Etiology of vocal cord paralysis

Can Resident Auditory-Perceptual Voice Assessments Predict Medical Urgency of Voice Disorders?

BACKGROUND/OBJECTIVES

Growing reliance on telemedicine has created new triaging challenges. This study investigated how effectively otolaryngology resident auditory-perceptual voice assessments performed via telemedicine determined the need for urgent in-person clinic visits.

METHODS

Twelve otolaryngology resident physicians (PGY1-PGY5) performed auditory-perceptual assessments on 25 voice samples recorded during initial voice evaluations. Voice samples were balanced in severity and taken in equal numbers from patients with the following diagnoses: benign laryngeal lesions, laryngeal cancer, functional voice disorders, laryngeal edema (associated with LPR), and laryngeal paralysis/paresis. Urgent diagnoses were defined as laryngeal cancer and severe unilateral laryngeal paralysis. For each voice sample, residents were initially blinded to patient medical history. Residents rated severity of voice disorder, predicted patient diagnosis, and determined the urgency of seeing the patient in clinic. Residents then reviewed information from the patient's medical history and again rated urgency of voice disorder.

RESULTS

On average, residents identified urgent voice disorders in 56% of cases. After reviewing medical history, this number significantly increased to 77% (P = 0.001). Voice severity, smoking history, time since onset, and course of symptoms were considered most influential when determining medical urgency of voice patients. Year in residency program had no effect on rating accuracy. As expected, diagnostic accuracy of auditory-perceptual assessments was low, ranging from 40% for laryngeal paralysis/paresis to 5% for laryngeal edema.

CONCLUSION

Auditory-perceptual voice assessment, combined with medical history, predicted most medically urgent voice disorders. Further work should investigate if task-specific training might improve these results and which medical history items are most critical. Until accuracy of auditory-perceptual assessment of medical urgency is improved, these data underscore the importance of laryngeal examination in identifying medical urgency and etiology of dysphonia.

Management of Implant Extrusion following Thyroplasty for Vocal Fold Paralysis: A Case Report

The most widely used laryngeal surgery technique for patients with vocal fold paralysis is medialization thyroplasty. Materials such as Gore-Tex, silastic, and hydroxyapatite are often used, and the most worrisome possible complication is extrusion of the implant. A 36-year-old female patient with a history of pediatric cardiac surgery was diagnosed with left vocal cord paralysis after an episode of upper respiratory infection with a working diagnosis of subclinical left vocal cord paralysis following cardiac surgery. She underwent medialization thyroplasty with a Gore-Tex implant under local anesthesia. On the 21st postoperative day, she presented with sudden-onset hoarseness and dysphagia due to Gore-Tex implant extrusion. The implant was removed and augmentation of the left vocal cord with adipose tissue was performed. Only 14 cases of Gore-Tex implant extrusion have been described in the literature so far. The aim of this case report was not only to show one possible complication when using a Gore-Tex implant but also to present fat augmentation as one of the solutions for revision medialization and salvage treatment, with sustained long-term results.

Assessment of vocal fold movement through anterior-posterior view of videofluoroscopic swallowing study

Objective

The aim of this study is to assess the value of using videofluoroscopic swallowing study (VFSS) for assessing vocal fold paralysis.

Methods

This was a retrospective study of patients who underwent VFSS with a vocal fold testing maneuver from June 2020 to February 2022, and who had undergone laryngoscopy within 2 weeks before or after VFSS. The vocal fold testing maneuver consisted of making an 'e' sound for about 2-3 seconds during VFSS anterior-posterior (AP) view. The diagnostic value of the VFSS was evaluated by a trained reviewer, who assessed the presence and laterality of vocal fold paralysis by examining videos of the patients performing the vocal fold testing maneuver. Intra-rater reliability was determined by evaluation of the videos by the same reviewer 2 weeks later, and inter-rater reliability was determined by evaluation by a second reviewer.

Results

Seventy patients were enrolled in the study. The positive predictive value was 91.43% and the intra-rater and inter-rater reliabilities, as determined by Cohen's kappa value, were 0.746 and 0.824 respectively.

Conclusions

The presence and laterality of vocal fold paralysis were identified accurately and reliably by the reviewers, showing that VFSS can be used to assess vocal fold paralysis.

Level of evidence

2.

Clinical Experiences of Speech-Language Pathologists in the Rehabilitation of Unilateral Vocal Fold Paralysis

PURPOSE

Unilateral vocal fold paralysis (UVFP) is a neurological voice disorder that is often first treated by a speech-language pathologist (SLP). In literature, little consensus is found regarding voice therapy onset, duration, frequency, and content. The aim of the current study is to investigate the clinical practice of SLPs for treatment of UVFP regarding diagnostics and treatment characteristics. Additionally, the study examined the personal experiences of SLPs regarding UVFP care.

METHOD

An online survey was completed by 37 respondents, all SLPs with experience in treating UVFP. Demographic characteristics, experiences with voice assessments and treatment modalities were examined. Lastly, experiences and opinions of SLPs on evidence-based practice and their own clinical practice were surveyed.

RESULTS

Almost all respondents used a multidimensional voice assessment with findings from laryngovideostroboscopy to assess UVFP. Laryngeal electromyography is not yet integrated in regular clinical practices. The most commonly used vocal techniques were resonant voice exercises, laryngeal manipulation, semioccluded vocal tract exercises (SOVTEs), vocal hygiene, and Vocal Function Exercises, with SOVTEs most often considered effective. A total of 75% of the respondents feel confident treating UVFP, and 87.6% believe it is important to stay updated on evidence-based practice. Variation in therapy timing and dosage was observed, and 48.4% of SLPs usually started early voice therapy within 4 weeks after UVFP onset.

CONCLUSION

Flemish SLPs generally feel confident treating UVFP patients and show interest in improving evidence-based practice. Initiatives to train clinicians further in UVFP care and encouraging SLPs to provide practice-based evidence will enhance the knowledge base for evidence-based practice in UFVP.

Is There Any Reliable Predictor of Functional Recovery Following Post-thyroidectomy Vocal Fold Paralysis?

BACKGROUND

Predicting definitive outcomes of post-thyroidectomy vocal fold paralysis (VFP) is challenging. We aimed to identify reliable predictors based on intraoperative neuromonitoring (IONM) and flexible fiberoptic laryngostroboscopy (FFL) findings.

METHODS

Among 1172 thyroid operations performed from April to December 2021, all patients who exhibited vocal fold paralysis (VFP) at post-operative laryngoscopy were included. IONM data, including type of loss of signal (LOS), were collected. Patients underwent FFL, with arytenoid motility assessment, at 15, 45 and 120 days post-operatively. Patients were divided into two groups: those who recovered vocal fold motility (VFM) by the 120th post-operative day (recovery group) and those who did not (non-recovery group).

