What is the recommended management for unilateral recurrent laryngeal nerve palsy?

Management of Unilateral Recurrent Laryngeal Nerve Palsy

Immediate otolaryngology referral for flexible laryngoscopy within 2 weeks to 2 months postoperatively, combined with speech therapy as the primary treatment modality, is the recommended management approach for unilateral recurrent laryngeal nerve palsy. 1

Immediate Diagnostic Assessment

• Perform flexible laryngoscopy immediately in any patient with suspected laryngeal dysfunction (hoarseness, breathy voice, dysphagia, or aspiration symptoms) to confirm vocal cord palsy and document the position of the paralyzed fold 2, 1
• Laryngoscopy should be completed within 2 weeks to 2 months following surgery to establish baseline injury status 1
• Laryngeal electromyography (EMG) is highly valuable for differentiating true nerve paralysis from cricoarytenoid joint ankylosis and provides reliable prognostic information about recovery potential 3, 4
• EMG can predict unfavorable outcomes with high accuracy, though predicting complete recovery is more challenging 3

Primary Treatment Strategy

• Speech therapy is the treatment of choice for unilateral recurrent laryngeal nerve palsy and should be initiated immediately upon diagnosis 1, 3, 5
• Refer to a speech-language pathologist for compensatory voice techniques and swallowing assessment to address both phonatory and aspiration concerns 1
• Consider a short course of corticosteroids, though evidence supporting this intervention is limited 6, 1
• Ensure adequate hydration and voice rest during the acute recovery phase 6

Monitoring for Spontaneous Recovery

• Approximately 93% of transient injuries recover spontaneously within 6 months, making watchful waiting with supportive therapy the cornerstone of initial management 1
• Perform follow-up laryngoscopy at 4-6 weeks to assess recovery trajectory and vocal fold mobility 6, 1
• Continue regular laryngoscopic examinations beyond initial follow-up, not relying solely on clinical symptom assessment 1

Surgical Intervention for Persistent Palsy

• Medialization procedures should only be considered if a significant glottal gap persists after an adequate trial of conservative management and speech therapy 3, 5
• Both endoscopic and open surgical approaches are available for vocal fold medialization to improve voice quality and eliminate aspiration 3, 5
• These techniques are simple, have low complication rates, and are highly efficient in eliminating aspiration and improving voice quality and quality of life 5
• Surgical intervention should be delayed until prognosis is clear, typically after 6-9 months of observation, to avoid premature intervention in cases that may recover spontaneously 4

Multidisciplinary Team Coordination

• A cohesive team including an otolaryngologist and speech therapist plays a central and determining role in postoperative care and rehabilitation 2, 1
• The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends referral to an otolaryngologist when abnormal vocal fold mobility is identified 1
• Maintain empathetic communication with patients, reassuring them about outcomes while being honest about recovery timelines 2

Assessment of Aspiration Risk

• Evaluate swallowing function and aspiration risk, as unilateral RLN injury impairs vocal cord function and compromises airway protection during swallowing 7, 6
• The impaired ability to cough effectively in the early post-injury period further compromises airway protection 7
• Most unilateral injuries show compensation from the opposite vocal cord over time, reducing aspiration risk 7

Critical Pitfalls to Avoid

• Delayed diagnosis significantly worsens outcomes—any postoperative hoarseness warrants immediate laryngoscopy rather than waiting to see if symptoms resolve 6, 1
• Inadequate follow-up with failure to perform serial laryngoscopic examinations can miss recovery patterns or deterioration 1
• Focusing exclusively on voice symptoms while neglecting dysphagia and aspiration risk assessment leads to incomplete management 6, 1
• Premature surgical intervention before allowing adequate time for spontaneous recovery (minimum 6 months) may subject patients to unnecessary procedures 4

Patient Education and Expectations

• Explain that RLN injury is a predictable but not entirely preventable complication, occurring in 1-2% of cases even at tertiary centers with experienced surgeons 1
• Permanent injury rates are approximately 1.1% overall but significantly higher (up to 30%) in revision surgery 1
• Voice therapy continuation with compensatory techniques can substantially improve quality of life even without complete anatomical recovery 1, 5

budget:budget_used 8365 7254 1111 0.0