Vocal fold paralysis (VFP) – sometimes a complication of neck surgery – impacts quality of life and can have urgency when the ability to breathe or swallow is affected. Otolaryngologist VyVy N. Young, MD, provides tools for assessing the problem, explains when a workup is needed, and describes treatment options that can make a big difference to patients.
I am very excited to talk to you guys today about a topic that I get very, very excited about in case you can't tell and it's about how we assess and manage patients who have vocal paralysis and associated symptoms. So my understanding of this is that it's a pretty informal session and I really hope that we can keep that kind of environment. You should all know that I can't see any of you. So um if at any point you have a question, you have a comment, please feel free to jump in. Okay, so um I'm supposed to start with the disclosures. Of course. I'm not interesting enough to have any disclosures. You can see my spouses are listed here because he's way more interesting than me, but none of those are pertinent to this talk anyway, so really what I want to do is to cover sort of a few main points for today, um we want to be able to identify historical clues, signs and symptoms that should make you think about whether or not this patient has a vocal cord or vocal fold paralysis. To talk about why these patients need early assessment and treatment um and to have a broad understanding of what treatment for these people might entail. Okay, so let's just talk for a split second. Sorry, start with the boring stuff nomenclature. Okay, if you see notes from us, I bring it up because if you see Notes from us, you're going to see terms like this vocal fold, immobility. Hypermobility paralysis, praecis, they're all related terms but they're a little bit different. The immobility. Hypermobility refers to a change of movement for a reason. You don't know. Okay. And that's just a description of the the change of the motion of the vocal cords. If you know that it's a nerve problem. A neurologic problem. If you know this for certain, then that's when technically you should apply the term paralysis or process. That's nitty gritty, lyrical logic, nerdiness. For purposes of keeping it simple today, let's just call it all local practices as an umbrella term. Okay. Um so some case examples just to highlight what a patient typically might sound like, Tell me why why you're here today. I'm here to find that. What's wrong? My voice is getting weaker. How long have you sounded like this? How long have you sounded like this since my operation, February 3, 2004 for correct artery. The dr doesn't say anything. Okay. I love that patient snippet. That's the biggest complaint she had was that the doctor didn't tell her anything about why she sounded like that. The doctor being the surgeon here. Um and I think that's a common frustration for a lot of patients that they don't understand what's going on. And they're seeking help to figure this out. With a breath between each one. Mm hmm. Good. Take a breath between each he and try again for me. Chin way out you say? Yeah. Yeah. Chin way out now. I know you all are not accustomed to looking at these kind of laryngeal exams. All I wanted to highlight was there's a difference between one side to the other side and that's where we run into the issue of the vocal folds. Which is where the V. Is having one side that works in one side. That doesnt okay. Here's another example of a patient. I had a carotid endarterectomy left and that was on the left side. And that was November 22,014. Yeah. And since that time you've had two very significant problems. What are those? My biggest problem Is swallowing swallowing issue? 2nd biggest problem. Yes. Speaking. Okay. And you listen to the sound of his voice. It's just not normal. You hear his cough, It's not normal either. And he's describing some of the classic symptoms which we'll talk about in a moment just for completeness. This is what his throat looks like. E uh he's doing that, keep doing it and we'll talk some more about what these exams mean and how they look etcetera. But I'm just hearing these two patients and I'm not dogging on carotid surgery by the way. It just so happens. These two examples are people that had that. But how do you know that there's going to be a problem? Like vocal fold paralysis, right? Like what are the clues you should be looking for. Um the symptoms that patients will display related to unilateral vocal fold paralysis can affect all of their NGO functions. So that can be breathing, that can be voice that can be swallowing maybe even val salva, No picture related to that. But any or all of these symptoms may be involved. So let's talk for a moment about this voice symptoms. An assessment. The most common complaints that people will have is a decrease of volume and projection. Um With associated vocal fatigue and vocal effort. It's so much harder. I feel like I have to strain, it's tough for me to be heard. Um Some complaints of raspy quality or change of quality, hoarseness in general. Um but it's really the volume, fatigue and effort which I think patients will most commonly complain