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Table of Contents
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 44-47

Surgical management of bilateral abductor vocal cord paralysis using Coblation technology


1 Department of ENT, Army College of Medical Sciences, Delhi Cantonment, New Delhi, India
2 Department of ENT, Baba Saheb Ambedkar Hospital, New Delhi, India

Date of Web Publication13-Oct-2017

Correspondence Address:
Ashwani Sethi
E-80, Naraina Vihar, New Delhi - 110 028
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.JLV_11_16

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   Abstract 

Objective: Management of bilateral abductor paralysis of vocal folds often poses a surgical challenge. Among various surgical modalities, surgical transaction/excision of posterior aspect of the vocal folds is an established modality. The objective of the present study is to evaluate the effectiveness and safety of the technique using Coblation technology. Study Design: This was a retrospective review. Setting: This study was conducted in a tertiary health care center. Materials and Methods: Fourteen consecutive patients meeting inclusion criterion undergoing posterior cordectomy using Coblator were included in this study. Preoperative subjective voice analysis was done and compared with measurements at 6 months postprocedure. Parameters studied included voice handicap index (VHI), the need for repeat procedures, effect of decannulation, and subjective improvement in respiratory distress. Results: There was a significant improvement in the airway as adjudged by the postoperative subjective improvement in respiratory distress (in 2 nontracheostomized patients) and uneventful decannulation (in 12 tracheostomized patients). However, the postoperative VHI scores showed no statistically significant difference with the preoperative assessment. One of the patients required the procedure to be repeated owing to recurrence of respiratory distress. No untoward incident was reported in any of the surgical procedures. Conclusion: Posterior cordectomy using a Coblator offers a safe and efficacious option for the management of compromised airway secondary to bilateral abductor paralysis of vocal folds. It offers a significant airway improvement without any significant effect on voice.

Keywords: Bilateral abductor paralysis, Coblator, cordectomy, cordotomy, vocal fold


How to cite this article:
Sethi A, Anand V, Das A, Sethi D. Surgical management of bilateral abductor vocal cord paralysis using Coblation technology. J Laryngol Voice 2016;6:44-7

How to cite this URL:
Sethi A, Anand V, Das A, Sethi D. Surgical management of bilateral abductor vocal cord paralysis using Coblation technology. J Laryngol Voice [serial online] 2016 [cited 2017 Nov 24];6:44-7. Available from: http://www.laryngologyandvoice.org/text.asp?2016/6/2/44/216701


   Introduction Top


Bilateral abductor paralysis of vocal folds results from involvement of bilateral recurrent laryngeal nerves usually secondary to surgical trauma, neurological disorders, extralaryngeal malignancies, nonsurgical trauma, etc.[1],[2] Most of these patients have a normal voice and the most common cause for presentation is respiratory distress secondary to airway compromise. The occurrence and severity of this dyspnea depends upon the amount of glottic chink, body mass of arytenoids, kind of physical activity, and presence of any comorbidities.[3]

There are various surgical modalities reported for the management of this condition. These modalities include medial arytenoidectomy, total arytenoidectomy, posterior cordectomy, ventriculocordectomy, laterofixation, and posterior transverse cordotomy.[4],[5] These procedures are conventionally performed endoscopically and most of them are currently performed with the help of lasers. The aim of this study is to share our experience of using a relatively new tool (Coblator) in performing a posterior cordectomy for the management of this condition.


   Materials and Methods Top


The study group included 14 patients of either sex with age ranging from 22 to 64 years who presented to the ENT Department with complaints of respiratory discomfort secondary to bilateral abductor vocal fold paralysis. Twelve of the patients were tracheostomized and two were not. The patients underwent a thorough ENT examination and general physical examination for any associated systemic illness. Patients with vocal cord paralysis were further investigated with the help of chest and neck X-rays and computed tomography scans (wherever required), and suitable referrals were sought from chest/medical specialists to identify the cause of palsy.

