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) 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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