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Surgical Procedures for the Relief of Symptoms of Paralysis of the Recurrent Laryngeal Nerves
Surgical Procedures for the Relief of Symptoms of Paralysis of the Recurrent Laryngeal Nerves WALTER B. HOOVER
THE medical department of the Lahey Clinic is alert to the possibilities of disease associated with hoarseness. Many laryngeal examinations are carried out daily, and many patients with thyroid disease, with and without complications, are seen and treated. The subject of paralysis of the recurrent laryngeal nerve has been of primary importance at the clinic, and we have attempted to keep abreast of the literature on this subject and prevent this complication during thyroid surgery . Yet bilateral paralysis has occasionally occurred during a thyroid operation by the most experienced operator. Since attempts at restoration of function of the recurrent laryngeal nerve by direct suture, by graft and by anastomosis with other respiratory nerves have failed to restore function to the muscles supplied by it, surgical procedures of this character have been abandoned, but operative maneuvers have been devised for the relief of the symptoms produced by the loss of function of the muscles supplied by one or both recurrent laryngeal nerves. There is still no unanimity of opinion concerning the explanation for the clinical findings in cases of paralysis of a portion or more of the muscles supplied by the recurrent laryngeal nerves. King and Gregg,IS and Morrisonl7 • 18 recently have particularly emphasized the fact that the recurrent laryngeal nerve may divide well before its entrance into the larynx into branches which may control either the abductor or adductor muscles and they have emphasized the possibility of injury of one of the branches without the entire nerve being injured, thus explaining some of the controversial points associated with laryngeal paralysis. Clinically, unilateral paralysis of the recurrent laryngeal nerve may be considered an unfortunate incident in which there is often impairment of the voice. However, it may not be marked and after a lapse of 879
880
Walter B . Hoover
time the impaired voice may improve as the cords compensate by approximating each other in spite of the paralysis. Laryngeal obstruction has not been observed to occur from paralysis of one recurrent laryngeal nerve in an otherwise normal larynx. The voice impairment may persist due to lack of tension in the paralyzed cord and lack of approximation of the paralyzed cord with the normal vocal cord. Teachers, ministers and others who depend upon their speaking voice in their occupations find the impaired voice a marked handicap. Untreated bilateral paralysis of the recurrent laryngeal nerves leads to chronic invalidism, the resulting obstruction produces dyspnea and stridor of varying degrees, and may produce suffocation and death. Most patients with laryngeal obstruction from this cause have some dysphagia, and their activities are limited. They are particularly noisy during sleep, often disturbing the neighborhood. Any patient whose activities are limited by dyspnea from this cause should be relieved by a tracheotomy for a period of time up to eight months following thyroid surgery, or other specific treatment should be given if other causes are present, to permit the possible return of function of the nerve and the muscles it supplies. When recovery of function is considered hopeless, surgical treatment directed to the widening of the glottis is indicated unless the patient chooses to continue with the tracheotomy tube. When the tracheotomy tube is used for the relief of laryngeal obstruction resulting from paralysis of the recurrent laryngeal nerves, the Tucker valve tube is a distinct asset as it makes possible inspiration through the tracheotomy tube and expiration through the larynx. In most cases the speaking voice is excellent without the necessity of occluding the tracheotomy opening with the finger. It is to be noted here that in bilateral recurrent nerve paralysis with laryngeal obstruction the patient has no difficulty in expelling the air once it has been taken into the lungs. The obstruction is caused by the vocal cords being sucked together and lying in the midline during inspiration; often the greater the respiratory effort, the more complete becomes this valve action. No attempt will be made here to record all the possible etiologic factors that may produce paralysis of the recurrent laryngeal nerve. By far the most common cause of bilateral paralysis is trauma associated with surgical procedures on the thyroid gland. Dr. Lahey14 has particularly stressed its importance and the methods by which such injuries may be avoided, for the avoidance of such an injury is of the greatest value. In addition to the traumatic cases there are cases of congenital paralysis, paralysis due to neuritis and paralysis associated with disease of
Paralysis of Recurrent Laryngeal Nerves
881
