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D. Lancini et al.
the smallest cannula available for a given patient, checking
the position of its distal tip (especially in case of short and fat
neck), and monitoring the pressure of the cuff (deating it as
soon as possible), while maintaining scrupulous hygiene of
the tracheotomic wound also reduces undue damages to the
airway. Nevertheless, even in these optimal conditions, the
cuff, tip, or posterior curvature of the tracheostomy tube can
injure the inner tracheal wall. Moreover, the stomal site itself
may represent a possible source of granulation and suprastomal collapse, especially if a wide fenestration, or a large tube
with over-inated cuff, is applied for a long time.
Superinfection and poor local management may signicantly
increase the incidence of such problems.
An even worse scenario is represented by the simultaneous presence of a tracheotomic cannula (anteriorly in the airway) and a nasogastric feeding tube (posteriorly in the
esophagus). Bilateral compression of the posterior tracheal
wall by means of the tube/cuff and a large nasogastric feeding tube may, similar as seen above, determine pressure
necrosis of the oesophageal and tracheal mucosa, with ensuing perforation and formation of a tracheo-esophageal
stula.
Laryngeal fractures and joints dislodgement due to blunt
trauma or rush intubation may be further promoting processes for LTS.In this circumstance, the stenoses can grow
both from an altered spontaneous repair mechanism, as well
from damage of the airway cartilaginous framework itself
[8].
LTS can also be the presenting symptom of a number of
autoimmune conditions. The most common is Wegener’s
disease (i.e. ANCA positive granulomatosis with polyangiitis), a necrotizing vasculitis that can provoke LTS in both
adults and children (10–20% being diagnosed in the former,
up to 50% in the latter) [9, 10].
Idiopathic subglottic stenosis (ISS) is another potential
cause of progressive LTS involving the cricoid and rst tracheal rings. It purely affects women who result negative for
autoimmune disease markers (i.e., cANCA, pANCA, ACE),
have no medical history for major airway trauma, and present a well-dened histological picture of submucosal brosis
with imbalance of estrogens-progesterone hormone receptors. The pathogenesis of ISS is still unclear, even if female
sexual hormones and altered DNA methylation in response
to an otherwise trivial airway transient damage are possibly
involved in the aetiology of the disease [11–13].
In addition to the above-mentioned causes, congenital
issues are a separate and non-negligible category of
LTS.Their range of presentation varies from congenital subglottic stenosis to glottic-subglottic web, laryngeal atresia,
congenital tracheo-esophageal stula, complete tracheal
rings syndrome, and laryngo-tracheal cleft [14].
Moreover, LTJ can be involved by primary tumours or
tumour-like lesions, as well as by neoplasms arising in adja-
cent structures and secondarily growing into the airway.
Among primary tumours, cricoid chondroma and chondrosarcoma [15, 16], squamous cell carcinoma of the subglottis
and trachea, and minor salivary gland carcinomas (i.e. adenoid cystic and mucoepidermoid carcinomas) are the most
represented histotypes. Tumour-like lesions are mainly hamartoma, laryngeal papillomatosis, and airway localization of
systemic amyloidosis. The latter is a rare condition, characterized by the progressive accumulation of extracellular proteins in an abnormal brillar form [17]. Lastly, a fairly
common cause of LTS is secondary involvement of the airway by the extensive growth of thyroid tumours [18, 19].
5.4 Laryngo-tracheal Stenosis Evaluation
andGrading
According to European Laryngological Society (ELS) recommendations [20], a comprehensive and precise diagnostic
work-up should be always performed before planning LTS
surgical treatment. In detail, this work-up is articulated
through endoscopic and radiologic evaluation. The endoscopic study, in turn, is composed of different possible
modalities (to sometimes perform in mutual combination):
awake transnasal bre-optic laryngoscopy, asleep broscopy, direct transoral laryngo-tracheoscopy with 0° and
angled rigid endoscopes, suspension micro-laryngoscopy,
and bronco-esophagoscopy. The aims of these investigations
are to collect the most detailed information about LTS assessing vocal cord motility, swallowing, location of stenosis
(with respect to the glottis and a possible tracheostoma),
cranio-caudal extension, diameter, consistency (fresh, incipient, mature scar), evaluation of the length of residual normal
trachea, presence of associated airway morbidities (e.g.
obstructive sleep apnoea syndrome, chronic obstructive pulmonary disease), and possible sampling for histologic
denition.
