Bilateral Vocal Cord Paralysis (or Fixation)

by , last modified on 7/7/13
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Treatment for unilateral vocal cord
paralysis can be read here (it's different
than bilateral vocal cord paralysis).

In order to understand treatment of vocal cord paralysis, 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 or both of the vocal cords do not move resulting voice changes as well as difficulty breathing easily. Specifically, when both vocal cords are paralyzed, the vocal cords do not come together as tightly resulting in a weaker than normal voice. At the same time, given the vocal cords are not able to move apart, there is a smaller than normal opening thru which to breath resulting in shortness of breath, especially with exercise. Here are two video examples of when both vocal cords are paralyzed. Compare this to a normal example. Note the difference in how wide the vocal cords move apart.

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.
vocal cord paralysis
In this illustration, both vocal cords are paralyzed resulting in a small opening thru which to breath... as well as a weaker than normal voice as the vocal cords do not come tightly together either.

Other symptoms a patient may have from bilateral paralyzed vocal cords include:

Evaluation and Treatment

Why would the vocal cords both become paralyzed in the first place? The MOST common cause of bilateral vocal cord paralysis is surgery, especially thyroidectomy. Other less common causes include neck trauma, traumatic intubation, and cancer (especially lung or thyroid cancer). Regardless of cause, if the paralysis is permanent, the options are quite limited and require the sacrifice of either breathing or talking. You can't have both good breathing and a good voice. Please note that a patient may have bilateral vocal cord fixation and NOT paralysis which is treated completely differently.

Why can't you have both good breathing and a good voice when both vocal cords are paralyzed?

Because in order to have a good voice, the vocal cords need to come tightly together... but given they are paralyzed, they will not come together to allow for a good strong voice

In order to have good breathing, the vocal cords need to be widely apart... but given they are paralyzed, they will not be able to move apart to allow for good breathing.

Which in essence means you can't have both good breathing and strong voice. One or the other needs to be sacrificed... or a compromise of both is required resulting in so-so breathing and a so-so vocal quality.

Well... there is ONE option in order to have good breathing and a good voice... and that's a tracheostomy with a one-way valve. The vocal cords could be fixated together to allow for good voice. To allow for good breathing, airway is achieved through the tracheostomy (hole in the neck that goes directly into the airway). A one-way valve is placed with the tracheostomy such that when breathing in, the valve opens up to allow air passage thru the tracheostomy, but when breathing out, the valve will close to force air up thru the vocal cords to allow for talking.

BUT, if tracheostomy is out-of-the-question.. than a patient with bilateral vocal cord paralysis is stuck with a compromise between the voice and breathing.

Google CEO Larry Page suffers from bilateral vocal cord paralysis? Click for more info.

To explain this compromise of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%. If a patient desires to improve the vocal quality from 40% to 100% (an improvement of 60%), then the breathing WILL correspondingly decrease 60% down to 0% (or vice-versa). The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than the compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

In order to achieve such a 50:50 compromise of breathing and voice, a surgical procedure can be pursued that essentially cuts the vocal cords to allow more space for breathing, but not so much as to cause complete voice loss.There are in essence two surgical approaches: cordotomy and medial arytenoidectomy.

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) is usually recommended until after 1 year has passed after which more permanent procedures are recommended if symptoms are still present.

Surgical Treatment

Posterior cordotomy is when the vocal cord is detached from its joint (called the arytenoid). This procedure is typically accompiished using a CO2 laser.

Medial arytenoidectomy is a much more aggressive procedure where a cordotomy is performed along with partial removal of the joint itself! Why is this performed? Because sometimes even after a cordotomy, there STILL is not enough space for easy breathing.

Either procedure can be performed to one or both vocal cords in order to achieve an adequate airway for breathing, but not too much to the point where the voice is utterly sacrificed. For example, bilateral medial arytenoidectomy can be performed OR a left posterior cordotomy and a right medial arytenoidectomy can be done OR in any other combination.

vocal cord paralysis
Bilateral vocal cord paralysis before anything is done.
Posterior cordotomy performed to the left vocal cord. Note the incremental enlargement of space for breathing.
medial arytenoidectomy
Medial arytenoidectomy performed to the left vocal cord. Notice the larger opening.

Obviously, these procedures need to be performed under general anesthesia. It may require several procedures before an adequate airway is achieved as the patient may elect for cordotomy first... and if the breathing is still not adequate, to than pursue a second stage procedure with a medial arytenoidectomy. Such an incremental approach may be desired in order to preserve as much voice as possible. However, the downside is the need for several separate surgical procedures.

In summary, treatment for bilateral vocal cord paralysis is difficult and there is no perfect solution. Treatment to improve breathing usually makes the voice worse. Treatment to improve the voice usually makes the breathing worse. The best (but not perfect) treatment tries to pick a happy medium to address the breathing while trying not to hurt the voice too much, though some degradation in vocal quality is to be expected. Such a treatment includes posterior cordotomy +/- partial arytenoidectomy.

Bilateral Vocal Cord Fixation (NOT Paralysis)

On a side note... there are other scenarios that may give the appearance of bilateral vocal cord paralysis when there is no paralysis actually present. It can be due to physical immobility of the vocal cords due to either arytenoid dislocation/fixation OR scar tissue (posterior glottic web) preventing vocal cord mobility. This is the best case scenario as correction of the physical problem will resolve the vocal cord motion back to normal! As an example, here's a patient with bilateral vocal cord fixation due to scar tissue.

Be aware that our office is not able to offer any options beyond voice therapy and tracheostomy, mainly because our office does not have access to a CO2 laser which is required to perform cordotomy or medial arytenoidectomy.

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