Ivoicet – Elpida Koutsoumpaki

Voice therapy for vocal fold paralysis

Voice rehabilitation after unilateral or bilateral vocal fold paralysis is a real challenge with which I have specialized over the past 25 years.

The first and foremost is for each patient to understand that there are options for voice recovery! You are not stuck with a terminal diagnosis!!!!             Waiting for time to pass is just one of your options and, in my experience, not often the ideal option!!! So, please read on!!

Other options involve medical and surgical intervention, voice therapy, voice physiotherapy, psychotherapy, manual therapy or any combination of these. Ideally, all the specialists will be collaborating as members of an interdisciplinary team. All members of the team jointly decide on the optimal intervention plan for each individual case, carefully considering each of numerous factors that impact on such a decision.  A multidisciplinary diagnosis, early intervention, frequent re-evaluation and the patient’s dynamic involvement with the process of planning and implementing the intervention plan are critical for the success of every intervention program.

Over the past decade we have experienced a dramatic increase in the number of vocal fold paralysis patients that we see with my interdisciplinary team in Athens, Greece. Most are subsequent to total thyroidectomy with a significantly smaller proportion arising from heart or lung surgery, viral infection or idiopathic aetiology.

Vocal fold paralysis is the result of trauma to the recurrent laryngeal nerve that innervates critical muscles responsible for efficient voicing. The trauma is considered permanent after a period of at least 18-24 months post trauma. Prior to this period, the condition is termed a “paresis”. During this valuable 18 month period expectations run high as we wait in the hope for automatic recovery of the traumatized nerve.

Unfortunately, there are no definable indicators for who will be lucky to have the nerve recover and who will have to deal with permanent damage. For this reason, it is important to patiently hang on until the diagnosis can be confirmed by the ENT specialist. International scientific references confirm that 12-18 months is the minimal time period for waiting before considering a nerve permanently paralyzed.

It is during this waiting period that Voice Therapy can be extremely beneficial, irrespective of whether or not the nerve recovers!! The sooner the patient follows a specialized voice therapy program, the easier voice recovery will be either partial, or more frequently,  total recovery!!

Voice Therapy will NOT assist the recovery of the nerve.  

Voice therapy WILL assist recovery of the voice, irrespective of the nerve’s course. 

How? Voice is produced with a very complex mechanism that is not completely damaged by trauma to the recurrent laryngeal nerve. The larynx and voice mechanism have many capabilities that can be retrained such that voice is produced by reshaping those parts of the mechanism that have not incurred damage. In other words, even with a permanently damaged nerve and one or both vocal folds paralyzed, it is absolutely possible to learn how to produce a perfectly normal and functional voice as well as normal breathing, as if nothing ever happened to the nerve!! Please view the videos of patients who recovered voice after both unilateral and bilateral vocal fold paralysis.

With respect to waiting out the 12-24 month period before any intervention is decided on, my experience is that this is really NOT a good idea!  The voice mechanism is a system of multiple muscle groups that work together in a sensitively coordinated manner, much like a finely tuned orchestra expertly playing the most complex musical composition.  Like any muscular system, non use or immobility results in loss of coordination at the least, or muscle atrophy at the most. In either case, the fine tuning of this very complex mechanism is significantly distressed the more it is not used. Additionally, the more someone waits, the easier it becomes for negative movement patterns to turn into bad habits that create a vicious cycle of vocal hyperfunction and eventually lead to increasing difficulty with voice production.  This is why for patients who have waited with vocal fold paralysis for 1,2,7 or even more years,  vocal rehabilitation is considerably more difficult than when a patient comes soon after the trauma to the nerve. The patients who have had recent damage have not had time to develop ineffective voicing habits that voice therapy would then need to reverse.

Voice therapy aims are:

  • avoidance of further surgical intervention for voice and breathing rehabilitation
  • voice recovery so that is is clear, loud and comfortable to produce
  • breathing is comfortable, efficient and natural

Unilateral vocal fold paralysis

Voice Therapy intervention with the IVT approach aims for total voice rehabilitation.

  • Success rates are very high. At an average of 8-12 therapy sessions there is a recovery rate for 80-90% of cases with unilateral vocal fold paralysis and voice returns to comfortable and lour voicing with a comfortable and natural breathing pattern.
  • Even for the cases where for various reasons, organic and/or psychoemotional, we can not achieve a complete voice rehabilitation,  there is a notable improvement with both ease of voicing as well as a more comfortable breathing coordination so that the patient no longer feels out of breath.
  • Referrals to other relevant specialists is frequently necessary due to the multilayered difficulties related to vocal fold paralysis. Voice physiotherapy has been the specialization which I have found most valuable for assisting the efficacy of the voice therapy techniques.
  • Not all cases are success stories and there are cases when re-evaluation of our progress may lead us in a different direction.

