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Behavioral Management of Unilateral Vocal Fold Paralysis and Paresis

Sarah L. Schneider
UCSF Voice and Swallowing Center, Division of Laryngology, Department of Otolaryngology Head and Neck Surgery, University of California San Francisco San Francisco, California Disclosure: Sarah L. Schneider has no financial or nonfinancial relationships related to the content of this article.

Abstract
Purpose: In this article, I will summarize the process of selecting appropriate voice therapy candidates and relevant treatment techniques for patients with unilateral vocal fold paralysis or paresis. Methods: I will present a review of the literature and pertinent clinical experience while laying out diagnostic tools, considerations for choosing voice therapy candidates, and specific therapy techniques that clinicians may employ. In addition, I highlight how these decisions are guided by a thorough behavioral diagnostic voice evaluation. Results: There are a number of publications in the literature that discuss the role of voice therapy and the types of voice therapy techniques commonly used in treating vocal fold motion impairment. However, little efficacy data exist about the utility of voice therapy alone in this population. Conclusions: Behavioral management of patients with vocal fold paralysis and paresis is widely accepted as part of the treatment process. With little efficacy data to support outcomes for specific voice therapy techniques alone with this patient population, we must continue to rely primarily on our clinical experience and outcomes from other populations to guide the therapeutic process. The primary goal of voice therapy for patients with unilateral vocal fold paralysis or paresis is to achieve the best possible voice in the presence of the vocal fold motion impairment. Although there are a plethora of studies that discuss the role of voice therapy in treating vocal fold motion impairment, few studies support the efficacy of specific therapy techniques and the utility of voice therapy alone in this population. Throughout this article, I will discuss the process of making clinical decisions that are supported by the scientific literature and clinical experience. In particular, I will discuss how decisions are guided by a thorough behavioral diagnostic voice evaluation that includes laryngeal endoscopy, laryngovideostroboscopy, perceptual voice evaluation, aerodynamic/acoustic measurements, and patient self-assessment.

Evaluation
Vocal fold paralysis or paresis is most commonly the result of some type of injury to the recurrent laryngeal nerve, or more rarely, the superior laryngeal nerve (Meyer, Sulica, & Blitzer,

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2007). Nerve injury may be the result of iatrogenic trauma, malignancy, viral infection, or an idiopathic process (Meyer et al., 2007). This injury may produce some level of glottic incompetence leading to a myriad of complaints that may include decreased vocal intensity and range, vocal fatigue, breathiness, roughness, diplophonia, and dysphagia. While the severity of the complaints is often related to the position of the impaired vocal fold and the resultant glottal gap (Miller, 2004), patient self-characterization of impairment does not always coincide with our clinical assessment of perceptual severity or the degree of glottic gap. Clinicians typically use several tools when completing the voice evaluation of a patient with vocal fold paralysis. The results obtained through this evaluation affect our clinical decision-making and potential therapeutic approach. Specific tools include laryngeal endoscopy, laryngovideostroboscopy, laryngeal function studies, acoustic and aerodynamic voice measures, perceptual evaluation of voice quality, and patient self-assessment. As speechlanguage pathologists, it is within our scope of practice to assess the function of the larynx, in this case, related to changes in vocal fold motion. However, the diagnosis of a vocal fold paralysis or paresis is left solely to our otolaryngology colleagues. The aforementioned diagnostic tools are of great value to both disciplines. However, in this paper, I will focus on the utility of these tools in assessing laryngeal function to guide behavioral intervention. During endoscopy, the larynx is indirectly visualized with a steady state light source and motion and position of the impaired vocal fold are observed. In addition, assessment of supraglottic constriction may help determine the extent of any compensatory muscle tension that can coincide with voicing. As speech-language pathologists (SLPs), we are not diagnosing a motion impairment, but rather, we are studying vocal fold motion asymmetry and supraglottic constriction to determine how these changes in function may affect vocal output. These factors, however, are not the only determining variables when considering the role of behavioral management. Laryngovideostroboscopy, with an intermittent flashing light source timed to the vibratory frequency of the vocal folds, is considered the gold standard for assessing laryngeal function, especially for assessing vocal fold closure pattern (Woo, 1996). While laryngovideostroboscopy is limited to evaluation of relatively periodic vocal fold vibration, this procedure continues to be the cornerstone of the voice evaluation process (Connor & Bless, 2007). The vocal fold vibratory parameters are observed under stroboscopic light at various vocal pitches to give us insight into glottal function. There are several vibratory parameters that may be indicative of a vocal paralysis, according to Colton and Casper (1996). These parameters include decreased mucosal wave on the affected side and asymmetrical vibration. However, the amount (length) and duration of closure is of ultimate importance. The SLP should observe the vocal fold closure pattern in relation to the amount of supraglottic constriction that may be used to achieve this closure. With this information, we begin to appreciate the patients capabilities and potential for voice production. Acoustic and aerodynamic voice measures provide further insight into the physiology of voice production. To obtain these measures, special equipment is required that may not be readily accessible. There are currently several free or economical programs for completing acoustic analysis that can be obtained over the internet; however, I will not discuss these details in this paper. Specific acoustic and aerodynamic measurements are not standardized for evaluation or to gauge outcomes. Although Behrman (2004) suggests choosing specific measures related to the patients symptoms, the literature reports a wide variety of parameters that are not necessarily consistent for the same diagnosis. Therefore, a large grey area remains when attempting to select acoustic and aerodynamic parameters for evaluation purposes in this population. With these considerations in mind, clinicians might consider using the following measures: airflow and air pressure during phonation (Gorman, Weinrich, Lee, & Stemple, 2008), vocal range or a voice range profile (Behrman, Argesti, Blumstein, & Sharma, 1996), vocal intensity and intensity range (Behrman, 2004), noise to harmonic ratio, and

