Paralytic Dysphonia

Dr. Morton Cooper reports outstanding results from using Direct Voice Rehabilitation (DVR) with Unilateral Cord Paralysis. Covering over 100 cases between 1961 and 2005, his success ratio is excellent (90%+).

Dr. Cooper’s success and cures of this condition were detailed in his textbook Modern Techniques of Vocal Rehabilitation in 1973. From that time on, Dr. Cooper reports faster results because of discoveries he has made with locating the right pitch of voice, the right placement of voice, the better way to breathe right for speaking, and focusing in on the voice image and voice identity, which he finds are all key to successful voice rehabilitation.

​Direct Vocal Rehabilitation alone or in combination with surgical intervention for unilateral or bilateral paralytic dysphonia can restore the impaired speaking voice in many dysphonic patients.

In two peer-reviewed medical journals, Dr. Cooper reported 4 cures and four 90%-recoveries by using Direct Voice Rehabilitation with unilateral cord paralysis. For the 18 patients completing therapy, the results were “excellent” in 14 patients and “good” in 4 patients. (“Rehabilitation of Paralytic Dysphonia,” Eye, Ear, Nose and Throat Monthly, 49 [December 1970], 532-535, and “Rehabilitation of Paralytic Dysphonia,” California Medicine, 112 [January 1970], 18-20.)

Overview of Paralytic Dysphonia

Paralytic dysphonia has been discussed by various authors. Intracordal injection for this condition has been reviewed by Lewy (1966), Toomey and Brown (1967), Boedts, Roels, and Kluyskens (1967), and Rubin (1965a, 1965b, and 1967). Voice rehabilitation has been presented by Froeschels (1944), Froeschels, Kastein, and Weiss (1955), Weiss (1968) and Cooper (1970a and 1970m).

Beginning in 1955, Arnold has written a series of articles covering all aspects of paralytic dysphonia, including description of the paralysis (1962a), voice rehabilitation (1962b), and intracordal injection (1962c, 1963a). According to Moses (1940), following a thyroidectomy 3 percent of all patients have voice problems which are due to a lesions of the recurrent laryngeal nerve.

Curnut and Pierucci (1968) recommend voice retraining in paralytic dysphonia regardless of the prognosis, since they feel it always brings either objective or subjective improvement.

In regarding the types of therapy, Weiss comments:

In therapy we only ask whether it works. Scientific explanations change anyway with the further development of our basic knowledge, but [therapeutic] factors remain. (1968, p.383)

The Froeschels approach to this condition, namely that of forceful closure of the vocal folds, is appropriate in the initial stage of therapy when the paralyzed vocal fold is in the paramedian or in the cadaveric position.

Weiss agrees:

The pushing approach in the treatment of cases of the paralysis of the recurrent nerve has proven to have the most important earmark of any therapy: It works. (1968,p. 383)

Treatments for Paralytic Dysphonia

Whether the paralytic dysphonia is post surgical, viral, or idiopathic in etiology, a good to excellent prognosis in voice rehabilitation may be generally forecast for the condition if the paralyzed vocal fold is in the median or paramedian position.

Voice rehabilitation may play a major role in the resolution of the disorder whether the therapy is administered alone or in conjunction with a surgical procedure, such as an injection of Teflon or silicone into the paralyzed vocal fold. Voice rehabilitation alone is appropriate when the paralyzed vocal cord is in the mid-line or median position.

When the cord is in the median position, effortful closure of the cord is inappropriate. The median paralysis of the vocal fold does not interfere with the location and identification of the optimal pitch level by the competent voice therapist. The pitch level is almost invariably too low and needs to be raised in order to reach the optimal pitch level

Once the optimal pitch level is located, balanced oral and nasal resonance needs to be sought, if it has not already been established with the location of the optimal pitch level. The supraoptimal pitch level may be used first briefly. When the patient can maintain the supraoptimal pitch level, this pitch level is dropped to the optimal pitch level.

