Suture Lateralization in Patients With Bilateral Vocal Fold Paralysis

Endoscopic-Guided Suture Lateralization for Bilateral Vocal Fold Paralysis: Surgical Tips for Better Outcome

OBJECTIVE

This study aims to describe a precise description of suture lateralization (SL) technique and evaluate its effectiveness and safety in management of bilateral vocal fold paralysis (BVFP).

METHOD

A preclinical cadaveric study followed by application on a case series of BVFP patients. After the preliminary study executed to precisely localize the optimal sites for needle insertion, a prospective interventional study was conducted on 19 subjects presenting with respiratory distress due to BVFP. Data collection included their clinical presentation and a detailed assessment including auditory perceptual assessment, laryngoscopy (rigid or flexible), and video fluoroscopic swallowing study.

RESULTS

Widening of the inter-glottic distance at the site of the sutures was statistically significant (P < 0.001). Decannulation was achieved in three out of four tracheotomized patients. The suturing led to a significant difference in loudness, jitter, and harmonic-to-noise ratio (P = 0.042, 0.004, and ≤0.001, respectively).

CONCLUSION

This study suggests that SL is a feasible and effective technique with low incidence of adverse events and the potential of reversibility. Optimal localization of the suture insertion points translated into less intraoperative manipulation of the cords and shorter operative time.

The Management in Patients With Bilateral Vocal Fold Immobility: 15 Years' Experience at a Tertiary Centre

OBJECTIVE

In order to correct the varying vocal fold positions to meet the various clinical requirements in patients with bilateral vocal fold immobility, we present pertinent surgical methods to treat them.

MATERIALS AND METHODS

From 2005 to 2020, 115 patients diagnosed with bilateral vocal fold immobility were addressed for ventilation in 89 patients and for phonation in 26 patients. In the ventilation surgery group, all the neurogenic subjects received mere suture lateralization (SL) procedures and the mechanical ones underwent arytenoid release (AR) plus SL procedures if the cricoarytenoid joint fixation (CAJF) could be confirmed before operation. In the phonation group, neurogenic subjects received nonsurgical treatment and the mechanical ones underwent AR plus arytenoid adduction (AA) procedure. The decannulation rate and respiratory comfort rate for each subgroup will be calculated and the phonatory tests were conducted.

RESULTS

In the ventilation group, 55% (49/89) of subjects received related surgeries. Mere SL offered 40 successful decannulation or respiratory comfort in 42 neurogenic subjects (95.2%). The single episode rate was high as 95%. An AR plus SL procedure also obtained 100% of decannulation or respiratory comfort with a single episode of surgical procedure if the CAJF could be confirmed preoperatively. In the phonation group, 15% (4/26) of subjects received appropriate surgeries. Single AR plus AA procedures also led to 100% (4/4) of the appropriate candidates serviceable sound.

CONCLUSION

SL procedure keeping intact laryngeal mucosa usually offered permanent glottis enlarging effect or decannulation with a single episode of procedure. The use of arytenoid release for CAJF has led to remarkable advances in the ultimate surgical outcomes of both the ventilation and phonation in terms of decreasing revision surgeries.

LEVELS OF EVIDENCE

level 4.

Dilation, Steroid Injection, and Cough Exercise for Correction of Posterior Glottic Stenosis

OBJECTIVE

To describe the DISCO protocol (Dilation, Steroid injection, and post-operative Cough Exercise); a novel treatment for posterior glottic stenosis (PGS). Restoring glottic mobility in PGS is a major challenge. In orthopedic and plastic surgery, post-operative physical therapy is associated with improved motion range and flexibility; yet, this principle was never applied to laryngeal surgery.

METHODS

A retrospective cohort of PGS adult patients, treated by the DISCO protocol during 2018-2020. DISCO involves the following: scar release, glottic dilation, and steroid injection, followed by post-operative cough as glottic physical therapy. Maximal glottic opening angle (MGOA), relative glottic opening area (RGOA), and relative glottic insufficiency area (RGIA) were calculated before and post-operatively.

