1. Voice Disorders Due to Nerve Damage

2. Vocal fold paralysis
Inability of one or both folds to move because of the lack of innervation to particular intrinsic laryngeal muscles
lesion may be peripheral or central; most VFP are due to peripheral lesions e.g., damage to the SLN or RLN
Brodnitz (as far back as 1967) “most frequent cause…during thyroid operations”

3. Superior Laryngeal Nerve Paralysis
If bilaterally damaged, pt can not elevate pitch
if unilateral, one fold elongates for pitch change while the other is unaffected; results in hoarse voice, lacking pitch variation, and adequate loudness
result is an “oblique glottis”

4. Recurrent Laryngeal Nerve Paralysis
Can be unilateral or bilateral
Adductor paralysis: involved fold(s) can not be adducted to the central position
Abductor paralysis: paralyzed fold can not move laterally
paresis

5. Adductor Paralysis Bilateral adductor form Unilateral Adductor form
folds are open; usually in a paramedian position
pts is aphonic
Unilateral Adductor form
involved fold is in paramedian position; complete glottal closure is not possible
air is wasted during phonation
breathy, hoarse vocal quality

6. Unilateral adductor con’t
Tx.directed at increasing the “sharpness” of glottal attack possibly with effort closure
sometimes will give the pt. a stronger,better voice
Medical management: electrotherapy to stimulate the fold (muscle and nerve) and phonosurgery

7. Unilateral Adductor Paralysis, con’t
Boone: if bilateral, voice tx is rarely effective
medical tx: surgical repositioning, phonosurgery
Spontaneous recovery period: approximately 6-9 months; varies physician Vs. behaviorists

8. Abductor Paralysis
Unilateral abductor: results in the paralyzed fold lying near the midline
some cases may abduct laterally to the intermediate position, but never full abduction as in deep inhalation
pt complains more about SOB than dysphonia
Primary symptom: usually impaired respiration with little/no voice change

9. Bilateral Abductor Paralysis
Both folds are relatively fixed in an adducted midline position
immediate surgery required to preserve the airway
initially requires tracheotomy, then a second procedure to reposition the folds
voice tx may be prescribed

10. Therapy for vocal fold paralysis
Bilateral adductor: May try effort closure
often result of central brain stem lesion (Boone)
can have cerebral dysfunction, e.g., weakness of the tongue, palate or pharynx
Boone says tx is “probably contraindicated”
Surgery only if bilateral damage secondary to PNS damage, not CNS

11. Unilateral Adductor Paralysis
Usually due to unilateral involvement of RLN
Perceptual symptoms: marked dysphonia, severe breathiness. Note: breathiness is dependent upon the degree of glottal closure.
Mgmt determined by MD/DO; must preserve the airway.

12. Airway considerations
Laryngeal valving; biologic function
silastic injection may be require to protect the airway

13. More tx considerations
Boone: best voice is achieved with treatment that stresses increased breath control, increased hard glottal attack (why??) and pushing exercises

14. Tx for Unilateral Abductor Paralysis
One fold remains fixed in a central, adducted position
phonation is rarely effected since both folds approximate well
quiet breathing is unaffected; during physical activity breathing becomes difficult due to narrowed airway

15. Unilateral Abductor tx con’t
Surgery unlikely as the airway will be preserved
Generally voice tx requires goo vocal hygiene, maintenance of a relaxed, open vocal tract

16. Tx for adductor forms (Boone, Stemple,Aronson and Case)
Prognosis is better for pts with static lesion rather than degenerative PNS diseases
Unilateral forms are better tx risks than bilateral
Idiopathic VFP may experience spontaneous voice return
masks as a conversion aphonia: SEE ENT!

17. More Boone, et al.
Tx based upon the pt’s potential to compensate by means of adduction of the intact fold
Aronson: effort closure, dec. musculoskeletal tension, digital manipulation of the affected fold, gravity, head turns

18. Considerations for surgical augmentation
Typically “polytef” a mixture of 50% glycerin base
inserted into the lateral margin of the fold

19. Case: reasons for teflon laryngoplasty
Only if affected fold is in the paramedian, intermediate or abducted position AND unable to move toward the midline
inject one cord if bilateral bowing due to SLN paralysis; bowing in the midglottic space when adduction/abduction are “normal”

20. Case, con’t
Done after cordectomy, hemilaryngectomy or blunt laryngeal trauma when glottal incompetency occurs due to removed or damaged tissue
Done when arytenoidectomy produces glottic incompetency

