Head turn and phonation in vc palsy step by step
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head turn test vocal cord palsy unilateral mechanism step by step phonation
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head turn toward paralyzed side vocal cord palsy glottic closure mechanism ipsilateral
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"head turn" "vocal cord" OR "vocal fold" palsy "ipsilateral" mechanism phonation improvement
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https://pubmed.ncbi.nlm.nih.gov/15193658
Here is a complete step-by-step breakdown of the head turn and phonation maneuver in unilateral vocal cord (fold) palsy:
Head Turn in Unilateral VC Palsy - Step by Step
Background: Why the Voice Is Affected
In unilateral recurrent laryngeal nerve (RLN) palsy, all ipsilateral intrinsic laryngeal muscles are paralyzed except the cricothyroid (innervated by the superior laryngeal nerve). The paralyzed cord typically rests in a paramedian or intermediate position - near but not at the midline. During phonation, the normal (contralateral) cord adducts to the midline but cannot fully bridge the glottic gap left by the paralyzed cord. This produces:
- Breathy, hoarse dysphonia (flaccid dysphonia)
- Shortened maximum phonation time
- Reduced loudness
- Diplophonia (two simultaneous pitch levels - both cords vibrating at unequal frequency)
- Rapid voice fatigue (Localization in Clinical Neurology, 8e)
The Head Turn Maneuver
Step 1 - Identify the affected side
Before the maneuver, confirm which cord is paralyzed - on laryngoscopy/flexible nasendoscopy, the paralyzed cord lies in a fixed near-midline (paramedian) position at rest, while the normal cord swings across to meet it (or tries to) during phonation.
Step 2 - Patient positioning
Seat the patient upright, neutral posture. Ask them to breathe normally first.
Step 3 - Instruct the head turn
Ask the patient to rotate their head toward the side of the paralyzed cord (ipsilateral turn). For example, if the left cord is paralyzed, turn the head to the left.
Step 4 - Mechanism of action
When the head turns toward the paralyzed side:
- The ipsilateral sternocleidomastoid (SCM) contracts and the cervical muscles compress the ipsilateral thyroid ala against the paralyzed cord
- This mechanically pushes the paralyzed cord toward (and sometimes past) the midline
- The glottic gap narrows or closes
- The contralateral mobile cord can now make contact more easily with the medially displaced paralyzed cord
- Result: improved glottic closure during phonation
The principle is essentially a manual, external analog to surgical medialization.
Step 5 - Phonation test
While the head is turned ipsilaterally, ask the patient to:
- Sustain a vowel (e.g., "eeee" or "ahhh")
- Count or say a sentence
Positive response: Voice quality is noticeably improved - less breathy, louder, longer sustained phonation. This confirms that the paralyzed cord is close enough to midline that compression can close the gap, and that the voice deficit is indeed from glottic incompetence rather than other causes (e.g., sulcus vocalis, scar).
Negative/no improvement: Either the cord is too lateralized, there is significant atrophy/bowing, or the contralateral cord has its own pathology. May also indicate the diagnosis is not simple glottic incompetence.
Step 6 - Compare positions
Test all three head positions and compare:
| Head position | Expected effect |
|---|---|
| Neutral (center) | Baseline dysphonic voice |
| Ipsilateral (toward paralyzed side) | Improved voice - cord medialized |
| Contralateral (away from paralyzed side) | Voice worsens - cord lateralized further |
Note: A 2004 objective study (Paseman et al., J Voice) using airflow measures (open quotient, MFDR) in 10 UVFP patients found that head turn did not significantly improve measurable glottic closure in all patients, challenging the theoretical construct. The clinical improvement some patients report may therefore reflect compensatory supraglottic mechanisms rather than true glottic closure. The maneuver still has practical diagnostic and conservative management value.
Clinical Uses of the Head Turn
- Diagnostic confirmation - Helps distinguish glottic incompetence from other causes of dysphonia
- Swallowing management - Head turn toward the paralyzed side diverts food/liquid to the innervated (stronger) side, reducing aspiration risk (University of Iowa Laryngeal Paralysis Protocol)
- Voice therapy - Can be taught as a compensatory strategy while awaiting spontaneous recovery (up to 6-12 months post-injury)
- Pre-surgical planning - A good response to head turn suggests the patient may benefit from medialization laryngoplasty (Type I thyroplasty) or injection laryngoplasty
Summary Table
| Step | Action | Purpose |
|---|---|---|
| 1 | Confirm paralyzed side on laryngoscopy | Know which side to turn to |
| 2 | Seat patient upright | Proper laryngeal positioning |
| 3 | Turn head toward paralyzed side | Mechanically medialize the paralyzed cord |
| 4 | SCM compresses ipsilateral thyroid ala | Narrows glottic gap |
| 5 | Ask patient to phonate ("eeee") | Assess improvement in voice |
| 6 | Compare neutral vs. ipsilateral vs. contralateral | Confirm effect is position-dependent |
| 7 | Note subjective and objective improvement | Guides management decisions |
Key teaching point: The head turns toward the paralyzed side (not away from it) - this is the most commonly confused detail. Turning away would lateralize the cord further and worsen the voice.
Sources: Localization in Clinical Neurology 8e; University of Iowa Head & Neck Protocols; Paseman et al., J Voice 2004 [PMID: 15193658]
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