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Unilateral Vocal Cord ParalysisUnilateral Vocal Cord Paralysis

Nora Malaisrie, M.D.Nora Malaisrie, M.D.

Faculty Discussant: Natasha Mirza, M.D.Faculty Discussant: Natasha Mirza, M.D.

Thursday, July 24, 2008Thursday, July 24, 2008

Otorhinolaryngology: Head and Neck Surgery at PENN

Excellence in Patient Care, Education and Research since 1870


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IntroductionIntroduction

Affects quality of lifeAffects quality of life

Potential morbidity and mortalityPotential morbidity and mortality A sign ofa disease process withA sign ofa disease process with

multiple etiologies, necessitatingmultiple etiologies, necessitatingthorough evaluationthorough evaluation

Multiple therapeutic options that mustMultiple therapeutic options that mustbe tailored to the patientbe tailored to the patient


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AnatomyAnatomy

RecurrentRecurrentlaryngeal nervelaryngeal nerve 0.5% right non0.5% right non--

recurrentrecurrentlaryngeal nervelaryngeal nerve

MusclesMuscles LateralLateral

cricoarytenoidcricoarytenoid

PosteriorPosteriorcricoarytenoidcricoarytenoid

ThyroarytenoidThyroarytenoid

InterarytenoidInterarytenoid


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Etiology: NeurologicEtiology: Neurologic

StrokeStroke

CNS tumorCNS tumor Diabetic neuropathyDiabetic neuropathy

Amyotrophic lateral sclerosis (ALS)Amyotrophic lateral sclerosis (ALS)

Parkinson diseaseParkinson disease Myasthenia gravisMyasthenia gravis

GuillainGuillain--Barre syndromeBarre syndrome


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Etiology: Tumor infiltrationEtiology: Tumor infiltration

or mass compressionor mass compression

Skull baseSkull base

ThyroidThyroid

EsophagusEsophagus

LungLung


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Etiology: SystemicEtiology: Systemic

diseasedisease Systemic lupus erythematosusSystemic lupus erythematosus SarcoidosisSarcoidosis

AmyloidosisAmyloidosis TuberculosisTuberculosis CharcotCharcot--MarieMarie--ToothTooth Mitochondrial disordersMitochondrial disorders

PorphyriaPorphyria Polyarteritis nodosaPolyarteritis nodosa SilicosisSilicosis


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Etiology: MedicationsEtiology: Medications

Vinca alkaloidsVinca alkaloids

Vincristine and vinblastineVincristine and vinblastine

Unilateral or bilateralUnilateral or bilateral

Dose relatedDose related

Resolves with dose adjustment orResolves with dose adjustment or

cessationcessation


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Etiology: IdiopathicEtiology: Idiopathic

Not well understoodNot well understood Possible infectious causePossible infectious cause

Lyme diseaseLyme disease Tertiary syphilisTertiary syphilis EpsteinEpstein--Barr virusBarr virus Herpes simplex virus Type IHerpes simplex virus Type I

Diagnosis ofexclusionDiagnosis ofexclusion Urquhart et al. showed that 26% ofpatientsUrquhart et al. showed that 26% ofpatients

with a diagnosis of idiopathic VCP had awith a diagnosis of idiopathic VCP had apreexisting neurologic condition and 20%preexisting neurologic condition and 20%developed a subsequent CNS condition.developed a subsequent CNS condition.11

Urquhart et al. Idiopathic vocal cord palsies and associated neurological conditions.Arch Otolaryngol Head Neck Surg. 2005 Dec;131(12):1086-9.


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EtiologyEtiology

In a retrospectiveIn a retrospectiveanalysis of363analysis of 363

patients, Rosenthal etpatients, Rosenthal etal. showed thatal. showed thatunilateral VCP wasunilateral VCP wascaused bycaused by

1.1. Surgery (46%)Surgery (46%)

2.2. Idiopathic (18%)Idiopathic (18%)3.3. Malignancy (13%)Malignancy (13%)

Lung was mostLung was mostcommoncommon

Rosenthal et al. Vocal Fold Immobility: ALongitudinal analysis of Etiology Over 20 Years.Laryngoscope. 2007 Oct;117(10): 1864-1870.


