Abnormal Laryngeal Function

Abnormal Function
Department of Otolaryngology, Head and Neck Surgery

2. Unilateral Vocal Cord Paralysis

Patient History: This is a 45 year old female who has a left sided cord paralysis after her thyroidectomy which was performed two years ago. She complained that her voice was breathy and that she was unable to sing.

Physical Findings: The findings are a paralyzed left cord. It is not in the midline but off laterally into a paramedian position rather than median. The right cord is normal and is in the midline when the vocal cords are closed.

Paralysis of one cord will frequently result in a breathy voice because of a large gap in the midline during phonation. For some patients the mobile cord may be able to closely approximate the paralyzed cord and the voice sounds fairly normal.

Comments: The true vocal cords may be paralyzed as a result of a viral illness, a surgical procedure, by involvement of lymphadenopathy or a mass in the mediastinum that would affect the left recurrent laryngeal nerve. Neoplasms in the thyroid or the mediastinum can also cause this. The left cord is more frequently paralyzed than the right. Therapy for this may include speech therapy if there is adequate closure. If there is a breathiness with incomplete closure of the vocal cords then a unilateral vocal cord injection can be done to medialize the true cord. True vocal cord medialization will also help with aspiration that is frequently associated with this.

3. Bilateral cord paralysis

Patient History: - This is a 65 year old female who came here because of problems with breathing. She is experiencing shortness of breath but has fairly good sounds to her voice. She had a thyroidectomy ten years ago and most recently had a lesion on her right side which was resected that resulted in a right cord paralysis. Since that surgery she has had stridor on inspiration and shortness of breath.

Physical Findings: In bilateral paralysis one can see that neither of the cords wants to move laterally, that is there is no significant abduction, both cords appear to be close to the middle. There may be some vibration and thus allow for passage of air. In the photograph with bilateral cord paralysis open there is slightly more air than with cord paralysis closed.

Comments: This can occur most frequently with bilateral surgery where the recurrent laryngeal nerves are stretched, cut or simply compromised by edema. Central nervous system disease and brainstem compression can also cause bilateral paralysis. A tracheostomy is frequently needed if the patient has stridor and the cords are in the midline position.

4. Presbyphonia

Patient History: A 75 year old gentleman who has had hoarseness for several years but has been increasing over the last year and a half. He has loss of voice projection and breathiness but no shortness of breathHe has no shortness of breath. The second and third pictures are also of older patients who complain of hoarseness.

Physical Findings: In these photographs the incomplete closure is visible in all of the pictures. The vocal cords adduct normally into their midline position, however the cords have bowing that can cause air escape during speech.

Comments: On the presbyphonia this is a condition seen in aging in both male and female patients. It is a benign problem but frequently troublesome for the older patients because they have to use more effort to speak and frequently they cannot speak loudly and the voice is breathy. This occurs secondary to atrophy and can be treated with speech therapy and vocal cord injection.

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