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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 1-4

Swallowing outcomes after posterior cordectomy with partial arytenoidectomy in bilateral abductor palsy


1 Department of ENT-HN Surgery, NAMS, Kathmandu, Nepal
2 Department of Laryngology, Deenanathmangeshkar Hospital, Pune, Maharashtra, India
3 Department of ENT, ESIC Hospital, Pune, Maharashtra, India

Date of Submission29-May-2022
Date of Acceptance17-Aug-2022
Date of Web Publication8-Nov-2022

Correspondence Address:
K C Arun
Department of ENT-HN Surgery, NAMS, Kathmandu
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.jlv_3_22

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   Abstract 


Introduction: Laser posterior cordectomy with partial arytenoidectomy (PCPA) using CO2 laser is one of the treatment modalities for bilateral vocal fold immobility (BVFI). In addition to maintaining an adequate airway, the procedure may cause aspiration. Aim: The aim of this study was to study the swallowing outcomes after laser posterior cordectomy with PCPA in BVFI. Study Design: This was a prospective observational study. Materials and Methods: Patients undergoing laser posterior cordectomy with PCPA in bilateral abductor palsy from January 2012 to December 2014 had been examined with Fiber-optic Endoscopic Evaluation of Swallowing in 1st, 6th, and 12th weeks after surgery. Results: Thirty-six patients fulfilled the inclusion criteria. Two patients had penetration for liquid in 1st week but recovered without intervention. None of the patients had an aspiration to liquid, semisolid, and solid (P > 0.05). Conclusion: Swallowing is not hampered following laser PCPA done for bilateral immobile vocal folds.

Keywords: Aspiration, BFVI, fiber-optic endoscopic evaluation of swallowing, partial arytenoidectomy


How to cite this article:
Arun K C, Gandhi SS, Vishwavijetha S K. Swallowing outcomes after posterior cordectomy with partial arytenoidectomy in bilateral abductor palsy. J Laryngol Voice 2022;12:1-4

How to cite this URL:
Arun K C, Gandhi SS, Vishwavijetha S K. Swallowing outcomes after posterior cordectomy with partial arytenoidectomy in bilateral abductor palsy. J Laryngol Voice [serial online] 2022 [cited 2022 Nov 27];12:1-4. Available from: https://www.laryngologyandvoice.org/text.asp?2022/12/1/1/360573




   Introduction Top


Bilateral vocal fold immobility (BVFI) refers to all forms of reduced or absent movement of the vocal folds. It can result in stridor, which may turn life-threatening and requires management for securing the airway. Causes of vocal fold immobility differ according to age. In adults, the causes are mechanical, inflammatory, malignancy, surgery, neurological, radiation injury, metabolic, toxins, and idiopathic. In children, neurological abnormalities, idiopathic, and iatrogenic are important causes. Various treatment modalities are described in the literature.[1],[2],[3] Tracheostomy was the only treatment option for BVFI in the past century. Transoral laser surgery to provide adequate airway without a tracheostomy is gaining popularity. Advances in transoral surgery helped in preserving phonation along with adequate airway.[4] One of the most common transoral surgeries for bilateral vocal fold paralysis is posterior cordectomy with partial arytenoidectomy (PCPA). The aim of all surgical techniques used in the treatment of bilateral vocal fold paralysis is to restore a lumen sufficient for adequate breathing while preserving acceptable phonatory quality and laryngeal competence to avoid aspiration. The introduction of CO2 laser posterior cordectomy with PCPA is a major milestone or breakthrough in the management of BVFI.[5] It provided improved airway preserving acceptable phonation. Patients after posterior cordectomy with PCPA may be prone to aspiration for both food and saliva. Aspiration may be clinical or subclinical. Diagnosis of clinical or subclinical aspiration can be done by Fiber-optic Endoscopic Evaluation of Swallowing (FEES), which is a gold standard investigation to evaluate the pharyngeal phase of swallowing.[6],[7],[8] A fiber-optic endoscopic evaluation is performed with a flexible endoscope inserted trans-nasally into the hypopharynx, often to the level of the valleculae or laryngeal vestibule, where the larynx and surrounding structures are viewed. High-intensity light, transmitted by a fiber-optic bundle, illuminates the structure to be viewed and/or recorded by the clinician. The procedure provides an image of the vocal folds, laryngeal and velopharyngeal structures, and upper pharyngeal physiology during swallowing, with the potential for image recording and instant replay. The purpose of the FEES is to assess several specific indicators of an abnormal pharyngeal swallow including (a) premature spillage into the hypopharynx and laryngeal vestibule before swallowing, (b) ability of the vocal folds to adduct during coughing, breath holding, and swallowing, (c) the presence of residue in the hypopharynx and laryngopharynx after a swallow, and (d) the presence of laryngeal penetration or subglottic aspiration. Patients with bilateral immobile vocal folds have the possibility of clinical or subclinical aspiration after laser posterior cordectomy with PCPA. The most of previous studies which mention aspiration as a possible complication are based on subjective parameters. This study has been done with objective parameters to evaluate swallowing after posterior cordectomy with PCPA.