RESULTS

Fifty-nine VFP cases (5.0% of total patients) met the inclusion criteria. Eight patients were lost at follow-up and were excluded. Overall, 9 patients were included in the non-recovery group (0.8% of total patients) and 42 in the recovery group. Among various predictive factors, only arytenoid fixation (AF) at the 15th post-operative day and Type I LOS were significant predictors for no VFM recovery (p = 0.007, RR = 9.739, CI:1.3-72.3 and p = 0.001, RR = 9.25, CI:2.2-39.3 for AF and Type I injury, respectively). The combination of type of LOS and arytenoid motility at the 15th post-op day yielded satisfactory predictive values for the progression of transient VFP to permanent.

CONCLUSIONS

Arytenoid motility at the 15th post-op day and type II LOS are associated with recovery of VFM. Type of LOS and FFL could be included in the follow-up protocols of patients with VFP to reliably predict clinical outcomes.

Etiology and presenting features of vocal cord paralysis: changing trends over the last two decades

Background

The study was performed to evaluate the changing trends in etiology and presenting features of vocal cord paralysis (VCP) from March 1998 to March 2020.

Methods

Patient’s record collected from hospital database and divided into two groups, from March 1998 to March 2009 and from April 2009 to March 2020, to evaluate the changing trends in etiology and presenting features.

Results

Total of 711 VCP patients, 80.3% with unilateral (UVCP) and 19.7% with bilateral vocal cord paralysis (BVCP) included. The commonest etiology was non-surgical (57.1%) for UVCP and surgical (55.7%) for BVCP. The commonest surgical etiology was thyroid and parathyroid surgery for both UVCP (16.6%) and BVCP (38.5%). The commonest non-surgical etiology was idiopathic for UVCP (23.1%) and malignancies for BVCP (13.6%). There was increase in surgical etiology for both UVCP (39.3 to 45.3%) and BVCP (51.2 to 57.7%), and decrease in non-surgical etiology for both UVCP (60.7 to 54.6%) and BVCP (48.8 to 42.3%). The change in voice was most common presenting features for both UVCP (69.2%) and BVCP (92.8%). The frequency of the presenting features was comparable, with decrease in the duration of symptom onset over the time period.

Conclusion

The most common etiology for UVCP was idiopathic, and for BVCP was thyroid and parathyroid surgery. For both, UVCP and BVCP there was increasing trend for surgical and decreasing trend for non-surgical etiology. The change in voice was the most common presenting complain, with decrease in duration of symptom onset over time period.

Causes of Vocal Fold Paralysis

BACKGROUND

Vocal fold paralysis (VFP) can result from a variety of diseases or surgeries and has various causes. This study determined concurrent etiologies in patients who were treated in a teaching hospital (tertiary medical center).

METHODS

A retrospective review of medical records of patients with VFP from September 2010 to December 2019 was performed to determine the etiology. Patients with laryngeal/hypopharyngeal malignancies, those with incomplete examination and follow-up data were excluded from the study. During the follow-ups, cases involving recovery were also excluded.

RESULTS

One hundred and ninety-four patients with a determined etiology were included: 113 males and 81 females. Unilateral VFP was present in 178 patients, and 16 presented with bilateral VFP. The causes of unilateral VFP were surgical for 61.3%, neoplastic for 17.5%, idiopathic for 10.3%, traumatic for 1.5%, central for 4.7%, cardiovascular for 2%, radiation-induced for 1.5%, and inflammatory for 1%. Thyroidectomy was the most common surgery for unilateral VFP and was the cause for 54 patients. Lung cancer was responsible for 15 cases and was the most common neoplastic etiology of unilateral VFP. For those who presented with bilateral VFP, surgery was the most common cause and accounted for 56.3% of the incidences. In terms of gender, surgery was the most common cause for both sexes, accounting for 62 of 113 male patients and 57 of 81 female patients. Four cases recovered during the follow-ups and these were excluded.

CONCLUSION

Surgery and in particular, thyroidectomy, was the most common cause of VFP for these series. Central nervous system disorders were the cause of VFP (4.5%). Central nervous system disorders, especially cerebrovascular accidents that induced VFP, could not be neglected. Radiation-induced cranial nerve paralysis in the head and neck cancer was possible causes. The percentage for the causes of unilateral VFP, surgery increased and the percentage for neoplasm decreased for Taiwan.

Two trajectories of functional recovery in thyroid surgery related unilateral vocal cord paralysis

BACKGROUND

Iatrogenic unilateral vocal fold paralysis caused by thyroid surgery induces profound physical and psychosocial distress in patients. The natural course of functional recovery over time differs substantially across subjects, but the mechanisms underlying this difference remain unclear. In this study, we examined whether the anatomic site of the lesion affected the trajectory of recovery.

METHODS

In this prospective case series study in a single medical center, patients with thyroid surgery-related unilateral vocal fold paralysis were evaluated using quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, the Voice Outcome Survey, and the Short Form-36 quality-of-life questionnaire. Patients with and without superior laryngeal nerve injuries were compared.

RESULTS

Forty-two patients were recruited, among whom 15 and 27 were assigned to the with and without superior laryngeal nerve injury groups, respectively. Compared with the group without superior laryngeal nerve injury, the group with superior laryngeal nerve injury group demonstrated less improvement in the recruitment of vocal fold adductors, and the group also had more severe impairment of vocal fold vibration, maximum phonation time, jitter, shimmer, and harmony-to-noise ratio at the first evaluation. This difference was also found in the glottal gap and maximum phonation time 12 months after the injury.

CONCLUSION

Among patients with thyroid surgery-related unilateral vocal fold paralysis, superior laryngeal nerve injury induces a distinctively different recovery trajectory compared with those without superior laryngeal nerve injury characterized by less reinnervation of vocal fold adductors and worse presentation in terms of the glottal gap and maximum phonation time. This study emphasizes the importance of superior laryngeal nerve function and its preservation in thyroid surgery.

Ultrasound prediction for vocal cord dysfunction in patients scheduled for anterior cervical spine surgeries: a prospective cohort study

Prediction of vocal cord dysfunction is essential after anterior cervical spine surgeries. This study aimed to detect the validity of transcutaneous laryngeal ultrasonography by both anterior and novel lateral approaches for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries. A prospective cohort study conducted on 90 patients scheduled for anterior cervical spine surgeries underwent consecutive pre and postoperative vocal cord examination for edema and paralysis by both anterior and lateral approaches laryngeal ultrasonography. Rigid laryngoscopy was the standard confirmatory tool. For postoperative vocal cord edema, the anterior ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 78.9% with PPV = 78.9% and NPV = 88.2% and the novel lateral ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 94.7% with PPV = 93.75% and NPP = 90%. While for paralysis, the anterior ultrasonography approach diagnostic sensitivity = 86.7%, specificity = 85.7% with PPV = 81.25% and NPV = 90% and the novel lateral ultrasonography approach diagnostic (sensitivity, specificity with PPV and NPP) = 100%. The diagnostic accuracy of the novel lateral approach was more correlated to rigid laryngoscopy (91.7% and 100%) compared to anterior approach for vocal cord edema and paralysis (83.3% and 80.6%). Overall incidence of vocal cord paralysis was 16.6%. Risk of vocal cord paralysis was statistically significant more in female, multiple disc herniation, lower and mixed disc levels, Langenbeck retractor, cage and plate and duration of surgery ≥ 1.5 h. Transcutaneous Laryngeal ultrasound is a valid comfortable tool for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries with superiority of the novel lateral over anterior approach.

