Histological findings in arytenoid cartilages after long-lasting recurrent nerve paralysis

Management of bilateral arytenoid cartilage fixation versus recurrent laryngeal nerve paralysis

Bilateral arytenoid cartilage fixation (ACF) closely resembles vocal cord immobility due to recurrent laryngeal nerve paralysis (RLNP). This study sought to determine the etiologic differences between these two entities and to derive conclusions about treatment. The charts of 218 consecutive adult patients with immobility of both vocal cords requiring surgery for airway restoration were reviewed. The results of laryngeal electromyography and laryngotracheoscopy were used to distinguish ACF from RLNP. In 186 patients (85.3%), RLNP was identified. Of these, 154 paralyses (82.8%) were caused by surgical interventions, 5 (2.7%) were caused by previous intubation, 16 (8.6%) were caused by various malignancies, and 7 (3.8%) were neurogenic. In 4 patients (2.2%), the cause remained unclear. We identified ACF in 32 patients. The etiologic factors included previous long-term intubation in 22 patients (68.8%), short-term intubation in 3 patients (9.4%), Wegener's granulomatosis in 3 patients (9.4%), rheumatoid arthritis in 2 patients (6.3%), previous laryngeal surgery in 1 patient (3.1%), and caustic ingestion in 1 patient (3.1%). Additional second-site airway stenosis was found in 10 of the RLNP patients (5.4%) and in 15 of the ACF patients (46.9%). All RLNP patients had endoscopic surgery without temporary tracheotomy. Eighteen ACF patients required open surgery, and 4 were managed endoscopically but required temporary tracheotomy. The etiologic factors were significantly different for the two entities under study. Additional sites of stenosis were more frequent in ACF patients. Stenosis due to RLNP could be managed endoscopically without preliminary tracheotomy, while ACF frequently required open surgery and temporary tracheotomy.

Posterior glottic stenosis

Posterior glottic stenosis in children is not uncommon and must be differentiated from vocal cord paralysis when there is posterior glottic fixation. Procedures aimed at increasing the airway lumen by tissue excision have not been uniformly successful. Chronic aspiration and poor voice results have been reported. Expansion of the posterior glottis yields excellent results. Tracheotomy decannulation without aspiration and return of vocal cord mobility in children who have vocal cord fixation with achievement of a functional voice can be expected from widening the laryngeal framework. Scar incision without excision reduces the denuded laryngeal surface. The laryngeal framework is widened by anterior and posterior cricoid split and by stenting. Posterior cartilage grafting reduces scar tissue build-up and the duration of stenting.

Posterior glottic stenosis in children

The management of posterior glottic stenosis resulting from impaired crico-arytenoid joint (CAJ) mobility in infants and children presents a perplexing and frequently unrewarding surgical dilemma; any improvement in the airway is almost invariably at the expense of the voice. Progress in this area has been hampered not only by the rarity of cases, but also by the technical difficulty of achieving an accurate diagnosis at endoscopy. In order to address this problem we have undertaken a retrospective analysis of 35 infants and children, treated at Great Ormond Street between 1980 and 1991, with endoscopically confirmed impairment of CAJ mobility. Five cases of mild posterior glottic stenosis were successfully treated either conservatively or by laser scar division. Thirty cases of moderate or severe stenosis were identified, and 19 of these have undergone corrective surgery. Of these 19, 17 had a prior tracheostomy, and 12 have been decannulated. No problems with aspiration were encountered but five (i.e. 25%) of those treated surgically suffered a deterioration of voice quality.

Posterior glottic fixation in children

Vocal cord fixation from posterior glottic stenosis may produce progressive airway obstruction. Treatment involves scar excision with adjunctive procedures on healthy tissue, including arytenoidopexy, arytenoidectomy, cordectomy, and cordotomy. Twenty-five children with posterior glottic stenosis were studied; 6 had vocal cord fixation in the midline and 6 had limited vocal cord abduction. All were tracheotomy-dependent because of posterior glottic stenosis and secondary impairment of vocal cord mobility. All children were decannulated after scar incision and widening of the laryngeal framework with posterior cricoid split and stenting. Cartilage grafting was used in 11 patients to maintain an adequate glottic lumen. Ten regained full vocal cord mobility. One had limited adduction, while another's cords were refixed in the midline. A second procedure in the latter patient resulted in limited abduction. Aspiration did not occur in any of the patients, and the voice results were good. Scar incision with cricoid split, cartilage grafting, and stenting is an excellent method for treating posterior glottic fixation without destroying healthy tissue.