How To: Transverse Cordotomy with Thyroarytenoid Myectomy for Bilateral Vocal Fold Immobility

Endoscopic resection was done by CO₂ laser microlaryngoscopy. Rather than resection of the membranous vocal fold, the transverse cordotomy was done as a straight but narrow laser cut at the vocal process, extended laterally into the vocalis and the thyroarytenoid (TA) muscle. The cut was then followed by an anterior cordotomy lateral to the vocal ligament. This created an L-shaped mucosal flap that preserved the membranous vocal fold. A triangular wedge of TA muscle lateral to the vocal ligament and mucosal flap was liberally excised with the CO₂ laser. The L-shaped mucosal flap consisting of the vocal ligament and the membranous vocal fold was then sutured using a 4–0 vicryl suture. The preserved mucosal flap moved laterally to cover the myectomy defect (Figure 1B).

RESULTS

The resection described creates a triangular-shaped defect that is covered with mucosa with an airway angle of 30 degrees. A video of the surgical procedure can be found online, with each of the four main steps of the procedure shown. The image in Figure 2 shows an example patient five years after such a resection, showing good triangular airway with adequate voice.

This technique was performed on 11 patients. Six patients had tracheostomies, and five of these patients were able to be decannulated. No frank aspiration was reported by any patient. All patients reported their voices as either “good” (6/11) or “fair” (5/11) after the procedure.

The modifications outlined in the TAM cordotomy can create the same initial airway opening provided by a traditional transverse cordotomy, but additionally can decrease the lateral bulk of the vocal fold through myectomy, and, through suture lateralization, allow for a smaller raw mucosal surface. This may promote faster healing and may limit scarring and restenosis. The TAM cordotomy seems to create a stable triangular-shaped glottis. In the surgeons’ opinions, these patients had a stable airway while preserving phonatory function. Although we have not systematically reviewed all TAM procedures done over the last 10 years, we continue to use this technique as first-line endoscopic treatment of patients with bilateral vocal fold paralysis and Type I or Type II posterior glottis stenosis.