MDL - Total arytenoidectomy

Considerations

• • See the book Operative Techniques in Laryngology (2008) by Rosen and Simpson, Chapter 27 (page 167) 

• Bilateral vocal fold paralysis (BVFP) generally causes airway restriction

  • Treatment is aimed to improve the airway while minimizing aspiration and vocal dysfunction 

  • Treatment should be step-wise, moving from least to most aggressive

    • Tracheostomy - although invasive, may be needed early on

    • Endoscopic suture lateralization - temporizing measure 

      • MDL with posterior transverse cordotomy (PTC) or medial arytenoidectomy (MA)

    • Extended version of either (or a combination) of PTC or MA

    • MDL with total arytenoidectomy (TA)

    • Open total arytenoidectomy

  • Choose the side for TA based on 

    • Presence of any meaningful movement - the best mobility should be preserved 

    • Palpation of the cricoarytenoid joint - the best mobility should be preserved 

• 1996: Endoscopic laser medial arytenoidectomy versus total arytenoidectomy in the management of bilateral vocal fold paralysis

• 2012: Endoscopic total arytenoidectomy for bilateral abductor vocal fold paralysis: a new flap technique and personal experience with 50 cases

• 2013: Comparison of voice and swallowing parameters after endoscopic total and partial arytenoidectomy for bilateral abductor vocal fold paralysis: a randomized trial

Preparation

• • ETT: Smallest armored tube

    • Tape to left lower lip

• Eyes: Paper tape over lids

  • Wet "eye pads" over tape

  • Another long strip of paper tape over both eye pads

• Head: Wrap with 2 blue towels

  • Avoid towel clamp 

• Split drape 

  • Do not remove sticky cover 

• Tooth guard 

• Check all equipment including light cables and light sources 

Procedure

• • Basic DL with either/or 

    • Hollinger (anterior commissure) laryngoscope 

    • Dedo laryngoscope 

• Place the operative larygoscope in suspension

  • Bouchayer laryngoscope 

  • Zeitels laryngoscope

• Adjust the head and neck positioning as needed

  • Sniffing position (neck flexion with head extension)

  • Anterior tracheal pressure with tape 

• Photograph using both 0 and 30 degree Hopkins rod endoscope 

• Bring in the operative microscope 

• Perform the planned total arytenoidectomy 

  • Continuous CO2 laser ablation of arytenoid tissue until the operative defect is flush with the walls of the cricoid ring, both posteriorly and laterally

  • Tissue removal posteriorly should not remove any interarytenoid mucosa

  • Evaluation of this goal can be done by:

    • Placement of a curved elevator on the lateral aspect of the subglottis and then slowly drawing the instrument in a cephalad direction feeling for a glottic level “overhang” of arytenoid tissue

      • If there is an “overhang,” additional arytenoid tissue can be removed

    • In addition, the endoscopic evaluation of the posterior glottic airway with a 70° telescope, can identify if there is any residual arytenoid overhang that needs further laser ablation to maximize the glottic airway to complete the total arytenoidectomy procedure

• Obtain hemostasis with small pledget soaked with topical 1:1000 Epinephrine 

• Photograph using both 0 and 30 degree Hopkins rod endoscope 

  • Spray the glottis with 3 ml topical 4% Lidocaine

  • Remove the laryngoscope and tooth guard

  • Examine the airway for any unintentional injury 

Post-op

• • For Dr. Durr, use the the University of Texas Voice Rest protocol here

    • See the smartphrase by J Gilde: JEGPIVOICERESTPO

High-Yield

Links

• eMedicine - Arytenoidectomy