International Journal of Pediatric Otorhinolaryngology (2009) 73, 9—13 Results: The laser posterior partial cordotomy allowed the decanulation after one session (n = 2) or avoided tracheotomy (n = 5), one patient had significant improve- 1. Introduction Vocal cord paralysis is the second aetiology of neo- natal stridor [1], after laryngomalacia. It remains a common cause of hoarseness in infants. A significant ment of his respiratory function. Two patients needed a second session of laser cordotomy and were decanulated. The functional results for the voice and swallowing qualities were subjectively satisfactory. One patient had pejorative evolution. Conclusion: Posterior partial cordotomy is an effective, minimal invasive technique which can be proposed to avoid tracheotomy in infants with bilateral adduction vocal cord paralysis. No functional sequelae were observed. # 2008 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +33 491 386 081; fax: +33 491 387 757. E-mail address:
[email protected] (R. Nicollas). 0165-5876/$ — see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2008.09.009 Laser cordotomy for the treatment of bilateral vocal cord paralysis in infants Aude Lagier, Richard Nicollas *, Me´lanie Sanjuan, Lafont Benoit, Jean-Michel Triglia Department of Pediatric Otorhinolaryngology, La Timone Children’s Hospital, 264 rue Saint Pierre, 13385 Marseille cedex 5, France Received 30 June 2008; received in revised form 1 September 2008; accepted 4 September 2008 Available online 18 November 2008 KEYWORDS Vocal fold paralysis; Vocal cord palsy; Laser cordectomy; Cordotomy Summary Objective: Vocal cord paralysis is the second cause of neonatal stridor. Several surgical treatments are proposed in order to avoid tracheotomy or to decanulate patients. Laser posterior partial cordotomy is supposed to be a minimal invasive procedure. The purpose of the study is to share our experience in management of laryngeal paralysis with this technique in infants and appreciate its role in avoiding tracheotomy in infants. Design: Retrospective study. Patients: The charts of 0—2-year-old patients treated for vocal cord paralysis from 1996 to 2007 are reviewed. Eleven infants with bilateral laryngeal paralysis in adduction presented severe dyspnoea. Tracheotomy was performed in four out of them, proposed in five others. One infant out of 11 underwent long-term intubation, and one presented with progressive dyspnoea. www.elsevier.com/locate/ijporl proportion of bilateral vocal cord paralysis (52%) of the pediatric cases spontaneously resolve, which is worse than unilateral ones (70% of spontaneous recovery) [2,3]. Tracheotomy is necessary for 66% of bilateral paralysis [3]; but it is associated with a significant morbidity and mortality [4,5]. The objec- tives of surgical treatments of vocal cord paralysis are: [1] to enlarge the airway, [2] to preserve the voice quality, [3] to ensure a good swallowing func- tion. The surgical techniques proposed to avoid the tracheotomy are arytenoidopexy, arytenoidectomy (by endoscopic or external approach), laser cordect- omy or cordotomy. This last surgical technique was first described in 1989 by Kashima [6] and was adapted in pediatric patients in 1999 by Friedman et al. [7]. The purpose of this retrospective study is to review the results of the laser posterior transversal cordotomy and ana- lyze if this method can be considered as a minimal invasive surgery in the treatment of bilateral vocal cord paralysis in adduction in infants under 2 years. 2. Patients Laser posterior partial cordotomy was proposed to patients with bilateral vocal folds paralysis in adduc- tion who presented severe dyspnoea and who required tracheotomy. Laser cordotomy was consid- ered as an alternative procedure to tracheotomy. From 1996 to 2007, 18 bilateral vocal fold paraly- sis in adduction were treated in our department of pediatric otorhinolaryngology using the laser pos- terior partial cordotomy technique. Eleven out of them were infants (from 0 to 2 years old), the study focuses on these cases. Table 1 outlines the aetiologies of bilateral vocal cord paralysis in adduction. The congenital aetiol- ogies, including idiopathic paralysis, foetal hypo- trophy, and cardiac or neurological malformations, are the most frequent (6/11). The acquired aetiol- ogies were sequels of oesophageal surgery (5/6) (Table 2). All the patients were in the first three months of life at the onset of the symptoms. Especially, seven were symptomatic since the neonatal period. Two patients presented glottic and subglottic stenosis associated, and three patients suffered of gastro- oesophageal reflux. The median age at the first consultation was 9 months old (0—24 months). The median delay between the date of first symp- toms and the date of the first consultation was 8 months (0—23 months). Out of the 11 patients, 4 had undergone tracheot- omy before the procedure, 1 was intubated for 4 weeks and was initially proposed for tracheotomy. 