Speech is an important element of human life. Since it helps to express thoughts, emotions and build relationships with other people. The larynx, which occupies an intermediate position between the pharynx and trachea, takes part in the formation of the voice and the performance of the respiratory function. The larynx contains vocal cords, the functioning of which depends on nerve impulses. However, when the nerve fibers are damaged or inflamed, paresis of the vocal cords develops.
The Yusupov Hospital provides treatment for vocal cord paresis and voice restoration after illness. In a multidisciplinary medical institution, specialists practice an individual approach to each patient, which improves the quality of therapy.
Causes of laryngeal paresis
Laryngeal paresis is a polyetiological pathology that often develops against the background of another disease. For example, laryngeal paresis can occur during an inflammatory disease, which can be laryngitis. Also, laryngeal paresis can occur in parallel with infections such as influenza, ARVI, tuberculosis, typhoid (or typhus), secondary (tertiary) syphilis or botulism. Traumatic brain injury, myasthenia gravis, polymyositis, syringomyelia, as well as tumors and vascular disorders (ischemic stroke, atherosclerosis, etc.) - all this can also accompany laryngeal paresis.
The development of laryngeal paresis may also be associated with damage to the branch of the vagus nerve, that is, the recurrent nerve, which leaves the chest cavity and passes to the larynx, contacting the aortic arch, heart, mediastinum, thyroid gland and other organs.
Among the pathological changes in organs that can damage or compress the recurrent nerve are pericarditis, aortic aneurysm, tumor (or enlargement) of the mediastinal lymph nodes, as well as a tumor of the esophagus, possible cervical lymphadenitis, and thyroid cancer, which occurs with the formation of a goiter.
Paresis of the larynx can also be provoked by increased vocal strain, as well as inhalation of cold or dusty air. The functional type of laryngeal paresis can occur as a result of stress or strong psycho-emotional experience. It happens that laryngeal paresis develops against the background of hysteria, neurasthenia, psychopathy and VSD.
Symptoms of laryngeal paresis
The first and main symptom of developing laryngeal paresis is voice disturbance (or dysphonia), as well as disturbance of the breathing process. Manifestations of voice impairment are a decrease in its sonority (sometimes there is complete aphonia, that is, absence of voice), a transition to speaking in a whisper, loss of the usual timbre of the voice, hoarseness, hoarseness of the voice or its rattling, and rapid fatigue during vocal stress.
Breathing problems in the case of laryngeal paresis are associated with very difficult air flow into the airways due to narrowing of the glottis. The latter can be expressed to varying degrees, including even asphyxia. Also, breathing problems can be caused by forced exhalation in order to perform phonation. Clinical manifestations of laryngeal paresis depend on its type.
So, for example, myopathic laryngeal paresis is usually characterized by bilateral lesions. It is characterized by disturbances in phonation or breathing, which is expressed in the form of asphyxia (in the case of paresis of the dilator larynx muscles).
If we talk about neuropathic paresis of the larynx, it is often unilateral, characterized by the slow development of weakness in the muscle itself, as well as an enlarged glottis. A few months after the disease, restoration of phonation begins by compensatory adduction of the vocal cords on the side that is healthy. Asphyxia threatens bilateral neuropathic paresis of the larynx only in the first days of the disease.
If we are talking about functional paresis of the larynx, then this type is observed in those people who have a labile nervous system. The latter, as a rule, happens after severe emotional stress or during a respiratory disease. This type of paresis is characterized by the incoming nature of impaired phonation. The voice with this type of paresis is quite loud, especially when crying or laughing, and pronounced sensations such as tickling, tickling or grinding are observed. The latter is characteristic of the larynx and pharynx. Irritability, sleep disturbance, headache, anxiety and imbalance can also be characteristic symptoms of this type of laryngeal paresis.
Results and discussion
The main complaints of patients before the start of therapy were voice timbre disorder in the form of hoarseness, increasing after vocal stress (90% of observations) or aphonia (10%), coughing (100%), shortness of breath when talking (72%) and/or during physical activity ( 94%), choking while eating liquid or solid food (34%). The severity of symptoms was determined by limited mobility and vibrator activity of the vocal fold on the affected side (3 patients in group A and 4 patients in group B) or complete immobility of the fold during phonation (22 and 21 patients, respectively), which was confirmed by stroboscopy data. In most cases (90%), the vocal fold on the affected side was in the paramedian position (22 observations in group A and 23 in group B). Only 10% of patients (3 from group A and two from group B) had a lateral location of the fold, which caused aphonia, created additional difficulties in therapy and worsened the prognosis of the disease.
