Functional results of endoscopic arytenoid abduction lateropexy for bilateral vocal fold palsy.

PURPOSE: Endoscopic arytenoid abduction lateropexy (EAAL) is a reliable surgical solution for the minimally invasive treatment of bilateral vocal fold palsy (BVFP), providing a stable airway by the lateralization of the arytenoid cartilages with a simple suture. The nondestructive manner of the intervention theoretically leads to higher regeneration potential, thus better voice quality. The study aimed to investigate the respiratory and phonatory outcomes of this treatment concept. METHODS: 61 BVFP patients with significant dyspnea associated with thyroid/parathyroid surgery were treated by unilateral EAAL. Jitter, Shimmer, Harmonics to Noise Ratio, Maximum Phonation Time, Fundamental frequency, Voice Handicap Index, Dysphonia Severity Index, Friedrich's Dysphonia Index, Global-Roughness-Breathiness scale, Quality of Life, and Peak Inspiratory Flow were evaluated 18 months after EAAL. RESULTS: All patients had a stable and adequate airway during the follow-up. Ten patients (16.4%) experienced complete bilateral motion recovery with objective acoustic parameters in the physiological ranges. Most functional results of the 13 patients (21.3%) with unilateral recovery also reached the normal values. Fifteen patients (24.6%) had unilateral adduction recovery only, with slightly impaired voice quality. Eleven patients (18.0%) had false vocal fold phonation with socially acceptable voice. In 12 patients (19.7%) no significant motion recovery was detected on the glottic level. CONCLUSION: EAAL does not interfere with the potential regeneration process and meets the most important phoniatric requirements while guaranteeing the reversibility of the procedure-therefore serving patients with transient palsy. Further, a socially acceptable voice quality and an adequate airway are ensured even in cases of permanent bilateral vocal fold paralysis.

Glottic configuration changes and outcomes of endoscopic arytenoid abduction lateropexy.

INTRODUCTION: Endoscopic arytenoid abduction lateropexy (EAAL) is an effective glottis enlarging procedure for the treatment of bilateral vocal cord palsy (BVCP). The postoperative glottic configuration changes can be evaluated by modern, high-resolution, 3D image reconstructions. Functional results are described by spirometry as well as objective and subjective phoniatric tests. METHODS: Unilateral EAAL was performed in ten malignant thyroid gland tumor patients (eight women, two men), who had BVCP after thyroid surgery. Slicer 3D® software was used for morphometric analysis. Pre- and postoperative peak inspiratory flow (PIF) and standard phoniatric parameters were compared. RESULTS: The glottic gap improved significantly (+ 60%). Significant improvement of PIF was found in all cases. Phoniatric tests revealed better quality of voice and patient satisfaction. Their voices changed from a severely impaired to a socially acceptable, almost normal, quality. CONCLUSION: The results support our clinical observations that the ideal position of the lateralization sutures is the one which provides a physiological abduction position of the arytenoid cartilage. Considering these good results, the surgical indications for minimally invasive endoscopic arytenoid lateropexy may be extended.

[Phoniatric outcomes of endoscopic arytenoid abduction lateropexy in patients with transient bilateral vocal cord paralysis]. / Endoszkópos arytaenoid abdukciós lateropexia foniátriai eredményei átmeneti kétoldali gégebénulás esetén.

INTRODUCTION: Dyspnea caused by bilateral vocal cord paralysis often requires surgical intervention to prevent acute asphyxiation. The regeneration of the laryngeal nerves may last weeks or months and it is difficult to predict the outcome. In the past decades, several open and endoscopic surgical techniques have been introduced for treatment to avoid tracheostomy, however, these procedures with resection of the glottis resulted in irreversible changes in the laryngeal structure, thus the voice quality decreased over a long-term period. AIM: Endoscopic arytenoid abduction lateropexy is an accepted reversible, minimally invasive technique that provides an immediate patent airway by the lateralisation of the arytenoid cartilage with a suture. The aim of our study was to analyze the phonatory and respiratory outcomes of this treatment concept. METHOD: Two patients suffering from bilateral vocal cord palsy were treated with endoscopic arytenoid abduction lateropexy. After recovery of the vocal cord movements, the sutures were removed. Spirometric and phoniatric results of the two patients were analysed after suture removal. RESULTS: Good spirometric parameters and normal voice quality were detected in both cases. CONCLUSIONS: These results prove the high reversibility of the minimally invasive endoscopic arytenoid abduction lateropexy. Lateralization suture can be removed in the case of vocal cord movement recovery, and phonation may be physiological. Orv Hetil. 2018; 159(29): 1188-1192.