RESULTS

Seventeen patients were included; PGS etiology was post-intubation (n = 10), post-irradiation (n = 3), both (n = 1) and joint sclerosis (n = 3). Six patients also had additional airway disorders. Sixteen patients were tracheostomy-dependent. 2 (12%), 8 (47%) and 7 (41%) patients had type II, III and IV stenosis, respectively. Surgery included scar release, dilation and steroid injection alone in 7 patients; and additional unilateral sub-mucosal arytenoidectomy in 10. The mean follow-up was 17.5 months. There were no major complications. Successful outcomes (e.g., decannulation or permanent capping) were achieved in 14 (82%) patients with some restoration of joint movement. None had a persistent voice or swallowing complaints. Both MGOA and RGOA increased in all patients (p < 0.001). RGIA remained unchanged (p = 0.878).

CONCLUSIONS

The DISCO protocol is a novel, effective and safe approach for PGS correction that can be easily applied. It can restore vocal fold mobility and may expand the glottic airway without causing glottic insufficiency.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:883-889, 2023.

Surgery for bilateral vocal fold paralysis: Systematic review and meta-analysis

Objectives

To determine the decannulation rate (DR) and revision surgery rate after surgery for bilateral vocal fold paralysis (BVFP).

Data Sources

Five databases (MEDLINE, PubMed, Embase, Web of Science, Scopus) were searched for the period 1908-2020.

Methods

The systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were pooled using a random-mixed-effects model. Randomized controlled trials and non-randomized studies (case-control, cohort, and case series) were included to assess DR and revision surgery rate after different surgical techniques for treatment of BVFP.

Results

The search yielded 857 publications, of which 102 with 2802 patients were included. DR after different types of surgery was: arytenoid abduction (DR 0.93, 95%-confidence interval [CI], 0.86-0.97), endolaryngeal arytenoidectomy (DR 0.92, 95%-CI, 0.86-0.96), external arytenoidectomy (DR 0.94; 95%-CI, 0.71-0.99), external arytenoidectomy and lateralisation (DR 0.87; 95%-CI, 0.73-0.94), laterofixation (DR 0.95; 95%-CI, 0.91-0.97), posterior cordectomy (DR 0.97, 95%-CI, 0.94-0.99), posterior cordectomy and arytenoidectomy (DR 0.98, 95%-CI, 0.93-0.99), posterior cordectomy and subtotal arytenoidectomy (DR 0.98, 95%-CI, 0.88-1.00), posterior cordotomy (DR 0.96, 95%-CI, 0.84-0.99), reinnervation (0.69, 95%-CI, 0.12-0.97), subtotal arytenoidectomy (DR 1.00, 95%-CI, 0.00-1.00) and transverse cordotomy (DR 1.0, 95%-CI, 0.00-1.00). No significant difference between subgroups for DR could be found (Q = 15.67, df = 11, p = 0.1540). The between-study heterogeneity was low (τ2 = 2.2627; τ = 1.5042; I2 = 0.0%). Studies were at high risk of bias.

Conclusion

BLVP is a rare disease and the study quality is insufficient. The existing studies suggest a publication bias and the literature review revealed that there is a lack of prospective controlled studies. There is a lack of standardized measures that takes into account both speech quality and respiratory function and allows adequate comparison of surgical methods.

Suture lateralization in congenital bilateral vocal cord immobility in neonates and infants: A hybrid approach

INTRODUCTION

Bilateral vocal cord immobility (BVCI) is a leading cause of stridor and airway obstruction in neonates which may arise idiopathically, as a result of birth trauma, or in the setting of Central nervous system lesions such as Arnold-Chiari malformation. Although many children with BVCI may be managed conservatively, surgical intervention may be necessary in those patients with ongoing upper airway obstruction. Many interventions have been described including, tracheostomy, cordotomy, cricoid splitting procedures, and arytenoidectomy. Vocal cord suture lateralization has the advantage of being both reversible and less morbid than other surgical interventions for BVCI. This study describes a novel variation of the suture lateralization procedure which aids in correct placement of the suture thus minimizing multiple needle passes and associated laryngeal edema.

METHODS

A retrospective chart review was undertaken of five patients undergoing suture lateralization of the vocal cord for BVCI at a single institution over a 10 year period. Post-operative voice and swallow outcomes were recorded.

RESULTS

Of five patients undergoing this procedure four returned to normal diet. One was diagnosed with a progressive neurological disorder and was persistently fed via gastrostomy tube. Three of the five patients spontaneously recovered vocal cord function and went on to have normal voice after suture removal.

CONCLUSION

Suture lateralization is a safe and effective means of alleviating upper airway obstruction in BVCI. It has the advantages of being reversable and minimally invasive; however, optimal suture placement is both vital and challenging. The novel technique described in this study allows identification of landmarks as and aid to suture placement thus reducing the need for multiple needle passes into the lumen of the larynx.