Study protocol to develop a patient-reported outcome measuring disability associated with unilateral vocal fold paralysis: a mixed-methods approach with the CoPE collaborative

INTRODUCTION

Patient-reported outcome (PRO) measures are increasingly developed with multisite, representative patient populations so that they can serve as a primary endpoint in clinical trials and longitudinal studies. Creating multisite infrastructure during PRO measure development can facilitate future comparative effectiveness trials. We describe our protocol to simultaneously develop a PRO measure and create a collaborative of tertiary care centres to address the needs of patients with unilateral vocal fold paralysis (UVFP). We describe the stakeholder engagement, information technology and regulatory foundations for PRO measure development and how the process enables plans for multisite trials comparing treatments for this largely iatrogenic condition.

METHODS AND ANALYSIS

The study has three phases: systematic review, measure development and measure validation. Systematic reviews and qualitative interviews (n=75) will inform the development of a conceptual framework. Qualitative interviews with patients with UVFP will characterise the lived experience of the condition. Candidate PRO measure items will be derived verbatim from patient interviews and refined using cognitive interviews and expert input. The PRO measure will be administered to a large, multisite cohort of adult patients with UVFP via the CoPE (vocal Cord Paralysis Experience) Collaborative. We will establish CoPE to facilitate measure development and to create preliminary infrastructure for future trials, including online data capture, stakeholder engagement, and the identification of barriers and facilitators to participation. Classical test theory psychometrics and grounded theory characterise our approach, and validation includes assessment of latent structure, reliability and validity.

ETHICS AND DISSEMINATION

Our study is approved by the University of Wisconsin Health Sciences Institutional Review Board. Findings from this project will be published in open-access journals and presented at international conferences. Subsequent use of the PRO measure will include comparative effectiveness trials of treatments for UVFP at CoPE Collaborative sites.

Morphometric Differences in the Recurrent Laryngeal Nerve in Patients with Vocal Fold Paralysis

OBJECTIVES

Injury to the recurrent laryngeal nerve (RLN), if severe enough, can result in vocal fold paralysis. Reinnervation surgery can improve patient outcomes, but previous studies have reported a negative correlation between time since onset of paralysis and surgical outcomes. The ability of the paralyzed nerve to serve as a conduit for donor nerve fibers may be a factor in the success of reinnervation; however, changes in RLN composition after paralysis have not been well studied. Therefore, we investigated the morphometric composition of explanted RLN sections from patients who had experienced vocal fold paralysis for varying length of times.

METHODS

Nine nerve sections from unilateral vocal fold paralysis (UVP) patients and seven control nerve sections were analyzed for morphometric parameters including fascicular area, fiber count, fiber density, fiber packing, mean g-ratio, and fiber diameter distribution. Nerves from UVP patients were also compared as a function of time since UVP onset.

RESULTS

In comparison to control nerves, paralyzed nerves were found to have significantly lower fiber densities and fiber packing, higher mean g-ratio values, and a shift in diameter distributions toward smaller diameter fibers. With respect to paralysis duration, no significant differences were observed except in fiber diameter distributions, where those with paralysis for >2 years had distributions that were significantly shifted toward smaller diameter fibers.

CONCLUSIONS

The morphometric data presented here suggest that correlations between the time since onset of vocal fold paralysis and reinnervation outcomes may be due to fiber size changes in the paralyzed nerve over time.

Using intraoperative optical coherence tomography to image pediatric unilateral vocal fold paralysis

OBJECTIVES

Unilateral vocal fold paralysis (UVFP) impairs communication and reduces academic performance and social interactions in children. Deciding between temporary, permanent, or potentially destructive surgical interventions can be challenging, as there currently exists no reliable means of predicting vocal fold recovery or assessing the presence of vocal fold atrophy. Regarding vocal fold atrophy, optical coherence tomography (OCT) has been shown to be an appealing non-invasive alternative for accessing vocal fold structures. This study describes UVFP microanatomy and identifies possible vocal fold atrophy using OCT.

METHODS

Three UVFP patients (ages 1, 11, and 17 years) underwent bilateral OCT imaging using a handheld probe while under general anesthesia for direct laryngoscopy, and the laryngoscopic images were compared with images obtained from OCT. Structural morphological features were extracted and compared to a healthy patients' cohort.

RESULTS

While endoscopy showed no evidence of vocal fold atrophy in two of three cases, OCT images revealed distinct differences between the lamina propria of the paralyzed and functional vocal folds in all patients. In two cases, the paralyzed vocal fold morphology was similar to a healthy patient at the age of nerve injury. The third case exhibited extensive scarring in the lamina propria of the paralyzed vocal fold.

CONCLUSION

This pilot study characterizes and compares vocal fold microanatomy in three UVFP patients. In most cases, lamina propria development halted at the age of paralysis, suggesting that lamina propria maturation may be dependent on vocal fold functionality. OCT shows potential to aid UVFP assessment and treatment decisions by evaluating the presence of atrophy.

Vocal cord paralysis as primary and secondary results of malignancy. A prospective descriptive study

Objective

Vocal cord paralysis (VCP) may be caused by a primary malignancy and associated immune cross-reactivity. We aimed to illuminate underlying causes of VCP and to assess if onconeural antibodies occur in association to VCP as an early predictor of cancer.

Methods

A prospective study was performed in patients with newly diagnosed VCP from 2014 to 2016. All patients underwent fiberoptic laryngoscopy, ultrasound of the neck and computed tomography (CT) of the neck and thorax. Patients with idiopathic VCP underwent neurological examination, positron emission tomography/CT, and serum analysis for onconeural antibodies. All patients were offered a one-year clinical follow-up.