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spectral analysis of the sound signal (Titze, 1995). In some cases, the clinical world is not ideal, specialized equipment is not available, and acoustic and aerodynamic measures cannot feasibly be completed. Despite these challenges SLPs can still develop an appropriate voice therapy treatment plan. Perceptual voice evaluation is valuable to establish a baseline of voice quality and a point of reference from which to compare throughout the therapy process. Variable nomenclature is used to describe voices and there are often different perceptions associated with the same word (think hoarseness). By using a systematic or more standardized approach to assess voice quality with the Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale (Hirano, 1981) and/or Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V; Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kraemer, & Hilman, 2009; Zraick et al., 2011), we may begin to bridge this semantic gap and, in the short term, gain further insight into how the patient is managing his or her voice. Patients with vocal fold paralysis often present with an asthenic voice quality that is breathy with reduced intensity and intermittent diplophonia. Speaking pitch may increase or decrease depending on the compensatory strategies the patient employs. Dysphonia varies in degree, and is likely related to the position of the affected vocal fold and size of the resulting glottal gap. However, voice quality alone is not enough to guide therapeutic intervention. Quality is significantly influenced by compensatory strategies and voice use patterns that may not be representative of the actual degree of motion impairment or glottal incompetence. As we put together what we see on still-light endoscopy and videostroboscopy with acoustic and aerodynamic data and auditory-perceptual analysis, several scenarios may emerge. For example, we may begin to think the patient sounds worse than his or her vocal function measures might indicate, suggesting that we may be able to guide them towards improved voice use patterns. Alternatively, all of their vocal function measures may be consistent, and might indicate that despite poor voice quality, patients are using their voice to the best of their ability at this time. In addition to the tools discussed previously, SLPs should gather a thorough patient history with a specific focus on the present vocal complaints, inciting event, and motivation to change. They also should obtain patient self-assessment scales in order to document the psychosocial effects of the voice disorder on the individual. For example, self-assessment scales such as the Voice Handicap Index (VHI; Jacobson, et al., 1997) and Voice-Related Quality of Life (V-RQOL) scale (Hogikyan & Sethuraman, 1999) commonly are used in both clinical situations and the scientific literature. With all of the information discussed so far, we begin to develop a full picture of the patients voice changes, vocal complaints and demands, voice handicap, vocal quality and laryngeal function, and vocal fold motion and closure. SLPs can use this clinical picture to guide them towards management decisions. I summarize factors that SLPs must consider when determining the role of behavioral intervention in Table 1.

