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Vocal Cord Paralysis

Vocal cord paralysis is a voice disorder that occurs when one or both of the vocal cords (or vocal folds) do not open or close properly. Vocal cord paralysis is a common disorder, and symptoms can range from mild to life threatening.

The vocal cords are two elastic bands of muscle tissue located in the larynx (voice box) directly above the trachea (windpipe). The vocal cords produce voice when air held in the lungs is released and passed through the closed vocal cords, causing them to vibrate. When a person is not speaking, the vocal cords remain apart to allow the person to breathe.

Someone who has vocal cord paralysis often has difficulty swallowing and coughing because food or liquids slip into the trachea and lungs. This happens because the paralyzed cord or cords remain open, leaving the airway passage and the lungs unprotected.

What causes vocal cord paralysis?

Vocal cord paralysis may be caused by head trauma, a neurologic insult such as a stroke, a neck injury, lung or thyroid cancer, a tumor pressing on a nerve, or a viral infection. In older people, vocal cord paralysis is a common problem affecting voice production. People with certain neurologic conditions, such as multiple sclerosis or Parkinson's disease, or people who have had a stroke may experience vocal cord paralysis. In many cases, however, the cause is unknown.

What are the symptoms?

People who have vocal cord paralysis experience abnormal voice changes, changes in voice quality, and discomfort from vocal straining. For example, if only one vocal cord is damaged, the voice is usually hoarse or breathy. Changes in voice quality, such as loss of volume or pitch, may also be noticeable. Damage to both vocal cords, although rare, usually causes people to have difficulty breathing because the air passage to the trachea is blocked.

What are the symptoms?

People who have vocal cord paralysis experience abnormal voice changes, changes in voice quality, and discomfort from vocal straining. For example, if only one vocal cord is damaged, the voice is usually hoarse or breathy. Changes in voice quality, such as loss of volume or pitch, may also be noticeable. Damage to both vocal cords, although rare, usually causes people to have difficulty breathing because the air passage to the trachea is blocked.

How is vocal cord paralysis diagnosed?

Vocal cord paralysis is usually diagnosed by an otolaryngologist-a doctor who specializes in ear, nose, and throat disorders. Noting the symptoms the patient has experienced, the otolaryngologist will ask how and when the voice problems started in order to help determine their cause. Next, the otolaryngologist listens carefully to the patient's voice to identify breathiness or harshness. Then, using an endoscope--a tube with a light at the end--the otolaryngologist looks directly into the throat at the vocal cords. A speech-language pathologist may also use an acoustic spectrograph, an instrument that measures voice frequency and clarity, to study the patient's voice and document its strengths and weaknesses.

How is vocal cord paralysis treated?

There are several methods for treating vocal cord paralysis, among them surgery and voice therapy. In some cases, the voice returns without treatment during the first year after damage. For that reason, doctors often delay corrective surgery for at least a year to be sure the voice does not recover spontaneously. During this time, the suggested treatment is usually voice therapy, which may involve exercises to strengthen the vocal cords or improve breath control during speech. Sometimes, a speech-language pathologist must teach patients to talk in different ways. For instance, the therapist might suggest that the patient speak more slowly or consciously open the mouth wider when speaking.

Surgery involves adding bulk to the paralyzed vocal cord or changing its position. To add bulk, an otolaryngologist injects a substance, commonly Teflon, into the paralyzed cord. Other substances currently used are collagen, a structural protein; silicone, a synthetic material; and body fat. The added bulk reduces the space between the vocal cords so the nonparalyzed cord can make closer contact with the paralyzed cord and thus improve the voice.

Sometimes an operation that permanently shifts a paralyzed cord closer to the center of the airway may improve the voice. Again, this operation allows the nonparalyzed cord to make better contact with the paralyzed cord. Adding bulk to the vocal cord or shifting its position can improve both voice and swallowing. After these operations, patients may also undergo voice therapy, which often helps to fine-tune the voice.