the central nervous system. Neoplasms are a relatively common cause, especially those of the thyroid gland, upper esophagus and those encroaching on the upper thoracic strait. Traumatic accidents otlier than those during operation are occasional causes and there may be a combination of lesions which may affect the laryngeal nerve of either side, in any location, from the brain stem to the arch of the aorta. In cases in which comprehensive examination fails to reveal the possible cause for paralysis of the recurrent laryngeal nerve, the condition is termed idiopathic. The diagnosis of unilateral and bilateral paralysis of recurrent laryngeal nerves can usually be made by examination with the laryngeal mirror. However, to test the mobility of the arytenoid cartilages it is necessary to use instrumentation. The direct method is more satisfactory in my hands. On some occasions when the paralysis has existed for a considerable period of time, the arytenoid may become fixed or an" kylosed. The surgical treatment of unilateral paralysis of the recurrent laryngeal nerve is for voice improvement only, that is, to bring the vocal cords together with greater tension. The procedure consists of implantation of a piece of rib cartilage of proper size and shape underneath the wing of the thyroid cartilage, wedging the vocal cord toward the midline and the arytenoid posteriorly. Meurman,16 of Finland, reported 15 patients operated on by this method with quite satisfactory improvement in voice. The surgical treatment of bilateral paralysis of the recurrent laryngeal nerves is directed primarily to the relief of the laryngeal obstruction as in practically all such instances when obstruction is present the vocal cords are found together and the voice is of good quality, if enough air can be inspired with which to speak. In some cases there is sufficient airway for ordinary respiration in the sedentary state. There is a variety of surgical methods for the relief of the obstruction associated with bilateral paralysis of recurrent nerves. These procedures only ameliorate the condition, they do not correct it, for there is no function-restoring operation at this time. It is paradoxical that any surgical procedure that separates the vocal cord-s sufficiently for adequate respiration during strenuous exercise markedly decreases their efficiency for phonation. Such matters should be discussed with the patient before operation. In 1932, I reviewed the literature4 available at that time and presented a method of submucous resection of the vocal cord. This gave relief from the obstruction largely by preventing failures from secondary cicatricial contractures. A few failures resulted owing to infection and poor technique. Since the advent of antibiotics there have been no failures and it has remained a satisfactory procedure for the relief of the obstruction.
882
Walter B . Hoover
In some cases, a very satisfactory voice was acquired by the use of the false cords; in others the voice remained poor. In 1939, King'sll extralaryngeal operation and his enthusiasm gave great impetus and aroused further interest in the treatment of this condition. His method was soon modified by others and by himself12 and the King or modified King's method has been adopted by a number of otolaryngologists2. 5. 17. 18 and surgeons in treating the obstruction produced by bilateral paralysis of the recurrent laryngeal nerves. The main points in the operation were the freeing of the arytenoid from its fellow on the opposite side by severing the interarytenoid muscle, the disarticulation of the joint and the fixation of the arytenoid with its attached vocal cord laterally by permanent suture to the ala of the thyroid cartilage. In 1940, Kelly6 described an extralaryngeal arytenoidectomy through a window in the thyroid cartilage. Kelly7-10 also was an enthusiastic and persistent worker in this field. Through his enthusiasm he attracted many followers l5 . 28 who, like himself, made modifications of his procedures, many of whom gave up the window approach to the arytenoid and adopted a posterior approach.19. 20. 26. 27 Kelly thought that the arytenoidectomy more successfully permitted movement of the cord into the abductor position and provided more space in the larynx. He found it necessary to suture the cord laterally. It might be said that the original King and Kelly procedures have given way to extralaryngeal lateral transfixation of the vocal cord without or with arytenoidectomy. The most recent surgical approach to this problem is that advanced by Thorne1l21 in 1948, who described intralaryngeal arytenoidectomy. This method is now attracting followers1. 25 with their modifications of his operative procedure. Thornell himself has also instituted some modifications in his original work. 22-24 Edwards'3 excellent report is the most recent to come to my attention; he furnishes a very good bibliography. From this brief review it is apparent that there is no simple, easy, foolproof, satisfactory, trouble-free method of relieving the obstruction produced by bilateral paralysis of the recurrent laryngeal nerves even though a tremendous effort has been expended on this problem, and surely new methods are yet to come. All too frequently there are technical difficulties. and the possibility of unsatisfactory results. Were this not true, variations, modifications and the multiple methods used would seem quite unnecessary. A review of the problem reveals that some good results may be obtained by almost any of these methods. Some procedures may be technically easier than others and one method may not be equally satisfactory in the hands of different experienced operators. When there is no unanimity of opinion among the old experienced operators and with such a diversified array of methods and modifications, the young laryngologist may find it difficult to select the best method to follow.
