What are the management options for vocal cord paresis?

Management of Vocal Cord Paresis

Early evaluation by an otolaryngologist with laryngoscopy followed by a combination of voice therapy and surgical interventions based on severity is the recommended approach for managing vocal cord paresis to improve voice outcomes and quality of life. 1

Diagnostic Evaluation

• Laryngoscopy: Essential first-line diagnostic tool to visualize vocal fold mobility and structure

  • Should be performed early as it offers significant advantages in terms of resumption of normal activities and improved quality of life 1
  • CT or MRI should NOT be obtained prior to visualization of the larynx 1

• Laryngeal Electromyography (LEMG):

  • Useful for confirming diagnosis of vocal fold paresis when clinical findings are ambiguous
  • Can help differentiate between neurological and mechanical causes of impaired vocal fold mobility 1
  • May provide prognostic information for recovery from acute unilateral vocal fold paralysis/paresis 1
  • Serial LEMG examinations over time may be helpful for monitoring progress 1

Treatment Algorithm

1. Voice Therapy (First-line for mild-moderate paresis)

• Specific Voice Therapy Techniques 1, 2:

  • Vocal exercises focusing on glottal fry at the bottom of vocal range
  • Singing exercises with rising and falling scales on tongue trills
  • Postural manipulations (bending over, leaning back while phonating)
  • Redirection of attentional focus through bubble blowing, large body movements
  • Amplification or headphones to alter auditory feedback

• Assistive Techniques 2:

  • Digital compression of the larynx (Seeman technique) - compressing the thyroid cartilage to improve vocal cord position
  • Head and neck rotation to change anatomic relations in the neck and improve vocal cord contact

2. Surgical Interventions (For moderate-severe cases or when voice therapy is insufficient)

• Injection Laryngoplasty:

  • Early intervention (within 6 months of onset) is associated with decreased need for more invasive long-term therapy 1
  • Can be repeated when previous injection showed some benefit but was insufficient 3
  • Materials include calcium hydroxylapatite (Prolaryn gel) which provides temporary but longer-lasting results 3
  • Can be performed in office setting with good patient tolerance and minimal complications 1

• Transcervical Vocal Fold Medialization:

  • For cases with persistent symptoms despite injection laryngoplasty
  • More permanent solution for long-standing vocal fold paresis

Treatment Decision Factors

1. Severity of symptoms:

   • Mild: Voice therapy alone
   • Moderate-severe: Consider early surgical intervention

2. Duration of symptoms:

   • Early intervention (<6 months) improves long-term prognosis 1
   • Patients who receive early injection have decreased need for more invasive procedures 1

3. Glottic gap size:

   • Larger gaps typically require surgical intervention
   • Smaller gaps may respond to voice therapy alone

4. Patient's vocal demands:

   • Professional voice users may require more aggressive intervention
   • Those with lower vocal demands may do well with conservative management

Outcomes and Follow-up

• Regular follow-up with repeat laryngoscopy to assess vocal fold position and mobility
• Objective voice assessment including acoustic and aerodynamic measures
• Patient self-assessment of voice-related quality of life

Important Considerations

• Early identification and management of vocal fold paresis significantly improves quality of life and functional outcomes 1
• Current injectable materials are largely resorbable, leaving no long-term effect if motion returns 1
• Patients with unrecovered vocal fold paralysis who receive temporary injection medialization are statistically less likely to ultimately require permanent surgical intervention 1
• Voice therapy should be considered both as primary treatment and as adjunctive therapy following surgical intervention 4

Voice disorders from vocal cord paresis can significantly impact quality of life, affecting work and social interactions. The evidence strongly supports early evaluation and intervention, with a combination of voice therapy and surgical approaches tailored to the severity of the condition and the patient's vocal needs.