Vocal fold paralysis


Introduction

 

Paralysis of the vocal folds is a complex and specific diagnostic problem, for rehabilitation and operation. Paralysis of the vocal folds is the result of damage to the laryngeal nerve. The cause of laryngeal nerve palsy may be associated with damage to the central nervous system (5%) or more frequently concerns the nerves themself.

 

Most frequently nerve paralysis is due to operations of the thyroid gland, performed because of struma and thyroid cancer. Less frequently, the nerve palsy occurs due to tumors of trachea, bronchus and esophagus, mediastinal disease, aortic or subclavian artery aneurism, cardiac hypertrophy, pulmonary tuberculosis, operations and injuries in the chest and neck, and toxic poisoning.

 

In the last decade, is noted an increase in idiopathic cases whose cause is not fully understood. It is believed that this may be the result of a viral infection.

 

Symptoms

 

The vocal fold paralysis causes disorder of following three functions of the larynx: breathing, defense, and voice. The severity of symptoms depend on whether there has been a unilateral or bilateral laryngeal nerve palsy and from the position of vocal folds in relation to median line.

 

In unilateral paralysis of the larynx there are is respiratory distress. Glottis is wide enough to ensure proper ventilation of the lungs. Shortness of breath can only occur during strenuous exercise or severe infection.

 

In bilateral paralysis primarily respiratory disorders occur. Depending on the setting of both vocal folds, glottis have a different size which determines the severity of dyspnea.

 

In some patients in whom glottis is very narrow (0.5-1mm) there is a strong shortness of breath. Patients require immediate intubation or surgical intervention, usually tracheostomy. Patients in whom glottis is more than 1 mm, typically without exercise does not have symptoms of shortness of breath, but even the smallest exercise causes dyspnea. The voice (phonation) as for unilateral and bilateral vocal fold paralysis is dependent on the position of the vocal folds.

 

Diagnostics

 

It is important to diagnose the possible cause of a paralysis of the vocal folds, which elimination in individual cases bring back the function of the vocal folds. Diagnosis of patients with vocal folds paralysis is based on phoniatric, otolaryngologic and speech examination, endoscopic and stroboscopic diagnostics, objective and subjective voice quality examination, spirometr, computed tomography and the necessary consultations of other specialists.

 

Treatment

 

In the treatment of vocal fold paralysis, depending on disorders of the larynx pharmacotherapy, physiotherapy or surgery is used. Each of these stages is accompanied by phoniatric and speech therapy rehabilitation. Surgical treatment is usually preceded by a 6-12 month conservative therapy. Surgical treatment aims to restore respiratory function, restore or improve the function of the voice and the restoration of the defense function of the larynx in cases of persistent aspiration of saliva or foods.

 

In the unilateral palsy primary goal is to restore or improve the function of the voice, which in most cases is achieved by conservative treatment. In the case of ineffective conservative treatment, surgery is used with the goal of restoring or improving the voice function of the larynx. Bilateral vocal folds paralysis in the vast majority require surgical treatment, which is a challenge for the surgeon, as the extension of glottis improves respiratory function, but worsens the conditions of voice.

 

Surgery due to unilateral as for bilateral paralysis can be done with the infra-laryngeal or outer-laryngeal access.

 

The Department of Otolaryngology, Medical University of Warsaw glottis widening operation for bilateral palsy is done with the infra-laryngeal access using a laser. After surgery, complications may occur as bleeding, swelling of the throat, swallowing disorders. In the operating area while time passes it is possible the growth of granulation tissue or adhesion appearance that may cause shortness of breath, and require re-operation.

 

Postoperative follow-up

 

  1. During the operation temporary tracheotomy, with usage of silicone tracheostomy tube, is performed.
  2. On the second day after surgery silicone tube is exchanged for a metal tracheostomy tube.
  3. Tracheostomy tube is removed, if the next three days with clogged aperture of the tube there is no shortness of breath.
  4. Tracheostomy wound usually heals by itself and does not require stitches.

 

To perform the operations it is required that each patient is familiar with the informed consent form and signed it. Detailed information about the possible course of the operation, the chances of achieving the surgery goal, postoperative care and the risk of complications may be obtained from the doctor and / or the head of the operating team and the course of anesthesia, from the anesthesiologist.

 

Control tests

 

After the operation of widening of glottis patients should submit to periodic visits in outpatient clinic.

 

Recommended test dates are as follows :

 

  • every month for the first six months after treatment
  • every three months to one year after treatment
  • every 6 months to 3 years after treatment
  • every year in the following years

 

During the control otolaryngological, phoniatric and speech therapy examination is performed, endoscopic and stroboscopic diagnostic, objective and subjective examination of voice quality, at 1, 3, 6 and 12 months after surgery spirometry test is performed. Since the operations patients have phoniatric and speech therapy rehabilitation, whose periods are determined individually.

 

Prognosis

 

Glottis widening laser surgery in bilateral vocal folds paralysis in most cases allow you to achieve good results with the respiratory and voice function.

 

Antoni Bruzgielewicz MD