List of Abbreviations
LP – laryngeal paralysis/paresis
CT – computed tomography
US – ultrasound
MDT – multidisciplinary rehabilitation team
Terms and Definitions
Laryngeal paresis - temporary (up to 6 months) absence or restriction of laryngeal muscle mobility due to impaired innervation.
Laryngeal paralysis - prolonged (more than 6 months) absence of laryngeal muscle mobility resulting from impaired innervation.
Stridor - wheezing, noisy breathing caused by turbulent airflow in the airways.
Laryngeal stenosis - partial or complete narrowing of the laryngeal lumen leading to difficult airflow during breathing.
Dysphonia - voice disorder characterized by changes in pitch, timbre, loudness, and other voice characteristics.
Aphonia - complete loss of voice function or voicelessness.
Synkinesia - simultaneous contraction of antagonist muscles, leading to their mutual opposition.
Laryngospasm is a sudden involuntary contraction of the laryngeal muscles, leading to partial or complete closure of the glottis and temporary airway obstruction.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Laryngeal paresis - temporary (up to 6 months) absence or restriction of laryngeal muscle mobility due to impaired innervation.
Laryngeal paralysis is the prolonged (more than 6 months) absence of mobility of the laryngeal muscles due to impaired innervation [1, 2, 3, 4, 5, 6].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Laryngeal paralysis (LP) is a multi-etiological disease. The etiology of peripheral LP is due to the significant length of nerve trunks; asymmetry of the right and left recurrent laryngeal nerves; as well as the anatomical proximity of the laryngeal nerves and the variety of their topographic relationships with the anatomical structures of the neck and thoracic cavity [7].
The most common causes of unilateral LP include: surgical interventions on the thyroid and parathyroid glands (72.4%), operations for carotid artery atherosclerosis, lung cancer, and congenital heart defects (7.2%). In some cases, LP develops after surgical treatment of a cervical intervertebral disc hernia or cervical spine trauma, brain neoplasms, acute cerebrovascular accident, or progressive demyelinating neuropathy (5.7%). It should be noted that in 6.8% of patients, LP is diagnosed in the presence of neoplasms leading to compression of the recurrent nerve, such as thyroid cancer, lung cancer, esophageal cancer, or breast cancer metastases (or cancer of other localizations) to mediastinal lymph nodes. LP develops in 4.5% of cases after a prior acute respiratory infection or pulmonary tuberculosis. In 3.4% of individuals, the cause of LP cannot be established [8].
Bilateral LP is the result of surgical trauma (44%), malignant neoplasms of various localizations (17%), endotracheal intubation (15%), and neurological diseases (12%). In 12% of patients with bilateral LP, the cause of paresis is unknown [9, 10, 11].
In some cases, after ruling out all major causes of recurrent laryngeal nerve paresis, the etiology of the disease remains unclear. This condition is termed idiopathic [1, 8].
In addition to peripheral lesions of the vagus nerve, central types of LP of organic and functional origin are diagnosed (10%), which may be supranuclear or bulbar. Supranuclear pareses include cortical paresis, resulting from cerebral cortex damage, and corticobulbar paresis, developing due to damage to corticonuclear pathways. Bulbar paresis is characterized by damage to the vagus nerve nuclei in the medulla oblongata. LP of central origin develops in cerebrovascular disorders, brain neoplasms, traumatic brain injuries, infectious and inflammatory diseases (meningoencephalitis, poliomyelitis), congenital cerebral palsies, multiple sclerosis, and as a result of brain surgery [12, 13, 14, 15].
Functional central LPs form in neuropsychiatric disorders due to a disturbance in the interaction between excitation and inhibition processes in the cerebral cortex and are most commonly observed in hysteria [12-16].
The causes of unilateral LP in children may include: neoplasms (29%), postoperative complications (24%), inflammatory processes (21%), post-intubation and external laryngeal trauma (8%), central (5%), and idiopathic paralysis (13%). Recurrent nerve injury occurs during cardiac surgery in children. The incidence of intraoperative injuries is up to 4%, and 2.5% in procedures for aortic coarctation. Surgical closure of the ductus arteriosus, especially in newborns with extremely low birth weight (< 1000 g), frequently leads to paresis (paralysis) of the left recurrent laryngeal nerve, manifesting as postoperative stridor, hoarseness, feeding difficulties, and aspiration [17, 18].
Such a variety of etiological causes of LP requires the physician to take a very thorough medical history.
1.3 Epidemiology of the Disease or Condition
Unilateral LP is diagnosed in 14% to 29.9% of cases among patients with chronic laryngeal pathology (chronic laryngitis, benign laryngeal diseases). Furthermore, impaired mobility of the right and left halves of the larynx accounts for 63.36% and 56.82%, respectively [1, 19-23].
Bilateral recurrent laryngeal nerve paralysis is detected in 6.82% to 20% of patients [9, 10, 11].
1.4 Features of Coding the Disease or Condition
J38.0 – Paralysis of vocal cords and larynx
1.5 Classification of the disease or condition
The classification of LP distinguishes various forms of the disease according to the following criteria: level of n. vagus lesion, etiology, and extent of the pathological process [1, 10, 13, 14, 22, 23].
By level of n. vagus lesion:
central,
peripheral.
By etiology:
congenital,
acquired.
By prevalence:
unilateral,
bilateral.
1.6 Clinical presentation of the disease or condition
In paresis and paralysis of the larynx in both children and adults, all its functions are affected to varying degrees: protective function, manifested as impaired separation function; voice production (phonation) function, characterized by hoarseness of varying severity; and respiratory function, with clinical manifestations of laryngeal stenosis or hyperventilation symptoms. Clinical manifestations of LP depend on the position of the paralyzed vocal cords, their muscle tone state, the severity of atrophic processes, displacement and ankylosis of the cricoarytenoid joint, and compensatory-adaptive changes in the larynx.
In LP in adults, the vocal cords can assume a median, paramedian (2 mm from the midline of the glottis), intermediate (4 mm from the midline of the glottis), or lateral position (maximum abduction of the vocal cord during a deep forced inspiration).
In unilateral LP, the median or paramedian position of the vocal cord is optimal for voice function. Dysphonia may be mild. Patients with this position of the paralyzed vocal cord complain of respiratory failure during increased physical exertion or in case of obesity. Dysphagia is absent. In the intermediate or lateral position, dysphonia is more pronounced, up to aphonia; there is no respiratory failure during physical exertion, but hyperventilation symptoms are present, clearing the throat is difficult, and patients choke because the separation function of the larynx is impaired, especially in the early stages of paralysis development. The lateral position is observed in complete damage to the vagus nerve (including the superior and inferior laryngeal nerves), when the internal and external muscles of the larynx are immobile. Breathing is free, and dysphonia or aphonia is markedly pronounced.
The clinical course of bilateral LP has a number of features and similarly depends on the position of the paralyzed vocal cords and the tightness of their closure. With the lateral position of the vocal cords, the patient complains of impaired separation function, aphonia, inability to clear the throat, and symptoms of hyperventilation (dizziness that worsens with physical exertion and speech). In intermediate, paramedian, and median positions, symptoms of respiratory failure come to the forefront. The voice may be resonant, and separation function may be unimpaired. The degree of respiratory failure depends on the size of the laryngeal lumen, which determines the stages of stenosis.
Compensation stage: shortness of breath at rest is absent, but appears when walking. The glottis lumen in adults is 6-8 mm.
Subcompensation stage: inspiratory dyspnea appears, accessory muscles are involved in the act of breathing during physical exertion, retraction of the intercostal spaces, supraclavicular, infraclavicular, jugular fossae, and epigastric region is noted, breathing becomes noisy (stridor), pallor of the skin increases, blood pressure remains normal or elevated, and the glottis is 3-4 mm.