   Materials and Methods Top


Place of study: This study was conducted at Deenanath Mangeshkar Hospital and Research Center Erandwane, Pune.

Study design: This was a prospective observational study.

Study duration: The duration of the study was 36 months (January 2012 to December 2014).

The ethical clearance from the institutional review board was taken. The patient was explained about the study, and informed consent from all the patients was obtained.

Inclusion criteria

  1. All patients who have undergone posterior cordectomy with PCPA for bilateral vocal fold immobility
  2. Age above 14 years.


Exclusion criteria

  1. Patients in whom consent cannot be obtained
  2. Patients with a history of central neurological and malignant disease
  3. Patients are not available for follow-up at 1, 6, and 12 weeks.


All the patients coming to the ENT OPD are diagnosed with bilateral immobile vocal folds on the basis of

  1. Clinical examination of throat and indirect laryngoscopy
  2. Flexible laryngoscopy and digital videostroboscopy.


Method of measurement and data collection

Patients, who are diagnosed to have bilateral immobile vocal folds underwent CO2 laser posterior cordectomy with PCPA. These patients were subjected to swallowing evaluation with FEES at 1, 6, and 12 weeks after cordectomy as per the inclusion and exclusion criteria of the study.

Objective parameters

The objective parameters include

  1. Penetration
  2. Aspiration of solid, semisolid, and liquid food.


FEES

Materials used:

  1. Food: Liquid (boiled warm milk), semisolid (curd), solid (biscuit), blue and green edible artificial food colours
  2. Cups (to prepare and mix food and colour)
  3. Spoons (to feed)


Patient preparation

After explaining the procedure in the patient's own language, patient was seated on a chair in front of the swallowing station, facing the examiner.

Food preparation

Food materials are prepared, a cup each warm milk, curd, and biscuit are taken in separate bowls, and mixed thoroughly with artificial food color. Milk with blue, curd and biscuit mixed with green, for better visualization during evaluation and appreciation of aspiration/penetration.

Static evaluation

Flexible laryngoscope with illumination passed trans-nasally. Static evaluation of the morphology and function of the upper airways and upper digestive tract was done. Velopharyngeal competency and sensation assessed. Normal swallowing movement without food (laryngeal elevation and “white out”), pyriform sinuses (pooling of saliva) and adequacy of epiglottis, valleculae, aryepiglottic folds, cricopharynx with vocal cord movements assessed. Penetration or aspiration of saliva was assessed and recorded.

Swallowing evaluation

In the next step, food preparations of different consistencies are given to the patient with help of a spoon. The evaluation started with semisolid in the form of curd, followed by liquid in the form of milk and biscuit as solid at the last. Initially, small bolus of about 2 ml was given and examined. If there are no signs of dysphagia encountered, then a large bolus (5–10 ml) of the same consistency is given. The same repeated for all the three mentioned food items. After each feed, spillage of food, laryngeal penetration, and aspiration were assessed and recorded in a digital swallow work station.

Statistical analysis for penetration and aspiration of liquid, semisolid, and solid were done using Wilcoxon sign-rank test (for P value). P < 0.05 is taken as the level of significance.


