Vocal Cord Paralysis Research Articles

Outcomes of Immediate Total Thyroidectomy in First-Side Loss of Neuromonitoring Signal

Use of intraoperative neuromonitoring (IONM) during thyroidectomy can nearly eliminate the risk of postoperative bilateral vocal cord palsy (VCP) by indicating staged surgery in cases of loss of signal (LOS) on the first side of planned total thyroidectomy. However, aborting planned total thyroidectomy may lead to persistence of symptoms, delay in adjuvant treatment, and patient inconvenience and distress. There are few data to guide a selective approach to total thyroidectomy in patients with first-side LOS. To investigate outcomes of immediate bilateral surgery in patients undergoing total thyroidectomy with first-side LOS. This cohort study was a retrospective review of outcomes for patients undergoing thyroidectomy between January 2016 and July 2023 at an academic tertiary referral center for thyroid surgery. Consecutive patients scheduled for total thyroidectomy using IONM were included. Exclusion criteria were preoperative VCP, deliberate sacrifice of recurrent laryngeal nerve (RLN), inadvertent RLN resection, and surgery performed without IONM. Total thyroidectomy performed using IONM. Vocal mobility on first postoperative day as assessed by flexible laryngoscopy; secondary outcome measures included subjective voice assessment, other postoperative complications, and long-term vocal mobility. Among 400 patients undergoing planned total thyroidectomy (mean age, 50.5 years [range, 4-88 years]; 318 female [79.5%]), 51 (12.8%) had first-side LOS, of whom 37 (9.3%) had persistent LOS. Twenty-nine patients (56% of procedures with first-side LOS, including 18 with persistent LOS) proceeded to immediate total thyroidectomy. Postoperatively, 16 patients (55% of patients undergoing total thyroidectomy following first-side LOS, including 14 of 18 with persistent LOS) had impaired vocal mobility. One patient had bilateral VCP that did not require tracheostomy, and 2 had postoperative hypoparathyroidism. Of those whose surgery was aborted after first-side LOS, 8 of 22 (36%) underwent completion thyroidectomy at a later stage. In those undergoing completion thyroidectomy, 2 of 8 (25%) had temporary VCP after the second surgery, 2 (25%) had permanent hypoparathyroidism, and 1 (12.5%) developed inoperable cancer. Postoperative VCP was fully reversible in all but 1 patient. Among patients planned for total thyroidectomy who develop first-side LOS, immediate total thyroidectomy may be considered among those who have pressing reasons for same, and where surgical difficulties might be anticipated in a secondary surgery.

Classification of laryngeal diseases including laryngeal cancer, benign mucosal disease, and vocal cord paralysis by artificial intelligence using voice analysis

Voice change is often the first sign of laryngeal cancer, leading to diagnosis through hospital laryngoscopy. Screening for laryngeal cancer solely based on voice could enhance early detection. However, identifying voice indicators specific to laryngeal cancer is challenging, especially when differentiating it from other laryngeal ailments. This study presents an artificial intelligence model designed to distinguish between healthy voices, laryngeal cancer voices, and those of the other laryngeal conditions. We gathered voice samples of individuals with laryngeal cancer, vocal cord paralysis, benign mucosal diseases, and healthy participants. Comprehensive testing was conducted to determine the best mel-frequency cepstral coefficient conversion and machine learning techniques, with results analyzed in-depth. In our tests, laryngeal diseases distinguishing from healthy voices achieved an accuracy of 0.85–0.97. However, when multiclass classification, accuracy ranged from 0.75 to 0.83. These findings highlight the challenges of artificial intelligence-driven voice-based diagnosis due to overlaps with benign conditions but also underscore its potential.

Velopalatine and Bilateral Vocal Cord Paralysis Associated with Atezolizumab Treatment: A Severe and Previously Undocumented Side Effect in Cancer Immunotherapy.

Adverse effects of immunotherapeutic treatments like atezolizumab remain largely unknown due to limited experience. We present a 65-year-old man with sudden dyspnea and other symptoms, implicating immunotherapy. Prompt intervention and suspension were crucial. This study identifies a novel unreported adverse effect-bilateral vocal cord and velopalatine paralysis-associated with atezolizumab use.