Functional outcomes of endoscopic arytenoid abduction lateropexy for unilateral vocal cord paralysis with dyspnea.

In unilateral vocal cord paralysis (UVCP), hoarseness is usually the leading symptom; however, the diminished airway might lead to breathing problems as well, especially with exertion. The application of the classic resection glottis enlarging or medialization procedures might shift the breathing and/or the voice to a worse condition. The non-destructive endoscopic arytenoid abduction lateropexy (EAAL) might be a solution for this problem. The aim of our study was to analyze the phonatory and respiratory outcomes of this treatment concept. The first year phoniatric [Jitter, Shimmer, harmonics-to-noise ratio (HNR), maximum phonation time (MPT), fundamental frequency (F 0), Voice Handicap Index (VHI), Dysphonia Severity Index (DSI), Global-Roughness-Breathiness scale (GRB)], peak inspiratory flow (PIF), and quality of life (QoL) were evaluated in ten UVCP patients treated by EAAL for dyspnea generally presented on exertion. PIF, Jitter, QoL, GRB, and VHI significantly improved. DSI, HNR, and MPT got non-significantly better. F 0 slightly increased in all patients, a mild deterioration of shimmer was observed. These results prove that improving respiratory function is not necessarily associated with a deterioration in voice quality. The EAAL provides a significant improvement in breathing and the vibratory parameters of the postoperative, more tensed and straightened vocal cords proved to be more advantageous than the original (para) median 'loose' position. The over-adduction of the contralateral side more or less compensates for the disadvantageous, more lateral position of the operated side. EAAL might be an alternative treatment for unilateral vocal cord paralysis associated with breathing problems.

[New method for measuring the cortical auditory evoked potentials: the HEARLab]. / Új lehetoség az akusztikusan kiváltott corticalis válaszok mérésére: a HEARLab.

INTRODUCTION: Cortical auditory evoked potentials can provide objective information about the highest level of the auditory system. AIM: The purpose of the authors was to introduce a new tool, the "HEARLab" which can be routinely used in clinical practice for the measurement of the cortical auditory evoked potentials. In addition, they wanted to establish standards of the analyzed parameters in subjects with normal hearing. METHOD: 25 adults with normal hearing were tested with speech stimuli, and frequency specific examinations were performed utilizing pure tone stimuli. RESULTS: The findings regarding the latency and amplitude analyses of the evoked potentials confirm previously published results of this novel method. CONCLUSIONS: The HEARLAb can be a great help when performance of the conventional audiological examinations is complicated. The examination can be performed in uncooperative subjects even in the presence of hearing aids. The test is frequency specific and does not require anesthesia.

Endoscopic arytenoid abduction lateropexy for the treatment of neonatal bilateral vocal cord paralysis - Long-term results.

OBJECTIVES: Bilateral vocal cord paralysis often causes severe dyspnea requiring an early airway intervention in neonates. Endoscopic arytenoid abduction lateropexy (EAAL) with suture is a quick, reversible, minimally-invasive vocal cord lateralizing technique to enlarge the glottis. The arytenoid cartilage is directly lateralized to a normal abducted position. It can be performed even in early childhood with the recently-introduced pediatric endoscopic thread guide instrument. The long-term results and the stability of the lateralization were evaluated. METHODS: Three newborns had inspiratory stridor immediately after birth. Laryngo-tracheoscopy revealed bilateral vocal cord paralysis. Unilateral, left-sided endoscopic arytenoid abduction lateropexy was performed with supraglottic jet ventilation. The follow-up period was >3 years. RESULTS: After extubation on the 4-7th postoperative day no dyspnea or swallowing disorder occurred. Laryngo-tracheoscopy, clinical growth charts and voice analysis showed satisfactory functional results. CONCLUSIONS: The endoscopic arytenoid abduction lateropexy might be a favorable solution for neonatal bilateral vocal cord paralysis. In one step, airway patency can be achieved without irreversible damage to the glottic structures. Normal swallowing function was preserved. The results are durable, and neither medialization nor dyspnea re-appeared during observation.