Radiologic work-up is not always mandatory and usually
plays a secondary role compared to endoscopic evaluation. It
is mainly represented by CT and/or MR, aiming to evaluate
the presence of compression/inltration of the airway by
external lesions, assess the integrity of the laryngo-tracheal
framework, examine the distal portion of the airway if not
otherwise possible, and exclude the presence of other malformations in case of congenital airway anomalies. Also, in
presence of complete LTS with a tracheotomic cannula in
place, radiologic imaging allows to precisely quantify the
cranio-caudal extent of the resectable airway, which is sometimes difcult to ascertain through endoscopy alone due to
the variable thickness of the stenotic diaphragm itself
(Fig.5.4).
Concerning grading of LTS severity, the literature reports
several available systems which we consider herein:
(from below)
to be evaluated
5 Tracheal andCricotracheal Resection andAnastomosis forSubglottic and/or Proximal Tracheal Stenoses
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bine the 2 grading systems reported above by multiplying
them. For example a grade 3 stenosis according to the
MOC system and involving the subglottis and trachea
(stage II according to LN) is considered as LTS grade 6,
which is intuitively easier to manage than a grade 4 MOC
involving all 3 LN subsites (i.e. an LTS with an overall
grade of 12). This 3-D staging system may be also
expressed as described by Monnier and coworkers who
use the Roman numerals for MOC and letters “a,” “b,”
“c,” and “d” (also including the supraglottis as airway
Visible
stenosis
(from above)
subsite) for LN, adding a “+” in case of associated severe
comorbidity Laryngo-tracheal junction (LTJ) evaluation
and grading or cardiovascular and/or pulmonary
congenital anomalies [20].
61
Visible
stenosis
Fig. 5.4 In case of complete subglottic/tracheal stenosis, CT can be
useful in quantifying the vertical height (thickness) of the cicatricial
tissue between the most caudal portion of the airway visible through the
nose and the tracheostomy site. The precise measurement of this length
is of fundamental importance in accurate planning of TRA/CTRA, particularly in the presence of a long LTS approximating the ideal limit for
resectability of 5.5cm
Thickness
by imaging
Tracheostomy
– Myer–O’Connor–Cotton (MOC) grading system [21],
dividing airway stenoses in 4 grades, based on the entity
of axial lumen narrowing (grade 1, <50% obstruction;
grade 2, 51–70%; grade 3, 71–99%; grade 4: no detectable lumen or 100% obstruction);
– Lano–Netterville (LN) grading system [22], dividing LTS
in 3 stages, based on the number of cranio-caudal subsites
involved (glottic, subglottic, and trachea). Therefore, a
stage I stenosis may be a purely glottic or subglottic or
tracheal issue, while stage II may be either a glotticsubglottic stenosis, or a subglottic-tracheal problem. The
stage III issue is clearly the most complicated, involving
all 3 airway subsites.
As an adjunctive and comprehensive index of the severity
of LTS, the authors of the present chapter normally com-
5.5 Treatment Indications andOverview
Data collected during the above-mentioned preoperative
work-up are necessary to select the appropriate treatment
modality. In fact, two approaches can mainly be used:
endoscopic (by balloon dilatation, laser vaporization,
rigid bronchoscopic dilatation, endoluminal stenting) or
open (laryngo-tracheoplasty by cartilaginous grafting or
circumferential resection approaches such as tracheal
[TRA] and crico-tracheal resection and anastomosis
[CTRA], which represent the main topics of the present
chapter).
Our policy, supported by a number of authors in the most
recent literature, is to consider patients affected by LTS less
than 1cm in length, cicatricial, web-like, and with an intact
cartilaginous framework as candidates for an endoscopic
approach. However, endoscopy may be a useful option even
in case of temporary or palliative tumour debulking and to
obtain denitive histopathologic evaluation of the lesion,
when open treatment is not otherwise suitable for the
patient’s poor general conditions, or to bridge the gap
between an emergent airway obstruction and its denitive
open management.
