Acute Management of Bilateral Vocal Fold Paralysis

[Dr. Gopi Shah]
Before we get into it, actually, this might be a very basic question, but when you'd introduced the topics, Steve, you switched it from bilateral vocal cord paralysis to bilateral vocal fold paralysis. Is there a nuance in that? Can we get into that a little bit?

[Dr. James Daniero]
Sure. When we think about the vocal cords, that's the common parlance we discuss, but really it's a three-dimensional structure. I'm coming from our voice center here and we were just teaching our voice course and going through the three-dimensional anatomy of the vocal folds and describing why it is a fold rather than a cord. It's a three-dimensional structure from the top down view.

We only see it as like a little strip of tissue, but there is some height to it, and that's really important for restoring voice and for restoring proper function of airway as well. Knowing that it is that fold of tissue is really important in talking about any reconstructive options rather than just like a vibrating rubber band that's there in the larynx.

[Dr. Stephen Schoeff]
I think moving into the discussion, when we talk about bilateral vocal fold paralysis, really that's almost a subset of bilateral immobility, particularly in adult patients. Gopi and I were just talking a little bit about the pediatric versus adult components of this, too, beforehand. What's the general presentation that you're experiencing, and what is the breathing like in a patient who's presenting? We can even start with bilateral immobility, and then narrowing into paralysis from there.

[Dr. James Daniero]
Immobility is more of a broader term that includes iatrogenic injury or immobility that is fixation of the vocal folds, not necessarily paralysis. They're commonly used in replace of each other where they just are a misnomer of what actually is happening. We'll see a lot of times-- and our coding, unfortunately, is also off on this. We don't really have a great code for immobility. The best code is the paralysis, bilateral paralysis code to show that the vocal folds are immobile and to come up with our connections with our CPT codes. Unfortunately, we're forced to use that misnomer as well.

Immobility, typically, will refer to either we don't know what the cause is, or we know the cause is not a neurogenic cause. That would be fixation from ankylosis that could be autoimmune, rheumatoid arthritis, ankylosing spondylitis. Sometimes we'll see fixation of the cricoarytenoid joints, and they stop moving, but it's not because the nerve's injured. It's a local mechanical problem rather than a neurogenic.

Then more commonly, what the situation is, is acute laryngeal injury that is healed poorly and caused ankylosis of the cricoarytenoid joint or fixation of the vocal folds by scarring them together. In that case, it's not paralysis, but the immobility shows up and the history is really the differentiator there. There is some sort of intubation or some sort of trauma.

Then the time course is pretty predictable. It's four to six weeks out from that injury, and then you see this fibrotic state setting in as the wound healing progresses. Then they show up with stridor. There become progressively shorter breath and respiratory distress. Hopefully, they seek care of the emergency department or get into an ENT clinic quickly because that diagnosis typically has to be made by a laryngoscopy. Then unfortunately, often, a quick transition to a suitable airway, which is generally tracheotomy.

One more distinction is, in those patients, intubation is a really difficult and dangerous situation. In patients that are paralysis or they have a neurogenic injury, typically, intubation is a little bit easier in those cases because the vocal folds will push out of the way. On presentation for immobility with the ankylosis, with the fibrotic joint, those vocal folds will not separate with intubation and can be really dangerous to approach intubation even fiber-optically. Therefore, those patients typically have to have a tracheotomy placed under an awake, under local anesthesia.

[Dr. Gopi Shah]
Just going back to the tracheostomy, this is just curiosity. When you're going back, I think it was Steve's initial question of, in the acute setting, how do you set up your patient, how do you secure the airway, if you could go into some of those details. Then just for you guys, Bjork flap, no Bjork flap, a seven, those little stay sutures, no horizontal, if we get into some of those details as well.

[Dr. James Daniero]
There's certainly a lot of surgeon preference there. I can tell you a little bit about mine. For the paralysis patients where we're pretty sure that this is not a fixation, this is not a post-laryngeal injury patient, then we can often actually proceed with intubation as they're relaxed. Typically, we can positive pressure ventilate past these passively mobile vocal folds, and so I feel a bit more confident.

Obviously, these are situations that you don't take anything for granted and you're always prepared to proceed with a tracheotomy surgical airway. In those cases, it can be very safe to just put in an endotracheal tube and put the patient to sleep, slide a small tube through. Often, we use a GlideScope or some type of video laryngoscopy to pass the endotracheal tube because you may have more medialized vocal folds, even though they're passively mobile.

It's a little easier to see how to pass the tube without damaging the vocal fold. Last thing we want to do is add another iatrogenic injury as we're intubating, and then proceed with the standard tracheotomy that way. Very different than the bilateral immobility that I talked about previously. Those patients, they're almost fully awake. I really argue strongly for it to be straight local to limit any type of loss of the airway due to some mild sedation. We proceed with those under local anesthesia. As far as technique-wise, I am very partial to a Bjork flap. That's how we train.

[Dr. James Daniero]
Yes, there can be some A-frame deformity that happens from damaging a cartilage ring after decannulation. In these patients that don't have an airway above, accidental decannulation is often fatal. I want to decrease the risk of that. Just had too many close calls and things over the years that it just reinforces having the most secure airway possible when we're potentially rolling a patient and a tracheotomy can just come out on post-op day zero or one, decrease that risk. It just makes me feel better. I think we have great ways of dealing with the airway as well if we need to down the road. You can't help somebody if they don't survive the tracheotomy.

[Dr. Gopi Shah]
What about you, Steve? What do you like to do?

[Dr. Stephen Schoeff]
Let's think about it. Absolutely, I'd echo the same considerations in terms of anesthetic and avoiding sedation in the immobility fixation-type patients. With the paralysis patients, you do have definitely more leeway. I haven't gotten to experiment with high-flow nasal cannula or THRIVE. I'm quite intrigued by what that could potentially do in these situations. You'd have to be a little bit aware of the high-oxygen environment, for sure. I think that could be potentially a little bit of a help particularly in the fixation situations that I haven't gotten a chance to explore, really.

In terms of the technique of the tracheostomy, I tend to vary quite a bit whether I use a Bjork flap or not, but definitely, in these situations where you may not have any airway above, I absolutely agree. Just doing anything to make it more secure is quite valuable, particularly since I'm in a hospital setting where there's probably a little less familiarity with tracheostomy and less frequent high acuity patients like you'd have in the university setting.

I don't have residents, I don't have on-call residents who are closely either at the hospital a lot or closely associated. It's a little bit of a different situation where I tend to play things a little more safely for the logistical reasons because I just know that it can be a little harder to support the hospital in that way.

[Dr. Gopi Shah]
That's an interesting point. I always have to think about this when I have an older kid that needs a tracheostomy, like the teenager. To me, that's a lot more of an adult airway, because in infants, we're still using vertical incision, we have our stays. In my older kids, I'll do the same thing though as we do in the infants because it's got to be the same in the hospital.

RT and in nursing, if they look at any trach baby, it should be familiar, the same. I still just, in my older kids, just still do a vertical incision like I would in an infant, and then put stays and just do it that way. I'm always like, huh. In the 15-year-old, should I be doing it differently, but usually, that's just how I do it.


[Dr. Stephen Schoeff]
I think the stay sutures are a perfectly safe technique, but if someone's not familiar with what to do with the stay sutures and what they are, then it's exactly to Dr. Schoeff's point that this is an institutional learning, often effects of technique because that may be foreign to somebody and that's not going to help if they don't know what to do in the situation.