Isolated Recovery of Adductor Muscle Function Following Bilateral Recurrent Laryngeal Nerve Injuries.

OBJECTIVES/HYPOTHESIS: The aim of this study was to analyze the phoniatric and respiratory outcomes of a subset of bilateral vocal cord paralysis (BVCP) patients who were all treated with unilateral endoscopic arytenoid abduction lateropexy (EAAL). EAAL is a nondestructive, minimally invasive glottis widening operation, which does not damage either the surgically treated or the contralateral vocal cord. Therefore, it does not impair the regeneration potential of the recurrent laryngeal nerve. STUDY DESIGN: Case series. METHODS: Ten out of 21 BVCP patients who were treated with EAAL showed signs of isolated adduction recovery at 1 year and were chosen for this study. Functional results (objective and subjective voice analysis, spirometric measurement) and vocal cord movements were assessed preoperatively, 1 week and 1 year after EAAL. Laryngeal electromyography was performed on the 12th postoperative month. RESULTS: The volitional adductor movement seen on laryngoscopy was corroborated by laryngeal electromyography evaluation. Peak inspiratory flow increased significantly after EAAL. Quality-of-life scores also showed high patient satisfaction. Shimmer showed consistent improvement along with harmonic-to-noise ratio and average maximal phonation time in parallel with the improving vocal cord movement. Complex voice analysis and subjective self-evaluation tests also demonstrated significant improvement. CONCLUSIONS: EAAL, as a minimally invasive, nondestructive airway widening technique, does not interfere with the potential regeneration process that can still occur after BVCP, allowing for laryngeal functional recovery. It is a safe and effective treatment for BVCP that allows a simple solution with good phonatory, swallowing, and respiratory benefits by unilateral passive and reversible vocal cord lateralization. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2334-2340, 2019.

Minimally invasive endoscopic treatment for pediatric combined high grade stenosis as a laryngeal manifestation of epidermolysis bullosa.

Epidermolysis bullosa refers to a clinically and genetically heterogeneous group of inherited mucocutaneous diseases. Laryngotracheal lesions are momentous regarding the risk of sudden airway obstruction. The traditional treatment is tracheostomy. This case report highlights the advantages of minimally invasive interventions. A successful combined endoscopic management of a life-threatening respiratory crisis is presented in a 4-year-old child. Combined commissure stenosis with supraglottic spread was treated by CO2 laser dissection and bilateral endoscopic arytenoid abduction lateropexy, supplemented with mitomycin C application. Due to expectable less scarring, the combination of these modern methods may be an efficient solution in these vulnerable respiratory tracts.

Rotational thyrotracheopexy after cricoidectomy for low-grade laryngeal chrondrosarcoma.

OBJECTIVES: The complex laryngeal functions are fundamentally defined by the cricoid cartilage. Thus, lesions requiring subtotal or total resection of the cricoid cartilage commonly warrant total laryngectomy. However, from an oncological perspective, the resection of the cricoid cartilage would be an optimal solution in these cases. The poor functional results of the few reported cases of total and subtotal cricoidectomy with different reconstruction techniques confirm the need for new approaches to reconstruct the infrastructure of the larynx post cricoidectomy. STUDY DESIGN: Retrospective case series review. METHODS: Four consecutive patients with low-grade chondrosarcoma were treated by cricoidectomy with rotational thyrotracheopexy reconstruction to enable the functional creation of a complete cartilaginous ring that can substitute the functions of the cricoid cartilage. The glottic structures were stabilized with endoscopic arytenoid abduction lateropexy. Patients were evaluated with objective and subjective function tests. RESULTS: Tumor-free margins were proven; patients were successfully decannulated within 3 weeks. Voice outcomes were adequate for social conversation in all cases. Oral feeding was possible in three patients. CONCLUSION: Total and subtotal cricoidectomy can be a surgical option to avoid total laryngectomy in cases of large chondrosarcomas destroying the cricoid cartilage. The thyrotracheopexy rotational advancement technique enables the effective reconstruction of the structural deficit of the resected cricoid cartilage in cases of total and subtotal cricoidectomy. An adequate airway for breathing, swallowing, and voice production can be reconstructed with good oncological control. In cases where the pharynx is not involved, good swallowing function can also be achieved. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1109-1115, 2017.

