In patients with bilateral vocal cord paralysis, the classic treatment has been an arytenoidectomy, either performed endoscopically or from the laryngofissure approach.8,9 If a patient has arytenoid fixation, either traumatic or from rheumatoid arthritis, this is still the procedure of choice. The arytenoid is removed and the posterior cord is sutured laterally to the thyroid cartilage. If the arytenoids are mobile, a simpler technique is to endoscopically lateralize the vocal cord.10-12 A no. 20 spinal needle is passed through the skin under binocular vision, using the laryngoscope with the Lewy suspension attached. With one eye looking through the laryngoscope and the other eye on the needle, one can quite accurately aim the needle, so that figure 35-6 Conforming stent in place with the mucosal graft over the stent at the level of the denuded mucosa.
when it penetrates the thyroid cartilage, it will come out at the level of the vocal process. One needle is placed below the cord and the other into the ventricle so that it comes out above the cord. The obturators are removed and a no. 0 or 2-0 nylon suture is threaded down the needle and into the larynx where it is grasped with a small forceps and brought out through the mouth (Figure 35-7A). This is done with both sutures and a square knot is tied (Figure 35-75). An incision is made externally between the two needles down to the cartilage. One of the needles is then removed and that suture drawn back until the knot is pulled through the cartilage. The other needle is left in place until the knot has been pulled through. With nylon, even a square knot may untie during the pull through. By leaving one needle in place, it is much easier to reinsert the other needle into the proper place. Once the knot is pulled through, the second needle is removed, the cord pulled laterally, and the suture is tied down so that the knot is on the thyroid cartilage (Figures 35-7C,D). If one is quite certain that recovery will not take place, then prior to pulling the cord over, scarring is created lateral to the vocalis muscle, either by using a laser or a long laryngeal electro-cautery needle. This tends to hold the cord lateral if the suture later cuts through the tissue or otherwise becomes loosened. Examining through the laryngoscope, one can immediately ascertain as to whether enough airway has been obtained. If not, a second suture is placed more anteriorly in the midvocal cord. On occasion, both cords can be lateralized, but that is rarely necessary. An ideal result is an angulated cord, where the two cords approximate in the anterior portion for vocalization and are separated posteriorly for respiration. With arytenoidectomy, a temporary tracheostomy must be performed; most patients will already have one. An endoscopic lateralization procedure can often be done without a tracheostomy if the patient is covered with steroids during surgery, though they must always be warned that a tracheostomy may become necessary if edema develops.
In addition to the fact that this procedure is simple and usually successful, another advantage is that it is easily reversible if function recovers. Guided by the scar, the skin is incised under local anesthesia and the suture is cut at the knot on the lateral surface of the thyroid cartilage and removed. Many paralyses do recover, especially the idiopathic ones and those due to retractor pressure or stretching of the recurrent laryngeal nerve in thyroid or cardiac surgery. In the pediatric age group, recovery is even more frequent, but it may take up to 5 years.13 Others have advocated partial excision of one or both vocal cords, using either knife or laser.14,15 These do restore an airway and preserve some voice, but they are not reversible and so are not recommended unless one is certain the recurrent laryngeal nerve has been severed with no attempted grafting.
One must always discuss preoperatively with patients the fact that the better the airway, the worse the voice will be postoperatively, no matter which procedure is used. A patient with bilateral cord paralysis will usually come in with a good voice and a poor airway. Indeed, some patients, when presented with the alternatives, will prefer a permanent tracheostomy and simply plug the tube with a finger when talking, or have a cannula with a speaking valve.
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