Treating people who have two paralyzed vocal cords may involve performing a surgical procedure called a tracheotomy to help breathing. In a tracheotomy, an incision is made in the front of the patient's neck and a breathing tube (tracheotomy tube) is inserted through a hole, called a stoma, into the trachea. Rather than breathing through the nose and mouth, the patient now breathes through the tube. Following surgery, the patient may need therapy with a speech-language pathologist to learn how to care for the breathing tube properly and how to reuse the voice.

RADIESSE Voice is an injectable implant containing synthetic Calcium Hydroxylapatite (CaHA) microspheres, which have a diameter range of 25 to 45 µm, suspended in an aqueous gel carrier. These consistently shaped and sized particles have proven safe and biocompatible while allowing gradual tissue in growth for a long lasting augmentation shown to be effective up to 12-24 months.

RADIESSE® Voice Gel

RADIESSE Voice Gel is an injectable implant containing synthetically derived polymers, and no CaHA microspheres, suitable for 1-2 month, short-term vocal fold augmentation, in patients where reversible nerve damage is suspected, or in patients wishing a short term augmentation before making a decision to have a long term augmentation done with RADIESSE Voice.

The injection volume and location should conform to the following recommendations:

  • The vocal fold injections should be at the level of the vocal process.
  • The depth of the vocal fold injection should be approximately 5-7 mm.
  • The vocal fold injection volume should be done strictly on immediate clinical observation, and approximately 10-15% over correction is recommended.

RADIESSE Voice may be administered by:

  • In-office Trans-Oral Injection
  • In-Office Percutaneous Injection
  • Operating Room Trans-Oral Injection
  • In-office Trans-Oral Injection
  • Topical anesthesia (drip onto larynx)
  • Connect needle (notice alignment of green dot)
  • Prime needle (~0.18 cc dead volume)
  • Note start and end volume to determine volume injected

In-office Percutaneous Injection

  • Transnasal endoscopic guidance
  • Local anesthesia
  • Needle has non-coring “Huber” tip
  • Prime needle
  • Note start and end volume to determine volume injected

Operating Room Trans-Oral Injection

  • Direct laryngoscopy or micro-laryngoscopy
  • Similar to autologeous fat injections but only with a 10-15% over correction

How long will RADIESSE® Voice last?

The gel carrier dissipates over a few months allowing for new tissue infiltration. The CaHA particles gradually break down and are metabolized over several years into calcium and phosphate ions through the body’s own normal metabolic processes. In treatment of vocal fold insufficiency, RADIESSE Voice should provide a correction that lasts 1-2 years. RADIESSE® Voice Gel provides short-term improvement for 1-2 months.

Are there any side effects?

There are few reported side effects and those reported are commonly associated with injection of implant materials. These may include pain and tenderness at the injection site.

Will RADIESSE Voice become hard or noticeable to touch?

No, RADIESSE Voice will remain soft and pliable.

Tracheostomy

A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube.

A tracheostomy may be done if you have:

  • A large object blocking the airway
  • An inherited abnormality of the larynx or trachea
  • Breathed in harmful material such as smoke, steam, or other toxic gases
  • Cancer of the neck, which can affect breathing
  • Breathed in harmful material such as smoke or steam
  • Paralysis of the muscles that affect swallowing
  • Severe neck or mouth injuries

If the tracheostomy is temporary, the tube will eventually be removed. Healing will occur quickly, leaving a minimal scar.

Occasionally a stricture, or tightening, of the trachea may develop, which may affect breathing.

If the tracheostomy tube is permanent, the hole remains open and may require surgical closure when no longer needed.

Most patients require 1 to 3 days to adapt to breathing through a tracheostomy tube. It will take some time to learn how to communicate with others. Initially, it may be impossible for the patient to talk or make sounds.

After training and practice, most patients can learn to talk with a tracheostomy tube. Patients or family members learn how to take care of the tracheostomy during the hospital stay. Home-care service may also be available.

Normal lifestyles are encouraged and most activities can be resumed. When outside, a loose covering (a scarf or other protection) for the tracheostomy stoma (hole) is recommended. Patients must adhere to other safety precautions regarding exposure to water, aerosols, powder, or food particles as well.

Laryngectomy

Laryngectomy is surgery to remove the larynx (voice box) in your throat. All or part of the larynx may be removed in a laryngectomy.