The selected patients also underwent a preoperative voice analysis using subjective parameter in the form of Hindi version of voice handicap index (VHI). The two nontracheostomized patients were also asked to mark the severity of their dyspnea on the scale of 1–10 with 1 being no dyspnea even on climbing stairs and 10 being dyspnea on rest. The patients underwent posterior cordectomy using Coblator under general anesthesia. The laryngeal LW wand of the Coblator was used for the purpose with the Coblator settings of "8" for coblation and "4" for coagulation. The amount of the vocal fold excised is depicted in the images [Figure 1] and [Figure 2]. Roughly, 2 x 6 mm sleeve of muscle was excised in all the cases unilaterally [Figure 3] and [Figure 4]. The procedure was required to be repeated on the opposite side in one of the tracheostomized patients following 1 week of decannulation owing to recurrence of dyspnea. No untoward peri- or post-operative events were recorded. The 12 tracheostomized patients were given a decannulation trial with a subsequent decannulation 48 h following the surgery. One of the patients developed recurrence of dyspnea 1 week following decannulation and underwent a repeat surgical procedure on the opposite cord. All the patients were asked to refill the VHI 3 months following the surgery, and the two nontracheostomized patients were again asked to mark the severity of their dyspnea on the scale of 1–10. The results were recorded and statistically analyzed (VHI scores only).
Figure 1: Diagrammatic representation of posterior cordotomy (Kashima's procedure)

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Figure 2: Diagrammatic representation of our procedure. The extent of muscle removed is marked (all measurements in mm)

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Figure 3: Images of the surgical procedure in a tracheostomized patient. (a) Preprocedure (b) postprocedure

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Figure 4: Images of the surgical procedure in a nontracheostomized patient. (a) Preprocedure (b) postprocedure

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Voice handicap index scores

The average scores of the three domains (i.e., physical, functional, and emotional) were analyzed.


   Results Top


A total of 14 patients in the age range of 22–64 years (mean age = 48.6 years) of either sex underwent posterior cordectomy [Figure 5]. Nine of these patients developed the palsy secondary to thyroid surgery, three were idiopathic, one was secondary to intubation, and one was following a splinter injury to neck.
Figure 5: Age distribution of patients

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Voice handicap index scores

The mean total VHI score was 49.3 (standard deviation [SD] = 12.73) preoperatively, and at 3 months following the surgery, it was 58.30 (SD = 16.51). There was no significant reduction in total and individual VHI domains postoperatively as assessed by paired t-test (P > 0.05) [Table 1].
Table 1: Pre- and post-operative voice handicap index scores

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All the 12 tracheostomized patients had a successful decannulation 48 h following the surgery except for one patient who required a repeat tracheostomy 1 week following decannulation owing to recurrence of dyspnea. This patient also underwent a repeat procedure on the opposite cord following which a successful decannulation was done subsequently. The two nontracheostomized patients had a marked subjective improvement in the severity of dyspnea. All the 14 patients remained asymptomatic till their last follow-up (minimum follow-up period = 6 months).


   Discussion Top


Bilateral abductor paralysis usually presents with dyspnea and at times may present as an emergency. Tracheostomy may be required for securing the airway in patients presenting with an emergency airway compromise.[6] Twelve of our patients also had to undergo tracheostomy for this reason. However, most of these patients have a relatively well-preserved voice and dysphonia is not a presenting complaint.[2] Similarly, none of our patients had complaints of dysphonia.