Decompensation stage: breathing is shallow and frequent, stridor is pronounced. The patient assumes a forced sitting position. The larynx makes maximum excursions. The face becomes pale-cyanotic, increased sweating, acrocyanosis, rapid and thready pulse, and decreased blood pressure are noted. The glottis is 2-3 mm.
Terminal stage (asphyxia): breathing is intermittent (Cheyne-Stokes type) or stops altogether. The glottis is 1 mm. Marked depression of cardiac activity. The pulse is frequent, thready, often non-palpable. The skin is pale-gray due to spasm of small arteries. Loss of consciousness, exophthalmos, involuntary urination, defecation, and cardiac arrest are observed.
The patient's condition is also affected by concomitant somatic pathology: cardiovascular, pulmonary, endocrine (hypothyroidism, hypoparathyroidism, etc.), and deformation of the cervical and thoracic spine [1, 10, 16].
The absence of tight vocal cord closure and arytenoid cartilage rotation can lead to aspiration, manifested by choking, resulting in laryngitis, tracheitis, and aspiration pneumonia. The patient is troubled by shortness of breath, which worsens with voice load [8, 24-26].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for Establishing the Diagnosis/Condition
The criteria for establishing the diagnosis of laryngeal paresis/paralysis are:
anamnestic data, specifically information about past trauma or surgical interventions on the neck, mediastinal organs, cervical spine, brain, or infectious diseases;
complaints of dysphonia, aphonia, dysphagia, dyspnea;
physical examination: patient inspection, palpation of the larynx; visual assessment of respiratory function; presence/absence of signs of laryngeal stenosis;
instrumental examination: indirect laryngoscopy, fibrolaryngoscopy, videolaryngoscopy, microlaryngoscopy of the larynx.
2.1 Complaints and Anamnesis
It is recommended to carefully collect complaints and medical history in patients with suspected laryngeal paresis to identify factors that may influence diagnostics and the choice of treatment tactics [1].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: patients with unilateral laryngeal paresis most often suffer from vocal fatigue, breathiness, inspiratory dyspnea upon physical exertion, as well as aspiration when consuming liquids [8, 13, 27]. When motor innervation of the inferior pharyngeal constrictor and sensory innervation of the larynx are impaired, difficulty swallowing may occur [19, 27].
One of the causes of laryngospasm is the phenomenon of recurrent laryngeal nerve synkinesis—inadequate motor and sensory reinnervation of the larynx. In this process, the adductor fibers of the recurrent laryngeal nerve innervate the abductor muscles and vice versa. This contributes to chaotic muscle contraction that does not correspond to the respiratory phase: muscles that narrow the laryngeal lumen may contract during inspiration [28-30]. Other causes of laryngospasm include laryngopharyngeal reflux, a reflex response to pharyngeal irritation, hypocalcemia, allergic reactions, and neurological and psychiatric disorders [31-37].
In bilateral laryngeal paresis, patients are predominantly troubled by impaired breathing. Inspiratory stridor appears during physical exertion, sleep, or conversation.
Taking an anamnesis helps differentiate true laryngeal stenosis from respiratory disorders in hysteria; diagnosing this condition is associated with certain difficulties. During the daytime in the presence of others, these patients exhibit noisy stridulous breathing. If patients are distracted during conversation, their breathing becomes freer. During sleep, patients breathe completely calmly. Tracheotomy is contraindicated in this type of stenosis and may exacerbate the manifestations of hysteria; such patients should be treated in a psychoneurological inpatient facility [16, 38].
In children, there is a certain dependence of leading symptoms on the form of the lesion. Thus, in unilateral laryngeal paralysis, the most frequent leading symptom was hoarseness, which occurred in 100% of cases. Moreover, during the first month, it may manifest as aphonia. The second most frequent is aspiration, which most commonly manifests as choking during feeding. Stridor is detected in approximately 36% of cases.
In children with bilateral laryngeal paralysis, the leading symptom is inspiratory or biphasic stridor, observed in 100% of children, which may increase with physical and emotional exertion. However, in 30% of cases, this symptom may be absent during sleep. The predominant tonality is high-pitched with reprises. All patients with bilateral laryngeal paralysis show signs of grade 1-3 laryngeal stenosis, which depends on the position of the vocal folds. Thus, when taking the disease history, special attention is paid to possible etiological factors in the development of laryngeal paresis, as well as differential diagnostic signs of true laryngeal paresis, cricoarytenoid joint pathology, and respiratory disorders in hysteria [17, 91].
2.2 Physical Examination
It is recommended that all patients with suspected laryngeal paresis undergo an initial appointment (examination, consultation) with an otorhinolaryngologist for the purpose of diagnosis and determining the clinical manifestations of the disease [1, 5, 13].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: physical examination of all patients with laryngeal paresis includes mandatory inspection and palpation of the neck and regional lymph nodes, which helps identify inflammatory and tumor processes, as well as laryngeal trauma.
It is recommended to subjectively assess the state of respiratory function in all patients with laryngeal paresis for the diagnosis of respiratory failure [1, 5, 13].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: the severity of respiratory failure is determined by the following signs: grade I – dyspnea occurs with moderate physical exertion; grade II – dyspnea occurs with minor physical exertion; grade III – dyspnea occurs at rest.
In chronic paralytic laryngeal stenosis (bilateral vocal fold paralysis) in the respiratory compensation stage, there is a shortening of the pause between inspiration and expiration—inspiration is prolonged (inspiratory dyspnea). Breathing becomes noisy, and changes occur in pulse rate, tension, and rhythm. In respiratory decompensation, the patient's general condition is severe, characterized by weakness, apathy, or extreme restlessness. Cyanosis of the fingers and face, dyspnea at rest and with mild physical exertion, noisy breathing, sonorous inspiration (inspiratory dyspnea), increased breathing rate, involvement of accessory muscles in breathing, tachycardia, and elevated blood pressure are noted [9, 10, 16].
Attention should be paid to the condition of postoperative scars on the neck to rule out cicatricial adhesion of the skin to the trachea or scar deformation of the soft tissues of the neck, which leads to impaired physiological mobility of the larynx during speech and swallowing, causing dysphagia and increased dysphonia.
Neurological symptoms that may indicate the cause of laryngeal paresis in a given patient should also be identified: asymmetry and impaired mobility of the soft palate and tongue, the presence of tongue twitches (fasciculations), and impaired mobility of oromandibular muscles.
2.3 Laboratory Diagnostics
It is recommended to perform a complete blood count (CBC) for all patients with paresis and paralysis of the larynx with suspected acute inflammation of the ENT organs to clarify the diagnosis [8, 24].
GCR CLoE 5Grade of Recommendation C (Level of Evidence – 5)
2.4 Instrumental Diagnostics
It is recommended to perform laryngoscopy using endoscopic research methods (microlaryngoscopy, laryngoscopy using a stroboscope, videolaryngoscopy, fibrolaryngoscopy) in all patients with suspected paresis/paralysis for diagnostic purposes [39-43, 90].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: performing indirect laryngoscopy is a mandatory diagnostic procedure when examining patients aged 12 years and older. When examining preschool and early school-age children in an outpatient setting, indirect laryngoscopy is not feasible in emotionally labile children and those with a pronounced gag reflex. They are indicated for video fibrolaryngoscopy of the larynx or fibrolaryngoscopy, which are considered the "gold standard" for diagnosing neurogenic laryngeal pathology in children. These examinations help establish a definitive diagnosis in 100% of cases of laryngeal paralysis
The main laryngoscopic sign of laryngeal paresis is immobility or marked restriction of mobility of one or both vocal folds. The arytenoid cartilage has limited mobility or is completely immobile. During phonation, the vocal folds do not close, leaving an oval, linear, or triangular gap between them. The healthy vocal fold may compensatorily cross the midline during phonation, which improves closure. The paralyzed vocal fold is often shortened and atrophied. Atrophy of the vocal fold is diagnosed by weakened tension of the medial margin, which becomes sickle-shaped and concave, thinning of the vocal fold, a protruding vocal process of the arytenoid cartilage, and a lower position of the paralyzed vocal fold relative to the healthy one.