Results

In total 53 patients fulfilled the inclusion criteria. Left VCP occurred in 37 (70%), right in 15 (28%), and bilateral in one patient (2%). The cause of VCP was cancer in 27 (51%) patients, of those 15 (56%) had VCP as the primary symptom, including all cases with laryngeal and esophageal cancer. Median time interval between VCP and cancer was 7 days (range 1-30). In 12 (23%) VCP was a secondary symptom. Lung cancer was the most common etiology, 14 of 27 (52%), 12 patients (86%) with non-small cell lung cancer. Idiopathic VCP was diagnosed in 18 (34%) patients, of those nine patients had a neurological examination and were screened for well-known onconeural antibodies, which were not detected. Reactions against Purkinje cell nuclei were seen in three patients, none showed symptoms or signs of cancer at follow-up.

Conclusions

The causes of VCP were described. VCP was frequently the primary symptom, and also occurred as a secondary symptom of cancer. Exclusion of malignancy is important in patients with VCP.

Level of Evidence

1b.

Voice outcomes following medialization laryngoplasty with and without arytenoid adduction

OBJECTIVE

Voice outcomes following medialization laryngoplasty (ML) for unilateral vocal fold paralysis (UVFP) were compared to those who underwent ML plus arytenoid adduction (AA) (ML+AA).

METHODS

Single institution retrospective review of patients with UVFP undergoing ML and ML+AA (2009-2017). Demographic information and history of laryngeal procedures were collected. Preoperative and postoperative Voice Handicap Index-10 (VHI-10) and Consensus Perceptual Auditory Evaluation of Voice (CAPE-V) were assessed.

RESULTS

Of 236 patients, 119 met study criteria. Of those, 70 (59%) underwent ML and 49 (41%) underwent ML+AA. Significant differences between groups at baseline were found for age at time of thyroplasty (P = 0.046), VHI-10 scores (P < 0.001), and CAPE-V scores (P = 0.007). Baseline VHI-10 scores for ML+AA (28 ± 7) were greater than those for ML alone (24 ± 7). At 12 months, overall VHI-10 scores improved compared to baseline for both groups (ML+AA = 9 ± 7, ML = 16 ± 9); however, there was greater improvement for the ML+AA group compared to ML group (P = 0.001). CAPE-V scores at 3 or 12 months improved, but differences between the groups were not statistically significant once controlled for covariates.

CONCLUSION

Based on current findings, patients who undergo ML+AA likely have greater voice handicap at baseline compared to those undergoing ML alone. Patients selected for ML+AA improve as much or more than those who underwent ML alone. This highlights the importance of appropriate selection of candidates for AA.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1876-1881, 2019.

Risk factors for thyroid surgery-related unilateral vocal fold paralysis

Objectives/Hypothesis

We aimed to identify the risk factors for iatrogenic unilateral vocal fold paralysis (UVFP) caused by thyroid surgery, to allow the identification of patients requiring nerve‐protection procedures and monitoring technologies.

Study Design

Retrospective case study in a medical center.

Methods

Patients who underwent thyroid surgery from April 2011 to February 2016 and who were diagnosed with UVFP by laryngoscopy and laryngeal electromyography were included. Patient demographics, types of surgery, and characteristics of the thyroid lesions were analyzed.

Results

Sixty (2.1%) of 2,815 patients who received thyroid surgery developed UVFP. The risk of UVFP was higher in patients over 60 years old (odds ratio, 1.89; 95% confidence interval, 1.01‐3.26; P = .01). Involvement of the external branch of superior laryngeal nerve (EBSLN) occurred in 19 (31.7%) of the 60 UVFP patients, and was more likely to occurr in patients with diabetes mellitus (odds ratio, 14.19; 95% confidence interval, 3.80‐52.94; P < .001). The incidence of UVFP and involvement of the EBSLN differed among surgery types, and was the highest among patients undergoing total thyroidectomy with neck dissection (TTND) (10/158, 6.3% and 5/158, 3.2%, respectively).

Conclusions

The risk of thyroid surgery–related UVFP is higher in older patients. EBSLN involvement is more likely in patients with diabetes mellitus. TTND is associated with higher risks of UVFP and EBSLN injury than other types of surgery, implying the need of intraoperative nerve monitoring in these high‐risk characteristics.

Level of Evidence

4 Laryngoscope, 129:275–283, 2019

Imaging Modalities in the Etiologic Evaluation of Unilateral Vocal Fold Paralysis

OBJECTIVE

This study aimed to investigate the roles of computed tomography (CT) and neck ultrasonography (US) in evaluating unilateral vocal fold paralysis (UVFP) of unknown etiology and to compare our results with those of other studies to assess the differences in etiology of UVFP.

METHODS

We investigated the medical records of 202 eligible patients with UVFP. In total, 168 underwent chest CT, 118 underwent neck CT, and 108 underwent head CT. One hundred and three patients were also evaluated with high-resolution neck US. The etiologic causes of UVFP were also determined.

RESULTS

Of the 202 eligible patients, the occult cause of the UVFP was determined in 96 patients (47.5%). Idiopathic causes were the most common etiologies (n = 106). In occult causes group, chest lesions were the most common diseases causing paralysis (52 cases) and included lung cancer (n = 28) and mediastinal malignancy (n = 8). More than half of the neck lesions were of thyroid origin. Of the 18 thyroid lesions, 12 were thyroid malignancies. Chest CT had an intermediate yield of 30.9% (52 of 168). Neck US had a diagnostic yield close to that of neck CT (26.2%).

CONCLUSION

UVFP may result mainly from idiopathic, lung cancer, mediastinal, and thyroid malignancies. The initial use of neck US as an alternative to CT may be advocated for the determination of diseases resulting in UVFP.

Unilateral Vocal Cord Paralysis of a Great Jewish Opera Singer

George London was one of the most compelling vocal artists of the early twentieth century. At the age of 47, the great bass-baritone retired from singing. It has been suggested that the premature ending of his operatic career was due to unilateral vocal cord palsy (UVCP). When London retired, the common belief was that this UVCP was caused by viral hepatitis, although there is no evidence to support such an etiology. London's medical records eliminate the possible etiology of a neck neoplasm, and the long period of time between a heart attack he experienced and his diagnosis of UVCP makes a cardiovascular etiology an unlikely causative factor. London's relatively young age, the diagnosis of laryngitis prior to his UVCP, and the course of his disease indicate that the underlying cause of the termination of his singing career was post-viral neuropathy. This paper describes the clinical evidence related to London's vocal cord function and explores the possible causes for his UVCP, which apparently led to his early retirement.

Fine Needle Aspiration in the Investigation of Thyroid Nodules

BACKGROUND

Thyroid nodules are a common finding in Germany. Most are benign; thyroid cancer is very rare. The challenge for the physician is to diagnose malignant tumors early. Fine needle aspiration is an important tool for this purpose.

METHODS

This review is based on pertinent articles (1980-2014) retrieved by a selective search in PubMed and on the current recommendations of guidelines issued by the specialty societies in Germany and abroad.

