Vocal fold paralysis, although uncommon in general practice, can have devastating consequences for a patient. Dysphonia is the most common finding: breathy voice, loss of air, vocal fatigue (as well as systemic fatigue: winded), neck soreness, and inability to be heard on a phone are the most common complaints. Additionally, patients may also have signs of aspiration: cough (especially with liquids), choke, dysphagia, and recurrent pneumonia. With early diagnosis, complications and patient frustration can be avoided. In the past, the dogma was to wait 9 months as the nerve healed. Today, we have an armamentarium of treatments that can be instituted immediately to return a patient’s voice and swallowing ability.
Causes
- Surgical Trauma (Thyroid, Neck Fusion)
- Cancer (Thyroid, Lung, Metastasis)
- Post-Viral
- Stroke
- Neurological
- Toxin/Drugs
Diagnosis
Laryngeal Video-Stroboscopy is the gold standard tool to diagnose any voice disorder. Immobility, vocal fold position, associated muscular compensation are assessed. FEES or MBS testing is important to rule out aspiration EMG of the vocal folds can help with prognosis CT/MRI to rule out a mass Laboratory testing to rule out other causes
If vocal fold paralysis is suspected, do not delay: early diagnosis will lead to early treatment!
Treatment
All patients with vocal paralysis should be diagnosed, have aspiration ruled out, and be treated! There should never be a Watch and Wait policy! At the very least, voice therapy can greatly improve a patient’s voice and help protect against aspiration.
Injection Laryngoplasty
This is performed in the office; an injection of the para-glottic fold space with a filler agent helps medialize the paralyzed vocal fold – instant voice improvement that can last 6 months up to 2 years. This can help a patient overcome their symptoms while waiting for return of function, if it comes.
Thyroplasty
Performed in the OR under local anesthesia, a small implant is placed in the paraglottic space to medialize the paralyzed vocal fold. This is a permanent procedure.
Arytenoid Adduction
This suture technique helps reposition the paralyzed arytenoids to improve closure of the glottis, improving voice and preventing aspiration.