The study proved that adding the cholinergic drug Neuromidin to the treatment regimen for OPGS allows one to achieve better results. Thus, in group A, recovery occurred in 5 patients (20%), improvement in 17 (68%), and there was no effect in 3 cases (12%). In group B, recovery occurred in only 2 patients (8%), improvement in 16 (64%), and no effect in 7 (28%). Thus, the overall effectiveness of complex treatment of patients in group A was 88%, in group B - 72%. The differences between the groups are statistically significant in two assessment parameters: “recovery” and “no effect” ( p
<0,05).
The data presented above were confirmed based on an analysis of the dynamics of the compared parameters of the state of the respiratory function of the larynx, voice and quality of life of patients. It was noted that FEV before treatment was significantly reduced in both groups: in group A - 147.2±32.0 l/min, in group B - 152.6±37.9 l/min. During the treatment, there was a positive dynamics of the indicator, but in group A, FEV increased to 288.7 ± 37.7 l/min, i.e., almost 2 times, and in group B, the increase in FEV on average did not exceed 45 l/min and amounted to 197.2±34.5 l/min. The differences between the groups are statistically significant, p
<0,05.
Before treatment, the GRBAS score was 8.4±1.2 points in group A and 8.3±1.7 points in group B, after treatment - 4.1±0.6 and 5.9±0.7 points, respectively ( R
<0.05).
It was found that in group A, compared to group B, there was a more pronounced dynamics of almost all acoustic parameters of the voice. Thus, the initial value of VMF in group A was 5.2±1.4 s, after treatment - 11.6±1.7 s. In group B, IMF increased from 6.0±1.6 s to 9.1±0.6 s. In group A, there was a doubling of the frequency range, from 128.1±37.3 Hz to 275.3±46.7 Hz, and the dynamic range - from 14.0±2.3 dB to 24.0±2.7 dB ( p
<0.05).
In group B, the dynamics of indicators were not so noticeable. The frequency range increased from 139.0±26.3 Hz to 195.3±22.6 Hz, the dynamic range - from 14.9±1.9 dB to 19.0±1.3 dB. In group A, the rate of voice instability in frequency decreased threefold, from 3.4±1.5% to 1.0±0.3%. In group B, Jitter remained quite high, from 3.2±1.8% it decreased to only 2.9±0.3%, which explained the persistence of tremolation and diplophony in the patients’ voice. The change in the acoustic parameters presented above was accompanied by a shift in the dysphonia index towards positive values. However, in group B these changes were not so noticeable (from –2.9±2.3 to –0.1±1.4) compared to group A (–3.0±1.7 to –1.9 ±2.3). The differences between the groups are statistically significant, p
<0.05.
However, it should be noted that there were no significant differences between the groups for a number of parameters. Thus, in patients of group A, the loud voice strength increased from 74.0±4.5 dB to 85.8±6.9 dB, in group B - from 75.8±6.6 dB to 84.7±5, 5 dB( r
>0.05).
At the same time, the average values of the indicator were quite satisfactory in both groups and corresponded to the age norm. The dynamics of the quality of life indicator also did not have significant differences between the groups. In group A, VHI before treatment was 84.9±12.6 points, after treatment - 27.0±9.6 points. In group B, VHI decreased from 81.0±20.2 to 32.1±11.7 points ( p
>0.05). In general, in both groups compared, VHI did not correspond to normal values, which indicated that the quality of life disorder persisted in the majority of patients.
In the pictures
phonetograms of a patient from group A are presented. The dynamics of the vocal profile clearly demonstrates the effectiveness of complex treatment of OPGS. In this observation, complete restoration of vocal fold mobility on the affected side was achieved.
An analysis of all cases of ineffectiveness of the therapy, as well as patient dissatisfaction with respect to the dynamics of vocal function, suggested that possible reasons for the lack of effect are the patients’ late seeking of medical help (after 2 months or more), the lateral location of the vocal fold on the affected side, as well as failure by the patient to comply with recommendations on the advisability of systematically performing phonopedic exercises.
