patients following TESI, but resolved spontaneously within 1 month. TESI is a simple and practical office-based treatment modality for benign vocal fold lesions, suitable for most otolaryngologists. Treatment outcomes showed significant subjective and objective improvements that were comparable to the results of other injection procedures reported in the literature. 4.

Ortner's syndrome: a rare case of cardiovocal hoarseness

Introduction Ortner's syndrome, also known as cardiovocal syndrome, is a rare clinical entity with hoarseness due to left recurrent laryngeal nerve (RLN) palsy owing to a cardiovascular disease. Norbert Ortner ascribed hoarseness of voice RLN palsy in patients with several mitral stenosis, postulating that an enlarged left atrium could be responsible for the recurrent laryngeal nerve palsy. Case report A 63-year-old man with a history of progressive hoarseness of voice developed since over three months. Flexible laryngoscopy revealed a fixed left vocal cord in the paramedian position. The chest enhanced axial computed tomography confirmed a large left ventricular aneurysm. Conclusions Hoarseness has significant public health implications. Patients suffer from social deprivation, depression and a poor quality of life. Several underlying conditions are associated with the cardiovocal syndrome, including iatrogenic, congenital, mitral valve disorders, aortic and ventricular aneurysms. Laryngoscopy is indicated for the assessment of hoarseness if symptoms fail to improve or resolve within three months, or at any time when the clinician suspects a serious underlying disorder.

Utilizing the Productivity Analysis Module

Utilizing the Productivity Analysis Module

Inspiratory Stridor after Tracheal Intubation with a MicroCuff® Tracheal Tube in Three Young Infants

ncuffed tracheal tubes (TTs) have been the stan-dard for tracheal intubation in infants and children for decades until the recent introduction of the Microc uff (Kim-berley-clark, Roswell, GA) cuffed TT. e vidence suggests that the incidence of perioperative airway events after use of these new TTs is small,

Association Between Length of Intubation and Subglottic Stenosis in Children

To investigate the role of the length of intubation and other risk factors in the development of laryngeal lesions in children undergoing endotracheal intubation in an intensive care unit and to determine the incidence of subglottic stenosis (SGS). Prospective study. Children aged from birth to <5 years admitted to the Pediatric Intensive Care Unit of Hospital de Clinicas de Porto Alegre who required endotracheal intubation for more than 24 hours were eligible. Children underwent flexible fiber-optic laryngoscopy (FFL) after extubation. Those who presented moderate to severe abnormalities in this first examination underwent another FFL between 7 and 10 days. If lesions persisted or symptoms developed, regardless of initial findings, laryngoscopy under general anesthesia was performed. We followed 142 children. In the first FFL, 58 children (40.8%) had moderate to severe laryngeal lesions. During follow-up, 16 children developed SGS, representing an incidence of 11.3% (95% confidence interval, 7.1-17.5). Multivariate analysis showed that for every 5 additional days of intubation, there was a 50.3% increase in the risk of developing SGS, and for each additional sedation doses/day, there was a 12% increase in the same outcome. In this first prospective research protocol in children, we found a higher incidence of SGS than in most previous studies. The length of intubation and the need for additional sedation doses appear to be key factors for the development of SGS during endotracheal intubation.

Vocal cord paralysis during the treatment of mantle cell lymphoma with vincristine

We present a case of a seventy-eight year-old man who developed vocal cord paralysis without any sign of peripheral neuropathy during the treatment of Mantle Cell Lymphoma. He first presented in 2008 with a few bilateral small inguinal lymph nodes. Inguinal lymph node biopsy demonstrated Mantle Cell Lymphoma. Flow cytometry studies of peripheral blood and bone marrow cells were compatible with Mantle Cell Lymphoma. R-CHOP chemotherapy triweekly (Rituximab; Cyclophosphamide; Adriamycin; Vincristine; and Methylprednisolone) was planned. At the end of the second cycle, the patient complained of hoarseness without any symptoms of dysphagia or odynophagia. Direct flexible laryngoscopy showed bilateral vocal cord paralysis. Vincristine was discontinued and the patient's voice gradually resolved in about 4 months. Vincristine may cause peripheral, autonomic and cranial neuropathies. However cranial nerve involvement is quite uncommon.