   Results Top


This study was performed to find out the possibility of aspiration or penetration in the patients who underwent laser posterior cordectomy with PCPA evaluate at 1st, 6th, and 12th weeks after surgery. A total of 36 patients were evaluated, of which 21 (58.3%) were male and 15 (41.7%) were female. The age group ranged from 14 years to 63 years, maximum of eight patients (22.2%) in the 31–40 years age group. There were seven patients each in age groups 21–30 years and 51–60 years. Out of 36 patients, 21 (58.33%) patients were cases of idiopathic BVFI. Twelve (33.33%) out of 36 patients were due to prolonged intubation. Three (8.33%) patients had undergone total thyroidectomy.

None of the 36 patients had spillage or residues over vallecula and pyriform sinuses.

Only two patients had penetration to liquid in 1st week. None of the patients had penetration to liquid at 6th and 12th weeks. None of the patients had penetration to semisolid and solid in 1st, 6th, and 12th weeks. Using Wilcoxon sign-rank test, P value is > 0.05, therefore, there is no significant difference between 1st and 6th weeks and 1st and 12th weeks with respect to penetration for liquid, semisolid, and solid.

None of the patients had an aspiration to liquid, semisolid, and solid in 1st, 6th, and 12th weeks. Using Wilcoxon sign-rank test, P value is > 0.05, therefore, there is no significant difference between 1st and 6th weeks and 1st and 12th weeks with respect to aspiration for liquid, semisolid, and solid.


   Discussion Top


Bilateral vocal fold (vocal cord) immobility (BVFI) is a broad term that refers to all forms of reduced or absent movement of the vocal folds. It may be a life-threatening condition requiring interventions for securing the airway. Since the era of Chevalier Jackson's ventriculocordectomy to Sega's modification of Kashima's laser cordotomy, the aim of all surgical techniques used in the treatment to restore a lumen sufficient to guarantee adequate breathing through the natural airway while preserving acceptable phonatory quality and laryngeal competence to avoid aspiration.[9]

Patients with bilateral immobile vocal folds have the possibility of clinical or subclinical aspiration after laser posterior cordectomy. Arytenoid cartilage is vaporized along with its overlying mucosa by CO2 laser. This leaves a charred open wound, which has to be epithelialized by secondary intention. A scarred surgical area does not have sensation; hence, aspiration may be a potential problem. The published studies mention aspiration after cordectomy is based on subjective parameters. This study has been done using objective parameters to evaluate swallowing after posterior cordectomy with PCPA. A total of 36 patients were evaluated, of which 21 (58.3%) were male and 15 (41.7%) were female. The age group ranged from 14 years to 63 years, maximum of eight patients (22.2%) in the 31–40 years age group. Only two patients had penetration to liquid in the 1st week. Both of them recovered without any interventions. None of the patients had penetration to liquid at 6th and 12th weeks. Patients did not have penetration to semisolid and solid in 1st, 6th, and 12th weeks [Table 1]. Similarly, none of the patients had an aspiration to liquid, semisolid, and solid in 1st, 6th, and 12th weeks [Table 2]. Using Wilcoxon sign-rank test, P value is > 0.05 for both penetration and aspiration, therefore, there is no significant difference between 1st and 6th weeks and 1st and 12th weeks with respect to penetration and aspiration for liquid, semisolid, and solid. Joshua et al. shared their experience of laser-assisted posterior ventriculocordectomy without tracheostomy for BVFI in ten patients. None of the patients had severe aspirations, and only three patients had mild aspirations.[10] Khalil et al. did a prospective study on 18 patients with bilateral abductor vocal fold paralysis. All the patients were subjected to unilateral laser posterior cordotomy. Only one patient complained of mild aspiration to liquid and showed complete resolution after 3 weeks.[11] Remacle et al. in their study, where subtotal arytenoidectomy was done for bilateral abductor palsy, found some aspirations essentially with liquids that spontaneously resolved in days to weeks after surgery.[12] Various published studies by Saetti et al., Bilgen et al., Bosley et al., Oswal and Gandhi, and Bernstein et al. do not show the presence of any aspiration.[13],[14],[15],[16],[17] Our study showed almost similar results to their studies. We have objective evidence that patients do not have aspiration after laser posterior cordectomy with PCPA done for BVFI.
Table 1: Penetration during swallowing

