Widening of posterior glottis through rotation of the arytenoid on its axis: Report of nine cases

INTRODUCTION

Bilateral vocal folds' immobility is a challenge in laryngology. Multiple procedures have been proposed to improve breathing by statically enlarging the glottal airway, what also results in loss of voice and aspiration. We proposed a technique to enlarge the posterior glottis by rotating the arytenoids on its axis, imitating the function of the posterior cricoarytenoid muscle, with the objective of evaluating the results regarding decannulation, voice quality, and bronchoaspiration.

METHODS

This study is a clinical case series of patients with bilateral vocal fold paralysis who underwent an arytenoid rotation surgery at a single tertiary university care institution between 2011 and 2017. Data were prospectively collected and was complemented with information from medical charts. Patients were assessed for decannulation, dyspnea, posterior glottic opening, quality of voice, and swallowing disorders.

RESULTS

Nine patients were included in the study. Out of three patients who required tracheostomy, two were successfully decannulated. Six patients reported a significant improvement in their dyspnea, while four patients reported a worsening of their voice. The stroboscopy evidenced a posterior glottic opening of at least 7 mm in six patients. Eight patients had no aspiratory symptoms, and the acoustic analysis showed that only one patient has a normal voice.

CONCLUSION

The arytenoid rotation on its axis by imitating the posterior cricoarytenoid muscle preserves the physiological functions of the larynx, which allows sufficient opening of the posterior glottis for breathing, and could alter in a lesser extent the anterior glottis to maintain a good quality of voice and swallowing.

Comparison of vocal outcome following two different procedures for immediate RLN reconstruction

The objective of this study was to compare time-dependent improvements in phonatory function and stroboscopic findings following two different procedures for immediate reconstruction of the recurrent laryngeal nerve (RLN) during neck tumor extirpation. Seventeen patients with neck tumors, consisting of advanced thyroid cancer (n = 15), metastatic neck lymph nodes from other malignant lesions (n = 2), underwent resection of the primary lesion and involved RLN. Immediate RLN reconstruction by either: (1) ansa cervicalis nerve (ACN) to RLN anastomosis (n = 8); or (2) placement of the great auricular nerve (GAN) between the cut ends of the RLN (n = 9) was performed from 2000 to 2011. Phonatory function [maximum phonation time, mean airflow rate (MFR), jitter, and shimmer) and stroboscopic findings (regularity, amplitude, and glottal gap) were examined at 1, 6, and 12 months postoperatively. Stroboscopic findings were assessed by two otolaryngologists and one speech pathologist. There were no significant differences in any parameter for either phonatory function or stroboscopic findings between ACN and GAN with the exception of jitter and shimmer, in which ACN was superior to GAN at 1 month postoperatively. All parameters improved significantly between 1 and 12 months postoperatively for both phonatory function and stroboscopic findings (P < 0.05). Either method of immediate RLN reconstruction at the time of neck tumor extirpation (i.e., ACN or GAN) provided both excellent long-term postoperative phonatory function and stroboscopic findings, and there was little difference in vocal outcome between the two procedures.

Suture laterofixation of the vocal fold for bilateral vocal fold immobility

PURPOSE OF REVIEW

To review the recent published literature on the subject of suture laterofixation for bilateral vocal fold immobility, to evaluate outcomes, and to assess advances and modifications of the procedure during the review period.

RECENT FINDINGS

Suture laterofixation offers potential benefits over other surgical procedures employed in the treatment of bilateral vocal fold immobility. The procedure is potentially reversible, avoids long-term consequences of ablative procedures such as arytenoidectomy, and can be accomplished under jet ventilation without the need for tracheostomy. Modifications to the technique such as increasing suture size and utilizing a dual suture technique may decrease the risk of injury to the vocal fold mucosa. The advantages of suture laterofixation have argued for closer scrutiny as a potential treatment for pediatric patients.

SUMMARY

Suture laterofixation is an important option in the treatment of bilateral vocal fold immobility. Laryngologists should be aware of the potential advantages over other procedures, particularly those that necessitate surgical ablation of the arytenoid or vocal fold.

Arytenoid abduction for bilateral vocal fold immobility

PURPOSE OF REVIEW

The pathophysiology of bilateral vocal fold immobility includes two broad categories: mechanical fixation and neurogenic paralysis. A mobile arytenoid can be surgically abducted, and this procedure has been reported as a treatment for patients with bilateral neurogenic laryngeal paralysis. This article reviews the theoretical basis and clinical outcomes of this procedure.

RECENT FINDINGS

Two concepts form the theoretical basis for arytenoid abduction. First, in most cases of neurogenic paralysis, laryngeal muscles are not denervated; there is considerable residual or regenerated function of adductor muscles. The vocal fold lies near the midline, because there is inadequate force to abduct the vocal fold. Second, the cricoarytenoid joint is multiaxial. The posterior cricoarytenoid (PCA) muscle rotates the arytenoid about an oblique axis to pull the vocal process laterally and superiorly, while the axis of adduction is nearly vertical. Thus, surgical abduction of the arytenoid, by simulating contraction of the PCA muscle, should not preclude active adduction during phonation or swallow. Surgical arytenoid abduction has been reported to improve the airway in many patients with bilateral laryngeal paralysis, with little or no impairment of vocal function. It is less successful in patients with inspiratory adductor muscle activity, long-term immobility, or previous procedures to statically enlarge the glottis.

SUMMARY

Arytenoid abduction is a promising treatment for selected patients with bilateral neurogenic laryngeal paralysis.