This document reports on two cases of patients with iatrogenic bilateral vocal cord paralysis treated successfully with endoscopic transoral CO2 laser surgery. Both patients developed severe breathing problems after thyroid surgery that paralyzed both vocal cords. Laser posterior cordectomy and partial arytenoidectomy was performed to create a glottic opening while preserving voice quality and preventing aspiration. Both patients experienced significant symptomatic relief after surgery and were discharged within two days. The CO2 laser procedure allows for increased precision, hemostasis and minimal tissue handling in managing this condition.

1. Management of iatrogenic bilateral vocal
cord paralysis by endoscopic transoral CO2
laser surgery – Report of two cases

2. Case Report
Management of iatrogenic bilateral vocal cord
paralysis by endoscopic transoral CO2 laser
surgery e Report of two cases
Shantanu Panja
Senior Consultant, ENT & Head and Neck Surgery Apollo Gleneagles Hospitals, Kolkata, India
a r t i c l e i n f o
Article history:
Received 4 February 2014
Accepted 5 February 2014
Available online 17 March 2014
Keywords:
Bilateral vocal cord paralysis
CO2 laser
Cordectomy
Thyroidectomy
a b s t r a c t
Bilateral vocal fold paralysis is a rare condition. The commonest cause identified is mostly
iatrogenic. It can be extremely debilitating for the patient who usually suffers from severe
breathlessness on slightest exertion. Many of them requires a tracheostomy to maintain
airway. The treatment of bilateral vocal cord palsy is a balance between phonation, airway
and swallowing. Several surgical modalities have been described for cases which doesn’t
improve with conservative management. However transoral CO2 laser endoscopic aryte-
noidectomy has become the standard of management today for this condition. CO2 laser is
arguably the most appropriate tool for cordectomy with the advantage of increased pre-
cision, better hemostasis and minimal tissue handling. We describe the procedure of
posterior cordectomy with partial arytenoidectomy using transoral CO2 laser in two pa-
tients who were successfully managed for this condition in our centre.
Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Bilateral vocal cord immobility is a rare condition and is
mostly iatrogenic in nature. It can be caused by surgical
trauma (mainly thyroid surgery), malignancies, endotracheal
intubation, neurologic disease and idiopathic causes.1
The
voice quality is not affected as the vocal cords are in adduction
with an inability to abduct. However the patients develop
respiratory distress and sometimes stridor with minimal
exertion which can be life threatening. Many a times the pa-
tients need to undergo tracheostomy as a life saving measure
(Figs. 1 and 2).
The goal of treatment for this condition is to achieve a
delicate balance between phonation, respiration and aspira-
tion. Since 19th century various surgical techniques have
evolved to give an adequate glottic opening to the patient
without compromising on the voice quality and/or causing
aspiration. At present CO2 laser is considered to be the most
appropriate tool for carrying out cordectomy to achieve this
goal because of better hemostasis, increased precision, less
morbidity and superior outcomes.
In this article I present two cases of bilateral vocal cord
palsy following thyroid surgery that were managed in our
centre successfully by laser posterior cordectomy with partial
arytenoidectomy.
E-mail addresses: shantanu.panja@gmail.com, dr_spanja@yahoo.co.in.
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 4 6 e4 8
http://dx.doi.org/10.1016/j.apme.2014.02.001
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. 2. Case report
The first patient was a 32-year-old female from Kolkata who
underwent thyroidectomy for a colloid goitre elsewhere about
one year back before she presented to us. The second patient
was a 45-year-old female from Pakistan who underwent thy-
roid surgery twice in her country for a benign thyroid disease
leaving both her vocal cords paralysed. Both the patients
presented with severe respiratory distress and stridor on
slightest exertion, whistling sound at night and disturbed
sleep. The voice was unaffected and there was no difficulty on
swallowing. Both the patients were misdiagnosed and
wrongly treated for asthma by local physicians for several
months before they came to us for treatment.
Both the patients were investigated with endoscopy, radi-
ology and pulmonary function test (PFT). Fibreoptic laryn-
goscopy and digital videostroboscopy was carried out to
evaluate the vocal cords and airway. The vocal cords were
found to be fixed in paramedian position with minimal glottic
chink. Notably the second patient had a very high TSH level of
30.4. However a normal free T4 and T3 allowed us to take the
risk of surgery.
3. Operative technique
The surgery was carried out under general anaesthesia with a
double-cuffed stainless steel laser safe endotracheal tube and
placing wet cottonoids in the endolarynx.
A suspension laryngoscope was used to get adequate
exposure, especially of the posterior glottis. Cricoarytenoid
mobility was checked using a probe.
A CO2 laser was used, coupled with AcubladeÒ, an auto-
mated scanning device. This laser was coupled to an operating
microscope for surgery. Laryngeal microsurgical instruments
specially adapted for laser surgery with suction and cautery
attachments were used.
The surgery began by incising the vocal cord with laser just
anterior to the vocal process of arytenoids reaching upto the
paraglottic space thereby allowing the membranous vocal
cord to retract anteriorly. The vocal process of arytenoids
along with posterior third of true cord was excised. The medial
part of arytenoid was vaporised by using the laser in a scanner
mode leaving adequate posterior shell of arytenoids to pre-
vent aspiration. An adequate glottic chink of 5e6 mm was
created. Mitomycin-C soaked cottonoids were applied on the
operative bed for 2 min to prevent postoperative fibrosis. The
bed was then covered with fibrin glue to prevent any granu-
loma formation.
Postoperatively both the patients were extubated without
any complication. Antibiotics, steroids, mucolytic agents and
nebulisation were used in the postoperative period. Both the
patients had significant symptomatic improvement from the
very next day and started having normal diet without any
features of aspiration. Stridor and respiratory distress
completely disappeared. The initial dysphonia improved with
time as the neocord formation took place. The operative time
was about 45 min and the patients were discharged from the
hospital within 48 h.
4. Discussion
Surgical trauma is considered to be the commonest cause of
bilateral vocal fold immobility. Thyroid surgery by far ac-
counts for the maximum number of bilateral palsy. For pa-
tients with bilateral vocal fold paralysis (BVFP) due to
iatrogenic injury in which the recurrent laryngeal nerve (RLN)
or vagus nerve is injured (neurapraxia) but not severed,
Fig. 1 e Pre-operative bilateral abductor palsy.
Fig. 2 e Post-operative laser cordectomy.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 4 6 e4 8 47

