This document discusses current concepts in vocal cord paralysis. It summarizes that theories of vocal fold positioning following paralysis are now more simplified. The current theory considers lesion type, pathology, and synkinesis/fibrosis. Examination findings like breathy voice, diplophonia, and tense phonation are described. Management includes injections like Teflon, collagen, fat, and medialization procedures like type I thyroplasty. Bilateral paralysis requires tailored treatment including steroids, intubation, or lateralization surgeries in severe cases.

1. Vocal cord paralysis current
concepts
Balasubramanian Thiagarajan

2. What has changed?

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

3. Vocal fold positions

Abduction

Adduction

Midline

4. Current theory accounting for vocal vold
position following vocal fold paralysis

Type of lesion

Pathology of lesion

Synkinesis

Fibrosis

5. Types of vocal fold palsy

Unilateral recurrent laryngeal nerve palsy

Isolated unilateral superior laryngeal nerve
palsy

Bilateral recurrent laryngeal nerve palsy

Bilateral complete paralysis of vocal folds

6. Treatment algorithm of URLP

7. Role of speech therapy in URLP

Controversial

Does not hasten reinnervation

Helps in breath support

Helps psychologically

Swallowing therapy is useful in pts with
swallowing difficulty

8. Swallowing therapy

Swallowing while holding the breath

Push pull technique

Hand clasp technique

9. Clinical examination (vocal)

Glottic fry

Hard glottal attacks

Breathy voice

Diplophonia

Pitch breaks

Phonation breaks

Tense phonation

10. Glottic fry

Creaky voice

Cords vibrate slowly

Pt feels as if breath has run out while
speaking

11. Hard glottal attack

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

12. Breathy voice

Murmered voice

Vocal cord vibrates normally but are held
further apart then normal

Excessive air escape occurs between the
cords

13. Diplophonia

Simultaneous production of sound of
different pitches

Common in UVCP

Common in mass lesions of vocal folds

14. Pitch breaks

Speaking in inappropriately high pitch

Voice seems to be out of control

Pt does not know what sound will come out
next

Common in puberphonia

15. Phonation break

Complete cessation of phonation

Temporary

Commonly follows excessive use of voice

16. Tense phonation

Appears like speech while lifing something
heavy

Laryngeal muscle tension

Supralaryngeal muscle tension

Loud, high pitched and harsh voice

17. Quantitative evaluation

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

18. Stroboscopy

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

19. Stroboscopy-what to look for

Symmetry of movement

Aperiodicity

Glottic closure configuration

Horizontal excursion

20. Management

Reducing stress

Reducing hyperfunctional compensatory
mechanisms

Breathing exercises

Relaxation exercises

21. Cord injections

Teflon

Collagen

Autologous fat

22. Teflon injection

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

23. Teflon injection - Procedure

No sedation

Percutaneous approach (suitable)

LA

Performed under laryngoscopic guidance

Anterior / lateral approaches are possible

24. Teflon injection (contd)

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

25. Transoral teflon injection

Performed under DL scopy guidance

Preferably under GA with jet ventilation

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

26. Teflon injection - Limitations

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

27. Collagen injection

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

Collagen should be placed within lamina propria

URI increases collage resorption

28. Autologous fat injection -
Indications

Vocal fold paralysis

Vocal fold scarring

Vocal fold atrophy

Intubation injuries

29. Procedure

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

30. Advantages

Reversible

No reactions

Immediate results are good

31. Type I thyroplasty - indications

Unilateral / bilarateral vocal fold paralysis

Incomplete glottal closure

Vocal fold bowing

32. Contraindications

Following irradiation

In patients who have undergone
hemilaryngectomy (thyroid lamina is a must
to hold the prosthesis)

33. Type I Thyroplasty (Procedure)

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

34. Contd

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

35. Complications

Persistent dysphonia

Implant migration

Airway obstruction

Hematoma formation

Infections

Useless to close large posterior gap

36. Arytenoid adduction - Indications

To close a large posterior gap

If the vocal folds are not at the same level

37. Procedure

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

38. Contd

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

39. Reinnervation procedures

Experimental

Neuromuscular pedicle reinnervation

Ansa cervicalis and recurrent laryngeal
nerve anastomosis

40. Bilateral paralysis

Does not cause stridor always

Position of cord depends on fibrosis /
synkinesis

Treatment tailored to patient's needs

41. contd

Tracheostomy – emergency

Steroid injection (systemic)

Adrenaline nebulization

CPAP

Intubation / ICU Care

42. contd

Lateralizing procedures

Chordectomy

Arytenoidectomy

43. Thankyou