about. Um You also want to ask them about how this is impacting them. Are they working? Are they even able to work? Um Are they able to interact with family and friends? Is this affecting their social life or in pandemic? I don't know how much anybody has a social life. Can they order at the drive thru can they talk on the phone? Um Any of these um Changes to their normal function can point you in the direction of, Okay, there's an actual voice problem and it may or may not be related to focus full paralysis. Um we do have patient reported outcome measures or problems that can very specifically look at voice. This is a very short truncated 10 item questionnaire that can give you some sense of how much the voice issue is impacting them. If you happen to use it to score over 11 is technically abnormal, but we use this tool very commonly to assess patients, sort of where their current status is and how much the voice is impacting their ability to function from a swallowing perspective. I think it's really, really important to ask them what's happening with the swallowing. How are they eating and drinking? Are they having specific issues with solids or liquids? The liquids is probably the most concerning, but the presence or absence of desperation to liquids doesn't make or break your diagnosis here, it's probably one of the most important um clues with regard to swallowing about the presents, potential presence of the vocal fold paralysis. Um Other questions you might ask our surround the notion of any potential unintended weight loss or any pneumonia. Obviously we're thinking potentially aspiration pneumonia and along those same lines. Um The E 10 is a screening tool that can assess um dysplasia that patients are experiencing, and again, it's a very short efficient 10 item questionnaire On the E 10, a score over three is technically considered abnormal and if you look at it, it isn't very hard for patients to get over a score of three. And so what I think this highlights is the importance of asking about swallowing issues. Um and and really exploring those with our patients breathing also comes up a lot. Now, if if a patient actually has strider, we're into a different kind of beast here and then you're thinking about like a bilateral paralysis, which is a different animal entirely run of the mill, unilateral vocal fold paralysis. The most common complaint people have is going to be that they get short of breath when they talk, they run out of breath when they talk, they have to like stop in in the midst of a long sentence. They changed their sentences, so they only say a few words at a time in those clinical examples I started with you could hear that in some of their voice, right? Um of course there is a problem that assesses Disney a as well. And then you also have to think about what other medical conditions or considerations are present with this patient. Um You certainly want to assess if there really an aspiration risk they have other underlying like neurologic conditions. Um you know, are they a chronic aspirated already? Do they have um generalized frailty or debilitation or de conditioning? You know, are they just anxious or nervous or have other reasons to explain why they might have a symptom that relates to voice for swallowing or breathing, right? You have to think about all the other things. But if you're thinking like, when should I think about whether this is actually a vocal cord paralysis that's causing these symptoms to occur. I think you have to ask really pointed questions about when this all started. If there was something that happened around the time of onset, I had the worst cold I've ever had in my whole life or I was totally fine until I woke up from my X. Y. Z. Surgery. Um Or you know, I got hit in the neck with a hockey stick or something that happened at that time. Um That could be a sign that you're thinking about a vocal fold motion issue. Like a paralysis. Um How long ago this all started is important to know because that can impact what treatment we offer to these patients and we'll talk more about that in a little bit. Um And are there any other medical conditions that the patient already has that might be known to be related to potentially to vocal fold motion impairment. I probably should have put the mobility here, like rheumatoid arthritis affecting the cracker in a joint uncommon but does happen. So you have to think about all these types of things. I think the clues around the onset um is probably one of the main things to ask about. So what can commonly cause a vocal cord paralysis. Okay, surgery I a transgenic causes are are very, very high on the list. Um I've highlighted in red, the biggest offenders, even though you and I both know that the spine surgeons will always tell you that nothing ever happened and the thyroid surgeons will always tell you, oh I totally saw the nerve and it's always safe. Nothing ever happened to it during the surgery, yada yada yada. The data shows that these are the surgeries that are most likely to cause some kind of a issue with the vocal fold motion. And so if a patient has undergone any of these particular surgeries, I think the suspicion