Recurrent nerve/vocal cord paralysis and exercise

Hi!
I had a TT and left and central neck dissection on June 19. 10 of the 57 lymph nodes removed were cancerous as well as my thyroid. My surgery was somewhat more delicate than "usual" in that I also have Graves Disease. I had RAI ablation treatment for the Graves in Feb 2012. Consequently, the thyroid was very shrunken thus making the surgery a bit more tedious. Thankfully, everything went well during the course of the long surgery - the repositioning of the parathyroids and function - everything went smoothly - ALMOST. I suffered some thermal damage to the right vocal cord. The surgeon said that although they temporarily "lost signal" on that nerve during surgery, they were hopeful that the injury would be temporary as the nerve "regained signal" on its own accord during surgery.

It now has been almost 9 weeks since surgery and my voice is still weak, very soft, and somewhat hoarse. But, the bigger issue for me is the breathing issue it has created. I am an endurance athlete and I have a very difficult time getting enough air into my lungs when I increase my exertion level. Walking around and normal daily activities I am fine. But anytime I try to increase speed or effort (ie: climb any type of hill), I suffer terribly. It is like I have a very bad case of bronchitis or what I imagine asthma to be but have no inhaler to clear it up! I also feel like I have a bunch of gunk in my throat that I can't clear and I cough a lot.

A visit to the ENT today confirmed that the right vocal cord is indeed paralyzed (larynxscopy). The doc said I could give it more time or I could choose to have the collagen injection, which might help temporarily (her recommendation). From what I have read, this procedure is aimed more toward restoring normal voice sound but not necessarily breathing issues, which for me as an athlete, is more important than my voice right now. Plus, there is general anesthesia and always risks - neither of which I am too excited about at the moment.

Has anyone had any experience with this procedure? How about just giving the nerve more time to heal? I am willing to be patient. I am thankful I can still get out and run and ride - it just is very challenging.

Thanks for you input!

PS: RAI is tentatively scheduled for Sept 6. Low iodine diet, here I come!!! :-)

Edited August 20, 2013 at 9:09 am

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Hi Blue Skies, I just had the collagen injection done twice in the last 3 months. The first time I went under general anesthesia and my body absorbed the collagen within 3 weeks. The second time I opted to not be put under because I have had to undergo 7 surgeries within the last 12 months and it takes so much to get me breathing again, so it is possible not to be put under, but it was a very unpleasant experience and I don't know if I would do it again.

My voice has improved just a vey little, still choke on liquids but I am no longer running out of breath to finish my sentences. There are no guarantees on any procedure but it's worth a try.

Good luck on making your decision, it can be troublesome!

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I don't have much experience with this, but I am seeing a laryngologist next month for my hoarseness and choking. What I am aware of is that nerves have their own timetable for healing. Some nerves can take up to a year. I might want to wait and allow the nerve some more time to see if it will come around on its own, that is if the doctor thinks there is a possibility. I'm sorry you have this going on and hope you get your function restored.

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Hi, I was the same. I'm not an athlete but I struggled with my breathing just walking short distances and my voice was how you described and I was starting to think it would never improve. 13 weeks on from my surgery, it is at last getting better and breathing has improved. Hang in there, hopefully yours too will get better without treatment.

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Thank you, all, for your kind words of encouragement! I am willing to be patient and will continue to wait and just give the nerve time to heal. I am thankful that I am still able to run and ride some - just not to the level and extent that is normal for me - and thankful, too, that I do not have much problem with swallowing (although not completely normal but not bad) or any choking. I guess we have to count all of the positives! I really feel for people who experience this type of injury who are vocalists. It is the same kind of lifestyle loss as I am feeling but in a different area. My warmest wishes to all of you! :-)

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I've had two injections for my right vocal cord, both were under local anesthesia and I drove home immediately after. They did help a bit. I was scheduled to have the medialization thyroplasty done on Aug. 5th, but had to switch employers and health insurance before then. I saw a different Otolaryngologist coincidentally that same day. He (Dr. Albert Merati) said that he was happy I didn't have the implant done as there was still a small amount of the material still present. He then informed me of the possibility of doing a laryngeal nerve reinnervation instead of the implant. He's going to go over my surgery report and talk to the surgeon that did my thyroidectomy and neck dissection to see if its an actual option for me. I was quite fascinated to hear of this other option.