21. Contraindications of Teflon laryngoplasty
Not in majority of bilateral add. Paralyses as the procedure requires one competent v.f. to work against the displaced fold
can’t be done if v.f.s are paralyzed due to CNS lesion producing dysarthria and bilateral involvement
NOT done to add mass to v.f. to lower fundamental frequency

22. Contraindications, con’t
Not done before 6 mo after onset except in the case of CA-caused paralysis
may experience spontaneous recovery during the 6 mo period
Not done if pt is psychologically unstable
Not done for dysphonia from myasthenia laryngis or hypogenesis of the vocalis muscle

23. More contraindications
Not done for minor defects in the glottic area until vocal rehab via voice tx has been attempted
Should not be done in an attempt to move the arytenoid medially; only vocalis tissue should be moved by displacing the anterior 2/3 of the glottis

24. Phonosurgery
Any surgery designed primarily for the improvement or restoration of voice

25. Phonosurgery options Laryngeal injection techniques
Laryngeal framework surgery
Laryngeal innervation
Microsurgery of benign lesions
Laser
Instrumental

26. Evaluation History and physical exam Videostroboscoy
Aerodynamic analysis
Maximum phonation time (MPT)
Mean air flow rate (MFR)
Acoustic analysis
Laryngeal manual compression tests

27. Aerodynamic Analysis Max phonation time
indication of glottic competence
influenced by vital capacity
use sustained /a/
women: seconds
men: seconds

28. Aerodynamics, con’t Mean air flow rate
indicator of degree of glottic closure
Norm values
women: cm3/sec
men: cm3/sec

29. Lateral Compression Test
Most valuable in incomplete glottic closure
Unilateral RLNP
Vocal Fold atrophy
Sulcus vocalis
Sulcus vergeture
Sustain phonation using /o/
Type I thyroplasty

30. Injection Techniques in Vocal Fold Paralysis
1911- Wilhelm Brunings
Paraffin injection
Brunings syringe (0.05 ml)
Paraffinoma < 46 degrees C
1957 Godfery Arnold
Diced autogenous septal cartilage paste
1976-Lewy--teflon injection; 1039 procedures over 24 y ears; 96% improvement

31. Laryngeal Framework Surgery
1915-Erwin Payr: first thyroplasty, anteriorly based flap of the thyroid cart.
1942-Yrho Meurman: implanted costal cartilage via laryngofissure
1955-Odd Opheim: superior thyroid ala
1965- Tschiassny:approximate cricoid and thyroid cartilage to increase vocal pitch
1974-Isshiki thyroplasty

32. Laryngeal Framework Surgery Advantages
Less vocal fold trauma
Vibratory structure is preserved
Reversible
Intraoperative
Early voice restoration

33. Laryngeal Framework Surgery Indications
Unilateral RLNP
Vocal fold atrophy
Suclus vocalis
Sulcus vergeture

34. Laryngeal Framework Surgery Isshiki Classification
Type I Medialization
Type II Lateralization
Type III Shortening
Type IV Lengthening

35. Combined Lateral Compression and Cricothyoroid Approximation
Evaluates imperfect glottic closure due to VF atrophy and decrease in tension and stiffness
RLNP and presbylaryngis
CN X injury above the nodore ganglion
Thyroplasty Type I and IV or arytenoid adduction

36. Arytenoid Adduction
Procedure of choice when the glottic aperture is wide and the immobile vocal fold is at a higher level posteriorly
Technically difficult
Anterior placement-- junction of anterior and middle third of the thyroid ala
Open cricoarytenoid joint

37. Cricothyroid Approximation
Evaluates pitch disorders
Sustained /o/
Compression should rise pitch
Thyroplasty type IV

38. Vocal Fold Medialization
Intrafold injection: transoral via indirect, transoral with direct or transcutaneous through the cricothyroid space
surgical augmentation
medial shift of the thyroid
rotation of the arytenoid

40. Vocal Fold Lateralization
Laterofixation of the VF: move the vocal process laterally
Arytenoidectomy: removal of the arytenoid to widen the posterior glottis

41. Vocal Fold Tensing To raise pitch
Cricothyroid approximation: permanent approximation of the cricoid arch to the thyroid cart. Anteriorly
stimulates the cricothyroid m.
done under local to monitor pitch
anterior commissure advancement: intent is to stretch the VF by moving the anterior commissure anteriorly

42. Vocal Fold Slackening Reduce the tension of the VFs
move the anterior commissure posteriorly, toward the arytenoids