A case of bilateral abductor paralysis of vocal cord

Clinical details:

60 years old female patient was admitted with tracheostomy for decanulation.
she was on tracheostomy for the past 8 years. Tracheostomy was peformed for
bilateral abductor paralysis of vocal cords following total thryoidectomy 8 years back.
Two attempts of decannulation proved futile.

On examination:

Patient had a near normal voice.
She was on Fuller's tracheostomy tube

Videolaryngoscopy: showed bilateral abductor paralysis with vocal cords in paramedian position.
There was no pooling of saliva in the pyriform fossae.

Management:

Patient was taken up for surgery. Anesthesia was given after connecting the patient's tracheostomy tube (portex) to the
Boyle's apparatus. Using Klein Sausser suspension laryngoscope, vocal cords were exposed. Posterior third of the left
vocal cord was excised after taking strict hemostatic precaution. A triangular gap was created in the posterior glottic area.

Patient's portex tracheostomy tube was changed to Fuller's metal tube on the first post op day. The same tube was
spiggoted. Decannulation was successfully performed on the 6th post op day.

Discussion:

1. In all patients of bilateral abductor paralysis of vocal cords air way management takes precedence over voice. Air way should be secured immediately by performing tracheostomy.
2. Efforts should be made to decannulate the patient as early as possible

3. In patients who have failed the efforts of decannulation, surgical management becomes a necessity.

Posterior cordotomy can be performed in patients with mild / moderate compromise of the airway. This procedure is more conservative, and has very little risk of aspiration.

Posterior cordotomy was first performed by Kashima and Dennis in 1989.

Suspension laryngoscope is used to visualize the larynx.
If laser is available it is better to perform laser cordotomy, because bleeding is minimal when laser is used.
Incision is made over the posterior portion of the true cord, just in front of the vocal process of the arytenoid cartilage.
About 1/3 of the posterior portion of the vocal cord is removed. Care should be taken not to damage the ventricle as it would cause
irreversible damage to the patient's voice.

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