Arytenoid Abduction for Bilateral Vocal Fold Paralysis
The purpose of this operation is to improve the airway in those with bilateral vocal fold paralysis. Patients with bilateral laryngeal paralysis suffer primarily from airway obstruction because the vocal folds do not abduct during inspiration. However, many patients have some adductor action during phonation, so that the voice is not severely impaired and may even be near normal. Surgical treatments that statically enlarge the glottis improve the airway at the expense of voice. Arytenoid abduction (AAb) is a surgical procedure that simulates action of the posterior cricoarytenoid muscle (PCA), the only laryngeal abductor muscle. AAb externally rotates the arytenoid to move the vocal process laterally and rostrally. This increases the glottic airway. Arytenoid abduction involves an external approach and is technically more difficult than endoscopic procedures like arytenoidectomy or cordectomy. However, endoscopic procedures usually impair the voice and carry risks of stenosis and aspiration during swallow.
Indications/Contraindications
AAb is indicated to relieve glottic airway obstruction in patients with neurogenic vocal fold paralysis with mobile cricoarytenoid joints.
This procedure is not expected to benefit patients with glottic stenosis or cricoarytenoid joint fixation, since scarring around the cricoarytenoid joints will prevent lateral movement of the arytenoid sufficient to expand the glottic airway.
In the Clinical Setting
Key Points
Direct laryngoscopy is recommended prior to incision to palpate the arytenoids and confirm that they are not fixed. If they are fixed, then the procedure should not be performed.
Careful elevation of the piriform sinus mucosa is essential to prevent mucosal tears, which would lead to contamination of the wound by saliva.
Careful hemostasis with bipolar cautery permits improved visualization of the critical region of the muscular process of the arytenoid.
Assistance with retraction is essential to view this anatomic area.
Pitfall
The most common complication is failure to improve the airway. Other potential complications include acute airway obstruction due to edema or to hematoma.
From a Technical Perspective
Key Points
Rotation of the larynx assists in an optimal view.
The Freer elevator is an excellent tool for mobilization of the piriform sinus mucosa.
The white condensation of LCA and PCA fibers onto the muscular process of the arytenoid is a very helpful visual landmark for identification of the muscular process.
Pitfalls
The muscular process is often more superior than anticipated.
A double pass with suture through the muscular process can improve the purchase through this area and prevent the muscular process from fracturing off.
The most common complication is failure to improve the airway, due to synkinetic inspiratory activity of laryngeal adductor muscles. ANG is recommended before surgery to detect this.
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