No AccessSIG 3 Voice and Upper Airway DisordersClinical Focus19 Jun 2019

Update: Behavioral Management of Unilateral Vocal Fold Paralysis and Paresis


    Vocal fold motion impairment (VFMI) can be the result of iatrogenic or traumatic injury or may be idiopathic in nature. It can result in glottic incompetence leading to changes in vocal quality and ease. Associated voice complaints may include breathiness, roughness, diplophonia, reduced vocal intensity, feeling out of breath with talking, and vocal fatigue with voice use. A comprehensive interprofessional voice evaluation includes auditory-perceptual voice evaluation, laryngeal examination including videostroboscopy, acoustic and aerodynamic voice measures. These components provide valuable insight into laryngeal structure and function and individual voice use patterns and, in conjunction with stimulability testing, help identify candidacy for voice therapy and choice of therapeutic techniques.


    A comprehensive, interprofessional evaluation of patients with VFMI is necessary to assess the role of voice therapy and develop a treatment plan. Although there is no efficacy data to support specific voice therapy techniques for treating VFMI, considerations for various techniques are provided.


    • Asik, M. B., Karasimav, O., Birkent, H., Merati, L., Gerek, M., & Yildiz, Y. (2015). Airway and respiration parameters improve following vocal fold medialization: A prospective study.Annals of Otology, Rhinology & Laryngology, 124(12), 972–977.
    • Awan, S. N., & Roy, N. (2009). Outcomes measurement in voice disorders: Application of an acoustic index of dysphonia severity.Journal of Speech, Language, and Hearing Research, 52, 482–499.
    • Balasubramanium, R. K., Bhat, J. S., Fahim , S., III., & Raju, R., III. (2011). Cepstral analysis of voice in unilateral adductor vocal fold palsy.Journal of Voice, 25(3), 326–329.
    • Belafsky, P. C., Mouadeb, D. A., Rees, C. J., Pryor, J. C., Postma, G. N., Allen, J., & Leonard, R. J. (2008). Validity and reliability of the Eating Assessment Tool (EAT-10).Annals of Otology, Rhinology & Laryngology, 117(12), 919–924.
    • Bonilha, H. S., & Dawson, A. E. (2012). Creating a mastery experience during the voice evaluation.Journal of Voice, 26, 665.e1–665.e7.
    • Busto-Crespo, O., Uzcanga-Lacabe, M., Abad-Marco, A., Berasategui, I., Garcia, L., Maraví, E., … Fernández-González, S. (2016). Longitudinal voice outcomes after voice therapy in unilateral vocal fold paralysis.Journal of Voice, 30(6), 767.e9–767.e15.
    • Cates, D. J., Venkatesan, N. N., Strong, B., Kuhn, M. A., & Belafsky, P. C. (2016). Effect of vocal fold medialization on dysphagia in patients with unilateral vocal fold immobility.Otolaryngology—Head & Neck Surgery, 155(3), 454–457.
    • Colton, R. H., & Casper, J. K. (1996). Understanding voice problems: A physiologic perspective for diagnosis and treatment. Philadelphia, PA: Lippincott Williams & Wilkins.
    • Connor, N. P., & Bless, D. M. (2007). Videostroboscopy.In A. Merati & S. Bielamowicz (Eds.), Textbook of laryngology (pp. 75–84). San Diego, CA: Plural.
    • D'Alatri, L., Galla, S., Rigante, M., Antonelli, O., Buldrini, S., & Marchese, M. R. (2008). Role of early voice therapy in patients affected by unilateral vocal fold paralysis.Journal of Laryngology and Otology, 122, 936–941.
    • Dastolfo, C., Gartner-Schmidt, J., Yu, L., Carnes, O., & Gillespie, A. I. (2016). Aerodynamic outcomes of four common voice disorders: Moving toward disorder specific assessment.Journal of Voice, 30(3), 301–307.
    • Dejonckere, P. H., & Lebacq, J. (2001). Plasticity of voice quality: A prognostic factor for outcome of voice therapy.Journal of Voice, 15, 251–256.
    • El-Banna, M., & Youssef, G. (2014). Early voice therapy in patients with unilateral vocal fold paralysis.Folia Phoniatrica et Logopaedica, 66, 237–243.
    • Francis, D. O., Sherman, A. E., Hovis, K. L., Bonnet, K., Schlundt, D., Garrett, C. G., & Davies, L. (2018). Life experience of patients with unilateral vocal fold paralysis.JAMA Otolaryngology—Head and Neck Surgery, 144(5), 433–439.
    • Francis, D. O., Williamson, K., Hovis, K., Gelbard, A., Merati, A. L., Penson, D. F., … Garrett, C. G. (2016). Effect of injection augmentation on need for framework surgery in unilateral vocal fold paralysis.Laryngoscope, 126(1), 128–134.
    • Gartner-Schmidt, J. (2010). Flow phonation.In J. Stemple & L. T. Fry (Eds.), Voice therapy: Clinical studies (3rd ed., 84–92). San Diego, CA: Plural.
    • Gartner-Schmidt, J., Gherson, S., Hapner, E. R., Muckala, J., Roth, D., Schneider, S., & Gillespie, A. I. (2015). The development of conversation training therapy: A concept paper.Journal of Voice, 30(5), 563–573.
    • Gillespie, A. I., Dastolfo, C., Magid, N., & Gartner-Schmidt, J. (2014). Acoustic analysis of four common voice diagnoses: Moving toward disorder-specific assessment.Journal of Voice, 28(5), 582–588.
    • Gillespie, A. I., & Gartner-Schmidt, J. (2016). Immediate effect of stimulability assessment on acoustic, aerodynamic, and patient-perceptual measures of voice.Journal of Voice, 30(4), 507.e15–507.e20.
    • Gorman, S., Weinrich, B., Lee, L., & Stemple, J. C. (2008). Aerodynamic changes as a result of vocal function exercises in elderly men.The Laryngoscope, 118, 1900–1903.
    • Guzman, M., Jara, R., Olavarria, C., Caceres, P., Escuti, G., Medina, F., … Laukkanen, A.-M. (2017). Efficacy of water resistance therapy in subjects diagnosed with behavioral dysphonia: A randomized controlled trial.Journal of Voice, 31(3), 385.e1–385.e10.
    • Heuer, R. J., Sataloff, R. T., Emerich, K., Rulnick, R., Baroody, M., Spiegel, J. R., … Butler, J. (1997). Unilateral recurrent laryngeal nerve paralysis: The importance of “preoperative” voice therapy.Journal of Voice, 11, 88–94.
    • Hogikyan, N. D., & Sethuraman, G. (1999). Validation of an instrument to measure voice-related quality of life.Journal of Voice, 13, 557–569.
    • Husain, S., Sadoughi, B., Mor, N., Levin, A. M., & Sulica, L. (2018). Time course of recovery of idiopathic vocal fold paralysis.Laryngoscope, 128, 148–152.
    • Husain, S., Sadoughi, B., Mor, N., & Sulica, L. (2018). Time course of recovery of iatrogenic vocal fold paralysis.Laryngoscope, 1–5.
    • Jacobson, B. H., Johnson, A., Grywalski, C., Silbergleit, A., Jacobson, G., & Benninger, M. S. (1997). The Voice Handicap Index (VHI): Development and validation.American Journal of Speech Language Pathology, 6, 66–70.
    • Jafari, N., Salehi, A., Meerschman, I., Izadi, F., Ebadi, A., Talebian, S., … Van Lierde, K. (2018). A novel laryngeal palpatory scale (LPS) in patients with muscle tension dysphonia.Journal of Voice.
    • Kao, Y.-C., Chen, S.-H., Wang, Y.-T., Chu, P.-Y., Tan, C.-T., & Chang, W.-Z. D. (2017). Efficacy of voice therapy for patients with early unilateral adductor vocal fold paralysis.Journal of Voice, 31(5), 567–575.
    • Kempster, G. B., Gerratt, B. R., Verdolini Abbott, K., Barkmeier-Kraemer, J., & Hillman, R. E. (2009). Consensus Auditory-Perceptual Evaluation of Voice: Development of a standardized clinical protocol.American Journal of Speech-Language Pathology, 18, 124–132.
    • Khoddami, S. M., Ansari, N. N., & Jalaie, S. (2015). Review on laryngeal palpation methods in muscle tension dysphonia: Validity and reliability issues.Journal of Voice, 29(4), 459–468.
    • Kreiman, J., Gerratt, B. R., Kempster, G. B., Erman, A., & Berke, G. S. (1993). Perceptual evaluation of voice quality: Review, tutorial, and a framework for research.Journal of Speech and Hearing Research, 36, 21–40.
    • Mattioli, F., Bergamini, G., Alicandri-Ciufelli, M., Molteni, G., Luppi, M., Nizzoli, F., Grammatica, A., & Presutti, L. (2011). The role of early voice therapy in the incidence of motility recovery in unilateral vocal fold paralysis.Logopedics Phoniatrics Vocology, 36, 40–47.
    • Mattioli, F., Menichetti, M., Bergamini, G., Molteni, G., Alberici, M. P., Luppi, M. P., … Presutti, L. (2015). Results of early versus intermediate or delayed voice therapy in patients with unilateral vocal fold paralysis: Our experience in 171 patients.Journal of Voice, 29(4), 455–458.
    • McFarlane, S., Waterson, T., Lewis, K., & Boone, D. (1998). Effect of voice therapy facilitation techniques on airflow in unilateral vocal fold paralysis patients.Phonoscope, 1, 187–191.
    • Meyer, T., Sulica, L., & Blitzer, A. (2007). Vocal fold paralysis.In A. Merati & S. Bielamowicz (Eds.), Textbook of laryngology (pp. 219–237). San Diego, CA: Plural.
    • Miller, S. (2004). Voice therapy for vocal fold paralysis.Otolaryngologic Clinics of North America, 37, 105–119.
    • Patel, R. R., Awan, S. N., Barkmeier-Kraemer, J., Courey, M., Deliyski, D., Eadie, D., … Hillman, R. (2018). Recommended protocols for instrumental assessment of voice: American Speech-Language-Hearing Association expert panel to develop a protocol for instrumental assessment of vocal function.American Journal of Speech-Language Pathology, 27, 887–905.
    • Prendes, B. L., Yung, K. C., Likhterov, I., Schneider, S. L., Al-Jurf, S. A., & Courey, M. S. (2012). Long-term effects of injection laryngoplasty with a temporary agent on voice quality and vocal fold position.Laryngoscope, 122, 2227–2233.
    • Rosen, C. A., Lee, A. S., Osborne, J., Zullo, T., & Murry, T. (2004). Development and validation of the Voice Handicap Index-10.Laryngoscope, 114(9), 1549–1556.
    • Rosen, C. A., Mau, T., Remacle, M., Hess, M., Eckel, H. E., Young, V. N., … Dikkers, F. G. (2016). Nomenclature proposal to describe vocal fold motion impairment.European Archives of Oto-Rhino-Laryngology, 273, 1995–1999.
    • Roy, N., & Bless, D. M. (1998). Manual circumlaryngeal techniques in the assessment and treatment of voice disorders.Current Opinion in Otolaryngology & Head and Neck Surgery, 6, 151–155.
    • Roy, N., Bless, D. M., Helsey, D., & Ford, C. N. (1997). Manual circumlaryngeal therapy for functional dysphonia: An evaluation of short- and long-term treatment outcomes.Journal of Voice, 11, 321–331.
    • Sataloff, R. T. (1987). The professional voice: Physical examination.Journal of Voice, 1, 191–201.
    • Schindler, A., Bottero, A., Capaccio, P., Ginocchio, D., Adorni, F., & Ottaviani, F. (2008). Vocal improvement after voice therapy in unilateral vocal fold paralysis.Journal of Voice, 22, 113–118.