Outcomes of endoscopic percutaneous suture lateralization for neonatal and infantal bilateral vocal ford paralysis

OBJECTIVE

Bilateral Vocal Fold Paralysis (BVFP) is a rare but significant resource of respiratory distress in neonates and infants. The objective of this study was to evaluate the efficacy and functional outcomes of Endoscopic Percutaneous Suture Lateralization (EPSL) for the treatment of BVFP in neonates and infants.

METHODS

A case series study of nine patients undergoing EPSL for BVFP between January 2019 and June 2021 was conducted. All patients were candidates for tracheostomy prior to EPSL. Demographic features including gender, age at diagnosis and surgery, main symptoms, airway comorbidities, airway support, and etiology were collected preoperatively. Patients were evaluated for breathing, swallowing and phonation postoperatively. Surgical success was defined as the ability to avoid tracheostomy. Functional Endoscopic Evaluation of Swallowing (FEES) was conducted to identify aspiration. Voice evaluation was based on clinical observation.

RESULTS

Nine patients underwent ten EPSL procedures (one in the left vocal fold, and nine in the right vocal fold). Eight patients (8/9) were able to successfully avoid tracheostomy and feed orally without aspiration after the procedure. One patient experienced clinical improvement in respiratory support requirements and underwent laparoscopic nissen and gastrostomy tube placement. At the last follow-up, two patients regained normal voice, two patients had mild dysphonia, and five patients had moderate dysphonia. Five patients showed partial return of the contralateral vocal fold function.

CONCLUSION

EPSL is an effective and safe treatment for neonatal and infantal BVFP, which enables patients free from tracheostomy without significant impact on swallowing function or phonation.

LEVEL OF EVIDENCE

Level 4.

Care and Management of Voice Change for Thyroid Surgery: Korean Society of Laryngology, Phoniatrics and Logopedics Clinical Practice Guideline

Voice change is a common complaint after thyroid surgery and has significant impacts on quality of life. The Korean Society of Laryngology, Phoniatrics, and Logopedics set up a task force team to establish guideline recommendations on education, care, and management related to thyroid surgery. The guideline recommendations include preoperative voice education, management of anticipated voice change during surgery, and comprehensive voice care after thyroid surgery, including in-depth information and up-to-date knowledge based on validated literature. The committee constructed 14 key questions (KQ) in three categories: preoperative (KQ1-2), intraoperative (KQ 3-8), and postoperative (KQ 9-14) management and developed 18 evidence-based recommendations. The Delphi survey reached an agreement on each recommendation. Detailed evidence profiles are presented for each recommendation. The level of evidence for each recommendation is classified into high, moderate, and low-quality. The recommendation's strengths are adjusted to consider the level of evidence resulting in the recommendation and are divided into strong and weak. The guidelines are primarily targeted toward physicians who treat thyroid surgery patients and speech-language pathologists participating in patient care. These guidelines will also help primary care physicians, nurses, healthcare policymakers, and patients improve their understanding of voice changes and voice care after thyroid surgery.

Efficacy of Arytenoidectomy after Suture Lateralisation Failure in Patients with Bilateral Vocal Cord Paralysis

Background

Endolaryngeal suture lateralisation is an ideal operation for bilateral vocal fold paralysis. However, restenosis owing to breakage and slippage of suture can sometimes occur. In such a case, methods that are more effective in expanding the glottis, including arytenoidectomy, must be selected. Case Report. Herein, we report two female patients aged 86 and 54 years who presented with bilateral vocal cord paralysis and who had restenosis after suture lateralisation. Endoscopic partial arytenoidectomy was performed, and satisfactory outcomes were obtained. This method maintains the height of the arytenoid and preserves its sensation by leaving a part of the cartilage and mucous membrane.

Conclusion

Endoscopic partial arytenoidectomy is effective for securing the airway while preserving vocal function and preventing aspiration. This technique is suitable for patients with restenosis after they have undergone endolaryngeal suture lateralisation.

Therapy of bilateral vocal fold paralysis: Real world data of an international multi-center registry

Purpose

To collect data on diagnosis, treatment, patient’s management, and quality of life in patient with bilateral vocal fold paralysis (BVFP).

