|Year : 2020 | Volume
| Issue : 3 | Page : 91-94
Endoscopic suture lateralization of vocal cord with eyelet needle in patients with bilateral abductor paralysis
GM Mohammed1, AM Kirfi2, BT Gazali3, BM Ahmad4
1 Department of Surgery College of Medicine, Division of Otorhinolaryngology, Kaduna State University, Kaduna, Nigeria
2 Department of Otorhinolaryngology, Abubakar Tafawa Balewa University Teaching Hospital Bauchi, Bauchi, Nigeria
3 Department of Clinical Services, National Ear Care Centre, Kaduna, Nigeria
4 Department of Otorhinolaryngology, University of Maiduguri and University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
|Date of Submission||13-Oct-2020|
|Date of Acceptance||25-Jan-2021|
|Date of Web Publication||07-Aug-2021|
Dr. G M Mohammed
Department of Surgery College of Medicine, Division of Otorhinolaryngology, Kaduna State University, Kaduna
Source of Support: None, Conflict of Interest: None
Background: Vocal cord paralysis refers to absent or reduced function of vagus nerve or its distal branch, the recurrent laryngeal nerve. Several surgical procedures have been proposed for the management of respiratory distress secondary to bilateral vocal cord paralysis that are aimed at restoring glottic lumen sufficient to guarantee adequate breathing through the natural airway, without tracheotomy and preserving an acceptable voice quality. We aimed to present our experience in surgical management of bilateral abductor paralysis using endoscopic suture lateralization of vocal cord with eyelet needle.
Patients and Method: A prospective study of all consenting patients presenting with bilateral abductor paralysis managed from November, 2010 to December, 2018 in National Ear Care Centre Kaduna, Nigeria. Ethical approval was obtained from the institution's Health Research Ethics Committee (HREC). All patients were evaluated by taking detailed history, thorough clinical examination including flexible endoscopy and investigations. Eleven patients underwent endoscopic suture lateralization using proline 0 suture.
Results: Thyroid surgery was the main etiology, 8 out of a total of 11 that underwent lateralization procedure had tracheostomy elsewhere for duration of 1 to 2 years prior to presentation. All tracheostomized patients were successfully decannulated within 2 weeks after the procedure and final voice quality was subjectively good. None had any complications after surgery.
Conclusion: Endoscopic suture lateralization with eyelet needle is reversible; less invasive cost-effective technique that ensures stable airway and preservation of laryngeal sphincter with acceptable quality of voice especially in a resource constrained setting where laser is not available.
Keywords: Flexible laryngoscopy, vocal cord suture lateralization, vocal cord paralysis
|How to cite this article:|
Mohammed G M, Kirfi A M, Gazali B T, Ahmad B M. Endoscopic suture lateralization of vocal cord with eyelet needle in patients with bilateral abductor paralysis. Arch Int Surg 2020;10:91-4
|How to cite this URL:|
Mohammed G M, Kirfi A M, Gazali B T, Ahmad B M. Endoscopic suture lateralization of vocal cord with eyelet needle in patients with bilateral abductor paralysis. Arch Int Surg [serial online] 2020 [cited 2021 Dec 3];10:91-4. Available from: https://www.archintsurg.org/text.asp?2020/10/3/91/323467
| Introduction|| |
The most common cause of bilateral vocal fold paralysis (BVFP) is iatrogenic or surgical trauma commonly occurring after thyroidectomy (44%), and other causes include malignancies (17%), endotracheal intubation (15%), neurologic causes (12%), and idiopathic cases (12%). In unilateral recurrent laryngeal nerve (RLN) injury, patients present with hoarseness while in bilateral RLN injury, patients present with normal voice but with dyspnoea and sometimes life-threatening biphasic stridor.
BVFP is one of the most severe complications of thyroid surgery-associated RLN injury. The incidence of nerve palsy continues to vary widely in literature, where a transient RLN palsy is reported to range between 0.4% and 26%, and permanent RLN palsy can reach up to 5%-6%.
