Medial Arytenoidectomy Research Articles

Initial Outcomes of Endoscopic CO2 Laser Posterior Cordectomy and Partial Arytenoidectomy Among Patients with Bilateral Vocal Cord Paralysis: A Case Series


 
 
 
 ABSTRACTObjective: To describe the initial outcomes of endoscopic CO2 laser posterior cordectomy and partial arytenoidectomy among patients with bilateral vocal cord paralysis in our institution.
 
 
 
 
 Methods: 
 Design: Case Series
 Setting: Tertiary National University Hospital
 Participants: 17 Patients
 
 
 
 
 
 Results: Seventeen (17) patients who underwent transoral posterior cordectomy and partial arytenoidectomy using carbon dioxide laser were included in the study consisting of 14 females and 3 males. Iatrogenic injury was the most common cause of bilateral vocal cord paralysis in this subset of patients. Five patients who tolerated decannulation and another six who had no preoperative tracheostomy all reported subjective improvement in breathing. All of them were also observed to have resolution of stridor and increased respiratory comfort compared to their preoperative condition. The most common postoperative complication was granuloma formation at the medial arytenoidectomy site occurring only in 4 patients. None of the patients complained of aspiration episodes or dysphagia during the postoperative period.
 
 
 
 
 Conclusion: Our initial experience with transoral endoscopic posterior cordectomy and partial arytenoidectomy using carbon dioxide laser has good postoperative outcomes among patients with bilateral vocal cord paralysis.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Evaluation of Surgical Strategies for Bilateral Vocal Fold Paralysis Using Excised Canine Larynges

The objective of this study was to provide a theoretical basis for the selection of optimal surgical procedures in ex vivo simulated bilateral vocal fold paralysis (BVFP). Four surgical stages were sequentially performed on 10 excised canine larynges with simulated BVFP: (1) transverse cordotomy, (2) medial arytenoidectomy, (3) subtotal arytenoidectomy, and (4) total arytenoidectomy. The sound pressure level, the signal-to-noise ratio, the glottal resistance, the glottal airflow (GF), the maximal glottal area (MGA), and spectrograms were measured after each stage. For comparative analysis of variance, a randomized block design and the Student-Newman-Keuls test were performed. Under stable phonation, the sound pressure level showed no significant differences among the four stages. The signal-to-noise ratio was significantly different between the preoperative period and stage 1, as well as between stages 2 and 3. Glottal resistance was significantly different between the preoperative period and stage 1 and between stages 1 and 2. GF and MGA were significantly different among all stages, compared with those between stages 3 and 4 for GF and the preoperative period and stage 1 for MGA. The spectrograms indicated that the degree of disorder in the acoustic signals gradually increased. Based on a comprehensive analysis of GF and voice quality in excised canine larynges, which simulated BVFP, our results suggest that the optimal surgical choice for BVFP is either medial or subtotal arytenoidectomy.

Voice Outcomes Following Posterior Cordotomy With Medial Arytenoidectomy in Patients With Bilateral Vocal Fold Immobility.

Voice quality-of-life (VQOL) and perceptual voice outcomes are presumed to worsen following posterior cordotomy with medial arytenoidectomy for bilateral vocal fold immobility (BVFI); however, subjective and objective voice outcomes are not well studied in this postsurgical patient population. To evaluate VQOL and perceptual voice outcomes following posterior cordotomy with medial arytenoidectomy for BVFI. Retrospective medical record review of 15 patients with BVFI who underwent posterior cordotomy with medial arytenoidectomy at a tertiary care academic hospital from 2009 to 2012. Suspension microlaryngoscopy was performed to expose the posterior glottis. A posterior cordotomy and medial arytenoidectomy was performed anterior to the vocal process of the vocal fold in a medial to lateral fashion. Data included age, sex, tracheostomy status, number of cordotomies, and voice outcomes. Voice-Related Quality of Life (VRQOL) and Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) data were collected preoperatively and postoperatively surrounding a single procedure. Comparisons within a single group were performed with a paired t test. Statistical significance was determined at P ≤ .05. Eight patients (53%) were male, and 7 (47%) were female. Six patients (40%) required a tracheotomy at some point during treatment, 4 were successfully decannulated. For all 15 patients, the mean VRQOL scores improved 12 points from 47.33 to 59.33 after posterior cordotomy (P = .12). Mean CAPE-V overall severity scores in 13 patients increased 26 points after posterior cordotomy with medial arytenoidectomy from 38.12 to 62.77 (P = .01), indicating further deviance from normal. To our knowledge, this is the first study to compare VQOL with perceptual voice outcomes following posterior cordotomy with medial arytenoidectomy in a series of patients with BVFI. Patients who underwent posterior cordotomy in this study had significantly reduced perceptual voice outcomes with unchanged VQOL. While postcordotomy patients have a dysphonia that is noticeable to voice professionals, most patients in this study subjectively felt as though their voice improved after surgery. Surgeons should be aware of these factors when counseling patients considering cordotomy for BVFI.

