|Year : 2016 | Volume
| Issue : 1 | Page : 1-6
Suture lateralization for bilateral vocal fold immobility: A review of various techniques
Sachin Gandhi, Rohan R Bidaye, Divyank Bansal
Department of Laryngology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
|Date of Web Publication||5-Apr-2017|
Dr. Sachin Gandhi
Deenanath Mangeshkar Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Bilateral vocal fold immobility is characterized by narrowing of the glottic chink which could precipitate in the form of an acute airway insufficiency. The vocal cords may be immobile or fixed in the paramedian position depending upon the etiology and the time duration. The standard approach till the early part of the 19th century was to perform a tracheostomy in such patients. The glottis dilating operations which included cordectomy, arytenoidectomy were introduced in 1922 and have evolved over time. However most of the procedures being irreversible, were not the best line of management in cases with a recovering bilateral vocal fold paralysis. Suture lateralization was introduced as an alternative in the year 1978 which could be reversed if the paralysis resolved. This procedure had two main approaches 1) Endo – Extra laryngeal approach and 2) Extra- Endolaryngeal approach which have been published by different authors over the last 35 years. This current article reviews these techniques alongwith the published results.
Keywords: Bilateral vocal cord immobility, laryngeal paralysis, upper airway obstruction, vocal cord suture lateralization
|How to cite this article:|
Gandhi S, Bidaye RR, Bansal D. Suture lateralization for bilateral vocal fold immobility: A review of various techniques. J Laryngol Voice 2016;6:1-6
| Introduction|| |
Bilateral vocal fold immobility (BVFI) is a condition in which the vocal cords have restricted mobility secondary to neuropathy, muscular disorder, or mechanical fixation of the cricoarytenoid joint. As the vocal cords are in the paramedian position, the patient could present with breathlessness and there is worsening on exertion or with respiratory infection. This condition could turn life-threatening if not managed appropriately. The most common cause of BVFI is bilateral recurrent laryngeal nerve paralysis. The recurrent laryngeal nerve is most commonly affected or injured postsurgically, especially in thyroidectomy. Other causes would include postintubation, external trauma, malignancy, postviral, and certain neurological disorders.
| History and Evolution of Techniques|| |
Surgeons have long been searching for techniques to safely widen the glottis airway in patients with bilateral immobile vocal cords without compromising on the voice and/or causing aspiration. Surgical methods were designed to attain good respiration with minimal effect on phonation and swallowing. The treatment of bilateral immobile cords has evolved with time. Lichtenberger has extensively reviewed the endoscopic glottis dilating operations which included arytenoidectomy in his article. Damrose has provided an excellent review on suture lateralization techniques for BVFI. This would be an extension to the articles mentioned above emphasizing more on the technique of various surgeries and the recently published data on it.
Historically, tracheostomy was the only method of treatment for this condition before the 19th century. In 1922, Chevalier Jackson introduced ventriculocordectomy. In this procedure, he excised the entire vocal cord and the ventricle creating a wide airway. However, it resulted in a breathy voice postsurgery. In 1932, Hoover proposed submucosal resection of vocal fold for the treatment of bilateral abductor paralysis. The airway was better initially but scarring overtime gave rise to stenosis. King introduced the concept of suture lateralization of the arytenoid to open the posterior respiratory glottis (arytenoidopexy) in 1939. While Kelly was credited with the technique of arytenoidectomy, it was Woodman who combined near total arytenoidectomy with suture lateropexy of the remnant vocal process to the inferior thyroid cornu. Not only did it enlarge the posterior respiratory glottis but also the suture effectively lateralized the vocal fold in an abducted position. Thornell in 1948 performed an endolaryngeal arytenoidectomy. A major breakthrough occurred in 1968 when Kleinsasser introduced his methods of glottis dilation. In 1969, Cancura was the first person to report lateralization of the vocal cord using the endo-extralaryngeal technique during his experiments on animals. However, it took 10 years before Kirchner in 1979 introduced the concept of using a suture to lateralize the vocal fold in humans. The suture was passed through hypodermic needles inserted from outside. Ejnell et al. also performed suture lateralization from an extralaryngeal approach with the help of needles passed intralaryngeally. In 1983, Lichtenberger introduced the needle carrier capable of passing a needle and suture endolaryngeally through the thyroid ala out through the skin significantly simplifying the procedure. In the article by Sapundzhiev et al., they had divided the glottis dilating operations into the following: (1) Resection of anatomic structures; (2) displacing existing structures with minimal tissue resection; (3) displacing existing structures without tissue resection; (4) restoration or substitution of the missing innervation of the laryngeal muscles. In this article, we are going to include only the techniques of displacing existing structures with/without tissue resection. To simplify it, further, we have divided the techniques into (1) endo-extralaryngeal approach and (2) extra-endolaryngeal approach [Figure 1]. We will provide an in-depth review of the important articles published on the various techniques of suture lateralization [Figure 1].
