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Endo-extralaryngeal suture technique for endoscopic lateralization of paralyzed vocal cords
ENDO-EXTRALARYNGEAL SUTURE TECHNIQUE FOR ENDOSCOPIC LATERALIZATION OF PARALYZED VOCAL CORDS GYORGY LICHTENBERGER, MD, PhD, ROBERT J. TOOHILL, MD, FACS
The development of the Lichtenberger endo-extralaryngeal needle carrier has allowed suture lateralization of the vocal cord in 54 patients with bilateral abductor vocal cord paralysis. Of the 54 patients, 53 are included in the results, and in 50 patients this was the one and only operation necessary for improvement of their airway. Forty-eight patients underwent a tracheotomy, but underwent decannulation after the procedure. Five patients did not require a tracheotomy. Three patients' cases were considered failures because they required a second open operation to successful decannulate. Two basic methods of vocal cord lateralization are described. In 10 cases the procedure(s) was performed bilaterally to create an adequate airway. Voice quality remained excellent in 35 of the 53 patients. The remaining 18 patients had adequate airways but less than adequate voice.
The treatment of bilateral abductor vocal cord paralysis was initially performed by an operation that required open exposure of the larynx. These open techniques were greatly changed in 1948 when Thornell described an endolaryngeal approach of arytenoidectomy in bilateral abductor paralysis of the vocal cords. 1 This endoscopic method of performing an arytenoidectomy opened the w a y for many modifications, and several authors, especially Kleinsasser, over the next 30 years varied Thornell's technique of vocal cord lateralization. 2-s Naumann and Lang 9 in 1981 and Martin 1° in 1985 simplified these operations by using fibrin glue to hold the vocal cord lateral. However, this method required a stent to be placed in the larynx, after lateralization, which was left there for a certain amount of time. Kirchner n in 1979 and Ejnell et al, 12 in 1982, used an extra-endolaryngeal suture technique for lateralization of paralyzed vocal cords. Ossoff et aP 3 in 1984, Remsen et aP 4 in 1985, and Lim ~5in 1985 introduced the laser to dilate the larynx in abductor vocal cord paralysis. The widespread use of endoscopic operations in vocal cord paralysis was hindered by the fact that they require above-average technical skills and knowledge. Endolaryn-
From the Department of Otorhinolaryngology-Head and Neck Surgery, Szent Rokus Hospital, Budapest, Hungary, and the Department of Otolaryngology and Human Communication, Medical College of Wisconsin, Milwaukee, WI. Presented at The Second International Symposium on Laryngeal and Tracheal Reconstruction, Monte Carlo, Monaco, May 22-26, 1996. Address reprint requests to GySrgy Lichtenberger, MD, PhD, Department of Otorhinolaryngology-Head and Neck Surgery, Szent Rokus Hospital and Institutions, Gyulai Pal u.2., H-1085 Budapest, Hungary. Copyright © 1998 by W.B. Saunders Company 1043-1810/98/0903-0010508.00/0
1 66
geal arytenoidectomy with submucous cordectomy, with an attempt to save the mucous membrane, is not always easily performed. It is also technically difficult to suture the mucous membrane endoscopically. Even the smallest technical fault is likely to result in prolapse of the mucous membrane or scarring in the operating field, as noted by BanfaP in 1976 and Kirchner 16 in 1982. The sutures may also tear through the mucous membrane, resulting in the lateralized vocal cord slipping back to pretreatment position. As a result of animal experiments performed from 1977 through 1980,17-19 a new endo-extralaryngeal suture technique was developed that allowed for placement of suture material endoscopically from inside the airway out to the neck. The technique for lateral fixation of paralyzed vocal cords endoscopically using this endo-extralaryngeal suture technique was introduced into clinical practice in 1981 by Lichtenberger. 2° Further modifications of the technique were presented by Lichtenberger 21 in 1989 and Woodson et al, 22 in 1991. The purpose of this report is to review utilization of the new endo-extralaryngeal needle carrier (Fig 1) for repair of the narrowed laryngeal airway owing to bilateral vocal cord paralysis in 53 adult patients.
MATERIAL AND METHODS The records of 54 patients treated for bilateral vocal cord paralysis were reviewed from the otolaryngology services of the Szent Rokus Hospital in Budapest, Hungary, and the Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, over the past 12 years. The age, sex, and etiology
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 9, NO 3 (SEP), 1998: PP 166-171
....~,,~.....,,~,. FIGURE 1. Endo-extralaryngealneedlecarrier and microscalpel with safety lock. were noted. Follow-up data on the airway improvement and voice production were documented.
SURGICAL TECHNIQUE The endoscopic procedure used to lateralized the vocal cord in bilateral vocal cord paralysis is described in two procedures as follows.
