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StatPearls . Treasure Island (FL): StatPearls Publishing; 2021 Jan-.


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Continuing education Activity

Glottic insufficiency is characterized by incomplete closure that the vocal folds with phonation, which reasons an raised risk of aspiration. Glottic insufficiency also causes laryngeal symptoms consisting of dysphonia and also dysphagia. This activity reviews the evaluation and also management the airway glottic insufficiency and highlights the duty of the interprofessional team in the recognition and management the airway glottic insufficiency

Objectives:
Describe the need for an interprofessional team strategy to caring for a patient v airway glottic insufficiency.

Introduction

Glottic insufficiency is characterized by incomplete closure the the vocal folds as soon as phonating, which causes inappropriate leakage that air v the glottis ~ above attempting come phonate and there is an raised risk the aspiration. A wide variety of laryngeal symptoms consisting of dysphonia, dysphagia, and also aspiration through recurrent lung infections may result. The reasons are same wide-ranging and can incorporate anything that prevents complete closure that the vocal crease (static or dynamic), such as neoplasms, reactive changes, functional and also neurologic changes, focal distance neurologic deficits, trauma, and many others.


Etiology

There space a selection of reasons of glottic insufficiency; amongst the most typical are vocal wrinkles paralysis (complete immobility that the vocal fold) or vocal fold paresis (weakness or partial immobility that the vocal fold). Vocal fold immobility is a physics finding fairly than a diagnosis. Therefore, it is necessary to investigate the underlying reason to identify an basic diagnosis. The largest case collection to date cites the most common reason of unilateral vocal cord paralysis as surgical injury.<1> In patients there is no prior surgery or intubation, a thoroughly workup is required before labeling such a paresis "idiopathic." main and peripheral neurologic causes, contagious causes, and neoplasms the the CNS, head, neck, and upper chest have to be rule out, as anything impinging on the course of the recurrent laryngeal nerve native the brainstem to the chest come the larynx, can potentially weaken the vocal fold.

Other reasons of glottic insufficiency are presbylaryngis, sulcus vocalis, vocal wrinkles nodules or neoplasm, central neurologic injury, peripheral neurologic injury, intubation-related injury, arytenoid trauma, infection, scar or deformation that the vocal fold, and many others. The latter may be congenital, idiopathic, or secondary to iatrogenic reasons such together glottic tumor excision.


Epidemiology

A literature search does not expose any an extensive epidemiological data on glottic insufficiency; this is likely due to the change causes and complexity of reasons of glottic insufficiency, and potential under-diagnosis. It is an overwhelming to carry out a meaningful literature review on together a common and widely change symptom, together opposed to a definitive diagnosis. The threat of vocal fold paresis ~ thyroid surgery has actually been defined classically together 1%, though with more sensitive neuro-monitoring and measurements, up to 5.6% of post-thyroidectomy patient may have actually a demonstrable weakness. Presbylaryngeus has an enhancing incidence v age and also has been recorded in 8-10% in some geriatric facilities. True idiopathic vocal fold paresis/paralysis has been estimated at 1 case per 100,000 world per year in one multi-institutional populace study. <2><3><4>


Pathophysiology

One the the functions of the vocal folds is to defend the lower airway and also lungs, and also this security is particularly an essential during swallowing. The vocal wrinkle also duty to manage airflow and pressure and also to generate voice with vibration and meaningful phonation. A vocal keep in mind production is through repeated contact and the vibratory and mucosal wave motions of the vocal folds. Glottic insufficiency hampers this functions because of the incomplete contact between the 2 vocal folds, or through a readjust in the period or amplitude that the common fluid-wave motion, i beg your pardon can enable aspiration and hamper vocal function and projection.


