[DYSPHAGIA] transverse vocal cordectomy

[eripley@yahoo.com (Irene Campbell-Taylor)]

Dear Mary,
The terminology used is a bit confusing to me.
Usually, cordectomy is applied in cases of bilateral
ABductor paralysis, i.e. the cords won't open so the
patient is in danger of asphyxiating.  Sometimes the
terms are used very loosely, as in right CVA when the
writer means LCVA with Right sided paralysis. 
Transverse arytenoid - - only unpaired muscle of the
larynx.  If this muscle remains in the ADducted
position, the only treatment is to remove one cord. It
is, however, important to realize that an immobile
cord is not necessarily a paralyzed cord. It is almost
impossible by observation alone to determine if a
vocal fold is fixed or paralyzed. BUT it can only
remain ADducted if the ABductors are non-functional. 
The ABductor is the posterior cricoarytenoid.  In both
cases, innervation is by  the  inferior laryngeal 
nerve, from the recurrent laryngeal branch of the
vagus.                                                
         
The  transverse arytenoid lies anterior to the 
oblique arytenoid and the arytenoid is  considered  to
be one muscle with oblique and                        
                                                    
transverse parts. The recurrent nerve is notoriously
vulnerable to damage. In this case the possible
etiologies include intubation/trach trauma,
undiagnosed brainstem CVA (Wallenberg syndrome),
diabetes.
Dennis and Kashima (1989) introduced the posterior
partial cordectomy procedure using the carbon dioxide
laser. The surgeon
excises a C-shaped wedge from the posterior edge of
one vocal cord. If this posterior opening is not
adequate after 6-8
weeks, the procedure can be repeated or a small
cordectomy can be performed on the other vocal cord.
They claim relief of
airway obstruction with preservation of voice quality.
I guess I would want to know what the presumed
etiology is and that the cause is irreversible, i.e.
the recurrent nerve won't recover. Clearly, the
patient can't survive with continuing airway
obstruction, but is this the only possible approach? 
Depends on etiology and prognosis, of course.
Good luck!
Irene.  

--- Mspslp@aol.com wrote:
>    Need opinions and education regarding:
>    81 y/o male, intubated 8-12-00 secondary to
> hematoma, pneumonia, and subsequent respiratory
> failure.  PMHX significant for CVA, HTN, DM, and
> dementia.  Patient fitted with Passy-Muir speaking
> valve 9-1-00 with good result, valve well tolerated
> with good volume and vocal quality until 9-27-00. 
> Then patient began to exhibit increased agitation,
> desaturation, and strained vocal quality--at times
> aphonic--during valve wear.
>    ENT exam 10-7-00 indicates B/L adductor v.c.
> paralysis, and "transverse vocal cordectomy" is
> suggested.  Patient did not evidence any change of
> status that would explain vocal cord paralysis.  
>    Opinions solicited as to what may have caused the
> problem, what this procedure is, and how it may
> help.
> Mary S. Porter, M.A., CCC
> Northern Virginia Community Hospital
> Arlington, VA
>
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=====
Irene Campbell-Taylor, PhD
Clinical Neuroscientist

If one tells the truth, one is sure, sooner or later, to be found out.
Oscar Wilde.

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