ENDO-EXTRALARYNGEAL LARYNGOMICROSURGICAL LATERALIZATION (EExLL) This procedure is indicated when the paralyzed vocal cords are found in the paramedian position (Fig 2A). In addition, the cricoarytenoid joint is not ankylotic. The larynx is exposed microsurgically using endoscopic technique. It makes no difference if the right or left vocal cord is used, but rather the cord in the most medialized position is selected for the lateral fixation technique. A longitudinal incision is made on the superior surface of the vocal cord either with a microscalpel (Fig 1) or laser. The incision starts approximately 2 mm from the anterior commissure and finishes near the vocal process (Fig 2B). The vocal process is then grasped with a small hook, raised, and medialized. This allows for exposure of both the medial and lateral aspects of the thyroarytenoid muscles to be reached more easily for removal with the laser or cold cup. By spreading the mucous membranes of the incision and removing the muscles submucosally, the mucous membrane is preserved. The vocal cord is thus made thinner, which increases the lumen of the larynx, and the abductor muscles of the larynx gain balance over the adductor muscles. The more completely the abductor muscles are removed, the better the lumen of the larynx will be. However, this will cause some sacrifice to voice quality. Bleeding can be controlled by electrocautery or laser. In certain cases, the pressure of the endo-extralaryngeal stitch will tamponade any further bleeding. After completion of muscle removal the laryngoscope can be directed more posteriorly to allow for uncomplicated placement of the stitch. Conventional microlaryngoscopes are adequate for placement of the stitches with the needle carrier. The adjustable valve or bi-valve scopes, which can be opened widely at their tip, are very beneficial for suture placement. Using the Lichtenberger endoextralaryngeal needle carrier (Fig 1),2 a 2-0 prolene stitch is placed below the posterior one-third of the residual vocal
LICHTENBERGERANDTOOHILL
cord and then the other end is placed just above the posterior one-third of the residual vocal cord (Fig 2C-D). The stitch now exposed externally in the neck is knotted over a bent silicon tube placed on the skin of the neck. Placing proper tension on the stitch, the residual vocal cord is lateralized to the extent desired (Fig 2E). An additional suture may also be placed in the middle one-third of the vocal cord, allowing for further improvement of the airway and lateralization of the vocal cord. It is desirable to be certain to place the stitch anterior to the vocal process, because it is more difficult to push the needle through the thyroid cartilage into the neck at the level of the vocal process. The suture(s) are removed 3 weeks after the operation. The skin under the bent silicon tube may become somewhat discolored, but will regain its original color a few weeks following removal. Two to 3 months after this procedure, the stitch mark is scarcely visible.
ENDO-EXTRALARYNGEAL LARYNGOMICROSURGICAL LATERALIZATION OF THE VOCAL CORD WITH ARYTENOIDECTOMY (EExLL WITH ARYTENOIDECTOMY) This procedure is indicated when the paralyzed vocal cords are in the median or paramedian position a n d / o r there is ankylosis of the arytenoid cartilage(s). This operation can be performed without tracheostomy too, with FET anesthesia. A triangular incision is made laryngoscopically under microscopic magnification with a microscalpel and scissors or laser. The incision begins a few millimeters from the anterior commissure and extends posteriorly over the vocal process I to 1.5 mm from the edge of the vocal cord to the area above the arytenoid cartilage. Another incision is made from the vocal process to the muscular process to the arytenoid. The two incisions are then connected with a transverse incision at the height of the muscular process (Fig 3A). The arytenoid cartilage is prepared and removed with either dissection or with laser techniques. A submucous cordectomy is performed on the thyroarytenoid muscle as previously described, again sparing the mucous membrane (Fig 3B). In certain cases, a portion of the posterior false vocal cord can also be removed. The entire procedure is performed easier with the laser than with scalpel and forceps. The vocal cord is lateralized as described in procedure I, with the only difference being that if part of the false vocal cord is resected, the suture must be placed above the excised area of the false vocal cord. The suture then is again fixed in the neck as described in the previous procedure (Fig 3C-F). In some cases significant edema can occur as a result of the procedure, especially if the laser is not used. A course of antibiotics, antihistamines and, in certain cases, steroids are helpful in reducing or preventing edema from occurring. In most instances there is minimal edema present. The suture material is removed at the end of 3 weeks, and there is very little development of edema or granulation tissue. This is particularly true when 2-0 prolene is used.