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EtiologyEtiology

Rosenthal et al. showedRosenthal et al. showedthat surgical causes ofthat surgical causes ofunilateral vocal cordunilateral vocal cordimmobility were the resultimmobility were the result

ofof1.1. NonNon--thyroid surgeriesthyroid surgeries

(67%)(67%) Anterior cervical spineAnterior cervical spine

(15%)(15%) Carotid endarterectomyCarotid endarterectomy

(11%)(11%) Cardiac (9%)Cardiac (9%)

2.2. Thyroid surgeries (33%)Thyroid surgeries (33%) Thyroid (26%)Thyroid (26%) Parathyroid (6%)Parathyroid (6%) Thyroid and parathyroidThyroid and parathyroid

(1%)(1%)



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EtiologyEtiology

Rosenthal et al.Rosenthal et al.compared unilateralcompared unilateral

VCP from 1985VCP from 1985--1995 to1995 to19961996--20052005

Surgical causes doubledSurgical causes doubled

Malignant causesMalignant causes

decreaseddecreased



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EtiologyEtiology

Rosenthal et al. compared their study to previousRosenthal et al. compared their study to previousstudies to evaluate the changing etiology ofstudies to evaluate the changing etiology ofunilateral VCP.unilateral VCP.

Increase in surgical causes, with a greater proportionIncrease in surgical causes, with a greater proportionattributable to nonattributable to non--thyroid surgeriesthyroid surgeries Decrease in malignant causesDecrease in malignant causes



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EvaluationEvaluation HistoryHistory

SymptomsSymptoms

Voice changesVoice changes

Hoarseness to aphoniaHoarseness to aphonia Compensatory voice changesCompensatory voice changes

Vocal fatigue, neck painVocal fatigue, neck pain

AspirationAspiration

Weak, ineffective coughWeak, ineffective cough Past medical and surgical historyPast medical and surgical history

Social historySocial history


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EvaluationEvaluation Physical ExamPhysical Exam

VideostroboscopyVideostroboscopy

Increased amplitudeIncreased amplitude

ofvibrationofvibration Vocal fold heightVocal fold height

differencedifference

Vocal processVocal process

contactcontact


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Evidence Based MedicineEvidence Based Medicine

Levels and GradesLevels and Grades


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EvaluationEvaluation LabsLabs

In a survey of84 otolaryngologists,In a survey of84 otolaryngologists,Merati et al. found thatMerati et al. found that

20% found that serum testing was20% found that serum testing wasnecessarynecessary

The most commonly ordered labs wereThe most commonly ordered labs wereRF, Lyme titer, ESR, ANARF, Lyme titer, ESR, ANA11

Routine labs not supported by theRoutine labs not supported by theliterature if cause unknown.literature if cause unknown.2,32,3

1. Merati et al. Diagnostic testing for Vocal Fold Paralysis: Survey ofPractice and Evidence-Based Medicine Review.Laryngoscope. 2006 Sept; 116: 1539-1552.

2. Terris et al. Contemporary evaluation ofunilatereal vocal cord paralysis. Otolaryngol Head Neck Surg. 1992

Jul;107(1):84-90.3. MacGregor et al. Vocal Fold palsy: a re-evaluation of investigations. J Laryngol Otol. 1994;108:193-19.


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EvaluationEvaluation

Assess swallow functionAssess swallow functionand aspirationand aspiration

Modified barium swallowModified barium swallow

Functional endoscopicFunctional endoscopicevaluation of swallowingevaluation of swallowing(FEES)(FEES)

No additional work upNo additional work up

required if clear cutrequired if clear cutetiologyetiology


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EvaluationEvaluation ImagingImaging

ModalitiesModalities

CXR: May be most useful and costCXR: May be most useful and cost--effective.effective.

CT with contrast: May evaluate the entire courseCT with contrast: May evaluate the entire courseof the RLN.of the RLN.

MRI: May be useful in patients withMRI: May be useful in patients withpolyneuropathypolyneuropathy

Literature does not demonstrate superiorityLiterature does not demonstrate superiorityofany single modalityofany single modality

1. Merati et al. Diagnostic testing for Vocal Fold Paralysis: Survey ofPractice and Evidence-Based Medicine Review.Laryngoscope. 2006 Sept; 116: 1539-1552.

2. Terris et al. Contemporary evaluation ofunilatereal vocal cord paralysis. Otolaryngol Head Neck Surg. 1992Jul;107(1):84-90.

3. Glazer et al. Extralaryngeal causes ofvocal cord paralysis: CT evaluation. AJR am J Roentgenol 1983;141:527-531.4. ElBadawey et al. Prospective study to assess vocal cord palsy investigations. Otolaryng Head Neck Surg 2008;

138:78-790.


