Return to: Unilateral Laryngeal Paralysis or Vocal Cord Paralysis

See also:

• Wallenberg Syndrome PICA Syndrome Lateral Medullary Infarction
• Tapia Syndrome paralysis of vagus and hypoglossal nerves after intubation
• Vernet's Syndrome (Juguloforamen Syndrome) Laryngeal paralysis
• Vocal Cord Paralysis Evaluation and Etiology

"Vocal fold paralysis is not a rare clinical entity." Sulica and Blitzer 2006

Extent of Problem

• Overall incidence/prevalence of laryngeal paralysis in the United States and the world is not known. Difficulties in determining this information include:
  • Detection of laryngeal paralysis requires imaging of the larynx
    • usually by indirect mirror exam, transoral rigid video-endoscopy, or transnasal flexible laryngoscopy (either fiberoptic or distal chip)
    • alternative approaches exist - including ultrasound and evaluation under general anesthesia with rigid direct laryngoscopy
    • even with clear imaging of the larynx (not always possible due to anatomic restraints) interpretation of findings may be difficult
      • Movement of adjacent structures may make vocal cord appear mobile
      • Repeated viewing of video-recordings by different observers often result in different interpretation
      • Varying degrees of vocal fold paralysis (paresis) may result in minor degrees of movement confounding the diagnosis of true paralysis
      • Other causes of decreased vocal fold mobility need to be factored in (scarring from reflux/intubation; rheumatoid fixation of arytenoid)
  • Detection of laryngeal paralysis by reporting of symptoms by the patient (without examining the larynx) markedly under estimates the extent of the problem
    • Misdiagnosis
      • Dysphonia has many causes -- dysphonia from laryngeal paralysis is often ascribed to other disorders (i.e. reflux, muscle tension dysphonia)
      • Shortness of breath due to unilateral or bilateral laryngeal paralysis has been ascribed to disorders such as asthma
    • Perceived impairment of voicing problems may preclude full evaluation relative to other disorders associated with the paralysis
      • The dysphonia associated with laryngeal paralysis caused by malignancy may be discounted in view of the greater morbidity and potential mortality of a lung cancer or other process
      • Focus on attention to other medical problems may triage dysphonia to a problems whose evaluation (with laryngeal imaging) is deferred
    • Cases of laryngeal paralysis occurring in patient with good vocal fold position and good pulmonary function may escape detection due to lack of perception of symptoms
• Surgical management of unilateral laryngeal paralysis
  • A survey of cases Otolaryngologists in the United States by Rosen C (1998)
    • 33% response rate from mail survey to 7,364 Otolaryngologists (n= 2,436)
    • 43% performed medialization thyroplasty (defined as thyroplasty or arytenoid adduction - performed separately or concurrently)
    • Number of procedure (open medialization procedures) reported in this study = 14,621
  • Followup survey of Otolaryngologists in the United States (Young et al 2010)
    • 25.7% response rate from mail survey to 6,644 Otolaryngologists (n= 1,707)
    • 63% performed medialization thyroplasty (defined as thyroplasty or artyenoid adduction -performed separately or concurrently)
    • Number of procedures (open medialization procedures) reported in this study done between 1998- 2008 = 29,748
  • Perspective from thyroid surgery
    • Well differentiated thyroid cancer responsible for 50% of the 80,000 thyroidectomies done in the U.S. annually (Francis D et al 2014)
      • Review of SEER-Medicre data by Francis et al identified 5,670 total thyroidectomies for WDTC (1991-2009)
        • 9.5% complicated by vocal fold paralysis (8.2% unilateral; 1.3% bilateral)
        • 22% of patients with vocal fold paralysis were treated surgically (UVFP 21%, BVFP 28%)
    • Between 118,000 and 166,000 patients in the United States undergo thyroidectomy per year for benign or malignant disease (Chandrasekhar 2013)
      • About 1 in 10 patients expereience temporary laryngeal nerve injury after surgery with longer lasting voice problems in up to 1 in 25.
  • Perspective from cervical spine surgery (anterior approach Tan, 2014)
    • Review article identifies vocal cord paralysis to be a significant morbidity after anterior cervical spine surgery with incidence up to 24.2% in the immediate postoperative period.
    • Increased risk of postop vocal cord paralysis includes: reoperation and right-sided surgical approach. 

Etiology of Laryngeal Paralysis

• Most commonly reported for unilateral laryngeal paralysis
  • Demographics continually changing
• Increasing numbers associated with surgical procedures (below adapted from Sulica and colleagues, 2006)
• Nonsurgical causes of laryngeal paralysis
  • Idiopathic
  • Tumor involvement
  • Non-tumor involvement (i.e. Ortner's syndrome) 

References

Sulica L, and Blitzer A: Preface in  Vocal Fold Paralysis ed Sulica L and Blitzer A  Springer  New York  2006

Rosen C: Complications of PHonosurgery: Results of a National Survey. Laryngoscope, 1998, Nov 108:11 part 1 pp 1697-1703

Young V, Zullo T, and Rosen C: Analysis of Laryngeal Framework Surgery: 10- Year Follow-up to a National Survey. Laryngoscope, 120:1602-1608, 2010

Francis D, Pearce E, Ni S, Garrett CG, and Penson D: Epidemiology of Vocal fold Paralyses after Total Thyroidectomy for Well-Differentiated Thyroid Cancer in a Medicare Population. Otolaryngology Head and Neck Surgery 2014 (online publicatoin Jan 30 2014  

Chandrasekhar S, Randolph G, Seidman M et al Clincial Practice Guideline: IMproving Voice Outcomes after thyroid Surgery. Otolaryngology–Head and Neck Surgery 148(65)S1-S37 2013  

Sulica L, Cultrara A, and Blitzer A: Vocal Fold Paralysis: Causes, outcomes, and Clinical Aspects. Chapter 3 in Vocal Fold Paralysis ed Sulica L and Blitzer A  Springer  New York  2006

Tan TP, Govindarajulu AP, Massicotte EM, Venkatraghavan L   Vocal cord palsy after anterior cervical spine surgery: a qualitative systematic review.  Spine J. 2014 Jul 1;14(7):1332-42. doi: 10.1016/j.spinee.2014.02.017. Epub 2014 Mar 13.