In contrast, a long LTS (<5.5cm), extending to more than
one subsite, with framework involvement, either by fracture
as well as by malacia, are good indications for open techniques which, in our hands, are mainly represented by TRA
and CTRA.Moreover, open approaches may also be indicated for curative treatment of intrinsic and extrinsic airway
neoplasms (Fig.5.5).
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Fig. 5.5 Our treatment
algorithm for LTS
management. CTRA
crico-tracheal resection and
anastomosis, LT
tracheal, Grading of LTS is
herein reported according to
the MOC grading system [21]
laryngo-
Grade I-mild Ill,
web-like, mature scar
Endoscopic approach
by laser alone
Success
Diagnostic work-up of iatrogenic LT stenosis
Failure
5.6 Classication ofTRA/CTRA
We usually classify TRA and CTRA into ve types:
– Type A: tracheal resection alone, with tracheo-tracheal or
crico-tracheal anastomosis (without resection of any part
of the cricoid cartilage) (Fig.5.6a–d).
– Type B: removal of tracheal rings together with the ante-
rior portion of the cricoid arch, and subsequent thyrocrico- tracheal anastomosis (Fig.5.7a and b).
– Type C: removal of the anterior cricoid arch and inner part
of the cricoid plate (potentially up to the CAJs), with
ensuing thyro-crico-tracheal anastomosis and covering
the bare cricoid plate by a pedicled ap of posterior tracheal wall (Fig.5.8a and b).
Grade I-mild III,
funnel-shaped,
immature scar, no
immediate
possibility for CTRA
Endoscopic approach
by laser +/- stent
Success Failure
Severe grade Ill-IV,
fractured framework,
Bad general
conditions
funnel-shaped,
malacia
Discrete or good
general conditions
CTRA
– Type D: removal of the anterior cricoid arch, possible
removal of part of the cricoid plate, posterior median cri-
coid split up to the inter-arytenoid area, with positioning
and xation of a cartilaginous graft, with thyro-crico-
tracheal anastomosis as described in Type C (Fig. 5.9a
and b).
– Type E: removal of one hemicricoid including half of the
anterior arch and the corresponding half of the cricoid
plate, disarticulating the overlaying ipsilateral arytenoid,
then bridging the gap by a rotational thyro-crico-tracheal
anastomosis obtained by cutting in an asymmetrical fash-
ion the distal airway stump used to sustain the preserved
arytenoid. This procedure is a modication of total cri-
coidectomy with rotational tracheopexy as described by
Rovò and coworkers [23] (Fig.5.10a–c).
abcd
ab
a
b
ab
a
b
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Fig. 5.6 TRA Type A: removal of tracheal rings only, with subsequent
crico-tracheal anastomosis (a and b) in case of resection starting from
the rst tracheal ring or tracheo-tracheal anastomosis (c and d) when
more distal portions of the trachea have been resected. (a and c) Frontal
views. (b and d) Lateral views
Fig. 5.7 CTRA Type B: removal of the rst tracheal rings in association with the anterior arch of the cricoid cartilage and subsequent thyrocrico- tracheal anastomosis. (a) Frontal view. (b) Lateral view
Fig. 5.8 CTRA Type C: removal of the anterior cricoid arch and part
of the cricoid plate, potentially up to the crico-arytenoid joints, with
subsequent thyro-crico-tracheal anastomosis. (a) Frontal view. (b)
Lateral view
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Graft
Graft
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Fig. 5.9 CTRA Type D: removal of the anterior cricoid arch and part
of the cricoid plate between the crico-arytenoid joints, posterior midline
cricoid split through median thyrotomy, and placement of a costal graft
between the two halves of the divided cricoid lamina, with subsequent
thyro-crico-tracheal anastomosis. (a) Frontal view. (b) Lateral view
Fig. 5.10 CTRA Type E: resection extended to half of the cricoid arch
and plate (potentially up to 75%, involving one crico-arytenoid joint but
leaving the ipsilateral arytenoid cartilage disarticulated). The ipsilateral
recurrent nerve is resected, while the intrinsic laryngeal muscles are
removed or denervated. Reconstruction is then achieved by tracheal
reshaping and rotational tracheoplasty. (a) Frontal view. (b) Axial view.
