Vocal cord paralysis current concepts

Balasubramanian Thiagarajan

What has changed?

Various hypothetical positions of vocal cord following paralysis – Not valid anymore

More simplistic classification of vocal fold position

All the theories accounting for vocal fold positions following paralysis are not accepted anymore

Vocal fold positions

Abduction Adduction Midline

Current theory accounting for vocal vold position following vocal fold paralysis

Type of lesion Pathology of lesion Synkinesis Fibrosis

Types of vocal fold palsy

Unilateral recurrent laryngeal nerve palsy Isolated unilateral superior laryngeal nerve

palsy Bilateral recurrent laryngeal nerve palsy Bilateral complete paralysis of vocal folds

Treatment algorithm of URLP

Role of speech therapy in URLP

Controversial Does not hasten reinnervation Helps in breath support Helps psychologically Swallowing therapy is useful in pts with

swallowing difficulty

Swallowing therapy

Swallowing while holding the breath Push pull technique Hand clasp technique

Clinical examination (vocal)

Glottic fry Hard glottal attacks Breathy voice Diplophonia Pitch breaks Phonation breaks Tense phonation

Glottic fry

Creaky voice Cords vibrate slowly Pt feels as if breath has run out while

speaking

Hard glottal attack

Excessive air pressure is built up under the closed vocal cords

Sudden release of this causes the speaker to speak in explosive voice

Voice tires easily

Breathy voice

Murmered voice Vocal cord vibrates normally but are held

further apart then normal Excessive air escape occurs between the

cords

Diplophonia

Simultaneous production of sound of different pitches

Common in UVCP Common in mass lesions of vocal folds

Pitch breaks

Speaking in inappropriately high pitch Voice seems to be out of control Pt does not know what sound will come out

next Common in puberphonia

Phonation break

Complete cessation of phonation Temporary Commonly follows excessive use of voice

Tense phonation

Appears like speech while lifing something heavy

Laryngeal muscle tension Supralaryngeal muscle tension Loud, high pitched and harsh voice

Quantitative evaluation

Sustaining a single tone at the fundamental frequency F0 (reduced in patients with vocal abuse, cord paralysis)

Variations in amplitude (Shimmer) – variations due to decreased stability of vocal folds

Variations in pitch (jitter) – correlates with degree of hoarseness

Stroboscopy

Helps in dynamic assessment of vocal folds

If frequency of strobe light is the same as fundamental voice frequency then vocal folds will not be seen in movement at all

Stroboscopy-what to look for

Symmetry of movement Aperiodicity Glottic closure configuration Horizontal excursion

Management

Reducing stress Reducing hyperfunctional compensatory

mechanisms Breathing exercises Relaxation exercises

Cord injections

Teflon Collagen Autologous fat

Teflon injection

Indications ts– Irreversible unilateral vocal fold paralysis after a waiting period of 1 yr

Contraindications – should not be used in pts with vocal fold atrophy, bowing

Teflon injection - Procedure

No sedation Percutaneous approach (suitable) LA Performed under laryngoscopic guidance Anterior / lateral approaches are possible

Teflon injection (contd)

In lateral approach surgeon pierces thyroid cartilage at the level of vocal folds

In anterior approach needle is passed through cricothyroid membrane and angled supero laterally under endoscopic vision

Teflon injection should be placed lateral to vocalis muscle without disturbing endolaryngeal mucosa

Transoral teflon injection

Performed under DL scopy guidance Preferably under GA with jet ventilation The bevel of the needle should be held away

from the mucosal edge Excessive pressure to anterior commissure to be

avoided during the procedure as it would distort the cord

Needle is ideally placed lateral to the vocal fold about 2 mm deep at the level of vocal process

Teflon injection - Limitations

Irreversible If placed in a mobile cord mucosal wave is

lost If the cord function gets back to normal

after injection then results would be disastrous

Useless in central causes of voice disorders

Collagen injection

Modified bovine collagen is used (to minimize host response)

Histologically it is similar to deep layer of lamina propria

Gets assimilated into surrounding tissues by fibrobast invasion which replaces collagen with host collagen

Collagen should be placed within lamina propria URI increases collage resorption

Autologous fat injection - Indications

Vocal fold paralysis Vocal fold scarring Vocal fold atrophy Intubation injuries

Procedure Abdominal fat is used Cut into 1mm pieces, separated from

connective tissue Rinsed with ringer lactate and methyl

prednisolone solution Loaded in to a syringe Anterior, posterolateral and middle portions

of the cord are injected 50% over correction is aimed at

Advantages

Reversible No reactions Immediate results are good

Type I thyroplasty - indications

Unilateral / bilarateral vocal fold paralysis Incomplete glottal closure Vocal fold bowing

Contraindications

Following irradiation In patients who have undergone

hemilaryngectomy (thyroid lamina is a must to hold the prosthesis)

Type I Thyroplasty (Procedure)

LA Horizontal incision over midportion of

thyroid cartilage Window in thyroid ala created 8 mm

posterior to ant. Commissure and 3 mm superior to its inferior border

Inner perichondrial flaps created by inferior and posterior incisions

Contd

Under laryngoscopic guidance measurement for medialization is taken

Silastic block of appropriate size fashioned and inserted

Voice checked on the table Cartilage from the window is ideally

removed Inner perichondrium if preserved it is better

Complications

Persistent dysphonia Implant migration Airway obstruction Hematoma formation Infections Useless to close large posterior gap

Arytenoid adduction - Indications

To close a large posterior gap If the vocal folds are not at the same level

Procedure

Horizontal skin crease incision at the level of vocal folds

Posterior border of thyroid cartilage is exposed transecting strap muscles and detaching the inferior constrictor

Recurrent laryngeal nerve should be identified

Cricothyroid joint entered muscular process exposed

Contd

PCA muscle identified and cut Nylon sutures placed over muscular

process and pulled anteriorly through thyroid ala and anchored

Pt is asked to phonate and the appropriate medialization is assessed

Reinnervation procedures

Experimental Neuromuscular pedicle reinnervation Ansa cervicalis and recurrent laryngeal

nerve anastomosis

Bilateral paralysis

Does not cause stridor always Position of cord depends on fibrosis /

synkinesis Treatment tailored to patient's needs

contd

Tracheostomy – emergency Steroid injection (systemic) Adrenaline nebulization CPAP Intubation / ICU Care

contd

Lateralizing procedures Chordectomy Arytenoidectomy

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