Podcast Transcript: Evaluation & Management of Bilateral Vocal Fold Paralysis

[Dr. Gopi Shah]
Should we jump into our topic today? Before we get into it, actually, this might be a very basic question, but when you'd introduced the topics, Steve, you switched it from bilateral vocal cord paralysis to bilateral vocal fold paralysis. Is there a nuance in that? Can we get into that a little bit?

[Dr. James Daniero]
Sure. When we think about the vocal cords, that's the common parlance we discuss, but really it's a three-dimensional structure. I'm coming from our voice center here and we were just teaching our voice course and going through the three-dimensional anatomy of the vocal folds and describing why it is a fold rather than a cord. It's a three-dimensional structure from the top down view.

We only see it as like a little strip of tissue, but there is some height to it, and that's really important for restoring voice and for restoring proper function of airway as well. Knowing that it is that fold of tissue is really important in talking about any reconstructive options rather than just like a vibrating rubber band that's there in the larynx.

[Dr. Stephen Schoeff]
I think moving into the discussion, when we talk about bilateral vocal fold paralysis, really that's almost a subset of bilateral immobility, particularly in adult patients. Gopi and I were just talking a little bit about the pediatric versus adult components of this, too, beforehand. What's the general presentation that you're experiencing, and what is the breathing like in a patient who's presenting? We can even start with bilateral immobility, and then narrowing into paralysis from there.

[Dr. James Daniero]
Immobility is more of a broader term that includes iatrogenic injury or immobility that is fixation of the vocal folds, not necessarily paralysis. They're commonly used in replace of each other where they just are a misnomer of what actually is happening. We'll see a lot of times-- and our coding, unfortunately, is also off on this. We don't really have a great code for immobility. The best code is the paralysis, bilateral paralysis code to show that the vocal folds are immobile and to come up with our connections with our CPT codes. Unfortunately, we're forced to use that misnomer as well.

Immobility, typically, will refer to either we don't know what the cause is, or we know the cause is not a neurogenic cause. That would be fixation from ankylosis that could be autoimmune, rheumatoid arthritis, ankylosing spondylitis. Sometimes we'll see fixation of the cricoarytenoid joints, and they stop moving, but it's not because the nerve's injured. It's a local mechanical problem rather than a neurogenic.

Then more commonly, what the situation is, is acute laryngeal injury that is healed poorly and caused ankylosis of the cricoarytenoid joint or fixation of the vocal folds by scarring them together. In that case, it's not paralysis, but the immobility shows up and the history is really the differentiator there. There is some sort of intubation or some sort of trauma.

Then the time course is pretty predictable. It's four to six weeks out from that injury, and then you see this fibrotic state setting in as the wound healing progresses. Then they show up with stridor. There become progressively shorter breath and respiratory distress. Hopefully, they seek care of the emergency department or get into an ENT clinic quickly because that diagnosis typically has to be made by a laryngoscopy. Then unfortunately, often, a quick transition to a suitable airway, which is generally tracheotomy.

One more distinction is, in those patients, intubation is a really difficult and dangerous situation. In patients that are paralysis or they have a neurogenic injury, typically, intubation is a little bit easier in those cases because the vocal folds will push out of the way. On presentation for immobility with the ankylosis, with the fibrotic joint, those vocal folds will not separate with intubation and can be really dangerous to approach intubation even fiber-optically. Therefore, those patients typically have to have a tracheotomy placed under an awake, under local anesthesia.

Bilateral Paralysis: Etiology & Patient Presentation

[Dr. Gopi Shah]
For the neurogenic patients, when we think of paralysis, we're thinking about stroke, we're thinking about-- what are some of the other etiologies that come to mind? Are our thyroid patients with that? Is that this group as well, or is that the iatrogenic group?

[Dr. James Daniero]
The bilateral neurogenic injury of the paralysis patients, true paralysis, are often post-surgical. Total thyroidectomy, injury on both sides, or a second side surgery, unfortunately, that has an additional injury, and the anterior cervical spine surgeries. Sometimes even just approaching the spine on one side, there's enough stretch from retractors that both sides can be injured. It's pretty rare, but I have seen a few patients that have had bilateral injury from a unilateral spine approach. Pretty devastating complication, too.

[Dr. Gopi Shah]
Those symptoms are going to present quickly, like in PACU?

[Dr. James Daniero]
Most of the time, it is near immediate. You'll notice some noisy breathing, the stridor, shortness of breath. Sometimes it's almost immediate after extubation, and then there's concern for needing to re-intubate. Fortunately, in thyroid surgery, we're actually monitoring nerves frequently now, and we can have some expectation that this might be a problem as we extubate with losing some signal response on the EMG tubes.