(c) Frontal view at the end of the thyro-crico-tracheal anastomosis with
rotational tracheoplasty
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5.7 TRA/CTRA Surgical Techniques
Endotracheal intubation should be obtained under safe conditions with the help of a video-laryngoscope, exible nasal
berscope, serial dilatation by bougies of increasing diameters, or rigid bronchoscopy. If none of these manoeuvres are
successful in establishing a safer orotracheal intubation, tracheostomy through the airway stenosis should be carried out.
This can be obviously contraindicated in case of neoplastic
stenoses, in which violation of the tumour may lead to its
dissemination into the neck, in addition to bleeding and
tumour dislodgement into the distal airways. Once the endotracheal intubation has been safely accomplished, the patient
should be placed on the operating table with the head in a
hyper-extended position. A cervical collar incision is made
centering it on the tracheostoma (if present) or at the level of
the presumed airway stenosis. Moreover, it can be extended
laterally if a simultaneous neck dissection is required for
oncologic reasons. Next, superior and inferior subplatysmal
aps are elevated, and the supercial cervical fascia exposed.
This is vertically opened along the linea alba cervicalis and
the prelaryngeal muscles divided along the midline and lateralized with retractors. In order to completely expose the LTJ
and proximal trachea, thyroid isthmusotomy is performed
and lobes of the gland lateralized by dissecting them free
from the trachea. This manoeuvre should be performed in
strict adherence to the external tracheal perichondrium, in
order to not injure the RLNs, which run laterally into the
tracheo-esophageal groove. By lateralizing the thyroid lobes,
however, these nerves are also out of danger and, in fact, if
thyroidectomy is not needed for oncologic reasons, RLNs
should not be systematically identied and isolated during
such a procedure. The airway resection can be undertaken
only when the stenotic tract has been fully exposed. Attention
should be paid to not dissect the airway too far distally from
the stenotic segment, thus avoiding excessive tracheal
devascularization.
In case of purely tracheal stenosis, a Type A procedure is
usually required (Fig. 5.6a–d). The stenotic segment is
opened horizontally in its midpoint in order to explore the
inner aspect of the tracheal lumen. The endotracheal tube is
now withdrawn at the glottic level and hooked with a stitch,
in order to be easily retrieved at the end of airway resection.
Meanwhile, a second endotracheal tube is passed through the
tracheal opening into the distal airway stump. The stenotic
airway segment is then resected and removed entirely, as far
as healthy airway is encountered on both cranial and caudal
extremities. The posterior dissection is carried out to separate the membranous tracheal wall from the anterior oesophageal surface. This manoeuvre should not be extended far
beyond 1–1.5 cm from the circumferential resection line,
especially at the level of the distal stump, since the trachea,
after thyroid isthmusotomy, will receive the vast majority of
its blood supply from the oesophagus itself. After removal of
the stenotic segment, the procedure continues with an inferior tracheal release: the distal tracheal stump should be
mobilized by blunt dissection on its anterolateral surface,
detaching the mediastinal soft tissues and freeing the surrounding innominate artery and vein. This manoeuvre is usually complete when the surgeon’s index reaches the carina
and/or feels the origin of the innominate artery from the aortic arch, and usually allows a cranial mobilization of the distal tracheal stump of more than 1.5–2cm. However, every
attention should be paid to not extend the dissection laterally
for the risk of bleeding and/or damage to the RLNs. A couple
of “stay sutures” with 2-0 polyglactin 910 (encircling the full
thickness of one tracheal ring located at least two tracheal
rings below the resection line) are then symmetrically positioned in the lateral aspect of the distal tracheal stump
(Fig.5.11). The same manoeuvre is carried out at the level of
the superior stump, placing two stay sutures in the
corresponding o’clock position of the inferior ones. In case
of a crico-tracheal anastomosis (Fig. 5.6a and b), these
sutures will be passed through the cricoid cartilage (medially
to the RLNs laryngeal entry points) (Fig.5.12). In this way,
approximating the superior and inferior stay sutures, it is
possible to verify the tension of the future anastomosis. In a
long resection (>4cm), an additional laryngeal release may
be required by resecting the thyro-hyoid muscles, membrane, and lateral ligaments. This manoeuvre allows the larynx to drop towards the mediastinal inlet, but, as a
consequence, inevitably results in a certain degree of tempo-
Fig. 5.11 Inferior “stay sutures” encircling the full thickness of one
tracheal ring located at least two tracheal rings below the resection line
and symmetrically positioned in the lateral aspect of the distal tracheal
stump
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Vi
C
Vicryl 4-0
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rary dysphagia. Moreover, it is described to increase the risk
of bleeding with possible supraglottic haematoma and further transient dysphagia. Therefore, it should be carried out
only in selected cases.
