Surgical Treatment Applied to Bilateral Vocal Fold Paralysis in Adults: Systematic Review

The effect of unilateral endoscopic arytenoid abduction lateropexy on swallowing in cases of bilateral vocal fold palsy

Objective

Endoscopic arytenoid abduction lateropexy (EAAL) is a minimally invasive surgical technique for the immediate management of bilateral vocal fold palsy (BVFP). Specifically, it achieves a stable and adequate airway by lateralizing the arytenoid cartilage without resecting laryngeal structures. Thus, this study evaluated the effect of EAAL on swallowing in cases of BVFP.

Methods

The participants consisted of 17 adult patients (15 female, 2 male) who underwent unilateral EAAL for BVFP. Swallowing function was evaluated by using the fiberoptic endoscopic evaluation of swallowing (FEES) on the 6th postoperative day and in the 6th postoperative month. The results were assessed by using the pharyngeal residue severity scale (PRSS) and the modified penetration-aspiration scale (mPAS). Additionally, the M.D. Anderson Dysphagia Inventory (MDADI) questionnaire was self-administered during the 6th postoperative month.

Results

Overall, 16 of the 17 patients demonstrated normal swallowing function during the early and late postoperative periods. Moreover, one patient experienced mild fluid aspiration early on, but initially managed it with dietary adjustments and eventually resolved it with a head flexion compensatory maneuver. There was no significant deterioration in swallowing-related quality of life according to the MDADI assessments.

Conclusion

Based on this evaluation of unilateral EAAL, our results confirmed that this procedure is not only a reliable solution for BVFP from the perspective of respiratory function and phonation but also in terms of swallowing quality.

Level of Evidence

4.

European consensus on endoscopic surgery for bilateral vocal fold immobility: classification and nomenclature

INTRODUCTION

There are inconsistencies in how different endoscopic procedures to manage Bilateral Vocal Fold Immobility (BVFI) have been described in the literature. This limits our ability to compare functional outcomes. There is no unifying international terminology available that precisely describes the anatomical boundaries and extent of the different types of treatment. A pan-European consensus regarding terminology of different endoscopic surgical procedures to manage BVFI in adults was developed.

METHODS

Thirty-one expert laryngologists and phoniatricians of the European Laryngological Society (ELS) or Union of the European Phoniatricians (UEP), participated in a modified Delphi process. They voted on an initial series of 13 proposed statements, including graphical visualization of different endoscopic surgical techniques for BVFI. Statements reaching > 70% of agreement in the first voting round were accepted. In the second voting round, eight revised and newly proposed statements were accepted with an increased threshold of > 80%.

RESULTS

Fourteen statements were anonymously validated through two voting rounds. The following categories of endoscopic arytenoid and vocal fold surgery were defined: total arytenoidectomy, partial arytenoidectomy (subclassified into subtotal, anteromedial, posteromedial and superomedial), posterior cordectomy (subclassified into ligamental, transmuscular and ventriculocordectomy) and transverse cordotomy (subclassified into posterior cordotomy and ventriculocordotomy). The suffixes 'with mucosal preservation', 'with laterofixation' and 'combined procedure' were defined too.

CONCLUSION

This ELS-UEP consensus on endoscopic arytenoid and vocal fold surgery for BVFI provides a practical nomenclature and classification to improve reporting in literature and clinical practice and to allow comparison of functional outcomes.

Prevention and Management of Recurrent Laryngeal Nerve Palsy in Minimally Invasive Esophagectomy: Current Status and Future Perspectives

Recurrent laryngeal nerve palsy remains a significant complication following minimally invasive esophagectomy for esophageal cancer. Despite advancements in surgical techniques and lymphadenectomy precision, the incidence of recurrent laryngeal nerve palsy has not been improved. Recurrent laryngeal nerve palsy predominantly affects the left side and may lead to unilateral or bilateral vocal cord paralysis, resulting in hoarseness, dysphagia, and an increased risk of aspiration pneumonia. While most cases of recurrent laryngeal nerve palsy are temporary and resolve within 6 to 12 months, some patients may experience permanent nerve dysfunction, severely impacting their quality of life. Prevention strategies, such as nerve integrity monitoring, robotic-assisted minimally invasive esophagectomy, and advanced dissection techniques, aim to minimize nerve injury, though their effectiveness varies. The management of recurrent laryngeal nerve palsy includes voice and swallowing rehabilitation, reinnervation techniques, and, in severe cases, surgical interventions such as thyroplasty and intracordal injection. As recurrent laryngeal nerve palsy can lead to significant postoperative respiratory complications, a multidisciplinary approach involving surgical precision, early detection, and comprehensive rehabilitation is crucial to improving patient outcomes and minimizing long-term morbidity in minimally invasive esophagectomy. This review article aims to inform esophageal surgeons and other clinicians about strategies for the prevention and management of recurrent laryngeal nerve palsy in esophagectomy.