should be raised okay. But surgery is not the only reason that someone can have a local full paralysis. And so there are a number of other medical conditions um, that can also contribute to this possibility as well. And one of the most common that I see is going to be a lung cancer, whether it's media spinal disease or left upper lobe, but typically that's one of the most common reasons that's not surgical um for a vocal process to occur. Having said that, I think it's really, really important to identify that there are known a large known category of idiopathic vocal fold paralysis, I e, we don't know what it is. Um, a lot of times. Um, we make assumptions, particularly if it's followed, you know, a terrible yoo ri of some sort, worst cold I've ever had in my life. I had a flu. I had a bronchitis, I had something or another. We make assumptions of a viral ideology, but sometimes you just don't know why it happened at all. Um, and that's um important to identify as well. Okay, I would tell you this, this is my plug, that laryngeal examination is foundational and it's absolutely vital, especially with robots copy to be able to see to make this diagnosis. Um, why? Because you can actually see vocals eat. So this is a normal exam. E the vocal folds are the V. Down here, and you can see this normal person is able to open close, open, close, open, close, open, close open, close, all normal. Okay. And so we can actually watch the vocal folds move to assess the motion status. At the same time, I would submit to you. That strongbox copy is even more important because we're actually able to see the vocal folds vibrate against each other. So we can assess vocal fold vibration, but most importantly, vocal fold closure to see how well they come together in the midline when people are speaking and that has direct implications on treatment for sure. Okay. And also symptoms which is connected to treatment. Um. Work up for these patients. The very first question to ask is is there a clear ideology like they had a thyroid surgery? They were perfectly fine before the surgery and that they woke up from surgery. And ever since then they have had X. Y. Z symptoms. If you have a very, very clear ideology, I don't think you need to do any further work up. I really don't. You have a clear reason for why this has occurred? Carotid surgery. Spine surgery, you know, anything along those lines. Um, you don't have to do anything else. But if you don't have that kind of clear ideology, um, I think it's important to get imaging. I do, I will tell you truthfully that the literature is a little bit controversial on this. It's been studied many times. You know, it's chest X ray enough. Do you really need cT scan? My my opinion. I side with the literature that shows us that CT scans are the best option for making sure that you don't have some kind of a mess. Like we were talking about the media style mass or a left up or low, you know, lung cancer or something like that. Um, the issue with CT scans, like when I was a resident, do not ask me how long ago that was, but when I was a resident, we used to order a ct of the head, neck and chest to be sure that you cover the entire course of the recurrent energy will never from the skull base down to the aortic arch, which is not good. Right? Because then patients are getting charged for three different kinds of cT scans. It's unnecessary. It was expensive to fly out of time. All those things nowadays, I think that you can get just a cT scan of the neck. Um, provided that you are clear in your instructions to the radiologist that it it needs to be c Teaneck expanded to include school based down the aortic arch at UCSF. That is now standardized protocol here. If you put the words vocal fold paralysis in the indications it automatically pushes the CT scan into this protocol. Um so that you don't have to get multiple scans, but I think that I think that that's an area of potential um Q I you know, um for resource maximization and patient safety um sorry, soapbox. Um but I think it's important that a if you get the scan that has to be adequate, you don't want to get just a small slice of it and not see above or below to be able to make the final call. Okay. No labs people ask this all the time. Like should I get should I check thyroid labs, you know, um there have been people that have described like checking syphilis labs or Lyme disease typewriters and lots of other things. Labs have not been shown in any of the research really to be um super useful and and it's largely not utilitarian in my opinion. So I don't think labs bring you any benefit in these situations. Okay. Um this is my plug for early evaluation for these patients if you know, they have a vocal fold paralysis or even just suspect that they have a vocal fold paralysis. I would argue strongly that they need an early assessment why? Because when they're sitting in your office, they're going to ask you exactly three things is my vocal cord, let's just say you've got a ct scan and it says vocal cord paralysis and they're looking at you they're going but is it is it gonna become not paralyzed? Like is it gonna move again? Is my voice or swallowing or