Usually a hoarse, husky voice results from nothing more troublesome than overzealous cheering at a sporting event—but sometimes it signals a more serious problem called vocal cord paralysis. This condition involves the immobilization of one (or, rarely, both) of the vocal cords, which are bands of muscle tissue in the larynx (voice box). When a reader wrote to ask me about vocal cord paralysis, I contacted Seth M. Cohen, MD, MPH, an assistant professor of otolaryngology–head and neck surgery at the Duke Voice Care Center.
Dr. Cohen explained that normally when a person speaks, the vocal cords close (coming together to touch) and as air from the lungs passes through, the vocal cords vibrate to produce sound. But if there is damage to either of the nerves that control the muscles of the voice box, the vocal cords cannot close properly. These nerves, called recurrent laryngeal nerves, begin in the brain and loop down into the chest on the left and about to the level of the collarbone on the right. Possible causes for nerve damage leading to vocal cord paralysis include viral infection… intubation (being put on a respirator)… various neurological problems… or cancer in the brain, thyroid, lung or other areas. Damage to a recurrent laryngeal nerve also may occur during surgery—for instance, if the nerve is accidentally stretched, cut or otherwise injured as the surgeon operates nearby on the heart, lung, thyroid gland or neck. According to Dr. Cohen, in about 18% to 20% of cases, doctors just don’t know why patients get paralyzed vocal cords.
A hoarse, weak, breathy voice typically is the primary complaint of a person with vocal cord paralysis. Simply talking can be exhausting because the open vocal cords allow too much air to escape the lungs, so the person runs out of breath before he or she can finish a sentence. A patient also may have trouble swallowing because the open vocal cords allow food and drink to get into the windpipe. In addition, it may be difficult to grunt or to cough well enough to clear secretions, Dr. Cohen said. Anyone who experiences such symptoms should see an otolaryngologist (ear, nose and throat specialist). Referrals: American Academy of Otolaryngology–Head and Neck Surgery (www.ENTnet.org).
Depending on the cause, vocal cord paralysis sometimes gets better on its own, but that can take up to a year. In the meantime, symptoms often are greatly improved with a procedure in which the doctor injects collagen or another filler material (such as Cymetra or Gelfoam) through the neck or mouth and into the affected vocal cord. This bulks up the paralyzed vocal cord, effectively pushing it over a bit toward the other vocal cord, allowing the two to touch and improving closure, Dr. Cohen explained. The procedure can be done in the office with topical anesthesia or in an operating room with general anesthesia. There are few if any side effects. Symptoms generally improve within several days. Effects last for two to six months, depending on the filler. By that time, proper nerve function may (or may not) have returned.
A permanent option is to place an implant made of a malleable material behind the vocal cord. The implant acts like a tiny wedge or shim, repositioning the paralyzed vocal cord so that it can make contact with the other vocal cord. This procedure, done in an operating room under local anesthesia, involves making a small incision in the neck. There is usually some swelling for about a week afterward. Maximal improvement in voice and other symptoms develops within a month. Either procedure—injections or an implant—typically would be covered by insurance.
