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Vocal cord paralysis current
concepts
Balasubramanian Thiagarajan
What has changed?
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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
Vocal fold positions
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Abduction
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Adduction
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Midline
Current theory accounting for vocal vold
position following vocal fold paralysis
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Type of lesion
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Pathology of lesion
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Synkinesis
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Fibrosis
Types of vocal fold palsy
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Unilateral recurrent laryngeal nerve palsy
Isolated unilateral superior laryngeal nerve
palsy
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Bilateral recurrent laryngeal nerve palsy
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Bilateral complete paralysis of vocal folds
Treatment algorithm of URLP
Role of speech therapy in URLP
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Controversial
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Does not hasten reinnervation
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Helps in breath support
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Helps psychologically
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Swallowing therapy is useful in pts with
swallowing difficulty
Swallowing therapy
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Swallowing while holding the breath
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Push pull technique
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Hand clasp technique
Clinical examination (vocal)
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Glottic fry
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Hard glottal attacks
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Breathy voice
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Diplophonia
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Pitch breaks
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Phonation breaks
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Tense phonation
Glottic fry
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Creaky voice
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Cords vibrate slowly
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Pt feels as if breath has run out while
speaking
Hard glottal attack
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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
Breathy voice
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Murmered voice
Vocal cord vibrates normally but are held
further apart then normal
Excessive air escape occurs between the
cords
Diplophonia
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Simultaneous production of sound of
different pitches
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Common in UVCP
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Common in mass lesions of vocal folds
Pitch breaks
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Speaking in inappropriately high pitch
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Voice seems to be out of control
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Pt does not know what sound will come out
next
Common in puberphonia
Phonation break
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Complete cessation of phonation
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Temporary
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Commonly follows excessive use of voice
Tense phonation
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Appears like speech while lifing something
heavy
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Laryngeal muscle tension
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Supralaryngeal muscle tension
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Loud, high pitched and harsh voice
Quantitative evaluation
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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
Stroboscopy
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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
Stroboscopy-what to look for
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Symmetry of movement
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Aperiodicity
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Glottic closure configuration
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Horizontal excursion
Management
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Reducing stress
Reducing hyperfunctional compensatory
mechanisms
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Breathing exercises
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Relaxation exercises
Cord injections
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Teflon
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Collagen
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Autologous fat
Teflon injection
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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
Teflon injection - Procedure
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No sedation
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Percutaneous approach (suitable)
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LA
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Performed under laryngoscopic guidance
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Anterior / lateral approaches are possible
Teflon injection (contd)
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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
Transoral teflon injection
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Performed under DL scopy guidance
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Preferably under GA with jet ventilation
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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
Teflon injection - Limitations
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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
Collagen injection
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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
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Collagen should be placed within lamina propria
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URI increases collage resorption
Autologous fat injection Indications
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Vocal fold paralysis
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Vocal fold scarring
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Vocal fold atrophy
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Intubation injuries
Procedure
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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
Advantages
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Reversible
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No reactions
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Immediate results are good
Type I thyroplasty - indications
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Unilateral / bilarateral vocal fold paralysis
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Incomplete glottal closure
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Vocal fold bowing
Contraindications
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Following irradiation
In patients who have undergone
hemilaryngectomy (thyroid lamina is a must
to hold the prosthesis)
Type I Thyroplasty (Procedure)
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LA
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
Contd
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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
Complications
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Persistent dysphonia
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Implant migration
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Airway obstruction
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Hematoma formation
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Infections
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Useless to close large posterior gap
Arytenoid adduction - Indications
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To close a large posterior gap
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If the vocal folds are not at the same level
Procedure
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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
Contd
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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
Reinnervation procedures
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Experimental
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Neuromuscular pedicle reinnervation
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Ansa cervicalis and recurrent laryngeal
nerve anastomosis
Bilateral paralysis
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Does not cause stridor always
Position of cord depends on fibrosis /
synkinesis
Treatment tailored to patient's needs
contd
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Tracheostomy – emergency
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Steroid injection (systemic)
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Adrenaline nebulization
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CPAP
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Intubation / ICU Care
contd
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Lateralizing procedures
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Chordectomy
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Arytenoidectomy
Thankyou