1

Introduction

Bilateral vocal cord paralysis is a serious condition requiring emergency intervention to resolve the dyspnea that sometimes may become life threatening. The first option is very often a tracheotomy, performed upon admission of the patient or even in the immediate postoperative period following thyroidectomy. This latter surgical procedure is the most common cause of bilateral recurrent laryngeal nerve injury, with its consequent bilateral vocal cord paralysis .

Tracheotomy still remains an effective treatment, but is not acceptable as a long-term solution. Throughout the past century, several operations were proposed to eliminate the tracheostoma in those patients with permanent paralysis. Any such surgical procedure should ideally permit recovery of the upper airway patency, with minimal impairment of other laryngeal functions. The techniques proposed to achieve this objective included both extralaryngeal and endoscopic approaches.

In 1922, the first extralaryngeal approach was proposed by Jackson , who described a ventriculocordectomy. Since then, Hoover described a submucosal vocal cord resection; and King proposed a laterofixation of the vocal cord. Another extralaryngeal technique was successively proposed by Woodman , who advocated arytenoidectomy associated with suture of the vocal process to the inferior cornu of thyroid cartilage by a posterolateral approach to the larynx.

However, the extralaryngeal approaches were replaced with less invasive endoscopic approaches including arytenoidectomy proposed by Thornell (with electrocautery) and by Ossoff et al (with CO ₂ laser) and posterior cordotomy proposed by Dennis and Kashima . The arytenoidectomy was subsequently modified by Crumley , who described removal of the medial portion of one or both arytenoid bodies, and by Remacle et al , who advocated subtotal arytenoidectomy with preservation of a thin posterior portion.

A few authors found some advantage in treating this pathology by combining the 2 more commonly adopted approaches, namely, arytenoidectomy and posterior cordotomy, resulting in a more stable improvement of respiratory space . Although the techniques improved progressively with time, a risk of reoperation is still present, which is often caused by granulation, tissue formation, and narrowing of airway space. Motta et al in 2003 described arytenoidectomy with posterior cordectomy using CO ₂ laser, giving acceptable results.

In this study, we treated bilateral recurrent paralysis in adduction by arytenoidectomy and concomitant true and false posterior cordectomy; and we discuss our results.

2

Material and methods

We conducted a retrospective study of all the patients affected by bilateral vocal cord paralysis following total thyroidectomy. The patients underwent thyroidectomy between August 1998 and September 2009. Preoperative evaluation before the surgery for definitive management of vocal cord paralysis included clinical head and neck examination, clinical assessment of the cranial nerves, and fiberoptic laryngoscopy with assessment of laryngeal sensitivity by touching the larynx with the endoscope tip. Deglutition was assessed by videoesophagography with fluorine (in the presence of sensitivity disorders) after managing the acute dyspnea.

All patients underwent tracheostomy at the time of initial presentation with dyspnea following bilateral vocal cord paralysis. We waited for 6 to 12 months, following the cord palsy, before taking them up for definitive surgery. During this period, patients underwent scheduled periodic laryngoscopies for assessment of the possibility of spontaneous recovery.

During the initial 2 years of our study, only CO ₂ laser arytenoidectomy was adopted under suspension microlaryngoscopy. The procedure adopted was as follows: after incising the mucosa over arytenoids from vocal process to the apex, the arytenoid cartilage was exposed. Then the body and the vocal process were vaporized using CO ₂ laser. To provide even better results, the technique was changed in the subsequent years as described below: under suspension microlaryngoscopy, arytenoid cartilage was ablated using CO ₂ laser, paying particular attention to the interarytenoid area, along with removal of posterior third of the false cord and the true vocal cord.

In the immediate postoperative period, patients were treated with antibiotic therapy for 1 week and intravenous steroids (betamethasone 4 mg/d) for 2 days to reduce the postoperative edema. A proton pump inhibitor therapy was initiated in all cases to reduce the risk of endolaryngeal granulomas for 6 months. Follow-up consisted of fiberoptic laryngoscopies performed on a weekly basis until complete healing of the surgical site, then every month for the first 6 months following surgery, and subsequently once a year. In addition to clinical findings regarding the glottic space, a spectrography was done to evaluate the voice, analyzing the following data: subjective evaluation, maximal phonation time, and harmonics-noise ratio. Patients were divided into 2 groups according to the surgical technique adopted: group A had unilateral arytenoidectomy, and group B had unilateral arytenoidectomy and posterior true and false cordectomy. The data regarding surgical complications, postoperative care and time of recovery, need for reoperation, and time of complete stabilization were recorded.

An informed consent was obtained from each patient before surgical procedure. Our institutional review board approved the study.

2

Material and methods

We conducted a retrospective study of all the patients affected by bilateral vocal cord paralysis following total thyroidectomy. The patients underwent thyroidectomy between August 1998 and September 2009. Preoperative evaluation before the surgery for definitive management of vocal cord paralysis included clinical head and neck examination, clinical assessment of the cranial nerves, and fiberoptic laryngoscopy with assessment of laryngeal sensitivity by touching the larynx with the endoscope tip. Deglutition was assessed by videoesophagography with fluorine (in the presence of sensitivity disorders) after managing the acute dyspnea.

All patients underwent tracheostomy at the time of initial presentation with dyspnea following bilateral vocal cord paralysis. We waited for 6 to 12 months, following the cord palsy, before taking them up for definitive surgery. During this period, patients underwent scheduled periodic laryngoscopies for assessment of the possibility of spontaneous recovery.

During the initial 2 years of our study, only CO ₂ laser arytenoidectomy was adopted under suspension microlaryngoscopy. The procedure adopted was as follows: after incising the mucosa over arytenoids from vocal process to the apex, the arytenoid cartilage was exposed. Then the body and the vocal process were vaporized using CO ₂ laser. To provide even better results, the technique was changed in the subsequent years as described below: under suspension microlaryngoscopy, arytenoid cartilage was ablated using CO ₂ laser, paying particular attention to the interarytenoid area, along with removal of posterior third of the false cord and the true vocal cord.

In the immediate postoperative period, patients were treated with antibiotic therapy for 1 week and intravenous steroids (betamethasone 4 mg/d) for 2 days to reduce the postoperative edema. A proton pump inhibitor therapy was initiated in all cases to reduce the risk of endolaryngeal granulomas for 6 months. Follow-up consisted of fiberoptic laryngoscopies performed on a weekly basis until complete healing of the surgical site, then every month for the first 6 months following surgery, and subsequently once a year. In addition to clinical findings regarding the glottic space, a spectrography was done to evaluate the voice, analyzing the following data: subjective evaluation, maximal phonation time, and harmonics-noise ratio. Patients were divided into 2 groups according to the surgical technique adopted: group A had unilateral arytenoidectomy, and group B had unilateral arytenoidectomy and posterior true and false cordectomy. The data regarding surgical complications, postoperative care and time of recovery, need for reoperation, and time of complete stabilization were recorded.

An informed consent was obtained from each patient before surgical procedure. Our institutional review board approved the study.