| Discussion|| |
As mentioned previously, the method of extra-endolaryngeal suture lateralization was first described by Kirchner  and later followed up by Ejnell. Larynx was exposed by direct laryngoscopy and assessed for fixity of criocoarytenoid joint by palpation. After removal of the thyroarytenoid muscle, a suture was introduced into the larynx through two 18-gauge needles inserted into the larynx from outside. The first needle was inserted midway and below the vocal cord while the second was above the vocal cord. The sutures were pulled out through the laryngoscope, knotted, and the external ends pulled out gently advancing the suture to lateralize the vocal fold. On the external surface, padded buttons were attached to fishing lead sinkers which were crimped to adjust the tension. Two weeks later, the sutures were removed and the airway assessed. To secure a functional airway in adults, an opening of at least 12 mm was found to be adequate by Kirchner et al. A 5-mm right angle probe was considered an essential surgical adjunct for the measurement. He performed this procedure in 16 patients but has not published about the postoperative results in them [Table 1].
|Table 1: Comparison of the various techniques published in the literature|
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Litchenberger in his paper published in 2002 reported his findings on 63 cases of bilateral abductor palsy operated in 20 years from 1980 to 2000. The possible disadvantage of the endoscopic microsurgical glottis dilating operations was highlighted by the author. Arytenoidectomy for glottic dilation is very susceptible to granuloma and scar formation. A raw surface in the larynx will cause excessive scar formation and scar contracture inevitably leads to renarrowing of the airway. He proposed the use of an endo-extralaryngeal suture technique in which the mucous membrane of the vocal cord is preserved preventing scar tissue and renarrowing of the airway. Litchenberger's endo-extra laryngeal technique used the specially designed laryngeal needle carrier [Figure 2] for lateral fixation. A neck incision was made up to the platysma and a microlaryngoscope was used to visualize the paralyzed vocal cords. One end of the lateral fixation suture was pushed through the larynx below the posterior third of the vocal cord and the other end was pushed through above the vocal cord. Both ends of the fixation suture were pulled and knotted over the strap muscles. A second lateral fixation suture was placed 1–2 mm anterior to the first suture using the same technique [Figure 3]. In a paper published a year later in 2003, Lichtenberger  proposed the following classification for suture lateralization procedures: (1) Reversible endo-extralaryngeal lateralization (REExL), (2) endo-extralaryngeal laryngomicrochirurgical lateralization (EExLL), and (3) EExLL with arytenoidectomy. REExL was indicated when the irreversibility of the paralysis has not been confirmed and the cords are in paramedian position. The surgery was very similar to the technique mentioned in his previous paper. The only difference noted was that he placed three or four loops to prevent tension and cut through of the suture through the mucosa. EExLL – this procedure involved submucosal cordectomy with lateralization of the preserved vocal ligament of the vocal cord. As compared to a conventional cordectomy, this technique prevented granuloma and scar formation. Furthermore, aspiration in elderly patients was avoided by preserving the arytenoid. This procedure was performed with the cords in the paramedian position and a mobile cricoarytenoid joint. After endoscopic exposure of the larynx, a longitudinal incision was made on the superior surface of the vocal cord either with tmicroscalpel or laser. The incision extended 2 mm from the anterior commissure till the vocal process. The medial and lateral aspects of the thyroarytenoid muscle were exposed by grabbing the vocal process of the arytenoid. The muscle was removed