AAO_HNS 2012 - Decision Making in vocal fold paralysis

Decision Making in vocal fold paralysis

AAO-HNS Session 10:30, September 11, 2012

Chairman: Al Merati, MD

Panel: Joel Blumin, MD, Michael Johns, MD & Blake Simpson, MD

Several case studies were presented by Al Merati and he kept the discussion moving and lively. A few topics wer covered. Some of the more interesting notes included the following. There was general agreement that there is almost no reason to image a paresis without other neurologic findings. Along this line, it is important to examine the nasopharynx for palate movement and the pharynx for symmetric squeeze to evaluate the upper branches of the Xth cranial nerve whenever there is a laryngeal paresis or paralysis.

Restylane seems to be the new preference for temporary augmentation of early paresis, either in the office or in the Operating room. The location of injection and route of injection (trans-oral, supra-thyroid, trans-cricothyroid space) seems to be based entirely on personal preference. Radiesse, despite FDA approval doesn’t seem to be a preference because of either the risk of or actual experience with stiffness on the part of the panelists. Everyone reported variable lengths of durability with temporary vocal cord injections, estimating 3-6 months for most products, except for Radiesse gel which seems to have shorter durability (my experience is about 1-3 months durability for collagen and for Radiesse gel - longer periods then four months for me seem to represent reinnervation). Placement of the injection has an impact on durability. Many laryngologists don’t really look closely to know when the product reabsorbs and spontaneous reinnervation impacts the validity of this assessment of duration for all of them.

The panel has removed more goretex implants for late problems, such as late extrusion, than silastic implants, perhaps 3-1 or 4-1. They do not consider this a big problem, just an observation.

All of the panel gives preoperative cephalexin and 5 days of cephalexin after implant surgery. I have never given post op antibiotics and never seen an implant infection. During the discussion period, none of them had any scientific basis for the post-operative administration of antibiotics. Steve Bielamowicz noted that he has never given either pre-op or post-operative antibiotics for laryngeal augmentation surgery and he has never encountered any infections. It would seem that the risk of infection for clean surgery in the neck, even with an implant is quite low.

A brief discussion ensued on laryngeal reinnervation procedures for paralysis. The panelists seem to prefer medialization procedures over reinnervation procedures. Although not an in-depth discussion, I learned that the panel members reinnervate with ansa cervicalis to the main trunk of the recurrent laryngeal nerve. I reinnervate with ansa cervicalis to the anterior branch of the recurrent laryngeal nerve or to muscle through an inferior thyroid cartilage window, so I primarly reinnervate thryoarytenoid muscle and perhaps some lateral cricoarytenoid muscle. Dinesh Chhetri uses reinnervation almost to the exclusion of medialization surgery. He anastomoses ansa cervicalis to the anterior branch of the recurrent laryngeal nerve just posterior to the cricothryoid joint, so almost certainly supplies both the thyroarytenoid and lateral cricoarytenoid muscles directly (where I am a little less likely to directly reinnervate lateral cricoarytenoid muscle). However, he always performs an arytenoid adduction at the same time. Ultimately I learned that when we talk about reinnervation surgery for vocal cord paralysis, there is some significant variation in technique.