The risk factors for postoperative temporary vocal cord paralysis after thyroid cancer surgery: an observational retrospective cohort study.

To analyze the potential factors influencing new-onset postoperative transient vocal cord paralysis (VCP) in thyroid cancer patients. Case information of 8340 thyroid cancer patients hospitalized at China-Japan Union Hospital of Jilin University, Jilin Province, China, in the Thyroid Surgery Department from January 2018 to December 2020 was collected retrospectively and analyzed. The possible influencing factors were analyzed using a χ2 test, rank-sum test, and multiple logistic regression analysis. A nomogram was used to construct the clinical prediction model that was validated in the validation set by receiver operating characteristic, calibration curves, and Decision curve analysis. The strengthening the reporting of cohort, cross-sectional, and case-control studies in surgery (STROCSS) guideline was followed to conduct a retrospective cohort study. A total of 8340 patients, including 1817 (21.8%) men and 6523 (78.2%) women, were enrolled in this study. The rate of temporary VCP was 3.6% (308/8340). Based on the results of postoperative laryngoscopy, the patients were divided into VCP group and non-VCP group. Comparative analysis between the groups revealed that potential factors associated with postoperative transient VCP were tumor location on the dorsal side of the gland ( P =0.042), ultrasound showing a maximum nodal diameter >1cm ( P =0.002), multifocal carcinoma ( P <0.001), invasion of surrounding tissue ( P =0.005), lymph node metastases in the central compartment ( P =0.034), lateral cervical lymph node metastasis ( P <0.001), and prolonged operation ( P <0.001). A multiple logistic regression analysis showed that the independent risk factors in postoperative transient VCP were T stage (OR=1.411, P =0.013, 95% CI: 1.075-1.853), multifocal carcinoma (OR=1.532, P =0.013, 95% CI: 1.095-2.144), and duration of surgery (OR=1.009, P <0.001, 95% CI: 1.006-1.012). Finally, a clinical prediction model was established via a nomogram and was validated in the validation set, although its diagnostic efficacy needs to be improved further. High T stage, multifocal carcinoma, and prolonged operation time may be independent risk factors for the occurrence of postoperative transient VCP in patients undergoing initial surgery for thyroid cancer.

Solitary Bone Plasmacytoma of the Skull Base With an Unusual Presentation.

Solitary bone plasmacytoma (SBP) is a rare hematological malignancy that usually occurs in the spine and rarely in the skull. It rarely presents in the skull base, but presenting symptoms are associated with cranial nerve involvement depending on the site of the disease. We present the case of a 61-year-old man with an unusual presentation of hoarseness secondary to vocal fold palsy. Imaging showed a large bony lesion in the temporo-occipital region with involvement of the jugular foramen. Further detailed diagnostic procedures confirmed SBP of the skull base. Radiotherapy was given with an uneventful recovery of vocal fold function. Skull base plasmacytoma can be considered as a differential diagnosis of causes of unilateral vocal fold palsy. Early therapeutic management may improve vocal fold function.

A vocal cord palsy caused by the uterine cancer metastatic tumor in the mediastinum revealed in a patient with a thyroid lesion: a case report and review of the literature

