Unilateral Vocal Cord Paralysis
Nora Malaisrie, M.D.
Faculty Discussant: Natasha Mirza, M.D.
Thursday, July 24, 2008
Otorhinolaryngology: Head and Neck Surgery at PENN
Excellence in Patient Care, Education and Research since 1870
Introduction

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
Affects quality of life
Potential morbidity and mortality
A sign of a disease process with
multiple etiologies, necessitating
thorough evaluation
Multiple therapeutic options that must
be tailored to the patient
Anatomy




Upper motor neurons from
cerebral cortex to nucleus
ambiguus in the medulla
Lower motor neurons from
nucleus ambiguus exit the
medulla as the vagus nerve
Vagus nerve exits the skull
base via the jugular
foramen
Branches
– Pharyngeal branch
– Superior laryngeal nerve
– Recurrent laryngeal nerve
Anatomy

Recurrent
laryngeal nerve
– 0.5% right nonrecurrent
laryngeal nerve

Muscles
– Lateral
cricoarytenoid
– Posterior
cricoarytenoid
– Thyroarytenoid
– Interarytenoid
Etiology

Dysfunction at
– Brain and
brainstem nuclei
– Vagus nerve
– Recurrent
laryngeal nerve
Etiology: Neurologic
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


Stroke
CNS tumor
Diabetic neuropathy
Amyotrophic lateral sclerosis (ALS)
Parkinson disease
Myasthenia gravis
Guillain-Barre syndrome
Etiology: Tumor infiltration
or mass compression




Skull base
Thyroid
Esophagus
Lung
Etiology: Systemic
disease


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

Systemic lupus erythematosus
Sarcoidosis
Amyloidosis
Tuberculosis
Charcot-Marie-Tooth
Mitochondrial disorders
Porphyria
Polyarteritis nodosa
Silicosis
Etiology: Medications

Vinca alkaloids
– Vincristine and vinblastine
– Unilateral or bilateral
– Dose related
– Resolves with dose adjustment or
cessation
Etiology: Traumatic

Iatrogenic: Surgical
– Thyroidectomy
– Anterior cervical spine
procedures
– Esophagectomy
– Thymectomy
– Carotid endarterectomy
– Cardiothoracic surgery




Aortic surgery
Coronary artery bypass
grafting
Pulmonary lobar
resection
Mediastinoscopy

Iatrogenic: Non-surgical
– Endotracheal intubation


Arytenoid dislocation,
subluxation
Tapia’s syndrome
– Nasogastric tube
placement1

Non-iatrogenic
– Blunt or penetrating
trauma to the neck
Brousseau et al. A rare but serious entity: nasogastric tube syndrome. Otolaryngol Head
Neck Surg. 2006 Nov;135(5): 677-679.
Etiology: Idiopathic


Not well understood
Possible infectious cause
–
–
–
–

Lyme disease
Tertiary syphilis
Epstein-Barr virus
Herpes simplex virus Type I
Diagnosis of exclusion
– Urquhart et al. showed that 26% of patients
with a diagnosis of idiopathic VCP had a
preexisting neurologic condition and 20%
developed a subsequent CNS condition.1
Urquhart et al. Idiopathic vocal cord palsies and associated neurological conditions.
Arch Otolaryngol Head Neck Surg. 2005 Dec;131(12):1086-9.
Etiology

In a retrospective
analysis of 363
patients, Rosenthal et
al. showed that
unilateral VCP was
caused by
1. Surgery (46%)
2. Idiopathic (18%)
3. Malignancy (13%)
•
Lung was most
common
Rosenthal et al. Vocal Fold Immobility: A Longitudinal analysis of Etiology Over 20 Years.
Laryngoscope. 2007 Oct;117(10): 1864-1870.
Etiology

Rosenthal et al. showed
that surgical causes of
unilateral vocal cord
immobility were the result
of
1.
Non-thyroid surgeries
(67%)
•
•
•
2.
Anterior cervical spine
(15%)
Carotid endarterectomy
(11%)
Cardiac (9%)
Thyroid surgeries (33%)
•
•
•
Thyroid (26%)
Parathyroid (6%)
Thyroid and parathyroid
(1%)
Rosenthal et al. Vocal Fold Immobility: A Longitudinal analysis of Etiology Over 20 Years.
Laryngoscope. 2007 Oct;117(10): 1864-1870.
Etiology