with laser or cold instruments preserving the vocal ligament. Following this procedure, a 2-0 prolene suture was applied with the help of the endo-extralaryngeal needle carrier by Lichtenberger as described previously. EExLL with arytenoidectomy was indicated when there is ankyloses of the arytenoid cartilage and the vocal cords are in the median or paramedian position. He described a triangular incision with a microscalpel or laser. The incision extended from the front of the vocal process and continued posteriorly over it. Another incision began 1–1.5 mm from the edge of the vocal cord extending above the arytenoid cartilage laterally while the third edge of the incision was from the vocal process to the muscular process of the arytenoid. Partial arytenoidectomy was completed using laser or dissection technique. The above-described procedure of submucosal cordectomy was repeated followed by lateralization with a suture. In his paper published in 2003, 76 patients out of 81 patients had an adequate airway after definitive irreversible glottis dilating surgery [Table 1]. The airway was assessed 1 year after the surgery. Among 5 remaining patients, 2 were lost to follow-up while 3 patients required a revision surgery with an open approach. In 9 patients with an adequate airway, a contralateral lateralization was necessary for the full satisfaction of the patient. Out of 24 patients, with 1-year follow-up after reversible lateral fixation, 22 patients had an adequate glottic chink [Table 1]. Of the 22 patients, the vocal cord function never returned in 16 patients. In four patients of the 22, function returned in one of the cords while in 2 patients, it was restored in both the cords. The surgery was unsuccessful in 2 of the 24 patients.
|Figure 2: Lichtenberger's needle holder for endo-extralaryngeal approach. (a) Lichtenberger's needle holder, (b) Lichtenberger's needle holder with needle|
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|Figure 3: Suture lateralization (a) preoperative, (b) intraoperative, (c) postoperative|
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Mathur et al. published a technique to simplify suture lateralization in the year 2004. His technique had an extra-endolaryngeal approach without using any special instrument. Briefly describing the technique, two points A and B were marked on neck on the neck, opposite to the cord to be lateralized. Point A was 1.5 cm posterior to the mid-point between thyroid notch and the inferior border of thyroid cartilage. Point B was marked 5 mm below point A. An 18-gauge lumbar puncture needle was passed transversely from point B on the side which was not to be lateralized. The needle tip was visualized on laryngoscopy and was directed just below the level of opposite vocal cord (the vocal cord to be lateralized). The needle was pushed externally and removed out from opposite side of the neck. The stylet was removed and a suture was passed through the needle. The needle was removed leaving the suture in place and the intralaryngeal end of the suture was pulled out through the laryngoscope. Now, a needle with a slit in the eye was passed from point A into the larynx and removed out from the side to lateralize through the ventricle just above the vocal cord. The slit on the needle is visualized in the larynx and the suture end was hooked to it. The needle was pulled out along with the suture thus forming a loop around the vocal cord. This suture was tied externally after adequate lateralization over the strap muscles. All 10 patients operated by this technique by Mathur et al. were on a tracheostomy. All except 1 were decannulated, 1–4 weeks following the surgery [Table 1]. The time taken for this technique was 10 ± 1.58 min as compared to 15–30 min noted in the earlier described methods. Furthermore, the knot was outside the larynx as compared to the extra-endolaryngeal technique by Ejnell. The author never reversed the procedure as the palsy never recovered in any of the patients.