RESULTS Fifty-four patients were identified over the past 12 years with bilateral abductor vocal cord paralysis. The etiology of the paralysis is summarized in Table 1. Forty-four of the
167
A
C
E
FIGURE 2. (A) Paralyzed vocal cords. (B) The muscles are removed submucously, or at least saving the medial mucous membrane of the vocal cord, using a laser. (C) The needle, with one end of the laterofixing thread, is pushed below the posterior third of the residual vocal cord. (D) The other end of the thread is led above the posterior third of the residual vocal cord. (E) The situation after pulling the ends of the thread.
patients had previous thyroidectomies as the cause of their paralysis. One patient had a thyroidectomy plus prolonged intubation as the cause, another patient had thoracic surgery. One patient had congenital paralysis. There were 168
two cases of prolonged intubation. In four cases the cause was unknown. Forty-seven patients had bilateral paralysis with no other associated abnormality. Two patients had paralysis of infantile larynges. In five patients there were ENDO-EXTRALARYNGEAL SUTURE TECHNIQUE
A
C
D
E
F
FIGURE 3. (A) A triangular incision is made laryngoscopically in microscopic magnification with the laser. (B) The arytenoid cartilage and the adductor muscles are prepared and removed. (C) One end of the laterofixing thread is pushed through the larynx with the help of the needle carrier, below the posterior third of the residual vocal cord. (D) The other end of the thread is being led through the larynx above the posterior third of the residual vocal cord. (E) The ends of the thread are being pulled. (F) The ends of both threads are pulled.
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TABLE 3. Type of Operation in 54 Patients
TABLE 1. Etiology of Bilateral Abductor Vocal Cord Paralysis in 54 Patients Thyroidectomy Thyroidectomy and prolonged intubation Prolonged intubation Thoracic surgery Congenital Unknown
44 1 3 1 1 4
scars in the posterior commissure or the subglottic region (Table 2). There were 46 females and 8 males in the study group, with an age range from 19 to 79 years. Table 3 summarizes the type of operation performed. Twenty-three patients had unilateral EExLL and 20 patients had unilateral EExLL with arytenoidectomy (Fig 4A-D). Ten patients had bilateral procedures. In eight of these cases, EExLL procedures were done with EExLL with arytenoidectomy of the contralateral side. In one case, EExLL was done bilaterally, and in one case EExLL with arytenoidectomy was done bilaterally. One patient died on the first postoperative day owing to a sudden cardiac death, and thus 53 patients were included in the evaluation of results. Five recent patients had EExLL accomplished without the use of a tracheotomy. All of the cases involved use of the laser for the submucous cordectom]6 thus causing minimal edema and no airway problems. Forty-five patients were successfully decannulated after their endoscopic operation. Three patients required additional procedures using open techniques before they could be decannalized. One of these failures required an open procedure to remove further adductor muscle and an arytenoidectomy. The other two, both infantile larynxes, required posterior cricoid splits (Laminotomy by R6tni) and augmentation with hyoid bone transposition operations. The voices of 35 patients remain clearly understandable and very adequate, although somewhat more breathy. The voices of 10 patients were somewhat weaker than normal with some hoarseness. The voices of 8 patients were considerably deteriorated, being low pitched and hoarse, but with adequate airways that satisfied the patients.
EEx LL EExLL with Aryt. EExLL Bilateral EExLL and EExLLwith Aryt. Contralateral EExLL with Aryt. Bilateral
24 20 1 8 1
Abbreviations: EExLL, endo-extralaryngeallaryngomicrosurgicallateralization; EExLLwith Aryt., endo-extralaryngeallaryngomicrosurgicallateralization with arytenoidectomy.
more breathy and sometimes hoarse after surgery, all patients were more concerned about their airway than the quality of their voice. Each preferred to breathe through the normal patterns of laryngeal breathing as opposed to tracheotomy. The advantages of the present method over the external operation is that the cartilaginous structure of the larynx does not need to be touched. Although conventional cold instruments are adequate for performing this surgery; the addition of the laser creates precise removal of the thyroarytenoid muscle, the arytenoid cartilage, scar tissue, and part of the false vocal cord if necessary. The resultant hemostasis and lack of postoperative edema will allow the avoidance of tracheotomy in some cases. With the two methods described, suture placement under microscopic magnification and eye control is more exact than the older extraendolaryngeal suture techniques that were performed blindly) 1,12 These procedures avoid the risk of scar adhesions of the posterior commissure that are sometimes caused by arytenoidectomy. Because of the exact placement of sutures they rarely, if ever, break, causing the vocal cord to slip back into its paramedian position.