breathing problem going to come back to normal again? And can you make me better right now? Can you fix this problem for me right now? And I will tell you these questions. I get these all the time. Okay Because this is what's important to patients. This is how they're functioning on a day in day out basis. Okay So how do you know that the vocal fold is going to start moving again? Um You don't there's no clues from the history or the symptoms or the exam. When we're looking at the Lawrenceville exam there's no way to eyeball it and know for sure if it's going to get better or if it's not going to get better. Um We don't have any kind of crystal ball. Uh And sometimes patients just need to wait it out to see what happens. Um But sometimes if patients don't want to just wait and see what happens um We can offer them a specialized test. It's called a laryngeal electron biography Or in L. E. M. G. Um it actually assesses the electrical activity that's coming into the muscles of the larynx. Um I describe it to patients as kind of an E. K. G. Of the larynx. Um Because it's just looking at the signals that come through. It doesn't do any sort of you know um intervention or change anything. It just provides information about what's going on. Are there signals coming from the nerve, the recurrent laryngeal nerve into the muscle? Are they are they're signals at all? And are those signals like kind of normal kind of not normal terribly not normal. And all of that information gives us perspective about what to expect and what to do. So this is what uh Lauren julie MG looks like. Um the patient is laid back slightly supine. Um We anesthetize the skin of the neck and then we pass a very small skinny needle directly into the vocal fold and we listen and check for the signals and the sounds that come through. Lots to say about L. E. F. G. In the end it can tell you if there's truly a neurologic issue with the vocal fold itself so that you know for sure you confirm the paralysis. It can give you information about what to expect in terms of prognosis for that vocal fold to regain motion on its own or not. Um And that information I would submit to. You can often play a big role in decision making for these patients sometimes if things look absolutely fantastic like very mild injury nothing's gonna you know nothing looks too bad and hopefully this will just bounce back like a post intubation you're a proxy a kind of situation. Then sometimes patients feel like, okay, if I just waited to wait this out a little bit longer, then maybe it's going to get better on its own versus the opposite. If it looks like it's a very severe or significant injury, then it may change. You know, how quickly you're moving them to treatment or what type of treatment you're doing, circling back to the main clinical question that patients are asking is can you fix my symptoms? Can you make me better? I would tell you that this is the key. This is the point of what we're trying to do when we see these patients. So what can we offer to patients um at the voice and swelling center, We offer them either the continued observation with or without. AMG. Um Let's talk about voice therapy and when we can use this. Let's talk a little bit also about some kind of a vocal, full surgical surgical procedure. Okay. Um, no treatment. Sometimes patients just want to observe, right? I was in the hospital after my surgery. I've been doing so badly since then, so much has been happening. I'm tired of being poked and prodded and sometimes patients just want to wait it out. Okay. Sometimes, quite frankly, um The surgeons make patients wait it out. It is not uncommon for people to um site the very dated literature that says that vocal fold motion recovery takes a year. Nothing makes me sadder than the patient that has been sitting around with terrible symptoms for nine months, 12 months. And then they finally show up for treatment now because they're like, oh well my doctor told me it would, it could take a year to get better and I've waited the year and now here I am um different soapbox. Um but sometimes that does happen to patients and sometimes patients don't um have access or know that they can access treatment um to make it better. Have heard patients over time being like, oh I had no idea that something could be done to help me be better. Um and a lot of people sometimes are just hoping and praying for that spontaneous recovery of motion. Um I will tell you that's sort of a wishful thinking move. Um and I would make, I would make a strong argument to you that we can do better than that. Um voice therapy. I feel like I need to very specifically talk about this for a moment. Caveat, I work with 10 speech pathologists who are wonderful. We work on a purely multidisciplinary um mantra and I see all my patients with the speech language pathologists, we are heavily integrated in our clinics together. And the one thing that they tell me all the time is for patients with vocal fold paralysis, they have to have something to work with to do voice therapy. You have to have a voice, it can be a bad voice, but you have to have something to start with. And so their argument is that it makes