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EvaluationEvaluation LaryngealLaryngeal

electromyography (LEMG)electromyography (LEMG) Needle electrodeNeedle electrode

placement intoplacement into

thyroarytenoid andthyroarytenoid andcricothyoid musclecricothyoid muscle

AssessAssess Muscle at restMuscle at rest

Voluntary motorVoluntary motorunit recruitmentunit recruitment

May not be usefulMay not be usefulin diagnosisin diagnosis

1. Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000Aug;33(4):759-70.

2. Sataloffet al. Practice parameter: laryngeal electromyography (an evidence-based review). Otolaryngol HeadNeck Surg 2004; 130: 770-779.


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EvaluationEvaluation LEMGLEMG

Munin et al. reported that LEMG obtained 1Munin et al. reported that LEMG obtained 1--6 mo from onset6 mo from onsetmay be helpful in determining prognosis.may be helpful in determining prognosis.11

Prognosis good if there is absent spontaneous activity andPrognosis good if there is absent spontaneous activity andnormal recruitment with normal motor unit morphologynormal recruitment with normal motor unit morphology

Prognosis poor if there is spontaneous activity with absentPrognosis poor if there is spontaneous activity with absentrecruitment and presence offibrillationsrecruitment and presence offibrillations22

Wang et al. reported that LEMG obtained 2Wang et al. reported that LEMG obtained 2--6 mo from onset6 mo from onsethave a sensitivity and PPV of93% and accuracy of87%.have a sensitivity and PPV of93% and accuracy of87%.22

1. Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am.2000 Aug;33(4):759-70.

2. Koufman et al. Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999. OtolaryngolHead Neck Surg. 2001 Jun;124(6):603-6.

3. Wang et al. Prognostic indicators ofunilateral vocal fold paralysis. Arch Otolaryngol Head Neck Surg. 2008Apr;134(4):380-8.


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Differential DiagnosisDifferential Diagnosis

Cricoarytenoid fixationCricoarytenoid fixation

Caused byCaused by

Joint subluxation/dislocation with ankylosisJoint subluxation/dislocation with ankylosis

Jointfixation by rheumatoid arthritis or goutJointfixation by rheumatoid arthritis or gout

Normal EMGNormal EMG

Direct laryngoscopyDirect laryngoscopy Laryngeal malignancyLaryngeal malignancy


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TreatmentTreatment

Goal: Improve voice and prevent aspiration.Goal: Improve voice and prevent aspiration.Patientfactors affect treatment strategies.Patientfactors affect treatment strategies. Presence ofaspirationPresence ofaspiration

Nature ofnerve injuryNature ofnerve injury Vocal demandsVocal demands Medical comorbiditiesMedical comorbidities LEMG findingsLEMG findings

Strategies:Strategies: Observation for 6Observation for 6--12 months12 months Speech and swallow therapySpeech and swallow therapy Surgical interventionSurgical intervention

Temporary: Vocal fold injectionTemporary: Vocal fold injection Permanent: Vocal fold injection with durable material,Permanent: Vocal fold injection with durable material,

medialization thyroplasty +/medialization thyroplasty +/-- arytenoid adduction orarytenoid adduction orlaryngeal reinnervationlaryngeal reinnervation


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TreatmentTreatment Speech and swallowSpeech and swallow

Provides voice therapyProvides voice therapy

Teaches vocal hygiene andTeaches vocal hygiene and

compensatory strategiescompensatory strategies Identifies and eliminatesIdentifies and eliminates

counterproductive compensatorycounterproductive compensatory

strategiesstrategies PrePre--operative and postoperative and post--operativeoperative

assessmentassessment


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TreatmentTreatment Injection laryngoplastyInjection laryngoplasty

Injection withInjection withtemporarytemporary

materialsmaterialstemporizes thetemporizes thevoice until returnvoice until returnoffunctionoffunction

Many materialsMany materialsavailable foravailable foraugmentationaugmentation

OLeary et al. Injection Laryngoplasty. Otolaryngol Clin N Am 2006;39:43-54.


