Partial Arytenoidectomy Research Articles

Unilateral True Vocal Fold Synkinesis Presenting with Airway Obstruction

We present a case series of 10 patients with unilateral true vocal fold paralysis who presented with airway obstruction. A retrospective review of the authors' patients at 2 institutions with unilateral true vocal fold motion impairment was carried out over a 10-year period. Of these, 10 patients were identified who presented with stridor and dyspnea as a result of synkinesis. Six cases were a result of thyroidectomy, 1 case resulted from recurrent laryngeal nerve section for spasmodic dysphonia, 1 case occurred after anterior cervical diskectomy and fusion, and in 2 cases no cause was identified. Three patients underwent tracheotomy. Two patients underwent partial arytenoidectomy. Seven patients underwent botulinum toxin injection; 2 were treated with breathing therapy, and in 1 case breathing therapy was recommended. Seven patients underwent treatment with more than 1 method. Unilateral vocal fold paralysis may present with airway obstruction as a result of synkinesis. Treatment should be incremental and starts with breathing therapy and botulinum toxin injection. Partial arytenoidectomy or tracheotomy may be necessary for refractory cases.

Video‐Assisted Left Partial Arytenoidectomy by Diode Laser Photoablation for Treatment of Canine Laryngeal Paralysis

To evaluate the clinical outcome of left partial arytenoidectomy by video-assisted laser diode photoablation as a surgical treatment for canine laryngeal paralysis (LP). Case series. Dogs with bilateral LP (n=20). After endoscopic diagnosis of bilateral LP, left partial arytenoidectomy was performed by photoablation of arytenoid cartilage tissue using a diode laser (600 microm diameter, 15 W power, 980 nm wave length) to increase the width of the rima glottidis. Outcome was evaluated endoscopically (1 and 6 months) and clinically (1, 6, and 12 months). No substantial complications occurred during photoablation or in the immediate postoperative period. Postoperative width of the rima glottidis ranged from 6 to 10 mm at its widest aspect. At 1 month, respiratory function after walking and short running appeared good. Clinical and endoscopic examination revealed good outcome at 1 and 6 months. At 6 months, there was no evidence of hypertrophic scar, hypertrophic granulation tissue, or stricture of the laryngeal glottis in any dog. Two dogs developed aspiration pneumonia after 12 months. Partial arytenoidectomy using video-assisted diode laser photoablation appears to be an effective technique for treating LP. Partial arytenoidectomy by diode laser photoablation should be considered as an alternative technique for treatment of canine LP.

Racing performance after combined prosthetic laryngoplasty and ipsilateral ventriculocordectomy or partial arytenoidectomy: 135 Thoroughbred racehorses competing at less than 2400 m (1997–2007)

The success of combined prosthetic laryngoplasty with ipsilateral ventriculocordectomy (LPVC) has not been compared to that of partial arytenoidectomy (PA) in a clinical population. In Thoroughbred (TB) racehorses: (1) earnings after LPVC are unaffected by the severity of recurrent laryngeal neuropathy (RLN) (laryngeal grade III vs. grade IV); (2) LPVC and PA yield similar results in the treatment of grade III RLN; (3) performance outcome following PA is independent of diagnosis (RLN vs. unilateral arytenoid chondritis [UAC]); and (4) neither LPVC nor PA returns horses to the level of performance of controls. Medical and racing records of 135 TB racehorses undergoing LPVC or PA for the treatment of grade III or IV RLN or UAC were reviewed. Racing records of age and sex matched controls were also reviewed. After LPVC, horses with grade III RLN performed better compared to those with grade IV RLN. Furthermore, horses treated for grade III RLN by LPVC showed post operative earnings comparable to controls. Rate of return to racing were similar for PA and LPVC, although LPVC resulted in higher post operative earnings. Performance after PA was similar regardless of diagnosis (UAC or RLN). Finally, neither LPVC when performed for grade IV RLN, nor PA performed for either diagnosis restored post operative earnings to control levels. Thoroughbred racehorses treated by LPVC for grade III RLN show significantly better post operative earnings compared to horses treated for grade IV disease. In grade III RLN, LPVC returns earning potential to control levels. PA and LPVC lead to similar success in terms of rate of return to racing, but PA leads to inferior earnings after surgery. Laryngoplasty should be recommended for all TB racehorses with grade III RLN to maximise return to racing at a high level. This contradicts the common approach of waiting for complete paralysis.