Surgical Management of Bilateral Abductor Paralysis: Diode Laser Versus Coblation; A Prospective Study

OBJECTIVES

We aimed to compare the results of both diode laser and coblation in the treatment of bilateral vocal fold immobility (BVFI).

MATERIALS AND METHODS

This prospective clinical study was performed on 80 non-tracheostomised patients with bilateral vocal fold paralysis divided into two groups; Group A: diode laser, Group B: coblation. Medical Research Council "mMRC" Dyspnea scale, maximal phonatory time (MPT), Voice handicap index (VHI), and functional outcome swallowing scale (FOSS) were assessed preoperatively and postoperatively. Also, the VAS pain scale and operative time of both groups are recorded.

RESULTS

Within each group, there was a statistically significant decrease in the mMRC dyspnea scale and maximum phonation time and a significant increase in VHI (P < 0.001). There was a statistically significant difference between the studied groups postoperative and regarding the percent change of the MPT ( more decrease in the coblation group). Concerning the operative time and the VAS pain score, there was a statistically significant difference between the studied groups regarding operating time and the VAS pain scale (significantly lower in the coblation group) (P < 0.001).

CONCLUSION

Both Coblation and diode laser are effective tools in the treatment of BVFI with similar minimal voice quality affection. The maximum phonation time decreased more in the coblation group, while the voice handicap index did not significantly differ between both groups. However, Coblation may be superior to diode laser in terms of less operative pain and shorter intraoperative time. Coblation may be more favorable for patients at risk of prolonged general anesthesia duration.

Office-Based Blue Laser Posterior Cordectomy in Patients with Bilateral Vocal Fold Paralysis: A Novel Approach

OBJECTIVE

Bilateral vocal fold paralysis can be a disabling condition with an adverse impact on quality of life. Various glottal widening procedures to secure the airway have been described. These include total or partial arytenoidectomy with or without reinnervation, cordotomy, arytenoidopexy, and others. A review of the literature shows one case of office-based partial arytenoidectomy that was performed successfully using the thulium laser but no other in-office procedures for the treatment of bilateral vocal fold paralysis.

STUDY DESIGN

Retrospective case series with literature review.

METHODS

This report presents two patients with bilateral vocal fold paralysis who underwent office-based blue laser posterior cordectomy. The blue laser is a new photoangiolytic laser (wavelength of 445 nm) with good hemostatic and cutting properties. The surgical technique of office-based posterior cordectomy using the blue laser is described with a review of the literature on arytenoidectomy/posterior cordectomy.

RESULTS

Both procedures were well tolerated and patients showed marked improvement in breathing manifested by an increase in glottal gap on laryngeal examination with no worsening in voice quality. Long-term follow-up showed no interval changes in both cases.

CONCLUSION

The authors of this manuscript advocate office-based posterior cordectomy using the laser in patients who are at high risk for general anesthesia or who refuse to go to the operating room, and potentially for other patients.

Predictive Outcomes of Deep Learning Measurement of the Anterior Glottic Angle in Bilateral Vocal Fold Immobility

OBJECTIVE

(1) To compare maximum glottic opening angle (anterior glottic angle, AGA) in patients with bilateral vocal fold immobility (BVFI), unilateral vocal fold immobility (UVFI) and normal larynges (NL), and (2) to correlate maximum AGA with patient-reported outcome measures.

METHODS

Patients wisth BVFI, UVFI, and NL were retrospectively studied. An open-source deep learning-based computer vision tool for vocal fold tracking was used to analyze videolaryngoscopy. Minimum and maximum AGA were calculated and correlated with three patient-reported outcomes measures.

RESULTS

Two hundred and fourteen patients were included. Mean maximum AGA was 29.91° (14.40° SD), 42.59° (12.37° SD), and 57.08° (11.14° SD) in BVFI (N = 70), UVFI (N = 70), and NL (N = 72) groups, respectively (p < 0.001). Patients requiring operative airway intervention for BVFI had an average maximum AGA of 24.94° (10.66° SD), statistically different from those not requiring intervention (p = 0.0001). There was moderate negative correlation between Dyspnea Index scores and AGA (Spearman r = -0.345, p = 0.0003). Maximum AGA demonstrated high discriminatory ability for BVFI diagnosis (AUC 0.92, 95% CI 0.81-0.97, p < 0.001) and moderate ability to predict need for operative airway intervention (AUC 0.77, 95% CI 0.64-0.89, p < 0.001).

CONCLUSIONS

A computer vision tool for quantitative assessment of the AGA from videolaryngoscopy demonstrated ability to discriminate between patients with BVFI, UVFI, and normal controls and predict need for operative airway intervention. This tool may be useful for assessment of other neurological laryngeal conditions and may help guide decision-making in laryngeal surgery.

LEVEL OF EVIDENCE

III Laryngoscope, 133:2285-2291, 2023.