Paralysis of Recurrent Laryngeal Nerves
883
At the Lahey Clinic, some consideration is given the patient's occupation and desires in the matter. Those patients who value the voice most highly might do well to leave the vocal cords undisturbed and continue with a Tucker valve tracheotomy tube, and we occasionally advise this. In the young and vigorous patient who exercises strenuously and in whom the quality of the. voice is not of such great importance, a wide airway is demanded and can be achieved by the wide lateral displacement of the vocal cords by either the modified King or modified Kelly procedure, that is, without or with arytenoidectomy, or by submucous resection of the vocal cord. More sedentary patients may do well with much less space, and in such cases the voice in many instances will be better. In the clinic, tracheotomy, submucous resection of the vocal cord and lateral suture of the vocal cord with partial arytenoidectomy have been employed, with relief of obstruction resulting from bilateral recurrent nerve paralysis. At least one eversion has occurred in my experience in trying to rectify failures in cases in which bilateral arytenoidectomy had been done elsewhere. In these cases there was collapse of the laryngeal structures not only from each side but also anteroposteriorly. These patients have been especially difficult to decannulate. The arytenoids act somewhat as tent poles to hold the soft tissues of the larynx in position. I would be extremely cautious about removing both arytenoids, which permits such a collapse of the soft tissues over the glottis, and would advise against bilateral arytenoidectomy and employ another method in a case of failure from unilateral arytenoidectomy. SUMMARY
There is to date no function-restoring treatment for the paralyzed muscles secondary to paralysis of the recurrent laryngeal nerves. There is a variety of surgical methods which will in large part ameliorate the symptoms of obstruction, but with secondary impairment of the voice. None are foolproof, but most may be successful in a high percentage of cases when carefully executed. The best method may vary with the skill and experience of the operating surgeon and with the individual case. In the surgical treatment of laryngeal obstruction secondary to bilateral paralysis of the recurrent laryngeal nerves, careful consideration must be given to each patient. REFERENCES 1. Brown, L. A.: Intralaryngeal arytenoidectomy with observations in three
cases. Laryngoscope 61: 332-340 (Apr.) 1951. . 2. Clerf, L. H.: The surgical treatment of bilateral posticus paralysis of the larynx. Tr. Am. Laryng., Rhinol. & Otol. Soc., pp. 64-74, 1950. 3. Edwards, T. M.: Progress in the surgical treatment of bilateral laryngeal paralysis. Ann. Otol., Rhinol. & Laryng. 61: 158-178 (Mar.) 1952.
