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Paralysis of right vocal cord — Clinical Guidelines

Overview

Unilateral vocal fold paralysis (UVFP) results in glottal insufficiency, leading to voice quality impairment and potential swallowing difficulties. Treatment aims to restore glottal closure and improve vocal function through various modalities including voice therapy and surgical interventions. 3 5 15

Diagnosis

Clinical Presentation: Hoarseness, breathiness, and potential airway compromise.

Diagnostic Tests: Laryngostroboscopy, videolaryngoscopy for visualization of vocal fold movement.

Grading Systems: GIRBAS scale (Grade, Instability, Roughness, Breathiness, Asthenia, Strain) for assessing dysphonia severity. 4 15

Management

First-Line Treatments:

- Voice Therapy: Early intervention recommended, focusing on compensatory strategies and vocal hygiene. 10 13 - Speech Therapy Duration: Consider waiting up to 18 months for spontaneous recovery before surgical intervention. 13

Adjunctive Treatments:

- Medialization Laryngoplasty: Surgical option to improve glottal closure using materials like silicone or fascia. 8 15 - Laryngeal Reinnervation: Alternative surgical approach to preserve vocal fold mobility. 8 - Phonomicrosurgery: In-office procedures gaining popularity for certain voice disorders. 2

Special Populations

Pregnancy: Limited data; conservative management with voice therapy preferred initially. 5

Elderly: Cervical osteophytes can rarely cause UVFP; thorough imaging recommended. 7

Comorbidities: Swallowing dysfunction may coexist; comprehensive assessment including speech and language evaluations necessary. 11

Key Recommendations

Initiate Voice Therapy Early: Early intervention with voice therapy can significantly improve outcomes in patients with UVFP. (Evidence: Moderate 10 13)

Consider Waiting Period Before Surgery: Delay surgical intervention for up to 18 months to allow for potential spontaneous recovery. (Evidence: Expert opinion 13)

Evaluate for Underlying Causes: Comprehensive evaluation including imaging to rule out rare causes like cervical osteophytes. (Evidence: Moderate 7)

Use Combined Approaches: Combine voice therapy with surgical interventions like medialization laryngoplasty for optimal results. (Evidence: Moderate 8 15)

Monitor for Swallowing Issues: Regular assessment for swallowing dysfunction, especially in elderly patients with UVFP. (Evidence: Moderate 11)

References

1 Martín A, De Andrés J, Oishi N, Granell M, Hernández R, Otero M et al.. Is Sedation of Choice in Thyroplasty Surgery? A Study on the Effects of Sedatives on Voice Quality. Journal of voice : official journal of the Voice Foundation 2025. link 2 Haddad R, Mattei A, Blanc W, Michel J, Giovanni A. Impact of the in-office surgical activity on the classical phonomicrosurgical interventions in a laryngology referral center. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2024. link 3 Walton C, Carding P, Conway E, Flanagan K, Blackshaw H. Voice Outcome Measures for Adult Patients With Unilateral Vocal Fold Paralysis: A Systematic Review. The Laryngoscope 2019. link 4 Lovato A, Barillari MR, Giacomelli L, Gamberini L, de Filippis C. Predicting the Outcome of Unilateral Vocal Fold Paralysis: A Multivariate Discriminating Model Including Grade of Dysphonia, Jitter, Shimmer, and Voice Handicap Index-10. The Annals of otology, rhinology, and laryngology 2019. link 5 Walton C, Carding P, Flanagan K. Perspectives on voice treatment for unilateral vocal fold paralysis. Current opinion in otolaryngology & head and neck surgery 2018. link 6 Klein TA, Gaziano JE, Ridley MB. Vocal fold paralysis secondary to phonotrauma. Journal of voice : official journal of the Voice Foundation 2014. link 7 Virk JS, Majithia A, Lingam RK, Singh A. Cervical osteophytes causing vocal fold paralysis: case report and literature review. The Journal of laryngology and otology 2012. link 8 Paniello RC, Edgar JD, Kallogjeri D, Piccirillo JF. Medialization versus reinnervation for unilateral vocal fold paralysis: a multicenter randomized clinical trial. The Laryngoscope 2011. link 9 Shaw GY, Pierce E. Malpractice litigation involving iatrogenic surgical vocal fold paralysis: a closed-claims review with recommendations for prevention and management. The Annals of otology, rhinology, and laryngology 2009. link 10 D'Alatri L, Galla S, Rigante M, Antonelli O, Buldrini S, Marchese MR. Role of early voice therapy in patients affected by unilateral vocal fold paralysis. The Journal of laryngology and otology 2008. link 11 Ollivere B, Duce K, Rowlands G, Harrison P, O'Reilly BJ. Swallowing dysfunction in patients with unilateral vocal fold paralysis: aetiology and outcomes. The Journal of laryngology and otology 2006. link 12 Andrade Filho PA, Rosen CA. Bilateral vocal fold paralysis: an unusual treatment with botulinum toxin. Journal of voice : official journal of the Voice Foundation 2004. link 13 Tsunoda K, Kikkawa YS, Kumada M, Higo R, Tayama N. Hoarseness caused by unilateral vocal fold paralysis: how long should one delay phonosurgery?. Acta oto-laryngologica 2003. link 14 Zeitels SM. The evolution of the assessment and treatment of paralytic dysphonia. Otolaryngologic clinics of North America 2000. link70245-0) 15 Havas T, Lowinger D, Priestley J. Unilateral vocal fold paralysis: causes, options and outcomes. The Australian and New Zealand journal of surgery 1999. link 16 Rosen CA. Complications of phonosurgery: results of a national survey. The Laryngoscope 1998. link 17 Carlson E, Miller D. Aspects of voice quality: display, measurement and therapy. International journal of language & communication disorders 1998. link 18 Dixon-Wood VL, Williams WN, Seagle MB. Team acceptance of specific recommendations for the treatment of VPI as provided by speech pathologists. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 1991. link

Paralysis of right vocal cord