AAO-HNSF 2012: Challenging Vocal Fold Paralysis Cases

Dr. Blumin said he wouldn’t be likely to order EMG because it wouldn’t change the management: “She’s still four months [out] so there’s still a potential for spontaneous recovery.”

Dr. Johns said he used to do more diagnostic EMGs in cases like this, but he does fewer now. “It’s not a perfect test,” he said. Within the first two or three months of paralysis, an EMG wouldn’t change management, he added, and after about six months, recovery is not likely anyway. It’s that in-between period where an EMG may be valuable. “There’s that sweet spot in the two- to six-month period where maybe if there were unfavorable prognostic signs on a laryngeal EMG, we might consider early intervention with laryngeal framework surgery,” he said. But he said he’s stopped doing that—for the most part, anyway—because of recent studies showing that using a temporary injectable material leads to durable voice results in two-thirds of patients, regardless of recovery status.

Dr. Merati agreed. “An EMG may be helpful,” he said, “but just the act of relatively early injection laryngoplasty or medialization may reduce the rate of requiring permanent medialization later. I think that’s been a big change, particularly over the last couple years. I wonder if we’re all just sensitive now, just seeing the papers.” (Laryngoscope. 2010;120(11):2237-2240; Laryngoscope. 2012;122(10):2227-2233).

Dr. Johns said he would order a detailed voice assessment because that would be key in deciding whether to intervene at all. Dr. Simpson added: “I think it matters a lot what they do for a living,” and he’s more likely to intervene with a patient whose job involves using his voice a lot. He also cautioned against focusing too much on one vocal fold, because there could be subtle paresis on the other side, too. “That’s a mistake that I continue to learn from,” he said.

Dr. Blumin said that if the patient wanted treatment, he would see the patient with a speech pathologist, then come up with options. “This patient may do well with voice therapy alone,” he said.

Laryngoplasty

When doing an injection larygnoplasty—if that’s the course eventually taken—the panel said that, by and large, they perform the procedure without monitors. “In terms of precision of injection and fewer complications associated with the injection, there is decent evidence that doing these injections under general anesthesia, where you’ve got fine control, is more precise with fewer complications,” Dr. Johns said. “That being said, the complications of doing these awake is extremely low as well, about 5 percent.”