True Vocal Cord Paralysis Treatment (Treatment of bowed vocal cords too!)

by , last modified on 10/14/14
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Treatment for bowed vocal cords is at the
bottom
. However, in order to understand,
still read the entire article.


If BOTH your vocal cords are paralyzed, click
here
.


In order to understand treatment of vocal cord paralysis (and bowed vocal cords too), one needs to first understand how the voice works when everything is moving fine. If you already know, skip to the treatment section. If not, here is a more detailed tutorial on how the voicebox works. Briefly, the voicebox is composed of a right and left vocal cord that is attached on one end, much like a "V". When the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows one to breathe. When a person wants to sing/talk or say "eee," the vocal cords come together and vibrate very quickly creating the voice. The vocal cords and their movement can be visualized on fiberoptic laryngoscopy (watch movie of this exam).

vocal cord When the vocal cords are apart, one is moving air in and out from the lungs. vocal cord
When the vocal cords are together, they vibrate very quickly creating a voice.

A "paralyzed" vocal cord is when one of the vocal cords does not move resulting in a gap between the vocal cords. This gap when attempting to talk results in air escape which causes the "breathy" sounding voice. A real-life example of vocal cord paralysis and how the voice sounds with this condition can be found here.

paralysis
In this illustration, the patient is trying to say "eee," but notice that the vocal cord on the left is not moving to the middle resulting in a gap between the vocal cords. The left vocal cord is paralyzed.

Other symptoms a patient may have from a paralyzed vocal cord include:

  • breathy voice (as we mentioned already)
  • food/liquids going the wrong way (aspiration)
  • cough
  • unable to speak in full sentences in a single breath (constantly running out of breath while talking)
  • more difficult to walk up stairs, lift heavy objects, "hold" a breath
  • trouble swallowing


Why would a vocal cord become paralyzed in the first place? The 3 most common causes of vocal cord paralysis are viral infection of the vagus nerve, surgery (especially from thyroidectomy, PDA ligation, neck/chest/cardiac surgery), and cancer (especially lung or thyroid cancer). Regardless of cause, there are in essence THREE ways of treating a paralyzed vocal cord. The goal of treatment is to get the vocal cords to come together completely which would resolve many of the symptoms.

The three different options to treat are:

  • Nothing: Sometimes, a person is able to compensate for the paralyzed vocal cord to the point no further intervention is needed. It is up to the patient how long to go with this option prior to pursuing an intervention. Usually, most people wait 1-2 weeks.
  • Voice therapy: This mode of treatment is done under the guidance of a voice/speech therapist who will work with the patient to try and have the working vocal cord "compensate" for the vocal cord paralysis. This therapist will also assist in improving swallow which may be impaired as well. It may take many sessions and several weeks before a patient starts to see results.
  • Surgical: Almost IMMEDIATE improvement of all symptoms seen, especially vocal quality and strength, swallow, and shortness of breath.


An important factor to consider is that as long as the nerve is intact, the vocal cord paralysis may resolve on its own spontaneously up to one year after the paralysis occurs!!! As such, temporary measures (voice therapy or surgery using biodegradable substances) are usually recommended until after 1 year has passed after which more permanent procedures are recommended if symptoms are still present. More on this below...

Surgical Treatment

There are essentially TWO different surgical procedures to address the paralyzed vocal cord: injection or implantation. Both procedures involve physically moving the paralyzed vocal cord into a midline position so that the other non-paralyzed vocal cord can more easily come and meet it in the midline. There are many surgical terms to describe this basic surgical goal (medialization, laryngoplasty, thyroplasty, etc). Regardless of the exact surgical term used, keep in mind that all these procedures basically mean and accomplish the same thing... pushing the vocal cord into a more midline position. There is a third approach considered experimental known as reinnervation in which one takes a nerve away from another muscle to bring function back to the paralyzed vocal cord. Results with this approach have been mixed.


videoWatch Video on Vocal Cord Paralysis Surgical Treament By Injection or Implantation

The least invasive surgical procedure is known as True Vocal Cord Injection Medialization. With this procedure, a needle is placed into the vocal cord that is paralyzed and a biologically compatible substance is injected to one side of the vocal cord "pushing" it into a midline position. Watch a video of this procedure being performed.

injection The needle is placed just to the side of the paralyzed vocal cord. injection With injection of a biologically compatible substance, the vocal cord is pushed to the midline.


