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ORG/CONTENT/VOCAL-CORD-PARALYSIS

WHAT IS VOCAL CORD (FOLD) PARESIS AND PARALYSIS?

Vocal fold (or cord) paresis and paralysis result from abnormal nerve input to the voice box
muscles (laryngeal muscles). Paralysis is the total interruption of nerve impulse, resulting in
no movement; paresis is the partial interruption of nerve impulse, resulting in weak or
abnormal motion of laryngeal muscles. Paresis/paralysis can happen at any age, from birth to
advanced age, in males and females, from a variety of causes. The effect on patients may vary
greatly, depending on the patients use of his or her voice: A mild vocal fold paresis can be
the end to a singer's career, but have only a marginal effect on a computer programmer. If you
notice any change in your voice quality, immediately contact an otolaryngologisthead and
neck surgeon.
WHAT NERVES ARE INVOLVED?
Vocal fold movements are a result of the coordinated contraction of various muscles that are
controlled by the brain through a specific set of nerves.
The superior laryngeal nerve (SLN) carries signals to the cricothyroid muscle. Since this
muscle adjusts the tension of the vocal fold for high notes during singing, SLN paresis and

paralysis result in abnormalities in voice pitch and the inability to sing with smooth change to
each higher note. Sometimes patients with SLN paresis/paralysis may have a normal
speaking voice but an abnormal singing voice.
The recurrent laryngeal nerve (RLN) carries signals to different voice box muscles
responsible for opening vocal folds (as in breathing, coughing), closing the folds for vibration
during voice use, and closing them during swallowing. The RLN goes into the chest cavity
and curves back into the neck until it reaches the larynx. Because the nerve is relatively long
and takes a "detour" to the voice box, it is at greater risk for injury from different
causesinfections and tumors of the brain, neck, chest, or voice box. It can also be damaged
by complications during surgery in the head, neck, or chest, that directly injure, stretch, or
compress the nerve. Consequently, the RLN is involved in the majority of cases of vocal fold
paresis/paralysis.
WHAT ARE THE CAUSES?
The cause of vocal fold paralysis or paresis can indicate whether the disorder will resolve
over time or whether it may be permanent. When a reversible cause is present, surgical
treatment is not usually recommended, given the likelihood of spontaneous resolution of the
problem. Despite advances in diagnostic technology, physicians are unable to detect the cause
in about half of all vocal fold paralyses, referred to as idiopathic (due to unknown origins). In
these cases, paralysis or paresis might be due to a viral infection affecting the voice box
nerves (RLN or SLN), or the vagus nerve, but this cannot be proven in most cases. Known
reasons can include:
Inadvertent injury during surgery: Surgery in the neck (thyroid gland, carotid artery) or in the
chest (lungs, esophagus, heart, or large blood vessels) may inadvertently result in RLN
paresis or paralysis. The SLN may also be injured during head and neck surgery.
Complication from endotracheal intubation: Injury to the RLN may occur when breathing
tubes are used for general anesthesia or assisted breathing. However, this type of injury is
rare, given the large number of operations done under general anesthesia.
Blunt neck or chest trauma: Any type of penetrating, hard impact on the neck or chest region
may injure the RLN; impact to the neck may injure the SLN.
Tumors of the skull base, neck, and chest: Tumors (both cancerous and non-cancerous) can
grow around nerves and squeeze them, resulting in varying degrees of paresis or paralysis.
Viral infections: Inflammation from infections may directly involve and injure the vagus
nerve or its nerve branches to the voice box (RLN and SLN). Systemic illnesses affecting
nerves in the body may also affect the nerves to the voice box.
WHAT ARE THE SYMPTOMS?

Both paresis and paralysis of voice box muscles result in voice changes and may also result in
airway problems and swallowing difficulties.
Voice changes: Hoarseness; breathy voice; extra effort on speaking; excessive air pressure
required to produce usual conversational voice; and diplophonia (voice sounds like a gargle).
Airway problems: Shortness of breath with exertion, noisy breathing, and ineffective cough.
Swallowing problems: Choking or coughing when swallowing food, drink, or even saliva, and
food sticking in throat.
HOW IS VOCAL FOLD PARALYSIS/PARESIS DIAGNOSED?
An otolaryngologisthead and neck surgeon conducts a general examination and then
questions you about your symptoms and lifestyle (voice use, alcohol/tobacco use). Examining
the voice box will determine whether one or both vocal folds are abnormal, and will help
determine the treatment plan.
Laryngeal electromyography (LEMG) measures electrical currents in the voice box muscles
that are the result of nerve inputs. Looking at the pattern of the electric currents will indicate
whether there is recovery or repair of nerve inputs and the degree of the nerve input problem.
During the LEMG test, patients perform a number of tasks that would normally elicit
characteristic actions in the tested muscles. Because a wide list of diseases may cause nerve
injury, further tests (blood tests, x-rays, CT scans, etc) are usually required to identify the
cause.
WHAT IS THE TREATMENT?
The two treatment strategies to improve vocal function are voice therapy (like physical
therapy for large muscle paralysis), and phonosurgery, an operation that repositions and/or
reshapes the vocal folds to improve voice function. Voice therapy is normally the first
treatment option. After voice therapy, the decision for surgery depends on the severity of the
symptoms, vocal needs of the patient, position of paralyzed vocal folds, prognosis for
recovery, and the cause of paresis/paralysis, if known.

