Management Of Vocal Fold Paralysis Research Articles

Endoscopic management of vocal fold paralysis

Vocal fold paralysis is a challenging disorder to manage in the pediatric population. While many cases may be managed expectantly, patients with problematic dysphonia, aspiration, or dyspnea may require surgical intervention. Tracheostomy was performed in nearly all patients with bilateral vocal fold paralysis and some patients with unilateral vocal fold paralysis in the past. However, with modern endoscopic and open procedures for vocal fold paralysis, current tracheostomy rates have decreased to 4%-69%. Endoscopic interventions are particularly advantageous in children given high rates of eventual recovery. The perioperative considerations, indications, and techniques for various endoscopic interventions for unilateral and bilateral vocal fold paralysis will be discussed here.

Management of Vocal Fold Paralysis II: Role of Injection Medialization

Management of Vocal Fold Paralysis II: Role of Injection Medialization

Surgical management of complex neonatal airway abnormalities.

The neonatal airway is subject to a variety of developmental abnormalities with a wide range of complexity. Symptomatic pathologies present in a spectrum ranging from simple noisy breathing or poor feeding to frank respiratory distress. Diagnosis requires a high index of suspicion, characterization of noisy breathing, and identification of obstructive symptoms such as increased work of breathing, retractions, and difficulty feeding. Surgical management is directed by the pathology. The past several years have seen an expansion of surgical innovation as endoscopic and open techniques have evolved. We reviewed articles related to neonatal and infant airway diagnoses since 2020 with the goal of providing a current review and update of developing techniques. Specifically, we discuss some of the exciting trends in surgical management of vocal fold paralysis, laryngeal clefts, subglottic stenosis, tracheobronchomalacia as well as the role of ex utero intrapartum therapy (EXIT procedures). An underlying theme in evolving surgical management is the exciting advancements in technology, including 3-D printing, and expansion of minimally invasive endoscopic techniques. Though some of these developments are in the initial stages of utilization, they may be potential sources to transform surgical management in the future.

Management of Vocal Fold Paralysis and Dysphagia for Neurologic Malignancies in Children.

To evaluate our experience with a significant number of brain malignancy-related vocal fold paralysis patients and their response to vocal cord-related therapies. Vocal fold paralysis is a potentially devastating complication of various types of pediatric diseases and surgeries that can lead to significant vocal and swallowing difficulties. While there is significant data in the literature on outcomes of children treated for vocal fold paralysis following cardiac or thyroid surgery, there is a scarcity of such information on children following the treatment of neurologic malignancy. Records of 19 patients at a tertiary center who were treated for neurologic malignancies and developed either unilateral or bilateral vocal fold paralysis were reviewed for vocal fold pathology and vocal fold paralysis treatment-related variables, including initial diagnosis, management with observation or speech therapy, duration of therapy, pre- and postintervention swallow studies, and surgical intervention. Bilateral vocal fold paralysis was noted in 26% (5/19) patients. Eighty-four percent (16/19) of patients had stable or improved ability to vocalize and swallow following therapy. There was no statistically significant difference in speech or swallowing improvement after speech therapy alone or speech therapy in combination with injection laryngoplasty (P = .25). No complications were noted with surgical intervention. Patients with vocal fold paralysis secondary to neurologic malignancy can have an improvement in speech and swallowing after a variety of treatments, including speech therapy or early injection laryngoplasty. There was no statistically significant difference in improvement based on the type of intervention utilized. A larger sample size is needed to conclude whether surgical intervention combined with speech therapy leads to more rapid and significant functional improvement than speech therapy alone.

Short term management of vocal fold paralysis

Vocal cord paralysis is commonly encountered by ENT surgeons. The standard management usually involves waiting for 6-12 months to assess for recovery or reinnervation. During this time, the patient usually experiences poor quality voice, ineffective cough, and aspiration which may result in pneumonia. Management of these patients includes a search for the aetiology and often requires speech therapy. In addition to this, a reversible, office-based early injection laryngoplasty can minimize the patient morbidity of impaired vocal fold mobility while maximizing glottal function and improving phonatory quality. Methods: A retrospective study was conducted on consecutive patients with unilateral vocal cord paralysis. Voice handicap index, basic and aerodynamic/acoustic data were collected at the initial assessment and following intervention. Intervention consisted of an office-based, unsedated, paraglottic injection of hyaluronic acid to the effected side. All patients underwent videostroboscopy before, during and after office intervention and subjective assessment of these recordings was made. Patients also completed the voice related quality of life. Results: All 185 patients tolerated office-based injection well with no adverse events. All patients experienced an improvement in glottal competency and this was reflected in the aerodynamic and acoustic data.

