Preoperative Management of Patients at High Risk for Recurrent Laryngeal Nerve Injury During Esophagectomy

This case involved the management of a 62-year-old male patient at high risk for recurrent laryngeal nerve injury during esophagectomy. He presented with invasive moderately differentiated squamous cell carcinoma of the mid-esophagus on EGD. He underwent neoadjuvant chemotherapy and radiation, as well as feeding gastrostomy tube placement preoperatively due to severe malnutrition. Based on preoperative evaluation, he was deemed a candidate for resection via McKeown esophagectomy. His preneoadjuvant therapy PET scan demonstrated an FDG-avid esophageal mass in close proximity to the location of the left recurrent laryngeal nerve. The patient was then referred to otolaryngology for preoperative vocal fold assessment. On indirect laryngoscopy, both true vocal folds were functioning normally and were mobile. Based on the patient’s preoperative imaging, damage to the left recurrent laryngeal nerve during esophagectomy was anticipated. After a multidisciplinary discussion, the decision was made to preemptively inject and medialize the left true vocal fold with carboxymethylcellulose gel to avoid respiratory complications due to vocal fold paralysis following esophagectomy. This was successfully performed one week before the esophagectomy, with good medialization of the left true vocal fold post-injection.  

The patient then underwent McKeown esophagectomy with thoracoscopic mobilization, open abdominal portion, and cervical esophagogastric anastomosis. There was treatment effect from radiation with associated surrounding fibrosis. Dissection was carried out directly above the azygous vein to avoid damage to the recurrent laryngeal nerve. Postoperatively, the patient was noted to be hoarse but had a good cough and excellent pulmonary toilet. He had no postoperative respiratory complications. Otolaryngology was consulted during this immediate postoperative admission for indirect laryngoscopy to assess vocal fold function. Indirect laryngoscopy was performed, and in the accompanying video, the left true vocal fold is located on the right side of the screen. The indirect laryngoscopy showed excellent apposition of the true vocal folds.  

Following an esophagram that demonstrated no anastomotic leak, a video fluoroscopic swallow study was performed that showed subtle aspiration with thin liquids. The patient underwent a speech therapy evaluation and treatment, including safe swallowing exercises, but his diet was not advanced during the hospital admission. The patient was discharged with NPO status and J-tube feeds. He underwent repeat indirect laryngoscopy one month postoperatively, which demonstrated findings consistent with permanent left true vocal fold paralysis. Injection with calcium hydroxylapatite gel (a semi-permanent agent) was performed. The patient will return for indirect laryngoscopy in the clinic every four months for one year postoperatively, at which point thyroplasty will be considered. Repeat outpatient VFSS following the injection of the semipermanent agent demonstrated improved swallowing with no aspiration with thin liquids. His diet was subsequently advanced.  

In conclusion, preoperative true vocal fold injection has the potential to reduce the respiratory complications of recurrent laryngeal nerve injury post-esophagectomy and should be considered in patients deemed high risk for recurrent laryngeal nerve injury during esophagectomy based on preoperative imaging. 

References

1. Courey MS, Naunheim MR. Injection Laryngoplasty for Management of Neurological Vocal Fold Immobility. Adv Otorhinolaryngol. 2020;85:68-84. doi: 10.1159/000456684. Epub 2020 Nov 9. PMID: 33166968.
2. Zuniga S, Ebersole B, Jamal N. Improved swallow outcomes after injection laryngoplasty in unilateral vocal fold immobility. Ear Nose Throat J. 2018 Aug;97(8):250-256. doi: 10.1177/014556131809700822. PMID: 30138517.

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