BackgroundThe main cause of vocal cord palsy (VCP) is idiopathic impairment of the recurrent laryngeal nerve (RLN). However, solid tumors along the pathway of the RLN can also impact the nerve’s function. We presented a patient with a thyroid lesion and VCP due to a bulky metastatic mass (uterine cancer) on the aortic arch field in the mediastinum. The report aims to show the significance of comorbid tumors in thyroid pathology and the importance of additional diagnostic methods in avoiding unnecessary surgeries. A patient’s lifetime and the outcome of the disease were also presented.Case presentationA 58-year-old Ukrainian woman with a hoarse voice, intermittent dry cough, and weakness was presented to an endocrine surgeon. Thyroid pathology included signs of hypothyroidism treated with Thyroxine 112.5 µg and a nodule in the left lobe. The lesion is located on the posterior aspect of the lobe, which could probably be a cause of RLN involvement. Fine needle aspiration biopsy (FNAB) was performed twice with Bethesda category 2 result. Fibrolaryngoscopy (FLS) revealed the median position of the left vocal cord. Idiopathic, laryngeal, and thyroid causes of the VCP were excluded. Additionally, the patient displayed her anamnesis of the endometrial clear cell carcinoma following hysterectomy, external beam radiation therapy, and chemotherapy. The mediastinal metastasis was revealed sixteen years later. A chest computed tomography (CT) with intravenous contrast was done. A bulky tumor was found right under the aortic arch. Subsequently, the voice complaints reduced significantly after 4 chemotherapy courses. Cancer progression had led to the appearance of lymph node metastases on the supraclavicular region. Following six months the 60-year-old patient had passed away.ConclusionA history of the disease should always be kept in mind when assessing a patient’s complaints. VCP in case of thyroid pathology and previous secondary malignancy may be caused by metastatic tumor anywhere along the RLN pathway. Such a rare case shows the importance of additional methods of examination which may avoid unnecessary thyroid surgeries.

Comparison of the diagnostic and prognostic abilities of flexible laryngoscopy and dynamic digital radiography for vocal cord paralysis: A prospective observational study.

Although flexible laryngoscopy (FL) is the reference modality for diagnosing vocal cord paralysis (VCP), FL involves patient discomfort and insertion intolerance. Dynamic digital radiography (DDR) with high spatial and temporal resolution is easier to use and less invasive when evaluating VCP. Seventy-eight patients underwent FL and DDR before and after neck surgery. Qualitative and quantitative vocal cord movement (VCM) evaluations were conducted. Patients with postoperative VCP were followed-up regularly. DDR exhibited diagnostic performance with 67% sensitivity and 100% specificity. The cutoff for VCM was 2.4 mm, with DDR exhibiting 100% sensitivity and 78% specificity. All cords with transient VCP had positive VCM at both 3 weeks and 2 months. Additionally, 50% and 75% of cords with permanent VCP had negative VCM at 3 weeks and 2 months, respectively. DDR is promising for the diagnosis of postoperative VCP and early prediction of permanent postoperative VCP.

Analysis of factors on voice quality in thyroidectomy patients.

Vocal cord paralysis (VCP) is a serious complication in thyroidectomy operations; however, its management remains unclear. The present study evaluated the voice parameters of patients who underwent surgery using Intraoperative Neurophysiologic Monitoring (IONM). A total of 52 patients (41 females and 11 males) who underwent a total thyroidectomy operation were evaluated using objective and subjective voice analysis examinations before and after surgery. Acoustic parameters, such as Fundamental Frequency (F0), Shimmer, Jitter, Noise-to-Harmonic ratio (NHR), and aerodynamic parameters, including S/Z ratio and maximum phonation time (MPT), were analyzed. Objective findings, including the VHI-10 (Voice Handicap Index) and V-RQOL (Voice-Related Quality of Life), were also analyzed. The relationship between voice parameters and IONM values was investigated. The objective analysis (acoustic and aerodynamic parameters) showed no difference (p>0.05). However, the subjective analysis, which involved the VHI-10 and V-RQOL measures, revealed a significant difference before and after the operation (p<0.05). The Spearman correlation analysis showed that the NHR postoperative 1st-month parameter negatively correlated (rho=-0.317, p<0.059), while the F0 postoperative 6th-month parameter positively correlated (rho=0.347) with the amplitude difference before and after dissection (Right R2-R1 difference) for the right RLN measured in IONM. Patients who are planning to undergo a thyroidectomy procedure should undergo voice assessment during both the preoperative and postoperative periods. IONM could improve voice quality outcomes.

