Speaking Clearer: Updates on Vocal Cord Paralysis Treatment

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic Podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on Twitter @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI.

Today, I'm excited to talk with my friend and colleague, Dr. Will Tierney, a laryngologist and head and neck surgeon here at Cleveland Clinic. You can follow him on Twitter @TierneyMD. Dr. Tierney, welcome to Head and Neck Innovations.

William Tierney: Thank you, Dr. Bryson. It's good to be here.

Paul Bryson: Let's have you share some background on your journey to Cleveland Clinic, for our listeners - where you're from, where you trained, how your interests in laryngeal surgery and head and neck surgery developed.

William Tierney: So, I love sharing this with people. I grew up in Northern California and went to UC Berkeley for undergraduate and took a neuroanatomy course which really ignited sort of an interest in cranial nerves, which is a super nerdy reason to end up in head and neck surgery but it is actually what got me interested.

I thought I was going to be a neuroanatomist for a while, did a graduate degree in anatomy at Case Western Reserve University, and then decided I could not live the rest of my life in a lab working with cadavers or tissue specimens. Ended up in med school at the Cleveland Clinic Lerner College of Medicine. That was when I first met Paul Bryson and realized that laryngology is the most interesting part of our field, for me.

So, after meeting Paul Bryson as a medical student and working with him and the Cleveland Clinic Lerner College of Medicine, I did my surgical residency here at the Cleveland Clinic and confirmed my passion for laryngology and then went to Vanderbilt University for a fellowship in professional voice and airway reconstruction.

And so, following that, it was my honor to return to the Cleveland Clinic and get to work alongside some of the people who got my feet on the ground in the field, and got me involved in laryngology from really early in my training.

So, that's my background. I'm married to an endocrinologist. We have two little boys and my voice gets used both in clinic and then also taking care of them and I'm grateful for it, but it gives you perspective on how we talk and how we communicate with each other.

Paul Bryson: Well, it's a real pleasure and joy for me to be here with you today, to elaborate more on the Lerner College experience. Will and I have been working together now for more than 10 years, from medical student, to surgical resident, and now is our newest staff member in the Voice Center in Laryngology Section. So, to say it's an honor is an understatement. Just very proud of Will and his sort of critical mind and his interests and I'm hopeful we'll get to talk about all of that. But I know today we're going to talk about vocal fold paralysis and some of the impact that it can have on patients and some of the treatment options that Dr. Tierney specializes in and some emerging opportunities for patient care here at Cleveland Clinic.

So, when the vocal folds don't work right, it can really play havoc on somebody's voice and their world really. Do you want to share a little background for our listener on vocal fold paralysis? What that can mean? What it can look like? Sound like?

William Tierney: Absolutely. So, vocal cord paralysis, or vocal fold paralysis, is when one of the vocal folds doesn't work and ends up immobile, usually in what we call the paramedian position, which is just off midline. And so, then the other side of the larynx, in unilateral vocal fold paralysis, still works normally but can't make contact with the not working vocal cord. So, what you end up with is, rather than the vocal cords coming together vibrating and creating sound, you try to come together, but you have a gap between the two which results in inadequacy of that closure and you can't make sound well.

So, you can overcome it by just pushing a whole lot of air through the voice box, which is exhausting in a lot of our patients with vocal fold paralysis, complain of running out of voice. And people with vocal folds paralyzed further from the midline may not even be able to do that. And so, the vocal phenotype that you're looking for would be a breathy voice where patients are unable to get a whole lot of air through the vocal cords and have to take a lot of breaths.

And so, you want to look for this, sort of right after someone's maybe had a surgery, which could affect the recurrent laryngeal nerve and cause vocal fold paralysis, but it also happens to people idiopathically, just spontaneously.

Paul Bryson: I would say it's important to recognize there's actually a lot of common procedures and common things that can result in vocal fold or cord paralysis. In our audience here is likely otolaryngologists and others. Do you want to elaborate on some of the causes of vocal cord paralysis and just some of the predicaments that patients may undergo that then lead them to us?

