Download Vocal Fold Paralysis

Vocal Fold Paralysis:
A Dynamic Look at Treatment
Presented by: Theresa Gorman
Presented to: Rebecca L. Gould,
MSC, CCC-SLP
Brief Review
Bilateral and unilateral vocal fold
paralysis (VFP) disorders are caused
by peripheral involvement of the
recurrent laryngeal nerve branch and
less commonly by damage to the
superior laryngeal nerve. The site of
the lesion along the nerve pathway
will determine the type of paralysis,
and the vocal quality that results from
nerve damage.
Etiologies of VFP
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Common etiologies of unilateral and
bilateral vocal fold paralysis may include:
surgical trauma (thyroid surgery, carotid
artery surgery, anterior cervical fusion are
some of the common surgical causes of
the recurrent laryngeal nerve damage)
cardiovascular disease
neurological diseases
accidental trauma
(Glaze, Klaben & Stemple, 2000)
Symptoms of VFP
Typical symptoms include hoarseness,
breathy voice, inability to speak loudly,
limited pitch and loudness variations,
voicing that lasts only for a very short time
(around one second), choking or coughing
while eating, and possible pneumonia due
to food and liquid being aspirated into the
lungs
(McFarlane, Von Berg & Watson, 2001).
Unilateral abductor paralysis
Recurrent nerve damage - the paralyzed
fold remains at midline, but the
contralateral fold abducts and adducts
normally, allowing both airway protection
and quasi-normal speech and voice
production. Because of midline positioning,
the airway’s size will be reduced.
Inspiratory stridor will likely be evident
during arduous activity. Voice quality will
remain normal but increased loudness will
be difficult due to fold laxness of the
paralyzed fold (Glaze et al. 2000).
Unilateral adductor paralysis
Recurrent nerve damage - This is most
common type of fold paralysis - the
affected fold rests in a paramedian
(abducted) position whereas the
contralateral fold abducts normally. This
position and the vertical level of the fold, as
well as the size of the glottal gap determine
the effect of the paralysis on phonation.
Voice quality is characterized by breathiness
and diplophonia. The patient’s impaired
ability to build subglottic pressure results in
decreased vocal intensity and the inability to
be heard in background noise, as well as
regular physical fatigue (Glaze et al., 2000).
Treatment Options…UVFP
Voice therapy - techniques include hard glottal attack
exercises, lateral digital pressure, head tilt method, Vocal
function exercises, and half-swallow boom technique.
These methods are utilized to reduce the vocal and
laryngeal hyperfunction that results in an attempt to
compensate for lack of glottic closure.
Phonosurgery - Two surgical options used include
medialization thyroplasty and laryngeal reinnervation.
Medialization thyroplasty involves surgery to push the
paralyzed vocal fold closer toward the middle so that the
other vocal fold does not have to work so hard for the
vocal folds to come together for voicing, and may be a
helpful option when aspiration is persistent. It involves
implantation of a small device, made from silastic or
Gore-Tex, into the vocal fold to optimize its position for
better closure during speaking and singing.
Combination - because speech therapy, in isolation, is
often ineffective.
Beginning Treatment
When the cause for vocal fold paralysis is
known and it is determined that damage is
permanent and there is no chance for
return of function, then any form of
management may begin immediately
(Glaze, et al., 2000).
When the cause is idiopathic, most
surgeons will wait and observe the patient
for 6-12 months before surgical
intervention is applied.
Other Options
Reinnervation of the larynx involves surgery to
connect another nerve to the larynx to replace the
nerve that was damaged (Ford, 2005).
The promise of laryngeal re-innervation has existed
for years but has yet to be proven to be possible and
effective (Rosen, 2003).
The phonosurgical management alternatives for
UVFP address the midline glottic incompetence and
the loss of vocal fold body. Previously, the most
widely used surgical option has been the use of a
synthetic, alloplastic, Teflon paste into the lateral
portion of the fold that is paralyzed, which transforms
into a solid mass. This mass moves the paralyzed
edge medially to improve midline function. This
technique has been used for over 50 years, and has
attained great success.