Bilateral vocal fold paralysis

Voice and breathing rehabilitation for cases of bilateral vocal fold paralysis is a great challenge for both the patient and the therapist.  For patients, the prevalent distressing symptoms involve the feeling of an inadequate breath supply while, depending on the position of the paralyzed vocal folds, quality of voice is also impaired to a greater or lesser degree.

To my knowledge, there is no evidence based research to guide clinical voice therapy techniques for rehabilitating this particular group of patients. However, as the numbers of cases that came to my clinic with these complaints started increasing over the past decade, my team and I decided we needed to come up with some sort of strategy to help out. Over the years, we persevered and have arrived at a strategy that has offered impressive results for a significant proportion of our patients. This clinical based evidence is what we have to offer, for now, to the scientific community.

Let’s take it from the top and once again acknowledge the importance of the 18-24 month waiting period before the ENT can definitively diagnose a permanent paralysis. If the neurological trauma is permanent, depending on the degree of breathing and voicing difficulties, the ENT Surgeon and the multidisciplinary team can assist the patient with consideration of the options for improvement of breathing and voicing.

Technological advances are moving closer towards being able to offer permanent solutions.  Laryngeal pacemakers are developing and have offered impressive results in certain cases.

                                                                    

The aim of the laryngeal pacemaker, in simplified terms, is to direct an electrical impulse to the vocal fold(s) so that it is drawn open for inspiration and closes for expiration and speech, resulting in manageable breath and voice. I believe there are specific prerequisites for a patient to be considered for a laryngeal pacemaker.

There are also various surgical options for achieving improved airway patency. However, depending on particular surgical details there is a significant chance that, although airway patency can successfully be achieved, in certain cases the voice deteriorates significantly. Happily, there are also numerous cases where surgical intervention improves airway patency while also maintaining excellent voicing. Is is my understanding that the success of the surgical intervention depends on a number of critical factors including the experience and skill of the ENT surgeon, the strategy and surgical technique that will be used as well as person-specific prerequisites. For patients considering surgical intervention, I would recommend discussing all the relevant details with your ENT surgeon so that you are in knowledge of all the pros and cons of the procedure and in a position to make an informed decision.

The role of specialized voice therapy intervention can be significant both during this 18-14 month waiting period and after.  Even for those cases who have undergone surgical procedures for achieving airway patency but to the detriment of their voice (which is frequently reduced to little more than a whisper), specialized Voice Therapy might offer at least some assistance, despite critical difficulties that may hamper marked improvement of the voice. 

For those cases waiting out the 18-24 month period, Voice Therapy intervention can offer remarkably good results.

Voice Therapy Aims

  • Balancing breathing and maintaining breath adequacy and duration
  • Attaining functional voicing by capitalizing on supralaryngeal structures that develop vocal intensity and breath-phonation coordination
  • Functional loudness. In many cases, loudness reaches normalcy, for others loudness is adequate for daily activities but not loud enough for open spaces
  • Safe swallowing of liquids and solids in one of the priorities for Voice Therapy.

Successful voice rehabilitation depends on a number of individual variables. Unfortunately I have been unable to detect definitive positive prognostic criteria that cover all cases. In my clinical experience each individual is a unique case. Each and every time I find myself calling upon all of my clinical skills and experience and I literally experiment with various options until I find the combination of techniques that render the result I am after at each stage of the therapy program. There have been many many cases where results have been impressive for both voice and breathing comfort / adequacy.  There are unfortunately also those cases where I was unable to create significant results.

Voice Therapy Duration

There has been tremendous variation in the number of sessions needed until we reach success and, of course, not all cases are success stories. I have seen patients with unilateral vocal fold paralysis where super results were achieved in 1 single one hour session, while for others we needed anything between 5-20 sessions.  For bilateral vocal fold paralysis, sessions usually amount to approximately 20 though I have had excellent results in just 6 sessions.  I commonly see my cases on a once weekly basis but I have also worked with people from afar and we squeezed in 2 or 3 sessions per week, but this is pertinent only under very specific circumstances.  

A detailed home exercise program is given after each session which needs to be followed strictly. I have found that the more intensively a person follows the exercise program , the faster the results.

Do watch the videos that show some excellent examples of voice therapy intervention with before and after voices, albeit most of it in Greek. Nonetheless, you get the idea!!!