DISCUSSION
The management of laryngeal stenosis resulting from bilateral abductor vocal cord paralysis can for the most part be managed endoscopically with the technique described. It must be pointed out that even with this type of management, external operations may be necessar~ especially in those cases in which there is posterior commissure scarring and fixation of the arytenoids. The failures in our three cases included two small infantile-like larynxes and one case of subglottic scarring. In 10 cases an improved result was obtained by a contralateral operation that improved the airway to a greater extent. Cases with moderate posterior commissure scarring are now managed by incision of the scars and lateral fixation and insertion of a stent for 3 weeks' duration. Although voice production is TABLE 2. Preoperative Diagnosis in 54 Patients Isolated bilateral abductor paralysis Paralysis and posterior commissure scar Paralysis and subglottic scar Paralysis and infantile larynx 170
47 3 2 2
FIGURE 4. (A) The paralyzed vocal cords (indirect picture made with the Bauer-Bosch-R.Wolf videoprinter). (B) Endoscopic incision with the laser over the left true vocal cord in preparation for submucous cordectomy and arytenoidectomy (direct operational photo). (C) The view directly after arytenoidectomy and the laterofixation suture(s) of the left residual vocal cord. The endotracheal tube is seen distally (direct operational photo). (D) Endoscopic picture taken one year after the operation (indirect photo made with Bauer-Bosch-R. Wolf videoprinter). ENDO-EXTRALARYNGEAL SUTURE TECHNIQUE
CONCLUSION The Lichtenberger endo-extralaryngeal needle carrier a v o i d s t h e b l i n d a n d c u m b e r s o m e m e t h o d of p l a c i n g s u t u r e m a t e r i a l f r o m s k i n of t h e n e c k to t h e a i r w a y a n d b a c k o u t to s k i n a g a i n . L a t e r a l i z a t i o n of t h e v o c a l c o r d b y submucous cordectomy and the endo-extralaryngeal method are accomplished with ease using microlaryngoscopic techniques. The addition of laser technology allows c e r t a i n c a s e s to b e p e r f o r m e d w i t h o u t t r a c h e o t o m y . T h e p r o c e d u r e , c o m b i n e d w i t h a r y t e n o i d e c t o m y for t h o s e c a s e s of p a r a l y s i s a n d p o s t e r i o r c o m m i s s u r e s c a r r i n g , is a c c o m plished with incision of the scar and lateral fixation and occasionally stent placement. Bilateral procedures are successful w h e n t h e i n i t i a l l a t e r a l i z a t i o n p r o c e d u r e d o e s n o t provide a fully adequate airway.
REFERENCES 1. Thornell WC: Intralaryngeal approach of arytenoidectomy in bilateral abductor paralysis of the vocal cords. Arch Otolaryngol 47:505-508, 1948 2. VonLeden H: Intralaryngeal correction of bilateral abductor paralysis. Laryngoscope 60:1190-1200, 1950 3. Kleinsasser O: Endolaryngeale arytenoidektomie and submukose hemichordektomie zur erweiterung der glottis bei bilateraler abdukturenparese. Msch Ohr Hk 102:443-446, 1968 4. Kleinsasser O: Mikrolaryngoskopieand Endolaryngeale Mikrochirurgie. Schattauer, Stuttgart, 1968 5. Cancura W: Eine neue methode der laterofixation. Mschr Ohr Hk 103:264-271, 1969 6. Gammert C: Eine vereinfachte methode der endolaryngealen glottiserweiterung. Otol Rhinol Laryngo156:832-838, 1977
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7. Langnickel R, Koburg E: Die endolaryngeale lateralfixation des stimmbandes zur operativen behandlung der beiderseitigen posticusparese. HNO 18:239-242, 1970 8. Banfai P: Die operative losung der laryngotrachealen stenosen. HNO 24:371-382, 1976 9. Naumann C, Lang G: Fibrinkleber in der larynxchirurgie. Otol Rhinol laryngo160:364-366, 1981 10. Martin F: Die Durchfuhrung der modifizierten Thornellchen operation. Otol Rhinol Laryngol 64:322, 1985 11. Kirchner FR: Endoscopic lateralization of the vocal cords in abductor paralysis of the larynx. Laryngoscope 89:1779-1783, 1979 12. Ejnell H, Bake B, Hallen O, et ah A new simple method of laterofixation and its effects on orolaryngeal airway resistance and fonation. Acta Otolaryngo1386:196-197, 1982 13. Ossoff RH, Sisson GA, Moselle HI, et al: Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis. Laryngoscope 94:1293-1297, 1984 14. Remsen K, Lawson W, Patel N, et al: Laser lateralization for bilateral vocal cord abductor paralysis. Otolaryngol Head Neck Surg 93:645649, 1985 15. Lim RY: Laser arytenoidectomy. Arch Otolaryngo1111:262-263, 1985 16. Kirchner FR: Endoscopic rehabilitation of the airway in laryngeal paralysis. Ann Otol Rhinol Laryngo191:382-383, 1982 17. Lichtenberger G: Hangszalagok kozti synechia megoldasa endolaryngealis mikrochirurgiaval (allatkiserlet) egeszsegugyi iOusagi napok. Szeged, 1979 18. Lichtenberger G: Glottikus synechia laryngomikrokirurgias kialakitasa es megoldasa allatkiserletben. Ful-orr-gegegyogy26:13-19, 1980 19. Lichtenberger G: Vereinfachte laterofixation der stimmbander im tierversuch. HNO Praxis 8:311-314, 1983 20. Lichtenberger G: Endo-extralaryngeal needle carrier instrument. Laryngoscope 93:1348-1350, 1983 21. Lichtenberger G: Laryngomikrochirurgische laterofixation gelahmter stimmlippen mit hilfe eines neuen nahtinstrumentes. Laryngorhinootologie 12:678-682, 1989 22. Woodson BT, McFadden EA, Toohill RJ: Clinical experience with the Lichtenberger endo-extralaryngeal needle carrier. Laryngoscope 101: 1019-1023, 1991
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The development of the Lichtenberger endo-extralaryngeal needle carrier has allowed suture lateralization of the vocal cord in 54 patients with bilateral abductor vocal cord paralysis. Of the 54 patients, 53 are included in the results, and in 50 patients this was the one and only operation necessary for improvement of their airway. Forty-eight patients underwent a tracheotomy, but underwent decannulation after the procedure. Five patients did not require a tracheotomy. Three patients' cases were considered failures because they required a second open operation to successful decannulate. Two basic methods of vocal cord lateralization are described. In 10 cases the procedure(s) was performed bilaterally to create an adequate airway. Voice quality remained excellent in 35 of the 53 patients. The remaining 18 patients had adequate airways but less than adequate voice.