Surgical treatment for BVFP should aim at a compromise between respiratory and phonatory performance and should be adjusted according to patient's needs. Various Procedures for managing bilateral vocal fold (cord) paralysis include Tracheostomy, Re-innervation techniques and electrical pacing, which is at experimental stage. The permanent procedures include posterior cordotomy (unilateral or bilateral), Arytenoidectomy (endoscopic or external, partial or complete) while others are Cordopexy and lateralization of the vocal cord. Endoscopic Posterior cordotomy by means of a CO2 laser was introduced by Dennis and Kashimna. They described the resection of a 4-mm segment of the posterior aspect of the paralyzed VF from the vocal process of the arytenoid anteriorly and laterally to the false VF in the shape of the letter “C”. Availability of CO2 laser is a major issue in Sub Saharan Africa.
Ideal treatment for bilateral vocal cord paralysis should be simple, reproducible with good results, should be able to avoid tracheostomy, encourage early decannulation and shorten hospital stay. The treatment should not make matters worse. Revision surgery, if necessary, should be possible and cost effective.
| Patients and Method|| |
This was a prospective study of patients presenting with bilateral vocal cord paralysis to National Ear Care Centre Kaduna Nigeria and Dialogue specialist Hospital Kaduna from November, 2010 to December, 2018. Ethical approval for the study (Protocol number NECC/ADM/IV/12 0f 13th August 2009) was obtained from the Health Research Ethics Committee of the National Ear Care Centre, Procedure was explained to the patient and informed consent was taken before the procedure. Patients that were managed by laser cordotomy were excluded in this study. Suspension laryngoscopy was performed with video endoscope under general anesthesia via tracheostomy tube or small endotracheal tube size 5.5 or 6.0 in patients that were not on tracheostomy. Skin overlying the neck on the proposed suture lateralization was prepared and draped in sterile fashion. Horizontal skin incision 2 to 2.5 cm was made on the neck at the midpoint of thyroid cartilage. Size 21G needle was loaded with a size 2.0 or size 0 prolene suture which was then passed through the external skin incision until the tip appears below the vocal cord around the vocal process of arytenoid. Suture was then grasped and pulled until the free edge was seen.
An eyelet needle was then introduced through the external incision until the eye of the needle was visible through the endoscope above the vocal cord parallel to the first needle. Free edge of the suture was then threaded through the eye of the eyelet needle; the two needles were then pulled out through the external wound incision. Traction was applied on two ends of the suture to create lateralization of the posterior vocal fold and expansion of the static airway dimension, knot was then made to secure the suture in place and skin incision was closed in a standard fashion.
Post-operative care of tracheostomy was given in patients on tracheostomy, prophylactic antibiotic, steroid (Dexamethasone), analgesics and proton pump inhibitor were given. Process of decanulation was commenced one to two weeks postoperative period following flexible endoscopy to assess the airway. Two patients had transient aspiration of liquid which resolved within the first week post-operative.
| Results|| |
From this study, eleven patients from the National Ear Care center and Dialogue specialist hospital had endoscopic vocal cord lateralization with an eyelet needle following bilateral abductor paralysis. Their socio-demographic data is as shown in [Table 1].
Thyroid surgery was the main aetiology for bilateral vocal cord paralysis as shown in [Table 2]. Eight out of 11 patients that underwent endoscopic suture lateralization procedure had tracheostomy elsewhere for duration of 1 to 2 years prior to presentation. [Figure 1] shows a patient in severe respiratory distress before the surgery, [Figure 2] shows a pre-operative endoscopic image of the paralysed vocal cords in the paramedian position while [Figure 3] shows an intra-operative endoscopic image of the vocal cords with two eyelet needles endolaryngeally. Immediately after the procedure all patients noticed major improvement in their breathing when tracheostomy tube was blocked and all patients with tracheostomy were successfully decannulated within 2 weeks of the procedure. All patients of our study had a positive outcome with regard to relieving their respiratory distress as evidenced by a wide glottis space in one of the patients whose endolaryngeal endoscopic image is shown in [Figure 4]. We also achieved complete decannulation among all the patients who were tracheostomy dependent. Final voice quality was subjectively good; none had any complications after surgery.