I personally like to perform this procedure with the patient awake without any sedation. The whole purpose of this procedure is to improve the voice and the only way to know if the voice is good, is to have the person talking when the injection is being performed. In order to make sure the needle is in the correct location prior to injection, this procedure is performed under endoscopic guidance.

The major advantage of this procedure is that it can be performed without any cutting of the skin or general anesthesia and is an outpatient procedure with the patient allowed to go home after 2 hours of observation. The major disadvantage is that once injection is performed, one cannot "remove" the injected material easily. Some common materials injected include teflon, gelfoam, fat, and collagen. The injectables I use most often are: cymetra (collagen) and radiesse (hydroxyl-apatite).

Cymetra usually lasts about 6-12 months prior to disappearing. Radiesse is considered "permanent." Why would I inject a temporary substance? It's because oftentimes, the vocal cord paralysis will resolve on its own given time... How much time? Up to ONE YEAR!!! However, most people are not willing to wait one year prior to doing something. At the same time, one does not want to do something permanent until the paralysis is felt to be irreversible.

With injection, one actually tries to over-inject so that the voice sounds a bit "tight." The reason for over-injection is because the injected material tends to collapse/compress a bit over time. Over-injection anticipates this compression and a "normal" voice is usually obtained within 7 days after the procedure.

Understandably, there are some patients who would like to know if this technique will work before injecting a foreign material that sticks around for several months. In these folks, saline (otherwise known as saltwater) can be injected which will wear off in 1-2 days. If the patient noticed an improvement with the saline, they should anticipate a similar improvement with cymetra or alternative substance.

The more invasive treatment is known as True Vocal Cord Medialization Laryngoplasty. In this surgical procedure, an approximately 2-3 cm incision is made in the neck over the voicebox region. Once the voicebox is exposed, a small window is made on the side where the vocal cord is paralyzed. Through this window, an implant is placed pushing the vocal cord into a midline position. The implant material I typically use is made of hydroxl-apatite, though other surgeons may elect to use gortex or silastic. Watch a video of this surgical procedure.

implant

An implant is placed via a neck incision. The vocal cord is "pushed" to the middle by the implant resulting in good vocal cord approximation with talking. A picture of an actual implant is shown here below:

vocom

Just as for the injection medialization, I personally like to perform this procedure with the patient awake under light sedation and plenty of local anesthesia. I have the patient talk after placement of a variety of different sized implants in different positions until an implant that creates the best possible voice is found. I often have the patient himself choose which implant he thinks gives him the best voice.

After implant selection and placement, the wound is closed over a drain and I typically keep the patient overnight in the hospital for bleeding monitoring. The following day, the drain is removed and the patient is allowed to go home.

The major advantage with this procedure is that one can more precisely position and try different sized implants to obtain the best voice. Vocal quality and power by implantation is superior to that obtained by injection. The obvious disadvantage is that it does require an incision in the neck.

How is Breathing After a Medialization Procedure?

Breathing is actually improved for most patients after either procedure. Some patients have pointed out that by pushing the paralyzed vocal cord over into a fixed midline position, the opening between the vocal cords become smaller when one needs to breathe instead of talk. Although this point is true, the vast majority of patients do not notice any impairment in breathing. Paradoxically, breathing is subjectively better!

injectionimplant

The Bowed Vocal Cords (Presbylaryngeus)

In rare cases, even though both vocal cords may move quite well, the vocal cords themselves are so weak and small that even though they come together, there is still a gap in between resulting in a breathy voice. The vocal cords themselves, in fact, look "bowed" and is a common problem in the elderly population. A real-life example can be viewed here. The treatment for this condition is exactly the same as that for the paralyzed vocal cord, EXCEPT, the injection or implant placement is done on BOTH sides instead of on just one side. Also, instead of the goal being to push the vocal cord to the midline position, the aim is to "bulk up" the vocal cord just enough so that it does not bow out when the vocal cords come together. The example below illustrates the outcome after vocal cord injections to both sides.

bowed ->>bowedbowed


Prior to any type of surgical intervention for bowed vocal cords, however, voice therapy is strongly encouraged.

Treatment for both vocal cord paralysis and bowed vocal cords is covered by insurance.

If a breathy voice is affecting your quality of life, please contact our office for an appointment with Dr. Chang.

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