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.   

Why is My Voice Hoarse After Intubation?

When a breathing tube is placed into the airway for surgery or mechanical ventilation due to severe illness there is a chance of temporary or permanant damage to the vocal cords. Injury leading to vocal cord dysfunction can occur from a variety of mechanisms.

The first group of injuries occur during the intubation procedure. During intubation, a breathing tube (endotracheal tube) is passed through the mouth, throat, and vocal cords, into the windpipe. The tube can traumatize the vocal cords during placement, leading to bruising or ulceration of the vocal cord, dislocation of the arytenoid cartilage (part of the vocal cord), or a combination of injuries. Bruising of the vocal cord is referred to as a vocal hemorrhage. In particular, patients with difficult to expose larynges or those intubated emergently are at a higher risk.

The next group of injuries includes damage from a breathing tube sitting in place in the larynx and upper windpipe. The risk of injury correlates with the duration of the intubation. The inflated cuff on the breathing tube can create a pressure injury to the trachea or subglottis, leading to ulceration, inflammation, and scarring. When scarring occurs it can lead to a narrowing of the airway. If this occurs below the vocal cords it is called subglottic stenosis or tracheal stenosis. If the injury occurs at the level of the vocal cords it is referred to as glottic stenosis. And above the vocal cords it is called supraglottic stenosis.

More common than airway stenosis is the formation of a laryngeal granuloma. A laryngeal granuloma is also referred to as a pyogenic granuloma, contact ulceration, or intubation granuloma. Granulomas are inflammatory growths caused by injury to the covering of the arytenoids by the breathing tube. They normally resolve over time, although they can be difficult to eradicate often due to concurrent acid reflux or voice abuse.

Another group of injuries after intubation includes vocal cord paralysis and vocal cord paresis. A paralysis can occur from pressure exerted by the breathing tube on the recurrent laryngeal nerve. This can occur in conjunction with arytenoid dislocation. Paralysis can resolve on its own or persist. Permanent weakness can develop with varying degrees of recovery. A partially recovered paralysis is referred to as a vocal cord paresis. Treatment of the paralyzed vocal cord depends on the mechanism of injury, duration of vocal cord paralysis, and the symptoms experienced by the patient.

Treatment options include vocal cord injection (injection laryngoplasty), vocal cord medialization laryngoplasty (thyroplasty, Isshiki type I thyroplasty). Injection of the vocal cords is easily performed in the office setting in the unsedated patient. Materials used to inject or augment the vocal cords include Restylane, Radiesse Voice, Radiesse Voice Gel, Juvederm, Collagen, Cymetra, Fat, Gelfoam, etc. Injections can be temporary, semipermanent, or permanent, depending on the material used.

If your voice is hoarse after an intubation, you should seek the care of an otolaryngologist or laryngologist. Laryngeal examination will be performed and the cause of your hoarseness can be addressed.