Total laryngectomy is major surgery that is done in the hospital. Before surgery you will receive general anesthesia. This will make you unconscious and unable to feel pain.

In a total laryngectomy, first your surgeon will make an incision (cut) in your neck to open up the area. Important parts of this surgery are:

  • Your surgeon may remove the lymph nodes.

  • Your surgeon may do a tracheoesophageal puncture (TEP). A TEP is a small hole made in your trachea (wind pipe) and esophagus (the tube that moves food from your throat to your stomach). Your surgeon will place a small prosthesis (a man-made part) into this opening. The prosthesis will allow you to speak after your voice box has been removed.

  • Your surgeon will remove your larynx and the tissues around it.

  • Your surgeon will make an opening in your trachea and a hole in front of your neck. Your trachea will be brought up and attached to this hole. The hole is called a stoma. After surgery you will breathe through your stoma. It will never be removed.

  • Your muscles and skin will be closed with stitches or clips. You may have tubes coming from your wound for a while after surgery.

There are many less invasive surgeries to remove part of the larynx.

  • These may work for some people. The surgery you have may depend on how much your cancer has spread and what type of cancer you have.

  • The names of some of these less invasive procedures are endoscopic (or transoral resection), vertical partial laryngectomy, horizontal or supraglottic partial laryngectomy, and supracricoid partial laryngectomy.
Part of your pharynx may be removed in a total laryngectomy. Your pharynx is the tube air moves through from your nose. It connects with your larynx. The surgery takes 5 to 9 hours.

Usually laryngectomy is done to treat cancer of the larynx. It is also done to treat:

  • Severe trauma, such as a gunshot wound or other physical injury.
  • Severe damage to the larynx from radiation treatment. This is called radiation necrosis.

You will have many doctor visits and medical tests before you have surgery. Some of these are:

  • A complete physical exam and blood tests
  • A visit with a speech therapist and a swallowing therapist to prepare for changes after surgery
  • Nutritional counseling
  • Stop-smoking counseling, if you are a smoker and have not quit

Always tell your doctor or nurse:

  • If you are or could be pregnant
  • What drugs you are taking, even drugs, supplements, or herbs you bought without a prescription
  • If you have been drinking a lot of alcohol, more than 1 or 2 drinks a day

During the days before your surgery:

  • You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), clopidogrel (Plavix), warfarin (Coumadin), and any other drugs that make it hard for your blood to clot.
  • Ask your doctor which drugs you should still take on the day of your surgery.

On the day of your surgery:

  • You will be asked not to drink or eat anything after midnight the night before your surgery.
  • Take your drugs your doctor told you to take with a small sip of water.
  • Your doctor or nurse will tell you when to arrive at the hospital.

You will need to stay in the hospital for several days after surgery.

After the procedure, you will be groggy and will not be able to speak. An oxygen mask will be on your stoma. It’s important to keep your head raised, rest a lot, and move your legs from time to time to improve blood flow. Keeping blood moving reduces your risk of getting a blood clot.

You can use warm compresses to reduce pain around your incision. Your nurse will give you pain medicine.

You will receive nutrition through an IV (a tube that goes into a vein) and tube feedings. Tube feedings are given through a tube that goes through your stoma and into your esophagus (swallowing tube).

You may be allowed to swallow food as soon as 2 to 3 days after surgery. But, it is more common to wait 5 to 7 days after your surgery to start eating through your mouth.

Your trachea drain will be removed in 2 to 3 days. You will be taught how to care for your tracheostomy tube and stoma. You will learn how to safely shower or swim. You must be careful not to let water enter through your stoma.

Speech rehabilitation with a speech therapist will help you relearn how to speak.

You will need to avoid heavy lifting or strenuous activity for about 6 weeks. You may slowly resume your normal, light activities.

Follow up with your doctor as often as your doctor says you need to.

Your wounds will take about 2 to 3 weeks to heal. You can expect full recovery in about a month. Many times, removal of the larynx will take out all the cancer or injured material. People learn how to change their lifestyle and live without their voice box.

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