884
Walter B . Hoover
4. Hoover, W. B.: Bilateral abductor paralysis: Operative treatment by submucoUS resection of the vocal cord. Arch. Otolaryng. 15: 337-355 (Mar.) 1932. 5. Jackson, C. L.: Bilateral laryngeal paralysis. Postgrad. Med. 7: 430-432 (June) 1950. 6. Kelly, J. D.: Surgical treatment of bilateral paralysis of the abductor muscles of the larynx. Tr. Am. Acad. Ophth. 45: 133-149, 1940. 7. Kelly, J. D.: Surgical treatment of bilateral paralysis ot the abductor muscles. Arch. Otolaryng. 33: 293-304 (Feb.) 1941. 8. Kelly, J. D.: A supplementary report on extralaryngeal arytenoidectomy as a relief for bilateral abductor muscular paralysis of the larynx. Ann. Otol., Rhinol. & Laryng. 52: 628-636 (Sept.) 1943. 9. Kelly, J. D.: Some problems in the surgical treatment of bilateral abductor paralysis of the larynx. Ann. Otol., Rhinol. & Laryng. 53: 461-468 (Sept.) 1944. . 10. Kelly, J. D.: Surgery of the larynx in bilateral abductor paralysis. J.A.M.A. 134: 944-947 (July 12) 1947. 11. King, B. T.: A new and function-restoring operation for bilateral abductor cord paralysis: Preliminary report. J.A.M.A. 112: 814-823 (Mar. 4) 1939. 12. King, B. T.: A new and funC'.tion-restoring operation for bilateral abductor cord paralysis. Second report. J. Internat. CoIl. Surgeons 1: 223-232 (June) 1941. 13. King, B. T. and Gregg, R. L.: An anatomical reason for the various behaviors of paralyzed vocal cords. Ann. Otol., Rhinol. & Laryng. 57: 925-944 (Dec.) 1948. 14. Lahey, F. H. and Hoover, W. B.: Injuries to the recurrent laryngeal nerve in thyroid operations, their management and avoidance. Ann. Surg. 108: 545-562 (Oct.) 1938. 15. McCall, J. W. and Gardiner, F. S.: A simplified operation for bilateral abductor paralysis. Laryngoscope 53: 307-311 (May) 1943. 16. Meurman, Y.: Operative mediofixation of the vocal cord in complete unilateral paralysis. Arch. Otolaryng. 55: 544-553 (May) 1952. 17. Morrison, L. F.: Bilateral paralysis of the abductor muscles of the larynx. Arch. Otol. 37: 54-61 (Jan.) 1943. 18. Morrison, L. F.: Further observations on the King operation for bilateral abductor paralysis. Ann. Otol., Rhinol. & Laryng. 54: 390-408 (June) 1945. 19. Orton, H. B.: Surgical approach for arytenoidectomy in bilateral abductor paralysis of the larynx. Laryngoscope 53: 709-716 (Nov.) 1943. 20. Orton, H. B.: Extralaryngeal surgical approach for arytenoidectomy. Bilateral abductor paralysis of the larynx. Ann. Otol., Rhinol. & Laryng. 53: 303-307 (June) 1944. 21. Thornell, W. C.: Intralaryngeal approach for arytenoidectomy in bilateral abductor paralysis of the vocal cords. A preliminary report. Arch. Otolaryng. 47: 505-508 (Apr.) 1948. 22. Thornell, W. C.: Intralaryngeal approach for arytenoidectomy in bilateral abductor vocal cord paralysis. Tr. Am. Acad. Ophth. 53: 631-636 (JulyAug.) 1949. 23. Thornell, W. C.: A new intralaryngeal approach in arytenoidectomy in bilateral abductor paralysis of the vocal cords: Report of three cases. Arch. Otolaryng. 50: 634-639 (Nov.) 1949. 240. Thornell, W. C.: A new intralaryngeal approach for arytenoidectomy in the treatment of bilateral abductor vocal cord paralysis. J. Clin. Endocrinol. 10: 1118-1125 (Sept.) 1950. 25. Von Leden, H.: Intralaryngeal correction of bilateral abductor paralysis: A modification of the Thornell operation. Laryngoscope 60: 1190-1200 (Dec.) 1950.
Paralysis of Recurrent Laryngeal Nerves
885
26. Woodman, DeG.: A modification of the extralaryngeal approach to arytenoid,.)' ectomyforbilateralabductor paralysis. Arch. Otolaryng. 43: 63-65 (Jan.) I 1946. 27. Woodman, DeG.: Rehabilitation of the larynx in cases of bilateral abductor paralysis. Open approach to arytenoidectomy, with report of the past four years' experience. Arch. Otolaryng. 50: 91-96 (July) 1949. 28. Wright, E. S.: The Kelly operation for restoration of laryngeal function following bilateral paralysis of the vocal cords: Report of three cases. Ann. Otol., Rhinol. & Laryng. 52: 346-358 (June) 1943.
