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Etiology
Bilateral Vocal Fold
 BVFP PGS / CA joint fixation
Immobility: managing a  Surgical = 55-83%  Intubation = 78%
difficult issue  Up to 90% of these
related to thyroid surgery
Short-term = 9%
Long-term = 69%
 Malignancy = 9-10%  Wegener’s granulomatosis
 Intubation = 3-10% = 9%
C. Blake Simpson MD
Director, University of Texas Voice Center  Neurologic = 4-7%  RA= 6%
 Idiopathic = 8%  Caustic ingestion= 3%
VyVy N. Young MD  Previous laryngeal surgery
University of Pittsburgh Voice Center = 3%

Rosenthal LHS et al. Laryngoscope. 2007; 117:1864-70

Eckel HE et al. Ann Otol Rhinol Laryngol; 2003; 112: 103-8
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Physical exam pearls for BVFI Work up

 Detailed fiberoptic laryngoscopy  Labs = no “shotgunning”
 Record exam  Imaging
 Local anesthetic  Unexplained/idiopathic BVFI = MRI (brain/skull
 Important evaluations base down to chest)
 “eeee-sniff”  Consults (neuro)
 Vegetative tasks (cough/throat clear/sniff)  Parkinson’s plus syndromes (MSA, Shy-Drager,
 Interarytenoid space PSP)
 Beware: Bernoulli effect, PVFMD,  ALS, Guillain-Barre, MG, CMT

malingering
 Examine interarytenoid space
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Laryngeal electromyography Palpation of CA joint

 TA and CT muscles  Evaluate:
+/- PCA  Degree of effort required
 Differentiates neuro  Speed of recoil
vs mechanical  Effect on contralateral arytenoid
 Identifies synkinesis  Performed in OR or office
 Prognostic  Large cup forceps vs Abrams
cannula
information
Phonation Sniff

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You Can’t Have Your Cake

Management of BVFI and Eat it, Too Voice
 Temporizing Permanent
 Tracheostomy  Transverse
 Suture lateralization cordotomy
 Botox injection  Arytenoid surgery
Partial
Total
 Laser excision of
PGS
 Tracheostomy
 Laryngeal pacing
Airway
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Management of BVFI Temporary/temporizing

treatment options for BVFP
 Which surgical treatment is best?
 Description of technique  Tracheostomy
 Evidence-based outcomes comparison  Botulinum toxin (Botox)
○ Most studies = BVFP (not PGS)
 Suture lateralization
 Options:
 Temporary/Temporizing
 Permanent

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Botulinum toxin
Tracheostomy
 2.5U bilateral TA/LCA complex
 Acute setting  LEMG-guided
 Secures airway  Theory: block inappropriate reinnervation
 No “bridges burned” (synkinesis)
 Buys time  Unopposed PCA
 Diagnostic testing  Disadvantages
 Neural recovery – return VF motion  Marginal airway improvement
 Voice conserved  Requires repeat/serial injections
 Need to wait 3 months for synkinesis to
develop
Ekbom DC et al. Laryngoscope 2010; 120;758-763
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Suture lateralization Suture lateralization

 Temporizing  Pros Cons
 Iatrogenic injury with good  May avoid trach  Hoarseness to be

prognosis  Can be unilat or bilat expected

 Minimally invasive  May leave notch
 Apply unilaterally/bilaterally
 Reversible anterior to vocal
 More medialized side process
 Potentially adjustable
 2-0prolene
 Contraindication = recent
posterior glottic trauma from
ETT
Lichtenberger G et al. Laryngoscope 1997;107:1281–1283
Damrose EJ. Curr Opin Otolaryngol. 2011; 19:41-21
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Suture Lateralization Two sutures

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Permanent treatment options Glottal opening procedures

 Destructive

 Glottal opening procedures  Non-reversible

 Posterior transverse cordotomy  Endoscopic

 Arytenoidectomy
○ Medial  Posterior transverse cordotomy
○ Subtotal/Total
 Arytenoidectomy
 Excision of PGS
 Medial
 Flap tracheostomy  Subtotal/Total
 Laryngeal pacing  Excision of scar tissue in PGS
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Posterior transverse Posterior transverse

cordotomy cordotomy
 CO2 laser incision just anterior to vocal
process
 Extend far laterally (into FVF)
 Detach as much TA from arytenoid as possible
 TA retracts anteriorly
 Wedge shaped defect

Kashima HK. Ann Otol Rhinol Laryngol 1991;100:717–721

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Arytenoidectomy Medial arytenoidectomy

 CO2 laser removal  Currently, favored over total
 Medial arytenoidectomy
 Subtotal  CO2 laser
 Spares vocal process and
posterior commissure
mucosa