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Table 1. Factors To Consider When Determining the Role of Behavioral Intervention Etiology of injury concomitant disease processes iatrogenic trauma malignancy viral infection idiopathic Place of injury along the nerve high vagal injury distal injury Time from injury under 6-12 months from onset over 12 months from onset Position of the immobile vocal fold median paramedian lateral Tone of the vocal fold supple bowed flaccid Vocal fold closure pattern at various pitches low - modal - high Voice quality stable across pitches improved at higher pitches worse at lower pitches degree of dysphonia specific qualities observed Patient management of voice significant strain working with altered voice Vocal demand low demand vs. high demand public speaking amount of phone use requires projection Motivation willingness to practice receptive to recommendations resistant

Clinical Decision-Making in Voice Therapy

In my clinical experience, the more lateral the placement of the impaired vocal fold and larger the glottal gap, the more difficult it is to make progress with therapy alone. This caveat is outlined in discussing the appropriateness and prognosis of several voice therapy approaches (e.g., patient selection for Lessac-Madsen Resonant Voice Therapy; Verdolini, 2000). Depending on patients voice use patterns, they may benefit from a short course of preoperative voice

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therapy to reduce vocal strain and learn to use their voice in the presence of the motion impairment. Preoperative therapy can be the best post-operative voice therapy. Often, in these cases, our role as SLPs is to provide support for patients pre- and postsurgery and aid in maximizing vocal outcomes following medical surgical intervention (e.g., injection or surgical medialization procedures, etc.). When the impaired vocal fold is at or near midline, with at least touch closure, voice therapy may be most effective. Because of this glottal configuration, we can target balanced airflow during phonation to maximize the vocal fold closure pattern and use resonance to encourage amplification of the sound signal. These goals, based in physiology and voice science, guide our choice of vocal exercises and techniques. The above considerations, related to vocal fold positioning and closure, are impacted by the length of time from injury, vocal demand, and overall vocal impairment. Researchers have shown that patients who undergo early vocal fold injection are less likely to require a permanent procedure for vocal fold medialization (Yung, Likhterov, & Courey, 2011). Thus, it is important to employ a multidisciplinary team approach when making decisions regarding how behavioral and possible medical surgical intervention can complement each other to gain the best vocal outcome for the patient.

Voice Therapy
As mentioned, there are several studies that discuss the role of voice therapy in managing vocal fold paralysis and paresis; however there is little efficacy data to guide us to specific voice therapy techniques for this population. There are five studies, to my knowledge, that demonstrate the utility of various types of voice therapy in this population. These include: Colton and Casper (1996, pp. 279-280), Heuer and colleagues (1997), DAlatri and colleagues (2008), Schindler and colleagues (2008), and Mattioli and colleauges (2011). In general, results from these studies are promising in that they show improvement in various vocal function measures following voice therapy. However, the strength of these findings is limited by the inconsistency of measurement used to demonstrate outcomes, and the fact that these are single-group treatment designs. In other words, because researchers in these studies did not use control groups, these studies do not account for the issue of spontaneous nerve regeneration or recovery. In the world of evidence-based practice, to validate our work and solidify the role of voice therapy in managing patients with vocal fold motion impairment, it is paramount that these issues be addressed when designing future studies. With these caveats in mind, it is important to recognize how SLPs can use voice therapy to help patients with vocal fold motion impairment. First, voice therapy helps to provide the patient with a basic understanding of how the voice works and how voice, breathing, and swallowing may be altered by a change in vocal fold motion. It validates the patients complaints and provides a better understanding of how that person may be able to effect change in his or her voice. The primary goal of voice therapy is to improve the patients voice in the presence of the motion impairment. In doing so, we work to improve glottic closure, increase intrinsic muscle strength and agility, and develop abdominal support for breathing (D'Alatri et al., 2008). In addition, other potential benefits may even include promotion of vocal fold mobility (Mattioli et al., 2011). Once the SLP has determined that the patient may benefit from behavioral intervention, he or she must develop a patient-specific treatment plan. This plan should be guided by our understanding of the physiology of voice production and voice science, in addition to information gathered during our evaluation. Considerations include vocal fold positioning and closure, the patients vocal complaints, and compensatory voice use patterns, among other factors. With therapy, we work to achieve maximum output with minimum effort while potentially building vocal strength, balance, and stamina (Stemple, Lee, D'Amico, & Pickup,

