Treatment of Vocal Fold Paresis/Paralysis

Key Glossary Terms

Paresis
Partial paralysis; partial loss of nerve input to a muscle, resulting in muscle weakness

Paralysis
Complete loss of nerve input to a muscle resulting in complete loss of muscle function

Laryngeal Electromyography (LEMG)
Test that measures electrical signals of nerve inputs to muscles

Recurrent Laryngeal Nerve (RLN)
Branch of vagus nerve to voice box muscles that open and close vocal folds

Superior Laryngeal Nerve (SLN)
Branch of vagus nerve to cricothyroid muscle involved in control of pitch

Glossary

Currently, there are two main intervention approaches to vocal fold paresis/paralysis which improve vocal function:

1. Voice therapy: The equivalent of physical therapy for large muscle paresis/paralysis
2. Phonosurgery: Operation that repositions and/or reshapes the vocal fold(s) to improve voice function

After voice therapy, the decision to have some type of surgery is complex. Among the important factors in decision making are the severity of the symptoms, vocal needs of the patient, position of paralyzed vocal folds, prognosis for recovery, and cause of paresis/paralysis if known. There is no "one size fits all" in this area.

Key Information

A Third Approach – "Sit and Wait"

LEMG results may suggest that the hope for natural recovery is good. This justifies waiting from 4 to 12 months to see if vocal fold paresis/paralysis resolves and voice improves.

Patients are taught through several (2-12) one-on-one sessions to maximize the voice intensity and quality using a variety of breathing and muscle exercises.

Voice therapy for vocal fold paresis is often successful in improving voice function and may be the only intervention required.

Generally, voice therapy will improve voice function of patients with vocal fold paralysis by about 5 to 15 percent. Although this may not seem to be a dramatic improvement, for patients whose voice use is limited, or for those who do not wish to undergo surgery, it may represent a sufficient gain.

Success of voice therapy for vocal fold paralysis depends on a variety of factors: the nature and position of the paralyzed vocal fold and the patient's voice demands. (For more information, see Voice Therapy.)

There are two main surgical options for surgically treating paresis/paralysis.

1. Laryngeal injection augmentation
2. Laryngeal framework surgery

Both attempt to improve vocal fold closure in order to improve vocal fold vibration.

Key Information

Voice Adjustments Under Local Anesthesia

Because laryngeal framework surgery is done under local anesthesia with the patient awake, the surgeon is able to monitor the voice during the surgery and the implant can be adjusted to optimize voice improvements. In this way, voice adjustments can be done during the procedure.

Role for Both Procedures

Decision as to the optimal type of surgical intervention depends on the patient's individual case. Sometimes, one approach may make more treatment sense. In some cases, both surgical approaches may be necessary.

Similar Goals

Both laryngeal injection augmentation and laryngeal framework surgery have the same goal – better vibration of the vocal folds during the speaking and singing.

A Current Prospective

The actual technique used is likely to depend on the specific aspects of a patient's particular case, as well as physician's training and preferences.

Special Considerations

• Professional voice users: Professional voice users usually need special considerations in selecting treatment pathways. Consultation with a voice center's Voice Care Team provides a best care practice.
• Swallowing or breathing problems: If swallowing and/or breathing problems accompany vocal fold paresis/paralysis, surgery would be required earlier.

Treatment decisions and prognosis for recovery may be guided by LEMG results.

Readers are advised to discuss possible side effects and complications with their physicians.

As with all surgery, complications may occur.

1. Underinjection (of substance), which results in persistent breathiness or vocal fatigue
2. Overinjection (of substance), which results in strained voice and/or breathing difficulties
3. Reaction to injection substance
4. Injection substance does not last to provide benefit

1. Airway obstruction and/or swelling which may result in breathing difficulties
2. Undercorrection which may result in persistent breathiness and/or vocal fatigue
3. Overcorrection which may result in strained voice and/or breathing difficulties
4. Graft migration – the implant does not stay in the place where the surgeon put it
5. Implant extrusion – implant is "rejected" and pushed outwards

Diagnosis

Frontiers