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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