Endoscopic Arytenoidectomy
This purpose of this procedure is to enlarge the airway of an individual with glottic stenosis secondary to bilateral vocal fold immobility.
Indications/Contraindications
Bilateral vocal fold immobility due to vocal fold fixation or paralysis with airway compromise sufficient to require a tracheotomy or to restrict exercise capacity to a debilitating extent. Arytenoidectomy should be reserved for patients who have failed more conservative lateralization procedures or who have vocal fold immobility in association with stenosis.
The procedure is contraindicated in individuals with significantly impaired swallowing function as the operation can making safe swallowing more difficult, thereby putting them at risk for recurrent aspiration pneumonia. Difficulty with adequate laryngeal exposure at the time of microlaryngoscopy may preclude the successful performance of the procedure.
In the Clinical Setting
Key Points
An EMG is valuable both in differentiating fixation from paralysis and also in giving an estimate of the likelihood of recovery in vocal fold paralysis. If there is EMG evidence of innervation with recruitment, then it may be advisable to do a temporizing procedure, such as a partial arytenoidectomy or unilateral/bilateral cordotomies. An arytenoidectomy is indicated if these procedures fail to produce an adequate airway.
Distinguish between bilateral fixation and paralysis, as this will influence the surgical planning.
A unilateral lateralization procedure is highly successful in the management of bilateral vocal fold paralysis, since the wound healing will pull the vocal fold in a lateral position. In bilateral fixation, however, bilateral lateralization procedures or a total arytenoidectomy is usually required since the defect will partially fill back in, narrowing the surgically created defect.
Carefully consider management of the airway with the anesthesiologist during surgery if a tracheotomy is not used.
Remember that any procedure needs to balance widening of the airway to improve airflow with close approximation of the vocal folds to retain voice and swallowing. A preoperative swallowing assessment will help to assess if there is a significant degree of preoperative dysphagia, which excludes a patient from candidacy for arytenoidectomy. In general, a near-total or total arytenoidectomy will lead to noticeable change in voice.
Pitfalls
If a mucosal flap is not used to cover the wound after arytenoidectomy, there may be a large area of cartilage/bone exposure, which causes prolonged healing and possibly granuloma formation.
Poor laryngeal exposure is essential and endoscopic arytenoidectomy should be avoided if this cannot be achieved.
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