The Immobile Vocal Fold: Paralysis vs. Fixation
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1 The Immobile Vocal Fold: Paralysis vs. Fixation DISCLOSURE Ted Mau, MD PhD Director UT Southwestern Voice Center I have nothing to disclose DALLAS, TEXAS OUTLINE Terminology Vocal Fold Paralysis vs. Fixation Unilateral Vocal Fold Immobility Assessment Bilateral Vocal Fold Immobility Assessment Outline Terminology A vocal fold that doesn t move is not necessarily paralyzed pa ral y sis loss or impairment of motor function due to lesion of the neural or muscular mechanism - Dorland s Medical Dictionary 1
2 Outline Causes of Vocal Fold Immobility Outline Causes of Vocal Fold Immobility RLN/vagal dysfunction Posterior glottic stenosis Cricoarytenoid joint subluxation RARE Tumor involvement of CA joint RARE Outline Causes of Vocal Fold Immobility Outline Paralysis vs. Fixation Options for a fixed vocal fold are much more limited than options for a paralyzed vocal fold. RLN/vagal dysfunction Posterior glottic stenosis CA joint subluxation Tumor Correct diagnosis in the clinic leads to better prognostic assessment, patient counseling, and surgical planning. Most cases of bilateral immobility are due to scarring/fixation rather than paralysis. VF has passive mobility VF is fixed 2
3 The Immobile Vocal Fold Outline UNILATERAL VF Immobility Paralysis Immobility Fixation How to distinguish the two possibilities? (short of palpation under anesthesia) HISTORY Onset of voice change coinciding with neck or chest surgery in the vicinity of the course of the RLN or CN X, or non-surgical trauma to the same areas; surgery or non-surgical trauma to the skull base or brainstem; URI intubation* Suggestive of paralysis Unilateral vocal fold immobility following intubation for elective surgery Is it paralysis or CA joint subluxation/fixation? CA joint subluxation/dislocation is exceedingly rare from routine intubation, based on Simulated intubation in cadaveric larynges 1 Clinical experience There is a finite incidence of intubationassociated RLN dysfunction % in large series of elective intubations 2,3 Outline UNILATERAL VF Immobility CLINICAL LARYNGOSCOPY Flexible laryngoscopy with continuous (not strobe) light Look for more than just anatomy or position An overhanging arytenoid does NOT mean subluxation/dislocation 1 1. Friedman et al. Ann ORL 121:746 (2012) 2. Sariego J. J Voice 24:110 (2010) 3. Hsu & Hao AAO-HNS 1. Blitzer et al. Ann ORL (1996)105:
4 Outline The Dynamic Laryngoscopic Exam Outline The Jostle Sign Elicit glottal tasks to test rapid motion with maximal ABDUCTION Laugh/chuckle Whistle Alternating /i/-sniff Look for passive movement of the immobile arytenoid/tvf Meyer et al. (2007) in Textbook of Laryngology (pp ) Outline Interarytenoid Release Options for Unilateral VF Paralysis Isshiki Chhetri & Blumin Reinnervation Medialization Zeitels Arytenoid Repositioning 4
5 Options for Unilateral VF Fixation Outline BILATERAL VF Immobility? BVF Paralysis Posterior glottic stenosis Outline BILATERAL VF Immobility Outline The Normal Cartilaginous Glottis HISTORY 28 patients with PGS 26 patients with BVFP 89% 11% 19% 81% Intubation Neck/chest surgery What to look for in office laryngoscopy: The vocal processes The pink triangle Normal posterior commissure mucosa vs. scar Anterior-posterior length of the cartilaginous glottis Shape/contour of posterior commissure (in OR) Cohen et al. Ann ORL (2006) 115:
6 Outline The Normal Cartilaginous Glottis Outline Normal Posterior Commissure Vocal process Vocal process Pink triangle Pink triangle U-shaped Outline The Posterior Commissure Exam Outline Clinic Laryngoscopy Apply adequate local anesthesia with 4% lidocaine to the glottis: Repeated nasal spray with inspiration Shallow huff-n-puff Abraham cannula Channeled flexible laryngoscope 6
7 Outline Posterior Glottic Stenosis Outline Bilateral Vocal Fold Paralysis Outline Bilateral Vocal Fold Paralysis Outline Direct Laryngoscopy with Magnification Vocal processes are well-defined Pink triangles are visible Appropriate length of the cartilaginous glottis False vocal folds are bowed, with showing of the ventricular floor U-shaped V-shaped 7
8 Options for Bilateral VF Paralysis Options for Posterior Glottic Stenosis Bilateral adductor BOTOX injections Bilateral adductor BOTOX injections Partial submucosal medial arytenoidectomy Partial submucosal medial arytenoidectomy Suture lateralization Posterior transverse cordotomy Cordotomy with medial arytenoidectomy Total arytenoidectomy Tracheotomy PCA reinnervation Laryngeal pacer (experimental) Suture lateralization with partial arytenoidectomy Posterior transverse cordotomy Cordotomy with medial arytenoidectomy Total arytenoidectomy Tracheotomy PCA reinnervation Laryngeal pacer (experimental) Laryngeal EMG Take Home Points Fibrillation potentials Positive sharp waves Polyphasic potentials Recent or ongoing denervation Reinnervation Make the distinction between paralysis and fixation. Do a dynamic laryngoscopic exam in clinic. Unilateral VF immobility: Look for passive movement Presence/Absence of voluntary motor units Degree of recruitment Hillel & Robinson. In Vocal Fold Paralysis, Sulica & Blitzer Eds (2005). Sulica & Blitzer. In Vocal Fold Paralysis, Sulica & Blitzer Eds (2005) Sulica, Blitzer, Meyer. In Diagnosis and Treatment of Voice Disorders, Rubin et al. Eds. (2006) Bilateral VF immobility: Close inspection of the posterior commissure 8
9 Outline Good References Outline Contact Information Unilateral Vocal Fold Immobility Courey MS. Perspectives on Voice and Voice Disorders (2012) 22: ASHA Special Interest Group 3. Bilateral Vocal Fold Immobility Cohen et al. Ann Oto Rhino Laryngol (2006) 115: UT Southwestern Voice Center Dallas, Texas 9
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