MDL - Total arytenoidectomy

Considerations

Bilateral vocal fold paralysis (BVFP) generally causes airway restriction
- Treatment is aimed to improve the airway while minimizing aspiration and vocal dysfunction
- Treatment should be step-wise, moving from least to most aggressive
  - Tracheostomy - although invasive, may be needed early on
  - Endoscopic suture lateralization - temporizing measure
    - MDL with posterior transverse cordotomy (PTC) or medial arytenoidectomy (MA)
  - Extended version of either (or a combination) of PTC or MA
  - MDL with total arytenoidectomy (TA)
  - Open total arytenoidectomy
- Choose the side for TA based on
  - Presence of any meaningful movement - the best mobility should be preserved
  - Palpation of the cricoarytenoid joint - the best mobility should be preserved
1996: Endoscopic laser medial arytenoidectomy versus total arytenoidectomy in the management of bilateral vocal fold paralysis
2012: Endoscopic total arytenoidectomy for bilateral abductor vocal fold paralysis: a new flap technique and personal experience with 50 cases
2013: Comparison of voice and swallowing parameters after endoscopic total and partial arytenoidectomy for bilateral abductor vocal fold paralysis: a randomized trial

Eyes: Paper tape over lids
- Wet "eye pads" over tape
- Another long strip of paper tape over both eye pads
Head: Wrap with 2 blue towels
- Avoid towel clamp
Split drape
- Do not remove sticky cover
Tooth guard
Check all equipment including light cables and light sources

- Basic DL with either/or
  - Hollinger (anterior commissure) laryngoscope
  - Dedo laryngoscope

Place the operative larygoscope in suspension
- Bouchayer laryngoscope
- Zeitels laryngoscope
Adjust the head and neck positioning as needed
- Sniffing position (neck flexion with head extension)
- Anterior tracheal pressure with tape
Photograph using both 0 and 30 degree Hopkins rod endoscope
Bring in the operative microscope
Perform the planned total arytenoidectomy
- Continuous CO2 laser ablation of arytenoid tissue until the operative defect is flush with the walls of the cricoid ring, both posteriorly and laterally
- Tissue removal posteriorly should not remove any interarytenoid mucosa
- Evaluation of this goal can be done by:
  - Placement of a curved elevator on the lateral aspect of the subglottis and then slowly drawing the instrument in a cephalad direction feeling for a glottic level “overhang” of arytenoid tissue
    - If there is an “overhang,” additional arytenoid tissue can be removed
  - In addition, the endoscopic evaluation of the posterior glottic airway with a 70° telescope, can identify if there is any residual arytenoid overhang that needs further laser ablation to maximize the glottic airway to complete the total arytenoidectomy procedure
Obtain hemostasis with small pledget soaked with topical 1:1000 Epinephrine
Photograph using both 0 and 30 degree Hopkins rod endoscope
- Spray the glottis with 3 ml topical 4% Lidocaine
- Remove the laryngoscope and tooth guard
- Examine the airway for any unintentional injury

- For Dr. Durr, use the the University of Texas Voice Rest protocol here
  - See the smartphrase by J Gilde: JEGPIVOICERESTPO