The preparation of the anastomosis continues by passing
4–5 4-0 polyglactin 910 sutures between the membranous
tracheal wall of the inferior stump and the membranous or
posterior cricoid mucosa of the superior stump. When completing the anastomosis by passing the remnant 10–12 2- and
3-0 polyglactin 910 sutures into the lateral and anterior sectors of the suture line, attention must be paid to make the
stitches emerge on the external surface of the larynx in a subperichondral plane (Fig.5.13). Once the anastomosis prepa-
Fig. 5.12 Superior “stay sutures” passed through the cricoid cartilage
anteriorly and medially to the entry point of the recurrent laryngeal
nerves
ration is completed, the distal tracheal tube is removed and
replaced by pulling inferiorly the oro-tracheal one. At this
moment, the patient’s head should be gently exed by adding
a pillow or similar below its occiput. Subsequently, the
sutures are symmetrically tied in the following order: 2-0
stay sutures rst, 4-0 posterior stitches second, and 2- and
3-0 antero-lateral ones in a lateral to medial sequence.
When the site of stenosis involves the anterior part of the
cricoid cartilage, a Type B CTRA is indicated (Fig.5.7a and
b). In this procedure, the excision encompasses the anterior
portion of the cricoid arch, potentially resectable in a fullthickness way up to the crico-thyroid joints, while posterolaterally to these structures the RLNs is increasingly at risk
of potential damage. In case of posterior involvement of the
mucosa and cartilage forming the posterior cricoid plate,
these can be removed and/or drilled working from the inner
surface of the organ into an external-posterior direction, up
to the posterior cricoid perichondrium and posterior cricoarytenoid muscles, thus performing a Type C CTRA
(Fig.5.8a and b). Posterior to these, the RLNs are at risk of
an iatrogenic lesion (Fig.5.1). In CTRA Types B and C, the
distal tracheal stump needs to be adequately reshaped by
cutting it in an oblique way using a slope cut to t it in
between the inferior border of the thyroid cartilage, the lateral extremities of the cricoid ring, and the residual cricoid
plate. In Type C CTRA, the residual cricoid plate must be
covered by a pedicled ap of the membranous wall of the
distal tracheal stump. The distribution of sutures then follows the same order mentioned above, with the only difference that the proximal stay sutures will be placed
extra-mucosally into the inferior aspect of the thyroid alae.
This approach may be extended to the CAJs posteriorly and
to the inferior insertion of the conus elasticus laterally, for
example in case of idiopathic subglottic stenosis. In this
case, however, 1–2 stitches of 3- or 4-0 polyglactin 910
Fig. 5.13 The sequence of
sutures placed to accomplish
the airway anastomosis. The
same order will be followed
for tying them
cryl 2-0
Vicryl 2-0
17
20
19
18
Vicryl 3-0
11
10
9
4
5
15
12
14
13
12
8
7
6
3
Vicryl 2-
Vicryl 2-C
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should be placed in order to increase the tension of the vocal
cords inferior aspect, by tethering them to the inferior border
of the corresponding thyroid lamina.
When a posterior glottic stenosis is detected for the presence of inter-arytenoid scar tissue adducting the vocal cords,
a Type D CTRA (or “extended CTRA” following Monnier’s
nomenclature) [24] is advisable. This procedure requires
both an anterior midline thyrotomy and a posterior cricoid
plate split. The posterior cricoid mucosa is dissected from
the cartilage to form a bilateral pocket. A rectangular costal
cartilage graft (as long as the cricoid plate in the sagittal view
and with lateral anges in the axial plane to t with the
enlarged cricoid cartilage) is inserted and sutured in front of
the crico-pharyngeal muscle, thus expanding the cricoid circumference and opening the vocal cords. Even in this case, a
large membranous tracheal ap will be harvested in order to
coat both the split cricoid plate and the cartilaginous graft.