THE medical department of the Lahey Clinic is alert to the possibilities of disease associated with hoarseness. Many laryngeal examinations are carried out daily, and many patients with thyroid disease, with and without complications, are seen and treated. The subject of paralysis of the recurrent laryngeal nerve has been of primary importance at the clinic, and we have attempted to keep abreast of the literature on this subject and prevent this complication during thyroid surgery . Yet bilateral paralysis has occasionally occurred during a thyroid operation by the most experienced operator. Since attempts at restoration of function of the recurrent laryngeal nerve by direct suture, by graft and by anastomosis with other respiratory nerves have failed to restore function to the muscles supplied by it, surgical procedures of this character have been abandoned, but operative maneuvers have been devised for the relief of the symptoms produced by the loss of function of the muscles supplied by one or both recurrent laryngeal nerves. There is still no unanimity of opinion concerning the explanation for the clinical findings in cases of paralysis of a portion or more of the muscles supplied by the recurrent laryngeal nerves. King and Gregg,IS and Morrisonl7 • 18 recently have particularly emphasized the fact that the recurrent laryngeal nerve may divide well before its entrance into the larynx into branches which may control either the abductor or adductor muscles and they have emphasized the possibility of injury of one of the branches without the entire nerve being injured, thus explaining some of the controversial points associated with laryngeal paralysis. Clinically, unilateral paralysis of the recurrent laryngeal nerve may be considered an unfortunate incident in which there is often impairment of the voice. However, it may not be marked and after a lapse of 879
880
Walter B . Hoover
time the impaired voice may improve as the cords compensate by approximating each other in spite of the paralysis. Laryngeal obstruction has not been observed to occur from paralysis of one recurrent laryngeal nerve in an otherwise normal larynx. The voice impairment may persist due to lack of tension in the paralyzed cord and lack of approximation of the paralyzed cord with the normal vocal cord. Teachers, ministers and others who depend upon their speaking voice in their occupations find the impaired voice a marked handicap. Untreated bilateral paralysis of the recurrent laryngeal nerves leads to chronic invalidism, the resulting obstruction produces dyspnea and stridor of varying degrees, and may produce suffocation and death. Most patients with laryngeal obstruction from this cause have some dysphagia, and their activities are limited. They are particularly noisy during sleep, often disturbing the neighborhood. Any patient whose activities are limited by dyspnea from this cause should be relieved by a tracheotomy for a period of time up to eight months following thyroid surgery, or other specific treatment should be given if other causes are present, to permit the possible return of function of the nerve and the muscles it supplies. When recovery of function is considered hopeless, surgical treatment directed to the widening of the glottis is indicated unless the patient chooses to continue with the tracheotomy tube. When the tracheotomy tube is used for the relief of laryngeal obstruction resulting from paralysis of the recurrent laryngeal nerves, the Tucker valve tube is a distinct asset as it makes possible inspiration through the tracheotomy tube and expiration through the larynx. In most cases the speaking voice is excellent without the necessity of occluding the tracheotomy opening with the finger. It is to be noted here that in bilateral recurrent nerve paralysis with laryngeal obstruction the patient has no difficulty in expelling the air once it has been taken into the lungs. The obstruction is caused by the vocal cords being sucked together and lying in the midline during inspiration; often the greater the respiratory effort, the more complete becomes this valve action. No attempt will be made here to record all the possible etiologic factors that may produce paralysis of the recurrent laryngeal nerve. By far the most common cause of bilateral paralysis is trauma associated with surgical procedures on the thyroid gland. Dr. Lahey14 has particularly stressed its importance and the methods by which such injuries may be avoided, for the avoidance of such an injury is of the greatest value. In addition to the traumatic cases there are cases of congenital paralysis, paralysis due to neuritis and paralysis associated with disease of
Paralysis of Recurrent Laryngeal Nerves
881