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Pre-injection Post-injection


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Method: Under generalMethod: Under generalanesthesia via directanesthesia via directlaryngoscopylaryngoscopy

Adv: Patient comfort,Adv: Patient comfort,improved precisionimproved precision

Disadv: No voice feedbackDisadv: No voice feedback

Complications: UnderComplications: Under--

injection, overinjection, over--injection,injection,improper placement, foreignimproper placement, foreignbody reactionbody reaction


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TreatmentTreatment Medialization thyroplastyMedialization thyroplasty

Direct medialization ofDirect medialization ofthe vocal cordthe vocal cord

Performed alone orPerformed alone or

with arytenoidwith arytenoidadduction oradduction orreinnervationreinnervationprocedureprocedure

Implant materialImplant material Carved or prefabricatedCarved or prefabricated

Silastic implantSilastic implant Hydroxyapatite implantHydroxyapatite implant GoreGore--Tex stripsTex strips


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TreatmentTreatment MedializationMedialization

thyroplastythyroplasty Adv: Local anesthesia,Adv: Local anesthesia,

voice feedback, reversible,voice feedback, reversible,vocal fold integrityvocal fold integrity

preservedpreserved Disadv: Open procedure,Disadv: Open procedure,

technically difficult, closuretechnically difficult, closureofposterior gap limitedofposterior gap limited

Complications: PenetrationComplications: Penetrationof laryngeal mucosa,of laryngeal mucosa,infection, chondritis,infection, chondritis,implant migration, airwayimplant migration, airwayobstruction,obstruction,undercorrectionundercorrection


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TreatmentTreatment Arytenoid adductionArytenoid adduction

Adjunct to medialization thyroplasty ifAdjunct to medialization thyroplasty iflarge posterior glottic gap or vocallarge posterior glottic gap or vocalfolds at different levelsfolds at different levels

Kraus et al. showed that whenKraus et al. showed that whencombined with a medializationcombined with a medializationthyroplasty, there was improvementthyroplasty, there was improvementin symptoms as well as voicein symptoms as well as voiceparameters.parameters.11

Mucullough et al. showed that whenMucullough et al. showed that whencombined with medializationcombined with medializationthyroplasty, functional resultsthyroplasty, functional resultsexceeded the improvement attainedexceeded the improvement attainedwith medialization alone.with medialization alone.22

1. Kraus et al. Arytenoid adduction as an adjunct to type I thyroplasty for unilateral vocal cord paralysis. Head Neck.1999 Jan;21(1):52-9.

2. Mucullouch et al. Arytenoid adduction combined with Gore-Tex medialization thyroplasty. Laryngoscope. 2000Aug;110(8):1306-11.


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TreatmentTreatment Laryngeal ReinnervationLaryngeal Reinnervation

Nerve muscle pedicle (NMP)Nerve muscle pedicle (NMP)

Nerve with portion ofmotorNerve with portion ofmotor

units transferred to aunits transferred to adenervated muscle.denervated muscle.

Thyrotomy performed toThyrotomy performed toplace the NMP to the lateralplace the NMP to the lateralcricoarytenoid muscle.cricoarytenoid muscle.

Tucker et al. reportedTucker et al. reportedimprovement in voice qualityimprovement in voice qualityand restoration ofadduction.and restoration ofadduction.11

Tucker et al. Long-term results ofnerve-muscle pedicle reinnervation for laryngeal paralysis. AnnOtol Rhinol Laryngol 1989;98:674-676.


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TreatmentTreatment Laryngeal ReinnervationLaryngeal Reinnervation

Ansa cervicalis to RLNAnsa cervicalis to RLN Provides weak tonic innervation toProvides weak tonic innervation to

intrinsic laryngeal musclesintrinsic laryngeal muscles Adv: Extralaryngeal, no permanentAdv: Extralaryngeal, no permanent

implant material, does not affectimplant material, does not affectsubsequent proceduressubsequent procedures Disadv: Deeper dissection, requiresDisadv: Deeper dissection, requires

intact nerves , delay in voiceintact nerves , delay in voiceimprovementimprovement

Crumley reported improved vocalCrumley reported improved vocalquality and restoration of the mucosalquality and restoration of the mucosal

wave.wave.11 Lorenz et al. reported improved vocalLorenz et al. reported improved vocal

quality as well as glottic closure andquality as well as glottic closure andvocal fold edge straightening.vocal fold edge straightening.22

1. Crumley. Update: ansa cervicalis to recurrent laryngeal nerve anastomosis for unilateral laryngeal paralysis.Laryngoscope. 1991 Apr;101(4 Pt 1):384-388.

2. Lorenz et al. Ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis:experience ofa single institution. Ann Otol Rhinol Laryngol. 2008 Jan;117(1):40-5.