Experiences of Patients with Unilateral Vocal Fold Paralysis: A Mixed-Methods Study of the Insider’s Perspective

ObjectiveUnilateral vocal fold paralysis (UVFP) is often characterized by severe dysphonia and has a significant impact on a patient’s communication in daily and vocational situations. Having a better understanding of how UVFP influences quality of life and patient experiences can help improve patient-centered care in this population. Therefore, the purpose of this study was to explore the lived experiences of patients with UVFP. MethodsTwenty-five adults with UVFP (age range: 39 – 84 years) participated in the study. Quantitative data were collected from 22 participants, using the Voice Handicap Index (VHI), Dysphonia Severity Index (DSI), and Acoustic Voice Quality Index (AVQI). Qualitative data were collected from 25 individual semi-structured interviews, which were recorded, transcribed, and analyzed with the software program NVivo. The interviews were coded using an inductive thematic approach. ResultsQuantitative results showed a mean DSI of -1.6, mean AVQI of 3.80, and mean VHI of 45.8 in the participant group. A statistically significant, moderate (positive) correlation was found between VHI and time after onset (in years). From the qualitative analysis of the interviews, four main themes were identified: emotional impact, psychosocial impact, physical complaints, and coping strategies. Voice problems caused by UVFP generally had a negative impact on patients’ emotional and psychological well-being, with considerable effects on participation, self-identity, and professional activity. Participants demonstrated a combination of problem-focused and emotion-focused coping strategies to accommodate to these issues. Half of the participant group also showed avoidance as a coping style. VHI scores were significantly higher in participants who reported experiencing current emotional and participation problems due to UVFP, and who had not yet accepted their new voice. ConclusionThe themes from this study emphasize the importance of focused anamnesis and emotive counseling in practice, with specific attention to the psychosocial and emotional impact of UVFP. Data Availability StatementData is available from the authors upon request due to privacy reasons.

Volume and Practice-Setting Shift of Laryngology Procedures During the COVID-19 Pandemic: A Reg-ENT Database Analysis.

The onset of the coronavirus disease 2019 (COVID-19) pandemic changed practice patterns throughout medicine. The purpose of this study is to evaluate changes in the volume and location setting of laryngology procedures after the onset of COVID-19. Retrospective database cohort study. Reg-ENT registry. Retrospective review from 2017 to 2022 of patients who underwent a laryngology procedure identified by procedure code categorized by site of service code-"ambulatory surgical" versus "office" setting. Based on March 2020 as the cutoff point, the procedures were designated as pre-COVID versus COVID time period. A total of 5989 patients underwent laryngology procedures. Forty-two percent more procedures were performed in the COVID period (n = 3780) versus pre-COVID (n = 2209). Pre-COVID, the procedure distribution between office and ambulatory surgical setting was 70% (n = 1546) compared with 30% (663). This shifted to 77% (n = 2920) and 23% (n = 860) during COVID, P = .9. The most common diagnoses associated with laryngology procedures during the study period were vocal fold paralysis 47% (n = 2831), dysphonia 33% (n = 1392), and laryngotracheal stenosis 14% (n = 838). These trends remained in both pre-COVID and COVID time periods. After the start of the pandemic, among patients undergoing laryngology procedures, there was a 93% increase (n = 284-549) in the diagnosis of laryngotracheal stenosis, 70% increase (n = 520-882 patients) in dysphonia and 69% increase (n = 1054-1777) in vocal fold paralysis. An increase in laryngology procedures performed after the onset of the COVID-19 pandemic was identified with an overall procedural shift to the office-setting.

136 Initial Clinical Safety and Feasibility From the RESET RA Study of a Novel Implantable Neuroimmune Modulation Device for the Treatment of Rheumatoid Arthritis

INTRODUCTION: Electrical stimulation of the vagus nerve activates the inflammatory reflex to inhibit cytokines and decrease clinical signs and symptoms of chronic inflammatory disease such as rheumatoid arthritis (RA) (Genovese et al. Lancet Rheum 2020). METHODS: The device system consists of two implanted components: a miniature integrated pulse generator and a silicon sleeve positioning device that holds the generator in apposition to the nerve. There are two external components: a wireless charger and an iPad application for programming the pulse generator. Subjects were randomly assigned (1:1) after device implantation on the left vagus nerve to receive active or sham stimulation. The risks of the surgical procedure, device, and stimulation were blindly assessed after 12 weeks of stimulation therapy in the first 60 subjects enrolled in the study. RESULTS: All implant procedures were completed without intraoperative complications, infections, or surgical revisions. No unanticipated adverse events (AEs) were reported during the perioperative period and at the end of 12 weeks of follow-up. No serious AEs related to the device, stimulation, or explant procedures were reported. Vocal cord paresis and prolonged hoarseness were reported in two subjects. The former resolved following vocal cord augmentation with injectable filler; the latter is ongoing and improving with speech therapy. CONCLUSIONS: Initial results demonstrated that implantation and programming of the novel neuroimmune modulation device were safe, and the surgical procedure and device were well tolerated.