History and also Physical

Glottic insufficiency to produce a selection of symptoms. From the start of the consultation, the clinician should begin to assess the patient’s voice informally throughout the early stage conversation. The patient"s voice might sound weak, and they might complain of a weak voice, of effortful or painful phonation (odynophonia), and also may have actually shortness that breath when talking and have a weak cough (the so-called bovine cough, resulting from the inability to totally adduct the vocal folds).  There might be a background of dysphagia or coughing/choking v swallowing, an especially with thin liquids, or that recurrent chest infections as result of aspiration. It is essential to seek out “red-flag” symptom such together unilateral throat pain, ad otalgia, dysphagia, weight loss, or neck mass, which may suggest a neoplastic etiology.

Further history to be elicited native the patient should ascertain whether there has actually been any recent surgery, in particular, cervical, thyroid or thoracic surgery, or an extensive intubation for any kind of cause. Any background of cervical or whiplash trauma should be elicited. The patient’s vocal needs, even if it is socially or professionally, e.g., a professional singer or various other voice-user such together a teacher or preacher, have to be developed as this may assist determine the most perfect intervention. Patient with also minor dysphonic symptoms can be disproportionally influenced if they use their voice for a living. A in-depth neurologic and cardiovascular background should be sought, as stroke, seizure disorders, lot of sclerosis, or plenty of other neurologic problems may impact the voice and also cranial nerve functions.

The GRBAS (grade, roughness, breathiness, asthenia, and strain) range is a widely offered metric for assessing vocal health and can be offered in the clinic setting to price the patient’s voice.<5> though this relies on a trained perceptual evaluation, it might be helpful as a comparative tool pre- and post-intervention.

Prior to a concentrated examination that the phonatory apparatus, a general ear, nose, and also throat examination is required, consisting of flexible laryngoscopy to advice the larynx because that anatomic abnormalities. This may reveal reasons of dysphonia extrinsic come the phonatory apparatus such as neck masses, nasal polyps, enlarged tonsils which can contribute to alters in voice quality, and also intrinsic laryngeal pathology that can be directly or indirectly pertained to phonatory symptom such together chronic laryngitis or singer"s nodules. Palatal paralysis linked with one ipsilateral vocal wrinkles paralysis is suggestive the a high vagal lesion. A full cranial nerve examination should also be perform to evaluate the authorized of other cranial nerves to ascendancy out a high lesion.

Palpation that the larynx to assess because that tenderness, suppleness or too much tension may assist in ruling out muscle tension dysphonia together a reason of the patient’s dysphonia. The patient have the right to be asked to carry out the “ee-sniff” maneuver while the examiner slips their fingers behind the thyroid alar to straight palpate the cricoarytenoid joint. Vocal wrinkles paralysis will result in no activity on the ipsilateral side, and a gentle tap felt on the examiner’s finger top top the contralateral side.


Evaluation

Directly visualizing the glottis is the most sensitive and specific an approach for assessing vocal fold motion abnormalities, though indirect visualization with concomitant video stroboscopy is the most virtually useful method.<6>

Visualization deserve to start with flexible laryngoscopy in the clinic. Vocal fold asymmetry and also bowing may be visualized, and lesions such as vocal wrinkles scarring and also sulcus vocalis which may be leading to a closure deficiency of the vocal folds. The precise vocal cord positioning should be provided and may indicate the level of injury; e.g., a paramedian positioning of the cords is suggestive that injury in ~ the level that the recurrent laryngeal nerve contrasted with lateral placing of the cords saying both recurrent laryngeal and also superior laryngeal nerve injury (indicating either a high vagal injury or a central nervous mechanism lesion such as a stroke).

Video stroboscopy allows assessment the the dynamic functioning of the vocal folds. Subtle abnormalities of mucosal motion deserve to be detected, and also functional deficits the accompany symptoms such together breathy phonation can undergo assessment.

Serology tests have tendency to add small value when examining glottic insufficiency, however, have to the patient’s symptoms be suggestive that systemic disease as a reason of your glottic insufficiency, particularly if there is apprehension of rheumatoid arthritis or other autoimmune conditions, the relevant serology tests should be obtained.