10 A. Lagier et al. add pe eot arytenoidectomy ula (11 days) eot eot ate eot ed eot ed eot ed eot ed ate ved Cordotomy KTP Trach Cordotomy KTP Trach Intubated (n = 1) Cordotomy CO2 Extub Severe dyspnoea/ tracheotomy proposed (n = 5) Cordotomy KTP Trach avoid Cordotomy + laser treatment of glottic stenosis CO2 Trach avoid Cordotomy KTP Trach avoid Cordotomy KTP Trach avoid Cordotomy CO2 Intub Increasing dyspnoea (n = 1) Cordotomy CO2 Impro Table 1 Aetiologies of bilateral vocal cord paralysis in Pre-operative status First surgery Post-o Tracheotomy (n = 4) Arytenoidopexy — Trach Cordo- KTP Decan uction. rative status Second surgery Final status omy Cordo- arytenoidectomy KTP Decanulated (14 days) ted — — — omy Contro-lateral cordotomy KTP Decanulated (17 months) omy Laryngo- tracheoplasty (Cotton) — Decanulated (4 days) d (1 day) — — — omy — — — omy — — — omy — — — omy — — — d Contro-lateral cordotomy + tracheotomy CO2 Tracheotomy, died — — — omy). The dissection is carried out laterally to the session of laser and had bilateral cordotomy. One patient had laser treatment of his glotto-subglottic Laser cordotomy for the treatment of bilateral vocal cord paralysis in infants 11 Fig. 1 Intra-operative view of posterior partial laser cordotomy with KTP laser. Table 2 Aetiologies of vocal cords paralysis. level of the thyroid cartilage. The vertical extension concerns the real vocal fold: from the inferior limit of theMorgani ventricle to the immediate undersurface of the vocal fold. The technique enlarges the poster- ior part of glottis while the vocal folds still have a good contact on the anterior commissure (Fig. 1). Six patients presented progressive dyspnoea and five out of them were proposed for tracheotomy. The mean delay between the first symptoms and the surgery was 8months. Three patients (27%) were operated on during the first month following the diagnosis. 3. Method The laser posterior transverse partial cordotomy is performed under general anaesthesia, with sponta- neous ventilation or ventilation via the tracheotomy tube. Lidocaı¨ne hydrochloride is sprayed in the pharynx and the larynx before the procedure. The intervention is performed via suspension laryngo- scopy, using either KTP or CO2 laser. The mobility of the cricoarytenoid joint is tested before beginning the procedure. CO2 laser (n = 3) is performed when the larynx exposure is good enough with direct laryngoscope. In all the other cases, KTP laser is used (n = 8). KTP laser is used with a 400 mmfibre, denudated fibre, in contact shoot, at 1.6 W. CO2 laser is used at 1.5 W, in continued superpulse acuspot. The cordotomy consists on a section in the poster- ior third of the true vocal fold. This incision frees the vocal ligament and the vocalis muscle from the ary- tenoid cartilage. The section is performed at the anterior edge of the vocal process of the arytenoids (which remains intact and should not be exposed when cordotomy is not associated to arytenoidect- Congenital (n = 6) Idiopathic 3 Hypotrophy 1 Neurological malformations 2 Acquired (n = 5) Surgery for oesophageal atresia 5 The arytenoidectomy was associated to cordot- omy in two cases. It consists of a partial resection of the arytenoids and of the posterior part of the vocal cord, the posterior wall of the arytenoids remains intact. The side of the cordotomy (or cordo-arytenoidec- tomy) is determined at the pre-operative examina- tion or under spontaneous ventilation anaesthesia. If stenosis at the same time as the cordotomy. Post-operative cares are: anti-gastro-oesopha- geal reflux treatment for 8 weeks and oral antibio- tics for 1 week. Aerosol-therapy is used for 7 days. Steroids can be ordered. An endoscopy is systematically performed 3 days after the procedure when the KTP laser is used in order to clean the fibrinous residues [8]. Final heal- ing is obtained 1 month later (Fig. 2). When the CO2 laser is used, the follow up can be easier with flexible endoscopic evaluation. 