    • Schneider, S. L. (2012). Behavioral management of unilateral vocal fold paralysis and paresis.Perspectives on Voice and Voice Disorders, 22(3), 112–120.
    • Schutte, H. K. (1986). Aerodynamics of phonation.Acta Oto-rhino-laryngolica Belgica, 40, 344–357.
    • Stemple, J. C., Glaze, L. E., & Klaben, B. G. (2000). Clinical voice pathology: Theory and management (3rd ed.). San Diego, CA: Singular.
    • Stemple, J. C., Lee, L., D'Amico, B., & Pickup, B. (1994). Efficacy of vocal function exercises as a method of improving voice production.Journal of Voice, 8, 271–278.
    • Stone, R. E., & Casteel, R. (1982). Restoration of voice in nonorganically based dysphonia.In M. Filter (Ed.), Phonatory voice disorders in children (pp. 132–165). Springfield, IL: C. C. Thomas.
    • Sulica, L., Rosen, C. A., Postma, G. N., Simpson, B., Amin, M., Courey, M. S., & Merati, A. M. (2010). Current practice in injection augmentation of the vocal folds: Indications, treatment principles, techniques, and complications.Laryngoscope, 120, 319–325.
    • Titze, I. R. (2006). Voice training and therapy with a semi-occluded vocal tract: Rationale and scientific underpinnings.Journal of Speech, Language, and Hearing Research, 49, 448–459.
    • Tyler, A. A. (1996). Assessing stimulability in toddlers.Journal of Communication Disorders, 29, 279–297.
    • Van Stan, J. H., Roy, N., Awan, S., Stemple, J., & Hillman, R. E. (2015). A taxonomy of voice therapy.American Journal of Speech-Language Pathology, 24, 101–125.
    • Verdolini, K. (2000). Resonant voice therapy.In J. Stemple (Ed.), Voice therapy: Clinical studies (pp. 46–61). San Diego, CA: Singular.
    • Verdolini, K., Druker, D. G., Palmer, P. M., & Samawi, H. (1998). Laryngeal adduction in resonant voice.Journal of Voice, 12, 315–327.
    • Walton, C., Carding, P., & Flanagan, K. (2018). Perspectives on voice treatment for unilateral vocal fold paralysis.Current Opinion in Otolaryngology & Head and Neck Surgery, 26, 157–161.
    • Walton, C., Conway, E., Blackshaw, H., & Carding, P. (2017). Unilateral vocal fold paralysis: A systematic review of speech-language pathology management.Journal of Voice, 31(4), 509.e7–509.e22.
    • Watts, C. R., & Awan, S. N. (2011). Use of spectral/cepstral analyses for differentiating normal from hypofunctional voices in sustained vowel and continuous speech contexts.Journal of Speech, Language, and Hearing Research, 54, 1525–1537.
    • Watts, C. R., Hamilton, A., Toles, L., Childs, L., & Mau, T. (2015). A randomized controlled trial of stretch-and-flow voice therapy for muscle tension dysphonia.Laryngoscope, 125, 1420–1425.
    • Woo, P. (1996). Quantification of videostroboscopic findings—Measurement of the normal glottal cycle.Laryngoscopy, 106(Suppl. 79), 1–20.
    • Woodson, G. (2008). Evolving concepts of laryngeal paralysis.The Journal of Laryngology and Otology, 122, 437–441.
    • Yung, K. C., Likhterov, I., & Courey, M. S. (2011). Effect of temporary vocal fold injection medialization on the rate of permanent medialization laryngoplasty in unilateral vocal fold paralysis patients.Laryngoscope, 121, 2191–2194.
    • Zraick, R. I., Kempster, G. B., Connor, N. P., Thibeault, S., Klaben, B. K., Bursac, Z., … Glaze, L. E. (2011). Establishing validity of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).American Journal of Speech-Language Pathology, 20, 14–22.

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