Bilateral Vocal Cord Immobility

 

RED FLAGS

  • Any patient you suspect clinically to have airway compromise

 

WHY IS THIS IMPORTANT?

Both vocal cords should abduct on inhalation, opening the airway. When paralysed, vocal cords tend to lie in the paramedian or median positions. Paralysis of one cord might lead to voice change (dysphonia). If both vocal cords are paralysed and lie in the paramedian or median positions, this might obstruct airflow.


WHEN TO INVOLVE THE ENT REGISTRAR

  • Inform the ENT and Anaesthetic Registrars urgently if you think the patient’s airway is at risk

  • In an emergency situation, because most ENT Registrars are off-site out-of-hours, it is prudent to put out an emergency call for an experienced anaesthetist, ODP and emergency team, who are on site


WHO TO ADMIT

This emergency presentation is relatively rare.

  • Most patients presenting acutely should be admitted, as many will have significant medical comorbidities or increased frailty

  • Admit patients with significant acute dyspnoea or reduction in exercise tolerance

  • Admit patients with significant dysphagia leading to weight loss or aspiration


ASSESSMENT AND RECOGNITION

  • Patients should be assesed in Resus with appropriate monitoring

  • Use a methodical ABC approach to the patient as per ALS or similar protocol

The history is extremely important as it will give clues as to the potential cause of the vocal cord immobility.

Patients may present acutely with stridor, increased work of breathing or evidence of aspiration. More subtly they will have progressively worsening hoarseness, vocal fatigue and shortness of breath. They may not be able to speak at all, or only a few words. Take a concise history.

Some patients may desaturate, especially if there is concomitant lower airway pathology. Examine the neck, oral cavity and upper aerodigestive tract thoroughly; flexible nasendoscopy is invaluable if you are a competent endoscopist. It is important to take your time to observe for any vocal cord movement, and assess how much of the airway is being affected by the restricted movement. Sometimes one vocal cord will be immobile and held in the median position, with the other sluggish or only abducting partly.

Causes of bilateral vocal cord immobility:

  • Central nervous system pathology or denerative neurological conditions

    • Brainstem stroke or space occupying lesion affecting the nuclei of the vagus nerves

    • Multiple sclerosis

    • ALS (motor neuron disease)

    • Guillain-Barré Syndrome

  • Malignancy

    • Upper aerodigestive tract, thyroid cancer or intrathoracic malignancy can infiltrate the recurrent laryngeal nerves, especially if the patient has previously sustained an injury to the other side, for example after hemithyroidectomy

  • Iatrogenic injury

    • Prolonged intubation can lead to fixation of both cricoarytenoid joints

    • Surgery can lead to injury to the recurrent laryngeal or vagus nerves, for example thyroidectomy, oesophagectomy, neck dissection, aortic surgery or carotid endarterectomy; again the patient may have previously sustained an injury on one side and then undergone different surgery on the other

  • Cricoarytenoid joint fixation

    • Prolonged intubation, as above

    • Radiotherapy

    • Ankylosing musculoskeletal conditions, including rheumatoid arthritis

A note on Inducible Laryngeal Obstruction (ILO)

ILO describes a transient phenomenon whereby the vocal cords adduct (come together) during inspiration, whereas they should abduct (move apart). Synonyms include paradoxical vocal cord movement and vocal cord dysfunction. The vocal cords are not immobile as such, but ILO can cause stridor, a choking sensation and shortness of breath. This can reinforce the ILO as patients feel that they cannot breathe, which is very frightening. It can be difficult to distinguish from bilateral vocal cord immobility.

Precipitants of ILO include exercise, inhaled irritants, gastro-oesophageal reflux, stress and anxiety. Patients with ILO will typically not desaturate and many can still talk. It is generally not a life threatening condition. Nasendoscopy is helpful in distinguishing ILO from vocal cord immobility. This is important in order to avoid unnecessary emergency intubation or tracheostomy.

Patients with ILO should be treated non-judgementally: they have genuine symptoms due to paradoxical movements of the vocal cords. It is important to support patients and to help them feel safe. Ask the patient to concentrate on slowing their breathing down, sniffing in slowly through their nose, trying to hold their breath for a second or two, and then to exhale through their mouth.

IMMEDIATE AND OVERNIGHT MANAGEMENT

Oxygen, Humidification and Heliox

  • Give high-flow humidified oxygen (or back-to-back nebulised saline driven on 5-8L/min oxygen, depending on oxygen requirements)

  • If immediatley available, Heliox (a mixture of helium and oxygen) can be used to reduce work of breathing

Other interventions

Frequently, emergency department colleagues will have given the patient nebulised adrenaline, intravenous steroids and/or antibiotics by the time you arrive. This is very reasonable, but unless you see obvious endoscopic signs of infection or inflammation in the upper airway, these medications can be discontinued after discussion the ENT Registrar. In this situation, the problem is structural rather than inflammatory.

Enteral feeding might be necessary; patients are generally safer ‘nil by mouth’ in the acute setting. Refer the patient to dietetics and speech therapy.

Non-Invasive Ventilation (NIV) and endotracheal intubation

Most patients improve with oxygen and humidification and other supportive measures. NIV can be considered if your patient is desaturating or tiring from increased work of breathing. Occasionally, immediate endotracheal intubation may be indicated. Seek opinions from senior ENT, anaesthetic, critical care, respiratory and emergency department colleagues as appropriate. Despite being held together, the vocal cords do not usually present a significant obstruction to passage of an endotracheal tube.

FURTHER MANAGEMENT

Patients with bilateral vocal cord immobility may require further treatment as described below. This would normally be discussed with the patient in a multidisciplinary setting.

  1. Tracheostomy: Either to secure the airway initially or to allow rehabilitation in an intubated patient. This may or may not be permanent, depending on the cause of the bilateral vocal cord immobility. The patient’s preferences and background should be considered as a tracheostomy can affect their ability to speak or swallow, and some patients with neuromuscular conditions may not be able to manage their tubes themselves. Most patients are likely to need increased care on dicharge from hospital .

  2. Botulinum toxin: Depending on aetiology, injected Botox neurotoxin can be used to block the action of the adductor muscles.

  3. Cordectomy, cordotomy or arytenoidectomy: One vocal cord or arytenoid cartilage can be incised or reduced using a CO2 laser. This increases the glottic aperture, improving the airway. Risks include aspiration, dysphagia, poor cough and a weak, breathy voice.

Page last reviewed: 13 May 2023