It should be noted that the majority of patients in group A tolerated neuromidin satisfactorily, despite the long course of therapy. Side effects and adverse events were recorded in only 2 (8%) cases out of 25. One patient, a 67-year-old woman, complained of weakness and hand tremors after switching from the injection form of Neuromidin to the tablet form. The symptoms disappeared within 24 hours without stopping the drug. The second patient, a 46-year-old woman, noted frequent headaches throughout the entire period of neuromidin therapy. In this case, discontinuation of the drug was also not required.
Diagnosis of laryngeal paresis
Several specialists will be needed to diagnose laryngeal paresis. So, for example, a patient cannot do without an otolaryngologist, neurologist, neuropsychiatrist, thoracic surgeon, endocrinologist, phoniologist and psychiatrist. Taking an anamnesis is of great importance. It is the anamnesis that can determine the type of underlying disease, due to which laryngeal paresis subsequently occurred, as well as the patient’s tendency to have a psychogenic reaction. Great importance is also given to previously undergone operations performed in the chest area, on the thyroid gland, due to which the recurrent nerve could be damaged.
Any examination of a patient with laryngeal paresis begins with microlaryngoscopy, which allows us to assess the position of the vocal cords, as well as the distance between them and their condition. The study helps determine the condition of the laryngeal mucosa, the presence of various inflammatory processes, including hemorrhages.
An effective diagnostic method can be a CT scan of the larynx or radiography. The contractility of the laryngeal muscles can be assessed using electromyography or electroneurography. Any study of vocal function in the case of laryngeal paresis also involves stroboscopy, electroglottography, phonetography, and more.
If peripheral paresis of the larynx is suspected, additional CT scanning, chest x-ray, ultrasound of the heart and thyroid gland, x-ray of the esophagus and CT of the mediastinum may be used. In order to exclude central laryngeal paralysis, doctors prescribe a CT scan of the brain and an MRI. If the examination does not reveal morphological changes, then laryngeal paresis is most likely of a functional type. In order to confirm the latter, psychological testing and examination of the patient by a psychiatrist are carried out. During the examination, the doctor’s task is also to differentiate laryngeal paresis from croup, arthritis, congenital stridor or subluxation.
conclusions
Laryngeal paresis is a common complication that occurs after various diseases and surgical interventions. OPGS is characterized by significant disturbances in all acoustic characteristics of the voice, which certainly affects the quality of life of patients and their communication abilities.
The data obtained during the study indicate the advisability of complex therapy for OPGS, which is a combination of electrical stimulation of the larynx, phonopedia and the prescription of cholinergic drugs. The addition of neuromidin to the generally accepted conservative treatment regimen can increase its effectiveness from 72 to 88%.
In conclusion, it should be emphasized that in cases of development of OPGS, a correct attitude towards the patient, maximum effort, perseverance and professionalism is necessary to restore laryngeal function or, at least, improve voice quality.
Treatment of laryngeal paresis
Of course, therapy for laryngeal paresis depends on its etiology. This therapy consists of eliminating the main disease, which subsequently caused laryngeal paresis. The treatment of laryngeal paresis itself is carried out both medically and surgically.
Medicinal methods include antibiotic therapy, antiviral therapy (in the case of infectious-inflammatory etiology of laryngeal paresis), the use of neuroprotectors, as well as B vitamins (in the case of recurrent neuritis). Biogenic stimulants, as well as muscle activity stimulants, can be part of drug therapy. The use of psychotropic drugs such as antidepressants, various tranquilizers, and antipsychotics will also serve as good treatment if the patient has functional paresis of the larynx. An integral component in the treatment of laryngeal paresis can be one of the vascular drugs or a nootropic.
If we talk about surgical methods for treating laryngeal paresis, then first of all, it involves surgery to tension the vocal cord, as well as removal of diverticula, possible tumors in the esophagus, removal of tumors in the mediastinum, resection of the thyroid gland, and more. Sometimes a tracheostomy or tracheotomy procedure is an emergency.
Regardless of the type of laryngeal paresis and the primary type of treatment prescribed (medical or surgical), in addition, doctors also prescribe physiotherapeutic methods. In the case of neuropathic or myopathic paresis of the larynx, electrical stimulation, magnetic therapy, drug electrophoresis, DDT, and microwave therapy are used. If we talk about functional paresis of the larynx, then physiotherapy includes massage, reflexology, hydrotherapy and electrosleep. The doctor also prescribes a course of psychotherapy.
