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Vocal cord paralysis--1979: etiology and management.

Because of the development of reinnervation surgery, approximately 400 patients have been seen by the author with a referral diagnosis of vocal cord paralysis. Because these patients were being entered into a research protocol to evaluate the efficacy of reinnervation surgery, very careful evaluation and records have been kept. Retrospective analysis of these records has permitted an up-to-date evaluation of the epidemiology, natural history, symptoms, signs and presenting complaints, as well as the status of treatment of vocal cord paralysis at the present time. Since this subject has received only limited treatment in the recent literature, it was felt that such an opportunity to evaluate a large personal experience might be a worthwhile addition to current knowledge of the subject.

Gelatin Sponge, Absorbable↗

Facial nerve paralysis secondary to mandibular fracture.

When facial nerve paralysis complicates a mandibular fracture, it may be difficult to locate the point of injury, since the nerve may be injured in the fallopian canal by a secondary temporal bone fracture or in soft tissue by mandibular fragments. Following a review of eight previously reported cases, this paper presents two additional cases, one with bilateral, complete paralyses and the other with a unilateral paresis. In the first, the condyles were driven posteriorly, resulting in bilateral temporal bone fractures, a unilateral external canal stenosis, and a unilateral sensorineural hearing impairment. Good functional return followed decompression of the intratemporal facial nerves. In the second patient, facial function returned spontaneously. When the temporal bone is fractured, therapy follows guidelines for facial paralysis associated with basilar skull fractures from other causes. If soft tissue injury is suspected, the decision must be made whether to explore the nerve or wait for spontaneous recovery.

Adolescent↗

Bilateral vocal cord paralysis following general anesthesia.

A rare case of bilateral vocal cord paralysis after orotracheal intubation and inhalation anesthesia, in surgery not in relation to the neck, is presented. There was no obvious cause for the paralysis and possible etiological factors are discussed. Overextension of the neck during intubation is suspected of being the etiological agent causing stretching of both the vagus nerves. Normal laryngeal function returned after two months.

Adolescent↗

Congenital hypoplasia of the depressor anguli oris muscle in the differential diagnosis of facial paralysis.

Facial paralysis presents an interesting diagnostic challenge. Etiologies ranging from facial nerve neuromas and CPA tumors to inflammatory disease and traumatic injuries need be considered and evaluated. However, an asymmetric facial appearance may result from abnormalities of facial musculature as well as facial innervation. Two cases of congenital hypoplasia of the depressor anguli oris muscle, a child and an adult, are reviewed to examine its presentation and diagnostic differentiation from other forms of facial paralysis. Photographs presenting the facial deformity and electrodiagnostic studies will be reviewed.

Child, Preschool↗

Documentation of upper airway obstruction in unilateral vocal cord paralysis: flow-volume loop studies in 43 subjects.

Upper airway impairment of variable severity occurs in unilateral vocal cord paralysis (UVCP). Among 43 subjects with UVCP all had voice disturbance, 22 had symptoms of airway impairment, and 27 had some disturbance of swallowing. The severity of the airway impairment was evaluated by flow-volume loop spirogram which demonstrated reduced inspiratory flow rates (maximal and midvital capacity). Clinical recovery from paralysis or intracordal Teflon injection was accompanied by improvement in inspiratory flow rates. Airway impairment is most severe in subjects having UVCP due to intrathoracic disorder or intraoperative nerve interruption. Vocal cord position did not correlate with the severity of airway disturbance. The FVC and FEV1 determinations were normal in 33 and 29 cases, respectively, whereas the VI-50 and VE-50/VI-50 were normal in only 11 and 7 instances. This selective restriction of inspiratory flow rates and the abnormally low VE-50/VI-50 ratio was observed regularly. The sensitivity and reproducibility of the flow-volume loop examination support the utilization of this test to evaluate the nature and severity of upper airway impairment; consecutive examinations can be utilized to monitor the clinical course or outcome from treatment.

Adult↗

A simple operation for bilateral vocal cord paralysis.