RESULTS

Clinical, ultrasonographic, and scintigraphic criteria are used to identify high-risk nodules, which are then further studied by fine needle aspiration. Important ultrasonographic criteria for malignancy are low echodensity (positive predictive value [PPV]: 1.85), microcalcifications (PPV: 3.65), irregular borders (PPV: 3.76), and intense vascularization. Fine needle aspiration of the thyroid gland is an inexpensive and technically straight - forward diagnostic procedure that causes little discomfort for the patient. It helps prevent unnecessary thyroid surgery and is used to determine the proper surgical strategy if malignancy is suspected. The cytological study of fine needle aspirates enables highly precise diagnosis of many tumor entities, but follicular neoplasia can only be diagnosed histologically. In the near future, molecular genetic methods will probably extend the diagnostic range of fine needle aspiration beyond what is currently achievable with classic cytology.

CONCLUSION

Fine needle aspiration biopsy of the thyroid gland in experienced hands is an easily performed diagnostic procedure with very little associated risk. It should be performed on ultrasonographically suspect nodules for treatment stratification and before any operation for an unclear nodular change in the thyroid gland.

Unilateral Vocal Cord Paralysis Secondary to Central Bronchogenic Carcinoma

Vocal cord paralysis may arise from neurogenic paralysis or mechanical fixation. It is sometimes the only sign of an underlying disease. Thus, it is clinically important to diagnose the primary disease in cases of vocal cord paralysis because many of its potential causes, such as symptom-free malignant tumors, can be fatal or cause serious morbidity if detected late. Radiologic evaluation is often useful for determining the etiology of vocal cord paralysis.

The Phonetic Characteristics in Patients of Bilateral Vocal Fold Paralysis Without Tracheotomy

Objectives

Patients with bilateral vocal fold paralysis (BVFP) theoretically have difficulty producing voiceless consonants. However, perceptual studies have revealed clear production of voiceless consonants with good articulation scores in nontracheostomized patients. The purpose of this study was to clarify the production of voiceless stops during articulation in patients with BVFP compared to normal speakers.

Methods

The perceptual, acoustic, and aerodynamic characteristics of patients with BVFP and those with normal speech were investigated with special reference to voiceless stop consonants. Test words were prepared to place the stop consonants in different phonological environments, and were all nonsense words.

Results

The patients with BVFP perceptually produced the three types of stops successfully. However, they acoustically varied voice onset time to produce phonetically representative stops but decreased voice onset time of /p^h/ and /p/ compared to those of normal speakers. These patients may properly control air pressure to produce the three types of stop consonants similar to normal speakers.

Conclusion

The patients with BVFP realized the distinctions between the three types of stops similar to the normal speakers. Although vocal mobility was absent in the patients with BVFP, voice onset time, vowel duration, closure duration, and air pressure were similar to those of normal speakers.

Laboratory Evaluation of Vocal Fold Paralysis and Paresis

OBJECTIVES

This study aimed to assess the value of comprehensive laboratory evaluation in patients with vocal fold paralysis or paresis.

STUDY DESIGN

This is a retrospective chart review.

METHODS

Records of 231 patients with vocal fold paralysis or paresis were reviewed to determine whether there is a significant increase in the number of abnormal test results compared with rates of abnormal results for these tests in the general population and whether testing resulted in clinically important diagnosis. Laboratory data were collected from charts from initial visits from 2010 to 2014 and compared with national data.

RESULTS

When controlled for age and sex, white blood cell count was found to have a significantly higher rate of abnormal test results (P < 0.001) in patients with vocal fold paralysis or paresis than the general population. Although hemoglobin, thyroid-stimulating hormone, and thyroid antibody tests were more likely to be abnormal in our patient population, the trend was not statistically significant. Further, the prevalence of syphilis and myasthenia gravis was found to be higher in these subjects than their respective national prevalences, and the incidence of Lyme disease was found to be higher than the national prevalence of Lyme disease. Several patients were diagnosed with medically important conditions such as diabetes, thyroid dysfunction, syphilis, myasthenia gravis, and Lyme disease based on these tests.

CONCLUSION

This study suggests that comprehensive testing of patients with vocal fold movement disorders results in diagnoses that would be missed without a comprehensive evaluation, some of which are important medically, although their causal relationship to vocal fold paralysis or paresis was not investigated or established.

Distinct Disease and Functional Characteristics of Thyroid Surgery-Related Vocal Fold Palsy

BACKGROUND

Iatrogenic trauma induced by thyroid surgery is the most common etiology of unilateral vocal fold paralysis (UVFP). UVFP after thyroid surgery may lead to profound physical and psychosocial distress. This study comprehensively evaluated UVFP caused by thyroid surgery, and compared the results with those caused by other surgical trauma.

METHODS

Patients with surgery-related UVFP were evaluated using quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, the Voice Outcome Survey, and the Short Form-36 Health Survey quality-of-life questionnaire. Patients with thyroid surgery and other surgeries were compared.

RESULTS

A total of 105 patients were recruited, of whom 52 and 53 were assigned to the thyroid surgery and the other surgery group, respectively. Patients in the thyroid surgery group had a higher proportion of external branch of superior laryngeal nerve (eSLN) involvement, longer duration from disease onset to the first laryngeal electromyography examination, lower jitter, higher harmonic-to-noise ratio, and better quality of life compared with the other surgery group. Specifically for patients in the thyroid surgery group, those with eSLN involvement tended to have more pronounced impairment in jitter and shimmer compared with patients without eSLN involvement.

CONCLUSION

UVFP caused by thyroid surgery has a distinct clinical presentation with relatively high involvement in the eSLN, better voice acoustics, longer waiting time before asking for evaluation, and less impact on quality of life. The involvement of eSLN in these patients further impaired their voice. Early referral is suggested for these patients, especially with suspected eSLN injury.

Feasibility of vocal fold abduction and adduction assessment using cine-MRI

Objective

Determine feasibility of vocal fold (VF) abduction and adduction assessment by cine magnetic resonance imaging (cine-MRI)

Methods

Cine-MRI of the VF was performed on five healthy and nine unilateral VF paralysis (UVFP) participants using an axial gradient echo acquisition with temporal resolution of 0.7 s. VFs were continuously imaged with cine-MRI during a 10-s period of quiet respiration and phonation. Scanning was repeated twice within an individual session and then once again at a 1-week interval. Asymmetry of VF position during phonation (VF phonation asymmetry, VFPa) and respiration (VF respiration asymmetry, VFRa) was determined. Percentage reduction in total glottal area between respiration and phonation (VF abduction potential, VFAP) was derived to measure overall mobility. An un-paired t-test was used to compare differences between groups. Intra-session, inter-session and inter-reader repeatability of the quantitative metrics was evaluated using intraclass correlation coefficient (ICC).