A new solution for neonatal bilateral vocal cord paralysis: Endoscopic arytenoid abduction lateropexy.

OBJECTIVES/HYPOTHESIS: Bilateral vocal cord paralysis in early childhood is a life-threatening condition, which often requires immediate intervention. One of the treatment options is a quick, reversible simple suture vocal cord lateralizing technique, whereby the arytenoid cartilage is directly lateralized to the normal abducted position. Considering pediatric laryngeal anatomy, a small endolaryngeal thread guide instrument was designed for precise suture insertion. STUDY DESIGN: New instrument validation. METHODS: Four newborns had inspiratory stridor immediately after birth; two had to be intubated. Laryngotracheoscopy revealed bilateral vocal cord paralysis. Unilateral, left-sided endoscopic arytenoid abduction lateropexy was performed with supraglottic jet ventilation on the 4th, 5th, 5th, and 27th day of life for the four patients, respectively. RESULTS: All babies remained intubated for 3 to 7 days with an uncuffed tracheal tube. After extubation, no dyspnea or swallowing disorder occurred. A subjective quality of life questionnaire, laryngotracheoscopy, clinical growth charts, and voice analysis showed satisfactory functional results. CONCLUSIONS: Minimally invasive, quick, reversible endoscopic arytenoid abduction lateropexy might be a more favorable solution for neonatal bilateral vocal cord paralysis than earlier treatment strategies. In one step, the airway can be maintained without the risk of any permanent damage to voice production. Good swallowing function is also preserved. The specially modified endolaryngeal thread guide instrument gives a fast and effective option for creating the lateralized arytenoid position even in the technically challenging surgical context of a neonate larynx. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1608-1614, 2017.

A comparison between transoral glottis-widening techniques for bilateral vocal fold immobility.

OBJECTIVE: Comparison of different endoscopic glottis-widening procedures designed for bilateral vocal cord immobility (BVCI) is a challenge. This is because a statistically efficient analysis and comparable clinical series is hard to obtain considering the variable aspects of the results and the evaluation methods. This study of a large number of cadaver larynges provides comparable, objective data for the evaluation of the possible postoperative breathing and voicing function. STUDY DESIGN: A morphometric study was performed on 50 male and 50 female larynges to compare the different suture lateralization and resection procedures. METHODS: The postoperative characteristic of glottic configuration was evaluated following vocal cord laterofixation, endolaryngeal arytenoid abduction lateropexy (EAAL), Schobel's external lateralization procedure (SELP), transverse cordotomy (TC), and medial and total arytenoidectomies (AE). The glottic area and the parameters determining the phoniatric outcomes were assessed by a digital image analyzer program. RESULTS: Improvement of glottic area was observed after all procedures, but arytenoid abduction procedures were significantly the most effective. However, the smallest vocal cord angles were found in TC and AE; the injury of the voicing structures results in a deterioration of vocal mechanics and can be reasonably assumed to negatively influence the voice. Endolaryngeal arytenoid abduction lateropexy and SELP may provide the best phonation closure when residual adduction regeneration can occur. CONCLUSION: This study demonstrates the complexity of the correct surgical decision making in BVCI. Procedures that utilize physiological abduction of the arytenoid cartilage seem to be more advantageous, especially if recovery of adductor function occurs. LEVEL OF EVIDENCE: N/A.