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1994). Addressing the patients primary complaint in the context of this plan can promote patient buy-in and ultimate compliance. In patients with vocal fold motion impairment, compensatory patterns typically develop as a result of the glottic incompetence. Patients begin to use increased supraglottic hyperfunction at the level of the larynx or further up in the vocal tract with pharyngeal squeeze and/or increased base-of-tongue tension (Schindler et al., 2008). Clinicians may begin by encouraging patients to work with the air loss rather than fight it; patients may start to change these behaviors by learning to accept shorter utterance length and use of a softer voice. This change can result in reduced strain and may ease vocal fatigue. Based on the patient-specific level of vocal strain, laryngeal and extralaryngeal tension reduction techniques including laryngeal massage (Roy, Bless, Helsey, & Ford, 1997) and physical stretching or breathing/relaxation exercises may prove useful. The SLP may be able to improve voice use patterns by promoting more balanced airflow and maximizing resonance. The SLP must also shift his or her expectations for resonance related to the amount of glottal incompetence or the weakness at the level of the sound source. Patients and clinicians must understand that reduced vocal fold closure time leads to a weaker sound signal, which in turn leads to a weaker harmonic structure. Therefore, the sensation of resonance may not be as intense as that achieved by someone with intact vocal fold closure. As DAlatri and colleagues (2008) reported, during voice therapy, auditory and proprioceptive training is completed throughout to enable the patient to hear and feel the appropriate voice production (p. 937). Despite the shift in the potential intensity of resonance, overall kinesthetic awareness of how the target therapy voice feels is paramount in promoting carryover of vocal techniques. With all of these considerations in mind, SLPs must be aware of the variety of voice therapy techniques that they may employ with this population. The list that follows is not meant to be exclusive or exhaustive. Rather, I hope that this summary will provide clinicians with an overview of voice exercises and techniques that they may include in a clinical armamentarium. Finding the best fit for the patient is paramount. Relaxation Exercises Clinicians often observe that patients with vocal complaints have increased tension in the neck, shoulders, upper back, and chest. Patients with vocal fold paralysis or paresis demonstrate this pattern as well, and may benefit from stretching, progressive relaxation, meditation, and/or breathing exercises that work to release and refocus tension in the body. Although this approach may target secondary behaviors, it is not meant to be used in isolation or in lieu of other techniques that focus on altering voice production (Stemple, Glaze, & Klaben, 2000). The Half-Swallow Boom The half-swallow boom is a technique that originated with McFarlane and colleagues (McFarlane, Waterson, Lewis, & Boone, 1998) as a facilitator to promote vocal fold closure and increase vocal intensity. Facilitators such as the half-swallow boom may be helpful in assessing the patients ability to increase vocal intensity. However, clinicians should pay attention to avoiding hyperfunction that may lead to additional vocal fatigue and ineffective compensation. Circumlaryngeal Massage Researchers have proven that circumlaryngeal massage and laryngeal reposturing (Roy et al., 1997) are useful for achieving more consistent voicing when used with certain populations. In the case of patients with vocal fold motion impairment, SLPs can use these techniques to achieve neutral laryngeal positioning and release compensatory hyperfunction that may lead to fatigue or anterior neck discomfort. Patients with particular dysphagia-related complaints (e.g., food or pills feeling stuck in the throat) may also benefit from these