William Tierney: Yeah, so the iatrogenic causes of vocal cord paralysis or vocal fold paralysis are neck surgery, thoracic surgery, and then anything that could potentially stretch the recurrent laryngeal nerve. Which if you'll remember from anatomy, has sort of a tortuous path going down into the thorax on the left, looping under the ligament arteriosum and then coming back up to the larynx. And so anywhere along that line, you can have interruption or irritation of the nerve.

And so, the surgical procedures we think of are certainly any esophageal procedures, as the nerve runs in the tracheoesophageal groove on its way back up to the larynx. Thyroid surgery is one of the more common things that we have to think about in our world. Nodal laryngology, head and neck surgery. But then really any thoracic procedure has the potential to stretch the nerve.

We also see a certain amount of vocal fold paralysis, or hypo-mobility, where we're not sure necessarily that it's paralyzed versus immobile, after some other common procedures like intubation. The thought being that the nerve can be put under some pressure by an endotracheal tube within the larynx and you can have a temporary or permanent immobility following an intubation, either short term or long term. And there are some other causes that we see them for a number of different reasons, but I think those are sort of the common ones that everybody should be aware of and look out for.

Paul Bryson: I think you demonstrated what the voice can sound like, significant vocal fatigue, difficulty projecting. People will really feel left out socially and occupationally with vocal fold paralysis, sometimes. Is it just voice? Are there other things that people complain about or experience?

William Tierney: That's a great question and there are a bunch of different things that people feel are impaired when they lose the motion in half of their larynx. The first is voice. After that, there's also difficulty swallowing and the classic presentation there is difficulty swallowing thin liquids, patients coughing and choking on water. And then of course you also have impairment of cough, which reduces your ability to clear things from the upper airway and you can have things like increased risk for pneumonia from that, both from aspiration risk and then also the inability to effectively clear the trachea if there were an aspiration event.

And then the last thing, which we've kind of touched on, but many patients will in fact complain of a primary concern of shortness of breath. And when you dig that out a little bit in the history of present illness, you realize that it's because when they talk, they run out of breath, versus if they're walking up a flight of stairs, they get out of breath. Although it obviously can happen concurrently in some of these people.

Paul Bryson: I appreciate you elaborating on that. So, what do we have to offer patients? What are the treatment options versus, and I guess I'd frame it this way. Sometimes people have the ability to see us pretty shortly after something happens and their voice changes and we discover this. We get a call from the surgeon sometimes, and we can get the patient in quickly if there's a concern. And then other times, people will walk into the door well over a year after an injury, or well after a year where the voice has been different and problematic. So how do you break down treatment and what are the options in these scenarios?

William Tierney: So, treatment for this condition is not simple, but I try to simplify it because that's how my brain works. And so typically the way I look at this is, early vocal cord paralysis and late vocal cord paralysis. And in early vocal cord paralysis, people have a relatively high chance of recovery when the recurrent laryngeal nerve is known to be intact. And so, if it hasn't been severed during a surgery, or destroyed by a tumor, then you have a fairly high likelihood of people recovering, somewhere in the 80 percent range if you catch it within the first month, but then it drops off every month thereafter. And so, I think you're down to about a 50 percent recovery rate by six months and an under 10 percent chance of recovery at a year. And so, the traditional teaching has been to treat things as early paralysis until about a year out because people still have a chance of recovery.

Early paralysis treatment focuses on reversible treatment with typically an injection augmentation, which is a filler that's placed into the paraglottic space, next to the vocal fold, to push the immobile vocal cord towards the midline where it can make contact with the mobile vocal fold.

There are a bunch of different injectables which are available, and they can be injected either in the office or in the operating room, depending on equipment and surgeon comfort. We here at the Cleveland Clinic often use Restylane, which is a hyaluronic acid filler, and it lasts in the three-to-five-month range. And so, if you meet someone the week after their vocal fold has been paralyzed, or is found to be hypomobile after a surgery, you potentially can inject them early so that they have reduction in symptoms and then inject all the way through until they're about a year out, when you would consider treatment for late vocal fold paralysis, which is typically a more permanent option and there are a few things that exist.