the central nervous system. Neoplasms are a relatively common cause, especially those of the thyroid gland, upper esophagus and those encroaching on the upper thoracic strait. Traumatic accidents otlier than those during operation are occasional causes and there may be a combination of lesions which may affect the laryngeal nerve of either side, in any location, from the brain stem to the arch of the aorta. In cases in which comprehensive examination fails to reveal the possible cause for paralysis of the recurrent laryngeal nerve, the condition is termed idiopathic. The diagnosis of unilateral and bilateral paralysis of recurrent laryngeal nerves can usually be made by examination with the laryngeal mirror. However, to test the mobility of the arytenoid cartilages it is necessary to use instrumentation. The direct method is more satisfactory in my hands. On some occasions when the paralysis has existed for a considerable period of time, the arytenoid may become fixed or an" kylosed. The surgical treatment of unilateral paralysis of the recurrent laryngeal nerve is for voice improvement only, that is, to bring the vocal cords together with greater tension. The procedure consists of implantation of a piece of rib cartilage of proper size and shape underneath the wing of the thyroid cartilage, wedging the vocal cord toward the midline and the arytenoid posteriorly. Meurman,16 of Finland, reported 15 patients operated on by this method with quite satisfactory improvement in voice. The surgical treatment of bilateral paralysis of the recurrent laryngeal nerves is directed primarily to the relief of the laryngeal obstruction as in practically all such instances when obstruction is present the vocal cords are found together and the voice is of good quality, if enough air can be inspired with which to speak. In some cases there is sufficient airway for ordinary respiration in the sedentary state. There is a variety of surgical methods for the relief of the obstruction associated with bilateral paralysis of recurrent nerves. These procedures only ameliorate the condition, they do not correct it, for there is no function-restoring operation at this time. It is paradoxical that any surgical procedure that separates the vocal cord-s sufficiently for adequate respiration during strenuous exercise markedly decreases their efficiency for phonation. Such matters should be discussed with the patient before operation. In 1932, I reviewed the literature4 available at that time and presented a method of submucous resection of the vocal cord. This gave relief from the obstruction largely by preventing failures from secondary cicatricial contractures. A few failures resulted owing to infection and poor technique. Since the advent of antibiotics there have been no failures and it has remained a satisfactory procedure for the relief of the obstruction.
882
Walter B . Hoover
In some cases, a very satisfactory voice was acquired by the use of the false cords; in others the voice remained poor. In 1939, King'sll extralaryngeal operation and his enthusiasm gave great impetus and aroused further interest in the treatment of this condition. His method was soon modified by others and by himself12 and the King or modified King's method has been adopted by a number of otolaryngologists2. 5. 17. 18 and surgeons in treating the obstruction produced by bilateral paralysis of the recurrent laryngeal nerves. The main points in the operation were the freeing of the arytenoid from its fellow on the opposite side by severing the interarytenoid muscle, the disarticulation of the joint and the fixation of the arytenoid with its attached vocal cord laterally by permanent suture to the ala of the thyroid cartilage. In 1940, Kelly6 described an extralaryngeal arytenoidectomy through a window in the thyroid cartilage. Kelly7-10 also was an enthusiastic and persistent worker in this field. Through his enthusiasm he attracted many followers l5 . 28 who, like himself, made modifications of his procedures, many of whom gave up the window approach to the arytenoid and adopted a posterior approach.19. 20. 26. 27 Kelly thought that the arytenoidectomy more successfully permitted movement of the cord into the abductor position and provided more space in the larynx. He found it necessary to suture the cord laterally. It might be said that the original King and Kelly procedures have given way to extralaryngeal lateral transfixation of the vocal cord without or with arytenoidectomy. The most recent surgical approach to this problem is that advanced by Thorne1l21 in 1948, who described intralaryngeal arytenoidectomy. This method is now attracting followers1. 25 with their modifications of his operative procedure. Thornell himself has also instituted some modifications in his original work. 22-24 Edwards'3 excellent report is the most recent to come to my attention; he furnishes a very good bibliography. From this brief review it is apparent that there is no simple, easy, foolproof, satisfactory, trouble-free method of relieving the obstruction produced by bilateral paralysis of the recurrent laryngeal nerves even though a tremendous effort has been expended on this problem, and surely new methods are yet to come. All too frequently there are technical difficulties. and the possibility of unsatisfactory results. Were this not true, variations, modifications and the multiple methods used would seem quite unnecessary. A review of the problem reveals that some good results may be obtained by almost any of these methods. Some procedures may be technically easier than others and one method may not be equally satisfactory in the hands of different experienced operators. When there is no unanimity of opinion among the old experienced operators and with such a diversified array of methods and modifications, the young laryngologist may find it difficult to select the best method to follow.
