Vocal cord paralysis

Paralysis of the vocal cords results from disease of or injury to the superior or, most often, the recurrent laryngeal nerve.

Causes

Vocal cord paralysis commonly results from the accidental severing of the recurrent laryngeal nerve or of one of its extralaryngeal branches during thyroidectomy.

Other causes include pressure from an aortic aneurysm or from an enlarged atrium (in patients with mitral stenosis), bronchial or esophageal carcinoma, hypertrophy of the thyroid gland, trauma (such as neck injuries) and intubation, and neuritis due to infections or metallic poisoning. Vocal cord paralysis can also result from hysteria and, rarely, lesions of the central nervous system.

CLINICAL TIP:  In some cases, cause isn’t identified and spontaneous recovery can occur within a year.

Signs and symptoms

Unilateral paralysis, the most common form, may cause vocal weakness and hoarseness. Bilateral paralysis typically produces vocal weakness and incapacitating airway obstruction if the cords become paralyzed in the adducted position.

Diagnosis

Patient history and characteristic features suggest vocal cord paralysis. Visualization by indirect laryngoscopy shows one or both cords fixed in an adducted or partially adducted position and confirms the diagnosis.

Treatment

In unilateral vocal cord paralysis, treatment consists of injection of Teflon into the paralyzed cord, under direct laryngoscopy. This procedure enlarges the cord and brings it closer to the other cord, which usually strengthens the voice and protects the airway from aspiration.

Thyroplasty also serves to medialize the vocal cord, but in this procedure an implant is placed through a neck incision. The ansa cervicalis nerve transfer allows for reinnervation of the vocal cord muscles. Bilateral cord paralysis in an adducted position necessitates tracheotomy.

Alternative treatments for adults include encloscopic arytenoidectomy to open the glottis, and lateral fixation of the arytenoid cartilage through an external neck incision. Excision or fixation of the arytenoid cartilage improves airway patency but produces residual voice impairment. Treatment of hysterical aphonia may include psychotherapy and hypnosis.

Special considerations

❑ If the patient chooses direct laryngoscopy and Teflon injection, explain these procedures thoroughly. Tell him these measures will improve his voice but won’t restore it to normal. Patients are sometimes placed on voice rest for 24 to 48 hours to reduce stress on the vocal cords, which would increase the edema and might lead to airway obstruction.

CLINICAL TIP: Do not allow the patient on voice rest even to whisper. Whispering involves approximating the vocal cords, which will irritate the cords and increase swelling.

❑ Many patients with bilateral cord paralysis prefer to keep a tracheostomy instead of having an arytenoidectomy; their voices are generally better with a tracheostomy alone than after corrective surgery.

❑ If the patient is scheduled to undergo a tracheotomy, explain the procedure thoroughly, and offer reassurance. Because the procedure is performed under a local anesthetic, the patient may be apprehensive.

❑ Teach the patient how to suction, clean, and change the tracheostomy tube.

❑ Reassure the patient that he can still speak by covering the lumen of the tracheostomy tube with his finger or a tracheostomy plug.

❑ If the patient elects to have an arytenoidectomy, explain the procedure thoroughly. Advise the patient that the tracheostomy will remain in place until the edema has subsided and the airway is patent.

Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

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