Evaluation & Management of Bilateral Vocal Fold Paralysis

[Dr. James Daniero]
It's really exciting field. Fortunately, it's a pretty rare diagnosis, but it has no really good solution currently. Typically, I'd talk to patients about the whole ladder of interventions. The first option is tracheotomy speaking valve. That requires us not to touch your vocal folds and leaves the door open for future interventions that may be coming mainstream to avoid a destructive surgery.

The next level up from that is actually to perform a surgery. There's suture lateralization to try and decrease the amount of injury to the vocal fold. At least in my hands, when I've done that, there's always been some level of scarring that remains behind even after that lateralization. I haven't seen it dramatically change the amount of invasiveness of that procedure.

Then I think what most people would say is the standard option is the posterior cordotomy or posterior cordotomy plus or minus an arytenoidectomy, and that endoscopic removal of the posterior more airway portion of the larynx, leaving the membranous portion as untouched as possible, but still leaving an airway. Allow some phonation, some vibration, but certainly, I counsel them, it's a significant decrease in the voice.

One of the things is, since their vocal folds are normal anatomically, their voice is very strong and good. Even though their vocal folds are not working, once we create the airway, they're going to have a significant sacrifice in their vocal quality, and that's permanent. Sometimes we can do some little things to titrate and improve vocal quality afterwards, but it's very limited success in restoring normal voice after those procedures.

They're very effective, they achieve decannulation 80% of the time or more. You can get some good results. Sometimes they require revision, sometimes bilateral surgery is necessary, which obviously affects the voice even more. It can be the tried and true way of proceeding with trying to achieve decannulation in the patients that have more severe obstruction up front.