When the paralysis occurs in the paramedian position, the basic approach is, as has been noted, a forceful closure of the cords by emphatic volume starting from the upper range of the voice and extending down to the basal or near basal pitch level. The reverse procedure, for the bottom to the top, may also be used.

Therapeutic Measures

The vowels /o/ and /i/ prove extremely effective in effecting closure of the cords with volume. The following therapeutic measures may be considered as an outline.

  1. Begin with /o/ prolonging each utterance of the /o/ for a few seconds at the optimal or supraoptimal pitch level. Then proceed to “/o/-one, /o/-two,” to ten at the same pitch level.
  2. Try the /o/ alone with a staccato utterance at the optimal or supraoptimal pitch level.
  3. Alternate between the prolonged /o/ and the staccato /o/ producing one ten times and then the other ten times.
  4. Lower the pitch approximately one note and repeat the above exercises.
  5. Continue progressing downward one note at a time with the above exercises.
  6. When the lowest pitch level has been reached, start with that pitch level and progress upward on note at a time, with same exercises, until the optimal or supraoptimal pitch is reached.

Once the skips and breaks in the voice as well as the breathiness or hoarseness have been reduced or eliminated, effortful volume should be discontinued for the most part. When the cord is in the cadaveric or intermediate position, a longer period of effortful volume is to be expected. Following the establishment of the optimal pitch level and proper tone focus, if the volume remains too loud, it should be modified at this point.

Other Considerations

Depending upon the patient’s needs and desires as well as the discretion of the laryngologist, a silicone or Teflon injection may be considered for paralysis in either the paramedian or intermediate position. Some physicians inject Teflon or silicone immediately position. Others prefer to try voice rehabilitation for a period of at least six months. If this program does not prove successful, the physician may elect to inject a synthetic substance into the vocal folds followed by voice rehabilitation.

Arnold writes:

Intrachordal injection should not be considered before all possible attempts at vocal rehabilitation by voice therapy have been made. As is well known, many patients are capable of overcoming their vocal disability through systematic development of intralaryngeal compensation and better exploitation of the vocal-auditory feed-back mechanism…For the same reason, injection should not be considered before 6 months have elapsed since the onset of laryngeal paralysis. (1962c, p. 363)

Regarding the postoperative course, Arnold recommends: “Afterwards, voice therapy should be resumed again for achievement of optimal functional results.” (p. 367) Luchsinger and Arnold state:

Vocal rehabilitation through appropriate voice therapy should always be tried first…Following phonosurgical intervention, voice therapy is important to achieve an optimal “tuning” of the artificially changed vocal- cord dimensions. (1965, p. 174)

Rubin (1971, personal communication) injects silicone immediately to afford temporary relief. If cordal function does not return of the paralyzed cord remains in the paramedian or intermediate position, he then injects Teflon. Experience with this modality is generally favorable in experienced hands, according to Rubin.

Some laryngologists do not afford voice rehabilitation following a synthetic substance injection for paralytic dysphonia. The intracordal injection may well afford a closure of the vocal folds, but the laryngeal control may be irresolute. Immediately after the injection or after a period of some months following the injection or after a period of some months following the injection, voice rehabilitation may be necessary for the patient to achieve an efficient voice.

Clinical Results

Of 59 patients seen with paralytic dysphonia, the following conclusions may be drawn:

  1. Of the 59 patients seen, 29 (49.2%) entered therapy.
  2. Of the 29 patients entering therapy, 26 (89.7%) completed therapy.
  3. Of the 26 patients completing therapy, 9 (34.6%) had long-term therapy and 17 (65.4%) had short-term therapy.
  4. Of the 26 patients completing therapy, the results were: 15 (57.7%) excellent, 6 (23.1%) good, and 5 (19.2%) fair.
  5. The comparison between males and females seen: 27 (45.8%) males and 32 (54.2%) females.

Testimonials

A few examples of former Paralytic Dysphonia patients: