[Glottic immobility: retrospective study of 229 cases]

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.

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.

Laser Posterior Cordotomy: Is it a Good Choice in Treating Bilateral Vocal Fold Abductor Paralysis?

BACKGROUND

Bilateral abductor vocal fold paralysis can lead to respiratory distress and dyspnea.

OBJECTIVES

To assess the efficacy of CO₂ laser unilateral posterior cordotomy in cases with bilateral abductor paralysis as regards improvement of dyspnea with preservation of satisfactory voice and swallowing after the operation.

METHODS

A prospective study was done on 18 patients with bilateral abductor vocal fold paralysis (10 females and 8 males) from November 2010 to December 2012 with their ages ranging from 32 to 64 years.

RESULTS

All patients showed improvement of dyspnea after the operation, most of the patients suffered from mild to moderate dyspnea in the immediate post-operative period, and two patients needed another intervention to solve it. All the patients had satisfactory results of their voice after the operation, and one patient only suffered from temporary aspiration.

CONCLUSION

Unilateral CO₂ laser posterior cordotomy is an easy and effective procedure to solve the dyspnea after bilateral vocal fold abductor paralysis without aspiration or significant voice alteration.

Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis

OBJECTIVE

To determine the etiology, laterality, and time to presentation of unilateral vocal fold paralysis (UVFP) at a tertiary care institution over 10 years.

STUDY DESIGN

Case series with chart review.

SETTING

Academic medical center.

SUBJECTS AND METHODS

All patients seen between 2002 and 2012 by the Department of Otolaryngology at the Washington University School of Medicine (WUSM), with a diagnosis of unilateral vocal fold paralysis, were included. Medical records were reviewed for symptom onset date, presentation date(s), and etiology of UVFP.

RESULTS

Of the patients, 938 met inclusion criteria and were included. In total, 522 patients (55.6%) had UVFP due to surgery; 158 (16.8%) were associated with thyroid/parathyroid surgery, while 364 (38.8%) were due to nonthyroid surgery. Of the patients, 416 (44.4%) had nonsurgical etiologies, 124 (13.2%) had idiopathic UVFP, and 621 (66.2%) had left-sided UVFP. The diagnosis was more common on the left side in cases of intrathoracic surgeries and malignancies, as expected, but also in idiopathic, carotid endarterectomy, intubation, and skull base tumors. In total, 9.8% of patients presented first to an outside otolaryngologist at a median time of 2.1 months after onset, but these patients presented to WUSM at a median time of 9.5 months. Overall, 70.6% of patients presented to a WUSM otolaryngologist within 3 months of onset.

CONCLUSION

Iatrogenic injury remains the most common cause of UVFP. Thyroidectomy remains the leading cause of surgery-related UVFP. Patients are typically seen within 3-4 months of onset; however, a significant delay exists for those referred to WUSM.

[Aetiology and treatment of vocal fold paralysis: retrospective study of 108 patients]

OBJECTIVES

To review the aetiology and treatment of laryngeal paralysis diagnosed at our hospital and to describe the available therapeutic options.

METHODS

Retrospective review of medical records of 108 patients diagnosed with unilateral and bilateral vocal fold paralysis between 2000 and 2012, identifying the cause of paralysis and its treatment.

RESULTS

Of the 108 cases analysed, 70% had unilateral vocal fold immobility and 30% bilateral immobility. The most frequent aetiology in both cases was trauma (represented mainly by surgical injury), followed by tumours in unilateral paralysis and medical causes in bilateral paralysis. Half of the patients with unilateral paralysis (38) were treated surgically, with medialization thyroplasty. In bilateral vocal fold immobility, the treatment consisted of tracheostomy in patients with threatened airway (40%). We planned to widen the air passage in 9 patients (27%), performing cordectomy in most of them.

CONCLUSIONS

The aetiology observed in our patients is similar to that described in the literature. In cases of unilateral vocal fold paralysis, we believe thyroplasty is the procedure of choice. In bilateral paralysis, it is possible to perform cordectomy in selected patients once the airway has been secured.

Paediatric vocal fold paralysis

INTRODUCTION AND OBJECTIVES

Vocal fold paralysis (VFP) is a relatively common cause of stridor and dysphonia in the paediatric population. This report summarises our experience with VFP in the paediatric age group.

METHODS

All patients presenting with vocal fold paralysis over a 12-month period were included. Medical charts were revised retrospectively. The diagnosis was performed by flexible endoscopic examination. The cases were evaluated with respect to aetiology of the paralysis, presenting symptoms, delay in diagnosis, affected side, vocal fold position, need for surgical treatment and outcome.

RESULTS

The presenting symptoms were stridor and dysphonia. Iatrogenic causes formed the largest group, followed by idiopathic, neurological and obstetric VFP. Unilateral paralysis was found in most cases. The median value for delay in diagnosis was 1 month and it was significantly higher in the iatrogenic group. Surgical treatment was not necessary in most part of cases.

CONCLUSIONS

The diagnosis of VFP may be suspected based on the patient's symptoms and confirmed by flexible endoscopy. Infants who develop stridor or dysphonia following a surgical procedure have to be examined without delay. The surgeon has to keep in mind that there is a possibility of late spontaneous recovery or compensation.