Injection Laryngoplasty for Children with Dysphagia after Cardiac Surgery.

To determine whether injection laryngoplasty (IL) resolves thin liquid aspiration among children with unilateral vocal cord paralysis (UVCP) after cardiac surgery. Retrospective case-control. Tertiary children's hospital. Consecutive children (<5 years) between 2012 and 2022 with UVCP after cardiac surgery were included. Resolution of thin liquid aspiration after IL versus observation was determined for children obtaining videofluoroscopic swallow studies (VFSS). A total of 32 children with left UVCP after cardiac surgery met inclusion. Initial surgeries were N = 9 (28%) patent ductus arteriosus ligations, N = 7 (22%) aortic arch surgeries, N = 9 (28%) surgeries for hypoplastic left heart syndrome, and N = 7 (22%) other cardiac surgeries. The mean age at initial surgery was 1.8 months (SD: 3.7). All children had a VFSS obtained after surgery that confirmed aspiration. There were 17 children that obtained an IL at 33.6 months (SD: 20.9) after cardiac surgery and 15 children observed without IL procedure. No surgical complications after IL were noted. The rate of aspiration resolution based on postoperative VFSS was N = 14 (82%) for the IL group and N = 9 (60%) for the control group P = .24. Documented VFSS aspiration resolution after cardiac surgery occurred by 9.6 months (SD: 10.0) in the observation group and 47.4 months (SD: 24.1) in the IL group (P < .001). IL can help treat aspiration in children with UVCP after cardiac surgery but the benefit beyond observation remains unclear. Future studies should continue to explore the utility for IL in managing dysphagia in this pediatric population.

Evaluating the Potential of AI Chatbots in Treatment Decision-making for Acquired Bilateral Vocal Fold Paralysis in Adults

ObjectivesThe development of artificial intelligence-powered language models, such as Chatbot Generative Pre-trained Transformer (ChatGPT) or Large Language Model Meta AI (Llama), is emerging in medicine. Patients and practitioners have full access to chatbots that may provide medical information. The aim of this study was to explore the performance and accuracy of ChatGPT and Llama in treatment decision making for bilateral vocal fold paralysis (BVFP). MethodsData of twenty clinical cases, treated between 2018-2023, were retrospectively collected from four tertiary laryngology centres in Europe. The cases were defined as the most common or most challenging scenarios regarding BVFP treatment. The treatment proposals were discussed in their local multidisciplinary teams (MDT). Each case was presented to ChatGPT-4.0 and Llama Chat-2.0, and potential treatment strategies were requested. The Artificial Intelligence Performance Instrument (AIPI) treatment sub score was used to compare both Chatbots’ performances to MDT treatment proposal. ResultsMost common aetiology of BVFP was thyroid surgery. A form of partial arytenoidectomy with or without posterior transverse cordotomy was the MDT proposal for most cases. The accuracy of both Chatbots was very low regarding their treatment proposals, with a maximum AIPI treatment score in 5% of the cases. In most cases even harmful assertions were made, including the suggestion of vocal fold medialisation to treat patients with stridor and dyspnoea. ChatGPT-4.0 performed significantly better in suggesting the correct treatment as part of the treatment proposal (50%) compared to Llama Chat-2.0 (15%). ConclusionChatGPT and Llama are judged as inaccurate in proposing correct treatment for BVFP. ChatGPT significantly outperformed Llama. Treatment decision-making for a complex condition such as BVFP is clearly beyond the Chatbot’s knowledge expertise. This study highlights the complexity and heterogeneity of BVFP treatment, and the need for further guidelines dedicated to the management of BVFP.