Long‐term study of partial arytenoidectomy with primary mucosal closure in 76 Thoroughbred racehorses (1992–2006)

The effectiveness and best method to perform a partial arytenoidectomy in racehorses is unclear. This study was performed to evaluate the success of and complications that can occur after a unilateral partial arytenoidectomy with primary mucosal closure in Thoroughbred racehorses. Partial arytenoidectomy is an effective surgical procedure to return Thoroughbred racehorses, afflicted by arytenoid chondropathy or a failed laryngoplasty, to preoperative levels of performance. Seventy-six Thoroughbred racehorses admitted to the New Bolton Centre between 1992 and 2006 were assessed. Information was obtained from the medical records about the horse, laryngeal abnormalities, surgery and other findings during hospitalisation. Racing information was evaluated relative to those independent variables by an analysis of variance with a level of significance of P<0.05. Arytenoid chondropathy was the presenting complaint in 54 horses and failed laryngoplasty in 22 horses. Thirteen horses (17%) underwent a second surgery for laser excision of intralaryngeal granulation tissue at the arytenoidectomy site. Seventy-three horses were discharged from the hospital and racing outcome was evaluated. Sixty horses (82%) raced after surgery and 46 horses (63%) raced 5 or more times after surgery. The median time from surgery to the first start was 6 months. The average earnings/start was not significantly different before and after surgery. There was no association between earnings after surgery and age, gender, location of lesion, type of lesion, duration of tracheal intubation or undergoing a second surgery. A Thoroughbred racehorse is likely to race after a unilateral partial arytenoidectomy with primary mucosal closure and return to a preoperative level of performance.

A Comparison of Laryngoplasty and Modified Partial Arytenoidectomy as Treatments for Laryngeal Hemiplegia in Exercising Horses

To compare upper airway mechanics, arterial blood gases, and tracheal contamination in horses with induced left laryngeal hemiplegia (recurrent laryngeal neuropathy [RLN]) treated by laryngoplasty/vocal cordectomy (LPVC) or modified partial arytenoidectomy (MPA). Repeated measures under the following conditions: Control, RLN, LPVC, and MPA. Six horses. Two trials were conducted under all conditions at 80% and 100% of maximal heart rate (HR(max)). In Trial 1, arterial blood gases, tracheal and pharyngeal pressures, and laryngeal videoendoscopy were recorded. In Trial 2, upper airway pressure and airflow were determined. Tracheobronchial aspirates were performed after exercise to quantify airway contamination. Compared with control, RLN significantly increased inspiratory impedance and worsened exercise-induced hypoxemia. At 80% HR(max), LPVC restored most variables to control values. At 100% HR(max), LPVC improved all variables, but did not restore minute volume, arterial pH, and PaCO(2). At 80% HR(max), MPA restored all variables except bicarbonate to control values. At 100% HR(max), MPA improved all variables, but did not statistically restore minute ventilation or bicarbonate level. Only minor differences were noted between LPVC and MPA. Both resulted in equivalent tracheal contamination. Airway mechanics and arterial blood gas values were not restored to normal after either LPVC or MPA in horses exercising at HR(max). This does not affect ventilation at sub-maximal exercise, but has clinical implications at HR(max). Both procedures diminish normal laryngeal protective mechanisms. At sub-maximal exercise intensities both LPVC and MPA restore airway ventilation to normal. At maximal exercise the superiority of LPVC over MPA is slight.

Partial Laser Arytenoidectomy in the Management of Bilateral Vocal Fold Immobility: A Modification Based on Functional Anatomical Study of the Cricoarytenoid Joint

