Laryngeal Paralysis and Paresis

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Laryngeal Paralysis and Paresis

Laryngology, Voice and Swallowing
Author Credentials 

Ozlem E. Tulunay-Ugur, MD
Professor
University of Arkansas for Medical Sciences
Department of Otolaryngology Head and Neck Surgery
Little Rock, AR

Module Summary

Vocal fold paralysis etiology can be divided into three main groups, idiopathic, iatrogenic and compression due to a mass. It can lead to frustrating symptoms for the patient, with a weak and breathy voice, vocal fatigue and loss of projection. For professional voice users this may determine the timing of intervention. Risk of aspiration needs to be assessed, especially for older patients and patients with high vagal injuries, such as carotid endarterectomy. Imaging is of outmost importance, as compression due to a mass is not uncommon and can lead to diagnosis of cancer. There are many treatment options and it is very important to know the risks and benefits of each, as well as when patients can be observed and when more prompt intervention is needed. The surgeon should be aware of the properties of all fillers and implant materials, as well as technical details of each procedure. The role of in-office procedures has been steadily increasing in Otolaryngology and there are various techniques for injection laryngoplasty, especially beneficial for temporary injections as well as in sick, older and lung cancer patients. 

Module Learning Objectives 
  1. Describe the anatomy of laryngeal innervation
  2. Recgonize the symptoms of vocal fold paralysis
  3. Explain the work-up of vocal fold paralysis
  4. Differentiate patients at higher risk for morbidity and mortality
  5. Identify potential treatment options in the management of vocal fold paralysis
  6. Explain the risks and benefits of surgical treatment options and patient selection

Embryology

Learning Objectives 
  1. Understand the embryology of the recurrent laryngeal nerve

Anatomy

Learning Objectives 
  1. Understand the anatomy of the larynx
  2. Understand the anatomy of the recurrent and superior laryngeal nerve

Pathogenesis

Learning Objectives 
  1. Describe etiology of unilateral vocal fold paralysis
  1. Iatrogenic or non-iatrogenic trauma
    1. Neck surgeries (Thyroidectomy, anterior cervical fusion, carotid endarterectomy)
    2. Chest surgeries (Mediastinoscopy, esophagectomy, lobectomy)
  2. Compression due to mass
  3. Idiopathic
  4. Collagen vascular disease
  5. Infections
  6. Rare conditions
References 
  1. Misono S, Merati AL. Evidence-based practice: evaluation and management of unilateral vocal fold paralysis. Otolaryngol Clin North Am. 2012;45(5):1083-108.
  2. Stager SV. Vocal fold paresis: etiology, clinical diagnosis and clinical management. Curr Opin Otolaryngol Head Neck Surg. 2014;22(6):444-9. 
  3. Walton C, Carding P, Flanagan K. Perspectives on voice treatment for unilateral vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surg. 2018;26(3):157–161
  4. Gardner GM, Benninger MS. Vocal fold paralysis. In:n Rubin JS, Sataloff RT, Korovin, editors. Diagnosis and Treatment of Voice Disorders. San Diego: Plural; 2006. p. 471-91.
  5. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin North Am. 2007;40(5):1109-31.

Patient Evaluation

Learning Objectives 
  1. Know common presenting symptoms 
  2. Weak and breathy voice, loss of vocal projection, vocal fatigue, inconsistent voice
  3. Know risk of aspiration
  4. Dysphagia, increased aspiration, aspiration pneumonia
  5. Findings on Laryngostroboscopy
  6. Immobile true vocal fold (TVF), possible atrophy of TVF, gap between the TVFs on phonation, asymmetrical and aperiodic waves on stroboscopy, supraglottic compression, pooling of secretions in the pyriform sinus 
  7. Understand which patients may require specific lab work

Measurement of Functional Status

Learning Objectives 
  1. Speech therapy evaluation 
  2. Laryngeal EMG
     
References 
  1. Smith LJ, Rosen CA, Munin MC. Vocal fold motion outcome based on excellent prognosis with laryngeal electromyography. Laryngoscope. 2016;126(10):2310-4
  2. Smith LJ, Rosen CA, Niyonkuru C, Munin MC. Quantitative electromyography improves prediction in vocal fold paralysis. Laryngoscope. 2012;122(4):854-9. 
  3. Mattei A, Desuter G, Roux M, Lee BJ, Louges MA, Osipenko E, Sadoughi B, Schneider-Stickler B, Fanous A, Giovanni A. International consensus (ICON) on basic voice assessment for unilateral vocal fold paralysis. Eur Ann Otorhinolaryngol Head Neck Dis. 2018;135(1S):S11-S15. 