Superomedial Submucosal Partial Arytenoidectomy for Improved Posterior Glottic Closure

Endoscopic medial partial arytenoidectomy has been described previously for expansion of the posterior glottic airway in bilateral vocal fold paralysis. Superomedial submucosal partial arytenoidectomy (SSPA), a modification of this technique, can improve glottic closure in the setting of an obstructing anteromedially prolapsed arytenoid. We present our surgical technique and a case example. A 45-year-old man presented with dysphonia attributable to unilateral true vocal fold paralysis. Laryngoscopy revealed right true vocal fold atrophy and an anteriorly prolapsed right arytenoid cartilage preventing posterior glottic closure during adduction. Right SSPA and ipsilateral vocal fold injection augmentation were performed without complication. One-month and 11-month postoperative evaluations showed marked improvement in voice, with complete glottic closure. Quality-of-life assessment and patient report showed a durable result at 50 months. SSPA may be a valuable technique in the management of breathy dysphonia associated with posterior glottic gap and other sequelae of the malpositioned arytenoid.

Endoscopic laser medial arytenoidectomy for treatment of bilateral vocal fold paralysis

Endoscopic laser medial arytenoidectomy for bilateral vocal fold paralysis has the advantage of preserving the structure and the position of the vocal fold, contrary to a transverse cordotomy or total arytenoidectomy. Our objective was to evaluate the functional results of this procedure. This is a prospective non-randomized study. Twenty patients were included: five patients had a tracheotomy preoperatively and 15 patients had dyspnea on exertion. Acoustic voice measurements, spirometric parameters and the voice handicap index 120 (VHI), were evaluated 1 week before surgery and 3 months after. All the five patients with tracheotomy were successfully decannulated. Acoustic records and VHI were available for eight patients. Jitter and shimmer were worse (p = 0.0078), whereas the VHI was not significantly different after surgery. Spirometric records, available for six patients, were not modified. Endoscopic laser medial arytenoidectomy allowed decannulation and subjective improvement of quality of life in patients with bilateral vocal fold paralysis.

Arytenoid and posterior vocal fold surgery for bilateral vocal fold immobility

Many procedures exist to address the airway restriction often seen with bilateral vocal fold immobility. We review the most recent studies involving arytenoid and/or posterior vocal fold surgery to provide an update on the issues related to these procedures. Specific focus is placed on selection of the surgical approach and operative side, use of adjunctive therapies, and outcome measures including decannulation rate, revision and complication rate, and postoperative results. Ten studies were identified between 2004 and 2011. Modifications to the orginal transverse cordotomy and medial arytenoidectomy techniques continue to be investigated to seek improvement in dyspnea symptoms with minimal decline in voice and/or swallowing function. Decannulation rates for these approaches are high. Postoperative dysphagia appears to be less commonly observed but requires continued study. The use of mitomycin-C in these procedures has been poorly studied to date. Both transverse cordotomy and medial arytenoidectomy procedures result in high success rates. However, many questions related to these procedures remain unanswered, particularly with respect to preoperative and postoperative evaluations of voice quality, swallowing function, and pulmonary status. There is need for rigorous prospective clinical studies to address these many issues further.

