Paralysis

  • Unilateral True Vocal Fold Paralysis

    • Description and Etiology

    A unilateral true vocal fold paralysis occurs when there is complete immobility in one vocal fold.  This occurs from damage to the recurrent laryngeal nerve (RLN) branch of the vagus nerve.  This nerve is primarily responsible for vocal fold abduction and adduction(opening and closing) of the vocal folds for the purposes of respiration, phonation, and swallowing. Perceptual Signs and Symptoms

    o      May exhibit

    §       Aphonia(voice loss)

    §       Completely normal voicing

    o      When paralyzed in a abducted(open) position:

    §       Breathy 

    §       Weak

    o      Dysphagia(swallowing problem) is common

    §       Due to difficulty closing the glottis(vocal folds)

    • Features of Visual Assessment

    o      May appear weakened or bowed

    o      Saliva or mucous secretions may pool

    o      Arytenoid cartilage will not abduct or adduct(close or open)

    o      Asymmetry is characterized by

    §       Slower initiation of the vibration of the vocal folds on the affected side

    • Management

    o      Direct trauma

    §       “Wait and see” approach is often preferred

    §       6-month time window

    o      Behavioral voice therapy to facilitate vocal fold closure

    §       Pushing Techniques

    §       Vocal Function Exercises

    §       Resonant Voice Therapy

    §       Lee Silverman Voice Therapy (LSVT)

    o      Surgical interventions consist of

    §       Medialization (Ishhiki Type I thyroplasty)

    §       Vocal fold augmentation

    §       Reinnervation surgical procedures

     

    Bilateral True Vocal Fold Paralysis

    • Description and Etiology

    A bilateral true vocal fold paralysis occurs when there is complete immobility in both vocal folds.  This occurs from damage to the recurrent laryngeal nerve (RLN) branch of the vagus nerve.  This nerve is primarily responsible for vocal fold abduction and adduction(opening and closing) of the vocal folds for the purposes of respiration, phonation, and swallowing. Vocal fold paralysis is typically considered a symptom of an underlying disease process (tumor pressing against a nerve... etc.)  This commonly results from surgical trauma, malignancies, endotracheal intubation neurologic disease, or idiopathic causes.  A bilateral true vocal fold paralysis can be life threatening when the folds are fixed in the paramedian(closed) position, making it difficult if not impossible for a person to breath.

    • Perceptual Signs and Symptoms

    o      Voice is highly variable:

    §       Completely normal

    §       Complete aphonia(no voice)

    §       Inspiratory stridor(noise)

    • May signal airway obstruction
    • Features of Visual Assessment

    o      Vocal folds that appear

    §       Floppy

    §       Bowed

    o      No discernable opening or closing movement

    o      Immobility can be confirmed through laryngeal EMG(electromyography)

    • Management

    o      If no emergent need

    §       “Wait and see”approach

    o      Concern for airway patency:

    §       Tracheotomy

    §       Cordectomy

    • Widen the glottis

    §       Pacing strategies implantable electrical stimulators

    §       Secondary adductor muscle block

    • Botulinum toxin

     

    Superior Laryngeal Nerve Paralysis

    • Description and Etiology

    A superior laryngeal nerve paralysis occurs when there is complete immobility of one or both sides of the cricothyroid muscle. This nerve is primarily responsible for vocal fold elongation(lengthening the vocal folds to produce higher pitches). This occurs from damage to the superior laryngeal branch of the vagus nerve. Vocal fold paralysis is typically considered a symptom of an underlying disease process (tumor pressing against a nerve... etc.) It can also be caused by trauma, neoplastism, or infectious conditions with viral infections.  A common cause of superior laryngeal nerve paralysis would be damage during surgery of the thyroid gland.

    • Perceptual Signs and Symptoms

    o      Extension of the disruption in the ability to:

    §       Adduct(close the vocal folds)

    §       Elongate to increase pitch

    o      Characteristics of voices:

    §       Weak

    §       Breathy voice

    §       Hoarse

    §       Disruption in vocal range

    • Features of Visual Assessment

    o      Highly variable

    o      Laryngeal electromyography is useful for reaching diagnosis

    o      Most common findings:

    §       Ipsilateral(same side) vocal fold bowing and shortening

    §       Height asymmetry of the vocal processes(prominence at the back of the vocal folds)

    §       Ipsilateral(same side) hyper adduction(compensation) of the false vocal fold

    §       Frequently visualized only during phonation(a voiced sound)

    §       At rest the larynx will appear “rotated” toward the weakened side

    • Management

    o      “Wait and see” approach

    o      Surgical interventions:

    §       Fusion of the thyroid and cricoid cartilages

    §       Other procedures are being tested in the animal model