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Surgical procedures offer dramatic improvement in patients with vocal cord paralysis

People with chronic hoarseness and breathy voices often learn to live with their impediment, accepting it as an unfortunate characteristic that they feel can never change. In some cases, this voice change is due to vocal cord paralysis, a condition that can be a sign of other serious medical conditions which can lead to other health problems and affect quality of life.

Yet modern treatments offer an almost certain improvement of the condition and are surprisingly less traumatic than one might imagine. At Thomas Jefferson University Hospital, two procedures are being offered by otolaryngologists-head and neck surgeons to patients with vocal cord paralysis. With both, a significant voice improvement is achieved within weeks–and in some cases right after the procedure. The procedures-- thyroplasty and vocal cord injection--have demonstrated a high rate of success and are associated with a low level of discomfort, a one-day hospital stay and a short post-surgery recovery period.

The surgeries can be beneficial to very ill patients–especially patients suffering from severe lung cancer, cervical spine fractures, and stroke–who may have lost some or all of their ability to speak because of resulting vocal cord paralysis. Stripped of their ability to communicate with their physicians and family at a time of critical illness, the surgery can restore their ability to speak–a vital part of their existence. This results in a significant, immediate improvement in their quality of life.

Vocal cord paralysis affects the vocal cords, folds of mucous membranes positioned within the larynx. "When the vocal folds are in normal position, they are in a V pattern," explained Joseph R. Spiegel, M.D., associate professor of otolaryngology-head and neck surgery, Jefferson Medical College of Thomas Jefferson University." The folds open into an open V for breathing and then close and come together for speaking.

“The voice is a function of air that blows up through the vocal folds. For the voice to work and sound the right way, the folds must be able to close together like two reeds on a reed instrument in order to vibrate and create the proper sounds. "When a vocal cord is paralyzed, it cannot come into the middle to touch the other vocal cord," said Dr. Spiegel. "There is a leak between them in which the air that is blowing up is not being used to make the vocal cords vibrate."

With paralysis, the voice becomes weak and hoarse. Whether the vocal cord is partially or completely paralyzed, the person may suffer from anything from a mildly hoarse voice to almost no voice at all.

"Some people with vocal cord paralysis complain that they get short of breath when they try to talk simply because so much air is escaping through the vocal cords that they can only get a few words out before they have to take a breath," said Dr. Spiegel. "It can be exhausting.”

One of the first procedures offered at Thomas Jefferson University Hospital is thyroplasty-- a viable surgical option for many. With thyroplasty, local anesthesia is used and a small cut is made in the neck along one of the natural neck wrinkles. Surgery is conducted through the incision, and a material is wedged into and implanted next to the vocal cord to move the paralyzed vocal cord to a position that allows the folds to come closer together. Because the patient is awake, he or she can speak upon request so that the surgeons can test the placement of the implant. The implant is malleable and can be adjusted by the surgeon if need be.

"The immediate voice correction with thyroplasty is quite remarkable," said Maurits S. Boon, M.D., clinical instructor in otolaryngology-head and neck surgery, Jefferson. "It’s something that can be appreciated the day of surgery." This is not to say that the final voice product will occur that day. Healing and swelling after surgery affect the voice for a few weeks.

The second option offered is the vocal cord injection procedure, which involves injections of material placed in the vocal fold to move the folds closer together to create a more normal voice. In injection cases, surgeons must decide carefully on the amount of substance introduced. "We purposefully insert more substance than we want to be there permanently because we know some of it is going to be absorbed," explained Dr. Spiegel. "In these cases, the patient is usually under general anesthesia and we cannot interact to hear the voice changes, we have to gauge how we think it’s going to be three to six weeks afterward."

Although most patients undergo the procedures to restore or improve the ability to speak, it is sometimes recommended for health reasons, said Dr. Boon. "Vocal cord paralysis can affect the way people swallow. So, what is swallowed may go down the wrong pipe, if you will." Indeed, the vocal folds are a final barrier that keeps unwanted material, such as food and drink, from going into the windpipe.

"If the vocal folds cannot close completely, people lose that final barrier," said Dr. Spiegel. "This is not always a problem, but if people have additional problems, such as when they have had a stroke or weakness of other muscles in their throat, then the addition of vocal cord paralysis can be a real concern."

Thyroplasty and injection surgery have been successful for patients, but the success rate must be weighed against the goals that are expected. Said Dr. Boon, "We look at goals on different levels. Some patients have the goal of basic speech communications and conversational speech because they are unable to have conversational speech prior to the procedure. In these cases, the procedure is almost entirely successful."

Dr. Boon added, "As we have become more experienced with the procedure, we have been using both the thyroplasty and the injection procedure to try to improve the voices of people who have had more minor losses and weaknesses due to scarring and other problems."

In such patients, surgery might be used to restore a high pitch that the patient couldn’t achieve before, or restore the ability to "raise" the voice, which may be vital to a classroom teacher or other professional. "In these cases, these procedures are slightly less successful in terms of fine goals. About three-quarters of these cases are successful," said Dr. Spiegel.

Vocal cord paralysis can be the result of a variety of causes and can affect individuals of all ages. Children can be born with vocal cord paralysis. The most common symptom in very young children is stridor, a sound produced by turbulent flow of air through a narrowed segment of the respiratory tract. Other symptoms of vocal cord paralysis in children include obstruction, a weak cry, difficulty speaking, and aspiration.

Children make up only a small percentage of patients seen for evaluation of vocal cord paralysis. "Most commonly, the vocal cord paralysis patients we see are in the older age groups because the most common causes we see are stroke, lung cancer, and paralysis caused by surgery for heart problems and thyroid problems," said Dr. Spiegel. "Most patients are 50 and older. Still, because of trauma and other problems, we do see and routinely treat younger people."

Patients who come to otolaryngologists with vocal cord paralysis must undergo a complete evaluation to determine the cause of the problem, said Dr. Boon. "We cannot assume we know the cause unless we have an extremely good story. For example, if someone were stabbed in the neck on the left side and suddenly has a left side vocal cord paralysis, we don’t have to look a lot further into what caused it. But if somebody comes in with a change in their voice and is found to have a vocal cord paralysis, we have to do all the necessary studies."

These studies include imaging patients using computed axial tomography (CAT scan) and magnetic resonance imaging (MRI). Because the vocal folds primarily receive nervous control from a nerve called a recurrent laryngeal nerve that has a relatively long course, the studies are needed to ensure that there is not a malignancy affecting the nerve. Additionally, blood tests may be called for to rule out infectious or inflammatory causes of vocal cord paralysis.

After either procedure, patients are observed for up to 24 hours to rule out breathing problems. Few restrictions are placed on recovering patients. Patients are instructed to "take it easy" for a few days, but they generally eat normally and return to their normal daily lives very quickly.

The list of patients who would not qualify for thyroplasty or implant surgery is limited. Many patients who are relatively sick cannot tolerate general anesthesia because of heart, lung, or other problems, but can undergo thyroplasty with local anesthesia.

In such cases as lung cancer and stroke, surgeons may “push the limits” a bit and undertake the procedure in patients who are tenuous. “Verbal communication is so vital to their existence, and we respect that,” said Dr. Spiegel. “We often do not realize how valuable our voice is until something goes wrong. Fortunately, modern medicine offers viable, successful treatments.”

For more information, or to make an appointment, please call 1-800-JEFF-NOW.