"Finding a Voice": Imaging Features after Phonosurgical Procedures for Vocal Fold Paralysis.

Altered communication (hoarseness, dysphonia, and breathy voice) that can result from vocal fold paralysis, secondary to numerous etiologies, may be amenable to surgical restoration. In this article, both traditional and cutting-edge phonosurgical procedures targeting the symptoms resulting from vocal fold paralysis are reviewed, with emphasis on the characteristic imaging appearances of various injectable materials, implants, and augmentation procedures used in the treatment of vocal fold paralysis. In addition, complications of injection laryngoplasty and medialization laryngoplasty are illustrated. Familiarity with the expected imaging changes following treatment of vocal fold paralysis may prevent the misinterpretation of posttreatment changes as pathology. Identifying common complications related to injection laryngoplasty and localization of displaced implants is crucial in determining specific management in patients who have undergone phonosurgical procedures for the management of vocal fold paralysis.

Surgical Management of Vocal Fold Paralysis and Cricopharyngeal Dysfunction as a Cause of Aspiration

Aspiration and pharyngeal dysphagia occur across various age groups as a result of numerous conditions, such as neurological, oncological, or inflammatory processes. After nonsurgical techniques fail, surgical options for treatment of the larynx or cricopharygeus muscle are considered. The most common causes of laryngeal causes of dysphasia/aspiration can be treated with procedures aimed at closing the laryngeal gap resulting from paralysis. Cricopharyngeal dysfunction often can be identified by various diagnostic modalities, but dilation, botulinum toxin, and myotomy are commonly employed management options.

Embryologic innervation of the rat laryngeal musculature—a model for investigation of recurrent laryngeal nerve reinnervation

Optimal management of vocal fold paralysis would entail recurrent laryngeal nerve (RLN) reinnervation resulting in normal vocal fold motion. Unfortunately, RLN reinnervation currently results in a nonfunctional vocal fold due to synkinetic reinnervation. Therapeutic interventions that guide regenerating axons back to the appropriate muscle would prevent synkinesis and restore vocal fold and glottal function. The initial step toward developing these therapies is the elucidation of the embryologic innervation of the larynx. This study aimed to identify the age of occurrence, timing, and pattern of embryologic innervation of the rat larynx, hypothesizing that differences in these parameters exist between distinct laryngeal muscles. Descriptive anatomic study. The larynx of rats aged embryologic day (E) 15, 16, 17, 19, and 21 were harvested and then sectioned. Two rats were used for each age. Sections were colabeled with neuronal class III β-tubulin polyclonal antibody to identify the presence of axons and alexa 488 conjugate α-bungarotoxin to identify the presence of motor endplates. The age at which axons and motor endplates were first present was noted. The position and pattern of the axons and motor endplates was recorded in relation to each other as well as the musculoskeletal anatomy of the larynx. The time at which axons appeared to innervate the medial thyroarytenoid (MTA) muscle, lateral thyroarytenoid (LTA) muscle, and the posterior cricoarytenoid (PCA) muscle was documented. Findings in the rat suggest the RLN reaches the larynx and begins branching by E15. Axons branch dorsally first and reach the PCA muscle before the other muscles. Branching toward the MTA muscle occurs only after axons have reached the LTA muscle. By E19, RLN axons have been guided to and selected their respective muscles with formation of neuromuscular junctions (NMJs) in the PCA, LTA and MTA muscles, though the formation of NMJs in the MTA muscle was comparatively delayed. This study describes the embryologic innervation of the rat larynx and suggests that there are distinct differences in the age of occurrence, timing, and pattern of innervation of the PCA, LTA, and MTA muscles of the rat. These findings lay the foundation for studies investigating the role of guidance cues in RLN axon guidance and the utility of these cues in the treatment of RLN injury via the stimulation of functional, nonsynkinetic reinnervation.

