(Radiesse), which is undergoing evaluation for durability at the time of this writing, are the only exceptions to this. Definitive medial-ization therefore comprises medialization la-ryngoplasty and arytenoid repositioning procedures. Although absent from the algorithm presented here (Fig. 6.1), voice and swallowing therapy may prove useful in addition to these surgical measures in the symptomatic patient.
Because of potentially life-threatening consequences, the presence or absence of aspiration remains the most important consideration in patients with vocal fold paralysis. Selection of treatment depends on the duration of paralysis. In practice, patients with dysphagia present shortly after the onset of paralysis, making injection augmentation of a temporary substance a particularly suitable means of addressing their problems. Injection has been criticized as ineffective for closing posterior glottic gaps due to arytenoid malposition. If such an insufficiency appears to be a significant problem, framework surgery may be considered regardless of the time elapsed since the onset of paralysis.
In patients without significant dysphagia, and with unilateral vocal fold paralysis of long duration, framework surgery maybe performed without further work-up. Although our algorithm specifies 6 months, the time interval after which medialization laryngoplasty becomes appropriate is not precisely established. Some surgeons prefer to wait as long as 12 months, both because of the potential for recovery, and because atrophy or reinnervation may shift the position of the vocal fold, even when mobility does not return. Since laryngoplasty provides a stable degree of medial vocal fold displacement, it is advantageous that the neuromuscular status of the vocal fold stabilize prior to the surgery. There is no information regarding the amount of time this takes, but obviously, the more time that is allowed to pass since onset, the likelier it is that there will be little further change.
Patients with vocal fold paralysis due to tumor compression or invasion, or nerve section, may also be treated early because of the dismal prospect for recovery of vocal fold motion. Atrophy may be more likely in these patients, a factor which may need to be taken into ac count, particularly if a medialization laryngoplasty is being performed soon after onset.
Laryngeal electromyography is useful to evaluate patients who present within a few months of the onset of their dysphonia, and in iatrogenic cases of vocal fold paralysis when status of the nerve is unknown or presumed to be intact. In most practices, the majority of patients fall into this category. Patients with poor prognosis should be considered for early definitive treatment. On the other hand, patients with good or indeterminate prognosis may be observed, or, if dysphonia is bothersome, may undergo injection augmentation. If dysphonia returns after the injectate resorbs, medialization laryngoplasty provides a long-term remedy.
An assessment of certain simple aspects of each case of vocal fold paralysis, combined with a choice of surgical techniques, allows the development of a rational treatment strategy that approaches the ideal proposed in the introduction. There is no doubt that it could be further refined by additional information regarding the natural history of vocal fold paralysis, which, in many respects, remains poorly defined despite more than a century of clinical study. More sophisticated electrodiagnostic techniques, combined with a better understanding of laryngeal neurophysiology, is needed to understand the phenomenon of inappropriate reinnervation in the larynx and its clinical implications.
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