Vocal Cord Cordotomy
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Endoscopic laser posterior cordotomy is performed in patients with bilateral vocal fold paralysis in adduction. [1] It is considered as an alternative procedure to tracheotomy. [2, 3, 4]
Laser cordectomy was first described in 1989 by Kashima. [5] In 1999, Friedman et al described the application of the cordotomy in children from 14 months to 13 years old. [6] The technique was effective and associated with good functional results. [2]
Surgical treatment for bilateral vocal fold paralysis should aim at a compromise between respiratory and phonatory performance and should be adjusted according to patient’s needs. [7, 8, 9]
An image depicting vocal cord cordotomy can be seen below.
The vocal folds, also known as vocal cords, are located within the larynx (also colloquially known as the voice box) at the top of the trachea. They are open during inhalation and come together to close during swallowing and phonation. When closed, the vocal folds may vibrate and modulate the expelled airflow from the lungs to produce speech and singing. For more information about the relevant anatomy, see Vocal Cord and Voice Box Anatomy.
Laser posterior cordotomy is a minimal invasive procedure done for the bilateral vocal fold paralysis in midline position. [2]
Surgical management to address bilateral vocal fold paralysis is generally undertaken in tracheotomy-dependent patients with a goal of decannulation. [10]
Endoscopic laser surgery is contraindicated if general anesthesia is a threat to the patient’s life, such as in the following cases:
Recent infarct
A patient with aneurysms
Bradycardia [11]
Endoscopic laser surgery is not possible in patients with the following:
Fracture of the cervical spine
Mandibular deformity
A patient with a short, thick neck associated with marked prognathism [11]
Relative contraindications for endolaryngeal laser surgery of vocal folds are persistent vocal fold edema and inflammation that cannot be resolved. [7]
Cordotomy has become a procedure of choice for the treatment of bilateral vocal fold paralysis for the following reasons: [2]
The procedure is short and reduces the time of anesthesia.
Cordotomy is quite easy to perform, and the technique is quickly acquired.
It can be proposed as an alternative to tracheotomy even at the time of diagnosis.
Cordotomy is considered as a minimal invasive procedure because functional results as swallowing and voice quality are good.
It can be proposed even if the patient later recovers spontaneously.
Vocal fold tissue is not significantly excised.
The cordotomy only frees the vocal ligament and the vocal muscle from the vocal process of the arytenoids. Tissue retraction enlarges the airway.
Because of the small size of the larynx in children, this procedure is often sufficient and safe.
Anesthesia
This procedure is performed under general anesthesia. In the absence of a pre-existing tracheotomy, a small laser-protected endotracheal tube is placed. If a tracheotomy is present, the patient is intubated via the stoma with a laser-safe endotracheal tube. [12]
Some authors recommend endoscopic carbon dioxide laser posterior cordotomy without tracheotomy, believing that the minimal postoperative edema does not compromise respiration. [7]
Antibiotics, steroids, and H2 blockers are given intraoperatively. [12]
Equipment
Various size laryngoscopes, including bivalve adjustable laryngoscopes
Two suction devices: one is mounted on to the operating microscope and the other suction is used by the surgeon to evacuate the plume and to manipulate the tissue
Microlaryngeal surgery instruments
Laser safe endotracheal tubes [13]
Carbon dioxide laser coupled to an operating microscope
KTP-532 laser can also be used [7, 14]
Positioning
The correct position is essential for the optimal introduction of laryngoscope. The patient should preferably lie horizontally flat on operating table, with neither head ring nor sand bag under the shoulders. The dental plate is put in place before the laryngoscope is introduced. [11]
See the list below:
The procedure begins with the orotracheal intubation with a laser-safe endotracheal tube. The patient’s eyes are then taped and padded and a head drape and upper tooth guard is applied. [15] When the patient is fully relaxed and sufficiently anaesthetized, the largest possible laryngoscope is introduced to get a good view of larynx. Once the laryngoscope is correctly positioned, the chest holder is put in place to fix the scope in position. After exact adjustment of the scope, both vocal cords can be seen as far as the apex of vocal process. When the laryngoscope is in the desired position, the light carrier is removed and an operating microscope is used. [11]
The patient’s head and face are protected with moist towels and the operating microscope, which is fitted with a microspot carbon dioxide laser and 400 mm lens, is brought into position. To protect the endotracheal tube cuff, a moist cottonoid sponge is placed in the subglottis. [15]
The site of cordotomy is determined at the preoperative examination or under spontaneous ventilation anesthesia. If one vocal fold seems to have a light degree of motion, the cordotomy is performed on the opposite side. Undercorrecting is better than risking the voice and vocal functions. When the first procedure is not sufficient, a second one is possible (cordotomy homolateral or contralateral), with a good result after this procedure. [2]
Carbon dioxide laser with 0.2 mm spot size and a power setting of 3-5 Watts is used. Using carbon dioxide laser, a cordotomy is performed 1-2 mm anterior to the vocal process. This is carried laterally through the width of the vocal ligament and the vocalis muscle to the thyroid lamina. The cordotomy both opens the air way posteriorly and provides access to the arytenoid cartilage. Postoperatively, patient is maintained on antibiotics and antireflux medications until mucosal healing is complete (see the images below). [12]
See the list below:
Anti-gastroesophageal reflux treatment is given for 8 weeks.