Pneumonia and unilateral vocal fold immobility: a single centre 6-year review

Pneumonia and unilateral vocal fold immobility: a single centre 6-year review

Efficacy Of Vocal Cord Medialization by Injection Thyroplasty Using Liquid Paraffin In Relieving Hoarseness Of Voice In Idiopathic And Traumatic Unilateral Vocal Cord Paralysis

Objective: The objective of the study was to measure the efficacy of injection thyroplasty by liquid paraffin in the medialization of vocal cords in permanent post-traumatic or idiopathic hoarseness. Methodology: A total of 37 patients were enrolled in the study after obtaining approval from the ethical review board. The sample size was calculated using the WHO sample size calculator. All the patients in the study presented with hoarseness of voice due to either traumatic injury, idiopathic aetiology, or post-thyroidectomy. Samples were selected by simple random sampling. It was a Quasi-experimental study. All patients underwent an injection thyroplasty procedure using liquid paraffin to medialize the vocal cords. All the procedures were done under local anaesthesia. The patients were kept in follow-up for 1 year at an interval of 3 months. All the data was entered and analyzed by using SPSS version 24. Paired sample t-test was applied to measure pre-procedure and post-procedure scores. Results: The mean age of the participants was 38 years. Out of 37 patients 23 (62%) patients presented within 6 months of hoarseness of voice. 14 (38%) patients presented after 6 months of hoarseness of voice. 19 out of 23 patients (83%) underwent only a single dose of liquid paraffin via injection thyroplasty to resolve hoarseness of voice. However, out of 14 patients, 7 patients (50%) reportedly had to undergo 2 doses of liquid paraffin via injection thyroplasty. The p-value calculated was &lt;0.005 which was statistically significant. Out of patients presenting after 6 months, 11 patients (79%) underwent transcervical phonation surgery. The p-value calculated was &lt;0.05 which is statistically significant. Conclusion: Our study concludes that liquid paraffin is a safe and cost-effective solution for vocal cord paralysis. Liquid paraffin is not expensive and easily available which can be implied to yield excellent results to improve hoarseness of voice. Patients with late presentation are less likely to get the benefit of this procedure and may have to go for invasive transcervical phonation surgeries. It is recommended that this procedure should be done within 6 months of the development of hoarseness of voice. Keywords: vocal cord palsy, unilateral vocal cord paralysis, laryngeal paralysis, liquid paraffin, injection thyroplasty

Speech and Swallowing Outcomes of Surgically Managed Cervical Chordoma: A Case Series.

Cervical chordoma is a rare, low-grade primary bone tumor occurring in the axial skeleton. Due to challenges in surgical exposure caused by anatomic location, patients may experience dysfunction in speech and swallowing. The objective of this study was to characterize speech and swallowing outcomes for patients undergoing surgical resection of cervical chordoma. Moreover, we detail in-depth two cases with similar initial presentations to compare prognostic factors and management strategies. Eleven patients with histologically confirmed cervical chordoma treated between 1993 and 2020 were included in this retrospective case series. Outcomes measured included overall survival, disease-free survival, need for enteral feeds, as well as results of modified barium swallow study (MBSS) and fiberoptic laryngoscopy. The mean age at diagnosis was 55.9 years. The patient population was 81.8% male. Mean survival after diagnosis was 96 months. Four (36.4%) patients required post-operative MBSS and demonstrated aspiration. All four of these patients presented with tumors in the superior cervical spine and received surgeries utilizing anterior approaches. Of the four, 2 required enteral feeds long-term. Four (36.4%) patients endorsed dysphonia. One patient developed post-operative right vocal fold paresis. The remaining three patients experienced stable dysphonia pre- and post-operatively. Additionally, three (27%) patients required tracheostomy placement, two of which remained in place long-term. Dysphagia is a common side effect of cervical chordoma resection. It is associated with the use of an anterior approach during resection and with tumors located in the superior cervical spine. Patients with postoperative dysphagia should receive early multidisciplinary swallow rehabilitation. 4 Laryngoscope, 134:3706-3712, 2024.