http://www.mayoclinic.org/diseases-conditions/vocal-cord-paralysis/basics/treatment/con20026357

Definition
By Mayo Clinic Staf

Vocal cord paralysis occurs when the nerve impulses to your voice box (larynx)
are disrupted. This results in paralysis of the vocal cord muscles.
Vocal cord paralysis can afect your ability to speak and even breathe. That's
because your vocal cords, sometimes called vocal folds, do more than just
produce sound. They also protect your airway by preventing food, drink and even
your saliva from entering your windpipe (trachea) and causing you to choke.
There are a number of causes of vocal cord paralysis including nerve damage
during surgery, viral infections and certain cancers. Treatment for vocal cord
paralysis usually involves surgery. Voice therapy can sometimes be an option.

Symptoms
By Mayo Clinic Staf

Multimedia

Vocal cords open and closed

Your vocal cords are two flexible bands of muscle tissue that sit at the entrance to
the windpipe (trachea). When you speak, the bands come together and vibrate to
make sound. The rest of the time, the vocal cords are relaxed in an open position,
so you can breathe.
In most cases of vocal cord paralysis, only one vocal cord is paralyzed. If both of
your vocal cords are afected, you may have vocal difficulties, as well as
significant problems with breathing and swallowing.
Signs and symptoms of vocal cord paralysis may include:

A breathy quality to the voice

Hoarseness

Noisy breathing

Loss of vocal pitch

Choking or coughing while swallowing food, drink or saliva

The need to take frequent breaths while speaking

Inability to speak loudly

Loss of your gag reflex

Inefective coughing

Frequent throat clearing

When to see a doctor

If you have unexplained, persistent hoarseness for more than two weeks, or if you
notice any unexplained voice changes or discomfort, contact your doctor.

Causes
By Mayo Clinic Staf

In vocal cord paralysis, the nerve impulses to your voice box (larynx) are
disrupted, resulting in paralysis of the muscle. Doctors often don't know the cause
of vocal cord paralysis. Known causes may include:

Injury to the vocal cord during surgery. Surgery on or near your neck or
upper chest can result in damage to the nerves that serve your voice box.
Surgeries that carry a risk of damage include surgeries to the thyroid or
parathyroid glands, esophagus, neck, and chest.

Neck or chest injury. Trauma to your neck or chest may injure the nerves
that serve your vocal cords or the voice box itself.

Stroke. A stroke interrupts blood flow in your brain and may damage the
part of your brain that sends messages to the voice box.

Tumors. Tumors, both cancerous and noncancerous, can grow in or

around the muscles, cartilage or nerves controlling the function of your voice
box and can cause vocal cord paralysis.

Viral infections. Some viral infections, such as Lyme disease, EpsteinBarr and herpes, can cause inflammation and damage directly to the nerves in
the larynx.

Neurological conditions. If you have certain neurological conditions,

such as multiple sclerosis or Parkinson's disease, you may experience vocal
cord paralysis.

Risk factors
By Mayo Clinic Staf

Factors that may increase your risk of developing vocal cord paralysis include:

Undergoing throat or chest surgery. People who need surgery on their

thyroid, throat or upper chest have an increased risk of vocal cord nerve
damage. Sometimes breathing tubes used in surgery or to help you breathe if
you're having serious respiratory trouble can damage the vocal cord nerves.

Having a neurological condition. People with certain neurological

conditions such as Parkinson's disease or multiple sclerosis are more
likely to develop vocal cord weakness or paralysis.