Moreover, an endolaryngeal mold will be inserted to guarantee adequate stability of the reconstructed LTJ in the rst
perioperative period, which will be left in place for some
weeks.
Type E CTRA (Fig. 5.10a–c) is indicated in case of
involvement of one-half of the cricoid arch and plate by subglottic tumours such as chondroma, low-grade chondrosarcoma, minor salivary glands tumours, or other rare histotypes.
In this procedure, the resection starts by transecting the cricoid arch along the midline and then proceeds posteriorly to
separate the ipsilateral hemicricoid plate from the inferior
thyroid cornu, thyroid ala, lateral crico-arytenoid and vocal
muscles, conus elasticus, and, nally, the arytenoid by passing through the CAJ.The mucosa of the cricoid plate is then
cut along the posterior midline and the full thickness of the
cricoid plate is sectioned vertically from the inter-arytenoid
area to the inferior margin of the cricoid itself. The ipsilateral
posterior crico-arytenoid muscle is then dissected free from
the mucosa of the retrocricoid area and the ipsilateral RLN
transected.
At the level of the distal tracheal stump, the resection is
carried out in an asymmetric fashion, by reshaping the rst 4
tracheal rings in order to t them into the hemicricoidectomy
performed (Fig. 5.10). In particular, the ipsilateral angle
between the cartilaginous and membranous parts of the tracheal stump will be rotated and put below the disarticulated
arytenoid. In the same way, the inferior border of the vocal
cord and conus elasticus will be sutured infero-laterally to
the inferior margin of the thyroid lamina to tether the denervated vocal fold. Tracheal rotation is aimed to suture the vertical cut of the residual hemicricoid plate to the lateral edge
of the tracheal party wall, thus reinforcing the retrocricoid
mucosa that was previously dissected free from the cricoid
plate. The asymmetric thyro-crico-tracheal anastomosis is
then accomplished by 4-, 3-, and 2-0 polyglactin 910 sutures,
similar to the previous description. In comparison to the
other types of CTRAs, a larger number of sutures are usually
required due to the presence of the vertical component of the
anastomotic line between the lateral edge of the rst two tracheal rings and the residual hemicricoid arch (Fig.5.10).
After a type D and E CTRA, tracheotomy is mandatory
and should be positioned at least 2–3 tracheal rings below the
level of the anastomosis in order to not hamper the healing
process. Regardless of the type of procedure, the thyroid
isthmus and strap muscles are then closed on the midline and
drainage placed supercially to the muscles themselves. A
couple of “guardian sutures” are tied from chin to chest to
maintain the patient’s head in a exed position. Patient awakening should be carried out under transnasal bre-optic control while checking vocal cords mobility, respiratory space,
and mucosal oedema.
5.8 Postoperative Management
Antiemetics, antitussives, and proton-pump inhibitors are
administered in the rst postoperative days to minimize the
probability of vomit, cough, and gastro-oesophageal reux.
Prophylactic antibiotics should be prolonged for at least one
week after surgery. Corticosteroids should be avoided as
much as possible due to their well-known detrimental effect
on anastomotic healing. Generous air humidication should
be maintained for the rst postoperative days. The neck and
surgical wound should be carefully monitored to detect early
signs of anastomotic leakage (i.e. dry cough, subcutaneous
emphysema, and cutaneous hyperaemia). Oral feeding is
generally started on the second postoperative day, and nasogastric feeding tube rarely employed, and usually just for
Type E CTRA.Surgical drainage is normally removed on the
third postoperative day, and the “guardian sutures” cut on the
eighth postoperative day (i.e. at completion of the healing
process of the anastomosis). In case of very complex resections in fragile patients, or in case of redo-CTRA procedure
after surgical complications (such as anastomotic dehiscence), postoperative monitoring in the intensive care unit
may be required to maintain the patient sedated and intubated. When a tracheotomy is performed, the cannula should
be downsized and removed in the shortest time possible, thus
allowing the patient to breathe through his/her physiological
airway. After hospital discharge, periodic endoscopic follow up is scheduled to evaluate the healing process; after this,
further endoscopic evaluations are tailored to the individual
condition and planned according to the underlying disease.