Rosenthal et al.
compared unilateral
VCP from 1985-1995 to
1996-2005
– Surgical causes doubled
– Malignant causes
decreased
Rosenthal et al. Vocal Fold Immobility: A Longitudinal analysis of Etiology Over 20 Years.
Laryngoscope. 2007 Oct;117(10): 1864-1870.
Etiology

Rosenthal et al. compared their study to previous
studies to evaluate the changing etiology of
unilateral VCP.
– Increase in surgical causes, with a greater proportion
attributable to non-thyroid surgeries
– Decrease in malignant causes
Rosenthal et al. Vocal Fold Immobility: A Longitudinal analysis of Etiology Over 20 Years.
Laryngoscope. 2007 Oct;117(10): 1864-1870.
Evaluation – History

Symptoms
– Voice changes



Hoarseness to aphonia
Compensatory voice changes
Vocal fatigue, neck pain
– Aspiration
– Weak, ineffective cough


Past medical and surgical history
Social history
Evaluation – Physical Exam


Cranial nerve exam
Nasopharyngolaryngoscopy
–
–
–
–
–
–
–
Vocal cord asymmetry
Horizontal and vertical position
Glottic gap
Poooled secretions
Aspiration
Maximal phonation time (MPT)
Supraglottic hyperfunction
Evaluation – Physical Exam

Videostroboscopy
– Increased amplitude
of vibration
– Vocal fold height
difference
– Vocal process
contact
Evidence Based Medicine
Levels and Grades
Evaluation – Labs

In a survey of 84 otolaryngologists,
Merati et al. found that
– 20% found that serum testing was
necessary
– The most commonly ordered labs were
RF, Lyme titer, ESR, ANA1

Routine labs not supported by the
literature if cause unknown.2,3
1. Merati et al. Diagnostic testing for Vocal Fold Paralysis: Survey of Practice and Evidence-Based Medicine Review.
Laryngoscope. 2006 Sept; 116: 1539-1552.
2. Terris et al. Contemporary evaluation of unilatereal 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.
Evaluation

Assess swallow function
and aspiration
– Modified barium swallow
– Functional endoscopic
evaluation of swallowing
(FEES)

No additional work up
required if clear cut
etiology
Evaluation – Imaging

Modalities
– CXR: May be most useful and cost-effective.
– CT with contrast: May evaluate the entire course
of the RLN.
– MRI: May be useful in patients with
polyneuropathy

Literature does not demonstrate superiority
of any single modality
1. Merati et al. Diagnostic testing for Vocal Fold Paralysis: Survey of Practice and Evidence-Based Medicine Review.
Laryngoscope. 2006 Sept; 116: 1539-1552.
2. Terris et al. Contemporary evaluation of unilatereal vocal cord paralysis. Otolaryngol Head Neck Surg. 1992
Jul;107(1):84-90.
3. Glazer et al. Extralaryngeal causes of vocal 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.
Evaluation – Laryngeal
electromyography (LEMG)


Needle electrode
placement into
thyroarytenoid and
cricothyoid muscle
Assess
– Muscle at rest
– Voluntary motor unit
recruitment

1.
2.
May not be useful
in diagnosis
Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000
Aug;33(4):759-70.
Sataloff et al. Practice parameter: laryngeal electromyography (an evidence-based review). Otolaryngol Head
Neck Surg 2004; 130: 770-779.
Evaluation – LEMG

Munin et al. reported that LEMG obtained 1-6 mo from onset
may be helpful in determining prognosis.1
– Prognosis good if there is absent spontaneous activity and
normal recruitment with normal motor unit morphology
– Prognosis poor if there is spontaneous activity with absent
recruitment and presence of fibrillations2