4. Results A surgical treatment was proposed to the patients presenting bilateral adduction paralysis of the vocal onevocal fold seems to have a light degreeofmotion, the cordotomy is performed on the other one. The cordotomywas unilateral for nine patients (three left and six right sides). Two patients needed a second Fig. 2 Endoscopic control, 4 weeks after surgery. folds and severe dyspnoea, in order to decanulate if Two patients had partially improved symptoms. One patient needed a contro-lateral cordotomy. He in proposed to patients with important dyspnoea. This controversial. The tracheotomy is still a very effec- 12 A. Lagier et al. is not our experience and most of our patients presented severe dyspnoea and were proposed for tracheotomy. The choice of the intervention is also cop e well without any intervention, which is only children is still very controversial. In the literature, a high proportion of patients can The was decanulated 17 months after the second proce- dure (he was a foreigner and was lost of follow up during 16 months. He was decanulated without any other session). One patient who presented a tracheal stenosis (grade II) was operated on for this pathology, and was decanulated 4 days after this procedure. One patient had a bad evolution with necessity of tracheotomy after bilateral procedures of cordo- tomies. This new born was microcephalic and hypo- trophic. He died when 2 months old. Arytenoidectomy was associated to cordotomy in two cases. Thefirst patient had undergonepreviously an arytenoidopexy (King technique) that failed to treat the dyspneoa; the cordo-arytenoidectomy was performed in second intention, and immediately allowed the decanulation. Another patient had a cordo-arytenoidectomy in first intention which allowed the decanulation 1 month later. This last patient was our first case of endoscopic laser treat- ment for bilateral laryngeal paralysis in adduction in first intention, that is why he was not decanulated immediately: he did not need any second session. The mean follow up is 27 months (2 months to 7 years), and one patient was lost to follow up. Except for the patient with pejorative evolution, no swal- lowing problem was reported. During the follow up, the parents evaluated subjectively the voice quality of the patient, and judged it as good as, or better than before the cordotomy. The perceptive analysis performed by the ENT practitioners on the GRB scale were noted G1 R1 B0 to B1. 5. Discussion management of the bilateral laryngeal paralysis tracheotomized, or to avoid the tracheotomy. For the nine patients treated by cordotomy, eight had a good result after one procedure: - four avoided tracheotomy (initially proposed), - one was extubated immediately and also avoided tracheotomy, - one patient had clinical and functional improve- ment. tive management for vocal cord paralysis. But it is associated with mortality (0.5%) and high morbidity (58% to 70 %) [4,5]. Several techniques were pro- posed as alternatives to the tracheotomy in the management of vocal fold paralysis in adduction. King [9], in 1939, described the latero-fixation of the arytenoids by an external approach. Arytenoidect- omy was described first by external approach [10], then via endoscopic approach [11]. Laser techniques are used since the 1980s [12]. Dennis and Kashima [6] described the technique of the CO2 laser cor- dectomy in adults in 1989. This techniquewas shown to be as effective as the laser arytenoidectomy for the management of bilateral vocal paralysis in adults [13], the short operative time is interesting for the frail patients [14]. Cordotomy was also better for the functional aspects with better vocal results and reduced risk of post-operative aspiration [15]. In 1999, Friedman described the application of the cordotomy in children from 14 months to 13 years old. The technique is effective in children and associated with good functional results for the qual- ity of the airway, voice and swallowing. [7]. Brigger and Hartnick [16,17] outlined that the laser endoscopic approaches were not as effective as the external approaches, especially the associa- tion of vocal cord lateralization and partial aryte- noidectomy. Nevertheless, that surgery is much more invasive and associated with higher voice sequelae and aspiration risks than the endoscopic approaches such as partial cordotomy. The study begins in 1996 because it was the date of the first cordotomy realised in our department. Before 1996, when surgery was necessary, we prac- ticed latero-fixation of the arytenoid [18]. The first patient who underwent laser endoscopic treatment was a failure of the external latero-fixation of the arytenoid. This experience led to endoscopic tech- niques, and the first approach was the endoscopic arytenoidectomy. The surgical evolution toward the technique of laser cordotomy came naturally. And since 1996, almost all patients operated on have benefited of cordotomy isolated (9/11). We prefer the term ‘‘cordotomy’’ instead of ‘‘cor- dectomy’’ because there is no significant excision of vocal fold tissue. The cordotomy only frees the vocal ligament and the vocalmuscle from the vocal process of the arytenoids. The tissue retraction enlarges the airway. Because of the small size of the larynx in children, this procedure is often sufficient, and safe. It is better to undercorrect than to take risks for the voice and the