In case of TRA/CTRA performed for oncologic reasons,
radiologic surveillance is scheduled according to the histotypes and stage of disease.
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Surgery forVocal Fold Immobility
https://t.me/med1917
DeclanCostello, GauthierDesuter, andJulieT.van Lith-Bijl
6
6.1 Introduction
Patients with unilateral vocal fold paralysis (UVFP) will
typically present to the clinic with a breathy, quiet, and highpitched voice. Poor vocal fold closure on phonation leads to
glottic insufciency, and hence the loss of air and a breathy
quality. The high pitch of the voice is a function of a compensatory technique employed instinctively by most patients:
By tensioning the vocal folds, better closure can be achieved,
but this tension results in a raised phonatory pitch. Patients
also frequently complain of a subjective sensation of breathlessness; in fact, this is not genuine dyspnoea, but with the
incompetence of the glottis and excessive air loss, the patient
perceives shortness of breath.
One of the primary functions of the larynx is protection of
the airway; loss of adequate glottic closure on deglutition
can result in aspiration. This is particularly true for liquids,
but can also occur with solid or semi-solid textures. In addition, some patients experience spontaneous aspiration of
saliva causing paroxysms of coughing. It is now known that
silent aspiration results in excess morbidity and mortality
[1].
The degree of breathy dysphonia is very variable and is a
function of the position taken by the vocal fold. In general, a
vocal fold sitting in a median/paramedian position results in
better glottic closure, and hence a stronger voice (Fig.6.1).
D. Costello
King Edward VII’s Hospital, London, UK
e-mail: dc@dcostello.net
G. Desuter
Voice and Swallowing Clinic, Department of Otolaryngology Head
and Neck Surgery, Cliniques Universitaires Saint-Luc,
Brussels, Belgium
e-mail: Gauthier.desuter@uclouvain.be;
gdesuter@post.harvard.edu
J. T. van Lith-Bijl (*)
Flevoziekenhuis, Almere, the Netherlands
Cliniques Universitaire Saint-Luc, Brussels, Belgium
Conversely, a vocal fold sitting in a lateral position (Fig.6.2)
will result in a very breathy voice. Most treatments for UVFP
are aimed at repositioning the paralysed vocal fold into a
more medial position.
After appropriate investigation (or even in parallel with
investigation), treatment options can be considered. The
management of UVFP has changed considerably in recent
years. In the past, a period of clinical observation for up to
12months would have been advocated to allow for spontaneous recovery of the paralysis and/or compensation from the
contralateral vocal fold. At the end of this period, if the voice
had not improved sufciently, surgical intervention can be
considered, usually in the form of an injection medialization
under general anaesthetic or laryngeal framework surgery
(Isshiki type 1 thyroplasty—medialization laryngoplasty).
However, improvements in outpatient endoscopic stack
systems (particularly the advent of chip-tip endoscopes) and
better injection materials mean that it is now easy and quick
to perform a medialization injection (injection laryngoplasty) under local anaesthetic in the clinic. In current practice, a variety of options are available for management:
• Direct repair of the injured nerve. If the recurrent laryn-
geal nerve is transected (either deliberately or acciden-
tally) in the course of a surgical procedure, it might be
reasonable (if the surgeon is appropriately trained) to per-
form a primary end-to-end nerve anastomosis. If there is
a loss of length of the nerve, an interposition graft can use
the greater auricular nerve.
• Voice and swallow therapy. All patients who present to
clinic (or indeed those who are inpatients) should be
referred for speech therapy, to address not only dysphonia
but also the swallow dysfunction. In some circumstances,
patients at high risk of aspiration (either clinically or on
functional endoscopic evaluation of swallowing, FEES)
may be placed nil-by-mouth to avoid life-threatening
aspiration pneumonia.
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_6
69
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