The gold standard is a Type 1 thyroplasty, which is an open surgical procedure performed under local anesthesia with the patient awake typically, so that the voice can actually be tuned to the patient's demands. People nationally do this with either Gore-Tex strips, which are fed into the paraglottic space through the thyroid cartilage, to bolster the vocal fold, or using a silicone rubber called SILASTIC, which is my preferred method and the preferred method of all my partners here at the Cleveland Clinic.

In that procedure, a customized implant is crafted from a block of SILASTIC rubber and tailored to specifically fit that patient and push the vocal fold into exactly the spot it needs to be in, to achieve a good phonatory pattern and get patients back to, I usually tell people 90 to 95 percent of their original voice and they'll actually have the opportunity to tweak what they want on the table.

Paul Bryson: Now I've also heard that you can do vocal fold injections, awake in the office setting. Is this true? I've even heard that we've done this for patients while they're hospitalized, recovering from other things like complex aortic surgery, spine surgery, and things like that.

William Tierney: So, obviously Paul is aware that these things are possible, and he and I both do them in the clinic, frequently. So, office injection with Restylane, or another filler substance is possible, and in fact, preferred in my professional opinion.

We've done some research here that looks at hemodynamic changes during office versus operating room interventions and found that hemodynamic instability in patients is actually reduced by doing this in the office, which is a little counterintuitive. You think the awake patient is going to be extremely stressed out by, typically injection augmentation is performed through the mouth with a long-curved cannula with a needle on the end. And so that sounds pretty stressful having somebody put that through your mouth. But it's actually a lot less physiologically stressful on the cardiovascular system, than going to sleep in the operating room and undergoing suspension laryngoscopy.

And so, the way that we perform these procedures in the office, there are several different approaches to it, but typically the patient will be anesthetized with lidocaine throughout the oral pharynx and larynx, and then endoscopy either with a rigid endoscope or a trans-nasal flexible endoscope is performed.

And then an injection is completed, one of two ways. The first is what I already mentioned. A curved cannula can be inserted through the mouth, while the tongue is held in protrusion and injection into the vocal fold is conducted through the mouth, with the needle entering the vocal fold and then going into the paralytic space, through the superior surface of the vocal fold.

The other ways of performing that injection are transcervical, where a needle is inserted through the neck and a little local lidocaine is used to make that comfortable, either through the cricothyroid or thyrohyoid spaces. And there's one other way, which is a trans-thyroid cartilage, a trans-cartilaginous approach, where a needle is bored through the cartilage. But all of those options exist and my preferred way of doing an injection augmentation is in the office, on the awake patient, who can then show me what their voice sounds like, and I can do a videostroboscopy at the same time, to confirm that we have a good placement of our filler.

Paul Bryson: Well, I appreciate that. We usually can tailor the treatment and the approach to the patient. We really want to maximize comfort for people, so that they can have a good experience and successful outcome.

I wanted to spend just a moment too, to talk about new research and innovations and some alternative approaches for vocal fold paralysis. One that we could touch upon is re-innervation of the larynx, reanimation of the larynx, really a fertile area for continued research.

One of our partners here, Dr. Lorenz, we talked to earlier on another podcast, but we have learned laryngeal re-innervation from him. And any comments on laryngeal re-innervation for unilateral vocal fold paralysis?

William Tierney: Yeah. So, I think laryngeal re-innervation is a really interesting topic because when I first heard about it as really a medical student, I didn't think it was going to do exactly what it does. And so, re-innervation is basically when you connect a nerve to a non-working nerve.

And so, in the case of laryngeal re-innervation, we often are talking about an ansa cervicalis anastomosis to the recurrent laryngeal nerve. There are some other donor nerves which can be used, branches from the phrenic nerve, and you can also do some cross-midline graphs, but they do not restore the original functional capacity of the vocal fold with full movement, typically. But instead through sort of a synkinetic renovation, will get bulk and muscle tone back, to effectively medialize the vocal fold.

Now, there are exceptions to that, and some patients do get some purposeful motion, which is of course the hope with many of these procedures, but I've come to counsel my patients to expect more of a medialization effect, which takes place over one to two years after re-innervation surgery.

