Monday, April 25, 2011

Vocal Cord Paralysis - Paralyzed Vocal Cord - Vocal Cord Immobility

 Image 1 - Maximal Closure Prior to Injection

 Image 2 - Concave, immobile left vocal cord, pre-injection (right side of screen)

 Image 3 - Injection needle seen in left vocal cord

Image 4 - Convex left vocal cord, post-injection

Vocal Cord Paralysis, Vocal Cord Paresis, Vocal Cord Immobility
To produce a normal voice, the vocal cords must be able to approximate one another completely.  Air from the lungs is then able to oscillate, or vibrate the vocal cords.  Vocal cord immobility arises from a number of different causes, but the end result is an inability of the vocal cords to come together completely.  When one vocal cord is immobile, there is often a breathy, rough vocal quality.  Common causes of vocal cord immobility include thyroid surgery, chest surgery, intubation, cancer in the neck or chest, and viral infections.  Important in the workup of vocal cord paralysis, paresis, and immobility is finding the cause of the disorder. 

Paresis implies a partial immobility of the vocal cord.  There may be sluggish or partial motion, and some times lack of normal tone of the affected vocal cord.  Paralysis implies complete immobility.  The degree of immobility does not necessarily relate to the degree of tone of the affected vocal cords.  Some completely immobile vocal cords develop good tone, while some partially immobile vocal cords have flaccidity.

Treatment for vocal cord paralysis and paresis depends on the degree of disability for the patient.  If the voice sounds normal, and if there is no difficulty swallowing, there is no need for intervention.  When the voice is breathy and weak, intervention is indicated.  Treatement options include injection laryngoplasty (seen in the photo above), medialization laryngoplasty (thyroplasty), and speech therapy.

Injection laryngoplasty can be performed in the office or in the operating room.  I perform the vast majority of my procedures in the office.  Some patients have anxiety associated with the procedure, and in some cases a severe gag reflex, making office-based injection challenging.  Thyroplasty is always performed under anesthesia, usually conscious sedation without a breathing tube.  The patient is able to speak throughout the procedure, so that the voice can be optimized and the size of the implant properly tailored. 

In the photos above, a patient is undergoing transoral injection laryngoplasty with a temporary filler material for vocal cord paralysis arising after thyroidectomy.  Because we expect that the nerve may recover spontaneously, we use a material known to last 2-3 months.  If need be we can repeat the procedure while we await neurologic recovery.   

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