Paralysis of Recurrent Laryngeal Nerves
883
At the Lahey Clinic, some consideration is given the patient's occupation and desires in the matter. Those patients who value the voice most highly might do well to leave the vocal cords undisturbed and continue with a Tucker valve tracheotomy tube, and we occasionally advise this. In the young and vigorous patient who exercises strenuously and in whom the quality of the. voice is not of such great importance, a wide airway is demanded and can be achieved by the wide lateral displacement of the vocal cords by either the modified King or modified Kelly procedure, that is, without or with arytenoidectomy, or by submucous resection of the vocal cord. More sedentary patients may do well with much less space, and in such cases the voice in many instances will be better. In the clinic, tracheotomy, submucous resection of the vocal cord and lateral suture of the vocal cord with partial arytenoidectomy have been employed, with relief of obstruction resulting from bilateral recurrent nerve paralysis. At least one eversion has occurred in my experience in trying to rectify failures in cases in which bilateral arytenoidectomy had been done elsewhere. In these cases there was collapse of the laryngeal structures not only from each side but also anteroposteriorly. These patients have been especially difficult to decannulate. The arytenoids act somewhat as tent poles to hold the soft tissues of the larynx in position. I would be extremely cautious about removing both arytenoids, which permits such a collapse of the soft tissues over the glottis, and would advise against bilateral arytenoidectomy and employ another method in a case of failure from unilateral arytenoidectomy. SUMMARY
There is to date no function-restoring treatment for the paralyzed muscles secondary to paralysis of the recurrent laryngeal nerves. There is a variety of surgical methods which will in large part ameliorate the symptoms of obstruction, but with secondary impairment of the voice. None are foolproof, but most may be successful in a high percentage of cases when carefully executed. The best method may vary with the skill and experience of the operating surgeon and with the individual case. In the surgical treatment of laryngeal obstruction secondary to bilateral paralysis of the recurrent laryngeal nerves, careful consideration must be given to each patient. REFERENCES 1. Brown, L. A.: Intralaryngeal arytenoidectomy with observations in three
cases. Laryngoscope 61: 332-340 (Apr.) 1951. . 2. Clerf, L. H.: The surgical treatment of bilateral posticus paralysis of the larynx. Tr. Am. Laryng., Rhinol. & Otol. Soc., pp. 64-74, 1950. 3. Edwards, T. M.: Progress in the surgical treatment of bilateral laryngeal paralysis. Ann. Otol., Rhinol. & Laryng. 61: 158-178 (Mar.) 1952.
