76 Chapter 4
Case Study 4-2: A 24- Year- Old Man With
Unilateral Adductor Paralysis
Bryan graduated from the university with a degree in civil engineering. In college, he had
worked eve nings as a bartender but still had thousands of dollars in student loans. Fi nally, after
5 grueling years, his hard work paid off. Bryan got his first job as a civil engineer and began sur-
veying an addition to the interstate highway system. Years later, Bryan would start his own engi-
neering com pany, which would become one of the largest in the state. However, throughout his
life, he would be plagued by the inability to speak loudly— a constant source of irritation because
it interfered with his ability to communicate at job sites. Bryan’s vocal cords had been damaged in
a terrible car accident during the second week of his first job.
Bryan and two surveyors were returning from the site of the new overpass. The cloverleaf
interchange would provide safe access to the freeway for thousands of motorists. The eve ning
sun was just starting to dis appear below the high desert horizon as they drove their jeep onto the
freeway. The surveyors were sitting in the front of the vehicle, and Bryan was in the back seat.
Unexpectedly, a sedan with an intoxicated driver hit the rear of the jeep. Later, the highway patrol
investigators concluded that this driver was traveling at nearly 100 miles per hour, and the sun had
blocked his vision. He and the two surveyors were killed. Bryan was propelled forward, his larynx
crushed by the metal bar on the front seat of the jeep, and as the jeep rolled into the gutter, he was
thrown onto the freeway.
Bryan would have died that summer eve ning had it not been for a good Samaritan. The police
investigators suspected that the person who did the emergency tracheotomy was either an off-
duty emergency medical technician or a nurse. When Bryan’s larynx was crushed, he was unable
to breathe. The motorist saw Bryan’s respiratory distress, cut a small hole in his neck just below
the larynx, and placed a tube in the hole for breathing. The tube was the casing of a pen. When
the ambulance arrived, the motorist melted into the crowd of spectators and was never found.
The doctors in the hospital’s intensive care unit believed that the emergency tracheotomy was too
meticulous to have been done by a lay person but not professional enough to have been done by a
surgeon. Regardless of the surgical competence, that anonymous motorist saved Bryan’s life. Bryan
endured several surgeries to repair his larynx. Ultimately, normal structure and function were
restored except for muscular movement on the right side. The laryngeal nerve had been severed,
leaving Bryan’s vocal cord para lyzed on one side, a condition called unilateral adductor paralysis.
The state vocational rehabilitation department’s counselor arranged for Bryan’s rehabilitation.
Because the accident occurred during work, he was covered by the rehabilitation program. The
rehabilitation counselor worked with professionals from several disciplines to help Bryan return
to gainful employment. He received occupational and physical therapy for his broken pelvis, hand,
and arm and counseling to deal with the anger and grief resulting from the accident. Bryan also
received therapy for the unilateral adductor paralysis, which ultimately helped to restore his voice.
At first, Bryan could not produce any vocal cord vibration. All that he could manage was a loud
whisper. The clinician showed him that doing strenuous exercises while trying to produce a voice
would force the unimpaired vocal cord to contact the para lyzed one. The strenuous exercises and
grunting did produce some voice. The clinician had Bryan do push- ups, sit- ups, and pull- ups while
shouting sounds, syllables, and words. Isometric exercises, in which he pulled or pushed on a body
part, also resulted in the necessary muscular force to produce a voice. Bryan jokingly called the
voice therapy “boot camp.” Gradually his voice improved, and eventually he could speak during
normal conversation. Of course, because there was only one vocal cord with functional movement,
his voice had a low- pitched, breathy- hoarse quality, and he was able to talk loudly only with great
effort. After several months of therapy, the quality of his voice was the best that could be achieved.
Bryan was then scheduled to see a laryngologist about a vocal fold implant.