perfect sense to me if there's a big gap in the vocal folds that they're not able to close together, they can't even touch together. And the patients essentially like at a whisper level, they have no voice. Voice therapy is probably not the answer at this moment. Right? Um if you can assess them and um there's a whole other conversation to have about the speech pathologist assessing patients for their appropriateness for voice therapy. Um but voice therapy might be most effective after you can get vocal full closure to be completed. Okay, so um voice therapy is oftentimes not the out of the gate treatment option for these patients, I would tell you oftentimes it works better after a lyrical intervention, but let's just say that the patient chooses or they get sent for voice therapy. The other caveat, I would say, is that the average number of voice therapy sessions to make someone better is for four, if they are making no progress in four sessions, do not drag it out. Do not let someone drag it out to eight, 1220 sessions, all of which I've seen. Okay, let's talk about surgery. The goals of surgery is simply to bring the vocal folds close together again to bring that closure and that contact between the two sides. There are lots of different ways that we do this fundamentally. It boils down to just two, which is to use some kind of an injectable material to help bring the vocal folds close together or some kind of an implant material. Um There have been some layering jewelry, innovation procedures that have been done. Um but none of them that I am aware of have reliably consistently and long term showed recovery of motion. So what you're really trying to achieve is some tone and better positioning of the vocal folds. How do you decide who needs treatment? I think that you have to assess the level of their symptoms. I would tell you specifically with relation to swallowing probably is the highest priority for me. Um, voice secondarily, particularly if they're working because for some people, these symptoms keep them from being able to work. Um and also I keep in mind other general health issues. If this is someone with a large lung cancer with terrible life expectancy, we definitely want to talk about what kind of treatment we're doing when we're going to do it and what we're gonna do. Um We have to have special considerations about timing of treatment. As I mentioned, if they're gun shy from previous treatments or if they are in a hurry because they need their symptoms to be better. All of these are factors that we need to take into account. Um, and I mentioned some of the medical conditions before that we keep in mind for our patients. So vocal fold injection I've referenced is one of the one of the main tools that we use to help vocal folds clothes better together. There's a whole slew of things to think about about relation to material that we inject. There are temporary materials. There are permanent materials. There are in between options. There are different settings that we can do these types of procedures in. Um sometimes you can do it in the office. Sometimes an endoscopy or bronchoscopy gi type suite or the operating room. We can do it in different kinds of settings and there's different levels of anesthesia from the awake um local anesthesia. Just lidocaine to some mild sedation through an I. V. To full on general anesthesia. And so we can make a lot of very specific um tweets to how the patients undergo this procedure to make it as comfortable and it's convenient for them. This is the goal of what we're trying to achieve right So before is on the left we're looking at vocal folds in the operating room. Through the laryngoscope. Vocal folds are the v. Here you can just see before they're skinny they're apart from each other and this is after the vocal fold injection to plump them up. And you can just imagine that when this patient wakes up and goes to talk. The vocal cords are going to have an easier time coming together just because they're just better and fuller and it's just gonna be easier to make that contact. Okay? Um Here is um a brief video to show you what that looks like. This is done in the operating room, asleep under general anesthesia. We use a microscope so we can see exactly what the vocal folds looks like. And you can see this material filling in here and you see how the vocal fold is ballooning outward and it's enlarging its medial izing. It's plumping up beautifully. There are very specific pros and cons to doing it asleep versus awake. I'm just trying to give you guys a brief look at what it would look like for the patient. Okay? Um awake injections are really that so the patient's awake um seated upright, they're breathing on their own. Were looking through the nose with a camera. And then for for us our team we generally tend to pass the instrument through the mouth that there's other ways to do it as well. And you can actually watch the needle entering into the vocal chord here. Vocal fold. Same thing and you can literally watch it start to balloon up in this area here where the vocal folds just getting a little bit more full and more fat. The goal is to augment this vocal folds