Isj

Fig. 6.1. Treatment of unilateral vocal fold paralysis

(Radiesse), which is undergoing evaluation for durability at the time of this writing, are the only exceptions to this. Definitive medial-ization therefore comprises medialization la-ryngoplasty and arytenoid repositioning procedures. Although absent from the algorithm presented here (Fig. 6.1), voice and swallowing therapy may prove useful in addition to these surgical measures in the symptomatic patient.

Because of potentially life-threatening consequences, the presence or absence of aspiration remains the most important consideration in patients with vocal fold paralysis. Selection of treatment depends on the duration of paralysis. In practice, patients with dysphagia present shortly after the onset of paralysis, making injection augmentation of a temporary substance a particularly suitable means of addressing their problems. Injection has been criticized as ineffective for closing posterior glottic gaps due to arytenoid malposition. If such an insufficiency appears to be a significant problem, framework surgery may be considered regardless of the time elapsed since the onset of paralysis.

In patients without significant dysphagia, and with unilateral vocal fold paralysis of long duration, framework surgery maybe performed without further work-up. Although our algorithm specifies 6 months, the time interval after which medialization laryngoplasty becomes appropriate is not precisely established. Some surgeons prefer to wait as long as 12 months, both because of the potential for recovery, and because atrophy or reinnervation may shift the position of the vocal fold, even when mobility does not return. Since laryngoplasty provides a stable degree of medial vocal fold displacement, it is advantageous that the neuromuscular status of the vocal fold stabilize prior to the surgery. There is no information regarding the amount of time this takes, but obviously, the more time that is allowed to pass since onset, the likelier it is that there will be little further change.

Patients with vocal fold paralysis due to tumor compression or invasion, or nerve section, may also be treated early because of the dismal prospect for recovery of vocal fold motion. Atrophy may be more likely in these patients, a factor which may need to be taken into ac count, particularly if a medialization laryngoplasty is being performed soon after onset.

Laryngeal electromyography is useful to evaluate patients who present within a few months of the onset of their dysphonia, and in iatrogenic cases of vocal fold paralysis when status of the nerve is unknown or presumed to be intact. In most practices, the majority of patients fall into this category. Patients with poor prognosis should be considered for early definitive treatment. On the other hand, patients with good or indeterminate prognosis may be observed, or, if dysphonia is bothersome, may undergo injection augmentation. If dysphonia returns after the injectate resorbs, medialization laryngoplasty provides a long-term remedy.

Conclusion

An assessment of certain simple aspects of each case of vocal fold paralysis, combined with a choice of surgical techniques, allows the development of a rational treatment strategy that approaches the ideal proposed in the introduction. There is no doubt that it could be further refined by additional information regarding the natural history of vocal fold paralysis, which, in many respects, remains poorly defined despite more than a century of clinical study. More sophisticated electrodiagnostic techniques, combined with a better understanding of laryngeal neurophysiology, is needed to understand the phenomenon of inappropriate reinnervation in the larynx and its clinical implications.

References

1. Tabaee A, Murry T, Zschommler A, Desloge RB (2005) Flexible endoscopic evaluation of swallowing with sensory testing inpatients with unilateral vocal fold immobility: incidence and pathophysiology of aspiration. Laryngoscope 115:565-569

2. Bhattacharyya N, Kotz T, Shapiro J (2002) Dysphagia and aspiration with unilateral vocal cord immobility: incidence, characterization, and response to surgical treatment. Ann Otol Rhinol Laryngol 111:672-679

3. Heitmiller RF, Tseng E, Jones B (2000) Prevalence of aspiration and laryngeal penetration inpatients with unilateral vocal fold motion impairment. Dysphagia 15:184-187

4. Flint PW, Purcell LL, Cummings CW (1997) Pathophysiology and indications for medialization thy-roplasty in patients with dysphagia and aspiration. Otolaryngol HeadNeck Surg 116:349-354

5. Baron EM, Soliman AMS, Gaughan JP, Simpson L, Young WF (2003) Dysphagia, hoarseness and unilateral true vocal fold motion impairment following anterior cervical diskectomy and fusion. Ann Otol Rhinol Laryngol 112:921-926

6. Bielamowicz S, Gupta A, Sekhar LN (2000) Early arytenoid adduction for vagal paralysis after skull base surgery. Laryngoscope 110:346-351

7. Netterville JL, Civantos FJ (1993) Rehabiliation of cranial nerve deficits after neurotologic skull base surgery. Laryngoscope 113 (Suppl 6o):45~54

8. BhattacharyyaN, BatirelH, Swanson SJ (2003) Improved outcomes with early vocal fold medialization for vocal fold paralysis after thoracic surgery. Auris Nasus Larynx 30:71-75

9. Mom T, Filaire M, Advenier D, Guichard C, Naa-mee A, Escande G, Llompart X, Vallet L, Gabril-largues J, Courtalhiac C, Claise B, Gilain L (2001) Concomitant type I thyroplasty and thoracic operations for lung cancer: preventing respiratory complications associated with vagus or recurrent laryngeal nerve injury. J Thorac Cardiovasc Surg 121:642-648

10. Abraham MT, Bains MS, Downey RJ, Korst RJ, Kraus DH (2002) Type I thyroplasty for acute unilateral vocal fold paralysis following intrathoracic surgery. Ann Otol Rhinol Laryngol 111:667-671

11. Nayak VK, Bhattacharyya N, Kotz T, Shapiro J (2002) Patterns of swallowing failure following medialization in unilateral vocal fold immobility. Laryngoscope 112:1840-1844

