What are the implications for a 65-year-old patient (sixty-five years old) who is status post (S/p) cervical spine surgery for traumatic injury, presenting with vocal cord paralysis, but without respiratory distress, specifically difficulty breathing (dyspnea) or stridor?

From the Guidelines

This patient requires immediate evaluation and management for vocal cord paralysis following cervical spine surgery, despite the absence of breathing difficulty and stridor, as indicated by the most recent clinical practice guideline update in 2018 1. The patient's condition necessitates prompt attention to prevent potential complications and improve quality of life.

Key Considerations

• The patient's age (65) and recent cervical spine surgery increase the risk of vocal cord paralysis due to injury to the recurrent laryngeal nerve, as highlighted in the 2018 update 1.
• The absence of breathing difficulty and stridor is reassuring, but it does not eliminate the need for intervention, as emphasized in the 2018 executive summary 1.
• An otolaryngology consultation should be arranged promptly for direct laryngoscopy to confirm the diagnosis and assess the extent of paralysis.

Management Options

• Initial management includes voice therapy to help with compensation techniques and preventing aspiration.
• If the paralysis is unilateral, temporary vocal cord injection with materials like hyaluronic acid or collagen can provide symptomatic relief while waiting for potential spontaneous recovery, which may occur within 6-12 months, as suggested by the 2018 update 1.
• For permanent paralysis, surgical options such as medialization thyroplasty or arytenoid adduction may be necessary, as discussed in the 2013 guideline 1.

Monitoring and Prevention

• The patient should be monitored for signs of aspiration and taught techniques to reduce this risk when eating and drinking.
• The vocal cord paralysis likely resulted from injury to the recurrent laryngeal nerve during the cervical spine surgery, which can occur due to direct trauma, compression, or stretching of the nerve during the procedure, as noted in the 2009 guideline 1.

From the Research

Vocal Cord Paralysis in Patients with Traumatic Injury

• Vocal cord paralysis (VCP) can be caused by surgical injury, intubation, malignancy, neurologic diseases, and trauma 2
• Patients with unilateral VCP may experience changes in voice, breathing, and swallowing, usually evident within 24 hours after injury 2
• Symptoms of acute bilateral VCP range from mild stridor with exertion to acute airway obstruction 2

Management of Unilateral Vocal Fold Paralysis

• Voice therapy provided by a speech-language pathologist can help maximize vocal function and improve quality of life in patients with unilateral vocal fold paralysis (UVFP) 3
• However, there is a lack of methodological rigor and clinical efficacy in the speech-language pathology management of dysphonia arising from UVFP in adults 3
• Medialization thyroplasty and injection augmentation are treatments targeted at reducing glottal incompetence, but improvements in swallowing function are less clear 4

Swallowing Function in Patients with Unilateral Vocal Fold Paralysis

• Glottal incompetence caused by UVFP is a common cause of dysphagia and aspiration 4
• A systematic review found limited evidence that injection augmentation and medialization thyroplasty improve swallowing function and/or safety 4
• Seven out of nine studies demonstrated clinically significant improvement in swallowing function following medialization, but the studies were heterogeneous and had multiple risks of bias 4

Considerations in Care of Patients with Vocal Cord Paralysis

• Patients with unilateral VCP require maintenance of function of the mobile vocal cord and prevention of laryngeal edema 2
• Patients with bilateral VCP have a fixed glottic size, making preventing airway edema critical to avoid respiratory distress requiring intubation or tracheostomy 2