The treatment of bilateral abductor vocal cord paralysis was initially performed by an operation that required open exposure of the larynx. These open techniques were greatly changed in 1948 when Thornell described an endolaryngeal approach of arytenoidectomy in bilateral abductor paralysis of the vocal cords. 1 This endoscopic method of performing an arytenoidectomy opened the w a y for many modifications, and several authors, especially Kleinsasser, over the next 30 years varied Thornell's technique of vocal cord lateralization. 2-s Naumann and Lang 9 in 1981 and Martin 1° in 1985 simplified these operations by using fibrin glue to hold the vocal cord lateral. However, this method required a stent to be placed in the larynx, after lateralization, which was left there for a certain amount of time. Kirchner n in 1979 and Ejnell et al, 12 in 1982, used an extra-endolaryngeal suture technique for lateralization of paralyzed vocal cords. Ossoff et aP 3 in 1984, Remsen et aP 4 in 1985, and Lim ~5in 1985 introduced the laser to dilate the larynx in abductor vocal cord paralysis. The widespread use of endoscopic operations in vocal cord paralysis was hindered by the fact that they require above-average technical skills and knowledge. Endolaryn-
From the Department of Otorhinolaryngology-Head and Neck Surgery, Szent Rokus Hospital, Budapest, Hungary, and the Department of Otolaryngology and Human Communication, Medical College of Wisconsin, Milwaukee, WI. Presented at The Second International Symposium on Laryngeal and Tracheal Reconstruction, Monte Carlo, Monaco, May 22-26, 1996. Address reprint requests to GySrgy Lichtenberger, MD, PhD, Department of Otorhinolaryngology-Head and Neck Surgery, Szent Rokus Hospital and Institutions, Gyulai Pal u.2., H-1085 Budapest, Hungary. Copyright © 1998 by W.B. Saunders Company 1043-1810/98/0903-0010508.00/0
1 66
geal arytenoidectomy with submucous cordectomy, with an attempt to save the mucous membrane, is not always easily performed. It is also technically difficult to suture the mucous membrane endoscopically. Even the smallest technical fault is likely to result in prolapse of the mucous membrane or scarring in the operating field, as noted by BanfaP in 1976 and Kirchner 16 in 1982. The sutures may also tear through the mucous membrane, resulting in the lateralized vocal cord slipping back to pretreatment position. As a result of animal experiments performed from 1977 through 1980,17-19 a new endo-extralaryngeal suture technique was developed that allowed for placement of suture material endoscopically from inside the airway out to the neck. The technique for lateral fixation of paralyzed vocal cords endoscopically using this endo-extralaryngeal suture technique was introduced into clinical practice in 1981 by Lichtenberger. 2° Further modifications of the technique were presented by Lichtenberger 21 in 1989 and Woodson et al, 22 in 1991. The purpose of this report is to review utilization of the new endo-extralaryngeal needle carrier (Fig 1) for repair of the narrowed laryngeal airway owing to bilateral vocal cord paralysis in 53 adult patients.
MATERIAL AND METHODS The records of 54 patients treated for bilateral vocal cord paralysis were reviewed from the otolaryngology services of the Szent Rokus Hospital in Budapest, Hungary, and the Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, over the past 12 years. The age, sex, and etiology
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 9, NO 3 (SEP), 1998: PP 166-171
....~,,~.....,,~,. FIGURE 1. Endo-extralaryngealneedlecarrier and microscalpel with safety lock. were noted. Follow-up data on the airway improvement and voice production were documented.