To reduce the laryngeal obstruction in bilateral vocal cord paralysis, a new method of laterofixation was developed. The method is technically simple and less traumatic than previously published methods. No peroperative tracheostomy is needed. During surgery two needles are inserted through the thyroid cartilage. A nylon thread is passed through the needles and the needles are then withdrawn. The thread thus forms a permanent loop around the vocal cord. The effects of the laterofixation on breathing and on the voice are documented by assessment of upper airway resistance and by two listening panels respectively. Thirteen patients have been operated upon so far. In most cases the breathing was improved and the influence on the voice was moderate and adjustable. If needed the possibility to perform a more extensive surgical procedure still remains. We suggest our method of laterofixation to be the first treatment of choice in patients suffering from bilateral vocal cord paralysis.

Adult↗

True vocal cord paralysis following intubation.

True vocal cord paralysis may follow endotracheal intubation and be the result of peripheral nerve damage. This damage can occur as the result of compressing the nerve between an inflated endotracheal tube cuff and the overlying thyroid cartilage. A series of anatomic dissections defined the likely site of injury to be at the junction of the vocal process of the arytenoid cartilage and the membranous true vocal cord approximately 6 to 10 mm below the level of the cord. Cuff pressures were monitored during anesthetics. Analysis of the results indicated that nitrous oxide diffuses into endotracheal tube cuffs causing a substantial increase in the intracuff pressure. We have concluded that true vocal cord paralysis which follows endotracheal intubation is usually temporary. The solution to the problem lies in its prevention and several methods are described whereby it may be avoided.

Adolescent↗

Fascial pulley: cross-commissure lip reanimation for inferior division facial nerve paralysis.

The risks of causing further harm to the facial nerve are greater in surgery for partial facial paralysis. We present a new active and passive reconstruction technique for paralysis of the buccal-mandibular divisions of the facial nerve. Our fascial pulley technique of reanimation and suspension of the oral commissure produces no further injury to the facial nerve and the eyelids. In addition, it adds a better technique to the armamentarium of the reconstructive surgeon dealing with partial lower facial nerve paralyses.

Facial Muscles↗

Central vocal cord paralysis and paresis presenting as laryngeal stridor in children.

Vocal cord paralysis or paresis as the initial presenting symptom for intracranial tumors in children are rare. Recently, two pediatric patients who were later diagnosed as having intracranial tumors presented with the symptom of voice changes and stridor. Telescopic examination revealed bilateral vocal cord paresis and paralysis as demonstrated by video recordings. The majority of pediatric brain tumors present with both generalized and localized complaints; however, by discussing these two rare cases, we hope to underscore the importance of a thorough workup of the paralyzed or paretic vocal cords.

Brain Neoplasms↗

Vocal cord paralysis resulting from neck injections in the intravenous drug use population.

Intravenous drug use patients present to the head and neck surgeon when injections are directed "in the pocket," or more appropriately, toward the internal jugular vein in the neck. The more common complications of this practice include the development of cellulitis, abscess, and venous thrombophlebitis and, potentially, pulmonary embolism and pseudoaneurysm of the carotid and subclavian arteries. Vocal cord paralysis as a result of neck injection in the intravenous drug-using population is rarely described, and a review of the literature has yielded only two reports addressing this uncommon phenomenon. During a 7 1/2-year period between October 1981 and June 1989, nine patients presented to Detroit Medical Center with hoarseness, upper-airway obstruction, or both following the injection of heroin or related substances into the neck. Otolaryngologic evaluation demonstrated unilateral or bilateral vocal cord paralysis coincident with recent neck injections. The clinical signs and symptoms, location of the injections, acute management, and subsequent complications are catalogued. Acute management of these patients consisted of airway assurance via tracheotomies when indicated and observation for the development of cellulitis, abscess, or more life-threatening neurovascular complications. Follow-up laryngeal examinations ranged from 4 months to 4 1/2 years and found no demonstrable return of vocal cord function in any of the nine patients.