After the operation, during the period of restoration of vocal functions, various phonopedic classes are usually prescribed, which include the acquisition of high-quality phonation skills and the development of the performance of the vocal apparatus.
Conservative and surgical treatment
Treatment for paresis should begin immediately after confirmation of the diagnosis. Therapeutic measures are selected individually, the main task is to eliminate the causes of laryngeal paralysis. In most cases, the patient requires hospitalization.
Specialists use complex therapy, including the following measures:
- therapeutic blockades,
- biogenic stimulants,
- electrical nerve stimulation,
- muscle relaxants,
- decongestants,
- antihistamines,
- electrophoresis,
- stimulation of endolaryngeal type muscles,
- antiviral,
- anti-inflammatory,
- antibiotics.
If drug therapy for acute inflammation does not bring results, one has to resort to surgical methods. Surgical intervention for paresis is indicated for scars and tumors in the larynx. Certain techniques are used:
- laryngeal reinnervation,
- correction of the thyroid gland,
- tracheotomy,
- implantation,
- tracheostomy,
- displacement of the vocal cords.
Surgical intervention is not always a panacea for paresis. Efficiency depends on the individual strength of the body, the duration of the disease, the benefit of drug treatment and the clinical picture.
- Causes, symptoms, first aid and treatments for knee sprains
After surgery or conservative therapy, the patient expects long-term rehabilitation. To restore the dividing function of the larynx and proper voice guidance, breathing exercises and phonopedia classes are necessary. Depending on the overall picture of the disease, rehabilitation after laryngeal paralysis can take from three to five months.
Folk remedies
Patients use traditional medicine as auxiliary methods for the treatment of laryngeal paralysis. They cannot completely replace basic drug treatment.
The following recipes are considered effective for laryngeal paralysis.
Recipe No. 1:
- a tablespoon of dry snakehead herb is poured into 250 ml of boiling water,
- leave for 15–20 minutes, then add a spoonful of liquid natural honey,
- drink three times a day on an empty stomach, three teaspoons.
Recipe No. 2:
- a tablespoon of garden purslane is poured into 300 ml of boiling water,
- leave until the liquid cools to room temperature,
- drink four times a day after meals, a single dosage is three teaspoons.
Recipe No. 3:
- For 300 ml of water you need a tablespoon of marina root herb,
- keep in a water bath for 10–15 minutes,
- leave the prepared decoction for 50–60 minutes,
- drink 100 ml on an empty stomach, no more than three times a day.
Before using a prescription, it is advisable to first obtain the approval of your doctor. It is necessary to take into account the individual characteristics of the body: some components are allergens. If side symptoms appear, you will have to stop using the product and choose another treatment for paresis.
Forecast and prevention of laryngeal paresis
We can talk about the prognosis of laryngeal paresis only based on its type. If treatment was carried out in a timely manner, and the etiological factor of laryngeal paresis was eliminated, then the patient can be sure that vocal function will be restored completely, but vocal data may be lost forever. If we are talking about functional paresis, then the disease is characterized by spontaneous recovery. If laryngeal paresis is not treated and continues to torment the patient for a long time, then the irreversibility of atrophic changes in the laryngeal muscles with the further development of phonation disorders cannot be ruled out.
The main prevention of laryngeal paresis is the alternation of vocal stress and rest. Anyone should avoid hypothermia of the larynx and not stay in dusty rooms for a long time. Prevention will also include timely treatment of any inflammatory processes in the upper respiratory tract, treatment of infectious diseases, neuroses, the thyroid gland, as well as compliance with the correct operating technique when interfering with the thyroid gland.
Why are vocal cords easily injured during inflammation?
There are two true vocal cords. At rest, they are at a fairly large distance from each other, forming a triangle with a wide base and coming together only in the area of the anterior ends (at the point of their connection), while the edge of each vocal cord is free.
When producing sound (and when coughing), the vocal cords come closer and touch each other. During inflammation, the edges of the vocal cords are swollen, inflamed and very easily injured during voice formation, as well as when coughing, which can not only increase their inflammation, increase the duration of the recovery process of the vocal cords, but also contribute to the chronicity of inflammation and provoke the appearance of benign neoplasms along the edge of the vocal cords , coarsening of the edges of the vocal cords and, as a result, a change, deepening of the voice. Therefore, it is so important to remain silent during their inflammation, maintaining a safe distance between the vocal cords, avoiding their traumatization.