Results

VF position asymmetry (VFPa and VFRa) was greater (p=0.012; p=0.001) and overall mobility (VFAP) was lower (p=0.008) in UVFP patients compared with healthy participants. ICC of repeatability of all metrics was good, ranged from 0.82 to 0.95 except for the inter-session VFPa (0.44).

Conclusion

Cine-MRI is feasible for assessing VF abduction and adduction. Derived quantitative metrics have good repeatability.

Key points

• Cine-MRI is used to assess vocal folds (VFs) mobility: abduction and adduction.

• New quantitative metrics are derived from VF position and abduction potential.

• Cine-MRI able to depict the difference between normal and abnormal VF mobility.

• Cine-MRI derived quantitative metrics have good repeatability.

Effect of injection augmentation on need for framework surgery in unilateral vocal fold paralysis

OBJECTIVES/HYPOTHESIS

To determine whether injection augmentation reduces the likelihood of ultimately needing definitive framework surgery in unilateral vocal fold paralysis (UVFP) patients.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients diagnosed with UVFP (2008-2012) at the academic center were identified. The time from symptom onset to presentation to either community otolaryngologist and/or academic center, as well as any directed treatment(s), were recorded. Stepwise, multivariate logistic regression analysis was used to determine whether injection augmentation independently affected odds of needing definitive, framework surgery among patients who were seen within 9 months of symptom onset and had not undergone any prior rehabilitative procedures.

RESULTS

Cohort consisted of 633 patients (55% female, 80% Caucasian, median age 60 years) with UVFP. The majority of etiologies were either surgery (48%) or idiopathic (37%). Duration to presentation at community otolaryngologist was shorter than to the academic center (median 2 vs. 6 months). Overall, less than half of UVFP patients had any operation (46%). Multivariate logistic regression found that earlier injection augmentation did not affect odds of ultimately undergoing framework surgery (odds ratio 1.13; confidence interval, 0.92-1.40; P = 0.23).

CONCLUSION

Nearly half of UVFP patients do not require any rehabilitative procedure. When indicated, early injection augmentation is effective at temporarily alleviating associated symptoms but does not reduce likelihood of needing a definitive framework operation in patients with UVFP. Understanding practice patterns and fostering early detection and treatment may improve quality of life in this patient population.

Prospective investigation of nimodipine for acute vocal fold paralysis

INTRODUCTION

Nimodipine has been shown to be beneficial for recovery from acute vocal fold paralysis (AVFP) in an animal model.

METHODS

prospective, open-label trial of patients with AVFP was performed using nimodipine. Consecutive patients were evaluated and offered nimodipine therapy.

RESULTS

Fifty-three patients were considered for treatment with nimodipine. Thirteen did not qualify for inclusion, 5 were lost to follow-up, and 7 had side effects requiring cessation of treatment. Thus 28 patients (30 paralyzed vocal folds) were analyzed. Eighteen of the paralyzed vocal folds experienced recovery of purposeful motion (60%). Historical controls and laryngeal electromyography meta-analysis suggest no more than a 20% recovery rate from AVFP.

CONCLUSIONS

This open label study using nimodipine for treatment of AVFP demonstrates tripling of the recovery rate of vocal fold motion compared with historical controls. Further study in a randomized, controlled manner is warranted.

Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis

OBJECTIVE

To determine the etiology, laterality, and time to presentation of unilateral vocal fold paralysis (UVFP) at a tertiary care institution over 10 years.

STUDY DESIGN

Case series with chart review.

SETTING

Academic medical center.

SUBJECTS AND METHODS

All patients seen between 2002 and 2012 by the Department of Otolaryngology at the Washington University School of Medicine (WUSM), with a diagnosis of unilateral vocal fold paralysis, were included. Medical records were reviewed for symptom onset date, presentation date(s), and etiology of UVFP.

RESULTS

Of the patients, 938 met inclusion criteria and were included. In total, 522 patients (55.6%) had UVFP due to surgery; 158 (16.8%) were associated with thyroid/parathyroid surgery, while 364 (38.8%) were due to nonthyroid surgery. Of the patients, 416 (44.4%) had nonsurgical etiologies, 124 (13.2%) had idiopathic UVFP, and 621 (66.2%) had left-sided UVFP. The diagnosis was more common on the left side in cases of intrathoracic surgeries and malignancies, as expected, but also in idiopathic, carotid endarterectomy, intubation, and skull base tumors. In total, 9.8% of patients presented first to an outside otolaryngologist at a median time of 2.1 months after onset, but these patients presented to WUSM at a median time of 9.5 months. Overall, 70.6% of patients presented to a WUSM otolaryngologist within 3 months of onset.

CONCLUSION

Iatrogenic injury remains the most common cause of UVFP. Thyroidectomy remains the leading cause of surgery-related UVFP. Patients are typically seen within 3-4 months of onset; however, a significant delay exists for those referred to WUSM.

Improved voluntary cough immediately following office-based vocal fold medialization injections

OBJECTIVES/HYPOTHESIS

This study examined changes in voluntary cough airflow measures immediately following in-office injection of Radiesse in patients diagnosed with glottic insufficiency. Due to significant comorbidities, these patients were poor candidates for medialization under general anesthesia. Each patient presented with dysphonia and dysphagia and ineffective voluntary cough, resulting in a poor clearing of secretions and a presence of ingested fluids on examination.

STUDY DESIGN

Prospective cohort and case series study.

METHODS

Three patients with a diagnosis of glottic insufficiency were included for study based on flexible endoscopy and laryngostroboscopic examination. Voluntary cough airflow measures were obtained approximately 30 minutes before and after the Radiesse injections. The airflow measures were: compression phase duration (CPD), expiratory rise time (EPRT), expiratory phase peak airflow (EPPF), and cough volume acceleration (CVA).

RESULTS

Injection of Radiesse was found to improve voluntary cough airflow measures.

CONCLUSION

The immediate increase in the objective airflow measures obtained from voluntary cough production after Radiesse injections can be used to document airway protection improvements. Cough airflow is a straightforward measure to obtain and is considered an objective measure of cough function.

LEVEL OF EVIDENCE

4.

Assessment of patient experience with unilateral vocal fold immobility: a preliminary study

OBJECTIVE

Systematically moving toward patient-centered care for unilateral vocal fold immobility (UVFI) requires comprehensive understanding of the variability of actual patient experiences. This rigorous qualitative study assesses UVFI-related disability and proposes a preliminary taxonomy of UVFI patient experience.

STUDY DESIGN

(1) Semistructured interviews and (2) taxonomy development.

METHODS

Consecutive UVFI patients presenting July to September, 2012, prospectively underwent open-ended interviews investigating how UVFI affected their quality of life (QOL) and had caused disability. Comments reported by >20% were synthesized into axes based on content similarity. Variables were arranged into a preliminary taxonomy of UVFI patient experience, which was evaluated for four attributes of face validity.