Now…methods are different
Teflon is no longer the preferred treatment method
(complications - foreign-body granuloma and vocal
cord stiffness). (Glaze et al., 2000).
Silicone was reported to be a very safe material for
injection laryngoplasty, but related adjuvant
diseases halted its use.
Autologous fat has been used for injection
laryngoplasty because of its safety. It has a rapid
absorption rate, which limits its long-term success;
success may be increased by an overinjection of fat,
initially, to compensate for the expected partial
resorption. The technique’s advantages include that
it is natural, soft, and flexible. The attributes of the
autologous fat help it to vibrate well, while not
posing any risk for antibody or foreign body
response (Glaze et al., 2000).
…New methods continued
New bioimplants have been explored as injectable
alternatives to Teflon.
A cross-linked bovine collagen has been developed for
injections. The bioimplant is injected superficially into
the lamina propria of the vocal fold where it
incorporates into the cellular structure of the fold and
reportedly enhances the vibratory properties of the
paralyzed fold, even where scarring is present.
Patients, after lipoinjection, are placed on voice rest to
enhance the survival of the transplanted fat. This is
typically for 6-7 days in duration. No or minimal voice
rest is used after laryngeal framework procedures or
Teflon injection (Rosen, 2003).
While injection laryngoplasty techniques become
increasingly popular for vocal fold augmentation in
cases vocal fold paresis, atrophy, and scarring, its role
in the treatment of UVFP should be limited to cases
with an appropriate glottal defect.
…New methods continued
In 1999, Zeitels described a new laryngeal
framework procedure for UVFP called
cricothyroid subluxation. This procedure
involves anteriorly displacing the ipsilateral
inferior cornu of the thyroid cartilage. This
is performed by placement of a suture that
runs from the inferior cornu of the thyroid
cartilage to the midline of the cricoid
cartilage. This effectively rotates the thyroid
cartilage on the cricoid cartilage, providing
additional length to the paralyzed vocal fold
(Rosen, 2003).
Surgical Management
Complications
poor voice outcome
airway difficulties
unwanted movement (migration) of the
medialization implant
surgical treatment for UVFP involves
manipulation of the airway, so factors such
as swelling or possible hematoma from
either laryngeal framework surgery or vocal
fold injection can cause airway difficulties –
life threatening
Current Behavioral Approaches
It is comparable to physical therapy, but specifically targets
the voice mechanism.
The individual will work with the SLP on pitch alteration,
increasing breath support and loudness, and finding the
correct position for optimal voicing (such as turning the head
to one side or manipulating the thyroid cartilage). Rosen
(2003) explained that voice therapy is utilized as the primary
treatment for those who have a favorable position of their
vocal fold paralysis or are unwilling or unable to have
surgery because of psychological or medical limitations.
Therapy techniques include hard glottal attack exercises,
lateral digital pressure, head tilt method, Vocal function
exercises, and half-swallow boom technique. These methods
are utilized to reduce the vocal and laryngeal hyperfunction
that results in an attempt to compensate for lack of glottic
closure (Glaze et al., 2000).
Behavioral Treatment continued…
Research continues to show professionals in our
field that voice therapy is an effective
intervention in the interim period between
diagnosis of the paralysis and final resolution of
the problem.
Generally, voice therapy will improve voice
function of patients with vocal fold paralysis by
about 5 to 15 percent. Although this may not
seem to be a dramatic improvement, for patients
whose voice use is limited, or for those who do
not wish to undergo surgery, it may represent a
sufficient gain.
Bilateral adductor paralysis
(Recurrent Laryngeal nerve)
BVFP occurs when fold are positioned laterally in
an abducted paramedian position. The main
concern becomes protection of the airway. This
condition often requires that a patient have a
gastrostomy tube for feeding due the insufficient
airway protection. Bilateral abductor paralysis is a
critical condition in which the folds are fixed at
midline and cannot open. An adequate airway will
be established surgically, often through a
tracheostomy.
