Unilateral vocal cord paralysis: A guide for voice therapy

1. Unilateral vocal cord paralysis: A guide for voice therapy Voice EBP Extravaganza 2010

2. Background Common caseload (inpts > outpatients) Unknown: When to provide therapy and for how long What therapy to provide Contraindications Role of surgery in recovery Prognosis and pattern of recovery

3. Question For patients with unilateral vocal cord paralysis, does voice therapy improve voice outcomes?

4. Search strategy Search words: Unilateral vocal fold/cord paralysis/paresis RLN palsy Voice therapy Voice disorders Hemiplegia Databases: Medline / PubMed Web of science Cochrane Scopus

5. Results Critically appraised 16 articles Each article appraised by 2 people Developed specific Q�s to assist our broad clinical Q Mix of retrospective and experimental time series studies No control groups Level of evidence: III to IV Range of participants per study: 3 - 91

6. Trends of presenting S&S Hoarseness (53%), dysphagia (34%), difficulty breathing (12.8%). Kelchner low intensity, low pitch, rough, breathy, reduced phonation time, vocal fatigue, little resonance, loud whisper, intermittent voicing, rapid rate, excessive glottal leak, intermittent flutter Heuer Increased mean values of GRBAS (Overall severity, roughness, breathiness, asthenia, strain) D�Alatri Sudden onset hoarseness Tsunoda Overall, no pattern of symptoms described GRBAS � grade, roughness, breathiness, asthenia/weakness, strainGRBAS � grade, roughness, breathiness, asthenia/weakness, strain

7. Rx techniques Mostly eclectic approaches where many techniques were used in combination In all of these studies, these techniques were shown to improve the voice on a range of measures. D�Alatri et al used specific techniques targeting specific symptoms e.g. glottic competence and hyperfunction Smith Accent Method was also effective in 3 reported participants (Khidr, 2003) Yawning Breath Pattern (breath support, lower larynx) with biofeedback was effective in a larger group of patients (Xu, 1991) Head turn was not effective (Paseman, 2004) Eclectic approaches: Vocal hygiene ROC Abdo support/ breath control Intrinsic laryngeal muscle ex�s Accent method H&N relaxation Resonant voice / humming Some cases � half swallow boom, HGA h/e caution with hyperfunction Range of voice measures: Acoustic Auditory perceptual characteristics VHI Stroboscopy NasendoscopyEclectic approaches: Vocal hygiene ROC Abdo support/ breath control Intrinsic laryngeal muscle ex�s Accent method H&N relaxation Resonant voice / humming Some cases � half swallow boom, HGA h/e caution with hyperfunction Range of voice measures: Acoustic Auditory perceptual characteristics VHI Stroboscopy Nasendoscopy

8. Time frame for Rx? Many studies didn�t consider spontaneous recovery and timing of intervention often not specified Voice therapy improved voice outcomes. Eclectic approach equally effective < 3 months or 3 mths - 21 years post-onset (Cantarella et al, 2010) Effective 1-13 years post-onset (Khidr, 2003). Voice therapy may be more effective closer to onset, but this is unclear in the literature Lack of control groups and small subject numbers = unable to ascertain if Rx is more effective early rather than later KB to start hereLack of control groups and small subject numbers = unable to ascertain if Rx is more effective early rather than later KB to start here

9. Length of Rx? Cantarella = 10-40 sessions Khidr = 16 sessions Heuer = 3-7 sessions (less for non-surgical) D�Alatri = 8-35 (mean = 24) sessions Schindler = 6-20 (mean 12.6) sessions Xu = 10 weekly sessions Overall: > 10 sessions. Frequency = weekly or twice-weekly

10. Position of paralysed VC? Kelchner = paramedian or lateral Impact of position not discussed in relation to voice outcomes

11. Reliability and validity of outcome measures? Most studies use multidimensional outcome measures videostroboscopy, acoustic measures, perceptual evaluation, aerodynamic measures and patient-reported quality of life (i.e. VHI). No reported blinding for rating Intra or inter-rater reliability for perceptual evaluation often not reported Acoustic measures used h/e type of acoustic signal not specified to ensure reliability Only type 1 signal can be used for acoustic analysisOnly type 1 signal can be used for acoustic analysis

12. Role of Sx Surgery > voice therapy for sig dysphonia Surgery = voice therapy for less severe dysphonia (Kelchner et al , 1999) Pre-op voice therapy may help patients achieve adequate voicing without surgery (Heuer, 1997) Many studies reported voice outcomes from surgery alone ? no CAP

13. Evidence from clinical practice Timing of Rx � early is better than later to prevent hyperfunction Rx techniques � gentle vocal adduction while preventing hyperfunction Position of cord � therapy more beneficial for those with smaller glottic gaps Length of therapy � re-evaluate if no improvement after approx. 4 sessions Outcomes � use a range but all using perceptual ratings Early therapy is often education DO NOT use hard glottal attack (pushing) as this will encourage hyperfunctionEarly therapy is often education DO NOT use hard glottal attack (pushing) as this will encourage hyperfunction

14. Clients values Patient choice was not documented in most studies The only reference to patient choice was in Heuer and Khidr, where patients elected to have voice therapy vs surgery As a group we all consider client choice and other factors e.g. compliance, fatigue, cognition

15. Clinical bottom line Yes voice therapy is effective for UVFP to some degree Therapy approaches appear to be eclectic in nature We are still unsure how effective specific therapy approaches are We are also unsure of when it�s best to intervene with therapy and the nature of spontaneous recovery

16. Clinical application Increased confidence discussing literature evidence with clients and referrers Voice therapy for those clients with mild dysphonia / small glottic gap Clients with severe dysphonia / large glottic gap may benefit more from ENT for surgical intervention Continue current voice therapy techniques and re-refer to ENT if no improvement Continue collecting voice outcomes to evaluate success of therapy Surgical intervention � temporary or permanent augmentationSurgical intervention � temporary or permanent augmentation

17. NSW EBP members Judy Rough Katrina Blyth Sam Warhurst Danielle Stone Katherine Kelly Asta Fung Beth Atkins Sharon Moore Margaret Jacobs Therese Dodds Helen Brake Academic link: Cate Madill