884
Walter B . Hoover
4. Hoover, W. B.: Bilateral abductor paralysis: Operative treatment by submucoUS resection of the vocal cord. Arch. Otolaryng. 15: 337-355 (Mar.) 1932. 5. Jackson, C. L.: Bilateral laryngeal paralysis. Postgrad. Med. 7: 430-432 (June) 1950. 6. Kelly, J. D.: Surgical treatment of bilateral paralysis of the abductor muscles of the larynx. Tr. Am. Acad. Ophth. 45: 133-149, 1940. 7. Kelly, J. D.: Surgical treatment of bilateral paralysis ot the abductor muscles. Arch. Otolaryng. 33: 293-304 (Feb.) 1941. 8. Kelly, J. D.: A supplementary report on extralaryngeal arytenoidectomy as a relief for bilateral abductor muscular paralysis of the larynx. Ann. Otol., Rhinol. & Laryng. 52: 628-636 (Sept.) 1943. 9. Kelly, J. D.: Some problems in the surgical treatment of bilateral abductor paralysis of the larynx. Ann. Otol., Rhinol. & Laryng. 53: 461-468 (Sept.) 1944. . 10. Kelly, J. D.: Surgery of the larynx in bilateral abductor paralysis. J.A.M.A. 134: 944-947 (July 12) 1947. 11. King, B. T.: A new and function-restoring operation for bilateral abductor cord paralysis: Preliminary report. J.A.M.A. 112: 814-823 (Mar. 4) 1939. 12. King, B. T.: A new and funC'.tion-restoring operation for bilateral abductor cord paralysis. Second report. J. Internat. CoIl. Surgeons 1: 223-232 (June) 1941. 13. King, B. T. and Gregg, R. L.: An anatomical reason for the various behaviors of paralyzed vocal cords. Ann. Otol., Rhinol. & Laryng. 57: 925-944 (Dec.) 1948. 14. Lahey, F. H. and Hoover, W. B.: Injuries to the recurrent laryngeal nerve in thyroid operations, their management and avoidance. Ann. Surg. 108: 545-562 (Oct.) 1938. 15. McCall, J. W. and Gardiner, F. S.: A simplified operation for bilateral abductor paralysis. Laryngoscope 53: 307-311 (May) 1943. 16. Meurman, Y.: Operative mediofixation of the vocal cord in complete unilateral paralysis. Arch. Otolaryng. 55: 544-553 (May) 1952. 17. Morrison, L. F.: Bilateral paralysis of the abductor muscles of the larynx. Arch. Otol. 37: 54-61 (Jan.) 1943. 18. Morrison, L. F.: Further observations on the King operation for bilateral abductor paralysis. Ann. Otol., Rhinol. & Laryng. 54: 390-408 (June) 1945. 19. Orton, H. B.: Surgical approach for arytenoidectomy in bilateral abductor paralysis of the larynx. Laryngoscope 53: 709-716 (Nov.) 1943. 20. Orton, H. B.: Extralaryngeal surgical approach for arytenoidectomy. Bilateral abductor paralysis of the larynx. Ann. Otol., Rhinol. & Laryng. 53: 303-307 (June) 1944. 21. Thornell, W. C.: Intralaryngeal approach for arytenoidectomy in bilateral abductor paralysis of the vocal cords. A preliminary report. Arch. Otolaryng. 47: 505-508 (Apr.) 1948. 22. Thornell, W. C.: Intralaryngeal approach for arytenoidectomy in bilateral abductor vocal cord paralysis. Tr. Am. Acad. Ophth. 53: 631-636 (JulyAug.) 1949. 23. Thornell, W. C.: A new intralaryngeal approach in arytenoidectomy in bilateral abductor paralysis of the vocal cords: Report of three cases. Arch. Otolaryng. 50: 634-639 (Nov.) 1949. 240. Thornell, W. C.: A new intralaryngeal approach for arytenoidectomy in the treatment of bilateral abductor vocal cord paralysis. J. Clin. Endocrinol. 10: 1118-1125 (Sept.) 1950. 25. Von Leden, H.: Intralaryngeal correction of bilateral abductor paralysis: A modification of the Thornell operation. Laryngoscope 60: 1190-1200 (Dec.) 1950.
Paralysis of Recurrent Laryngeal Nerves
885
26. Woodman, DeG.: A modification of the extralaryngeal approach to arytenoid,.)' ectomyforbilateralabductor paralysis. Arch. Otolaryng. 43: 63-65 (Jan.) I 1946. 27. Woodman, DeG.: Rehabilitation of the larynx in cases of bilateral abductor paralysis. Open approach to arytenoidectomy, with report of the past four years' experience. Arch. Otolaryng. 50: 91-96 (July) 1949. 28. Wright, E. S.: The Kelly operation for restoration of laryngeal function following bilateral paralysis of the vocal cords: Report of three cases. Ann. Otol., Rhinol. & Laryng. 52: 346-358 (June) 1943.