Voice therapy for vocal fold paralysis

There is no doubt that vocal fold paralysis is a debilitating condition affecting an individual's general health and quality of life. Optimal management of a patient with vocal fold dysfunction by an otolaryngologist, speech scientist, and speech language pathologist results in detailed objective videostroboscopic evaluation of glottal configuration during phonation, acoustic and aerodynamic measures, laryngeal EMG (if appropriate), and the patient's self-rating of vocal disability. Profound glottal incompetence is typically managed surgically with a few voice therapy sessions after surgery to ensure optimal vocal function. Patients with more adequate glottal closure are often seen for voice therapy and lost to follow-up when their voices improve enough to satisfy their vocal needs. It is essential that a complete battery of assessments, including perceptual, aerodynamic, acoustic, and stroboscopic measures, be obtained at periodic intervals in surgical and nonsurgical patients so as to evaluate vocal function over time. One of the few rigorous studies of perceptual, acoustic, aerodynamic, and videofiberscopic findings in patients after medialization with fat and thyroplasty assessed patients before surgery and at short (1-3 months),middle (4-6 months), and long (7-12 months) intervals after surgery. Improvement in most parameters at short- and long-term intervals was noted but not in the middle interval. The best results were obtained in women. Continued difficulty in increasing and maintaining subglottal pressure for high-intensity phonation was observed in both male and female patients. This fine study raises a number of questions as follows. What objective phonatory measures should be assessed before and after intervention and at what time intervals? Why were the women's results better than the men's results when no correlation of age, pulmonary function, or severity of preoperative voice and aerodynamic impairment was observed? Should voice therapy be initiated at the 4- to 6-month interval when voice quality diminished or within 1 to 2 months after surgery so that the decrement in vocal function might not occur? Why did vocal function ultimately improve after 7 to 12 months? Heuer et al and Colton and Casper found similar outcome satisfaction in patients electing surgery compared with those that were seen for voice therapy; however, the patients with lesser glottal incompetence in both studies opted for therapy. Can we better define vocal parameters that help to predict which patients may need surgery rather than therapy? Should all patients with high airflow measures but near-normal subglottal pressures and MPT greater than 10 seconds undergo 6 weeks of voice therapy rather than medical intervention? If all surgical patients were seen for 6 weeks of postoperative therapy, would voice satisfaction ratings increase to greater than 70%? Can we perceptively or objectively differentiate patients whose postoperative voices will be excellent from those whose voices will be merely adequate? These questions can only be answered by the development and implementation of a rigorous protocol studying women and men of varying ages with unilateral vocal fold paralysis choosing medialization surgery and electing voice therapy. Standardized assessments must include perceptual,aerodynamic, acoustic, stroboscopic, and patient satisfaction measures during soft- and loud-intensity tasks before and at periodic intervals after the two interventions.