Middle Frontal Horizontal Partial Laryngectomy (MFHPL): A Treatment for Stage T1b Squamous Cell Carcinoma of the Glottic Larynx Involving Anterior Vocal Commissure

ObjectiveThe therapeutic effect of middle frontal horizontal partial laryngectomy (MFHPL) in treating stage T1b squamous cell carcinoma of the glottic larynx involving anterior vocal commissure (AVC) was compared with that of the anterior frontolateral vertical partial laryngectomy (AFVPL). The feasibility and practical significance of MFHPL in clinical application was discussed in the present study.MethodsFrom January 1996 to January 2010, a total of 65 patients diagnosed with stage T1bN0M0 glottic laryngeal cancer were treated with MFHPL or AFVPL. The postoperative complications, glottic reconstruction, recurrence rate, voice quality and survival rates were evaluated and compared between two treatments.ResultsAFVPL and MFHPL were performed in 34 and 31 patients, respectively. Flexible fiberoptic laryngoscopy revealed that in the MFHPL-treated patients the reconstructed glottis was spacious and symmetric. In contrast, AFVPL treatment resulted in irregular glottic area with poor symmetry and tubular glottis. The incidence of postoperative laryngeal stenosis significantly differed between the MFHPL- and AFVPL-treated groups (P = 0.025). No significant difference was detected in the 3- and 5-year overall- or tumor-free survival rates between two treatments. The Voice Handicap Index (VHI) and maximum phonation time (MPT) after surgery were 51.0±12.99 and 12.42±3.44 sec in the AFVPL-treated group; while in the MFHPL-treated patients they were 31.81±7.48 and 7.65±1.98 sec, respectively. Both differences in VHI (P = 0.012) and MPT (P = 0.024) were significant between two treatments.ConclusionsMFHPL was comparable to AFVPL with respect to postoperative complications, recurrence rate and survival rates, but possessed advantages over AFVPL in terms of the incidence of laryngeal stenosis and voice quality. Our study indicated that MFHPL has a potential value in clinical practice of treating stage T1b squamous cell carcinoma of the glottic larynx involving AVC.

The role of direct laryngoscopy in the diagnosis of laryngeal cleft

Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, presenting features, and results of bedside swallow evaluation. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Eleven patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy. Nine of eleven had signs of aspiration on modified barium swallow study (MBSS). Of the eight subjects who underwent flexible laryngoscopy by a pulmonologist, a deep interarytenoid groove was only reported in four cases. In all eleven cases, the arytenoids could be physically separated during direct laryngoscopy, allowing for definitive diagnosis of the cleft and identification of its type and severity. Conclusion: Video swallow studies and flexible laryngoscopy may raise suspicion or even diagnose a laryngeal cleft, however, a laryngeal cleft must be confirmed by direct laryngscopy in which the interarytenoid space is palpated. Furthermore, a patient in whom symptoms persist but no laryngeal cleft is identified on flexible examination should have a direct laryngoscopy to rule out a cleft.

Exercise-Induced Bronchoconstriction and Vocal Cord Dysfunction

Patients are referred often because of self-reported symptoms of dyspnea and wheeze during exercise. The two common causes of exercise-induced dyspnea are exercise-induced bronchoconstriction (EIB) and vocal cord dysfunction (VCD). It can be extraordinarily difficult to differentiate between the two, especially because they may coexist in the same patient. EIB is caused by bronchial smooth muscle constriction in the lower airways due to the inhalation of dry air or allergens during exercise; it is associated with the release of bronchoconstricting mediators from airway cells. EIB can occur in patients with or without persistent asthma. In contrast, VCD is associated with the paradoxical adduction of the vocal cords, especially during inhalation, which may produce inspiratory stridor. VCD can be solitary or comorbid with asthma and/or EIB. EIB classically is most severe after the cessation of exercise, while VCD typically occurs during exercise and resolves quickly upon exercise cessation. However, history is not adequate to differentiate between EIB and VCD, and appropriate challenge tests and flexible laryngoscopy during exercise are often necessary for diagnosis. This article examines our current understanding of these entities and discusses the mechanism, prevalence, diagnosis, and treatment.

Use of a Low-fidelity simulator to improve trans-nasal fibre-optic flexible laryngoscopy in the clinical setting: A randomized, single-blinded, prospective study

BackgroundTrans-nasal flexible fibre-optic laryngoscopy (TFFL) is an essential skill for otolaryngologists. There is evidence to suggest that simulators help residents acquire procedural skills. The objective of this study was to examine the effect of simulation on endoscopy skill acquistion.MethodsA randomized controlled trial was conducted utilizing medical students and junior residents with limited experience in TFFL. Learners all performed a baseline endoscopy and were then randomized to receive either 45 minutes of simulation training or not. Following this, a second endoscopy was performed. Time to adequate visualization of the glottis, the percentage of time adequate visualization of the airway was maintained, and the number of collisions with mucosa were analyzed. Qualitative assessments were also obtained from the learner, patient, and staff laryngologist.ResultsTime to adequate visualization of the glottis and the number of mucosal collisions were significantly less during the second endoscopy, irrespective of the use of simulation (84.8 sec vs. 68 sec, p < 0.01; 5.0 vs. 3.2, p < 0.01, respectively). Analysis using a two-way ANOVA with interaction established that none of the quantitative measures analyzed in this study improved with the addition of simulation.ConclusionImprovements in time to visualization of the glottis and number of mucosal contacts were seen between the first and second endoscopy irrespective of simulator use. No additional benefit was conferred with the use of a low-fidelity simulator.