RESULTS

The majority of 39 patients had "extensive" baseline voice use (56%) and an iatrogenic etiology (62%). Taxonomy of patient experience included three main axes of symptomatic classification: (1) voice, (2) swallowing, and (3) breathing-all with intrinsic (physical and emotional) and extrinsic (social) subaxes that describe major impacts on QOL. Voice complaints were 100% penetrant, whereas breathing and swallowing symptoms afflicted 76% and 66%, respectively, of interviewees. Of affected patients, solid and liquid dysphagia was experienced by 70% and 63%, respectively. Of dyspneic patients, shortness of breath existed with talking (97%) and exercise (72%). Persistent throat congestion (76%), weakened cough (62%), globus (62%), and dysfunctional valsalva (41%) were frequent.

CONCLUSIONS

Patient experience with UVFI has been incompletely characterized. This qualitative assessment and preliminary taxonomy highlight several related patient experiences not well documented in the literature or incorporated into currently available metrics.

Vocal cord paralysis and its etiologies: a prospective study

Introduction: Vocal cord paralysis is a common symptom of numerous diseases and it may be due to neurogenic or mechanical fixation of the cords. Paralysis of the vocal cords is just a symptom of underlying disease in some cases; so, clinical diagnosis of the underlying cause leading to paralysis of the vocal cords is important. This study evaluates the causes of vocal cord paralysis.

Methods: In a prospective study, 45 patients with paralyzed vocal cord diagnosis were examined by tests such as examination of the pharynx, larynx, esophagus, thyroid, cervical, lung, and mediastinum, brain and heart by diagnostic imaging to investigate the cause vocal cord paralysis. The study was ended by diagnosing the reason of vocal cord paralysis at each stage of the examination and the clinical studies.

Results: The mean duration of symptoms was 18.95±6.50 months. The reason for referral was phonation changes (97.8%) and aspiration (37.8%) in the subjects. There was bilateral paralysis in 6.82%, left paralysis in 56.82% and right in 63.36% of subjects. The type of vocal cord placement was midline in 52.8%, paramedian in 44.4% and lateral in 2.8% of the subjects. The causes of vocal cords paralysis were idiopathic paralysis (31.11%), tumors (31.11%), surgery (28.89%), trauma, brain problems, systemic disease and other causes (2.2%).

Conclusion: An integrated diagnostic and treatment program is necessary for patients with vocal cord paralysis. Possibility of malignancy should be excluded before marking idiopathic reason to vocal cord paralysis.

Framework Surgery for Treatment of Unilateral Vocal Fold Paralysis

Laryngeal framework surgery is the current gold standard treatment for unilateral vocal fold paralysis. It provides a permanent solution to glottic insufficiency caused by injury to the recurrent laryngeal nerve. Various modifications to the original Isshiki type I laryngoplasty procedure have been described to improve voice and swallowing outcomes. The success of this procedure is highly dependent on the experience of the surgeon as it epitomizes the intersection of art and science in the field. The following article reviews the evidence, controversies, and complications related to laryngoplasty for unilateral vocal fold paralysis. It also provides a detailed analysis of how and when arytenoid-positioning procedures should be considered, and summarizes the literature on postoperative outcomes.

Vocal cord paralysis and Dysphagia after aortic arch reconstruction and Norwood procedure

OBJECTIVES

To determine the incidence of vocal cord (VC) paralysis and dysphagia after aortic arch reconstruction, including the Norwood procedure.

SETTING

Tertiary children's hospital.

STUDY DESIGN

Retrospective cohort.

METHODS

Database/chart review of neonates requiring Norwood or arch surgery between January 2005 and December 2012. Demographics, postoperative VC function, dysphagia, need for gastrostomy tube and/or tracheotomy, and long-term follow-up were reviewed.

RESULTS

One hundred fifty-one consecutive subjects (96 Norwood, 55 aortic arch) were reviewed. Median age at repair was 9 days (interquartile range [IQR], 7-13) for Norwood and 24 days (IQR, 12-49) for arch reconstruction (P < .001). Documentation of VC motion abnormality was found in 60 of 104 (57.6%) subjects and unavailable in 47 (16 without documentation and 31 who died prior to extubation). There were no significant differences in proportions of documented VC motion (P = .337), dysphagia (P = .987), and VC paralysis (P = .706) between the arch and Norwood groups. Dysphagia was found in 73.5% of Norwood and 69.2% of arch subjects who had documented VC paralysis. Even without unilateral VC paralysis (UVCP), dysphagia was present (56% Norwood, 61% arch). Overall, 120 of 151 (79.5%) required feeding evaluation and a modified feeding regimen. Gastrostomy was required in 31% of Norwood and 23.6% of arch reconstruction overall. To date, mortality in this series is 55 of 151 (36.4%) patients. Of those with VC paralysis, only 23 (22%) had any otolaryngology follow-up after discharge from surgery. More than 75% with VC paralysis with follow-up after hospital discharge had persistent VC paralysis 11.5 months after diagnosis.

CONCLUSION

There is high incidence of UVCP and dysphagia after Norwood and arch reconstruction. Dysphagia was highly prevalent in both groups even without UVCP. Preoperative discussion on vocal cord function and dysphagia should be considered.

Acquired unilateral vocal fold paralysis: retrospective analysis of a single institutional experience

Background:

Vocal cord paralysis continues to be an important issue in laryngology and is considered as a sign of underlying disease; the etiologies of this problem are varied and changing.

Aims:

The study was to carry out a retrospective analysis of patients with unilateral vocal fold paralysis diagnosed.

Materials and Methods:

The medical records of 53 patients diagnosed and treated for unilateral vocal fold paralysis were studied retrospectively. Data regarding age, sex, duration of symptoms, etiology, and side of paralysis were recorded.

Results:

Out of the 53 cases, 36 were females and 17 males with a ratio of 2.1:1. The age of the patients ranged from 17-75 years. In 18.9% the cause was idiopathic. Surgical trauma (iatrogenic) problems was the most encountered etiology (66%), others included malignancy (non laryngeal) (7.5%), central (3.8%), external neck trauma (1.9%) and radiation therapy 1.9%. Thyroid surgery was the most commonly reported neck surgery in 50.9%.

Conclusions:

Thyroidectomy continues to be the single most common surgical procedure responsible for unilateral vocal cord paralysis. For this reason, routine pre and postoperative laryngoscopy should be considered in all patients undergoing surgeries with a potential risk for recurrent nerve paralysis to reduce the postoperative morbidity.

Uncommon and rare causes of vocal fold paralysis detected via imaging

BACKGROUND

Cross-sectional imaging can be used to trace the course of the vagus nerve and its laryngeal branches to detect many of the causes of vocal fold paralysis. The most frequent aetiologies are surgical injury and tumoural involvement of the recurrent laryngeal nerve anywhere along its course.