12. Woodson G (1997) Cricopharyngeal myotomy and arytenoid adduction in the management of combined laryngeal and pharyngeal paralysis. Otolaryngol Head Neck Surg 116:339-343

13. Pietersen E (1982) The natural history of Bell's palsy. Am J Otol 4:107-111

14. Pietersen E (2002) Bell's palsy: The spontaneous course of 2500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol (Suppl) 549:4-30

15. Postma GN, Shockley WW (1998) Transient vocal fold immobility. Ann Otol Rhinol Laryngol 107:236-240

16. Blitzer A, Jahn AF, Keidar A (1996) Semon's law revisited: an electromyographic analysis of laryngeal synkinesis. Ann Otol Rhinol Laryngol 105:764-769

17. Crumley RL (2000) Laryngeal synkinesis revisited. Ann Otol Rhinol Laryngol 109:365-371

18. Netterville JL, Stone RE, Rainey C et al. (1991) Recurrent nerve avulsion for treatment of spastic dysphonia. Ann Otol Rhinol Laryngol 100:10-14

19. Aronson AE, Santo LW de (1983) Adductor spastic dysphonia: Three years after recurrent laryngeal nerve section. Laryngoscope 93:1-8

20. Apfelbaum RI, Kriskovich MD, Haller JR (2000) On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine 25:2906-2912

21. Morpeth JF, Williams MF (2000) Vocal fold paralysis after anterior cervical diskectomy and fusion. Laryngoscope 110:43-46

22. Netterville JL, Koriwchak MJ, Winkle M, Courey MS, Ossoff RH (1996) Vocal fold paralysis following the anterior approach to the cervical spine. Ann Otol Rhinol Laryngol 105:85-91

23. Jung A, Schramm J, Lehnerdt K, Herberhold C (2005) Recurrent laryngeal nerve palsy during anterior cervical spine surgery: a prospective study. J Neurosurg Spine 2:123-127

24. Woodson GE, Miller RH (1981) The timing of surgical intervention in vocal cord paralysis. Otolaryngol Head Neck Surg 89:264-267

25. Hahn FW, Martin JT, Lilliei JC (1970) Vocal cord paralysis with endotracheal intubation. Arch Otolaryngol 92:226-229

26. Netterville JL, Jackson CG, Miller FR, Wanamaker JR, Glasscock ME (1998) Vagal paraganglioma: a review of 46 patients treated during a 20-year period. Arch Otolaryngol Head Neck Surg 124:11331140

27. Tsunoda K, Kikkiwa YS, Kumada M, Higo R, Ta-yama N (2003) Hoarseness caused by unilateral vocal fold paralysis: How long should one delay phonosurgery? Acta Otolaryngol 123:555-556

28. León X, Venegas MP, Orús C, Quer M, Maranillo E, Sañudo JR (2001) Inmovilidad glótica: Estudio retrospectivo de 229 casos. Acta Otorrinolaringol Esp 52:486-492

29. Havas T, Lowinger D, Priestly J (1999) Unilateral vocal foldparalysis: causes, options and outcomes. Aust NZJ Surg 69:509-513

30. Gupta SR, Bastian RW (1993) Use of laryngeal electromyography in prediction of recovery after vocal cord paralysis. Muscle Nerve 16:977-976

31. Munin MC, Murry T, Rosen CA (2000) Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin N Am 33:759-770

33. Hiroto I, Hirano M, Tomita H (1968) Electromyographic investigation of human vocal cord paralysis. Ann Otol Rhinol Laryngol 77:296-304

34. Hirano M, Nozoe I, Shin T, Maeyama T (1991) Electromyography for laryngeal paralysis. In: Hirano

M, Kirchner JA, Bless DM (eds) Neurolaryngology: recent advances. Singular, San Diego, pp 232-248

35. Min YB, Finnnegan EM, Hoffman HT, Luschei ES, McCulloch TM (1994) A preliminary study of the prognositic role of electromyography in laryngeal paralysis. Otolaryngol Head Neck Surg 111:770775

36. Crumley RL, McCabe BF (1982) Regeneration of the recurrent laryngeal nerve. Otolaryngol Head Neck Surg 90:442-447

37. Zealear DL, Hamdan AL, Rainey CL (1994) The effects of denervation on posterior cricoarytenoid muscle physiology and histochemistry. Ann Otol Rhinol Laryngol 103:780-788

38. Mostafa BE, Gadallah NA, Nassar NM, Al-Ibiary HM, Fahmy HA, Fouda NM (2004) The role of la-

ryngeal electromyography in vocal fold immobility. Otorhinol Laryngol 66:5-10

39. Sittel C, Stennert E, Thumfart WF, Dapunt U, Eckel HE (2001) Prognostic value of laryngeal electromyography in vocal fold paralysis. Arch Otolaryngol Head Neck Surg 127:155-160

40. Parnes SM, Satya-Murti S (1985) Predicitive value of laryngeal electromyography in patients with vocal cord paralysis of neurogenic origin. Laryngoscope 95:1323-1326

41. Munin MC, Rosan CA, Zullo T (2003) Utility of laryngeal electromyography in prediciting recovery after vocal fold paralysis. Arch Phys Med Rehabil 84:1150-1153

Was this article helpful?

0 0
How To Quit Smoking

How To Quit Smoking

Did You Ever Thought You Could Quit Smoking And Live A Healthy Life? Here Are Some Life Saving Tips On How To Do It. Have you ever thought about quitting smoking, but either thought it was impossible or just simply wasn’t that important? Research shows that most smokers do want to quit smoking and they are waiting for that auspicious day eagerly.

Get My Free Ebook


Post a comment