In spine surgery, we are often not monitoring at the level of the vocal folds. They're monitoring other nerves typically, and cranial nerves, but may or may not be monitoring the recurrent laryngeal nerve. The only other thing I'd say, I've seen a few from bilateral injury from, unfortunately, strangulation and/or attempted suicide.

In those cases, I've seen that it may not show up immediately that there is some delayed presentation of edema. Maybe there's a neurogenic injury where the vocal folds are in a more lateralized position. Over time, they begin to medialize and obstruct. They may actually present with some breathy hoarseness first, and then slowly, over time, begin to have a worsening shortness of breath from that source.

[Dr. Stephen Schoeff]
I think, obviously, you hit on one of the things that we often have a sense of what's going on in bilateral vocal fold paralysis, in that there may have been an immediate postoperative consultation or something to that effect where we have a pretty good idea of what's going on. Although I've had one or two sneak in in situations where it wasn't obvious, maybe sequential injury, pulmonary thoracic surgery.

What's your approach when you're in this, oftentimes, semi-acute, particularly if you were consulted right away in this patient, although oftentimes, we are getting the patient maybe later in the course to evaluate them? What's your assessment and acuity in how we proceed in stabilizing the airway in this semi-urgent or urgent or maybe even office setting if we're lucky?

[Dr. James Daniero]
It's interesting. A lot of times, as they're coming in, we'll be fooled a little bit, or meaning, the surgeon that is referring in may refer for dysphagia or a little bit of shortness of breath and not be as convinced that there could be bilateral paralysis. They usually have a normal voice.

One of the telltale signs often of paralysis unilateral is the hoarse voice. I think people get lulled into a false sense of security in saying, "Oh, no, the voice is fine. It can't be the cords that are paralyzed, and maybe something else is gone. Maybe it's pulmonary and they're getting nebulizers and different things to treat their shortness of breath," and really, that deep inspiratory breath through the mouth. I usually have my patients demonstrate that for me.

Sometimes you can mask the symptoms, mask the stridor by breathing slowly in through the nose and getting some air through the cords that are very closed without making a lot of noise. People particularly try to compensate and slow the amount of airflow through the larynx to decrease that stridor. What I have them do is I'm like, "Take a real deep breath in through your mouth wide open, and I want to hear what that sounds like." Usually that's going to be the loudest reproduction of stridor as a pretty good indicator that we have at least the vocal folds close together.

It's a little bit different than the stridor we get with subglottic stenosis, like what you talked about previously, Dr. Schoeff. With subglottic stenosis, it's an airway turbulence type of sound. You'll hear some noisy airflow, but in bilateral paralysis, it's a musical quality to it. The vocal folds are actually, they're making voice as you're breathing in, and we call it inhalation phonation. It's a backwards way of making voice. Instead of airflow out, it's airflow in with the vocal folds closed. That musical stridor is a way I like to describe that's really very specific for bilateral paralysis.

[Dr. Gopi Shah]
I nod because babies with idiopathic, for example, bilateral vocal cord paralysis have that very similar. Their voices, you hear it. When they cry, it's a nice strong, but when they're crying and they're breathing, that stridor, it has a separate different sound than the laryngomalacia babies. It does have a musical sound when you describe it that way. I'm like, "Oh," because they sound different.

Do these patients, some would you say are commonly in you all's clinic then like four to six, or is it usually in the acute setting, or how often do you see them in the ER, PACU, or in your clinic?

[Dr. James Daniero]
It varies a good amount. I think it's not one presentation or the other. There's certainly post-surgical consultations we get that are right from PACU. Typically, that's our surgeons in house. Then the folks that are referred in, they either have hopefully already have a secured airway and they're coming from another institution where they've had some difficulty. They consult ENT at their place. They don't have the means of any advanced techniques for treating bilateral vocal fold paralysis.

They're going to resort to a tracheotomy, secure the airway, and refer at that point, which I think is totally appropriate. Occasionally, we'll get somebody that comes in and they don't see an otolaryngologist. They aren't scoped. They don't know what's going on and they're sent for an evaluation. They come in and stridor and respiratory distress. Those patients we end up taking to the OR probably that day. We don't let the sun set on any bilateral vocal fold paralysis with respiratory distress.

[Dr. Stephen Schoeff]
It's interesting for me being outside hospital at this point, I sometimes get these presentations without a stable airway. In the clinic, I've actually had a couple now from either PGS or bilateral vocal fold paralysis that have shown up with non-distressed, but not happy.

It creates a really interesting dynamic in how we evaluate this and the idea of trach and send on to the university, which is always, I think, a really safe and good option versus the different options we'll talk about in terms of airway management. It's a very interesting dynamic a little bit being outside the university setting and seeing these as well.

Outpatient Evaluation & Management