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Bilateral Vocal Cord Paralysis

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by

Pedro Monteiro

on 5 March 2013

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Transcript of Bilateral Vocal Cord Paralysis

Vocal Cord Paralysis in the Newborn Pedro Monteiro VOCAL CORD INJECTION Improve Airway Aspiration Voice Quality and Volume SURGICAL DILEMMA STRIDOR IN NEWBORN UNILATERAL VOCAL CORD PARALYSIS BILATERAL VOCAL CORD PARALYSIS WATCHFUL WAIT SURGERY WATCHFUL WAIT SURGERY Laryngomalacia
Vocal Cord Paralysis
Congenital Subglottic Stenosis
Laryngocoele
Subglottic Cysts
Laryngeal Webs/Atresia
Subglottic Haemangioma
Laryngeal/Tracheal Clefts
Vascular Abnormalities (Double Aortic Arch) Less common in the newborn than BVCP
Often unnoticed
Hoarseness, breathy cry, feeding difficulty (+/- aspiration)

Aetiology:
Idiopathic
Birth trauma (RLN or Vagus injury)
Lesions in mediastinum (tumours or vascular malformations)
Iatrogenic (50%) - cardiovascular (PDA), oesophageal atresia (TOF) or neck surgery MANAGEMENT Often requires no treatment

May remain undiagnosed (natural improvement in voice occurs over time even when VC mobility does not)

Dietary recommendations:
eat on affected side
thickened fluids Tracheostomy: intractable aspiration/dyspnoea - 8%


VC medialisation: ONLY for older children/adolescents if failed ST
Injection
Reinnervation


Laryngeal Pacing? VOCAL CORD MEDIALISATION Injection:
Autologous fat
Human-derived materials (Cymetra collagen)
Non-resorbable material (silicone paste, teflon, calcium hydroxyapetite) should NOT be used in a growing larynx
Laryngeal framework surgery (thyroplasty Type I) - ADULTS


Reinnervation:
Described, not commonly used
Increase muscle tone
Ansa hypoglossal-RLN anastamosis
Nerve-muscle pedicle implantation into the lateral thyroarytenoid muscle MANAGEMENT >50% paediatric VCP
Inspiratory stridor (high pitched) - worsened on agitation
Near-normal phonation (cry)
Airway obstruction - respiratory distress (nasal flaring, supraclavicular/ intercostal recession, cyanosis)
Aspiration - chest infections


AETIOLOGY:
Stretch or compression on Vagus
Idiopathic
Birth trauma
Neuromuscular, Arnold-Chiari malformation II, CP, hydrocephalus, myelomeningocele, spina bifida, hypoxia, or intracerebral hemorrhage
Flexible +/- rigid endoscopy (other airway anomalies)

CT (mediastinum/neck), MRI (brain), USS (cranial)

Laryngeal EMG
distinguish between vocal cord fixation and paralysis
?predictive value for vocal cord recovery Urgent stabilisation of airway:
Intubation + MRI (Arnold-Chiari Type II with hydrocephalus - may improve with a shunt)

Tracheostomy:
>50% BVCP
>>50% in patients with co-morbidities/ neurological aetiology
50% of these patients will recovery spontaneously and be decannulated (1 - 2+ years) ? RESPIRATORY DISTRESS ? NO YES 50%

Especially if no other co-morbidity/ neurological abnormalities

Regular follow-up - airway/feeding/speech FURTHER DEFINITIVE SURGERY OPEN SURGICAL TECHNIQUES ENDOSCOPIC SURGICAL TECHNIQUES AVOID for as long as possible to allow for spontaneous recovery of cords

Consider if no recovery after 2 years (some argue longer)

Ideal intervention age = case-by-case decision
social environment
ability to care for trachy
communication skills Arytenoidopexy using lateral approach


Arytenoidectomy +/- lateralisation through larygofissure or lateral approach


Arytenoid separation by posterior cricoid split and cartilage grafting Surgeon's
Expertise CO2 laser arytenoidectomy

CO2 laser posterior cordotomy

Arytenoidopexy with the Lichtenberger needle-carrier

Posterior cricoid split with cartilage grafting WORKUP - VOCAL CORD PALSY Review article 2013: 16 articles, 69 patients (1950-2011)
Mean age @ diagnosis = 32 days
Fibreoptic endoscopy = 92%, Direct laryngoscopy = 87%, Both = 72%

9% concomitant airway malformations
54% underlying co-morbidities
59% tracheostomy
44% decannulated (mean age 14-15 months)
17% further laryngeal surgery AND FINALLY .... Most UVCP can be treated conservatively

BVCP is a rare but serious cause of airway obstruction in the newborn

Workup should include both flexible and rigid endoscopy + investigations for other co-morbidities

RULE OF 50'S:
50% Co-morbidities
50% require tracheostomy
50% of these decannulated (spontaneous recovery)

Wait at least 2 years before considering further surgical intervention - Then wait some more
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