In most cases, the arytenoid cartilage tilts forward following the shortening of the paralyzed vocal fold and shifts (rotates) medially. In paralysis of the posterior cricoarytenoid muscle, the arytenoid cartilage also tilts forward.
It is necessary to perform differential diagnosis between laryngeal paresis and cricoarytenoid joint pathology. Perichondritis (arthritis of various etiologies) of the cricoarytenoid joint clinically manifests as edema, infiltration, and hyperemia of the mucous membrane. In ankylosis of the cricoarytenoid joint, the arytenoid cartilage is completely immobile. Joint dislocation is diagnosed by their asymmetry, the presence of inflammatory phenomena in the joint area, and the displacement of the arytenoid cartilage into an atypical position.
Unilateral or bilateral hypertrophy of the vestibular folds is a compensatory-adaptive mechanism of pathological phonation and does not require surgical treatment. In some cases, phonation with the vestibular folds (vestibular-fold phonation), vibration of their edges, and rotation of the epiglottis can be observed.
Attention should be paid to the presence of neoplasms with endophytic or exophytic growth, which may be located in the vocal or vestibular parts of the larynx, in the area of the arytenoid cartilage, extend into the laryngopharynx, and lead to immobility of the vocal fold [15-16].
In children with suspected vocal fold paralysis, fiberoptic nasopharyngolaryngoscopy involves a more prolonged laryngeal examination. This is due to the negative reaction of most young children to the procedure, which results in the examination of the larynx during a phase of prolonged phonation (crying) with periodic sighs. In this state, the vocal folds remain adducted, which can simulate bilateral laryngeal paralysis. To avoid overdiagnosis of bilateral laryngeal paralysis, it is necessary to wait for an adequate inspiration with abduction of the vocal folds, which will not occur in bilateral paralysis.
It is recommended to perform computed tomography (CT) of the upper airway and neck or, in cases where CT is not feasible, perform radiography of the larynx or lateral and anteroposterior cervical spine radiography in all patients with laryngeal paresis/paralysis to clarify the diagnosis [5, 37, 40, 43, 44, 45, 47].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform contrast-enhanced CT of the upper airway and neck in all patients with vocal fold paresis/paralysis when neoplasm is suspected [44].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
It is recommended to perform computed tomography of the chest organs in all patients with vocal fold paresis/paralysis to diagnose space-occupying lesions [24, 44, 45].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform ultrasound of the larynx and ultrasound of the neck lymph nodes in all patients with vocal fold paresis/paralysis to diagnose space-occupying lesions [8, 24, 48, 49].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.5 Other Procedures
It is recommended to conduct an initial consultation (examination) with an endocrinologist and an initial consultation (examination) with a neurologist in patients with vocal fold paresis/paralysis to determine the cause of its development and select a treatment method [50].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comments: if diseases of various organs and systems that may cause vocal fold paresis/paralysis are suspected, consultations with other related specialists are also required: pulmonologist, gastroenterologist, oncologist.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Pharmacotherapy
Treatment depends on the etiology of laryngeal paresis and includes therapy for the underlying condition combined with cholinesterase inhibitors (anticholinesterase drugs). These drugs have a direct stimulating effect on impulse conduction along nerve fibers, interneuronal, and neuromuscular synapses of the peripheral and central nervous system [51-55].
It is recommended to use drugs affecting neuromuscular transmission: in adult patients with vocal fold paresis/paralysis in the early stages of the process, #Neostigmine methylsulfate** orally at 0.015 g twice a day or 1 ml of a 0.05% solution subcutaneously 1–2 times a day for 2 weeks [13].
GRC CLeE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to administer #Ipidacrine intramuscularly 1 ml (15 mg) once a day for 10 days, followed by transition to the oral form: 1 tablet of 20 mg 3 times a day for 45 days (month) in adult patients with unilateral vocal fold paresis/paralysis to restore mobility of the paralyzed vocal fold [53].
Level of Recommendation CLevel of Evidence 2Level of recommendation C (level of evidence – 2)
Comment: the drugs are contraindicated in children under 18 years of age.
It is recommended to use vitamin therapy with vitamin B1 preparations combined with vitamins B6 and/or B12 in adult patients with vocal fold paresis/paralysis in the early stages of the process to restore nerve impulse conduction in synapses and restore mobility of the paralyzed vocal fold [13].
GRC CLeE 5Grade of Recommendation C (Level of Evidence – 5)
Comment: it is necessary to consider contraindications to vitamin therapy in patients with a history of oncological diseases, as well as in children under 18 years of age.
3.2 Non-pharmacological therapy
It is recommended to develop an individual speech therapy correction program (classes with a medical speech therapist) for voice and respiratory function in adult patients and children with unilateral vocal fold paresis/paralysis at the earliest stages from the onset of the disease to establish a new compensatory mechanism of phonation, restore a sonorous voice, normalize respiratory function, phonatory breathing, and swallowing function [26, 56-58].
Adults: Oxford Centre for Evidence-Based Medicine level of recommendation C (level of evidence – 4)
Children: grade of recommendation C (level of evidence – 5)
Comments: development of an individual speech therapy rehabilitation program in adults and children with laryngeal paresis and paralysis should begin as early as possible after diagnosis, before the completion of the patient's examination and the end of the course of drug therapy. It should be performed in the absence of pain in the postoperative wound area, acute inflammatory diseases, and with the patient's general satisfactory well-being. A new phonation mechanism is formed due to the compensatory shift of the healthy vocal fold across the midline and its maximum approximation to the immobile vocal fold. The development of an individual speech therapy rehabilitation program is conventionally divided into 3 stages: initial (preparatory), main, and final. At each stage, classes are conducted simultaneously in three directions: 1) physiological and phonatory breathing; 2) normalization of the muscle tone of the vocal apparatus and activation of laryngeal mobility; 3) pitch, loudness, and timbre of the voice, as well as coordination of breathing, phonation, and articulation. The duration and sequence of the training stages are selected individually for each patient, taking into account their physical and psychoemotional status, as well as the clinical and functional state of the larynx.
It is recommended to develop an individual speech therapy rehabilitation program for all patients with laryngeal paralysis in the postoperative period to restore breathing and voice function [56].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform an examination (consultation) by a physical therapy doctor for all patients suffering from laryngeal paralysis in order to normalize trophic processes and restore neuromuscular synaptic transmission [58–62, 89].
GCR BLEL 5Grade of Recommendation B (Level of Evidence – 5)
3.3 Surgical treatment in adults
It is recommended to perform surgical treatment in the volume of tracheotomy in adults with bilateral laryngeal paralysis, respiratory function decompensation (decompensated stage of laryngeal stenosis) [63–65].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform surgical treatment in the volume of temporary chordopexy (laterofixation of the vocal fold) in adults with bilateral laryngeal paralysis upon respiratory function decompensation within up to 6 months from the moment of recurrent laryngeal nerve injury [67–69].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform surgical treatment in the volume of bilateral chordopexy (laterofixation of the vocal folds) in adult patients more than 6 months after the onset of laryngeal paralysis [70–72].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform surgical treatment in the volume of microendolaryngeal laryngeal resection using video-endoscopic and laser technologies in adults, as well as laryngeal plastics in adult patients with bilateral laryngeal paralysis, in case of impossibility of adequate breathing through the natural pathways and ineffectiveness of conservative treatment for a period of more than 6 months from the onset of recurrent laryngeal nerve injury in order to restore respiratory function [73–77, 84].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform surgical treatment in the volume of reinnervation and reconstructive functional plasty of the larynx and trachea using microsurgical techniques in adults with bilateral and unilateral laryngeal paralysis in order to restore function [80–82].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is not recommended to perform surgical treatment (laryngeal plasty, microendolaryngeal laryngeal resection using video-endoscopic technologies) in adult patients with bilateral laryngeal paralysis in the presence of unresectable neoplasms of the thyroid gland, lungs, esophagus, or mediastinal metastases [63].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: upon respiratory function decompensation due to unresectable neoplasms of the thyroid gland, lungs, esophagus, or mediastinal metastases, tracheotomy is indicated.
