Office-based arytenoid palpation for diagnosis of disorders of bilateral vocal fold immobility

Ear, Nose & Throat Journal, August, 2006 by Priya Krishna, Clark A. Rosen

Abstract

Bilateral vocal fold immobility is an uncommon but serious condition with many causes. Accordingly, accurate diagnosis is essential in order to treat patients promptly and avoid long-term sequelae. Historically, diagnosis has been performed in the operating room with the patient under general anesthesia. We present the case of a patient who was diagnosed with bilateral vocal fold immobility by in-office arytenoid palpation that required only topical anesthesia of the larynx. The patient subsequently underwent appropriate treatment. In our opinion, office-based arytenoid palpation is a simple, safe, and accurate procedure for diagnosing bilateral vocal fold immobility.

Introduction

Bilateral vocal fold immobility is a potentially life-threatening disorder. Therefore, a prompt and accurate diagnosis followed by appropriate treatment is imperative. Vocal fold immobility or fixation has several etiologies that should be distinguished from one another because treatments vary. Four conditions account for nearly all cases of bilateral vocal fold immobility: (1) neurogenic bilateral vocal fold paralysis, (2) cricoarytenoid joint fixation, (3) laryngeal synkinesis, and (4) interarytenoid scar/posterior glottic stenosis. (1) Differentiation of these etiologies is based on the history and findings on flexible laryngoscopy, direct laryngoscopy (with arytenoid palpation), and laryngeal electromyography (EMG). (2) Historically, diagnostic laryngoscopy has been performed in the operating suite. Recently, an advanced technology called chip-tip flexible laryngoscopy has made it possible to move the setting for many diagnostic procedures from the operating suite to the office. We present the case of a patient who was diagnosed with posterior glottic stenosis during an in-office arytenoid palpation procedure.

Case report

The patient was a 69-year-old woman who had presented to an outside facility with a 6-month history of breathing difficulty and hoarseness. She complained that the quality of her voice would change intermittently. She would experience shortness of breath, particularly when supine. She also complained of a globus sensation and frequent throat clearing. Her medical history was significant for breast cancer (she had undergone a mastectomy 9 years earlier), hypothyroidism, hypertension, and coronary artery disease. She had no history of neck or chest surgery. She had been initially seen by a pulmonologist, who made a diagnosis of chronic obstructive pulmonary disease. She was then referred to an otolaryngologist, who noted bilateral vocal fold immobility with a small glottic airway. She underwent a tracheotomy and was subsequently referred to our institution.

Our examination by flexible laryngoscopy confirmed the bilateral vocal fold immobility (figure 1). Tracheoscopy performed via the tracheotomy opening revealed a normal distal airway and subglottis. Findings on laryngeal EMG were essentially normal except for the detection of a few large-amplitude motor units within the left thyroarytenoid muscle that were not consistent with a focal laryngeal mononeuropathy. (2) Arytenoid palpation and examination of the posterior glottis were required to complete the evaluation.

[FIGURE 1 OMITTED]

During the procedure, an assistant used a chip-tip flexible laryngoscope with a working channel (EndoEYE model CYF-V; Olympus Surgical America; Orangeburg, N.Y.). A flexible Silastic spray catheter (model PW-6P-1; Olympus Surgical America) with an inner diameter of 1.8 mm and a working length of 19 cm was inserted through the working channel of the laryngoscope. Topical lidocaine 4% droplets were administered to the endolarynx by the surgeon. A total of 1.5 ml of lidocaine was applied to the base of the tongue, laryngeal surface of the epiglottis, aryepiglottic folds, posterior glottis, and the true and false vocal folds (figure 2). An Abraham cannula from a peroral approach was used to palpate the endolarynx to test for adequate depth of anesthesia. Once anesthesia was confirmed, two Abraham cannulas passed perorally were used simultaneously to passively move the arytenoids laterally and expose the posterior glottis (figure 3). The arytenoids displayed minimal mobility on simultaneous passive movement. When one arytenoid was pushed laterally, the other moved medially. An interarytenoid scar band was noted with lateral retraction of the arytenoids.

[FIGURES 2-3 OMITTED]

The patient tolerated the procedure well and experienced no complications. She ultimately underwent C[O.sub.2]-assisted laser lysis of the scar band with application of mitomycin C, and she was decannulated. She was prescribed a daily proton-pump inhibitor and a behavior-modification regimen to treat gastroesophageal reflux disease.

Discussion

Bilateral vocal fold immobility is a broad term that is used to describe any condition in which both vocal folds do not exhibit purposeful motion. From among the four most common general etiologic categories--paralysis, cricoarytenoid joint fixation, synkinesis, and interarytenoid scar/posterior glottic stenosis--the most important specific causes are iatrogenic or surgical trauma, intubation trauma, neoplasms, neurologic disorders, inflammatory diseases, and psychogenic disorders. (1,3)