Oral antibiotic are given for 1 week.
Endoscopy should be performed 3 days after the procedure, when the KTP laser is used, in order to clean the fibrinous residues. When carbon dioxide laser is used, the follow-up is done using flexible endoscopes.
The resulting voice quality is fair to good, and most patients with tracheotomy can be decannulated within 6 weeks of the procedure once mucosal healing is complete. [2]
Complications are as follows: [7, 14]
Postoperative edema
Granuloma
Scar formation
Posterior glottic web
A rare but possible complication during endolaryngeal carbon dioxide laser surgery is ignition of the gas mixture within the airway, with involvement of the endotracheal tube. [16]
Basterra J, Castillo-Lopez Y, Reboll R, Zapater E, Olavarria C, Krause F, et al. Posterior cordotomy in bilateral vocal cord paralysis using monopolar microelectrodes and radiofrequency in 18 patient. Clin Otolaryngol. 2018 Feb. 43 (1):340-343. [Medline]. [Full Text].
Lagier A, Nicollas R, Sanjuan M, Benoit L, Triglia JM. Laser cordotomy for the treatment of bilateral vocal cord paralysis in infants. Int J Pediatr Otorhinolaryngol. 2009 Jan. 73(1):9-13. [Medline].
Oysu C, Toros SZ, Tepe-Karaca Ç, Sahin S, Sahin-Yilmaz A. Endoscopic posterior cordotomy with microdissection radiofrequency electrodes for bilateral vocal cord paralysis. Otolaryngol Head Neck Surg. 2014 Jan. 150(1):103-6. [Medline].
Li Y, Garrett G, Zealear D. Current Treatment Options for Bilateral Vocal Fold Paralysis: A State-of-the-Art Review. Clin Exp Otorhinolaryngol. 2017 Sep. 10 (3):203-212. [Medline]. [Full Text].
Dennis DP, Kashima H. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol. 1989 Dec. 98(12 Pt 1):930-4. [Medline].
Friedman EM, de Jong AL, Sulek M. Pediatric bilateral vocal fold immobility: the role of carbon dioxide laser posterior transverse partial cordectomy. Ann Otol Rhinol Laryngol. 2001 Aug. 110(8):723-8. [Medline].
Segas J, Stavroulakis P, Manolopoulos L, Yiotakis J, Adamopoulos G. Management of bilateral vocal fold paralysis: experience at the University of Athens. Otolaryngol Head Neck Surg. 2001 Jan. 124(1):68-71. [Medline].
Anand V, Kumaran BR, Chenniappan S. Cordoplasty: a new technique for managing bilateral vocal cord paralysis and its comparison with posterior cordotomy and external procedure in a large study group. Indian J Otolaryngol Head Neck Surg. 2015 Mar. 67:40-6. [Medline]. [Full Text].
Naunheim MR, Song PC, Franco RA, Alkire BC, Shrime MG. Surgical management of bilateral vocal fold paralysis: A cost-effectiveness comparison of two treatments. Laryngoscope. 2017 Mar. 127 (3):691-697. [Medline].
Brigger MT, Hartnick CJ. Surgery for pediatric vocal cord paralysis: a meta-analysis. Otolaryngol Head Neck Surg. 2002 Apr. 126(4):349-55. [Medline].
Kleinsasser O. Microlaryngoscopy and endolaryngeal microsurgery. First India edition. New Delhi: JP Medical Ltd; 1995. 17-30.
Benninger MS, Bhattacharya N, Fried MP. Surgical management of bilateral vocal fold paralysis. Operative Techniques in Otolaryngology-Head and Neck Surgery. 1998. 9:224-9.
Eckel HE, Perretti G, Remacle M, Werner J. Endoscopic Approach. Remacle M, Eckel HE. Surgery of larynx and trachea. Berlin, Germany: Springer-Verlag; 2010. 107-214.
Hazarika P, Nayak DR, Balakrishnan R, Raj G, Pujary K, Mallick SA. KTP-532 laser cordotomy for bilateral abductor paralysis. Indian J Otolaryngol Head Neck Surg. 2002. 54(3):216-20.
Hogikyan ND, Batisan RW. Surgical therapy of glottic and subglottic tumors. Thawley SE, Panje WR, Batsakis JG, Lindberg RD. Comprehensive management of head and neck tumors. 2. Philadelphia: WB Saunders Company; 1039-68.
de Vincentiis M, Fusconi M, Benfari G, Pagliuca G, Pulice G, Gallo A. The use of forced ventilation during microlaryngoscopy with laser CO2. Eur Arch Otorhinolaryngol. 2008 Aug. 265(8):943-5. [Medline].
B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg) Professor of Otolaryngology (ENT), Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute, India
B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg) is a member of the following medical societies: Association of Otolaryngologists of India, Indian Medical Association, Indian Society of Otology
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Vocal Cord Cordotomy
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