This presentation discuss

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