SURGICAL TECHNIQUE The endoscopic procedure used to lateralized the vocal cord in bilateral vocal cord paralysis is described in two procedures as follows.
ENDO-EXTRALARYNGEAL LARYNGOMICROSURGICAL LATERALIZATION (EExLL) This procedure is indicated when the paralyzed vocal cords are found in the paramedian position (Fig 2A). In addition, the cricoarytenoid joint is not ankylotic. The larynx is exposed microsurgically using endoscopic technique. It makes no difference if the right or left vocal cord is used, but rather the cord in the most medialized position is selected for the lateral fixation technique. A longitudinal incision is made on the superior surface of the vocal cord either with a microscalpel (Fig 1) or laser. The incision starts approximately 2 mm from the anterior commissure and finishes near the vocal process (Fig 2B). The vocal process is then grasped with a small hook, raised, and medialized. This allows for exposure of both the medial and lateral aspects of the thyroarytenoid muscles to be reached more easily for removal with the laser or cold cup. By spreading the mucous membranes of the incision and removing the muscles submucosally, the mucous membrane is preserved. The vocal cord is thus made thinner, which increases the lumen of the larynx, and the abductor muscles of the larynx gain balance over the adductor muscles. The more completely the abductor muscles are removed, the better the lumen of the larynx will be. However, this will cause some sacrifice to voice quality. Bleeding can be controlled by electrocautery or laser. In certain cases, the pressure of the endo-extralaryngeal stitch will tamponade any further bleeding. After completion of muscle removal the laryngoscope can be directed more posteriorly to allow for uncomplicated placement of the stitch. Conventional microlaryngoscopes are adequate for placement of the stitches with the needle carrier. The adjustable valve or bi-valve scopes, which can be opened widely at their tip, are very beneficial for suture placement. Using the Lichtenberger endoextralaryngeal needle carrier (Fig 1),2 a 2-0 prolene stitch is placed below the posterior one-third of the residual vocal
LICHTENBERGERANDTOOHILL
cord and then the other end is placed just above the posterior one-third of the residual vocal cord (Fig 2C-D). The stitch now exposed externally in the neck is knotted over a bent silicon tube placed on the skin of the neck. Placing proper tension on the stitch, the residual vocal cord is lateralized to the extent desired (Fig 2E). An additional suture may also be placed in the middle one-third of the vocal cord, allowing for further improvement of the airway and lateralization of the vocal cord. It is desirable to be certain to place the stitch anterior to the vocal process, because it is more difficult to push the needle through the thyroid cartilage into the neck at the level of the vocal process. The suture(s) are removed 3 weeks after the operation. The skin under the bent silicon tube may become somewhat discolored, but will regain its original color a few weeks following removal. Two to 3 months after this procedure, the stitch mark is scarcely visible.
ENDO-EXTRALARYNGEAL LARYNGOMICROSURGICAL LATERALIZATION OF THE VOCAL CORD WITH ARYTENOIDECTOMY (EExLL WITH ARYTENOIDECTOMY) This procedure is indicated when the paralyzed vocal cords are in the median or paramedian position a n d / o r there is ankylosis of the arytenoid cartilage(s). This operation can be performed without tracheostomy too, with FET anesthesia. A triangular incision is made laryngoscopically under microscopic magnification with a microscalpel and scissors or laser. The incision begins a few millimeters from the anterior commissure and extends posteriorly over the vocal process I to 1.5 mm from the edge of the vocal cord to the area above the arytenoid cartilage. Another incision is made from the vocal process to the muscular process to the arytenoid. The two incisions are then connected with a transverse incision at the height of the muscular process (Fig 3A). The arytenoid cartilage is prepared and removed with either dissection or with laser techniques. A submucous cordectomy is performed on the thyroarytenoid muscle as previously described, again sparing the mucous membrane (Fig 3B). In certain cases, a portion of the posterior false vocal cord can also be removed. The entire procedure is performed easier with the laser than with scalpel and forceps. The vocal cord is lateralized as described in procedure I, with the only difference being that if part of the false vocal cord is resected, the suture must be placed above the excised area of the false vocal cord. The suture then is again fixed in the neck as described in the previous procedure (Fig 3C-F). In some cases significant edema can occur as a result of the procedure, especially if the laser is not used. A course of antibiotics, antihistamines and, in certain cases, steroids are helpful in reducing or preventing edema from occurring. In most instances there is minimal edema present. The suture material is removed at the end of 3 weeks, and there is very little development of edema or granulation tissue. This is particularly true when 2-0 prolene is used.