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i was the same blue-skies, couldnt even jog 10 meters at first when i tried exercise again.. i have a friend who is a physio and he said still keep going and try to build up slowly.. this will force your throat to stretch all the scar tissue building up.. if not it could stay tight once healed for good! as your voice gets better so will the breathing when one side is paralysed it cant move across to clear the airways hense not being able to breath fully.. my TT was 4 months ago now.. took 2 months to get talking again and 4 months to full fitness :) full breathing took about 2.5 - 3 months to come back for me but i still did light weights in the house all through. when you better blue skies come back on here and let people know they will be fine too hang in there ;)

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I've been doing strengthening and loudness exercises through my speech pathologist. It has helped with being able to breathe better. I was on vacation for a week and she was on a trip for a week after. I was supposed to do my exercises during that time, but failed to keep up with them. So yesterday when I had my first appt. in 2 weeks, it showed. :( But, as she had me doing the exercises in her office, she noticed an improvement with sustaining breath control just in that hour. She said my laryngeal muscles have a good memory, but I need to keep up with them during this rehab period. It's been nearly 4 months since my TT and damaged laryngeal nerves.

Try this for strengthening: Take a big breath and lock it in for a second. Say the sound "ah" medium loud and time yourself. Try to get up to 30 seconds and more if you can. Do this 6-10 times in a row and be sure and use a stopwatch. I use the stopwatch setting on my iPhone clock. It's surprising how much lung power this takes. But it builds up breath control.

Also, practice reading paragraphs for 3-5 minutes. Take a breath in between sentences as needed. This also builds up those muscles.

You can say the sound "ee" and try to hold the highest note you can without straining for 5 seconds. Do this 6-10 times. I also do inflection sentences. For instance: say "Is it raining?" as in a question and then "It is raining." as a loud statement. You can make up several questions and statements. I have a whole list she gave me.

It's hard work doing these exercises! Oh, also, do the Masako exercise where you stick your tongue out between your teeth and swallow. Do it 3 times followed by a sip of water. Do a total of 10 times. And, to loosen up your vocal folds (cords), do a "hum and press" for about a minute before and after these exercises to relax the vocal cords. Gently press and move your fingers quickly on the soft area under your sternum and hum. You should feel it in the nasal area--a slight vibration. You can do this anytime your voice feels tired.

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Thank you, Dan 007! It is encouraging to hear that your breathing came back within 4 months! I will be happy for 6 months! Even a year! I can be patient if I know there is a high probability that the nerve will heal, given plenty of time. Again, I am SO THANKFUL that I have been able to still run and ride - just can't go fast or climb steep hills - and it feels quite challenging to get enough air in when my heart rate elevates - but I am encouraged to hear your happy ending and am hoping for my own. Thank you for taking the time to share and keep up with your fitness! And, WHEN my breathing does return to normal, I will make sure to post! :-)

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Thank you, Linsifer, for taking the time to describe the exercises in such good detail. I will make sure to start a regimen beginning tomorrow! I am going to try to get in with a speech therapist for several sessions, too. I have read frequently that some speech therapy is super helpful. Your thoughtful response helps reinforce I need to follow through and get an appointment, stat! Thank you, again, for the wonderful insight. Best wishes! :-)

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My pleasure, Blue Skies. I hope you'll be able to work with a good speech therapist to help you regain the strength in your laryngeal muscles and the breath support that's so important to this whole process. It can be frustrating and discouraging at times, believe me. I told my SLP (Speech, Language Pathologist) just yesterday that sometimes I want to just say "forget it" and just accept things the way they are. She said "That's always an option, of course". We both knew that I won't go that route! Instead I'll continue to do whatever it takes to try and improve my voice and ability to breathe better.

You know, it's almost as if the cancer is on the back burner. For now it's more about being able to get back to normal vocally. It's just too bad that some of us had to end up with one of the complications of this surgery.

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Hi Linsifer!
Made an interesting observation tonight - was playing around with a few of the exercises you mentioned and had some music playing softly in the background. I started to try to hum and although it wasn't perfectly lovely, the tone almost sounded a bit like my normal sound so I tried to sing slowly. Again, it wasn't perfect, but my singing voice sounded more like my normal voice than my speaking voice sounds now. Is that strange? I think it is hopeful. Now I will just have to sing all of my conversations! LOL! My physical therapist friend is going to get me hooked up with a very good speech pathologist. Will be excited to see how that goes! Thanks again for the exercise info!

