Pre-emptive glottic enlargement before laryngotracheal surgery in patients at high risk for postoperative bilateral vocal fold paralysis.

Objectives: Bilateral vocal fold paralysis (VFP) is a severe complication after laryngotracheal (LT) surgery. The reduced glottic opening leads to significant respiratory distress immediately after the operation and requires the placement of a tracheostomy in most cases. Patients with a pre-existing unilateral VFP or expected recurrent nerve resection are at the highest risk for glottic failure. These patients might benefit from a pre-emptive glottic enlargement before LT surgery.
Methods: We performed a retrospective review of patients who received a pre-emptive glottis enlargement before LT surgery at the Medical University of Vienna from October 2011 to December 2016. Peri- and postoperative outcomes of this strategy were analysed.
Results: Six patients underwent preparatory glottic enlargement prior to LT resection. Four patients had recurrent thyroid cancer, and 1 patient had thymic cancer invading the cervical airway. The remaining patient had a complex benign glotto/subglottic stricture complicated by a pre-existing bilateral VFP. All patients received oblique cricotracheal resections extending into the larynx [resection length 39 ± 7 mm (mean ± SD)]. Extubation within 24 h after surgery was achieved in 5 of 6 cases, although all patients had postoperative unilateral (n = 5) or bilateral (n = 1) VFP as anticipated. In 5 of the 6 patients, oral intake could be started immediately after the operation. The remaining patient regained full swallowing function after intensive swallowing rehabilitation. Postoperative voice quality was subjectively perceived as satisfactory by all patients.
Conclusions: Pre-emptive glottic enlargement is a valuable treatment strategy in patients at highest risk for postoperative bilateral VFP. It facilitates immediate postoperative extubation, despite at least unilateral VFP and extensive LT surgical procedures.