Vocal fold paralysis is when one or both vocal folds do not move properly. Since the vocal folds, which are the major part of the larynx or voice box, need to be apart to be able to breathe and tightly together to sing or speak, movement problems of the vocal fold can have an effect on the voice with hoarseness if one vocal fold does not move and breathing if both vocal folds are not working. Since there are many reasons that people can be hoarse or can have problems with breathing, it is important that they should be seen by a doctor or preferably an Ear, Nose and Throat doctor if they have these symptoms and they persist for longer than a week or two.
There are many causes of vocal fold paralysis. The most common causes are following surgical procedures. These include thyroid surgery, other surgeries in the neck such as carotid artery surgery or neck spine procedures, and sometimes surgery in the chest for the heart or lungs. Other times it can be due to a tumor in the neck or chest and this is one of the important reasons to have these symptoms evaluated. There are a group of people who have vocal fold paralysis without an identifiable cause. These are called idiopathic.
When the ENT doctor evaluates people with voice problems they will either look at the larynx with a mirror or with a small scope that is passed down to the larynx. These are simple and comfortable procedures that can be done in the office. They may arrange for special evaluations of voice to confirm the diagnosis and plan treatment. The treatment of paralysis will differ depending on whether there is paralysis of one side (unilateral) or both sides (bilateral). In general if the vocal folds have not returned motion in a year they will likely not.
For unilateral paralysis, the objective is to try to get the paralyzed vocal fold in the midline so that the normal vocal fold can approximate against it. If done well, this can return the voice nearly to normal. These techniques are varied and also depend on the length of time since the vocal fold paralysis started. If it is within a few months and there is still a chance for recovery, most doctors will recommend an injection of a temporary substance that would push the vocal fold over in the midline. These procedures are generally pretty simple and are reliable and can be performed either in the operating room or in the clinic. If the paralysis has lasted longer or if there was a clear indication that vocal fold motion is not going to return, then the vocal fold can be put back into position by an operation done through the neck where an implant is used to push the vocal fold over. The nerve can also be reinnervated by attaching a normal nerve in the neck. This takes a little bit longer to recover, but can in some cases provide good motion.
Since for bilateral vocal fold paralysis the symptoms are primarily related to difficulty breathing, the primary objective is to get the vocal folds apart. Many patients will already have had a tracheostomy. The management of bilateral vocal fold paralysis will usually require a surgical procedure. The objectives of these operations are to move one or more vocal folds to get it in a more lateral position. The difficulty is that these procedures have to carefully balance improving the breathing without worsening the voice. The better the airway the worse the voice and vice versa, so the surgeon must be careful to try to get both an adequate voice and decent voice. These procedures are usually done through the mouth under anesthesia and there is rarely a need to have a more extensive procedure. If the patient has done well without a tracheostomy, it may or may not need to be done when the lateralization procedure is performed.
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