Oral presentation at IALP congress in 2013 - Turin, Italy. Authors: Pedro Melo Pestana; Susana Vaz Freitas; Cecília Almeida e Sousa PMP terapia - Esposende, Portugal

1. THE EFFECTIVENESS OF
INTERVENTION BY SPEECH THERAPY
IN VOCAL FOLD PARALYSIS
FP45
Pedro Melo Pestana1; Susana Vaz-Freitas1, 2; Cecília Almeida e Sousa 2
1Universidade Fernando Pessoa – Faculdade de Ciências da Saúde
2Centro Hospitalar do Porto – Hospital de Santo António

2. Introduction
Vocal fold paralysis (VFP) as:
• Peripheral neuropathy of the recurrent laryngeal nerve
and superior laryngeal nerve
• Affects more the left side than the right one (>
extension)
introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN
2
(Sulica, Cutrara and Blitzer, 2006)

3. Introduction
Consequences
of vocal fold
paralysis
1st
Dysphonia
aphonia
Breathiness
Wet voice
Dysphagia
Hyper
functioning
Extreme
and
unstable
pitch
introduction objectives methods results summary
Adapted from Verdolini et al (2005) and Simpson and Rosen (2008)
3
If dysphagia occurs:
• Aspiration of liquids (> common in
SLN)
• Weak and ineffective cough
• Difficult in swallowing solids (<
common)
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

4. Objectives
• Analyze the results achieved by a group of
patients with vocal fold paralysis using
objective assessment measures, before and
after intervention of Speech Language
Pathology (SLP)
4introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

5. Methods
5introduction objectives methods results summary
1st - 69 patients with
VFP
•2000-2010
2nd - 38 patients due
to exclusion criteria
•Missing values
•Signs of dysphagia
•Withdrawal due to lack of
attendance
Male (n/%) Female (n/%) Total
Gender 12 31,6% 26 68,4% 38
Mean(SD) Min Max
Age 49,58 (11,3) 22 69
Etiology n=38 %
Total thyroidectomy 16 42,1
Hemithyroidectomy 5 13,2
Neck surgery 5 13,2
Idiopathic 4 10,5
Esophageal surgery 2 5,3
Others 6 15,6
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

6. Methods
• Retrospective analysis of the results obtained
by a group of 38 patients with vocal fold
paralysis underwent intervention by Speech
Therapy at a Central Hospital in Portugal
6introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

7. Methods
• Clinical history
• Videostroboscopy
– Storz, Germany
– Conducted by Phoniatrician
• Acoustic Assessment – vowel [ α ]
– Sampling frequency: 44100 Hz
– 16 bits
– Philips SBC ME 400, unidirectional (cardioid)
– Room noise level <40 dB SPL
– Distance: 10cm
– Dr. Speech (Tiger, DRS, Inc.)
• Statistics:
– SPSS v 18.0.0 (SPSS Inc, Chicago, Illinois, EUA)
– Descriptive statistics
– Inferential statistics: Wilcoxon test
7introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

8. Methods
8introduction objectives methods results summary
Major therapeutic goal
Complete glottal closure, using the other intrinsic and
extrinsic laryngeal muscles
• If UVFP, the non-injured vocal fold compensation can be used
• Wrong compensations must be avoided
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

9. Results
9introduction objectives methods results summary
n=38 %
Unilateral paralysis - paramedian 19 50,0
Unilateral paralysis - intermediate 17 44,7
Unilateral palsy - paramedian 1 2,6
Bilateral palsy - paramedian 1 2,6
Videostroboscopy
Mean SD
13,29 7,95
Number of sessions
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

10. Results
Acoustic Analysis
10introduction objectives methods results summary
Parameter Pre-therapy Post-therapy
F0 (Hz) 206,74±59,86 212,72±59,80
Jitter (%) 1,023±0,98 0,44±0,70 **
Shimmer (%) 6,73±5,91 3,11±3,11 **
NNE (dB) -5,64±4,63 -9,55±6,17 **
The values are the mean+ standard deviation; ** p < 0,05
comparingpre- and post-therapymoments throughWilcoxon
test
202 204 206 208 210 212 214
0,00 0,20 0,40 0,60 0,80 1,00 1,20
0,00 2,00 4,00 6,00 8,00
-12,00 -10,00 -8,00 -6,00 -4,00 -2,00 0,00
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

11. Summary
• SLP in VFP started early (1 month after the onset)
is effective.
• Due to SLP intervention,these patients didn’t
need to undergo surgery.
• The type of paralysis was variable – most of them
with unilateral paralysis, in paramedian position.
• The average number of sessions needed was
13.29 ± 7.95.
11introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

12. Summary
• Differences in performance parameters
of jitter, shimmer and NNE were
significant (p <0.05)
• Jitter (local), shimmer (local) and NNE
were the best acoustic measurements to
reveal the SLP efficiency.
Consistent with those of Schindler et al (2008) and Cantarella et al (2010)
12introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

13. Future research
• Increase the amount of subjects involved
(> VFP types; > etiologies)
• Correlate type of paralysis and efficiency
• Isolate different therapeutical techniques
facing different types of VFP
13introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

14. Considerations
• If evidence based guidelines were created,
the decision making process will be easier
and faster
• Investing in SLP will allow the institutions to
attain economic advantage, avoiding
surgeries (13 SLP sessions are cheaper than many surgeries
and are not that invasive)
• The patient must not need to wait so much
time for a therapeutical decision
– < impact of voice disorderon quality of life
14introduction objectives methods results summary
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN

15. • Sulica, L., Cultrara, A., e Blitzer, A. Vocal Fold Paralysis: Causes, Outcomes and Clinical Aspects. In: Sulica L,
Blitzer A. Vocal fold paralysis. New York: Springer; 2006. p. 33-48.
• Verdolini K, Rosen CA, Branski RC, Andrews ML, American Speech-Language-Hearing Association. Special
Interest Division 3 V, Disorders V. Classification manual for voice disorders-I: Lawrence Erlbaum; 2005.
• SchindlerA, BotteroA, Capaccio P, Ginocchio D, Adorni F, Ottaviani F. Vocal improvement aftervoice therapy in
unilateral vocal fold paralysis. J Voice. 2008 Jan;22(1):113-8.
• Cantarella G, Viglione S, Forti S, Pignataro L. Voice therapy for laryngeal hemiplegia: the role of timing of
initiation of therapy. J Rehabil Med. 2010 May;42(5):442-6.
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melopestana@gmail.com
FP 45 – Pestana, Vaz-Freitas and Sousa - IALP 2013, TURIN