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Table 2: Aspiration during swallowing

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   Conclusion Top


Swallowing is not hampered following laser posterior cordectomy with PCPA done for bilateral immobile vocal folds.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kirchner FR. Endoscopic lateralization of the vocal cord in abductor paralysis of the larynx. Laryngoscope 1979;89:1779-83.  Back to cited text no. 1
    
2.
Ossoff RH, Sisson GA, Duncavage JA, Moselle HI, Andrews PE, McMillan WG. Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis. Laryngoscope 1984;94:1293-7.  Back to cited text no. 2
    
3.
Remsen K, Lawson W, Patel N, Biller HF. Laser lateralization for bilateral vocal cord abductor paralysis. Otolaryngol Head Neck Surg 1985;93:645-9.  Back to cited text no. 3
    
4.
Sapundzhiev N, Lichtenberger G, Eckel HE, Friedrich G, Zenev I, Toohill RJ, et al. Surgery of adult bilateral vocal fold paralysis in adduction: History and trends. Eur Arch Otorhinolaryngol 2008;265:1501-14.  Back to cited text no. 4
    
5.
Gandhi S. Management of bilateral abductor palsy: Posterior cordectomy with partial arytenoidectomy, endoscopic approach using CO2laser. J Laryngol Voice 2011;1:66.  Back to cited text no. 5
    
6.
Dennis DP, Kashima H. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1989;98:930-4.  Back to cited text no. 6
    
7.
Eckel HE, Thumfart M, Wassermann K, Vössing M, Thumfart WF. Cordectomy versus arytenoidectomy in the management of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1994;103:852-7.  Back to cited text no. 7
    
8.
Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia 1988;2:216-9.  Back to cited text no. 8
    
9.
Jackson C. Ventriculocordectomy. A new operation for the cure of goitrous glottic stenosis. Arch Surg 1922;4:257-74.  Back to cited text no. 9
    
10.
Joshua B, Feinmesser R, Zohar L, Shvero J. Endoscopic laser-assisted posterior ventriculocordectomy without tracheostomy for bilateral vocal cord immobility. Isr Med Assoc J 2004;6:336-8.  Back to cited text no. 10
    
11.
Khalil MA, Abdel Tawab HM. Laser posterior cordotomy: Is it a good choice in treating bilateral vocal fold abductor paralysis? Clin Med Insights Ear Nose Throat 2014;7:13-7.  Back to cited text no. 11
    
12.
Plouin-Gaudon I, Lawson G, Jamart J, Remacle M. Subtotal carbon dioxide laser arytenoidectomy for the treatment of bilateral vocal fold immobility: Long-term results. Ann Otol Rhinol Laryngol 2005;114:115-21.  Back to cited text no. 12
    
13.
Saetti R, Silvestrini M, Galiotto M, Derosas F, Narne S. Contact laser surgery in treatment of vocal fold paralysis. Acta Otorhinolaryngol Ital 2003;23:33-7.  Back to cited text no. 13
    
14.
Bilgen C, Kirazli T, Oğüt F. Laser posterior cordectomy in bilateral vocal cord paralysis. Kulak Burun Bogaz Ihtis Derg 2002;9:286-90.  Back to cited text no. 14
    
15.
Bosley B, Rosen CA, Simpson CB, McMullin BT, Gartner-Schmidt JL. Medial arytenoidectomy versus transverse cordotomy as a treatment for bilateral vocal fold paralysis. Ann Otol Rhinol Laryngol 2005;114:922-6.  Back to cited text no. 15
    
16.
Oswal VH, Gandhi SS. Endoscopic laser management of bilateral abductor palsy. Indian J Otolaryngol Head Neck Surg 2009;61:47-51.  Back to cited text no. 16
    
17.
Bernstein JM, Jones SM, Jones PH. Unilateral transverse cordotomy for bilateral abductor vocal fold immobility. J Laryngol Otol 2012;126:913-7.  Back to cited text no. 17
    



 
 
    Tables

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