Administration, Cutaneous↗

Long-term results with a simple surgical treatment of bilateral vocal cord paralysis.

Since 1979, we have treated patients suffering from bilateral vocal cord paralysis with laterofixation of one vocal cord, a simple and comparatively atraumatic method. To evaluate the long-term results of this method of laterofixation, 11 consecutive patients were examined at least 5 years postoperatively regarding breathing capacity, voice function, and swallowing ability. Breathing capacity was assessed by determination of orolaryngeal (upper) airway resistance and spirometry. Voice function was judged by two listening panels. Swallowing ability was studied by barium contrast radiography. Postoperative improvement of breathing capacity was, in most cases, found to be long lasting. Furthermore, there was no deterioration of voice function, nor were there aspiration problems during the postoperative follow-up period. We suggest this method of laterofixation as the treatment of choice in patients suffering from breathing difficulties due to bilateral vocal cord paralysis.

Aged↗

Surgical therapy of the eyelids in patients with facial paralysis.

Patients with facial paralysis have a degree of lagophthalmos and paralytic ectropion. We present our experience in the surgical management of 25 consecutive patients treated for these problems. Paralytic lagophthalmos was corrected using gold weights inserted into the upper eyelid. The advantages and disadvantages of this surgical technique are reviewed. Medial canthoplasty and lateral canthoplasty were performed to rectify paralytic ectropion. Ancillary procedures included browpexy, upper-lid blepharoplasty, and temporalis sling. The results were excellent in 23 of 25 patients and good in the remaining two. After a minimum of 6 months' follow-up, there were no complications. The authors believe that the above procedures will yield consistently excellent cosmetic and functional results in patients with paralysis of the eyelids.

Cranial Nerve Neoplasms↗

Vocal evaluation of thyroplastic surgery in the treatment of unilateral vocal fold paralysis.

Vocal function was assessed in 15 patients who received thyroplasty type I for the rehabilitation of unilateral vocal fold paralysis. The function was assessed by perceptual evaluation, voice intensity and frequency range profiles, and questionnaire. Goals of the study were to evaluate the efficacy of thyroplasty in improving the voice, to compare postoperative thyroplasty voices to normal voices, and to correlate objective measurements to the results of the questionnaire regarding satisfaction with the voice. Perceptual evaluations were performed by randomizing normal and thyroplasty voices on a recording tape. The voices on the tape were then rated by independent, blinded, trained listeners. The perceptual qualities of pitch, intonation, and loudness were not statistically different than normals; however, voice qualities of strain, breathiness, hoarseness, harshness, and unsteadiness were different than normals. Mean frequency range and mean intensity range were moderately to severely reduced from normals with a wide variation being present in the results. The correlation between the higher threshold phonation pressures and decreased intensity ranges found in some patients is discussed. Questionnaire results indicated that a high degree of satisfaction with the surgery was present (92%). Extreme or general satisfaction with voice was present in 73%. The most difficult voicing was experienced at work, with 25% needing to adjust their employment to accommodate their voice abilities. These results indicate that thyroplasty type I is effective in partially rehabilitating unilateral voice fold paralysis. Voice function is still not normal, probably in part due to the underlying disease.

Adolescent↗

Ultrasonography for the diagnosis of Lyme disease in cases of acute facial paralysis.

Ultrasonography of the parotid gland was introduced in 1989 as part of the diagnostic protocol of every patient treated in our clinics with acute facial paralysis. Ten of 50 patients so tested were found to have unilateral nonpalpable enlarged lymph nodes in the caudal portion of the parotid gland around the stylomastoid foramen. All 10 patients were eventually diagnosed as having Lyme disease. It is suggested that in patients with acute facial paralysis, ultrasonography is an inexpensive tool to improve diagnosis of Lyme disease and may have a more useful purpose in monitoring therapy.

Acute Disease↗

The study of vocal fold vibratory patterns in patients with unilateral vocal fold paralysis before and after type I thyroplasty with or without arytenoid adduction.