RESULTS Fifty-four patients were identified over the past 12 years with bilateral abductor vocal cord paralysis. The etiology of the paralysis is summarized in Table 1. Forty-four of the
167
A
C
E
FIGURE 2. (A) Paralyzed vocal cords. (B) The muscles are removed submucously, or at least saving the medial mucous membrane of the vocal cord, using a laser. (C) The needle, with one end of the laterofixing thread, is pushed below the posterior third of the residual vocal cord. (D) The other end of the thread is led above the posterior third of the residual vocal cord. (E) The situation after pulling the ends of the thread.
patients had previous thyroidectomies as the cause of their paralysis. One patient had a thyroidectomy plus prolonged intubation as the cause, another patient had thoracic surgery. One patient had congenital paralysis. There were 168
two cases of prolonged intubation. In four cases the cause was unknown. Forty-seven patients had bilateral paralysis with no other associated abnormality. Two patients had paralysis of infantile larynges. In five patients there were ENDO-EXTRALARYNGEAL SUTURE TECHNIQUE
A
C
D
E
F
FIGURE 3. (A) A triangular incision is made laryngoscopically in microscopic magnification with the laser. (B) The arytenoid cartilage and the adductor muscles are prepared and removed. (C) One end of the laterofixing thread is pushed through the larynx with the help of the needle carrier, below the posterior third of the residual vocal cord. (D) The other end of the thread is being led through the larynx above the posterior third of the residual vocal cord. (E) The ends of the thread are being pulled. (F) The ends of both threads are pulled.
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TABLE 3. Type of Operation in 54 Patients
TABLE 1. Etiology of Bilateral Abductor Vocal Cord Paralysis in 54 Patients Thyroidectomy Thyroidectomy and prolonged intubation Prolonged intubation Thoracic surgery Congenital Unknown
44 1 3 1 1 4
scars in the posterior commissure or the subglottic region (Table 2). There were 46 females and 8 males in the study group, with an age range from 19 to 79 years. Table 3 summarizes the type of operation performed. Twenty-three patients had unilateral EExLL and 20 patients had unilateral EExLL with arytenoidectomy (Fig 4A-D). Ten patients had bilateral procedures. In eight of these cases, EExLL procedures were done with EExLL with arytenoidectomy of the contralateral side. In one case, EExLL was done bilaterally, and in one case EExLL with arytenoidectomy was done bilaterally. One patient died on the first postoperative day owing to a sudden cardiac death, and thus 53 patients were included in the evaluation of results. Five recent patients had EExLL accomplished without the use of a tracheotomy. All of the cases involved use of the laser for the submucous cordectom]6 thus causing minimal edema and no airway problems. Forty-five patients were successfully decannulated after their endoscopic operation. Three patients required additional procedures using open techniques before they could be decannalized. One of these failures required an open procedure to remove further adductor muscle and an arytenoidectomy. The other two, both infantile larynxes, required posterior cricoid splits (Laminotomy by R6tni) and augmentation with hyoid bone transposition operations. The voices of 35 patients remain clearly understandable and very adequate, although somewhat more breathy. The voices of 10 patients were somewhat weaker than normal with some hoarseness. The voices of 8 patients were considerably deteriorated, being low pitched and hoarse, but with adequate airways that satisfied the patients.
EEx LL EExLL with Aryt. EExLL Bilateral EExLL and EExLLwith Aryt. Contralateral EExLL with Aryt. Bilateral
24 20 1 8 1
Abbreviations: EExLL, endo-extralaryngeallaryngomicrosurgicallateralization; EExLLwith Aryt., endo-extralaryngeallaryngomicrosurgicallateralization with arytenoidectomy.
more breathy and sometimes hoarse after surgery, all patients were more concerned about their airway than the quality of their voice. Each preferred to breathe through the normal patterns of laryngeal breathing as opposed to tracheotomy. The advantages of the present method over the external operation is that the cartilaginous structure of the larynx does not need to be touched. Although conventional cold instruments are adequate for performing this surgery; the addition of the laser creates precise removal of the thyroarytenoid muscle, the arytenoid cartilage, scar tissue, and part of the false vocal cord if necessary. The resultant hemostasis and lack of postoperative edema will allow the avoidance of tracheotomy in some cases. With the two methods described, suture placement under microscopic magnification and eye control is more exact than the older extraendolaryngeal suture techniques that were performed blindly) 1,12 These procedures avoid the risk of scar adhesions of the posterior commissure that are sometimes caused by arytenoidectomy. Because of the exact placement of sutures they rarely, if ever, break, causing the vocal cord to slip back into its paramedian position.