The commonly reported causes for bilateral abductor paralysis include thyroid surgery, neurological afflictions, nonsurgical neck trauma, and idiopathic.[1],[2] In our patients also, the most common cause for this occurrence was thyroid surgery. Tracheostomy has remained the gold standard for management for this condition for a very long time until the introduction of laser-assisted posterior cordotomy by Dennis and Kashima in 1989.[7] This procedure involves giving an approximately 4 mm wide "C-"shaped incision starting at the free margin of the true vocal fold at the junction of its anterior two third and posterior third [Figure 1]. This procedure aims to release the tension of the glottic sphincter rather than actual removal of the glottal tissue. Our surgical procedure involved removing a part of thyroarytenoid muscle from the anterolateral aspect after giving the cordotomy incision. We believe that it further expands the glottic airway. A similar technique was also advocated by Reker and Rudert in 1998.[8] However, we utilized a Coblator for performing this surgery, whereas both of the previously stated studies had used a CO2 laser for the purpose. Although there are reports of Coblator being used for supraglottoplasty in patients with laryngomalacia and epiglottoplasty in patients with obstructive sleep apnea syndrome, the use of Coblator in the management of bilateral abductor paralysis is scarcely reported.[9],[10],[11],[12] The reported advantage of Coblator over CO2 laser is a minimal surrounding tissue charring and damage owing to a lesser rise in temperature in the adjoining tissues.[12],[13] This property of Coblator is also responsible for a lesser postoperative edema. The early decannulation that was possible in our patients was resultant from a lesser amount of postoperative edema.

A wide range of surgical options have been reported for the management of this condition. These include cordotomy, cordectomy, partial and complete arytenoidectomy, ventriculocordectomy, and laterofixation.[4],[5] Majority of these procedures are carried out with the help of lasers. Many a times, the surgical procedures are also combined to achieve a larger and long-lasting airway expansion. The most commonly combined surgical procedures include a posterior cordectomy with arytenoidectomy.[4],[14],[15],[16] We had performed posterior cordectomy on all of our patients with successful outcome. The results of this procedure have been comparable to endoscopic laterofixation.[15] Endoscopic laterofixation has also been reported as an emergency procedure to avoid the need for tracheostomy in one study in the past.[17]

The treatment outcomes measured in our study included a Hindi version of VHI for voice assessment and outcome of decannulation and subjective improvement in dyspnea for airway assessment. The Hindi version of VHI was validated in 2011 and has been used as an outcome measure in studies in the past.[18],[19] Similarly, these parameters have been used in similar studies in the past as outcome measures.[4],[15],[20] The other objective parameter used for assessing airway in the past is spirometry.[8],[14],[16],[21] We did not find any significant voice deterioration following surgery in any of our patients. Laryngeal compensation following cordectomy has been well documented in the past.[22]

Various complications associated with the procedure of cordectomy that has been reported in the past include hemorrhage, granuloma formation, immediate worsening of dyspnea, and anterior cervical abscess.[20],[23],[24],[25] However, we did not encounter any such complication in any of our patients although one of our patients required a repeat tracheostomy following cordectomy on the opposite cord.


   Conclusion Top


Various surgical options are available for the management of bilateral vocal fold abductor paralysis with their respective advantages and disadvantages. Posterior cordectomy is a well-established treatment modality for this condition. Application of Coblator in performing this surgery gives very good results with minimal surrounding tissue damage leading to early decannulation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Reker U, Rudert H. Modified posterior Dennis and Kashima cordectomy in treatment of bilateral recurrent nerve paralysis. Laryngorhinootologie 1998;77:213-8.  Back to cited text no. 8
    
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Misiolek M, Ziora D, Namyslowski G, Misiolek H, Kucia J, Scierski W, et al. Long-term results in patients after combined laser total arytenoidectomy with posterior cordectomy for bilateral vocal cord paralysis. Eur Arch Otorhinolaryngol 2007;264:895-900.  Back to cited text no. 14
    
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Sharan CJ, Bahadur S, Handa KK, Thakar A, Pande JN. Changes in ventilatory function following surgery for bilateral abductor paralysis. Indian J Otolaryngol Head Neck Surg 2009;61:208-12.  Back to cited text no. 16
    
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Oysu C, Sahin-Yilmaz A, Uslu C. Emergency endoscopic vocal cord lateralization as an alternative to tracheotomy for patients with bilateral abductor vocal cord paralysis. Eur Arch Otorhinolaryngol 2012;269:2525-9.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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