Primary Mucosal Melanoma Arising from the Eustachian Tube with CTLA-4, IL-17A, IL-17C, and IL-17E Upregulation

Primary malignant melanoma arising from the eustachian tube is extremely rare. We report the case of a 63-year-old white man who presented with a 1-month history of left-sided hearing loss and aural fullness. Flexible fiberoptic laryngoscopy detected a blue-purple mass that appeared to arise from the left lateral nasopharynx. Computed tomography demonstrated an enhancing mass arising from an orifice of the left eustachian tube. The tumor was debulked endoscopically and was confirmed to have originated in the left eustachian tube. Histologically, the tumor was made up of heavily pigmented pleomorphic spindle cells with frequent mitoses. The tumor cells were immunohistochemically positive for S-100 protein, HMB-45, Melan-A, and PNL-2. The final diagnosis was a mucosal malignant melanoma. We also performed a nested polymerase chain reaction assay for several genes of interest, including CTLA-4, IL-17A, IL-17B, IL-17C, IL-17D, IL-17E, IL-17F, PLZF, Foxp3, RORγt, CD27, and CD70. These genes have been studied mainly in cutaneous melanomas, especially for the development of immunotherapy, but only very limited studies have been done on mucosal melanomas. Our investigation found upregulation of CTLA-4, IL-17A, IL-17C, and IL-17E. Based on our finding of CTLA-4 upregulation, it may be suggested that our patient might have had low antitumor immunity and that he might have benefited from CTLA-4 blockade. On the other hand, upregulation of IL-17A and IL-17E might reflect increased antitumor immunity, which could suggest that patients with a mucosal melanoma might benefit from immunomodulators associated with the effect of Th17. These genes also have great potential to help melanoma patients obtain tailored treatment, and they can be used as biomarkers for predicting prognosis.

A Congenital Malformation of the Piriform Sinus Mimicking a Laryngeal Cyst. A Case Report

Objective: We report a type of hypopharyngeal congenital malformation not previously described in the world literature. Case report: A slightly preterm, female newborn presented with stridor immediately after birth. Flexible laryngoscopy showed the presence of a huge supraglottic cystic mass and endoscopic laser surgery under general anesthesia was carried out. During the operation it became clear that the cystic lesion had its origin from the piriform recess and not the laryngeal structure. The child was extubated the day after the operation without any problems and has since shown a normal development. Conclusions: A unique cystic congenital malformation of the piriform sinus is described. The challenges related to intubation and surgical treatment of this particular case and similar lesions are addressed.

Impact of laryngopharyngeal and gastroesophageal reflux on asthma control in children

ObjectiveA prospective study was carried out to determine the sensitivity and specificity of reflux symptoms and laryngeal findings to diagnose laryngopharyngeal reflux (LPR) and gastro-esophageal reflux (GER) in children with asthma by comparing the results of double probe pH monitorization and to determine the difference between controlled and uncontrolled asthma in terms of GER and LPR coexistence. MethodsA total of 50 patients (23 girls, mean age 10.8±0.4 years) with mild to moderate persistent asthma were included in this study. The patients were divided in two groups according to the asthma control status as controlled (n=27) vs. uncontrolled asthma (n=23). All patients completed the reflux symptom questionnaire and then they underwent flexible fiberoptic laryngoscopy and 24h double probe (pharyngeal and esophageal) pH monitorization. Laryngopharyngeal and gastroesophageal reflux were defined according to the double probe pH meter results. ResultsThe prevalences of LPR and GER were 70% and 46% in asthmatic patients, respectively. The reflux symptom score and LPR disease index were not useful to predict LPR or GER. There was no association between asthma control status and LPR and GER. Vocal nodule seems to be a valuable sign to evaluate LPR in asthmatic children. ConclusionsThe reflux symptom score and LPR disease index do not seem reliable to diagnose LPR and GER in children with asthma. The frequency of LPR and GER are independent of asthma control, atopy and long acting beta agonist usage.