It is recommended to perform surgical treatment in adult patients with unilateral laryngeal paralysis in the volume of endolaryngeal reconstructive and plastic intervention on the vocal folds using implants and microsurgical techniques over 6 months from the onset of the disease in adult patients in order to restore voice function [83, 92].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3.4 Surgical treatment in children
It is recommended to perform surgical treatment in the volume of tracheotomy in congenital and acquired bilateral laryngeal paralysis, respiratory function decompensation (decompensated stage of laryngeal stenosis) in children in order to restore respiratory function [66, 78].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform surgical treatment for bilateral laryngeal paralysis in the volume of laryngeal plasty with placement of a costal autograft into the posterior wall of the larynx in children over 4 years of age with a tracheostomy in order to expand the vocal region of the larynx [17, 96].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform surgical treatment in the volume of microendolaryngeal laryngeal resection using video-endoscopic technologies (chordarytenoidotomy) in children over 4 years of age with congenital and acquired bilateral laryngeal paralysis with subcompensation of respiratory function (subcompensated stage of laryngeal stenosis) in the absence of a previously placed tracheostomy in order to restore respiratory function [17, 96].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform surgical treatment in the volume of microendolaryngeal laryngeal resection using video-endoscopic technologies (chordarytenoidotomy followed by contralateral chordarytenoidotomy 6 months later) in children over 4 years of age with acquired bilateral vocal fold paralysis, in the presence of a previously placed tracheostomy, with the aim of restoring respiratory function and decannulation [17, 96].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform surgical treatment for acquired bilateral vocal fold paralysis in the volume of laryngeal plastic surgery with placement of a costal autograft into the posterior wall of the larynx in children over 4 years of age with a tracheostomy, in order to expand the vocal glottis [17, 96].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform surgical treatment for congenital bilateral vocal fold paralysis (in the absence of signs of recovery) in the volume of laryngeal plastic surgery with placement of a costal autograft into the posterior wall of the larynx in children over 5 years of age with a tracheostomy, in order to expand the vocal glottis [17, 96].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform surgical treatment in the volume of reinnervation and reconstructive functional plasty of the larynx and trachea using microsurgical techniques in bilateral and unilateral laryngeal paralysis in older children with the aim of restoring function [80-81].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
For patients suffering from laryngeal paresis or paralysis, the earliest possible restoration of lost functions—adequate breathing and voice—is vital. Rehabilitative measures should be initiated from the moment of the first medical consultation. The rehabilitation of such patients includes a comprehensive set of measures, including medical, surgical, and physiotherapeutic treatment, as well as sessions with a medical speech-language pathologist.
It is recommended for patients with laryngeal paresis and paralysis to undergo rehabilitation measures (development of speech-language rehabilitation programs, physiotherapy) to achieve the maximum quality of life, aimed at restoring or compensating for the lost functions of voice, swallowing, and breathing [21, 74, 85, 86, 87, 88].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: medical rehabilitation of patients with laryngeal paresis and paralysis should be carried out in outpatient settings and/or in a day patient department within a medical rehabilitation unit of federal healthcare facilities providing medical care in this profile, a phoniatric center (audiology and phoniatrics center) or a department providing care for patients with voice disorders, staffed with a multidisciplinary rehabilitation team (MDRT) appropriate for the rehabilitation profile (the center's staff may include: a physical and rehabilitation medicine physician, otorhinolaryngologist (phoniatrician), physical therapist, exercise therapy physician, psychotherapist, neurologist, medical psychologist, medical speech-language pathologist specializing in phonopedics).
When unilateral or bilateral laryngeal paresis is detected, including iatrogenic etiology or resulting from acute cerebrovascular accident, rehabilitation measures for voice, breathing, and swallowing functions should be initiated at the earliest possible time (no later than 72 hours after the diagnosis of laryngeal paralysis), involving members of the multidisciplinary rehabilitation team (MDRT) whenever possible.
5. Prevention and Dispensary Observation
It is recommended to conduct follow-up dispensary appointments (examinations, consultations) by an otorhinolaryngologist (phoniatrician) (performing indirect laryngoscopy, videolaryngoscopy) for patients with laryngeal paresis every 3 or 6 months, depending on the clinical presentation of respiratory failure, with the aim of determining the possibility of rehabilitating the lost function [1, 24].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
6. Organization of Medical Care
Indications for hospitalization in a medical organization:
1) indications for emergency hospital admission: acute and chronic paralytic laryngeal stenosis in the subcompensation and decompensation stages;
2) indication for planned hospital admission of patients with bilateral or unilateral laryngeal paralysis is surgical treatment.
Indications for patient discharge from a medical organization:
1) in case of emergency admission: restoration of respiratory function and elimination of signs of respiratory failure;
2) in case of planned admission: restoration or improvement of breathing through the natural airways, subsiding of postoperative reactive phenomena after surgical treatment for bilateral vocal fold paralysis; restoration or improvement of voice function in unilateral paralysis.
7. Additional Information
7.1 Laryngeal paresis in rare diseases
Tapia syndrome: combined lesion of the nucleus ambiguus (IX, X cranial nerves), nuclei of the XI and XII cranial nerves, as well as the pyramidal tracts. It is characterized by peripheral paresis of the pharyngeal and soft palate muscles and unilateral laryngeal paralysis (clinically: dysphagia, dysarthria in the form of rhinolalia, dysphonia); peripheral paresis of the sternocleidomastoid and part of the trapezius muscle; peripheral paresis of the tongue muscles; contralateral hemiparesis of the arm and leg. Tapia syndrome may develop as a complication during mask ventilation due to head displacement, during tracheal intubation during surgical procedures, or bronchoscopy.
Collet-Sicard syndrome is a combined lesion of the IX, X, XI, and XII cranial nerves. Clinically, the disease may manifest as hoarseness, dysphagia, and pharyngeal pain. Paresis of the soft palate, laryngeal, sternocleidomastoid, and trapezius muscles is diagnosed, along with dysphagia, taste disorders on the posterior third of the tongue, and hypesthesia of the soft palate, posterior pharyngeal wall, and larynx. Collet-Sicard syndrome is a very rare disease, the causes of which may include tumors in the jugular foramen region, trauma, internal carotid artery aneurysm, metabolic disorders, atherosclerosis, infections, intoxications, chronic trauma to the glossopharyngeal nerve; cases of focal primary tumor involvement or metastases to the temporal bone, sigmoid-jugular complex thrombosis, and prostate tumor metastases have been described. With timely diagnosis and treatment, recovery is possible.
In addition to Collet-Sicard syndrome, which is regarded as jugular foramen syndrome involving multiple cranial nerves simultaneously, this group also includes Vernet syndrome, Villaret syndrome, Avellis syndrome, etc. In Vernet syndrome (involving IX, X, XI), paralysis of the soft palate, larynx, pharynx, as well as the sternocleidomastoid and trapezius muscles is diagnosed. Clinically, it manifests as hoarseness, dysphagia, and loss of taste on the posterior third of the tongue. Pharyngoscopy reveals deviation of the posterior pharyngeal wall toward the healthy side when the tongue is displaced forward. Causes: gunshot wounds, skull base fractures, jugular vein thrombosis.
