From the Guidelines
For a 50-year-old woman with vocal cord palsy 6 months after hemithyroidectomy, I strongly recommend initiating speech-language therapy (SLT) in conjunction with arranging for laryngeal electromyography (EMG) to assess nerve function, as this approach is supported by the clinical practice guideline for improving voice outcomes after thyroid surgery 1.
Recommended Approach
- SLT should commence immediately with twice-weekly sessions focusing on vocal exercises to improve compensation and strengthen remaining functional muscles.
- If symptoms persist after 4-6 weeks of therapy, vocal cord injection with a temporary filler like hyaluronic acid should be considered to medialize the affected cord and improve voice quality.
- EMG is essential at this 6-month mark to evaluate the recurrent laryngeal nerve status and predict recovery potential.
- Conservative management alone is insufficient at this stage given the duration of symptoms and impact on quality of life.
- The patient should be counseled about potential long-term management options, including permanent medialization thyroplasty if the palsy proves permanent.
Rationale
The palsy likely resulted from surgical trauma to the recurrent laryngeal nerve during the hemithyroidectomy, and since 6 months have passed, complete spontaneous recovery becomes less likely, though partial improvement may still occur up to 12 months post-surgery 1. The clinical practice guideline emphasizes the importance of early referral for evaluation and management of abnormalities indicative of abnormal vocal folds to increase the chance of rehabilitation and improved voice outcomes 1. Voice therapy by a speech-language pathologist can lead to temporary or permanent improvement in voice quality by adjusting and compensating for altered laryngeal physiology 1. Injection laryngoplasty can provide temporary restoration of vocal fold position and bulk, and framework procedures or reinnervation can offer permanent solutions, though these are typically considered after assessing the outcomes of initial therapies 1.
From the Research
Treatment Options for Vocal Cord Palsy after Hemithyroidectomy
- Speech Language Therapy (SLT): Studies have shown that SLT can be effective in improving voice outcomes for patients with vocal cord palsy after thyroidectomy 2, 3.
- Injection: Hyaluronic acid (HA) injection and autologous fat injection (FI) have been used to treat unilateral vocal fold paralysis (UVFP) after thyroidectomy, with improvements in voice outcomes observed in some patients 3.
- Electromyography (EMG): EMG can be used to assess the function of the vocal cords and diagnose vocal cord palsy.
- Conservative Management: Some studies suggest that conservative management, including voice therapy and observation, can be effective in managing vocal cord palsy after thyroidectomy, with many patients experiencing improvement in voice outcomes over time 4.
Voice Outcomes after Thyroidectomy
- Long-term voice outcomes after thyroidectomy can vary, with some patients experiencing persistent hoarseness or vocal cord palsy 4.
- The incidence of vocal cord palsy after thyroidectomy can be significant, with one study reporting a rate of 10 patients with vocal cord palsy out of a total of 936 articles reviewed 2.
- Treatment outcomes for vocal cord palsy after thyroidectomy can be improved with early intervention, including speech therapy and injection treatments 3.
Management of Vocal Cord Palsy
- The management of vocal cord palsy after hemithyroidectomy should be individualized, taking into account the patient's preferences, vocal demands, and the interval between thyroidectomy and intervention 3.
- A multidisciplinary approach, including speech language therapy, injection treatments, and conservative management, may be necessary to optimize voice outcomes for patients with vocal cord palsy after thyroidectomy 2, 4, 3.