To establish the anatomical relationships between the arytenoid and cricoid cartilages and apply these findings to design an arytenoidectomy based on a sound anatomical basis. In 50 patients the length of the vocal process and the distance between vocal process tip and upper border of the cricoid cartilage were endoscopically measured. Twenty-five total laryngectomy specimens were sagittally and axially sectioned to verify the position of the arytenoids and their relation to the cricoid. The anatomical findings led to the design of laser partial arytenoidectomy and cordotomy (L-PAC), which was used in 45 patients with bilateral cord paralysis in adduction. The anatomical findings showed that the cricoarytenoid joint did not contribute to the airway in any of the measured specimens. Using L-PAC, 100% of the patients were decannulated and no patient needed a postoperative tracheostomy at any time. Only 3 patients experienced minimal postoperative aspiration to liquids (6.7%). Reasonable phonation was achieved as regarded by a speech analysis battery. Three patients (6.7%) needed a contralateral L-PAC. The shape of the cricoid and the location of its axis of maximum width ought to dictate the technique of glottic widening to be used in bilateral cord immobility in adduction. The present extra-articular technique, L-PAC, showed its versatility in providing an effective balance between the protective, the respiratory, and to lesser extent the phoniatory functions.

Laser posterior ventriculocordectomy with partial arytenoidectomy for the treatment of bilateral vocal fold immobility.

Bilateral vocal fold immobility in adduction usually creates severe dyspnoea. Many surgical procedures have been established to improve the airway insufficiency in affected patients. Over the last six years 22 patients with bilateral vocal fold immobility in our department have undergone CO(2) laser posterior ventriculocordectomy with partial arytenoidectomy (PVCPA). None had dyspnoea or a disturbance in the immediate post-operative period or during follow up, which ranged from five months to six years. Only one patient required a second procedure. Laser PVCPA appears to be an effective and reliable method for the treatment of bilateral vocal fold immobility in selected patients.

Surgery for pediatric vocal cord paralysis: a meta-analysis.

The study goal was to determine the impact of various surgical procedures for bilateral vocal cord paralysis in children by using established principles of meta-analysis. We conducted a retrospective review of the literature in which a predetermined protocol was used to identify articles for meta-analysis. Six articles met inclusion criteria, and pertinent data were extracted. Pooled data analysis demonstrated primary procedure-specific decannulation rates for external arytenoidopexy for 19 of 24 (79%), external arytenoidectomy for 14 of 19 (74%), CO2 laser arytenoidectomy for 4 of 10 (40%), and costal cartilage graft procedures for 2 of 2 (100%). External arytenoid procedures are more efficacious than CO2 laser procedures in terms of primary decannulation (P = 0.02). Meta-analysis of the existing literature reveals that external arytenoidopexy and external arytenoidectomy are equivalently effective procedures and that the two combined are significantly more effective than CO2 ablative procedures. External procedures appear to be more effective as a first-line treatment in pediatric vocal cord paralysis, with arytenoidopexy with or without partial arytenoidectomy offering an attractive first-line surgical option.

Minimally invasive laser treatment of arytenoid chondritis in horses

Arytenoid chondritis is a performance-limiting condition in horses. The underlying problem is a primary infection in the body or corniculate process of 1 or both arytenoid cartilages of the larynx. When chronic inflammation or abscessation may deform and permanently immobilize the affected cartilages, partial arytenoidectomy is indicated. Before that point, the process can be arrested by local debridement or drainage of the lesions, which has traditionally been accomplished by laryngotomy with the horse under general anesthesia. Infections of the arytenoid cartilages with granulomas and abscesses can be effectively treated in the standing horse by using the diode laser administered by an endoscopically guided ventral stab incision in the cricothyroid membrane.

Arytenoid prolapse as a consequence of cricotracheal resection in children.

Cricotracheal resection (CTR) is a technique introduced comparatively recently for treating severe laryngotracheal stenosis in children. The recognized complications of CTR include recurrent laryngeal nerve damage, anastomotic dehiscence, and restenosis. We describe a further complication of CTR, namely, prolapse of the arytenoid cartilage. The presentation may be late, with symptoms of shortness of breath on exertion and nocturnal stertor with a poor sleep pattern, or the prolapse may be an asymptomatic incidental finding. The diagnosis is performed with flexible nasopharyngoscopy with the patient unanesthetized, or with rigid endoscopy with the patient lightly anesthetized and spontaneously ventilating. The affected arytenoid cartilage is noted to prolapse anteriorly and medially with inspiration, partly obstructing the airway. If treatment is required, endoscopic laser partial arytenoidectomy is effective. In a series of 44 children who underwent CTR, 20 were noted to develop arytenoid prolapse after operation. Twelve were asymptomatic, and 8 required laser arytenoidectomy, 2 of whom now require continuous positive airway pressure for moderate supraglottic collapse.