Ossoff RH et al. Laryngoscope 1984;94:1293–1297

Crumley RL. Ann Otol Rhinol Laryngol 1993;102:81–84
Crumley RL. Ann Otol Rhinol Laryngol. 1993;102:81-84
Remacle M et al. Ann Otol Rhinol Laryngol 1996;105:438–445
Bosley B et al. J Otol Rhinol Laryngol 2005;114:922-926
Bosley B et al. J Otol Rhinol Laryngol 2005;114:922-926
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Comparison: subtotal cordectomy and Comparison: transverse cordotomy

Arytenoidectomy and medial arytenoidectomy
 Prospective: 18 TC, 10 Arytenoidectomy  Retrospective: 11 TC, 6 MA
 Flow volume loops: equally improved  Airway improved in 87.5%
 Voice results comparable
 100% decannulation rate
 Subclinical aspiration by FEES
 No significant difference in vocal
 5/10 vs 0/18
outcomes
 Conclusions: equally effective and reliable but
TC faster and no aspiration  No post-op dysphagia/aspiration
 Conclusion: results nearly identical

Eckel HE et al. Ann Otol Rhinol Laryngol. 1994;103:852-7 Bosley B et al. J Otol Rhinol Laryngol 2005;114:922-926
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Posterior glottic stenosis (PGS) Treatment of PGS

 CO2 laser excision
 Division of isolated
interarytenoid synechiae1
 Posterior mucosal flap 2

1Meyer TK et al. Laryngoscope. 2011;121:2165-71

2Rosen CA, Simpson CB. Operative techniques in laryngology. Springer, 2008
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Laryngeal pacing Laryngeal pacing

 Implanted electrode in PCA 7 patients
 Paced Abduction of vocal fold  Allhad pre-existing tracheostomy
 Few animal and human studies  2/7 long-term reanimation of larynx
 Continues to be investigated  Periodic Botox to antagonize adductors
 Primarily animal studies recently  Problems:
 Electrode corrosion
 Sensor for pacing with respiratory effort

Zealear DL et al. Ann Otol Rhinol Laryngol. 1996;105:689-693

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Pre-operative considerations Pre-operative considerations

 To trach or not to trach?  Airway
 Impending airway compromise = YES! management  Pre-operative office
 Recent reports suggest that routine trach  Pre-existing trach laryngoscopy
before surgery not needed  Jet ventilation  Appropriate patient
 May be able to wait if very early time period  Hunsaker jet vent tube counseling
or in patient with mild-moderate symptoms  Laser-safe 5.0 MLT  Coordination/
tube communication with
 Anterior anesthesia team
 Posterior

Bosley B et al. Ann Otol Rhinol Laryngol 2005;114:922-926

Bajaj Y et al. J Laryngol Otol 2009;122:1348-1351.
Olthoff A et al. Ann Otol Rhinol Laryngol 2005;114:599-604
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Pre-operative considerations Pre-operative considerations

 Timing of surgery  Side of surgery
 Expected window VF motion return = 6-  LEMG-guided
12 mos ○ Least mobile side
 Initial use of temporizing method ○ Worse side on LEMG
 Avoid destructive procedure prior to this  Surgeon-handedness
 LEMG may be useful

 Extensive patient counseling

 Trade-off between airway and voice

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Peri-operative considerations Peri-operative considerations

 Use of Mitomycin-C  Adjunctive medical therapies
 Wound healing effects ○? inflammation
○ risk granuloma, granulation tissue, scar  Corticosteroids (IV/topical)
 Dosing: 0.4mg/mL  Antibiotics
 Still controversial:  Anti-reflux medications
○ Low vs high dose?  No clear data regarding dose or timing
○ Optimal duration of application?  Pre-op vs intra-op vs post-op
○ Single vs repeated application?

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Post-operative considerations Treatment for BVFP

Treatment Pros Cons
Trach Best airway/voice Patient acceptance
 Decannulation rate = 60-100% Limited airway
Botox Minimally invasive
 Timing varies improvement
2nd procedure to
 Complications Suture Minimally invasive
remove suture
lateralization Reversible
 Revision rate = 0-29% ?residual defect
 Post-operative airway distress = 0-11% Transverse Preservation of voice
Destructive
cordotomy Decr risk of aspiration
 Granuloma/granulation tissue = 4-27%
Arytenoidectomy Preservation of voice
Destructive
○ Most common cause for revision surgery Partial Decr risk of aspiration
 Dysphagia/aspiration = 0-22% Arytenoidectomy Aspiration
Preservation of voice
Total Destructive
Limited experience
Only dynamic
Laryngeal pacing Technically difficult
treatment option
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