|Figure 1: Patient with bilateral vocal cord paralysis in respiratory distress|
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|Figure 2: Endoscopy showing paralyzed vocal cords in paramedian position|
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|Figure 3: Intraoperative endoscopic image showing two needles with an eyelet|
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|Figure 4: Left vocal cord lateralized with suture showing adequate space|
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| Discussions|| |
The external approach to the Crico arytenoid joint (CAJ) was proposed to medialize the vocal fold in 1978 by Ishiki et al. On the contrary Woodman et al. lateralized the vocal fold through the same approach in 1946, which was modified by Shetty et al. in 1998. Patients undergoing glottis enlargement procedure for BVFP must be counseled for an improved airway for decreased voice quality and volume, which improves with time. Varieties of surgical procedures are available for treatment of BVFP. [Figure 5] shows a simplified image of the procedure involved in vocal cord lateralization with eyelet needles. Compared to the tissue ablation procedure (laser arytenoidectomy), the functional outcomes including the respiratory, phonatory and swallowing functions varied with the magnitude of tissue ablation and tissue regrowth, endoscopic suture lateralization is a reversible procedure that maintained the tension of the laterilized vocal cord with non-absorbable suture warranting consistent effectiveness in respiratory function. The most conservative, limited procedures should be selected and the chance for another surgery should be considered. Endoscopic suture lateralization of vocal fold is effective in management of BVFP especially in resource constrained setting where facilities for laser surgeries are not available. Endoscopic suture lateralization of vocal fold is less aggressive and safe procedure; selection of side to perform surgery is based on variety of factors. The most important factor for selection is the presence of any purposeful motion, either adductory or abductory. Thus, the side with worst neuromuscular status is the best location for the surgical procedure. The crico-arytenoid joint with worst range of motion and mobility would be the best choice for surgical procedure to widen the glottis airway. Arytenoidectomy, posterior cordectomy/cordotomy (even assisted by laser) on the other hand, may result in granuloma or hypertrophic scar formation which in future, may lead to inspiratory stridor.,
|Figure 5: Diagram showing the use of two needles in endoscopic suture lateralization of vocal cord|
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| Conclusion|| |
Endoscopic suture lateralization with eyelet needle is reversible, less invasive, and cost-effective technique that ensures stable airway and preservation of laryngeal sphincter with acceptable quality of voice especially in a resource constrained setting where laser is not available.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal immobility. Laryngoscope 1998;108:1346-50.
Thamizharasan P, Madanagopal R. Iatrogenic bilateral recurrent laryngeal nerve injury: A retrospective study. Int J Otorhinolaryngol Head Neck Surg 2018;4:1444-51.
Mannelli G, Mochloulis G, Hughes OR, Gallo O, Santoro R. Continuous intraoperative nerve monitoring during thyroid surgery: Realistic utility. J Surg Open Access 2017;3. doi: http://dx.doi.org/10.16966/2470-0991.145
Narin NN-C, Chason M, Wengier A, Wasserzug O, Cavel O, Horowitz G, et al
. Endoscopic posterior cordotomy for treatment of dyspnea due to vocal fold immobility. Multidiscip Respir Med 2020;15:35.
Isshiki N, Olamura M, Tanabe M, Morimoto M. Differential diagnosis of hoarseness. Folia Phoniatr (Basel) 1969;21:9-23.
Isshiki N, Tanabe M, Sawada M. Arytenoid adduction for unilateral vocal cord paralysis. Arch Otolaryngol 1978;104:555-8.
Woodman D. A modification of the extralaryngeal approach to arytenoidectomy for bilateral abductor paralysis. Arch Otolaryngol 1946;43:63-5.
Su W-F, Lan M-C, Liu S-C. Suture lateralisation plus arytenoid cartilage release for treating bilateral vocal fold immobility with mechanical fixation. Acta Otorhinolaryngol Ital 2019;39:18-21.
Özdemir S, Tuncer Ü, Tarkan Ö, Kara K, Sürmelioglu Ö. Carbon dioxide laser endoscopic posterior cordotomy technique for bilateral abductor vocal cord paralysis: A 15-year experience. JAMA Otolaryngol Head Neck Surg 2013;139:401-4.
Miman MC. A combined endolaryngeal approach for bilateral vocal fold immobility: Microlaryngoscopic submucosal cordotomy and endo-extralaryngeal triple-suture lateralization. Clin Surg 2017;2:1471.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]