4. permanent surgical treatment should be postponed for at
least 9 months after injury to allow spontaneous recovery.
Laryngeal electromyographic (EMG) monitoring can be helpful
in obtaining an index of potential recovery. Both the patients
in our case presented after one year and fortunately didn’t
undergo a tracheostomy to maintain airway.
Since 1922 surgical treatment of bilateral immobile cords
have evolved with time. Several surgical methods have been
designed to attain good respiration, phonation and swallow-
ing. The method adopted by Chevalier Jackson introduced of
ventriculocordectomy, where by the entire vocal cord and
ventricle was excised,2
creating an excellent airway but
resulted in breathy voice. Sub mucosal resection of vocal fold
proposed by Hoover resulted in excessive scarring and thus
leading to glottic stenosis and postoperative dysphonia.3
Procedures on arytenoids included extra laryngeal arytenoi-
dectomy4
in which arytenoid cartilage was freed from all its
muscular and ligamental attachments except the vocal mus-
cle. In lateralization procedure, the arytenoids are fixed
laterally to the thyroid ala. This was modified by fixation of the
corresponding vocal fold in order to conserve a good glottic
opening.5
Various techniques of endoscopic approach for the
treatment of bilateral vocal fold immobility have been pro-
posed and have been modified by various surgeons.6,7
The
laser surgical technique described in the article is considered
to be one of the best, minimally invasive techniques which
gives a satisfactory outcome.
The distinct advantages of laser cordectomy with partial
arytenoidectomy in managing bilateral cord immobility are
less surgical time, minimum morbidity, no surgical scar,
absence of laryngeal edema, good hemostasis, better post-
operative pulmonary function, less hospitalization, satisfac-
tory outcome and scope of revision surgery if need arises. The
posterior cartilaginous shelf preserved provides good stability
to the arytenoid region and prevents aspiration.8
Patient does
have some dysphonia, but this can be minimized by preser-
vation of as much as possible of the vibrating portion of the
vocal cord. The contraindications for the surgery includes
patients with concurrent pulmonary, neurological and ma-
lignant disease, a simultaneous lesion compromising the
airway like a subglottic stenosis and pediatric age group with
age less than 12 years.
5. Conclusion
CO2 laser cordectomy with partial arytenoidectomy by
Transoral endoscopic route is an excellent and less morbid
alternative modality to open procedure for managing bilateral
vocal cord paralysis. However precision needs to be exercised
to maintain the balance between airway, phonation and
swallowing and to avoid long term complications.
Conflicts of interest
The author has none to declare.
r e f e r e n c e s
1. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal
fold immobility. Laryngoscope. Sep 1998;108(9):1346e1350.
2. Jackson C. Ventriculocordectomy. A new operation for the cure
of goitrous glottic stenosis. Arch Surg. 1922;4:257e274.
3. Hoover WB. Bilateral abductor paralysis, operative treatment
of submucous resection of the vocal cord. Arch Otolaryngol.
1932;15:337e355.
4. King BT. A new and function restoring operation for bilateral
abductor cord paralysis. JAMA. 1939;112:814e823.
5. Kelly JD. Surgical treatment of bilateral paralysis of the
abductor muscles. Arch Otolaryngol. 1941;33:293e304.
6. Thornell WC. Intralaryngeal approach for arytenoidectomy in
bilateral abductor vocal cord paralysis. Arch Otolaryngol.
1948;47:505e508.
7. Dennis DP, Kashima H. Carbon dioxide laser posterior
cordectomy for treatment of bilateral vocal cord paralysis. Ann
Otol Rhinol Laryngol. 1989;98:930e934.
8. Plouin-Gaudon I, Lawson G, Jamart J, Remacle M. Subtotal
carbon dioxide laser arytenoidectomy for the treatment of
bilateral vocal fold immobility: long term results. Ann Otol
Rhinol Laryngol. 2005;114:115e121.
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