1.
2.
3.
Wang et al. reported that LEMG obtained 2-6 mo from onset
have a sensitivity and PPV of 93% and accuracy of 87%.2
Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am.
2000 Aug;33(4):759-70.
Koufman et al. Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999. Otolaryngol
Head Neck Surg. 2001 Jun;124(6):603-6.
Wang et al. Prognostic indicators of unilateral vocal fold paralysis. Arch Otolaryngol Head Neck Surg. 2008
Apr;134(4):380-8.
Differential Diagnosis

Cricoarytenoid fixation
– Caused by
Joint subluxation/dislocation with ankylosis
 Joint fixation by rheumatoid arthritis or gout

– Normal EMG
– Direct laryngoscopy

Laryngeal malignancy
Treatment
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Goal: Improve voice and prevent aspiration.
Patient factors affect treatment strategies.
–
–
–
–
–
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Presence of aspiration
Nature of nerve injury
Vocal demands
Medical comorbidities
LEMG findings
Strategies:
– Observation for 6-12 months
– Speech and swallow therapy
– Surgical intervention


Temporary: Vocal fold injection
Permanent: Vocal fold injection with durable material,
medialization thyroplasty +/- arytenoid adduction or
laryngeal reinnervation
Treatment – Speech and swallow
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Provides voice therapy
Teaches vocal hygiene and
compensatory strategies
Identifies and eliminates
counterproductive compensatory
strategies
Pre-operative and post-operative
assessment
Treatment – Injection laryngoplasty


Injection with
temporary
materials
temporizes the
voice until return
of function
Many materials
available for
augmentation
O’Leary et al. Injection Laryngoplasty. Otolaryngol Clin N Am 2006;39:43-54.
Treatment – Injection laryngoplasty

Method: Under local
anesthesia via
transcutaneous or oral
approach with NPL
– Adv: Useful for poor
surgical candidates,
voice feedback
– Disadv: Pt discomfort
Treatment – Injection laryngoplasty
Pre-injection
Post-injection
Treatment – Injection laryngoplasty

Method: Under general
anesthesia via direct
laryngoscopy
– Adv: Patient comfort,
improved precision
– Disadv: No voice feedback

Complications: Underinjection, over-injection,
improper placement, foreign
body reaction
Treatment – Medialization thyroplasty
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Direct medialization of
the vocal cord
Performed alone or
with arytenoid
adduction or
reinnervation
procedure
Implant material
– Carved or prefabricated
Silastic implant
– Hydroxyapatite implant
– Gore-Tex strips
Treatment – Medialization
thyroplasty



Adv: Local anesthesia,
voice feedback, reversible,
vocal fold integrity
preserved
Disadv: Open procedure,
technically difficult, closure
of posterior gap limited
Complications: Penetration
of laryngeal mucosa,
infection, chondritis,
implant migration, airway
obstruction,
undercorrection
Treatment – Arytenoid adduction



1.
2.
Adjunct to medialization thyroplasty if
large posterior glottic gap or vocal
folds at different levels
Kraus et al. showed that when
combined with a medialization
thyroplasty, there was improvement
in symptoms as well as voice
parameters.1
Mucullough et al. showed that when
combined with medialization
thyroplasty, functional results
exceeded the improvement attained
with medialization alone.2
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.
Mucullouch et al. Arytenoid adduction combined with Gore-Tex medialization thyroplasty. Laryngoscope. 2000
Aug;110(8):1306-11.
Treatment – MT + AA

Complications of
medialization
thyroplasty with
arytenoid adduction
– Abraham et al.
compared ML + AA
patients to ML alone
and found no
statistical difference.
Abraham et al. Complications of type I thyroplasty and arytenoid adduction. Laryngoscope. 2001
Aug;111(8):1322-9.
Treatment – Laryngeal reinnervation



Goal: Increase bulk and tone
Indications: Poor chance of spontaneous recovery
Nerve characteristics
– RLN
– Ansa cervicalis

Types
– Neuromuscular pedicle
– Nerve-nerve anastamosis

May be combined with temporary injection
laryngoplasty until reinnervation
Treatment – Laryngeal Reinnervation

Nerve muscle pedicle (NMP)
– Nerve with portion of motor
units transferred to a
denervated muscle.
– Thyrotomy performed to
place the NMP to the lateral
cricoarytenoid muscle.
– Tucker et al. reported
improvement in voice quality
and restoration of adduction.1
Tucker et al. Long-term results of nerve-muscle pedicle reinnervation for laryngeal paralysis. Ann
Otol Rhinol Laryngol 1989;98:674-676.
Treatment – Laryngeal Reinnervation