In the study by Su et al., they used an extra-endolaryngeal approach and modified it by calling it as simple suture lateralization technique. They used this technique probably because of the limited availability of the Lichtenberger's needle worldwide. In his technique, the strap muscles were severed and thyrohyoid muscle was incised to expose the oblique line and the lower half of the thyroid cartilage on the lateralisation side. Similar to the technique by Ejnell, an 18-gauge injection needle was used to mark a point in the thyroid lamina approximately 13 mm from the midline and 5 mm superior to the inferior margin of the thyroid cartilage in men and 11 mm and 4 mm, respectively, in women. The needle tip entering the larynx was confirmed with laryngoscopy to be entering at the level of the ventricle. A second needle piercing was made 2 mm below the first one and confirmed to be below the vocal fold. Monofilament suture threads were passed through both the needles and the threads in the glottal lumen. The ends of the suture were pulled through the laryngoscope and a knot tied. The knot of the thread in the upper and lower needle was pulled out together with its needle. Care was taken that the knot remained as close to the lumen as possible and it appeared outside the thyroid lamina. The outside ends of the suture were knotted over a silicone block placed on the thyroid lamina after cutting a notch on it. Out of twenty patients, 17 had a satisfactory breathing capacity as well as phonation after the procedure. Two of the 3 tracheostomised patients were decannulated while one decannulation failed cause of intolerable aspiration [Table 1]. Revision surgery was performed in 2 patients. One had a dislocation of the silicone block and the other had inadequate lateralization. As far as voice quality immediately after surgery is concerned, 3/17 showed unchanged voice quality while 14/17 showed mildly changed voice quality. However, after 9 months, reassessment showed unchanged voice quality (14/17) while 3/17 had mild change in voice. The improvement in voice over time was because of ventricular compensation. 18/20 patients had mild or even no aspiration for a few days after the lateralization procedure, but it disappeared spontaneously. The authors claim this technique to be minimally invasive with the added advantage of reversibility and adjustment if required. The author claims to have made it feasible to perform suture lateralization under common oral intubation technique. Furthermore, the operation time was reduced to <10 min. The advantage of this simplified technique was the minimal manipulation of the posterior glottis allowing immediate extubation on table or decannulation in tracheostomized patients in a few days.
Ejnell and Tisell's procedure had practical difficulties as the insertion of needles externally often do not end up in the correct location. Even the original Lichtenberger device faced difficulty piercing the posterior part because of the thyroid cartilage being more dense in that area. Furthermore, the fixating threads were introduced through the oral cavity, which increases the risk of perichondritis of the thyroid cartilage. To overcome these difficulties, an endolarygeal thread guide instrument (ETGI) [Figure 4] was designed for safe, accurate, and fast suture loop creation for the endoscopic arytenoid lateropexy. The ETGI is made up of a built-in, movable curved blade with a hole at its tip allowing a suture thread to be guided from the laryngeal cavity and out from the neck. The method of use of the ETGI is described in short. After exposing the larynx, the mobile arytenoid cartilage is tilted backward and upward with the end of the instrument. The curved blade is then pushed out to the surface of the neck by passing it under the vocal process. A nonabsorbable suture thread is passed through the hole at its tip of the blade and the double loop thread is pulled back with the blade into the laryngeal cavity. Then, the suture along with the blade is pushed out above the vocal process externally [Figure 5]. A small incision is made to withdraw the ends of the suture on to the surface and knotted above the sternohyoid muscle. Thus, the procedure creates of two fixating loops in one step at suitable laryngeal locations which provides maximum abduction of the posterior part of the vocal cords. From 2005 to 2008, 34 patients were diagnosed and treated by ETGI, out of which only 2 cases required a postoperative tracheostomy. Rest of the 32 cases had no complications [Table 1]. Airway was analyzed by peak inspiratory flow rate which doubled in 1-year follow-up. Six patients out of 34 recovered from the vocal cord paralysis (4 bilateral, 2 unilateral). Sixteen patients had posterior phonation closure insufficiency, a more or less hoarse and breathy but socially acceptable voice. The biggest advantage of this technique is the double-loop creation in one maneuver without a need for an external recharge.
