Dr. Garrett said that in cases where clinically relevant nerve recovery is possible or unpredictable she will use Cymetra (LifeCell, Bridgewater, N.J.) if in the OR and often hyaluronic acid in the office setting as a temporary option.
Explore this issue:April 2015
Case 3: Large Vagal Paraganglioma
In this case, the vagus nerve and ansa hypoglossi are both “gone,” Dr. Netterville said.
Dr. Smith said he would be inclined to sew the ansa cervicalis to the RLN. “Another thing that I look at in this situation is the status of the external branch of the superior laryngeal nerve to the CT muscle—it depends on the level of injury to the vagus if the superior laryngeal nerve is also affected, then I will consider doing a double graft with two branches of ansa to both the both the RLN and the SLN [superior laryngeal nerve],” he said.
Case 4: Re-Innervate or Use a Static Procedure?
In this case, a woman is three to six months out after onset of true vocal fold paralysis with no known injury to the RLN. It is thought that she has a good chance of recovery. In these scenarios, common causes are idiopathic, anterior cervical fusion, and thyroidectomy.
Dr. Courey said he would likely image this patient for a neoplasm, even if she’d just undergone surgery. “If this was due to a known cause—the surgery—the use of imaging for ruling out neoplasm is probably not indicated,” he noted, adding that some literature supports that view. “Having said that, I still do it because you want to know. I had a patient the other day who had a known surgery and presented with vocal fold paralysis after the known surgery. And the surgeon got another image—a CT scan—showing a thyroid mass, which was the likely cause. So, even if there’s a known surgery, you could have a red herring.”
Dr. Burns agreed. “I just saw a lady who had 10-year history of having the nerve out that was presumed idiopathic, and I did image her because it wasn’t clear that she’d ever had any imaging, and we found a vagal schwannoma,” he said. He added that he will image again in six months if no cause is found, and in those instances has found thyroid cancer that wasn’t apparent at first.
Panelists tended to agree that they likely would not perform electromyography on this patient. “It’s really not going to impact what I offer as a surgical option,” Dr. Garrett said.