How To: Endoscopic Anterior and Posterior Cricoid Split for Bilateral Vocal Fold Paralysis

by Nicola M. Pereira, BA, and Vikash K. Modi, MD •

The case presented here demonstrates this approach for management of BVFP in a five-week-old patient who presented with stridor, upper airway obstruction, and dysphagia. This article is unique in that it presents a step-by-step surgical video of EAPCS (see supporting video).

METHOD

Preoperative management of patients with congenital BVFP includes a full history and physical examination including fiberoptic flexible laryngoscopy. A magnetic resonance imaging is also recommended to rule out intracranial pathology (i.e., Arnold–Chiari malformation).

While under spontaneous ventilation, the patient is placed in suspension with a Parsons laryngoscope of appropriate size. A false vocal fold retractor is then placed in an inverted fashion and suspended to the Mayo stand.

Next, a sickle knife and straight microlaryngeal scissor are used to divide the posterior cricoid completely. The full posterior cricoid division is ensured using a straight suction and a curved alligator. Note that the interarytenoid muscles remain intact and are not divided. Bleeding throughout the procedure is controlled with the use of oxymetazoline-soaked pledgets.

The anterior portion of the cricoid ring is then divided with a sickle knife, taking special care to not divide the anterior commissure. A hand may be used externally for palpation. Again, a curved alligator can be used to visualize the extent of cricoid division. An upcurved microlaryngeal scissor is then used to divide the remainder of the anterior cricoid.

Next, balloon dilation is performed using a size larger than the sized airway. The balloon is inflated for approximately 30 seconds to 2 minutes, depending on the patient’s level of saturation, and then removed. The area is then inspected to ensure that the anterior and posterior cricoid have been fully divided.

At the conclusion of the procedure, the patient is nasotracheally intubated with a half-size larger endotracheal tube (ETT). A direct laryngoscopy is performed two weeks postoperatively to evaluate the airway. At this time, the cricoid edges should be healing in a distracted position. This patient is then intubated with a half-size smaller ETT and given 24 hours of perioperative steroids. The patient is extubated the following day.

Subsequent balloon dilations are performed as needed if there is progressive stridor or upper airway obstruction.

RESULTS

The video demonstrates the use of EAPCS for management of congenital BVFP. Postoperative management involves nasotracheal intubation with subsequent evaluation of the airway to assess healing at the surgical site.