AAO-HNSF 2012: Challenging Vocal Fold Paralysis Cases

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October 2012

The session’s panel of experts shared ways they each approach difficult cases, acknowledging that most physicians have their “pet ways” of performing care.

WASHINGTON—A group of vocal fold experts gathered here to talk about patient cases involving vocal fold paralysis and to reflect on what treating those thousands of patients has taught them. Meeting in a session at the 2012 Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, held Sept. 9–12, the experts highlighted a few main points affecting the way they approach cases, approaches that have been shaped over the last several years:

• Changing perceptions on the need for electromyography (EMG), with the test generally not considered necessary except in limited circumstances;
• The use of monitoring during in-office procedures while patients are awake, with most panelists saying they don’t use monitoring but keep it accessible if a patient has difficulty; and
• New preferences for injectable materials, with most of the panel saying their main choice is hyaluronic acid gel, although they don’t consider it to be head and shoulders above many others.

The panelists included moderator Albert Merati, MD, chief of the laryngology service in the department of otolaryngology-head and neck surgery at the University of Washington in Seattle; Joel Blumin, MD, chief of otolaryngology at the Medical College of Wisconsin, Milwaukee; Michael Johns, MD, associate professor of otolaryngology at Atlanta’s Emory University and director of the Emory Voice Center; and C. Blake Simpson, MD, professor and director of the University of Texas Voice Center in San Antonio.

Case 1

The panel first discussed a 41-year-old patient in the Seattle area who had had a thyroid lobectomy four months earlier for disease that turned out to be benign. One day, she woke up breathy and frustrated with the quality of her voice. The original surgeon was confident the nerve had been identified and left unharmed during the lobectomy.

The patient had “clear left vocal fold paralysis,” with some volume loss or atrophy on the left side, Dr. Johns said after watching footage. “This is a patient who has potentially recoverable vocal fold paralysis, provided the nerve was left intact.” But, he added, “I’m not sure it’s going to change the management acutely.” Dr. Blumin agreed, saying it would only matter if the original surgeon actually said the nerve had been severed, in which case you would know recovery is less likely to occur spontaneously. Dr. Simpson added, “If it’s benign disease, they’ll very rarely say they think they cut the nerve or even injured the nerve.”