Villaret syndrome (lesion of the IX–XII cranial nerves, cervical sympathetic nerve, and fibers of the VII cranial nerve). Clinically manifested by dysphagia when swallowing solid food due to upper pharyngeal paralysis, unilateral paralysis of the soft palate, anesthesia of paralyzed areas, loss of sensation on the posterior third of the tongue, unilateral vocal fold paralysis, and unilateral paralysis of the sternocleidomastoid and trapezius muscles. Etiology: trauma, neoplasms, inflammatory processes, and abscesses localized posterior to the parotid gland.
Avellis syndrome (lesion of the IX–XII cranial nerves) clinically manifests as dysphagia, dysphonia, dysarthria, hemihypesthesia of the contralateral limbs, and possible paresis of the sternocleidomastoid and trapezius muscles. On the affected side, shoulder drooping and restricted arm elevation above the horizontal level are observed. Turning the head toward the paretic limbs is difficult.
Unilateral vocal fold paralysis may accompany amyotrophic lateral sclerosis, neuralgic amyotrophy (Parsonage-Turner syndrome), multiple system atrophy, as well as trauma, tumors, cerebrovascular disorders, and other brain lesions in various diseases, including systemic ones [93, 94, 95].
Criteria for Evaluating the Quality of Medical Care
Criteria for assessing the quality of primary health care provided to adults and children with laryngeal paresis/paralysis (ICD-10 codes J38.0)
№ | Quality criteria | Evaluation of compliance |
|---|---|---|
1. | Initial appointment (examination, consultation) by anotorhinolaryngologist was completed. | Yes/No |
2. | Computed tomography (CT) of the upper respiratory tract and neck and/or radiography of the larynx or radiography of the cervical spine in anteroposterior and lateral projections was performed in a patient with laryngeal paresis/paralysis of unclear etiology. | Yes/No |
3. | Computed tomography (CT) of the chest organs was performed in a patient with laryngeal paresis/paralysis of unclear etiology. | Yes/No |
Criteria for assessing the quality of specialized medical care provided to adults and children with laryngeal paresis/paralysis (ICD-10 codes J38.0)
№ | Quality criteria | Evaluation of compliance |
|---|---|---|
1. | Initial appointment (examination, consultation) by an otorhinolaryngologist was performed. | Yes/No |
2. | Surgical treatment was performed in all adult patients with vocal fold paralysis, except for patients with bilateral vocal fold paralysis due to inoperable neoplasms of the thyroid gland, lungs, esophagus, or mediastinal metastases. | Yes/No |
3. | Treatment with neostigmine methylsulfate** was administered orally at 0.015 g 2 times a day or 1 ml of a 0.05% solution subcutaneously 1–2 times a day for 2 weeks, and/or vitamin therapy with group B1 vitamins in combination with vitamins B6 and/or B12 in adult patients with vocal fold paralysis in the early stages of the process. | Yes/No |
4. | Treatment was administered with #Ipidacrine IM 1 ml (15 mg) once daily for 10 days, followed by transition to the oral form: 1 tablet (20 mg) 3 times daily for 45 days in adult patients with unilateral laryngeal paralysis | Yes/No |
References
Show references
Otorhinolaryngology: National Guidelines. Short Edition / Ed. by Yu.K. Yanov, A.I. Kryukov, V.V. Dvoryanchikov, E.V. Nosula. – 2nd ed., rev. and supp. Moscow: GEOTAR-Media, 2024. – 992 p.
Kutukov Yu.N. Functional state of the neuromuscular apparatus of the larynx after transection of the recurrent nerve or its individual branches // Zhurn. ushn., nos. i gorl. bol. – 1978. – No. 6. – P. 43-47.
Kutukov Yu.N. Electrodiagnostics of the functional state of the internal neuromuscular apparatus of the larynx in paresis and paralysis of the recurrent nerve: Author's abstract of the Cand. Sci. (Med.) dissertation. – L., 1981. – 25 p.
Krylov B.S., Felberbaum R.A., Ekimova G.M. Physiology of the neuromuscular apparatus of the larynx. – L.: Nauka, 1984. – 216 p.
Otorhinolaryngology: National Guidelines / Ed. by N.A. Daikhes, Yu.K. Yanov. – M.: Redkollegiya, 2024. – Vol. 2. – P. 184-187
Shindo M.L. et all. Effects of denervation on laryngeal muscles: a canine mode // Laryngoscope. -1992.-Vol.102, № 6.- P.663-669. DOI: 10.1288/00005537-199206000-00012
Mu L, S Yang S. An experimental study on the laryngeal electromyography and visual observations in varying types of surgical injuries to the unilateral recurrent laryngeal nerve in the neck // Laryngoscop. - 1991. Vol.101, № 7. - P.699-708. doi: 10.1288/00005537-199107000-00003.
Stepanova Yu.E., Gotovyakhina T.V. Algorithm for examining patients with unilateral laryngeal paresis of unclear etiology in the practice of an otorhinolaryngologist. Consilium Medicum. 2017; 19 (11.1. Respiratory Diseases): 37–40. DOI: 10.26442/2075-1753_19.11.1.37-40.
Kirasirova E.A., Piminidi O.K., Lafutkina N.V., Mamedov R.F., Rezakov R.A., Kuzina E.A. Diagnosis and treatment of bilateral vocal cord paralysis. Vestnik Otorinolaringologii. 2017;82(4):77–82.
Babiyak V.I., Govorun M.I., Nakatis Ya.A., Pashchinin A.N. Otorhinolaryngology. St. Petersburg: Piter, 2012. – 640 p.
Brayko I.I., Krivopalov A.A., Shamkina P.A. Prevalence, etiology, clinical presentation, and differential diagnosis of chronic paralytic laryngeal stenosis. Rossiyskaya Otorinolaringologiya. 2019;18(6):88–96. https://doi.org/10.18692/1810-4800-2019-6-88-96
Gotovyakhina T.V. Causes of voice function impairment after thyroid surgery. Rossiyskaya Otorinolaringologiya. 2014. – No. 1. – P. 45-48
Vasilenko Yu.S. The Voice. Phoniatric Aspects. M.: Dipak, 2013. – 396 p.
Badalyan O.A. Neuropathology. M.: Prosveshchenie, 1987. – 334 p.
Parnell F.W., Brandenburg J.H. Vocal cord paralysis. A review of 100 cases. F.W. Laryngoscope. 1970; Vol.80: p. 1036-1045.
Babiyak V.I., Gofman V.R., Nakatis Ya.A. Neuro-otorhinolaryngology: A Guide for Physicians. St. Petersburg: Hippocrates, 2002. – 728 p.
Zakharova M.L., Pavlov P.V. Laryngeal paralysis in children. Management tactics for patients. Rossiyskaya Otorinolaringologiya. 2017. No. 3 (88). – P. 41-45. Supplement
Tsvetkov E.A. Malformations of the Larynx and Trachea in Children. St. Petersburg: Sotis-Lan, 1999. – 128 p.
Gotovyakhina T.V. Causes of voice function impairment after surgical treatment of thyroid diseases // Ros. Otorinolaringol. – 2014. – No. 1. – P. 45-48.
Stepanova Yu.E., Gotovyakhina T.V., Koren E.E., Mokhotaeva M.V. Laryngeal diseases in voice professionals at the present stage. In: Proceedings of the XX Congress of Otorhinolaryngologists of Russia. 2021:424-425. https://xx-congress-msk.ent-congress.ru/materiali.html.
Greben N.I., Romanova Zh.G., Konoyko N.S., Zhurnevich V.I., Eremenko M.A. Main issues of rehabilitation of patients with postoperative laryngeal paresis and paralysis. Otorhinolaryngology. Eastern Europe. 2019; 2:140-148. https://elibrary.ru/download/elibrary_38563166_14413430.pdf.
Gotovyakhina T.V. Results of dynamic monitoring of patients with unilateral paresis of the laryngeal muscles due to thyroid surgery // Rossiyskaya Otorinolaringologiya. 2015. No. 1. – P. 44–48.