|Figure 4: Endolaryngeal thread guide for suture lateralization – endo-extralaryngeal approach|
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|Figure 5: (a-d) Suture lateralization technique with the use of Endolaryngeal thread guide|
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Ezzat et al. put forth the concept of adjustable laterofixation suture in the year 2010. As described in all the previous procedures, the suture tension was adjusted to the desired extent of the glottic chink under general anesthesia without voice quality assessment. The author proposed suture placement under general anesthesia, but the suture lateralization was performed the following day without anesthesia. After adjustment for optimal breathing and voice results, the suture was then tied at the appropriate tension and buried under the skin flap. The procedure was successful in 76% of patients but some patients required bilateral procedures. One patient suffered a knot slippage for which a revision surgery was performed.
In 2011, Katilmis et al. presented their modification to suture lateralization. There was a tendency of the flaccid ipsilateral cord to prolapse into the glottis with inspiration following laterofixation in some patients, producing suboptimal results with unilateral lateralization. Katilmis et al. proposed lateral crossing sutures in a figure of eight pattern to tackle the above problem. The figure of eight suture would pull not only the vocal process but also the posterior true and false cords as well preventing the prolapse during inspiration. This procedure was performed by a thyroplasty window approach with the sutures carefully introduced through the holes placed in four points around the window. After the suture placement is complete, the sutures are tied over the cartilage piece removed from the window. This was followed by rotation of the cartilage by 90° which crossed the sutures and also blocked them from medialization. The procedure was successful in the five patients described in the series.
Patients with BVFI can show a maladaptive phonatory practice of using the false cords for phonation. Friedrich et al. noticed this and used the suture laterofixation technique for the treatment of dysphonia plica ventricularis. The principle used was the reversibility of the procedure thus preventing the false cord approximation and breaking the maladaptive cycle. This procedure was, however, performed in only two patients and the suture was removed after 4 days as the vocal cords showed signs of recovery.
Kulasegarah J et al. published their technique of vocal cord lateralization using an Endo Close suturing device. The authors claim that it made the procedure quick and less cumbersome. However, no data regarding the number of patients operated on with this technique has yet been published.
| Recent Advances|| |
Electrical pacing of the laryngeal muscles has been attempted by many and published in literature since the 1990s. It comes with a stimulator which is implantable. However, due to the fixed rate of impulses, there is a lack of coordination with breathing and phonation. Selective activation of the different laryngeal muscles was studied by Broniatowski by implantation of electrodes around the recurrent laryngeal nerve. In case of device dysfunction, there is always a chance of closure of the glottis causing a life-threatening situation. This is the most eminent risk associated with electrical pacing of the larynx.
To summarize, both the approaches have been used and published by various authors over the last 35 years. Both approaches have given similar success rates. The endo-extralaryngeal approach cannot be carried out without the use of special instruments. They all had shortcomings, but the ETGI introduced recently seems to have overcome most of the difficulties. However, due to the absence of long-term data, its results need to be assessed over a larger sample size.
| Conclusion|| |
Suture lateralization is an important procedure in the management of BVFI. It affords a minimally invasive, reversible, and potentially immediate alternative not only to tracheostomy but also for ablative procedures such as cordectomy. It can be performed bilaterally and could be coupled to additional procedures such as arytenoidectomy if required. Serious complications are few although the only drawback being the need for revision procedures. To conclude, suture lateralization should be considered for all patients with BVFI, especially in cases of good prognosis for recovery.
We thank Dr. Madani Shahram (ENT consultant) for providing us the [Figure 4] of the ETGI. We would also like to thank Mrs. Sheetal Deshpande, Library incharge of the hospital for the providing access to the literature.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]