1. Vocal cord paralysis current concepts
Balasubramanian Thiagarajan

2. 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

3. Vocal fold positions
Abduction
Adduction
Midline

4. Current theory accounting for vocal vold position following vocal fold paralysis
Type of lesion
Pathology of lesion
Synkinesis
Fibrosis

5. 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

6. Treatment algorithm of URLP

7. 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

8. Swallowing therapy Swallowing while holding the breath
Push pull technique
Hand clasp technique

9. Clinical examination (vocal)
Glottic fry
Hard glottal attacks
Breathy voice
Diplophonia
Pitch breaks
Phonation breaks
Tense phonation

10. Glottic fry Creaky voice Cords vibrate slowly
Pt feels as if breath has run out while speaking

11. 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

12. Breathy voice Murmered voice
Vocal cord vibrates normally but are held further apart then normal
Excessive air escape occurs between the cords

13. Diplophonia Simultaneous production of sound of different pitches
Common in UVCP
Common in mass lesions of vocal folds

14. 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

15. Phonation break Complete cessation of phonation Temporary
Commonly follows excessive use of voice

16. Tense phonation Appears like speech while lifing something heavy
Laryngeal muscle tension
Supralaryngeal muscle tension
Loud, high pitched and harsh voice

17. 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

18. 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

19. Stroboscopy-what to look for
Symmetry of movement
Aperiodicity
Glottic closure configuration
Horizontal excursion

20. Management Reducing stress
Reducing hyperfunctional compensatory mechanisms
Breathing exercises
Relaxation exercises

21. Cord injections
Teflon
Collagen
Autologous fat

22. 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

23. Teflon injection - Procedure
No sedation
Percutaneous approach (suitable) LA
Performed under laryngoscopic guidance
Anterior / lateral approaches are possible

24. 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

25. 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

26. 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

27. 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

28. Autologous fat injection - Indications
Vocal fold paralysis
Vocal fold scarring
Vocal fold atrophy
Intubation injuries

29. 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

30. Advantages
Reversible
No reactions
Immediate results are good

31. Type I thyroplasty - indications
Unilateral / bilarateral vocal fold paralysis
Incomplete glottal closure
Vocal fold bowing

32. Contraindications Following irradiation
In patients who have undergone hemilaryngectomy (thyroid lamina is a must to hold the prosthesis)

33. 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

34. 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

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

36. Arytenoid adduction - Indications
To close a large posterior gap
If the vocal folds are not at the same level

37. 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

38. 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

39. Reinnervation procedures
Experimental
Neuromuscular pedicle reinnervation
Ansa cervicalis and recurrent laryngeal nerve anastomosis

40. Bilateral paralysis Does not cause stridor always
Position of cord depends on fibrosis / synkinesis
Treatment tailored to patient's needs

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

42. contd
Lateralizing procedures
Chordectomy
Arytenoidectomy

43. Thankyou