Sayed Toutounchi S. J., Eydi M., Golzari S. E., Ghaffari M. R., Parvizian N. Vocal cord paralysis and its etiologies: a prospective study. J Cardiovasc Thorac Res. 2014; 6:47–50. doi: 10.5681/jcvtr.2014.009
Otorhinolaryngology: National Guidelines / ed. by V.T. Palchun. – 2nd ed., rev. and supp. – M.: GEOTAR-Media, 2020. – 1024 p.
Stepanova Yu.E., Gotovyakhina T.V., Koren E.E., Mokhotaeva M.V. Laryngeal diseases in voice professionals at the present stage. In: Proceedings of the XX Congress of Otorhinolaryngologists of Russia. 2021: 424-425. https://xx-congress-msk.ent-congress.ru/materiali.html.
Stepanova Yu.E., Gotovyakhina T.V., Makhotkina N.N., Mokhotaeva M.V. Possibilities of medical and pedagogical rehabilitation of patients with unilateral laryngeal paresis // RMJ. 2017. No. 23. – P. 1712–1716.
Syamal M. N., Benninger M. S. Vocal fold paresis: a review of clinical presentation, differential diagnosis, and prognostic indicators. Curr Opin Otolaryngol Head Neck Surg. 2016; 3:197-202. DOI: 10.1097/MOO.000000000000025
Crumley R. L. Laryngeal synkinesis revisited. Ann Otol Rhinol Laryngol 2000; 109:365-371. DOI: 10.1177/000348940010900405.
Zealear D., Mainthia R., Li Y., Kunibe I., Katada A., Billante C., Nomura K. Stimulation of denervated muscle promotes selective reinnervation, prevents synkinesis, and restores function. The Laryngoscope. 2013;124(5):180-187. https://doi.org/10.1002/lary.24454.
Nisht A.Yu., Chirsky V.S., Fomin N.F. Morphological basis of the restoration of motor innervation in peripheral nerve injuries. Journal of Anatomy and Histopathology. 2019; 4:66-73. DOI: 10.18499/2225-7357-2019-8-4-66-73.
Wani M. K., Woodson G. E. Paroxysmal laryngospasm after laryngeal nerve injury. Laryngoscope. 1999; 109(5):694-697. DOI: 10.1097/00005537-199905000-00003.
Obholzer R. J., Nouraei S. A., Ahmed J., Kadhim M. R., Sandhu G. S. An approach to the management of paroxysmal laryngospasm. J Laryngol Otol. 2008;122(1):57-60. DOI: 10.1017/S0022215107005907.
Pinder D., McDonald S. E., Medcalf M., Bridger M. W. Idiopathic laryngeal spasm: management and long-term outcome. Eur Arch Otorhinolaryngol. 2007;264(2):159-162. DOI: 10.1007/s00405-006-0165-0.
Odokozov I.A., Khorov O.G. Features of the clinical and functional state of the vocal apparatus in patients with unilateral laryngeal paresis after thyroid surgery. Otorhinolaryngology. Eastern Europe. 2015; 2:27-38. https://elibrary.ru/item.asp?id=23876889.
Gotovyakhina T.V. Laryngeal pathology in the early postoperative period during thyroid surgery. Rossiyskaya Otorinolaringologiya. 2016; 2:25-30. DOI: 10.18692/1810-4800-2016-2-25-30.
Bellantone R, Lombardi CP, Bossola M, et al. Total thyroidectomy for management of benign thyroid disease: review of 526 cases. World J Surg. 2002;26(12):1468-1471. doi: https://doi.org/10.1007/s00268-002-6426-1
Kirasirova E.A., Lafutkina N.V., Mamedov R.F., Gogoreva N.R., Ekaterinchev V.A., Rezakov R.A. Examination and treatment tactics for patients with laryngeal paresis or paralysis of various etiologies // RMJ. Otorhinolaryngology. – 2013. – No. 11. – P. 564-566.
Karpova O.Yu. Voice disorder as a symptom of more than just laryngeal diseases. RMJ. 1999; No. 9.
Stepanova Yu.E. Modern methods of diagnosing laryngeal diseases // Doktor.Ru. 2009. No. 5. – P. 31–34.
Vasilenko Yu.S., Romanenko S.G. Clinical and functional examination of patients with unilateral laryngeal paralysis // Vestnik Otorinolaringologii. 2000. No. 5. – P. 50–53.
Stepanova Yu.E. The importance of timely diagnosis of laryngeal diseases during the initial examination by an otorhinolaryngologist / Yu.E. Stepanova, T.V. Gotovyakhina, N.N. Makhotkina // Meditsinsky Sovet. – 2018. – (20): 58-64.
Stepanova Yu.E. Innovative endoscopic technologies in the diagnosis of laryngeal diseases in adults and children / Yu.E. Stepanova // Vestnik Otorinolaringologii. – 2020. – 85 (6): 41-45. DOI: 10.17116/otorino20208506141
M.H. Bashir, C. Joyce, A. Bolduan, V. Sehgal, M. Smith and S.J. Charous Revisiting CT Signs of Unilateral Vocal Fold Paralysis: A Single, Blinded Study. Revisiting CT Signs of Unilateral Vocal Fold Paralysis: A Single, Blinded Study American Journal of Neuroradiology April 2022, 43 (4) 592-596; DOI: https://doi.org/10.3174/ajnr.A7451
Shy-Chyi Chin, Simon Edelstein, Cheng-Yu Chen, and Peter M. SomAUTHOR INFO & AFFILIATIONS Using CT to Localize Side and Level of Vocal Cord Paralysis Volume 180, Issue 4 https://doi.org/10.2214/ajr.180.4.180116
Mustafaev D.M., Svistushkin V.M., Osipenko E.V. et al. Clinical examination algorithm in unilateral laryngeal paresis and paralysis of unclear origin. Ros. Otorinolaringologiya. 2009; 2: 84-9.
Romanenko S.G., Pavlikhin O.G., Lesogorova E.V., Kurbanova D.I., Krasilnikova E.N., Safyannikova E.A. Possibilities of voice restoration in unilateral laryngeal paralysis (analysis of 3451 cases). Vestnik Otorinolaringologii. 2025;90(5):31–34. https://doi.org/10.17116/otorino20259005131
Surgery of the Larynx and Trachea / Remacle Marc, Eckel Hans, Edmund et al.; transl. from English ed. by Yu.K. Yanov. – M.: Panfilov Publishing House; BINOM. Knowledge Laboratory, 2014. – 368 p.: ill.
Gafurova A.I. Capabilities of ultrasound diagnostics of the head and neck organs. Rossiyskaya Otorinolaringologiya. 2018;6:91–97. https://doi.org/10.18692/1810-4800-2018-6-91-97
Frolova I.G., Choynzonov E.L., Goldberg V.E., Chizhevskaya S.Yu., Chernov V.I., Goldberg A.V., Belevich Yu.V. Radiation research methods in the complex diagnosis of lymphogenous metastasis in patients with laryngeal and hypopharyngeal cancer. Siberian Journal of Oncology. 2018; 17 (3): 101–108. – doi: 10.21294/1814-4861-2018-17-3-101
Gotovyakhina T.V., Stepanova Yu.E., Makhotkina N.N. Unilateral laryngeal paresis: clinical features and diagnostic challenges. Rossiyskaya Otorinolaringologiya. 2023. Vol. 22. No. 5 (126). – P. 19-27.
Temiraeva Z.K. Examination algorithm and complex treatment of patients with unilateral laryngeal paralysis. Rossiyskaya Otorinolaringologiya No. 1 (38) 2009, P. 143-148.
