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Full text of "Diseases Of The Nose Throat And Ear"

VOCAL CORD PARALYSIS                             189

cytology and carinal biopsy must always be performed. If a carcinoma
causing a nerve paralysis is discovered it is generally considered to be inoper-
able although, if it is small, other treatment methods may have a better than
usual chance of success.

TREATMENT. No treatment of the paralysed cord is generally indicated
because the voice problem is minimal and the other cord usually compensates.

BILATERAL INCOMPLETE (ABDUCTOR) PARALYSIS

This lesion is not common. Both vocal cords lie in the paramedian position,
and sooner or later every patient with this condition will have stridor. The
time of onset of the stridor depends generally upon the use to which the larynx
is put. For example, a thin old lady who is in the house all day will not have
stridor unless she gets laryngitis, but a well-built active man will have stridor
on any moderate exercise, such as climbing stairs. In all cases the voice is
acceptable, and in a few cases it is virtually normal.

TREATMENT. Given the two facts of stridor and a good voice, treatment must
be tailored to the needs of the individual patient. Basically, a permanent
tracheostomy in which a speaking tube (a valved tracheostomy tube) is worn
relieves the patient both from stridor and from the danger of respiratory
obstruction (and the anxiety which is engendered by this possibility). The
disadvantage of this is the aesthetic fact of a hole in the neck with a tube that
needs to be cleaned. One of the cordopexy operations will give the patient
freedom from stridor, but will leave a slightly breathy voice which is weak. On
the other hand, there is no hole in the neck, no external appliance and no
social embarrassments.

If a patient has stridor he should have a tracheostomy performed and must
be told that it will be there for at least 6 months. This is because recovery is
possible during this time, and also because it allows him to see what life with a
tracheostomy is like. If no recovery has taken place at the end of 6 months, the
patient should be told of the possibility, advantages and disadvantages of
cordopexy. The final decision must always be left to the patient.

A cordopexy is an operation the objective of which is to move and fix the
arytenoid, vocal process and vocal cord into an abducted position. A number
of variations have been described, but only two will be outlined.

1. External arytenoidectomy is performed by entering the larynx behind the
posterior lamina of the thyroid cartilage, removing the body of the arytenoid
and stitching the vocal process to the thyroid cartilage. As the suture is being
put into position a direct laryngoscopy is carried out by the assistant to guide
the surgeon into creating a gap of 4 mm at the posterior end.

2. Arytenoidoplasty is done by a laryngofissure approach. A wire is passed
from outside the thyroid lamina to enter the larynx below the vocal process; it
is then passed above the vocal process to the outside of the thyroid cartilage
again. As the wire is tightened the cord is abducted.

BILATERAL ADDUCTOR PARALYSIS (FUNCTIONAL APHONIA)

As the name suggests, inability to adduct the vocal cords is always bilateral
and always functional, and the symptom is always aphonia. In its most severe
form the voice may be barely audible because, as well as being a whisper, the