May 14, 2013

Google CEO Larry Page Suffers from Bilateral Vocal Cord Paralysis

Image by Marcin Mycielski from Wikipedia
Over the past year, there has been concern over the health of Google CEO Larry Page after missing a few important meetings and having a hoarse voice that is unusually soft and prolonged.

Apparently, it's because he suffers from bilateral vocal cord paralysis. [link]

He initially suffered from a unilateral vocal cord paralysis at the age of 14 years old. At that time, his left vocal cord became paralyzed after a viral URI. Beyond a viral infection of the nerve, no other specific cause was identified.

Than during the summer of 2012, he suffered another viral URI followed by the unfortunate paralysis of his opposite right side resulting in bilateral vocal cord paralysis. It is EXTREMELY rare that both vocal cords become paralyzed in this manner in the same individual.

With bilateral vocal cord paralysis, he now suffers from an even weaker voice along with reduced ability to exercise.

Now, why is that?

First, a basic anatomy lesson...

Briefly, the voicebox is composed of a right and left vocal cord that is attached on one end, much like a "V". When the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows one to breathe. When a person wants to sing/talk or say "eee," the vocal cords come together and vibrate very quickly creating the voice. The vocal cords and their movement can be visualized on fiberoptic laryngoscopy (watch movie of this exam).

A "paralyzed" vocal cord is when one or both of the vocal cords do not move resulting in voice changes as well as difficulty breathing easily. Specifically, when both vocal cords are paralyzed, the vocal cords do not come together as tightly resulting in a weaker than normal voice. At the same time, given the vocal cords are not able to move apart, there is a smaller than normal opening thru which to breath resulting in shortness of breath, especially with exercise. Here are two video examples of when both vocal cords are paralyzed. Compare this to a normal example. Note the difference in how wide the vocal cords move apart.

Why would the vocal cords both become paralyzed in the first place? The MOST common cause of bilateral vocal cord paralysis is surgery, especially thyroidectomy. Other less common causes include neck trauma, traumatic intubation, and cancer (especially lung or thyroid cancer). Regardless of cause, if the paralysis is permanent, the options are quite limited and require the sacrifice of either breathing or talking. You can't have both good breathing and a good voice. Please note that a patient may have bilateral vocal cord fixation and NOT paralysis which is treated completely differently.

Why can't you have both good breathing and a good voice when both vocal cords are paralyzed? Because in order to have a good voice, the vocal cords need to come tightly together... but given they are paralyzed, they will not come together to allow for a good strong voice.

In order to have good breathing, the vocal cords need to be widely apart... but given they are paralyzed, they will not be able to move apart to allow for good breathing. Which in essence means you can't have both good breathing and strong voice.

One or the other needs to be sacrificed... or a compromise of both is required resulting in so-so breathing and a so-so vocal quality... which seems to be the option Larry Page has gone with.

Well... there is ONE option in order to have good breathing and a good voice... and that's a tracheostomy with a one-way valve. The vocal cords could be fixated together to allow for good voice. To allow for good breathing, airway is achieved through the tracheostomy (hole in the neck that goes directly into the airway). A one-way valve is placed with the tracheostomy such that when breathing in, the valve opens up to allow air passage thru the tracheostomy, but when breathing out, the valve will close to force air up thru the vocal cords to allow for talking.

BUT, if tracheostomy is out-of-the-question.. than a patient with bilateral vocal cord paralysis is stuck with a compromise between the voice and breathing.

To explain this compromise of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%. If a patient desires to improve the vocal quality from 40% to 100% (an improvement of 60%), then the breathing WILL correspondingly decrease 60% down to 0% (or vice-versa). The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than the compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

Wondering what kind of workup is required as well as surgery to adjust the voice when both vocal cords are paralyzed? Click here to read more...

Larry Page Explains Why He Lost His Voice. Businessweek 5/14/13
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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