Partial cricotracheal resection with primary anastomosis for pediatric laryngotracheal stenosis

Severe laryngotracheal stenosis (LTS) in the pediatric age group has been traditionally treated by laryngotracheoplasty procedures. This approach may be complex and multistaged. High success rates have been reported in adults with severe LTS who underwent partial resection of the cricoid and primary thyrotracheal anastomosis. However, this procedure has not been widely reported in infants and children. Since November 1993, 38 patients with grade III or IV subglottic stenosis were treated with partial cricotracheal resection (CTR) and primary anastomosis. In some patients a posterior cricoid split or partial arytenoidectomy was performed as well. The preoperative evaluation, surgical techniques, and postoperative care are described. There were no significant operative complications or deaths. Thirty-three patients were decannulated after a single open surgical procedure. Our results as well as those of previous series suggest that CTR with primary anastomosis is a relatively safe and effective procedure in infants and children with severe LTS.

Evaluation of partial arytenoidectomy as a treatment for equine laryngeal hemiplegia.

The efficacy of partial arytenoidectomy was assessed in 6 Standardbred horses, with surgically induced laryngeal hemiplegia, at rest (Period A) and during exercise at speeds corresponding to maximum heart rate (Period C) and 75% of maximum heart rate (Period B). Peak expiratory and inspiratory airflow rate (PEF and PIF), and expiratory and inspiratory transupper airway pressure (PUE and PUI) were measured and expiratory and inspiratory impedance (ZE and ZI) were calculated. Simultaneously, tidal breathing flow-volume loops (TBFVL) were acquired using a respiratory function computer. Indices derived from TBFVL included airflow rates at 50 and 25% of tidal volume (EF50, IF50, EF25, and IF25) and the ratios of expiratory to inspiratory flows. Measurements were made before left recurrent laryngeal neurectomy (baseline), 2 weeks after left recurrent laryngeal neurectomy (LRLN) and 16 weeks after left partial arytenoidectomy coupled with bilateral ventriculectomy (ARYT). After LRLN, during exercise Periods B and C, Z1 and the ratio of EF50/IF50 significantly increased and PIF, IF50 and IF25 significantly decreased from baseline values. At 16 weeks after ARYT, Z1 returned to baseline values during Periods B and C. Although PIF, IF50, IF25, PEF/PIF, and EF50/IF50 returned to baseline values during Period B, these indices remained significantly different from baseline measurements during Period C. After ARYT, TBFVL shapes from horses during Period C approached that seen at the baseline evaluation. Partial arytenoidectomy improved upper airway function in exercising horses with surgically induced left laryngeal hemiplegia, although qualitative and quantitative evaluation of TBFVLs suggested that some flow limitation remains at near maximal airflow rates. These results indicate that, although the procedure does not completely restore the upper airway to normal, partial arytenoidectomy is a viable treatment option for failed laryngoplasty and arytenoid chondropathy in the horse.

Partial arytenoidectomy in the horse using an extralaryngeal approach.

An extralaryngeal approach to partial arytenoidectomy in the horse was developed by in vitro experiments on isolated larynges and then on intact equine cadavers. The goals of the approach were to preserve the laryngeal mucosa, eliminate the need for a laryngotomy or tracheotomy, and minimize postoperative complications. The new approach was evaluated in seven horses with normal upper respiratory tracts. Left laryngeal hemiplegia was surgically created, and, after a 30-day convalescence, left partial arytenoidectomy was performed using an extralaryngeal approach. The left-to-right hemilaryngeal ratio was calculated before and after left recurrent laryngeal neurectomy and 60 days after partial arytenoidectomy. Left partial arytenoidectomy was successfully completed in all horses without performing a laryngotomy or tracheotomy. Preservation of the laryngeal mucosa (6/7 horses) and apparent stabilization of the adjacent soft tissue (6/7 horses) was achieved. In one horse, a 1-cm laryngeal mucosal tear healed without complication, and in another some collapse of adjacent soft tissue occurred when a retention suture failed. The mean left-to-right hemilaryngeal ratio was significantly increased compared to horses with left laryngeal hemiplegia, but it remained significantly less than the pre-recurrent laryngeal neurectomy ratio (p < .05). Coughing, aspiration, and airway narrowing were not observed. Partial arytenoidectomy could be reliably performed through an extralaryngeal approach in horses with a normal underlying arytenoid cartilage with preservation of the laryngeal mucosa.

