Treatment of Vocal Cord Paralysis
The treatment of vocal cord paralysis should be tailored based on the cause, severity, and whether the paralysis is unilateral or bilateral, with voice therapy being strongly recommended as first-line management for patients with dysphonia that reduces voice-related quality of life. 1
Evaluation and Diagnosis
Initial Assessment
- Laryngoscopy is essential for all patients with dysphonia persisting beyond 4 weeks or immediately if serious underlying cause is suspected 2
- Complete evaluation should include imaging from skull base to thoracic inlet/arch of aorta to evaluate the entire path of the recurrent laryngeal nerve 1
- Risk factors requiring expedited evaluation:
- Recent head/neck/chest surgery
- Recent endotracheal intubation
- Presence of neck mass
- Respiratory distress or stridor
- History of tobacco use
- Professional voice user status 2
Diagnostic Imaging
- Contrast-enhanced neck CT extended through the aortopulmonary window is recommended for evaluating the full course of the vagus nerve and recurrent laryngeal nerve 2
- MRI is preferred for intracranial and skull base segments of the vagus nerve 2
Treatment Algorithm
1. Unilateral Vocal Cord Paralysis
Conservative Management (First-Line)
- Voice therapy focusing on:
- Proper vocal techniques
- Breathing exercises
- Vocal hygiene
- Resonance therapy
- Reduction of vocal strain 1
Surgical Options (When Conservative Management Fails)
- Vocal cord injection (temporary or permanent materials)
- Thyroplasty (medialization laryngoplasty)
- Arytenoid adduction
- Reinnervation procedures 1
2. Bilateral Vocal Cord Paralysis
Immediate Management
- Airway assessment and management are priorities
- Avoid intubation if possible; if necessary, use smaller endotracheal tubes
- Consider tracheostomy for severe airway obstruction 3
Definitive Treatment
- Surgical lateralization of vocal cords
- Cordotomy
- Arytenoidectomy
- Posterior transverse cordotomy 4
Treatment Selection Based on Etiology
Post-Surgical Paralysis
- Most common after thyroid surgery (incidence reduced to <5% in recent years) 5
- Observation for 6-12 months as spontaneous recovery is possible 2
- Voice therapy during observation period 1
Intubation-Related Paralysis
- Usually temporary, resolving within 6 months 3
- Contributing factors include endotracheal tube size, cuff location, and cuff inflation pressure 6
- Preventive measures:
- Atraumatic intubation technique
- Appropriate tube size selection
- Perioperative corticosteroid administration 3
Tumor-Related Paralysis
- Treatment of underlying malignancy is priority 7
- Options include radiation therapy, endoscopic transoral laser resection, endoscopic transoral robotic resection, or open partial laryngectomy 1
Idiopathic Paralysis
- Accounts for approximately 31% of cases 7
- Conservative management with voice therapy for 6-12 months 1
- Surgical intervention if no improvement after observation period
Special Considerations
Professional Voice Users
- More urgent evaluation due to occupational impact 1
- More aggressive treatment approach may be warranted
- Higher priority for voice preservation techniques 2
Pediatric Patients
- May present with severe respiratory distress even with unilateral paralysis 4
- Treatment options include intubation, tracheotomy, surgical lateralization, or reinnervation 4
Vagal Paragangliomas
- Patients with vagal paragangliomas should rarely be considered for resection due to high risk of resultant vocal cord paralysis 2
- Observation is recommended for newly diagnosed jugular, vagal, and carotid paragangliomas without compelling indications for treatment 2
Complications and Prevention
- Aspiration risk is significant, especially with unilateral paralysis 3
- Bilateral paralysis can lead to respiratory distress requiring tracheostomy 6
- Preventing laryngeal edema is critical, particularly in bilateral paralysis 3
- Voice changes occur in 0.5-7.9% of patients following thyroid thermal ablation 2
Follow-up Care
- Regular laryngoscopic examination to assess progress
- Documentation of symptom resolution, improvement, or worsening
- Continued voice therapy as needed
- Smoking cessation is critical for optimal outcomes 1
Remember that early evaluation and appropriate treatment selection can significantly improve outcomes and quality of life for patients with vocal cord paralysis.