What is the most appropriate next step in management for a 53-year-old woman with breathy hoarseness and right-sided vocal fold paralysis after cervical spine surgery with a right anterior approach?

Management of Vocal Fold Paralysis After Cervical Spine Surgery

Voice therapy is the most appropriate next step in management for this 53-year-old woman with right-sided vocal fold paralysis following cervical spine surgery.

Background and Assessment

This patient presents with:

• Breathy hoarseness immediately following right anterior approach cervical spine surgery
• Breathing well without stridor (indicating adequate airway)
• Confirmed right-sided lateralized vocal fold paralysis on laryngoscopy

Rationale for Voice Therapy as First-Line Treatment

Voice therapy is the optimal initial management strategy for this patient for several reasons:

1. High rate of spontaneous recovery: Approximately 80-83% of vocal fold paralysis cases following anterior cervical diskectomy and fusion (ACDF) resolve spontaneously within 12 months 1. This high recovery rate supports conservative management initially.

2. Evidence-based recommendation: Clinical practice guidelines strongly recommend voice therapy for patients with dysphonia that reduces voice-related quality of life 2. The guidelines state: "Voice therapy may be an important component of any comprehensive surgical treatment for dysphonia" 2.

3. Absence of airway compromise: The patient is breathing well without stridor, indicating no immediate need for surgical intervention to secure the airway.

4. Optimization of outcomes: Early voice therapy can help the patient compensate for the paralysis while natural recovery occurs, potentially improving long-term vocal outcomes regardless of whether the paralysis resolves spontaneously.

Management Algorithm

1. Initial management (0-3 months post-injury):

   • Voice therapy with a speech-language pathologist
   • Regular follow-up evaluations to monitor recovery
   • Conservative management of symptoms

2. If no improvement by 6 months:

   • Consider temporary injection medialization (option A: injection thyroplasty)
   • Early medialization creates a more favorable vocal fold position that may be maintained even with synkinetic reinnervation 2

3. If no recovery by 12 months:

   • Consider permanent medialization thyroplasty (option B)
   • This is indicated for persistent symptoms after the period when spontaneous recovery is most likely

Why Other Options Are Less Appropriate

• Injection thyroplasty (option A): While this could be considered, it is typically reserved for patients with persistent symptoms after a trial of voice therapy or those with severe symptoms like aspiration. This patient has breathy hoarseness but no mention of aspiration or severe quality of life impact.

• Medialization laryngoplasty (option B): This permanent surgical solution is not appropriate as first-line therapy given the high rate of spontaneous recovery within 12 months.

• Exploration of the neck (option C): This invasive procedure carries significant risks and is not indicated when the diagnosis is already confirmed by laryngoscopy and the etiology (surgical trauma) is known.

Important Considerations

• The right recurrent laryngeal nerve is at higher risk during anterior cervical approaches due to its anatomical course, which explains the right-sided paralysis in this case 3, 4.

• Patients should be counseled that recovery may take up to 12 months, and that voice therapy can significantly improve voice quality and function during this period.

• Regular follow-up with laryngoscopic examinations is essential to monitor recovery and adjust treatment plans accordingly 2.

• If the patient develops aspiration symptoms during the recovery period, earlier intervention with injection medialization may be warranted 1.