Ansa cervicalis to RLN
– Provides weak tonic innervation to
intrinsic laryngeal muscles
– Adv: Extralaryngeal, no permanent
implant material, does not affect
subsequent procedures
– Disadv: Deeper dissection, requires
intact nerves , delay in voice
improvement


1.
2.
Crumley reported improved vocal
quality and restoration of the mucosal
wave.1
Lorenz et al. reported improved vocal
quality as well as glottic closure and
vocal fold edge straightening.2
Crumley. Update: ansa cervicalis to recurrent laryngeal nerve anastomosis for unilateral laryngeal paralysis.
Laryngoscope. 1991 Apr;101(4 Pt 1):384-388.
Lorenz et al. Ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis:
experience of a single institution. Ann Otol Rhinol Laryngol. 2008 Jan;117(1):40-5.
Conclusion



Unilateral vocal cord paralysis affects
quality of life and may cause
significant morbidity
Thorough evaluation is mandatory to
determine etiology if initially unclear
Many treatment options are available
which are tailored to patient
Acknowledgements
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
Natsha Mirza, M.D.
Lauren Campe, M.S., CCC-SLP
References
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Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
Bailey: Head and Neck Surgery – Otolaryngology, 4th ed.
Rubin et al. Vocal Fold Paresis and Paralysis. Otolaryngol Clin N Am. 2007 Oct; 40(5): 1109-1131.
Urquhart et al . Idiopathic vocal cord palsies and associated neurological conditions. Arch Otolaryngol Head Neck Surg. 2005
Dec;131(12):1086-9.
Brousseau et al. A rare but serious entity: nasogastric tube syndrome. Otolaryng Head Neck Surg. 2006 Nov;135(5): 677-679.
Rosenthal et al. Vocal Fold Immobility: A Longitudinal analysis of Etiology Over 20 Years. Laryngoscope. 2007 Oct;117(10): 1864-1870.
Merati et al. Diagnostic testing for Vocal Fold Paralysis: Survey of Practice and Evidence-Based Medicine Review. Laryngoscope. 2006
Sept; 116: 1539-1552.
Terris et al. Contemporary evaluation of unilatereal vocal cord paralysis. Otolaryngol Head Neck Surg. 1992 Jul;107(1):84-90.
MacGregor et al. Vocal Fold palsy: a re-evaluation of investigations. J Laryngol Otol. 1994;108:193-19.
ElBadawey et al. Prospective study to assess vocal cord palsy investigations. Otolaryng Head Neck Surg 2008; 138:78-790.
Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000 Aug;33(4):759-70.
Sataloff et al. Practice parameter: laryngeal electromyography (an evidence-based review). Otolaryngol Head Neck Surg 2004; 130: 770779.
Koufman et al. Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999. Otolaryngol Head Neck Surg. 2001
Jun;124(6):603-6.
Wang et al. Prognostic indicators of unilateral vocal fold paralysis. Arch Otolaryngol Head Neck Surg. 2008 Apr;134(4):380-8. O’Leary et
al. Injection Laryngoplasty. Otolaryngol Clin N Am 2006;39:43-54.
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.
Mucullouch et al. Arytenoid adduction combined with Gore-Tex medialization thyroplasty. Laryngoscope. 2000 Aug;110(8):1306-11.
Abraham et al. Complications of type I thyroplasty and arytenoid adduction. Laryngoscope. 2001 Aug;111(8):1322-9.
Tucker et al. Long-term results of nerve-muscle pedicle reinnervation for laryngeal paralysis. Ann Otol Rhinol Laryngol 1989;98:674-676.
Crumley. Update: ansa cervicalis to recurrent laryngeal nerve anastomosis for unilateral laryngeal paralysis. Laryngoscope. 1991 Apr;101(4
Pt 1):384-388.
Lorenz et al. Ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis: experience of a single institution.
Ann Otol Rhinol Laryngol. 2008 Jan;117(1):40-5.