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techniques. Following laryngeal massage, patients often describe a sensation of openness in their throat, a smoother swallow, and increased ease of phonation. In certain cases, laryngeal massage may release compensatory hyperfunction and lead to improved voicing. In other cases, it may result in more appropriate pitch and less vocal strain, but increased breathiness and reduced intensity (i.e., the underlying symptoms of the vocal fold motion impairment). Breathing Exercises Abdominal support is referenced frequently in books, peer-reviewed studies, and lay articles (DAlatri, et al., 2008; Miller, 2004; Schindler et al., 2008), and often refers to the development of abdominal breathing or abdominal support for breathing. There is much debate about abdominal breathingwhat this means, how this works, and whether our task as clinicians is to promote this behavior in isolation or in coordination with phonation. Miller (2004) writes that extensive training in breath support or breath control is not necessary for the average speaker, but more important for the professional voice user. Miller further explains that breathing should be a continuous, relaxed cycle with inhalation happening quickly and exhalation being extended during phonation. Targeting breath support and utterance length (D'Alatri et al., 2008) as well as working to exploit expiratory flows with the coordination of breathing and phonation (Mattioli et al., 2011) have been shown to be useful in this patient population. I agree that extensive breath training is not typically necessary with this patient population. However, reducing unnecessary muscle effort during inhalation and implementing productive muscle engagement in the abdomen and rib cage during exhalation can be helpful. In my clinical opinion, the most important goal of teaching breathing exercises is to coordinate breathing with phonation. Patients with vocal fold motion impairment often feel out of breath with talking. Teaching these patients how to coordinate breathing with phonation and helping them to understand the effect of glottic incompetence (as well as how it feels), can help maximize vocal output and minimize effort. Trills Experts in voice therapy employ several types of trills, these include tongue trills, lip trills, and tongue out trills (Colton & Casper, 1996). These exercises can be useful in reducing laryngeal and extralaryngeal tension while promoting airflow and an increased sense of oral resonance. Once a patient can achieve trills consistently, they can shape these into vowels, words, and phrases in an attempt to maintain ease and quality of phonation from the trill to the spoken word. Vocal Function Exercises Vocal Function Exercises are a program of physiologic voice exercises designed to strengthen and balance the laryngeal musculature and to balance airflow to the muscular effort (Stemple et al., 1994). Although there is no efficacy data on this technique with regard to treating patients with vocal fold paralysis, it is widely accepted for use with this population. Clinicians may use this approach to reduce compensatory hyperfunction and to promote balance and strengthen of the vocal mechanism, as reported in populations with hypofunctional vocal issues such as vocal fold bowing (Gorman et al., 2008). Readers are referred to Stemple and colleagues (1994) for details regarding the therapeutic protocol. Resonant Voice Therapy Exercises The goal of resonant voice therapy exercises is to achieve easy phonation while experiencing energy or vibration of sound in the oral cavity (Verdolini, 2000). Verdolini, Druker, Palmer, and Samawi (1998) demonstrated that the vocal folds are nearly adducted at the onset of phonation during resonant voice production. Although there is no efficacy data regarding the use of this technique for patients with vocal fold paralysis, it may be useful with patients whose glottic gap is not substantial. Because of the nearly adducted vocal fold configuration at the onset of resonant voice production, a patient with paresis or paralysis in the median or

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slightly paramedian position may find success as they are predisposed to the slightly abducted vocal fold positioning. In addition, using this approach maximizes resonance, which can result in more efficient vocal output with less effort. Like the above listed approaches, more research is needed to determine the role of this behavioral intervention in this patient population. Is There a Role for Pushing and Pulling Exercises? Although I am not a proponent of pushing and pulling exercises or hard glottal attacks with this patient population, there are always exceptional cases. Researchers continue to describe these techniques in the literature (Mattioli et al., 2011; Miller, 2004; Schindler et al., 2008; Stemple et al., 2000). Typically, however, researchers present these with the caveat that they are used in special cases and with special attention to avoiding increased supraglottic hyperfunction and vocal strain. Some writers make a point to say that these must always be avoided (D'Alatri et al., 2008). It is important that we, as SLPs, have many tools with which to promote improved voice production for our patients and that we choose wisely about when to apply them. I would suggest proceeding with caution when considering use of these exercises.

Summary
The primary goal of voice therapy for patients with unilateral vocal fold paralysis or paresis is to guide our patients to achieve their best voice in the presence of the vocal fold motion impairment. Throughout this article, I have discussed in more detail the process of choosing appropriate voice therapy candidates and treatment techniques and how these decisions are guided by a thorough voice evaluation. I have reviewed present research that supports our work with this population and demonstrated the need for further investigation and higher level efficacy data. When completing a voice evaluation and treatment for patients with vocal fold paralysis and paresis, as part of the voice community at large, it is important to direct a keen eye (and ear) towards the dynamic nature of voice production and how anatomy, physiology, and voice science guide our understanding and approach to this process. Only by using this approach may we best serve our patients.

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