From: anonymous@aol.com
Subject: Vocal Cord damage from surgery Intubation.
Posted-By: xx108 (ENT Clinic Moderator)
Organization: Organization For Community Networks
Date: Sat, 22 Mar 1997 19:28:37 -0500 (EST)
Newsgroups: ofcn.clinic.ent

My 13 year old daughter had "Anteror Spinal Fusion" surgery for correction of scoliosis on Feb 5th. She was intubated for about 6 hours. (This surgery was after wearing a backbrace for 3 years- so she was pretty dissappointed). The day after surgery her voice was very weak, the next 24 hrs she had NO voice, then it returned weak again. After 7 days she was discharged from the hospital- still with a weak voice. At 2 week checkup I told them her voice was still weak and still they felt it was ok. At 4 weeks we went to her peditarician who recommend she see a local ENT. We got to see him 2 weeks later -He did a scope through her nose at 6 weeks post surgery- said it appears her left vocal cord is dislocated and the longer we wait to fix it the less odds of being succerssful-- said it was possible that too much time has already passed-he wanted to do surgery right away. We consulted her pediatrician and orthopedic Dr who did her spine surgery who were now very concerned and wanted her seen by the head of the ENT DEPT at their hospital. He recommends a scope under anesthesia to see behind and below her vocal cords, thinks left cord is paralyzed- not dislocated. Thinks it will return with voice therapy and time. So we have 2 very differant opinions... and don't know who we should listen too. We are leaning toward waiting and having the scope first as this is a more cautious approach and seems wiser. But we want to make the right decision as our daughter is very discouraged that she had her voice damaged from surgery, and is leary of anymore complications. We don't want to wait if we really could be decreasing the odds of it getting better- but don't want unnessary surgery! Any opinions? THANKS!!

Reply: ----------------------

It can be difficult to distinguish a dislocation of the arytenoid cartilage of a vocal cord from a paralysis of the vocal cord, particularly in a child whose larynx (voice box) is considerably smaller than adult size. The arytenoid cartilage makes up what might be considered the hinge of a vocal cord. If the cartilage is dislocated because of trauma from an endotracheal tube, the involved cord may appear to be paralyzed since it will not move normally.

During anterior spinal fusion surgery, if it is necessary to operate as high as the part of the spine in the neck region, it would be more likely that an immobile vocal cord is the result of paralysis. The nerve that innervates the vocal cord travels in the neck on either side of the windpipe and exposure of the anterior spine in the neck may require considerable traction on the windpipe such that the nerve may be overly stretched. This type of nerve injury is known as neuropraxia, and as long as the nerve has not been actually severed, it will likely recover. However, recovery from neuropraxia may take 6-12 months.

It is true that a dislocation of the arytenoid is best dealt with as quickly as possible after the presumed time of injury. This is because as time passes from the actual time of dislocation, scarring occurs which can fixate the vocal cord permanently. Reduction of a dislocated arytenoid cartilage however can be extremely difficult and scarring with subsequent vocal cord fixation may occur even if the arytenoid can be repositioned properly.

The best approach at this point would be to do a microlaryngeal exam under anesthesia. During this type of laryngoscopy, the arytenoid can be palpated and other causes of vocal cord dysmobility can be identified. Furthermore, if one can still not clearly determine whether the vocal cord is paralyzed or if it is simply not moving because of arytenoid dislocation, the diagnosis can be established by a test called laryngeal electromyography (EMG) combined with another type of endoscopy known as videostroboscopy. These two tests can determine with confidence the exact diagnosis and should be considered if the diagnosis remains in question after an endoscopy under anesthesia, and before any open surgical intervention is considered.

--

Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis

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