Methods

A retrospective, observational, multicenter registry study was performed. Medical records of 326 adults with permanent BVFP (median age: 61 years; 70% female, 60% after thyroid surgery) generated between 2010 and 2017.

Results

Median time between BVFP onset and inclusion was 1.2 years. Median post-treatment follow-up was 2 months (range: 0–42). Surgery was treatment of choice in 61.7% of the cases, with a 2-year revision rate of 32.4%. Prior to inclusion, 40.2% of the patients underwent at least one surgery. For tracheotomized patients, decannulation rate was 33.8%. Non-surgical treatments included voice therapy and botulinum toxin injection. Corticosteroid application was the most frequent treatment for post-treatment complications (18%; 1-month after surgery). Older age was an independent predictor for dyspnea (Hazard ratio [HR] = 1.041; CI = 1.005 to 1.079; p = 0.026) and the need for oxygen treatment (HR = 1.098; CI = 1.009 to 1.196; p = 0.031). Current alcohol consumption (HR = 2.565; CI = 1.232 to 5.342; p = 0.012) and a cancer-related etiology (HR = 4.767; CI = 1.615 to 14.067; p = 0.005) were independent factors of higher revision risk.

Conclusions

Surgery for BVFP is currently not standardized but highly variable. Postoperative and BVFP-related complications and revision surgery are frequent. Complications are linked to patients’ alcohol drinking habits and BVFP etiology. These results shall be confirmed by the upcoming evaluation of the prospective data of this registry.

Outcomes in Bilateral Vocal Fold Immobility: A Retrospective Cohort Analysis

OBJECTIVE

To test the hypothesis that the etiologies of bilateral vocal fold mobility impairment (BLVFI), bilateral vocal fold paralysis (BVFP), and posterior glottis stenosis (PGS) have distinct clinical outcomes. To identify patient-specific and procedural factors that influence tracheostomy-free survival.

STUDY DESIGN

Retrospective cohort study.

SETTING

Johns Hopkins Medical Center from 2004 to 2015.

SUBJECTS AND METHODS

Case series with chart review of 68 patients with PGS and 17 patients with BVFP. Multiple logistic regression analysis determined factors associated with airway prosthesis dependence at last follow-up and the procedural burden (defined as number of operative procedures per year).

RESULTS

PGS comprised the majority of BLVFI (76%). PGS injury arose primarily after endotracheal intubation (91%), while BVFP most commonly was due to iatrogenic surgical injury to bilateral recurrent laryngeal nerves (88%, P < .001). Overall in BLVFI, 66% were tracheostomy free at last follow-up (62% in PGS, 82% in BVFP). Of those who underwent an operative intervention to be decannulated, 88% were decannulated (90% PGS, 80% BVFP). Patients with PGS required higher procedural burden to achieve decannulation compared with the BVFP cohort (3.1 ± 5.2 vs 0.71 ± 1.4, P = .002). In multivariate analysis of PGS, smoking was a risk factor for tracheostomy dependence (P = .026).

CONCLUSIONS

BLVFI is primarily an iatrogenic complication. There are high rates of tracheostomy dependence in BLVFI, with procedural intervention needed for decannulation. Compared with BVFP, patients with PGS had a higher procedural burden overall and to achieve decannulation. Patients with PGS should be counseled that smoking, a modifiable risk factor, may increase the risk of tracheostomy dependence.

Suture lateralisation plus arytenoid cartilage release for treating bilateral vocal fold immobility with mechanical fixation

A suture lateralisation (SL) instead of an endolaryngeal tissue ablation procedure under endoscopy has been utilised to treat bilateral vocal fold immobility (BVFI) since 1980. However, mechanical fixation (MF) of the cricoarytenoid joint (CAJ) has continually challenged the effectiveness of glottic dilatation both in the SL procedure and the tissue ablation procedure. From 2007 to 2015, a total of 38 patients with BVFI underwent 40 exo-endolaryngeal suture lateralisation (exoeSL) procedures and three were diagnosed with MF in our hospital. For these MF, we introduced an external approach method to release the CAJ followed by a similar exoeSL procedure. The CAJ release procedure enabled the preservation of the endolaryngeal mucous membrane (ELM) and consequently spared the use of laser surgery. All three CAJ release procedures led to decannulations (one patient) or improvement of dyspnoea (two patients). The difference between the exoeSL and the endo-exolaryngeal suture lateralisation (endoeSL) procedure is discussed based on their effectiveness in MF management.