Complications
By Mayo Clinic Staf

Breathing problems associated with vocal cord paralysis may be so mild that you
just have a hoarse-sounding voice, or they can be so serious that they're lifethreatening.
Because vocal cord paralysis keeps the opening to the airway from completely
opening or closing, other complications may include choking on or actually
inhaling (aspirating) food or liquid. Aspiration that leads to severe pneumonia is
very serious and requires immediate medical care.

Tests and diagnosis

By Mayo Clinic Staf

Your doctor will ask about your symptoms and lifestyle, listen to your voice, and
ask you how long you've had voice problems. To further evaluate your voice
problems, the following tests may be performed:

Laryngoscopy. Your doctor will look at your vocal cords using a mirror or
a thin, flexible tube (known as a laryngoscope or endoscope) or both. You
may also have a test called videostrobolaryngoscopy that's done using a
special scope that contains a tiny camera at its tip or a larger camera
connected to the scope's viewing piece.
These special high-magnification endoscopes allow your doctor to view your
vocal cords directly or on a video monitor to determine the movement and
position of the vocal cords and whether one or both vocal cords are afected.

Laryngeal electromyography. This test measures the electric currents in

your voice box muscles. To obtain these measurements, your doctor typically
inserts small needles into your vocal cord muscles through the skin of the
neck.
This test doesn't usually provide information that might change the course of
treatment, but it may give your doctor information about how well you may
recover. This test is most useful for predicting how you'll recover when it's
done between six weeks and six months after your symptoms began.

Blood tests and scans. Because a number of diseases may cause a

nerve to be injured, you may need additional tests to identify the cause of the
paralysis. Tests may include blood work, X-rays, MRI or CT scans.

Treatments and drugs

By Mayo Clinic Staf

Treatment of vocal cord paralysis depends on the cause, the severity of

symptoms and the time from the onset of symptoms. Treatment may include
voice therapy, bulk injections, surgery or a combination of treatments.
In some instances, you may get better without surgical treatment. For this reason,
your doctor may delay permanent surgery for at least a year from the beginning of
your vocal cord paralysis.
However, surgical treatment with bulk injections containing collagen-like
substances is often done within the first 3 months of voice loss.
During the waiting period for surgery, your doctor may suggest voice therapy to
help keep you from using your voice improperly while the nerves heal.

Voice therapy
Voice therapy sessions involve exercises or other activities to strengthen your
vocal cords, improve breath control during speech, prevent abnormal tension in
other muscles around the paralyzed vocal cord or cords and protect your airway
during swallowing. Occasionally, voice therapy may be the only treatment you
need if your vocal cords were paralyzed in a location that doesn't require
additional bulk or repositioning.

Surgery
If your vocal cord paralysis symptoms don't fully recover on their own, surgical
treatments may be ofered to improve your ability to speak and to swallow.
Surgical options include:

Bulk injection. Paralysis of the nerve to your vocal cord will probably leave
the vocal cord muscle thin and weak. To add bulk to a paralyzed vocal cord, a
doctor who specializes in disorders of the larynx (laryngologist) may inject
your vocal cord with a substance such as body fat, collagen or another
approved filler substance. This added bulk brings the afected vocal cord
closer to the middle of your voice box so that the opposite functioning and
moving vocal cord can make closer contact with the paralyzed cord when you
speak, swallow or cough.

Structural implants. Instead of using a bulk injection, this procedure

known as thyroplasty, medialization laryngoplasty or laryngeal framework
surgery relies on the use of an implant in the larynx to reposition the vocal
cord. Rarely, people who have this surgery may need to have a second
surgery to reposition the implant.

Vocal cord repositioning. In this procedure, a surgeon moves a window

of your own tissue from the outside of your voice box inward, pushing the
paralyzed vocal cord toward the middle of your voice box. This allows your
unimpaired vocal cord to better vibrate against its paralyzed partner.

Replacing the damaged nerve (reinnervation). In this surgery, a healthy

nerve is moved from a diferent area of the neck to replace the damaged vocal
cord. It can take as long as six to nine months before the voice improves.
Some doctors combine this surgery with a bulk injection.

Tracheotomy. If both of your vocal cords are paralyzed and positioned

closely together, your airflow will be decreased. In this situation, you'll have a
lot of trouble breathing and require a surgical procedure called a tracheotomy.
In a tracheotomy, an incision is made in the front of your neck and an opening
created directly into the windpipe (trachea). A breathing tube is inserted,
allowing air to bypass the immobilized vocal cords.

Emerging treatments
Linking the vocal cords to an alternative source of electrical stimulation
perhaps a nerve from another part of the body or a device similar to a cardiac
pacemaker may restore opening and closing of the vocal cords. Researchers
continue to study this and other options.