Laryngology

Coblation Cordotomy for the Management of Bilateral Vocal Fold Immobility/Paralysis

Bilateral vocal fold immobility (BVFI) has an impact on both the voice and breathing. In some cases, tracheotomy is performed to establish a safe airway while the more sustainable management can be accomplished. Several static procedures have been developed to lateralize the vocal fold or arytenoid to improve the airway but attempt to minimize voice dysfunction, although there is growing interest in bilateral reinnervation for bilateral paralysis. The use of a coblator to perform a posterior cordotomy was shown in a preliminary report by the Head and Neck Institute to improve breathing but have a minimal impact on the voice. This study evaluated the use of coblation cordotomy for BVFI by a retrospective chart review of 94 patients who had undergone coblation cordotomies for BVFI performed by 4 surgeons. Patients with glottic stenosis requiring procedures other than cordotomy were removed from the evaluation.

The cause of the immobility was primarily from thyroidectomy or prolonged intubation; 13 patients had 19 prior procedures for their stenosis before cordotomy, with either CO2 or KTP lasers. Twenty-one procedures were performed in patients who had a tracheotomy already in place, but most procedures (73) were performed in patients without a tracheotomy. Two patients had tracheotomies at the time of the procedure and 2 had tracheotomies at some time after the procedure. Four patients who had tracheotomies were not decannulated during the time of this study, 2 for reasons other than their BVFI (sleep apnea, primary respiratory failure). Each of the 4 patients could plug during the day.

Most of the procedures were done with the patient under apneic anesthesia and a few were done using jet ventilation. Since over-lateralization can result in a permanent reduction in voice, the team erred on doing too little resection rather than too much. Consequently, 20 patients required a secondary revision, usually on the opposite side. This was more common in bilateral fixation than in bilateral paralysis. The mean follow-up was 16 months (1 to 38 months). The shorter follow-up was in part because of patients who had a good result and had no need for follow-up. Forty-four patients had formal preoperative and postoperative voice evaluations. The median Voice Handicap Index (VHI) scores improved from 62.2 to 37.4, contradicting the premise that improving airway results in a worsening in voice. Only 4 patients had worse VHI scores after the procedure. The improvement in voice is suspected to be largely due to improvements in airflow and aerodynamics rather than improvement of vocal fold vibration or pliability. The previous report of 19 patients showed short operating surgical time but was not collected for this analysis. Eight patients had a Dyspnea Index performed and the median score dropped from 18.3 to 12.

Coblation cordotomy is a fast and efficient way to lateralize 1 or both vocal folds in BVFI. It obviates the need for a tracheotomy and has high success rates in improving breathing and decannulation with improvements in VHI in all but 4 patients. An important advantage of this procedure is how quickly it can be done. After the patient has a laryngoscope in place and it is suspended, the actual cordotomy can take as little as 15 to 20 seconds and rarely longer than 2 minutes, which makes it an ideal procedure to be done under apneic anesthesia.