swallowing functions [7].When thefirst procedure is not sufficient, a second one is possible (cordotomy homolateral or contralateral), with a good result after this second procedure. Cordotomy rapidly became the procedure of choice for the treatment of bilateral vocal fold paralyses. The procedure is short, and reduces the time of anaesthesia. That is especially interest- ing for neonates or very young infants, who often the methodology of the objective evaluation has to be determined because in infants and neonates, References [1] K. Ungkanont, E. Friedman, M. Sulek, A retrospective ana- lysis of airway endoscopy in patients less than 1-month old, Laryngoscope 108 (1998) 1724—1728. Laser cordotomy for the treatment of bilateral vocal cord paralysis in infants 13 ww they are not easily reproducible. We used the KTP laser (n = 8) more often then the CO2 (n = 3). The CO2 micropulse laser is a priori preferred because of the better healing. But the quality of the larynx exposure for direct laryngo- scopy may not allow the use of the CO2 laser, especially in very young children, or children with malformative problems. KTP laser is used when the exposure is not good enough, with similar results. With KTP laser, endoscopic controls are necessary, because fibrinous residues have to be cleaned. 6. Conclusion Laser cordotomy is a minimal invasive treatment for the bilateral vocal fold paralysis in midline position. It can be used in frail children because of the rapidity of the procedure and represents an alter- native to tracheotomy for the infants. The proce- dure is efficient in most of the cases. A second session can be performed when the first one is not sufficient. The functional results on voice quality and swallowing are satisfactory even if the paralysis spontaneously recovers, so the procedure can be proposed early. Cordotomy becomes the procedure of choice in our department for the treatment of bilateral vocal fold paralysis in adduction. Available online at w present comorbidities. Cordotomy is quite easy to perform and the technique is quickly acquired. It can be proposed as an alternative to the tracheot- omy even at the moment of the diagnosis. Cordotomy is considered to be minimal invasive because functional results as swallowing and voice quality aregood. It canbeproposedeven if thepatient later recovers spontaneously. That is the reason why we did not wait systematically for 6—12 months as recommended by most of the authors [2,3,7]. Concerning functional aspects, we referred to the subjective appreciation by the parents as well as to the perceptual analysis by the ENT practi- tioner. Nevertheless this study should be completed by an objective evaluation of voice quality and swallowing tests before and after the surgery. But [2] I. de Gaudemar, M. Roudaire, M. Franc¸ois, et al., Outcome of laryngeal paralysis in neonates: a long term retrospective study of 113 cases, Int. J. Pediatr. Otorhinolaryngol. 34 (1996) 101—110. [3] D.F. Rosin, S.D. Handler, W.P. Potsic, et al., Vocal cord paralysis in children, Laryngoscope 100 (1990) 1174—1179. [4] M.M. Carr, C.P. Poje, L. Kingston, et al., Complications in pediatric tracheostomies, Laryngoscope 111 (2001) 1925— 1928. [5] R.F. Wetmore, R.R. Marsh, M.E. Thompson, et al., Pediatric tracheostomy: a changing procedure? Ann. Otol. Rhinol. Laryngol. 108 (1999) 695—699. [6] P.D. Dennis, H. Kashima, Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis, Ann. Otol. Rhinol. Laryngol. 98 (1989) 930—934. [7] E.M. Friedman, A.L. de Jong, M. Sulek, Pediatric bilateral vocal fold immobility: the role of carbon dioxide laser posterior transverse partial cordectomy, Ann. Otol. Rhinol. Laryngol. 110 (2001) 723—728. [8] R. Nicollas, A. Giovanni, J.J. 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Remacle, M. Hamoir, et al., Posterior cor- dectomy and subtotal arytenoidectomy for the treatment of bilateral vocal fold immobility: functional results, J. Voice 10 (1996) 314—319. [15] O. Laccourreye, M.I. Paz Escovar, J. Gerhardt, et al., CO2 laser endoscopic posterior partial transverse cordotomy for bilateral paralysis of the vocal fold, Laryngoscope 109 (1999) 415—418. [16] M.T. Brigger, C.J. Hartnick, Surgery for vocal cord paralysis: a meta-analysis, Otolaryngol. Head Neck Surg. 126 (2002) 349—355. [17] C.J. Hartnick, M.T. Brigger, J.P. Willging, et al., Surgery for pediatric vocal cord paralysis: a retrospective review, Ann. Otol. Rhinol. Laryngol. 112 (2003) 1—6. [18] J.M. Triglia, J.F. Belus, R. Nicollas, Arytenoidopexy for bilateral vocal fold paralysis in young children, J. Laryngol. Otol. 110 (1996) 1027—1030. .sciencedirect.com Laser cordotomy for the treatment of bilateral vocal cord paralysis in infants Introduction Patients Method Results Discussion Conclusion References