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Hi Blue-skies! That IS interesting! I wish my singing voice sounded more like normal than my speaking voice. I suppose if I were a tenor or low alto it might! :/ But, I know what you mean about certain sounds almost coming out normal. When I was doing the "ee" exercises today at my voice therapy appt. she said I had hit a higher octave. And, yet if I tried to do that during regular singing, there's no way I could reach any type of range that even resembled a high note. I'm so glad your PT friend will hook you with a good SLP! It will be interesting if she gives you some of the same type of exercises for loudness and clarity, etc.

My SLP wants me to see a local ENT in my network so he can do a videostroboscoby of my vocal folds and laryngeal structures. The ENT who performed my TT is about an hour away across from Stanford where she did my surgery. My SLP said it would be nice to see someone who she knows and works with frequently. And, she was instrumental in getting the first videostroboscoby machine in our community back in 1988. She feels it's an important tool to help with diagnosis and helping her with a treatment plan. That will happen on Sept. 12. I'm curious to see what they see.

Now I have 3 days of exercises to do before my Monday voice therapy appt. I need to DO it and not procrastinate ! :)

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Hi Linsifer!

The ENT, whom my surgeon and endocrinologist referred me to within their group of providers, did a videostroboscopy on me this past Monday. Very interesting, indeed. Although I wasn't keen on the ENT herself (all business, no opportunity for questions), she did review the video and explained what she was seeing = paralysis of the right vocal cord. I am sure you will find the procedure/video fascinating!

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Hi Blue-skies-- My ENT surgeon had done a regular laryngoscopy twice post op. First time my left vocal cord was paralyzed. About a month later it showed some movement, however bowed and still not coming to the midline normally. So, I think in HER mind, all was going to be well! She was confused as to why I still had ANY vocal issues, even at 6 weeks post op. She just kept reassuring me that she monitored the recurrent laryngeal nerve during surgery and that everything should heal in time. Well, at the time I no idea that my SUPERIOR laryngeal nerve also could have suffered trauma or damage. So, I didn't question her. All I stressed was how sad I was that I could no longer SING and that I had no pitch. Again, it felt like a pat on the back and she sent me on my way, feeling optimistic that my voice would come back soon. Arghh.

So, thank goodness that my speech pathologist is the type who likes to investigate and get to the bottom of things. She's obviously has had several more experience with voice and throat issues than the surgeon. It kind of irks me, though, that the surgeon wouldn't have suspected that my superior laryngeal nerve might have been affected given the symptoms I was having and the bowed cord. You would think if this is her specialty it would be a no-brainer. Heck, even after I did a little more research myself, I could see that my SLN was probably involved. Sigh.

Anyway, my speech therapist feels that the videostroboscoby will be a better tool to figure out what's going on. And, to see if her "diagnosis" is right. She said that since she's not a medical doctor, she doesn't want to overstep her boundaries. And sometimes the ENTs and speech pathologists don't always see eye to eye. It's more of an ego-thing with the MDs. They don't want a non-doctor doing what THEY should be doing. So, she has to be careful in how she approaches some doctors. At least she knows this local ENT and feels good about him. I don't think she got the same vibe with my female ENT surgeon in Palo Alto.

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Shortness of Breath can be aggravated by air leaking because your vocal cords cannot close properly with one weaker or paralyzed. It causes you to speak in shorter sentences and run out of air faster. Speech therapy helped me before and after my medialization surgery.

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Exactly, Dereth! When my left vocal cord was paralyzed, my swallowing and choking issues were worse. But it's a little better now that there's some movement. Since it's bowed, it's still not meeting the midline properly, causing some air leaking. I find that speaking in long sentences or carrying on long conversations can be very tiring and sometimes I just want to avoid talking a lot whenever I can. Worse In loud environments. This is one of the reasons my speech therapist is having me do the strengthening and breath support exercises. Also, she has me practicing reading paragraphs for 3-5 minutes at a time. It takes a lot out of me and I really feel like I've put my voice and laryngeal muscles through a workout when I'm done!

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