Imaging

Learning Objectives 
  1. CT from skull base to aortic arch
  2. Scan the entire course of the laryngeal nerve
  3. MRI brain
  4. Modified barium swallow
  5. In patients with suspected dysphagia or aspiration
References 
  1. Paquette CM1, Manos DC, Psooy BJ. Unilateral vocal cord paralysis: a review of CT findings, mediastinal causes, and the course of the recurrent laryngeal nerves. Radiographics 2012;32(3):721-40
  2. Noel JE, Jeffery CC, Damrose E. Repeat Imaging in Idiopathic Unilateral Vocal Fold Paralysis: Is It Necessary? Ann Otol Rhinol Laryngol 2016;125(12):1010-1014. 
  3. Paddle PM, Mansor MB, Song PC, Franco RA Jr. Diagnostic Yield of Computed Tomography in the Evaluation of Idiopathic Vocal Fold Paresis. Otolaryngol Head Neck Surg. 2015;153(3):414-9. 

Treatment

Learning Objectives 
  1. Speech therapy
    • Voice and swallowing therapy
  2. Medical management
    • Nimodipine
  3. Understand surgical management options and patient selection as well as surgical timing
  4. Understand the role of observation in acute iatrogenic paralysis and how to select patients that need temporary medicalization due to increased aspiration or high vocal use
References 
  1. McLaughlin CW, Swendseid B, Courey MS, Schneider S, Gartner-Schmidt JL, Yung KC.Long-term outcomes in unilateral vocal fold paralysis patients. Laryngoscope. 2018;128(2):430-436. 
  2. Rosen CA, Smith L, Young V, Krishna P, Muldoon MF, Munin MC. Prospective investigation of nimodipine for acute vocal fold paralysis. Muscle Nerve. 2014;50(1):114-8.

Surgical Therapies

Learning Objectives 
  1. Injection laryngoplasty
    • Understand the properties of different fillers
    • Understand the advantages and disadvantages of in-office versus operating room procedures
  2. Ishikii type 1 thyroplasty
    • Know available implants and understand various techniques
  3. Laryngeal reinnervation
References 
  1. Ballard DP, Abramowitz J, Sukato DC, Bentsianov B, Rosenfeld R.: Systematic Review of Voice Outcomes for Injection Laryngoplasty Performed under Local vs General Anesthesia. Otolaryngol Head Neck Surg. 2018 Jul.
  2. Vila PM, Bhatt NK, Paniello RC.: Early-injection laryngoplasty may lower risk of thyroplasty: A systematic review and meta-analysis. Laryngoscope. 2018;128(4):935-940. 
  3. Paniello RC, Edgar JD, Kallogjeri D, Piccirillo JF. Medialization versus reinnervation for unilateral vocal fold paralysis: a multicenter randomized clinical trial. Laryngoscope 2011; 121:2172–2179.
  4. Zuniga S1, Ebersole B, Jamal N. Improved swallow outcomes after injection laryngoplasty in unilateral vocal fold immobility. Ear Nose Throat J. 2018;97(8):250-256.
  5. Rosen CA, Amin MR, Sulica L, Simpson CB, Merati AL, Courey MS, Johns MM 3rd, Postma GN. Advances in office-based diagnosis and treatment in laryngology. Laryngoscope. 2009;119 Suppl 2:S185-212.
  6. Amin MR. Thyrohyoid approach for vocal fold augmentation. Ann Otol Rhinol Laryngol. 2006;115(9):699-702.
  7. Sulica L, Rosen CA, Postma GN, Simpson B, Amin M, Courey M, Merati A. Current practice in injection augmentation of the vocal folds: indications, treatment principles, techniques, and complications. Laryngoscope. 2010;120(2):319-25. 
  8. Rosen CA, Simpson CB. Operative Techniques in Laryngology. Berlin: Springer-Verlag; 2008. 
  9. Rosen CA, Gartner-Schmidt J, Casiano R, Anderson TD, Johnson F, Remacle M, Sataloff RT, Abitbol J, Shaw G, Archer S, Zraick RI. Vocal fold augmentation with calcium hydroxylapatite: twelve-month report. Laryngoscope. 2009;119(5):1033-41. 
  10. Anderson TD, Spiegel JR, Sataloff RT. Thyroplasty revisions: frequency and predictive factors. J Voice. 2003;17(3):442-8.

Case Studies

  1. A 35-year-old female presents with a 6 weeks history of a weak and breathy voice since a total thyroidectomy. The voice problems started right after the procedure. She states there is minimal improvement since the surgery. She works as a 4th grade teacher. She states she occasionally chokes on water. What would you expect to see on laryngostroboscopy? Are there any further studies you would want to order? What are initial the management options? Would any features of her history prompt early intervention? How would you follow her? What are the permanent treatment options? 
     
  2. A 65-year-old man who is a long-term smoker presents due to hoarseness and is referred to rule out laryngeal cancer by his primary care physician. He has been losing weight in the last 6 months and also coughs every time he eats. What do you expect to see on laryngoscopy? What further studies would you ask for? Would you offer any immediate treatment? Would have a preference of in-office versus operating room procedure?

Complications

Learning Objectives 
  1. Know the risk of aspiration and how to manage it
  2. Know the complications of all surgical options in each setting such as in-office and in the operating room
  3. Know the complications specific to various fillers, such as hydroxyl-apatite

Review

Review Questions 
  1. What are the most common reasons for TVF paralysis?
  2. What does a full work-up include? 
  3. What factors help determine the timing of surgery?
  4. What are the surgical options and how do you determine which one to choose?
Resources 

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