Bilateral vocal cord palsy

I saw a 60 year old patient a week or so ago with a long history of stridor on exercise. She had had a total thyroidectomy 10 years previously and noted the problem since then. Her voice had also changed. She got breathless on exercise and could not walk that far. She had had multiple treatment for asthma over this time. Her astute GP asked us to see her and check her vocal cords, suspicious of recurrent larygeal nerve injury. See endoscopic video(there is probably slight movement of the right vocal cord, but they are lying in a para-median position giving her a poor airway but reasonable voice.)

Bilateral vocal fold (vocal cord) immobility (BVFI) is a broad term that refers to all forms of reduced or absent movement of the vocal folds. Bilateral vocal fold (cord) paralysis (BVFP) refers to the neurologic causes of bilateral vocal fold immobility (BVFI) and specifically refers to the reduced or absent function of the vagus nerve or its distal branch, the recurrent laryngeal nerve (RLN). Vocal fold immobility may also result from mechanical derangement of the laryngeal structures, such as the cricoarytenoid (CA) joint.


According to Benninger's findings in a series of 117 cases BVFI can be attributed to the following causes: surgical trauma (44%), malignancies (17%), endotracheal intubation (15%), neurologic disease (12%), and idiopathic causes (12%).^[1]

History

The importance of a complete history cannot be overstated. The history should include the following:

• Chief symptom, as related to airway, voice, or swallowing
• Onset of symptoms (acute, subacute, chronic)
• Changes in the voice and airway over time
• Related events such as intubation, surgery, or other medical conditions that can affect vocal cord mobility
• Tobacco use

In children, obtaining a history of birth trauma, central nervous system abnormality, intubations, or surgeries is important.

Treatment options

Procedures for bilateral vocal fold (cord) paralysis (BVFP)

• Tracheostomy
• Reinnervation techniques (experimental)^[11]
• Electrical pacing (experimental)
• Permanent procedures

  • Posterior cordotomy (unilateral or bilateral)
  • Arytenoidectomy (endoscopic or external, partial or complete)
  • Cordopexy, lateralization of the vocal cord

 I have asked the specialist Laryngologists in Auckland to review her and suggest treatment options for her.