Surgical manipulation of one arytenoids cartilage
will also create sufficient airway by removing it
completely or suturing it laterally. Bilateral paralysis
is often medically treated and may require a
tracheotomy to allow the person to eat safely.
Superior Laryngeal Nerve damage
Due to the shorter course through the
body than the recurrent laryngeal
nerves, superior laryngeal nerve
paralysis occurs much less often.
Etiologies of these paralyses include
thyroid disease and thyroid surgery
that cause temporary or permanent
paralysis.
Diagnosis is difficult to attain.
Bilateral VFP
(Superior laryngeal nerve)
Bilateral paralysis is rare and must be
confirmed through the use EMG
studies. If paralysis occurs, vocal
folds will lack their normal tone and
will not lengthen sufficiently during
increased pitch attempts. Voice
quality is limited in frequency and
intensity range and stability.
Unilateral Superior Laryngeal Nerve
VFP
May result in an oblique positioning or an overlap
of the folds because of the unequal rocking of the
cricothyroid joint, which creates a gap between the
folds and limits closure patterns.
Vocal intensity is decreased due to the decrease
in ability to build subglottic air pressure.
Pitch is mainly affected.
Patients often complain of vocal fatigue and
inability to sing.
No medical treatment exists, but voice therapy
may be utilized for educational and voice
conservation purposes.
Unilateral Superior Laryngeal Nerve
VFP
A new alternative involves nerve-to-nerve
reinnervation. Recurrent laryngeal nerve
(RLN) to RLN reinnervation is not
consistently successful because does not
always provide functional return of the of
adductor and abductor activity (Glaze et
al., 2000). In addition, RLN-to-RLN
anastomosis may result is dysphonia as a
result of jerky movements and excessive
synkinesis of adductor and abductor
muscles simultaneously. The method is not
heavily relied upon
Futures Goals in Our Field
It is important to understand that
present surgical and medical
treatments may only provide static
improvement to the vocal fold and
cannot provide the dynamic activity of
the vocal fold to voice production that
was present in the premorbid state.
More to see in the future…
The future goal of laryngology research will need
to create a method of rehabilitation that is
dynamic. This goal has been present for decades,
and much work has been devoted to the concept
of reinnervation of the vocal fold. Unfortunately,
this type of work has been unsuccessful for most
surgeons to date, and much research is required
to better understand the delicate innervation of the
muscles of the larynx and their coordination. The
professionals in the fields of speech pathology and
otolaryngology will strive towards that goal and
actively perform new treatment approaches that
prove efficacious.
Pictures of Vocal Fold Paralysis
Recurrent Laryngeal N.
Paralysis
Unilateral left vocal fold
paralysis (Superior N.
Paralysis)
References
Buckmire, R. & Kwon, T. (2004). Injection laryngoplasty for management of
unilateral vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surgery.
6, 538-542. Retrieved July 7, 2005, from PubMed database.
Ford, C. N., (2005). Active Clinical Studies. Retrieved July 8, 2005, from
University of Wisconsin Clinical Science Center
site: http://www.surgery.wisc.edu/Oto/research/clinical_studies.shtml
Glaze, L. E., Klaben, B. G., & Stemple, J. C. (2000). Clinical voice pathology:
Theory and management. 3rd Ed. San Diego: Singular Publishing Group.
Gray, S., Johnson, D., Kelly, S., Smith, M. (2004). Vocal fold paralysisand
progressive cricopharyngeal stenosis reversed by cricopharyngeal
myotomy. Retrieved July, 10, 2005, from
http://uuhsc.utah.edu/otolaryngology/research.html#anchor9
McFarlane, S., Von Berg, S., Watterson, T., (2001). Vocal Fold Paralysis.
Retrieved July 9, 2005, from
http://www.asha.org/public/speech/disorders/vf_paralysis.htm
Rosen, C. A., (2003). Vocal Fold Paralysis, Unilateral. Retrieved July 8, 2005,
from http://www.emedicine.com/ent/topic347.htm
Vocal Fold Paralysis. (n.d.). Retrieved July 10, 2005, from
http://voicedisorders.upmc.com/VocalFoldParalysis/Treatment.htm