[Ramsay-Hunt syndrome presenting laryngeal paralysis]

The Ramsay-Hunt syndrome is the association of facial palsy and varicella-zoster virus infection with involvement of the ear canal and eardrum. It may be associated with deafness, tinnitus and dizziness. It can sometimes affect the lower cranial nerves. A case of an immunocompetent patient with affectation of the VII, VIII and X cranial nerves is presented.

Posterior cordectomy. Our experience

OBJECTIVE

Several surgical procedures have been proposed for the treatment of respiratory distress secondary to bilateral cord palsy. We performed a retrospective study of our experience in posterior cordectomy with a laser CO(2), analysing the improvement of dyspnoea and voice quality after surgery.

METHODS

This was a retrospective study of 13 cases (9 female, 4 male). The age range was 25-79 years. Iatrogenic post-thyroidectomy (4 cases) was the most common aetiology of bilateral laryngeal palsy in our study. We assessed the subjective improvement of respiratory function and voice quality after laser surgery using the Spanish adaptation of the Voice Handicap Index (VHI).

RESULTS

Dyspnoea improved in all patients. Two cases had a worsening of dyspnoea in the immediate postoperative period and one case was successfully solved with a new surgical intervention. After surgery, most of patients suffered from mild or middle dysphonia.

CONCLUSIONS

The posterior cordectomy is an easy, safe and effective treatment for dyspnoea secondary to bilateral laryngeal palsy, maintaining acceptable voice quality.

Ceratocricoid muscle: an embryological and anatomical study

This study aimed to document the prevalence and morphology of the ceratocricoid muscle in a large sample of fetuses and adults and to explain its possible origin in a sample of embryos. Forty-five embryos, thirty-four fetuses, and ninety human larynges from adults with no known laryngeal pathology were studied. The muscle was observed in 23% of the fetal sample and in 14% of the adult sample. No significant differences were observed in the laterality in any of the groups. The ceratocricoid muscle is attached between the cricoid lamina and the inferior horn of the thyroid cartilage and also into the capsule of the cricothyroid joint. The muscle is innervated by several branches (between one and three) from the anterior division of the recurrent laryngeal nerve as it courses behind the cricothyroid joint. The ceratocricoid muscle develops from tissue within the mesenchymal bridge which connects the external and internal laryngeal sphincters or rings from embryonic stages 15-20. The close relationship of the ceratocricoid muscle to the recurrent laryngeal nerve could mean that it can exert pressure on this nerve. This may be a possible explanation for the causation of certain idiopathic recurrent laryngeal nerve palsies.

The natural history of idiopathic unilateral vocal fold paralysis: evidence and problems

OBJECTIVES/HYPOTHESIS

To identify clinical evidence regarding outcome and duration of unilateral idiopathic vocal fold paralysis (IVFP).

STUDY DESIGN

Literature review.

METHODS

Medline search using the terms "vocal fold paralysis," "laryngeal paralysis," "vagal paralysis," and "recurrent nerve paralysis" was performed. Results were cross-checked by substituting "palsy" and "paresis" in place of "paralysis," "cord" in place of "fold," and adding "idiopathic" to each term. Furthermore, papers antedating the period of time covered by Medline were identified in references of publications. Case series identified by means of these searches were examined for information regarding duration and outcome of IVFP.

RESULTS

Seven hundred seventeen cases are reported. Complete recovery of motion occurred in 36 +/- 22% (range, 13-83%) of individuals. Some recovery of motion (complete and partial) occurred in 39 +/- 20% (range, 19-83%). Complete recovery of voice occurred in 52 +/- 17% (range, 25-87%) of cases, some degree of recovery in 61 +/- 22% (range, 25-87%). Most cases appear to recover in well under a year, with rare instances of markedly delayed recovery.

CONCLUSIONS

Review of available evidence reveals a highly variable rate of return of motion in IVFP. The rate of return of normal voice is consistently higher, although similarly variable. The marked differences in rates of recovery among reports appears to be the result of variable definitions of recovery, oversimplified all-or-none notions of paralysis and recovery, and inconsistent reporting of time elapsed from onset of paralysis to evaluation. All of these factors should be addressed in future prospective studies to shed further light on the natural history of vocal fold paralysis.

[Diagnosis and treatment of functional oropharyngeal dysphagia. Features of interest to the digestive surgeon]

Digestive surgeons should form part of the multidisciplinary team managing patients with oropharyngeal dysphagia. These patients can be diagnosed through clinical methods and complementary investigations such as videofluoroscopy and pharyngoesophageal manometry. These techniques also allow specific treatment to be selected. Up to one-third of patients with dysphagia suffer from malnutrition as a result of alterations in food bolus transport. Furthermore, up to two-thirds show alterations in swallowing safety (penetrations and aspirations, especially when swallowing liquids), as well as a high risk of respiratory infections and aspiration pneumonia. Increasing food bolus viscosity to 3500-4000 mPas (pudding viscosity) improves the effectiveness of swallowing and reduces the risk of aspirations. Botulinic toxin injection in the upper esophageal sphincter is indicated in patients with spasticity of neuromuscular origin. Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum and is also indicated in patients with alterations in the upper esophageal sphincter and preserved oropharyngeal motor response.