Choynzonov E.L., Balatskaya L.N., Chizhevskaya S.Yu., Cheremisina O.V., Krasavina E.A., Zhuikova L.D. Voice rehabilitation of patients with unilateral laryngeal paresis after surgical treatment of thyroid cancer, Problems of Endocrinology. 2018. Vol. 64. No. 6. – P. 356-362 56.
Shchilenkova V.V. On voice rehabilitation in unilateral vocal fold paresis. Vestn. Otorinolaringologii. 2016; No. 3(81): 67-72.
D.M. Mustafaev, V.M. Svistushkin, E.V. Osipenko, V.N. Selin, V.M. Isaev, S.B. Tsagadaeva. Clinical examination algorithm in unilateral laryngeal paresis and paralysis of unclear origin. Rossiyskaya Otorinolaringologiya No. 2 (45) 2009, P. 84-90.
Baizhumanova A.S. Restorative treatment methods for patients with laryngeal paralysis. J Clin Med Kaz 2015; 3(37):9-13.
Balatskaya L.N., Kitsmanyuk Z.D., Starokha A.V. Voice restoration in laryngeal paresis after surgical treatment of thyroid cancer // Novosti Otorinolaringologii i Logopatologii. – 2000. – No. 2. – P. 17-18.
Speech Therapy: Textbook for students of pedagogical institutes majoring in "Defectology" / Ed. by L.S. Volkova. – M: Prosveshchenie, 1989. – 528 p.
Stepanova Yu.E., Gotovyakhina T.V., Mokhotaeva M.V., Makhotkina N.N. Comprehensive rehabilitation of patients with unilateral laryngeal paresis after thyroid surgery (medical and pedagogical recommendations) // Rossiyskaya Otorinolaringologiya. 2014. No. 4. – P. 131–137
Makhotkina N.N., Stepanova Yu.E. Problems of rehabilitation and comprehensive treatment of patients with dysphonia in modern conditions // Physical and Rehabilitation Medicine. – 2026. – Vol. 8, No. 1. – P. 20-24.
Stepanova Yu.E., Makhotkina N.N. Principles of the syndrome-pathogenetic approach to prescribing physiotherapy in patients with dysphonia (review) Rossiyskaya Otorinolaringologiya. 2013. No. 5 (66). – P. 126-129.
Makhotkina N.N., Stepanova Yu.E. Neuromuscular electrophonopedic stimulation in the treatment of patients with voice function disorders: a manual for physicians / Saint Petersburg, 2010.
Makhotkina N.N., Stepanova Yu.E., Ponomarenko G.N., Yanov Yu.K. Clinical and physiotherapeutic foundations of the method of neuromuscular electrophonopedic stimulation of the larynx. Rossiyskaya Otorinolaringologiya. 2009;4(41):85-91.
Pluzhnikov M.S., Ryabova M.A., Karpishchenko S.A. Chronic laryngeal stenoses. St. Petersburg: Eskulap; 2004. 208 p.
Rekmal M., Eckel H.E., Yanov Yu.K., Ryazantsev S.V., Krivopalov A.A., Mokhotaeva M.V. Surgery of the larynx and trachea. Moscow: Panfilov Publishing House; 2014. 352 p.
Parshin V.D. Tracheostomy. Indications, technique, complications and their treatment. Moscow: GEOTAR-Media; 2008. 176 p.
Zakharova M.L. Tracheostomy in children: 17-year experience of the Saint Petersburg State Pediatric Medical University. M.L. Zakharova, P.V. Pavlov, A.V. Saulina. Rossiyskaya Otorinolaringologiya. 2015;(4):54-60. Supplement.
Dolgov O.I. Vocal fold laterofixation as a method of treatment for paralytic laryngeal stenosis. Rossiyskaya Otorinolaringologiya. 2013;62(1):68-72.
Young V.N., Rosen C.A. Arytenoid and posterior vocal fold surgery for bilateral vocal fold immobility. Current Opinion in Otolaryngology & Head and Neck Surgery. - 2011. - Vol. 19, № 6.- P. 422–427. doi:10.1097/moo.0b013e32834c1f1c.
Surgical Treatment Applied to Bilateral Vocal Fold Paralysis in Adults: Systematic Review/de Almeida R.B.S, Costa C.C., Lamounier E Silva Duarte P. [et al.]//. J Voice.- 2023.- 37(2).- P/ 289.e1-289.e13.
Krivopalov A.A., Shamkina P.A., Brayko I.I. The method of endoextralaryngeal laterofixation of the vocal folds in the treatment of chronic paralytic laryngeal stenoses. Rossiyskaya Otorinolaringologiya. 2019;18(1):64-69.
Krivopalov A.A., Brayko I.I., Shamkina P.A., Kanina A.D. Surgical treatment of bilateral paralytic laryngeal stenoses. Rossiyskaya Otorinolaringologiya. 2019;18(3):79-92.
Suture lateralization in patients with bilateral vocal fold paralysis./Su W.F., Liu S.C., Tang W.S. [et al.] // J Voice. 2014 Sep;28(5):644-51. doi: 10.1016/j.jvoice.2013.12.012. Epub 2014 Mar 12. PMID: 24629648.
Podkopaeva Yu.Yu. Laser endoscopic laryngoplasty method in the treatment of chronic laryngeal stenoses. Rossiyskaya Otorinolaringologiya. 2014;1(68):175-178.
Krivopalov A.A., Podkopaeva Yu.Yu. Laser endoscopic laryngoplasty in the treatment of chronic paralytic laryngeal stenoses. Meditsinskiy Sovet. 2015;(8):32-35.
Panchenko P.I., Krivopalov A.A., Shamkina P.A., Mazeina E.S. A new approach in the treatment of chronic bilateral paralytic laryngeal stenosis. Consilium Medicum. 2022;24(9):651-654.
Panchenko P.I., Shamkina P.A., Krivopalov A.A., Mazeina E.S. Method of surgical treatment of a patient suffering from chronic paralytic laryngeal stenosis using a 445 nm wavelength laser. Bulletin of the Russian Military Medical Academy. 2023;25(3):463-470.
Panchenko P.I., Krivopalov A.A., Shamkina P.A., Glushchenko A.I. Evaluation of the efficacy of using a 445 nm wavelength laser in the surgical treatment of chronic paralytic laryngeal stenosis. Bulletin of Otorhinolaryngology. 2024;89(4):89-90.
Chistyakova V.R., Bogomilskiy M.R. Pediatric otorhinolaryngology. Moscow; 2002. 254 p.
Vyazmenov E.O. Pareses and paralyses of the larynx in children: features of development and course, diagnostic and treatment methods / E.O. Vyazmenov, E.Yu. Radtsig, M.R. Bogomilskiy // Vestnik Otorinolaringologii. 2007;(2):63-67.
Li M., Chen S, Zheng H, [et al.] Reinnervation of bilateral posterior cricoarytenoid muscles using the left phrenic nerve in patients with bilateral vocal fold paralysis / Li M., Chen S, Zheng H, [et al.] // PLoS One. -2013. - 8(10). – P. 1-12.
Fancello V. Role of reinnervation in the management of recurrent laryngeal nerve injury: current state and advances / V. Fancello, S.A.R Nouraei, K.J. Heathcote // Curr Opin Otolaryngol Head Neck Surg. -2017. -25(6). – P. 480-485.
Smith M.E., Houtz D.R. Outcomes of Laryngeal Reinnervation for Unilateral Vocal Fold Paralysis in Children: Associations With Age and Time Since Injury / M.E. Smith, D.R. Houtz // Ann Otol Rhinol Laryngol. -2016.- 125(5). — P. 433-438.
Hess M. M. Fleischer S. Laryngeal framework surgery // Current Opinion in Otolaryngology & Head and Neck Surgery.- 2016.- Vol. 24, № 6.- P. 505–509.
Podkopaeva Yu.Yu., Krivopalov A.A. Modern concepts of diagnosis and treatment of chronic bilateral paralytic laryngeal stenoses (Literature review) // Rossiyskaya Otorinolaringologiya. 2013;(6):146-153.
