User:KevintheSLP/sandbox

Modifications for Treatment Sections of Vocal Fold Paresis:

1. Specific description of voice therapy exercises. 2. Introduce better flow of surgical content 3. Discuss relevant benefits and risks of surgery/voice therapy

Intervention
The treatment of vocal fold paralysis varies depending on its cause and main symptoms. For example, if laryngeal nerve paralysis is caused by a tumor, suitable therapy should be initiated. In the absence of any additional pathology, the first step of clinical management should be observation to determine whether spontaneous nerve recovery will occur. Voice therapy with a speech-language pathologist is suitable at this time, to help manage compensatory vocal behaviours which may manifest in response to the paralysis.

Voice Therapy
The overall goal of voice therapy is to narrow the glottis without causing hyperfunction of the surrounding muscles. In the past, forced adduction exercises were used to push the vocal folds together, but often resulted in additional stress on the vocal folds. Current methods focus more generally on improving abdominal support, muscle strength and agility.

Hard Glottal Attacks
Hard glottal attacks involve building up subglottal pressure (air pressure below the vocal folds) before letting out a vowel sound. Often, this method is beneficial for clients who compensate by use of a falsetto register.

Half-Swallow Boom
The Half-Swallow Boom allows for a repositioning of the vocal folds by taking advantage of laryngeal positioning when swallowing. The client is asked to take a breath and then initiate the movement of swallowing, followed by forcefully saying “boom”. When performed properly, the "boom" sounds loud and clear. Eventually, this sound can be generalized to other words and phrases.

Abdominal Breathing
Training in breath support is essential for those clients who identify as professional voice users. Shifting the awareness of the breath to the belly (diaphragmatic breathing) aids in efficient vocal function, reducing the risk of hyperfunction and muscular tension.

Lip and Tongue Trills
Lip and tongue trills aid in the balance of resonance, as well as coordinate the muscles of respiration, phonation and articulation. In addition, subglottal pressure may increase during lip trills, and result in the generation greater vocal fold vibration.

Surgical Intervention
After 9 months of observation, should the paralysis not resolve and the patient be dissatisfied with the outcomes of voice therapy, the next option is temporary injection medialization. In this procedure, a variety of materials can be injected into the body of the vocal fold in order to bring it closer to the midline of the glottis. This allows the paralyzed vocal fold to make contact with the alternate fold, in order to more efficiently produce phonation. While injection augmentation has been long considered best practice, neither technique nor materials used have been standardized across clinicians. With this, results prove to be both safe and effective, but variable in their duration, lasting anywhere from 2 to 12 months.

For patients with significant paralysis at 12 months post-onset, medialization thyroplasty may be suggested. This surgical procedure introduces a shim between the inner wall of the larynx and the soft tissue supporting the vocal fold. As a result, the paralyzed vocal fold is supported in a position closer to the midline of the glottis, and retains its ability vibrate and phonate efficiently.

Voice Therapy after Surgical Intervention
It is generally recommended that voice therapy start 1 to 2 months after surgery, when swelling has subsided. Post-surgical intervention is warranted to restore laryngeal muscle strength, agility and coordination.