Vocal wrinkles immobility is a physics finding fairly than a diagnosis. That is necessary to identify the basic cause. Generally there is no identifiable cause found during the initial consultation. A comparison CT or MRI native the level the the skull base down to the diaphragm may need come be done to assess for any kind of lesions along the complete course the the recurrent laryngeal nerve and the vagus nerve in the neck and also chest.

Laryngeal electromyography must be a factor to consider if over there is a suspicion of the etiology of the vocal cord immobility. That aids in differentiating between motion special needs due come structural concerns such together mechanical fixation, dislocation, and ankylosis that the cricoarytenoid share which may reason a closure defect, matches motion special needs caused through denervation that the vocal fold.

Due to its bad sensitivity, acoustic voice record is less useful as a device for screening phonatory apparatus pathology. However, the helps assist the objective analysis that voice outcomes and subsequent rehabilitation. The clinician have the right to compare results based upon computer-based evaluation of acoustic signals quite than relying on patient or examiner subjective reporting.


Treatment / Management

Restoration the glottic competence may boost voice quality, dysphagia, and also reduce the risk of aspiration. Addressing these symptoms may enhance the patient’s as whole quality of life. The patient’s features such as age, occupation, society circumstances and also their choices will aid dictate management.

Whatever the details etiology that the glottic insufficiency, voice treatment usually dram a far-ranging role. For unilateral vocal wrinkles paralysis, voice treatment is the initial management choice since up to 60% of instances will settle spontaneously.<7> for glottic scarring and also sulcus vocalis, surgical results tend to it is in unpredictable and also conservative procedures of anti-reflux medications, steroids, and voice therapy can serve as initial attempt therapy.  Voice therapy might be efficient alone however is likewise a helpful adjunct to phonosurgical management.

Surgical options for glottic insufficiency due to unilateral paralysis or paresis target to medialize the influenced vocal wrinkles such that glottic closure is achievable during phonation and the reduced airway is better protected. The methods employed space Injection augmentation, medialization thyroplasty (type 1 thyroplasty), laryngeal reinnervation, and also arytenoid adduction.

Injection augmentation uses a variety of products injected right into the vocal fold that provides mass to reclaim a more normal form to the vocal fold. The confers the benefit of creating immediate results and is a more minimally invasive option compared with laryngeal frame surgery. Materials right now used incorporate absorbable hemostatic powder, bovine and also human-derived collagen, fat, dermal filler (calcium hydroxylapatite), hyaluronic mountain gels, and micro-ionized acellular dermis.<8> Teflon has previously been used as an injectable agent, however, it correlated with international body gigantic cell granulomas, and also has associations with far-reaching vocal deficits that have actually persisted even with corrective procedures.<7>

In medialization thyroplasty, the position of the vocal cord is medialized by one external strategy in i beg your pardon a long-term implant is placed through a thyroid cartilage home window intraoperatively, regularly with mindful sedation and also intra-operative voice evaluation (albeit crude, offered the patient is heavily sedated). Medialization thyroplasty using various implants, commonly expanded polytetrafluoroethylene (E-PTFE) or Silastic, is considered the gold typical treatment for huge glottic gaps and also is the mainstay surgical intervention for unilateral vocal cord palsy.<9>

Arytenoid adduction involves recreating the traction of the lateral cricoarytenoid muscle for this reason repositioning the vocal procedure medially. It has tendency not come be supplied as the sole procedure however is helpful as one adjunct whereby there is impaired vocal procedure contact however some residual vocal wrinkles motion.

Non-selective laryngeal reinnervation involves anastomosing the ansa cervicalis to the recurrent laryngeal nerve, v the goal of preserving the thyroarytenoid muscle bulk and also tone. It has actually the potential for excellent vocal functioning together the vocal cords continue to be pliable compared with other techniques.

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For the therapy of sulcus vocalis and vocal fold scars, in addition to injection augmentation and medialization and laryngoplasty, which address the glottic gap, epithelium releasing techniques are generally employed in mix with injection augmentation or implantation to aid improve the vibratory role of the vocal fold.<10>