Common Questions about Vocal Fold Paralysis

By David Francis, MD, and Nathan Welham, PhD, CCC-SLP

Learn about diagnosis, treatment, and research of vocal fold paralysis.

Key takeaways
  1. Unilateral vocal fold paralysis often improves spontaneously over the first 6-12 months after the injury.
  2. Many treatments exist, including voice and swallow therapy, injection augmentation, and more permanent operations (e.g., framework surgery, reinnervation, arytenoid procedures).
  3. Decisions about treatment depend on time since injury, the severity of symptoms, and how it is affecting the affected person’s quality of life.

Frequently asked questions about vocal fold paralysis

Can laryngeal EMG confirm diagnosis and guide prognosis?

When the diagnosis is not clear, laryngeal EMG can be helpful to differentiate the cause of the vocal fold immobility and, in some cases, help determine whether vocal fold mobility is likely to return.

Does early injection affect later voice and swallow outcomes?

Early injection augmentation improves voice quality and reduces effort needed to voice. In some cases, it can help with swallowing, but not as consistently as it improves voice. Injection also can improve cough, which is usually weak in the setting of unilateral vocal fold paralysis. This is important for pulmonary toilet (e.g., clearing secretions) particularly when the vocal fold paralysis occurs in the setting of lung disease or neuromuscular disorders.

How soon can I consider framework surgery, arytenoid repositioning, or reinnervation?

These operations are considered permanent “fixes” for the unilateral vocal fold paralysis; thus, we tend to wait between 6 to 12 months before we recommend them. The reason for the delay is that in a majority of cases the injured nerve may recover to some degree, and in many cases, the improvement is sufficient and patients do not require these operations. The mantra is that we do temporary treatments for temporary problems and permanent treatments (like these) for problems that are not going to get better with time.

What voice and swallow measures are most relevant to vocal fold paralysis?

Classically, vocal fold paralysis results in glottal incompetence – reduced laryngeal valving ability due to an impaired ability of the vocal folds to meet at midline. Glottal incompetence manifests as a breathy voice, increased airflow through the larynx, and reduced laryngeal resistance during voicing. Glottal incompetence can also increase the risk of laryngeal penetration and aspiration during swallowing. Voice measures and swallow measures that capture these elements of glottal incompetence (e.g., auditory-perceptual ratings of breathiness, aerodynamic measures of maximum phonation time, mean airflow, and resistance; fluoroscopic and endoscopic assessments of swallow physiology and bolus clearance) are most relevant.

Importantly, vocal fold paralysis has been shown to have a substantial impact on quality-of-life and new tools are being developed to measure this impact. A comprehensive assessment of this disorder should therefore include consideration of quantity-of-life and the patient perspective.

Is there a role for voice therapy?

As vocal fold paralysis is a neuromuscular disorder, it cannot be reversed by voice therapy. Nevertheless, voice therapy often plays an important role in the management of voice difficulties due to paralysis. In some cases, if the paralyzed vocal fold is in an ideal (near-median) position and the patient has mild-to-no perceptual dysphonia and primary issues with endurance and fatigue, voice therapy techniques can be highly effective and medialization may not be needed. In most other cases, voice therapy is indicated as an adjunct to surgical medialization to assist with adjustments in phonatory technique and to manage maladaptive voicing behaviors that may have developed to compensate for glottal incompetence.

Recent vocal fold paralysis research from UW Otolaryngology, Voice and Swallow

Kammer RE, et al. High-resolution manometry and swallow outcomes after vocal fold injection medialization for unilateral vocal fold paralysis/paresis. Head Neck. 2019. [Epub ahead of print] doi: 10.1002/hed.25715.

Francis DO, et al. Life Experience of Patients With Unilateral Vocal Fold Paralysis. JAMA Otolaryngol Head Neck Surg. 2018 May 1;144(5):433-439. doi: 10.1001/jamaoto.2018.0067.

Comprehensive vocal fold paralysis care at UW Health

UW Health’s Laryngology and Voice and Swallow team offers comprehensive, individualized care for adults and children with vocal fold paralysis. Learn more about our world-class clinical program at UW Health.

You can reach the UW Hospital (Adult) Otolaryngology Clinic at (608) 263-6190 and the American Family Children’s Hospital (Pediatric) Otolaryngology Clinic at (608) 263-6420.