DISCUSSION
The management of laryngeal stenosis resulting from bilateral abductor vocal cord paralysis can for the most part be managed endoscopically with the technique described. It must be pointed out that even with this type of management, external operations may be necessar~ especially in those cases in which there is posterior commissure scarring and fixation of the arytenoids. The failures in our three cases included two small infantile-like larynxes and one case of subglottic scarring. In 10 cases an improved result was obtained by a contralateral operation that improved the airway to a greater extent. Cases with moderate posterior commissure scarring are now managed by incision of the scars and lateral fixation and insertion of a stent for 3 weeks' duration. Although voice production is TABLE 2. Preoperative Diagnosis in 54 Patients Isolated bilateral abductor paralysis Paralysis and posterior commissure scar Paralysis and subglottic scar Paralysis and infantile larynx 170
47 3 2 2
FIGURE 4. (A) The paralyzed vocal cords (indirect picture made with the Bauer-Bosch-R.Wolf videoprinter). (B) Endoscopic incision with the laser over the left true vocal cord in preparation for submucous cordectomy and arytenoidectomy (direct operational photo). (C) The view directly after arytenoidectomy and the laterofixation suture(s) of the left residual vocal cord. The endotracheal tube is seen distally (direct operational photo). (D) Endoscopic picture taken one year after the operation (indirect photo made with Bauer-Bosch-R. Wolf videoprinter). ENDO-EXTRALARYNGEAL SUTURE TECHNIQUE
CONCLUSION The Lichtenberger endo-extralaryngeal needle carrier a v o i d s t h e b l i n d a n d c u m b e r s o m e m e t h o d of p l a c i n g s u t u r e m a t e r i a l f r o m s k i n of t h e n e c k to t h e a i r w a y a n d b a c k o u t to s k i n a g a i n . L a t e r a l i z a t i o n of t h e v o c a l c o r d b y submucous cordectomy and the endo-extralaryngeal method are accomplished with ease using microlaryngoscopic techniques. The addition of laser technology allows c e r t a i n c a s e s to b e p e r f o r m e d w i t h o u t t r a c h e o t o m y . T h e p r o c e d u r e , c o m b i n e d w i t h a r y t e n o i d e c t o m y for t h o s e c a s e s of p a r a l y s i s a n d p o s t e r i o r c o m m i s s u r e s c a r r i n g , is a c c o m plished with incision of the scar and lateral fixation and occasionally stent placement. Bilateral procedures are successful w h e n t h e i n i t i a l l a t e r a l i z a t i o n p r o c e d u r e d o e s n o t provide a fully adequate airway.
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7. Langnickel R, Koburg E: Die endolaryngeale lateralfixation des stimmbandes zur operativen behandlung der beiderseitigen posticusparese. HNO 18:239-242, 1970 8. Banfai P: Die operative losung der laryngotrachealen stenosen. HNO 24:371-382, 1976 9. Naumann C, Lang G: Fibrinkleber in der larynxchirurgie. Otol Rhinol laryngo160:364-366, 1981 10. Martin F: Die Durchfuhrung der modifizierten Thornellchen operation. Otol Rhinol Laryngol 64:322, 1985 11. Kirchner FR: Endoscopic lateralization of the vocal cords in abductor paralysis of the larynx. Laryngoscope 89:1779-1783, 1979 12. Ejnell H, Bake B, Hallen O, et ah A new simple method of laterofixation and its effects on orolaryngeal airway resistance and fonation. Acta Otolaryngo1386:196-197, 1982 13. Ossoff RH, Sisson GA, Moselle HI, et al: Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis. Laryngoscope 94:1293-1297, 1984 14. Remsen K, Lawson W, Patel N, et al: Laser lateralization for bilateral vocal cord abductor paralysis. Otolaryngol Head Neck Surg 93:645649, 1985 15. Lim RY: Laser arytenoidectomy. Arch Otolaryngo1111:262-263, 1985 16. Kirchner FR: Endoscopic rehabilitation of the airway in laryngeal paralysis. Ann Otol Rhinol Laryngo191:382-383, 1982 17. Lichtenberger G: Hangszalagok kozti synechia megoldasa endolaryngealis mikrochirurgiaval (allatkiserlet) egeszsegugyi iOusagi napok. Szeged, 1979 18. Lichtenberger G: Glottikus synechia laryngomikrokirurgias kialakitasa es megoldasa allatkiserletben. Ful-orr-gegegyogy26:13-19, 1980 19. Lichtenberger G: Vereinfachte laterofixation der stimmbander im tierversuch. HNO Praxis 8:311-314, 1983 20. Lichtenberger G: Endo-extralaryngeal needle carrier instrument. Laryngoscope 93:1348-1350, 1983 21. Lichtenberger G: Laryngomikrochirurgische laterofixation gelahmter stimmlippen mit hilfe eines neuen nahtinstrumentes. Laryngorhinootologie 12:678-682, 1989 22. Woodson BT, McFadden EA, Toohill RJ: Clinical experience with the Lichtenberger endo-extralaryngeal needle carrier. Laryngoscope 101: 1019-1023, 1991
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