Nerve-muscle pedicle reinnervation of the larynx: avoiding pitfalls and complications

The procedure for innervation of bilateral vocal cord paralysis using nerve-muscle pedicle technique has now been well established in the literature. Moreover, several other centers have reported success using this technique. Nevertheless, the author is aware that a significant number of well trained otolaryngology-head and neck surgery practitioners have found difficulty in making the procedure successful in their hands. It therefore seems appropriate to address those aspects of patient evaluation, technique and postoperative follow-up that have brought a satisfactory level of success in the author's hands. Preoperative evaluation of patients is the cornerstone of success in nerve-muscle pedicle reinnervation. It is imperative that the larynx be properly evaluated to be certain that there does not exist fixation or ankylosis of one or both arytenoids in addition to paralysis. Clearly if such fixation exists, nerve-muscle pedicle reinnervation cannot be successful. Several pertinent aspects of technique with special reference to the identification of the proper nerve-muscle pedicle, the design of the pedicle and proper identification of the posterior cricoarytenoid muscle will be discussed. Postoperative evaluation of patients may be difficult for inexperienced operators. The author has seen at least three patients who were operated on by other surgeons who were referred because of "failure" of the procedure only to find that all three of them were successfully reinnervated with satisfactory motion of the reinnervated cord for reasonable day-to-day activity. All aspects of postoperative evaluation and management will be discussed as well.