Magomedova K.M., Davudov Kh.Sh., Nazhmudinov I.I., Osipenko E.V., Mikhalevskaya I.A., Hakobyan K.V., Kulikov I.O., Guseynov I.G., Khoranova M.Yu. Improving the treatment efficacy of unilateral laryngeal paralyses // Rossiyskaya Otorinolaringologiya. 2012;(4).
Vetshev P.S., Yankin P.L., Zhivotov V.A., Prokhorov V.D., Apostolidi K.G., Savchuk O.V., Poddubny E.I. Application of medializing thyroplasty in unilateral vocal fold paresis // Bulletin of the National Pirog Medical Surgical Center. 2018;(2).
Kirasirova E.A., Tarasenkova N.N., Lafutkina N.V. Rehabilitation of patients with bilateral laryngeal paralysis from a temporal perspective. Vestnik Otorinolaringologii. 2007;(3):44-47.
Physical and rehabilitation medicine. Ed. by G.N. Ponomarenko. National Guidelines. 2nd ed., rev. and supp. Moscow; 2023. 540 p.
Physiotherapy: national guidelines. Ed. by G.N. Ponomarenko. Ser. National Guidelines. Moscow; 2009. 480 p.
Kendall K. A. High-speed laryngeal imaging compared with videostrobos-copy in healthy subjects. Arch Otolaryngol Head Neck Surg. 2009; 135 (3): 274-281. DOI: 10.1001/archoto.2008.557
Zakharova M.L., Pavlov P.V., Masley P.I., Orusmurzaeva D.V., Breusenko D.V. Laryngeal paralysis in infants. Possible solutions. Rossiyskaya Otorinolaringologiya. 2025;24(3):15-23.
Daniero, J.J., Garrett, C.G. & Francis, D.O. Framework Surgery for Treatment of Unilateral Vocal Fold Paralysis. Curr Otorhinolaryngol Rep 2, 119–130 (2014). https://doi.org/10.1007/s40136-014-0044-y.
Golubev V.L., Vein A.M. Neurological syndromes: a guide for physicians. 7th ed. Moscow: Medpress-inform; 2019. 736 p.
Topolyansky A.V., Borodulin V.I. Syndromes and symptoms in clinical practice: an eponymous dictionary. Moscow: Eksmo; 2010. 464 p.
Handley T. P., Miah M. S., Majumdar S., Hussain S. S. Collet-sicard syndrome from thrombosis of the sigmoid-jugular complex: a case report and review of the literature. Int J Otolaryngol. 2010: 2010: 203587. https://. DOI: 10.1155/2010/203587.
Zakharova M.L. Therapeutic and diagnostic tactics in congenital malformations of the larynx in children / M.L. Zakharova, Yu.L. Soldatskiy, P.V. Pavlov. St. Petersburg: SPbSPMU Publishing House; 2017. 188 p.
Appendix A1. Working Group Composition
Stepanova Yu.E., MD, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Romanenko S.G., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Krivopalov A.A., MD, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Kirasirova E.A., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Starostina S.V., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Zakharova M.L., MD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Osipenko E.V., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Tkachuk I.V., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Nazhmutdinov I.I., MD, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Polyakov D.P., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Vinogradov V.V., MD, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;
Inkina A.V., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines:
Otolaryngologists.
General practitioners.
Neurologists.
General practitioners (family physicians).
Medical students.
Residents in training.
Medical speech therapists.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1. | Systematic reviews of studies with reference method controls or systematic reviews of randomized clinical trials using meta-analysis |
2. | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3. | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case report |
5. | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for grading levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definition |
|---|---|
1. | Systematic review of randomized controlled trials with meta-analysis |
2. | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3. | Non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case report or case series, case-control study |
5. | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The update mechanism for clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more than once every 6 months.
Appendix A3. Reference Materials
Order of the Russian Ministry of Health No. 905n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Otorhinolaryngology'."
Order of the Russian Ministry of Health No. 120n dated February 20, 2026, "On Approval of the Procedure for Providing Medical Care in the Profile 'Pediatrics'."
State Register of Medicines: https://grls.rosminzdrav.ru.
Order of the Ministry of Health of the Russian Federation No. 205n dated May 2, 2023, "On Approval of the Nomenclature of Positions of Medical Workers and Pharmaceutical Workers."
Federal Law No. 489-FZ dated December 25, 2018, "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'The Fundamentals of Healthcare Protection in the Russian Federation' Regarding Clinical Guidelines."
Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On Approval of the Procedure and Timeframes for the Development and Revision of Clinical Guidelines, Their Template Form, and Requirements for Their Structure, Composition, and Scientific Validity of Information Included in Clinical Guidelines".
Order of the Russian Ministry of Health No. 788n dated July 31, 2020, "On Approval of the Procedure for Organizing Medical Rehabilitation of Adults" (Registered with the Ministry of Justice of Russia on September 25, 2020, No. 60039).
Order of the Russian Ministry of Health No. 804n dated October 13, 2017 (ed. dated September 24, 2020, with amendments dated October 26, 2022) "On Approval of the Nomenclature of Medical Services."
Order of the Russian Ministry of Health No. 1094n dated November 24, 2021, "On Approval of the Procedure for Prescribing Medicinal Products, Prescription Form Templates for Medicinal Products, the Procedure for Issuing These Forms, Their Accounting and Storage, Prescription Form Templates Containing Prescriptions of Narcotic Drugs or Psychotropic Substances, the Procedure for Their Manufacture, Distribution, Registration, Accounting and Storage, as well as the Rules for Issuing Forms and Prescriptions, Including in the Form of Electronic Documents."
Federal Law No. 61-FZ dated April 12, 2010, "On the Circulation of Medicinal Products."
Appendix A3.1 Explanation of Notes
** – a medicinal product included in the List of Vital and Essential Medicinal Products for medical use (Order of the Government of the Russian Federation No. 3867-r dated December 18, 2025, "On Approval of the List of Vital and Essential Medicinal Products, as well as Lists of Medicinal Products for Medical Use and the Minimum Assortment of Medicinal Products Necessary for the Provision of Medical Care").
# – off-label use – outside the indications registered in the instructions of the medicinal product – is carried out by the decision of the medical commission, with the permission of the Local Ethics Committee of the medical organization (if any), subject to the signed informed consent of the parents (legal representative) and the patient over 15 years of age.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Unilateral laryngeal paralyses are a polyetiological disease.
If the etiology of the disease is unknown, the patient undergoes a comprehensive examination prescribed by an otorhinolaryngologist, which helps determine the cause of the pathological condition.
If the cause is known (thyroid or mediastinal surgery, stroke, etc.), the patient receives medical treatment for the underlying condition while simultaneously attending individual sessions with a medical speech-language pathologist for voice and respiratory rehabilitation. Sessions are conducted on an outpatient basis, but the patient receives homework assignments and must complete them. Upon the recommendation of the medical speech-language pathologist, sessions may take place once or twice a day, and the duration of the sessions is also determined by the specialist. The course includes at least 10 sessions. Patients must not whisper until voice function is restored.
The leading role in the etiology of bilateral laryngeal paralysis belongs to surgical trauma to the recurrent laryngeal nerve during operations on the neck organs (predominantly the thyroid gland), mediastinum, and chest.
The main complaints of patients with bilateral laryngeal paralysis are impaired breathing and, less commonly, altered voice function. The clinical manifestations of paralysis depend on the position of the vocal folds.
The first stage in case of respiratory deterioration (decompensation of laryngeal stenosis) is tracheotomy to restore respiratory function, followed by conservative treatment. If vocal fold mobility does not recover within 6 months, reconstructive plastic surgery on the laryngeal structures to widen the glottic lumen is indicated.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
No.