Surgical management of severe laryngomalacia.

Infants and children with laryngomalacia exhibit varying degrees of upper airway obstruction and dysphagia. Although the disorder is usually self-limited, the potential exists for symptoms so severe that operative intervention cannot be avoided. Relief of progressive airway compromise traditionally has involved bypassing the obstruction with tracheotomy. Recently, endoscopic surgical management of the most severe cases has been reexamined by the authors and others. Thirteen infants and children underwent supraglottoplasty (also referred to as epiglottoplasty or partial arytenoidectomy) for severe, complicated laryngomalacia. Endoscopic laser removal of flaccid supraglottic tissue resulted in improvement of the airway in all patients. In most patients, associated symptoms improved or completely resolved. Supraglottoplasty is an effective alternative to tracheotomy in carefully selected patients with severe laryngomalacia.

Partial Arytenoidectomy in the Horse with and without Mucosal Closure

Left-sided partial arytenoidectomy was performed in eight horses to evaluate healing. Four horses underwent conventional partial arytenoidectomy with suture apposition of the mucosa. In four horses, most of the arytenoid cartilage, including overlying mucosa, vocal fold, and laryngeal saccule, were excised en bloc without mucosal closure. The horses were monitored clinically by endoscopic examination. One horse from each group was euthanatized at weeks 2, 4, 8, and 16. Complete necropsies with gross and histologic examination of the arytenoidectomy sites were performed. Postoperative complications such as coughing, dysphagia, and aspiration pneumonia were not encountered and problems with wound healing were minimal in both groups. The defect created by partial arytenoidectomy without mucosal closure initially filled to the level of the luminal surface with granulation tissue, with a gradual transition to mature fibrous connective tissue. Grossly, the defect appeared to be healed and was completely epithelialized by week 16 without apparent narrowing of the laryngeal lumen. Partial arytenoidectomy sites with mucosal closure healed in a similar pattern by week 8. Partial dehiscence of the dorsal portion of the sutured mucosa occurred in three horses.

Partial Arytenoidectomy in Horses

Unilateral partial arytenoidectomy was performed in 22 horses. Six horses had arytenoid chondritis, 14 horses had idiopathic laryngeal hemiplegia (11 of which had been treated unsuccessfully by insertion of a laryngeal abductor muscle prosthesis), and two horses had laryngeal hemiplegia resulting from perivascular injection of an irritant drug. After surgery, eight horses (36%) developed a nasal discharge of food and/or water that was of clinical significance in only two of them. The operation resulted in marked improvement in exercise tolerance in all 20 horses tested, although two could not work because of severe exercise‐associated coughing. Mild inspiratory stertor was present in eight horses and was excessive in one. It was concluded that the high incidence of problems related to swallowing rendered the method unacceptable. Modification of partial arytenoidectomy by silicon augmentation produced improvement in one horse.

Partial Laryngectomy in the Dog I. Healing and Swallowing Function in Normal Dogs

Laryngeal paralysis was created in normal dogs by sectioning the recurrent laryngeal nerves. The dogs were treated with bilateral vocal fold resection and unilateral partial arytenoidectomy, and sacrificed from 6 hours to 28 days following surgery. Swallowing abnormalities were not found in any of the dogs. Healing by granulation‐epithelialization was complete by 14 days.

Partial Arytenoidectomy in the Horse

Four horses were examined because of inspiratory dyspnea and noise resulting from an inability to abduct one or both arytenoid cartilages. Two unilateral arytenoidectomies were done following failure of laryngoplasty, and two bilateral arytenoidectomies were done to correct permanent arytenoid adduction caused by laryngeal ossification. The surgical procedure included submucosal dissection of the arytenoid cartilage and removal of the vocal fold, lateral ventricle (when present), and the arytenoid cartilage, excluding the muscular process. Excessive mucous membrane was pulled caudally from the opening of the larynx and carefully sutured to close the mucous membrane and smooth the rima glottis. Postoperative swelling was greatest between the 3rd and 7th days. Long‐term results included one horse returned to normal function with no noise, one horse returned to normal function but with respiratory noise, one horse returned to light riding with reduced noise, and one horse salvaged for pasture use.