Management of Unilateral Vocal Fold Paralysis/Paresis: A Laryngologist's Perspective

This manuscript is a follow up to a panel presentation on “Vocal Fold Paresis & Paralysis: Controversies in Evaluation & Management,” which was held during the 2011 American Speech-Language-Hearing Association (ASHA) Convention in San Diego, California. In addition to me, the other members of the panel included Sarah L. Schneider, MS, CCC-SLP, Director, Speech-Language Pathology Service, UCSF Voice and Swallowing Center; Nelson Roy, PhD, Professor, Speech & Language Pathology, Department of Communication Sciences & Disorders, University of Utah; and Marshall Smith, MD, Professor of Otolaryngology, Department of Surgery, University of Utah. During the panel, I was tasked with presenting the reasons for controversies in the diagnosis and management of vocal fold paralysis. In this manuscript, I will summarize my portion of that presentation and will provide additional information on management options for unilateral vocal fold paralysis (UVFP) from the perspective of a laryngologist.

Vocal Fold Paralysis in Infants with Tracheoesophageal Fistula

We describe the clinical characteristics and management of vocal fold paralysis in infants who were born with a tracheoesophageal fistula (TEF). This retrospective case series included all infants born with TEFs who presented to our pediatric otolaryngology unit and intensive care unit because of dyspnea or aphonia in the years 2005 and 2006, and who were found to have vocal fold paralysis. Five boys and 1 girl were studied. One infant had stridor before TEF repair, and 5 after it. All children underwent flexible laryngotracheobronchoscopy and were treated in the pediatric intensive care unit before diagnosis of the vocal fold paralysis (5 bilaterally and 1 unilaterally) was made. The ages at diagnosis of paralysis ranged between 14 days and 14 months. Five infants required tracheostomy. Vocal fold paresis in infants is difficult to diagnose. The risk for recurrent laryngeal nerve injury associated with TEF and TEF repair should be emphasized in these children. We recommend that all newborns with TEF should be examined by an otolaryngologist before operation to confirm the mobility of the vocal folds and to rule out other associated airway malformations, and examined after operation if respiratory difficulties develop.

Diagnostic evaluation of vocal paralysis: What is the evidence?

The diagnosis and management of vocal fold paralysis remains a dominant clinical issue in laryngology. When a patient with vocal paralysis is identified without an obvious cause (such as recent cervical spine surgery), the otolaryngologist chooses from several additional investigations to help establish the nature and prognosis of the vocal fold paralysis. These investigations may be driven by the history and physical examination. Beyond this, the clinician may order blood tests, including serum glucose, rheumatoid factor, lyme titers, and ACE levels. What is the physiological basis for this? Is there any evidence to support this? These questions will be addressed in detail during the presentation. Radiographic studies remain a mainstay of investigation for the practicing otolaryngologist. “Imaging the course of the nerve” is a common approach cited in the evaluation of this important clinical entity. While this may be performed with chest radiography, computed tomography, or magnetic resonance imaging, it is difficult to draw many conclusions from the collective otolaryngology and radiology literature. The role of laryngeal electromyography in the management of vocal paralysis is an area of some controversy in the field. The literature on both sides of the controversy will be reviewed. Recommendations for clinical practice will be made. Short presentations on each of these topics will be followed by a critical analysis of the scientific basis of current practice. The relative strength and weakness of the evidence regarding these practices will be reviewed. A paradigm for the clinical evaluation of a suspected “idiopathic” vocal fold paralysis will be offered. Following this, illustrative cases will be presented in an interactive format. Audience questions are encouraged.

Gore-Tex Medialization Thyroplasty: Objective and Subjective Evaluation

Summary: Management of vocal fold paralysis and paresis continues to give rise to controversy and the use of numerous surgical techniques. The senior authors' (RTS, JRS) initial experience with fourteen patients using Gore-Tex Medialization Thyroplasty suggests that this technique has value. Evaluation included pre- and postoperative videostroboscopic assessment, aerodynamic measures, acoustic analysis, phonatory analysis, psychoacoustic evaluation, and patient self-evaluation. Stroboscopic and perceptual assessments were blinded. Statistical analysis supports the efficacy of this technique.