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ConclusionConclusion

Unilateral vocal cord paralysis affectsUnilateral vocal cord paralysis affectsquality of life and may causequality of life and may cause

significant morbiditysignificant morbidity

Thorough evaluation is mandatory toThorough evaluation is mandatory todetermine etiology if initially uncleardetermine etiology if initially unclear

Many treatment options are availableMany treatment options are availablewhich are tailored to patientwhich are tailored to patient


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AcknowledgementsAcknowledgements

Natsha Mirza, M.D.Natsha Mirza, M.D.

Lauren Campe, M.S., CCCLauren Campe, M.S., CCC--SLPSLP


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ReferencesReferences

Cummings:Cummings: Otolaryngology: Head & Neck SurgeryOtolaryngology: Head & Neck Surgery, 4th ed., 4th ed. Bailey:Bailey: Head and Neck SurgeryHead and Neck Surgery OtolaryngologyOtolaryngology, 4, 4thth ed.ed. Rubin et al. Vocal Fold Paresis and Paralysis.Rubin et al. Vocal Fold Paresis and Paralysis. Otolaryngol Clin N AmOtolaryngol Clin N Am. 2007 Oct; 40(5): 1109. 2007 Oct; 40(5): 1109--1131.1131. Urquhartetal . Idiopathic vocal cordpalsies andassociated neurologicalconditions.Urquhartetal . Idiopathic vocalcordpalsies andassociated neurologicalconditions. Arch OtolaryngolHeadNeckSurgArch OtolaryngolHeadNeckSurg. 2005. 2005

Dec;131(12):1086Dec;131(12):1086--9.9. Brousseau etal. A rare butserious entity: nasogastrictube syndrome. Otolaryng HeadNeckSurg. 2006 Nov;135(5): 677-679. Rosenthaletal. VocalFold Immobility: A Longitudinalanalysis ofEtiologyOver20 Years. Laryngoscope. 2007 Oct;117(10): 1864-1870. Merati etal. Diagnostictesting forVocal FoldParalysis: Surveyof Practice andEvidence-BasedMedicine Review. Laryngoscope. 2006 Sept;

116: 1539-1552. Terris etal. Contemporary evaluation ofunilaterealvocalcordparalysis. OtolaryngolHeadNeckSurg. 1992 Jul;107(1):84-90. MacGregoretal. Vocal Foldpalsy: are-evaluation of investigations. J LaryngolOtol. 1994;108:193-19. ElBadaweyetal. Prospective studytoassess vocalcordpalsy investigations. Otolaryng HeadNeckSurg 2008; 138:78-790. Munin etal. Laryngeal electromyography: diagnosticandprognosticapplications. OtolaryngolClin North Am. 2000 Aug;33(4):759-70. Sataloff etal. Practice parameter: laryngeal electromyography (an evidence-basedreview). OtolaryngolHeadNeckSurg 2004; 130: 770-

779. Koufman etal. Diagnosticlaryngealelectromyography: The Wake Forestexperience 1995-1999. OtolaryngolHeadNeckSurg. 2001

Jun;124(6):603-6. Wang etal. Prognostic indicators ofunilateralvocalfoldparalysis. Arch OtolaryngolHeadNeckSurg. 2008 Apr;134(4):380-8. OLearyetal.

Injection Laryngoplasty. OtolaryngolClin N Am 2006;39:43-54. Kraus etal. Arytenoidadduction as an adjuncttotype I thyroplastyforunilateralvocalcordparalysis. HeadNeck. 1999 Jan;21(1):52-9. Mucullouch etal. Arytenoidadduction combinedwith Gore-Tex medialization thyroplasty. Laryngoscope. 2000 Aug;110(8):1306-11.

Abraham etal. Complications oftype I thyroplastyandarytenoidadduction. Laryngoscope. 2001 Aug;111(8):1322-9. Tuckeretal. Long-term results of nerve-muscle pedicle reinnervation forlaryngealparalysis. Ann OtolRhinolLaryngol 1989;98:674-676. Crumley. Update: ansacervicalis torecurrentlaryngealnerve anastomosis forunilaterallaryngealparalysis. Laryngoscope. 1991 Apr;101(4

Pt1):384-388. Lorenz etal. Ansacervicalis-to-recurrentlaryngealnerve anastomosis forunilateralvocalfoldparalysis: experience ofasingle institution.

Ann OtolRhinolLaryngol. 2008 Jan;117(1):40-5.

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