The literature on this in children is actually, I would say, as developed or more developed than in adults, because they're not as good candidates for a Type 1 thyroplasty because they're still growing. And so laryngeal re-innervation is reached for more frequently in children, and the results there are, I think, a little bit better than the outcomes in adults.

That being said, there are a lot of differences in our neurologic development between childhood and adulthood and so I think it's an interesting procedure. It's something that I will usually use in patients where I know that the nerves to the larynx are going to be interrupted surgically, for example, a vagal schwannoma, or a thyroid cancer with loss of laryngeal function, where we can go in and do a laryngeal re-innervation at the time of a surgery, which exposing those nerves anyway. But everybody has a different approach to that, and that is just my practice.

Paul Bryson: Yeah, that's great. We really do try to have that team-based approach, particularly when it comes to re-innervation with kids and when we know that there's going to potentially be oncologic sacrifice, so the recurrent laryngeal nerve. It's a great opportunity to give a fresh nerve supply to the larynx and avoid some of the scar tissue that one might encounter on a re-exploration.

I guess I would say finally, in some of the research, we're trying to customize implants more. Dr. Tierney and I have been involved in some customization of implants, based on patient size, larynx shape, things like that. And then there's even some newer clinical trials where the implant can be inflated, or shaped, or augmented preferentially in different parts of the vocal fold. So, it remains a fertile area of research, and we're fortunate to have a very high-volume center, which to learn from and provide care to patients from.

Well, as you get your practice started here and are seeing patients, what can someone who is referring a patient to Cleveland Clinic with vocal fold paralysis, expect as far as a plan of care? In addition to you and your surgical techniques and surgery, who else might the patient see or who else might a provider refer to in the context of this?

William Tierney: So here at the Cleveland Clinic and at tertiary centers who do a lot of this, we work very closely with our speech and language pathology colleagues. And many of the patients who develop one of these paralysis will fall into a laryngeal posture, as we call it, where they're using their larynx in an unusual way, in order to produce voice through their impaired larynx.

And so, a lot of people will move to a higher pitch, where the vocal folds can be tightened more to get a little bit of a better closure with less airflow. And once you're able to treat the vocal fold paralysis, often they'll still have abnormal voice because they've fallen so far into this habitual posturing and so working with a good speech and language pathologist is, I think, critical to taking good care of these patients.

Some people get better with really just an injection augmentation, or a Type 1 thyroplasty, but many people need the insight of a voice sub-specialized SLP colleague, to really get full benefit from those services.

So, we do that I think very well here and work one-on-one with speech and language pathologists, both in the office and then also refer to one another, and I think our patients benefit from it dramatically.

Paul Bryson: Yeah, I would agree.

As we wrap up today, can you give the listener any take home messages? When to refer? We're going to provide some information for referring people to send patients, but any take homes for listeners today?

William Tierney: I think the most important thing is to know that if there's a voice problem that isn't easily fixed or identified in the clinic, have a low threshold to send them to a voice healthcare professional, a laryngologist, a speech and language pathologist who's been trained in voice, and it's a relatively small community nationally, so there's probably someone near where you practice that has access to videostroboscopy and can identify what's going on and then get them to the people who do the specific procedures that they need.

So, the biggest take home point, both within otolaryngology and outside, is to send dysphonia to people who specifically treat it and I think most people do very well with that approach.

Paul Bryson: Well, I really appreciate your time today. I'd encourage our listeners, if you have patients that you're concerned about with voice, please send them to Dr. Tierney and to our team. We're excited to help. We have a multidisciplinary team and a lot of tools at our disposal to try to give your patients the best care.

Well, Dr. Tierney, thanks for joining Head and Neck Innovations.

William Tierney: My pleasure, Paul.

Paul Bryson: For more information on vocal cord paralysis treatment at Cleveland Clinic, please visit clevelandclinic.org/vocalcordparalysis. That's clevelandclinic.org/vocalcordparalysis. And to speak with a specialist, or submit a referral, please call 216.444.8500. That's 216.444.8500.

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