Gastrointestinal Complications After Stage I Norwood Versus Hybrid Procedures

Patients undergoing palliation for hypoplastic left heart syndrome are at risk for gastrointestinal complications including necrotizing enterocolitis, gastroesophageal reflux, and intolerance to oral feeding. Few data exist comparing these outcomes between patients undergoing the Norwood and hybrid procedures. Forty-three patients with hypoplastic left heart syndrome or variants underwent 50 Norwood (n = 34) or hybrid (n = 16) procedures (2004 to 2011). Routine preoperative assessments included flexible fiberoptic laryngoscopy and oral feeding evaluations. Examinations were repeated postoperatively with modified barium swallows. A retrospective review was conducted to examine the incidence, causes, and consequences of gastrointestinal complications. In 18 of 50 cases (38%), patients were tolerating full oral feeding at discharge; abnormal preoperative feeding evaluation predicted the inability to feed orally (p < 0.002, positive predictive value 100%). Hybrid and Norwood patients had a similar incidence of vocal fold palsy (20.0% versus 34.5%, p = 0.3), and inability to feed orally at discharge (67.5% versus 56.3%, p = not significant). Both groups had a high incidence. Postoperative abnormalities were common, namely, abnormal oral feeding evaluations (70.7%) or modified barium swallows (81.8%). Predictors of abnormal postoperative examinations included noncardiac congenital anomalies (p = 0.08), preoperative mechanical ventilation (p = 0.01), and younger age (p = 0.01). Grade IIA/IIB necrotizing enterocolitis was more common among patients having hybrid procedures (26.7%, versus 2.9%, p = 0.01). Gastrointestinal complications are common after initial palliation of patients with hypoplastic left heart syndrome. Preoperative and perioperative factors play a significant role. Despite a more "limited" intervention, patients undergoing hybrid procedures remain at high risk for feeding issues, commonly leading to a prolonged hospital course. Close attention and proactive management are essential to optimize the nutritional status in these patients.

Bilateral abductor vocal cord palsy and pregnancy: a case report

Introduction/backgroundBilateral abductor vocal cord palsy in pregnancy is a rareclinical problem. Due to the rarity of this condition, there isno definite guideline on obstetric management.CaseA 23-year-old primigravida was referred to our tertiaryhospital at 23 weeks gestation. Her prior antenatal care hadbeen with a primary health care clinic. She was diagnosedwith papillary carcinoma of the thyroid when she was17 years old, and had undergone a total thyroidectomy. Shehad since been in remission, and had been on thyroxine200 lg daily. She reported hoarseness of voice since herthyroidectomy, but did not have respiratory compromise.On presentation, she complained of stridor, snoring andworsening episodes of sleep apnoea since early in thesecond trimester. On examination, her pulse rate was88 bpm, her blood pressure was 120/80. Her respiratoryrate was 20/min. Stridor was audible even without aus-cultation. Auscultation of her lungs was unremarkable. Heruterus size corresponded to her dates and ultrasonographyrevealed a structurally normal foetus with normal growthparameters. She was then referred to an otorhinolaryngol-ogist for assessment. A flexible laryngoscopy showedbilateral abductor vocal cord palsy in paramedian position(Fig. 1).Her condition remained stable until 32 weeks when herstridor worsened and she was having more difficultybreathing. A decision was made to electively insert a tra-cheostomy at 36 weeks, and to perform a lower segmentcaesarean section at 38 weeks. However, ultrasonographyat 36 weeks showed evidence of intrauterine growthrestriction (IUGR) and an amniotic fluid index of 6.0.Under general anaesthesia, a size 7.5 tracheostomy tubewas inserted. At the same sitting, lower segment caesareansection was performed uneventfully. A baby girl weighing2,600 g was delivered with an Apgar score of 8 at 1 minand 9 at 5 min. Estimated blood loss was 400 ml. Twoweeks later, left laser cordectomy was performed followedby removal of the tracheostomy. On follow-up 2 weekslater, her voice was still hoarse but she no longer hadstridor.DiscussionAbductor vocal cord palsy is caused by damage to one orboth recurrent laryngeal nerves (RLN). RLN palsy is acommon complication following neck/thyroid surgery witha reported frequency of 6.6–13.2 % [1, 2]. The incidencefollowing thyroidectomy for thyroid carcinoma is 10.1 %[3]. In bilateral RLN palsy, the vocal cords remain in theparamedian position. It commonly presents as stridor andhoarseness of voice. It may occur due to direct or indirectsurgical denervation of the RLN, or it can happen due to