so that um the two vocal folds are able to make better contact against each other. Okay what if the vocal fold motion doesn't come back and the vocal fold doesn't get better. We do have treatment options of a more permanent or lasting duration well beyond the confines of this, of this presentation today. But I just want you to be aware that we can do um a vocal fold injection with autologous fat is an option that we often uh proposed to patients. Or we can put in some kind of an implant. That's what's typically called the pyroclastic procedure, different kinds of materials. Sometimes in a written by deduction or suture maneuver. The short version is you can reposition the vocal fold in a permanent lasting fashion if they need that because the vocal fold paralysis doesn't get better on its own. Okay. I always think it's most interesting and maybe most helpful to see and hear some examples of patients who have um vocal fold paralysis. So this is a lady. I'll let you just listen to her. I had this operation I think 98. Okay, what kind of operations? Okay so since then your voice has been struggling. Yes. Yes I do. Now. It's like dr Roscoe says you're getting worse instead of better. This happens. This is what her larynx looks like mm hmm. Good breathe. So you can see this is her right vocal that opens and closes it moves and the left one just sits there and it doesn't do anything to be of assistance. And so the end result of that is that you can see there's this gap of space. Okay. And this gap of space is why this patient has complaints of hoarseness, can't get loud, can't yell at her husband anymore, chokes with liquids, get short of breath when she talks for long periods of time. It's that lack of contact. Um That really is the problem here and so here she is after she's had treatment. How you doing since your last visit a lot better. You had a month ago. How do you think you're being? A lot of people think they don't even know my voice? I think it's great. I do. I'm well satisfied with that. You hear the difference, right? The volume, the loudness is better. She doesn't have that breathy quality. Um She's better. She's happy. This is all good things. This is okay, go back and forth between the E. And the stiff E. A couple of times. Good try to glide from a low E. To I. So you can see when her vocal folds are open. Let's see. Well first of all you can see when her vocal folds close together, they close together completely. And when she opens you can see the bulge from where she had the implant put in. But the most important thing I would submit to you is that when she speaks her vocal cords closed together completely and that is what enables her to get that volume back again and that normal sounding voice. Okay? You may remember him had a carotid endarterectomy left. and that was on the left side. And that was nobody that's what he had sounded like you remember. And then this is what he looked like. E keep doing that, keep doing it. And you see every time he tries to say ee there's this large dark space where his vocal folds don't close together. And that's why he sounds so breathy. That's why his cough sounds so weak. Um That's why he has some dysplasia to, okay so he underwent a pyroclastic accurate noise reduction. And here's a sample of how he sounded after his surgery. When the sunlight strikes. Raindrops in the air. They act like a prison and form a rainbow. The rainbow is a division of white light into many beautiful colors. So you can hear him. Not only is he louder, but he's able to string together a much longer sentence without having to pause and take a breath to catch his breath again as he's speaking. Here's his um robotic api and you can actually see this is uh robotic api so it's got a little bit more flutter to it. But his vocal folds vibrate together really nicely. And now they also close together really quite beautifully. And that's a testament to the fact that we are able to achieve this on route to trying to help his symptoms to be better. This is a patient. Very interesting young lady came in three weeks after she had thyroid surgery. Great. And then tell me a little bit about what's changed with your voice since your surgery? Um Well, my voice is noticeably very horse and I have a hard time speaking for any length of time without needing tips, pause for deep breaths and um it's painful and distracting and bothers them. And you may also notice as she's speaking that there's moments that her voice sounds like super deep and low and in the basement and there's at the same time there's moments when you can hear her voice, it sounds more higher and that two different kinds of tones simultaneously can also be a clue um that there is a vocal fold paralysis issue at play. Um This is what her exam looks like. Just again, you can see this right side moves and then see again um this gap of space in between the two sides which leads to the issue. You may also may or may not also have noticed that a lot of all these exams that I've shown, you have been left sided vocal fold paralysis. Um I will tell you it is probably the much more commonly affected side for a variety of reasons. Um but be that as it may, both