METHOD

This review article focuses on the uncommon and rare causes of vocal fold paralysis that have been detected or diagnosed on cross-sectional imaging.

RESULTS AND CONCLUSION

Uncommon causes included a tortuous oesophagus, tracheal diverticulum, cervical osteophytes and cardiovocal syndrome. These examples are presented with clinical case histories and radiological appearances, and are discussed in the context of the current literature.

[Treatment of glottal gap]

Glottal gaps can be either physiological or pathological. The latter are multifactorial, predominantly organic in origin and occasionally functional. Organic causes include vocal fold paralysis or scarring, as well as a deficiency or excess of tissue. In addition to loss of the mucosal wave, the degree of hoarseness is primarily determined by the circumferential area of the glottal gap. It is thus important to quantify the extent of glottal insufficiency. Although a patient's symptoms form the basis for treatment decisions, these may be subjective and inadequately reflected by the results of auditory-perceptual evaluation, voice analysis and voice performance tests. The therapeutic approach should always combine phonosurgery with conventional voice therapy methods. Voice therapy utilises all the resources made available by the sphincter model of the aerodigestive tract and knowledge on the mechanism of voice production. The aim of phonosurgery is medialization, reconstruction or reinnervation by injection laryngoplasty or larynx framework surgery. These different methods can be combined and often applied directly after vocal fold surgery (primary reconstruction). In conclusion, the techniques described here can be effectively employed to compensate for glottal gaps.

Clinico-etiolological study of vocal cord paralysis

The purpose of this study was to identify patients of vocal cord paralysis and to establish an etiological diagnosis. Patients with vocal cord paralysis have been followed prospectively at a tertiary referral center. 120 patients identified with vocal cord paralysis by laryngeal endoscopy were evaluated clinically, radiologically and pathologically to make an etiological diagnosis. Those patients in whom no cause was found, a CT scan from base of skull to thorax was done before labeling them as idiopathic. Most of the patients presented in 5th (26.67 %) and 6th (21.67 %) decade. Males out numbered females in the ratio 2.3:1.0. The most common symptom of vocal cord paralysis was change in voice (98.21 %). Bilateral vocal cord palsy was found in 6.67 % patients and unilateral vocal cord palsy was found in 93.33 % patients. Among patients of unilateral vocal cord paralysis left vocal cord was paralyzed in 69.64 % and right cord in 30.36 %. Malignant (34.16 %) causes accounted for largest number of patients followed by central (15.00 %) and idiopathic causes (14.16 %). VCP has got a variable etiology which varies with the laterality of the vocal cord involvement. Malignant causes predominated in our series, occurring in 34.16 %, followed by central and idiopathic causes.

Reevaluation of FDG-PET/CT in patients with hoarseness caused by vocal cord palsy

OBJECTIVE

Vocal cord palsy (VCP) is a potential cause of hoarseness that results in decreasing mobility of the vocal cord. VCP can arise from a variety of causes; so, systematic screening is warranted for the management of patients with VCP. Asymmetrical fluorodeoxyglucose (FDG) uptake in vocal cords is a well-known feature in patients with VCP, but no detailed analysis has been performed. This study aimed at reevaluating the (18)F-FDG positron emission tomography/computed tomography (PET/CT) for patients with VCP.

METHODS

We retrospectively surveyed the results of FDG-PET/CT for 59 patients with VCP, compared to laryngoscopic findings. Quantitative analysis was performed using maximum standardized uptake value (SUVmax), and regions of interest were drawn over bilateral vocal cords as confirmed from the CT portion of PET/CT. Patients were divided into 3 groups: Group 1 (n = 14), in which VCP was caused by the lesion of the laryngeal area; Group 2 (n = 40), in which VCP was caused by the lesion on the root of the recurrent laryngeal nerve; and Group 3 (n = 5), in which VCP was caused by the lesion from the vagal center to the proximal vagus nerve.

RESULTS

For Group 1, higher FDG uptake in the paralyzed vocal cord was seen in 86 % of patients (mean SUVmax 8.1 ± 5.3 vs. 2.3 ± 0.4, paralyzed vs. non-paralyzed, respectively; P < 0.002). The sensitivity of FDG-PET/CT for indicating the lesion causing VCP was 79 % for Group 1. Group 2 showed dominant FDG uptake in the non-paralyzed vocal cord (mean SUVmax 2.1 ± 0.9 vs. 1.5 ± 0.4, non-paralyzed vs. paralyzed, respectively; P < 0.001). The sensitivity of FDG-PET/CT for indicating the lesion causing VCP was 93 % for Group 2. Group 3 showed no statistically significant difference in FDG accumulation between non-paralyzed and paralyzed vocal cords (mean SUVmax 1.8 ± 0.3 vs. 1.7 ± 0.3, non- paralyzed vs. paralyzed, respectively; P = 0.30). The sensitivity of FDG-PET/CT for indicating the lesion causing VCP was 60 % for Group 3.

CONCLUSIONS

FDG accumulation in the vocal cords is dependent on the lesion site causing VCP. In addition, FDG-PET/CT can contribute to identification of the lesion responsible for inducing VCP.

CT evaluation of vocal cord paralysis due to thoracic diseases: a 10-year retrospective study

PURPOSE

To discuss computed tomography (CT) evaluation of the etiology of vocal cord paralysis (VCP) due to thoracic diseases.

MATERIALS AND METHODS

From records from the past 10 years at our hospital, we retrospectively reviewed 115 cases of VCP that were evaluated with CT. Of these 115 cases, 36 patients (23 M, 13 F) had VCP due to a condition within the thoracic cavity. From these cases, we collected the following information: sex, age distribution, side of paralysis, symptom onset date, date of diagnosis, imaging, and primary disease. The etiology of VCP was determined using both historical information and diagnostic imaging. Imaging procedures included chest radiograph, CT of neck or chest, and esophagography or esophagoscopy.

RESULTS

Thirty-three of the 36 patients with thoracic disease had unilateral VCP (21 left, 12 right). Of the primary thoracic diseases, malignancy was the most common (19, 52.8%), with 18 of the 19 malignancies presenting with unilateral VCP. The detected malignant tumors in the chest consisted of thirteen lung cancers, three esophageal cancers, two metastatic tumors, and one mediastinal tumor. We also found other underlying etiologies of VCP, including one aortic arch aneurysm, five iatrogenic, six tuberculosis, one neurofibromatosis, three benign nodes, and one lung collapse. A chest radiograph failed to detect eight of the 19 primary malignancies detected on the CT. Nine patients with lung cancer developed VCP between follow-ups and four of them were diagnosed with a progression of malignancy upon CT evaluation of VCP.

CONCLUSION

CT is helpful for the early detection of primary malignancy or progression of malignancy between follow-ups. Moreover, it can reveal various non-malignant causes of VCP.