Medial Arytenoidectomy versus Transverse Cordotomy as a Treatment for Bilateral Vocal Fold Paralysis

Transverse cordotomy (TC) and medial arytenoidectomy (MA) are procedures performed to enlarge the glottic airway in patients with bilateral vocal fold paralysis (BVFP). Both are less destructive than total arytenoidectomy and have distinct theoretical advantages for voice preservation, but they have never been compared. The records of patients with BVFP treated with TC or MA were reviewed; information regarding the outcome measures of tracheotomy decannulation, dysphagia, Voice Handicap Index score, voice intensity, clinical course, and preoperative and postoperative voice quality was obtained. Seventeen patients were available for evaluation (11 with TC, 6 with MA). All 6 patients with a preoperative tracheotomy were decannulated. Four patients in the MA group and 2 in the TC group had an increase in their postoperative Voice Handicap Index score. Two of the patients in the MA group had a decrease in phonatory sound pressure level of 3 dB, and 1 in the TC group had a decrease of 2 dB sound pressure level. Patient self-report of airway status following TC or MA showed that 62.5% (10 of 16) were significantly better and 25% (4 of 16) were somewhat better. Blinded audio perceptual analysis comparing preoperative and postoperative voice quality showed no difference between the MA and TC groups. A swallowing quality-of-life instrument confirmed a lack of swallowing difficulties postoperatively. Both TC and MA are good treatment options for BVFP, with a low incidence of complications in postoperative voice or of swallowing difficulties and a consistent improvement of laryngeal airway restriction symptoms.

炭酸ガスレーザーによる拡大声門後方開大術

The extended posterior glottic opening technique was performed in 10 patients with bilateral vocal cord paralysis by CO2 laser laryngomicrosurgery. The subsequent phonatory function was then examined by the use PS-77 phonatory function test equipment, with the simultaneous measurement of subglottic pressure, during easy phonation preoperatively and again at one month post operation.This extended glottic opening technique consisted of an extended posterior cordectomy and a medial arytenoidectomy or arytenoidectomy. After the operation, the patients were free from dyspnea, and the tracheal fistulae were closed at 3 weeks after the operation.The patients' voices became slightly husky, weak, and the pitch was noticeably lower.The mean pre versus post operative phonatory function values (from pre-mean value to postmean value) revealed a shorter maximum phonation time (from 6.3 to 5.3 sec), a higher air flow rate (from 316 to 429ml/sec), a decreased subglottic pressure (from 12.7 to 5.9 cmH2O), a lower laryngeal resistance (from 93.3 to 34.1 cmH2O), and a lower level of laryngeal efficiency (from 2.09 to 1.53×10-4), respectively.However, the subglottic power remained almost the same (from 5.0 to 4.9×106) from pre to post operation.Based on our study, the extended posterior glottic opening technique by CO2 laser laryngomicrosurgery might be sufficient to open the glottis to avoid dyspnea and to maintain voice production in patients with bilateral abductor vocal paralysis.

Endoscopic Laser Medial Arytenoidectomy for Airway Management in Bilateral Laryngeal Paralysis

A review of our recent experience in patients with bilateral laryngeal paralysis is described. While we continue to use phrenic nerve transfers in patients with mobile arytenoids, patients with fixed arytenoids generally require some sort of vocal cord lateralization, either by arytenoidectomy and arytenoidopexy or by partial vocal cord resection. The endoscopic laser medial arytenoidectomy is a convenient and effective method for opening the posterior glottic airway. One arytenoid is reduced medially with the carbon dioxide laser. After about 3 months the opposite arytenoid can be treated similarly, if necessary. The procedure does not appear to affect arytenoid mobility, as the posterior commissure mucosa and underlying interarytenoid muscle are protected and hence unaffected by the procedure. Those patients with at least one mobile arytenoid cartilage are candidates for posterior cricoarytenoid muscle reinnervation. Although ansa cervicalis and phrenic nerve techniques have been described, the author has concentrated efforts on the phrenic nerve. This report describes the endoscopic laser medial arytenoidectomy procedure, while the phrenic nerve patients will be reported in a subsequent manuscript.