Reinnervation of the paralyzed vocal fold.

A 42-year-old woman presented to our clinic with an 18-month history of idiopathic paralysis of the left vocal fold. She complained of hoarseness, fatigue with prolonged speaking, and occasional aspiration of thin liquids. Examination revealed that the left vocal fold was paralyzed in a paramedian position; significant bowing was also present.

The patient was taken to the operating room, where she underwent a left arytenoid adduction and reinnervation of the left recurrent laryngeal nerve (RLN) with a branch of the ansa cervicalis. Intraoperative evoked electromyography showed no activity in the vocalis muscle following stimulation of the left RLN, indicating a true paralysis. It is our protocol to proceed with reinnervation in this situation, the techniques of which have been described elsewhere. (1)

Three weeks postoperatively, the patient noted improved phonation and no aspiration, but she still complained of persistent hoarseness and vocal fatigue. On examination, she was found to have an adducted vocal fold with closure of the posterior glottic gap and moderately severe bowing of the left vocal fold (figure 1). A percutaneous injection of collagen into the left vocal fold was attempted, but it was not successful because of the postsurgical changes in the left neck.

[FIGURE 1 OMITTED]

The patient was observed serially over the next several months for signs of reinnervation. By the fourth month, she noted an acute improvement in phonation. On examination, she was found to have a near-complete resolution of the bowing and markedly improved glottic closure (figure 2). Further functional improvement was expected as reinnervation progressed.

[FIGURE 2 OMITTED]

This case illustrates the delayed and somewhat striking physical changes that can accompany reinnervation of a paralyzed vocal fold.

Reference

(1.) Chhetri DK, Gerratt BR, Kreiman J, Berke GS. Combined arytenoid adduction and laryngeal reinnervation in the treatment of vocal fold paralysis. Laryngoscope 1999; 109:1928-36.

From the Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, Calif. (Dr. Damrose) and the Division of Otolaryngology Head and Neck Surgery/Department of Surgery, UCLA Medical Center, Los Angeles (Dr. Berke).