Vocal Cord Paralysis

Aka: Vocal Cord Paralysis, Laryngeal Nerve Palsy, Laryngeal Paralysis, Vocal Fold Paralysis

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II. Causes: Unilateral Vocal Cord Paralysis (Most cases)

  1. Tumor
    1. Infiltrating Thyroid Cancer
    2. Apical Lung Cancer
  2. Medications
    1. Vincristine
    2. Phenytoin
      1. Fried (1975) Laryngoscope 85:1770-81 [PubMed]
  3. Inflammation or Infection
    1. Collagen vascular disease
    2. Lyme Disease
    3. Mononucleosis
    4. Sarcoidosis
  4. Neurologic Conditions
    1. Myasthenia Gravis
    2. Parkinsonism
    3. Multiple Sclerosis
    4. Amyotrophic Lateral Sclerosis
  5. Toxic and Metabolic Causes
    1. Diabetes Mellitus
    2. Alcoholism
    3. Heavy Metal exposure
      1. Arsenic Poisoning
      2. Mercury Poisoning
      3. Lead Poisoning
  6. Trauma to recurrent laryngeal nerve
    1. Prolonged Endotracheal Intubation
    2. Neck or thoracic surgery (most common cause in infants and young children)
      1. Carotid surgery
      2. Neck dissection for head and neck cancer
      3. Cardiac surgery
        1. Patent Ductus Arteriosus ligation (newborns)
        2. Valve repair
      4. Thyroid surgery
      5. Tracheal surgery

III. Causes: Bilateral Vocal Cord Paralysis (rare)

  1. Neurologic abnormalities
  2. Trauma or post-surgical
  3. Chiari Malformation

IV. Symptoms

  1. Hoarseness
  2. Decreased endurance for speech and voice Fatigue
    1. Weak or hoarse cry in infants
  3. Swallowing difficulty or Choking on liquids
    1. Dysphagia and aspiration risk
  4. Singing difficulty

V. Signs: Infants

  1. Stridor
  2. Apnea
  3. Cyanosis
  4. Dyspnea
  5. Hoarse voice
  6. Weak cry
  7. Feeding problems

VI. Signs: Laryngoscopy

  1. Paralyzed vocal cord is fixed in paramedian position
    1. Just lateral to midline
    2. Slight adduction may be seen (collateral innervation)
  2. Paralyzed vocal cord is bowed and flaccid
    1. When speaking, drops lower than the unaffected cord
  3. Uninvolved vocal fold may compensate
    1. Uninvolved cord crosses midline over next 2-3 months
    2. Meets paralyzed cord

VII. Evaluation

  1. See Speech Exam
  2. Careful Lymph Node examination
    1. See Lymphadenopathy of the Head and Neck
  3. Nasolaryngoscopy
    1. Evaluates appearance and movement of Vocal Cords

VIII. Imaging

  1. Chest XRay (consider lordotic views)

IX. Management: General

  1. Laryngology or ENT referral in most cases
  2. Early speech pathology for voice building Exercises
  3. Bilateral Vocal Cord Paralysis typically requires Tracheostomy

X. Management: Surgery for unilaterally paralyzed vocal cord

  1. Medialization Laryngoplasty (Thyroplasty) with implant
    1. Various implant types (e.g. Gore-Tex, Silicon)
  2. Medialization via office injection
    1. Collagen injections
    2. Avoid Teflon augmentation due to granulation
  3. Reinnervation
    1. Requires more time to result than other procedures

XI. Complications

  1. Aspiration of food contents

XII. Resources

  1. Voice Doctor Website (Dr. Thomas)
    1. http://www.voicedoctor.net/diagnose/sx/urln.htm

XIII. References

  1. Feierabend (2009) Am Fam Physician 80(4): 363-70 [PubMed]
  2. House (2017) Am Fam Physician 96(11): 720-8 [PubMed]
  3. Rosen (1998) Am Fam Physician 57(11): 2775-2782 [PubMed]

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