sides can be affected. So um here she is after her vocal fold injection. Tell me in just maybe a couple of sentences. What you've noticed is different about your voice since the injection. I've gotten a lot of the volume and function back and um I'm able to swallow liquids again easily, which is great, okay, and then this is what she looks like. Perfect. How about a big sniff it? So you can see she's augmented, you see how much fatter it is on this left side, this left side, um and that's uh the material, right again, just trying to plump it up and augment it. Um And here she is. She ended up, you may also have heard she still had some raspy nous to her voice. So she ended ended up actually undergoing voice therapy as well. Um And here she is now six months since her surgery. Um So when I was reading the sentences, I was reading them in a higher pitch that I've found works for me to be able to communicate verbally and be understood. Um I feel like the way I'm speaking now is where I used to speak, like where my voice sits. Um So I'm here today to talk to dr young about it and then this is what she looks like, sniff it. So if you watch though, you may notice, watch this side, you may notice that it moves now. Okay, when she breathes in, It opens and when she speaks it closes together. Slow open, close, open, close, open, close. So she's one of the lucky ones that had recovery of her vocal fold motion. Um and you may be thinking, oh, but she had an injection and the injection was only to address the symptoms that she had at the time. Um While we were waiting and hoping that this would be her outcome, that her vocal fold would regain this motion back normally. Again. For patients who regain motion, this is a wonderful, wonderful thing for patients that don't, and they have a persistently paralyzed vocal cord. As I mentioned before, we have more permanent options that we can offer to them. But certainly this is, I would tell you this is the ideal, right? If you can help someone with their symptoms and let their body, he'll always reminds me of that old saying, right? Like, what do they say that medicine is the art of entertaining the patient while nature takes its course. Sometimes if we're lucky, that's that's really true. Okay. Um so just to wrap it all up, I would say that for vocal cord paralysis or vocal fold paralysis patients, it is absolutely critical that you have to have a high index of suspicion. Um Any symptoms in the realm of voice or swallowing or breathing um can potentially point in the direction of this diagnosis. Um I think that um I've highlighted um several times now, I think the key features in each of those realms. Um and and again, patients don't have to have all of them. Right? I have lots of patients that have a voice issue, but no dysplasia, no dysthymia or you know, hoarseness and dysosmia without dysplasia or any of those combinations. It doesn't have to be all or none. Um Any of these clues can make you think or ought to make you think about this as a possibility. Okay. I will once again put in my plug for the early evaluation for purposes of getting them a multidisciplinary evaluation for purposes of getting them that strongbox copy assessment. Um But really to be able to identify early when patients have a vocal fold paralysis so that we can give them some idea of what to expect over the course of healing. Of of hope for symptom improvement or not. Um And what what we can do to try to help them right. Because by treating the symptoms we can improve their functionality. We improve their quality of life, bring back some joy to their life. Um I am always amazed by how much of a difference we can make with patient symptoms in this room. I really am. Recovery of vocal fold motion is highly variable. So sometimes people get better and sometimes they don't. Um And it can be very frustrating to try to predict. E. M. G. Definitely gives us a tool to try to be better at predicting it, although it's not definitive by any stretch regardless of whether or not the vocal fold recovers motion. I think it's really really important to educate patients that you don't have to delay treatment. You don't have to wait to see what happens. Um and that we have a variety of treatment options available to us as I've reviewed today. Ultimately, I think we have to think about the timing and the type of the injury um to gauge, you know, what we expect in terms of potential for recovery and that sort of thing. Um Are the patients able to achieve closure and how does that impact their symptoms? Um Again, as I mentioned before, assessing where they are in relation to the symptoms of, you know, voice swallowing, breathing slp evaluation for their appropriateness or candidacy for voice therapy I think can be very, very helpful to do. Um As I mentioned, we have a tremendous team at the voice and swallowing center. Um This is our team, well as we were this was, you know, pre pandemic. So this is our team now. Um as I said, we have three large oncologists alarm oncology, fellow intense speech pathologist who all specialize in voice and swallowing. So we have a whole crew of people who are here to help with patients, mm hmm.