Management of Pediatric Bilateral Vocal Fold Paralysis: A State-of-the-Art Review of Etiologies, Diagnosis, and Treatments.

This paper reviews the current literature about epidemiology, etiologies, diagnosis, and management of pediatric bilateral vocal fold paralysis (PBVFP). According to PRISMA statements, a narrative review of the current literature was conducted through the PubMed, Scopus, and Cochrane Library databases about the epidemiology, etiologies, diagnosis, and management of PBVFP. PBVCP is the second most common congenital laryngeal anomaly in the pediatric population, accounting for 10% to 20% of pediatric laryngeal conditions. PBVCP is related to idiopathic (42.2%), congenital (19.7%), and neurological (16.9%) conditions. A tracheotomy is required in 60% of cases regarding stridor and dyspnea, which are the most prevalent symptoms. The diagnosis is based on the etiological features, clinical presentation, laryngoscopic findings, and objective examinations. Laryngeal electromyography may be used to support the diagnosis in difficult cases, but its reliability depends on the practitioner's experience. The primary differential diagnosis is posterior glottis stenosis, which needs to be excluded regarding therapeutic and management differences with PBVCP. Transient surgical procedures consist of tracheotomy or laterofixation of the vocal fold. Current permanent procedures include uni- or bilateral partial arytenoidectomy, posterior transverse cordotomy, cricoid splits, and laryngeal selective reinnervation. There is no evidence of the superiority of some procedures over others. PBVCP is the second most common laryngeal disorder in the pediatric population. Diagnosis is based on etiological and clinical findings and may require the use of laryngeal electromyography. Therapeutic management may involve several transient or permanent surgical procedures that are associated with overall subjective improvements in symptoms, laryngeal findings, and low complication rates.

Strategies for CO2 Laser Use in Laryngeal Microsurgery: A Systematic Review.

We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety. A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted. Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software. Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up). The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.

Predominantly unilateral laryngomalacia in infants with unilateral vocal fold paralysis

BackgroundNeonatal unilateral vocal fold paralysis may arise iatrogenically, idiopathically, or in the context of an underlying neurologic disorder. Management is often supportive, focusing on diet modification to allow for safe oral feeding. We describe the clinical course of six infants with unilateral vocal fold paralysis who developed predominantly unilateral laryngomalacia ipsilateral to the affected vocal fold with associated severe respiratory symptoms and feeding difficulty. MethodsRetrospective review of six infants with unilateral vocal fold paralysis and predominantly unilateral laryngomalacia. Charts were reviewed for etiology of vocal fold paralysis, presenting symptoms, operative details, postoperative course, and outcomes for breathing and swallowing. ResultsEtiology of vocal fold paralysis included cardiac surgery in four patients, intubation-related in one, and idiopathic in one. Presenting symptoms included increased work of breathing, stridor, feeding difficulty, respiratory failure requiring noninvasive respiratory support, and weak cry. All infants were on nasogastric tube feedings. Direct microlaryngoscopy with unilateral or predominantly unilateral (conservative contralateral aryepiglottic fold division) supraglottoplasty was performed. Stridor and work of breathing improved in all six patients within 1 week postoperatively. Oral feeding improved in three patients within 2 weeks. Three patients had persistent feeding impairment with improvement within one year. ConclusionsPredominantly unilateral laryngomalacia may arise in the context of unilateral vocal fold paralysis. Addressing the ipsilateral cuneiform collapse can improve breathing and feeding. This may be an under-described phenomenon and represents an additional reason to include the otolaryngologist early in the care of infants with suspected possible new unilateral vocal fold paralysis. Breathing and swallow can improve post-operatively, but feeding may remain limited by the vocal fold paralysis and any medical comorbidities. Ongoing follow-up and collaboration with speech-language pathology to optimize feeding are important.

Transcervical Vocal Fold Injection (In-Office)

Dr. Cohen performs an in-office vocal cord injection for a patient suffering from idiopathic unilateral vocal cord paralysis.