Type I thyroplasty and arytenoid adduction have been used for the treatment of symptomatic unilateral vocal fold paralysis since the mid-1970s. To this date, the vibratory patterns of the vocal folds in patients with unilateral vocal fold paralysis undergoing thyroplasty have not been studied in depth. Abnormal vibration of the vocal fold mucosa often contributes to voice problems in persons diagnosed with vocal diseases or disorders. The preoperative and postoperative videostroboscopic vibratory patterns including mucosal wave, amplitude, glottic closure, and symmetry were studied in 12 patients who underwent unilateral type I thyroplasty separately or in combination with an arytenoid adduction. The observed changes and clinical implications are discussed.

Adult↗

Factors affecting induction of neurological disorders in mice by paralysis-inducing Friend-related PVC viruses.

Our previous studies showed that the passage of the Friend virus complex through rats generated variant MuLVs, designated PVC111, PVC211, PVC321 and PVC441, that induced neurological disorders associated with tremor and paralysis. In this study, we tested the pathogenicity of four different PVC viruses in mice. Although histopathological studies revealed spongiform degeneration in the spinal cords of NFS mice infected with each PVC virus, only PVC441 frequently induced tremor and paralysis. After a long latency, all of these viruses induced leukemia associated with severe anemia. Further studies with PVC441 revealed dose- and age-dependence for tremor induction. In contrast to NFS mice, BALB/c, DBA/2 and C57BL/6 mice infected with PVC441 virus showed no neurological symptoms, although the virus could be isolated from the tissues of central nervous system. Despite the absence of neurological symptoms, a high degree of neuronal degeneration in the lumbar spinal cord was found in PVC441-infected BALB/c mice. A low degree of neuronal degeneration was found in PVC441-infected DBA/2 or C57BL/6 mice. Genetic crosses of these resistant mice with susceptible NFS mice indicated that resistance to tremor induction by PVC441 was dominant in all mouse strains and suggested that various host genes may control the susceptibility of mice to tremor induction by PVC441 virus.

Animals↗

Levator scapulae and rhomboid transfer for paralysis of trapezius. The Eden-Lange procedure.

Spinal accessory nerve palsy leads to painful disability of the shoulder, carrying an uncertain prognosis. We reviewed the long-term outcome in 16 patients who were treated for pain, weakness of active elevation and asymmetry of the shoulder and the neck due to chronic paralysis of the trapezius muscle, as a result of nerve palsy. Of four patients who were treated conservatively, none regained satisfactory function, although two became pain-free. The other 12 patients were treated operatively with transfer of the levator scapulae to the acromion and the rhomboid muscles to the infraspinatus fossa (the Eden-Lange procedure). At a mean follow-up of 32 years, the clinical outcome of the operatively treated patients was excellent in nine, fair in two, and poor in one patient, as determined by the Constant score. Pain was adequately relieved in 11 and overhead function was restored in nine patients. Pre-operative electromyography had been carried out in four patients. In two, who eventually had a poor outcome, a concomitant long thoracic and dorsal scapular nerve lesion had been present. The Eden-Lange procedure gives very satisfactory long-term results for the treatment of isolated paralysis of trapezius. In the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function.

Accessory Nerve Injuries↗

The flow-volume loop in bilateral vocal cord paralysis.

A 38-year-old man with posttraumatic bilateral vocal cord paralysis and a surgically repaired avulsion of the extrathoracic trachea presented with a slight increase of exertional dyspnea (grade 2). Spirometry showed high normal FEV1 for FVC variables, but the F-V loop was characteristic for highly variable UAO with an increased FEV1/PEF ratio of 11 ml/L/min as well as a MEF50/MIF50 of 4.55. Endoscopy during forced respiration showed near total inspiratory obstruction of the larynx due to paradoxical behavior of the vocal cords. In extrathoracic airway obstruction a FEV1/PEF ratio > 10 ml/L/min combined with a MEF50/MIF50 ratio > 4 is suggestive of variable UAO caused by bilateral vocal cord paralysis rather than by a tracheal lesion.

Adult↗