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Unilateral Vocal Cord Paralysis

Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870. Unilateral Vocal Cord Paralysis. Nora Malaisrie, M.D. Faculty Discussant: Natasha Mirza, M.D. Thursday, July 24, 2008. Introduction. Affects quality of life

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Unilateral Vocal Cord Paralysis

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  1. Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870 Unilateral Vocal Cord Paralysis Nora Malaisrie, M.D. Faculty Discussant: Natasha Mirza, M.D. Thursday, July 24, 2008

  2. Introduction • 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

  3. 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

  4. Anatomy • Recurrent laryngeal nerve • 0.5% right non-recurrent laryngeal nerve • Muscles • Lateral cricoarytenoid • Posterior cricoarytenoid • Thyroarytenoid • Interarytenoid

  5. Etiology • Dysfunction at • Brain and brainstem nuclei • Vagus nerve • Recurrent laryngeal nerve

  6. Etiology: Neurologic • Stroke • CNS tumor • Diabetic neuropathy • Amyotrophic lateral sclerosis (ALS) • Parkinson disease • Myasthenia gravis • Guillain-Barre syndrome

  7. Etiology: Tumor infiltration or mass compression • Skull base • Thyroid • Esophagus • Lung

  8. Etiology: Systemic disease • Systemic lupus erythematosus • Sarcoidosis • Amyloidosis • Tuberculosis • Charcot-Marie-Tooth • Mitochondrial disorders • Porphyria • Polyarteritis nodosa • Silicosis

  9. Etiology: Medications • Vinca alkaloids • Vincristine and vinblastine • Unilateral or bilateral • Dose related • Resolves with dose adjustment or cessation

  10. 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 Etiology: Traumatic Brousseau et al. A rare but serious entity: nasogastric tube syndrome. Otolaryngol Head Neck Surg. 2006 Nov;135(5): 677-679.

  11. 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.

  12. Etiology • In a retrospective analysis of 363 patients, Rosenthal et al. showed that unilateral VCP was caused by • Surgery (46%) • Idiopathic (18%) • 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.

  13. Etiology • Rosenthal et al. showed that surgical causes of unilateral vocal cord immobility were the result of • Non-thyroid surgeries (67%) • 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.

  14. 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.

  15. 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.

  16. 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

  17. 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

  18. Evaluation – Physical Exam • Videostroboscopy • Increased amplitude of vibration • Vocal fold height difference • Vocal process contact

  19. Evidence Based Medicine Levels and Grades

  20. 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.

  21. Evaluation • Assess swallow function and aspiration • Modified barium swallow • Functional endoscopic evaluation of swallowing (FEES) • No additional work up required if clear cut etiology

  22. 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.

  23. Evaluation – Laryngeal electromyography (LEMG) • Needle electrode placement into thyroarytenoid and cricothyoid muscle • Assess • Muscle at rest • Voluntary motor unit recruitment • 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.

  24. 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 • 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.

  25. Differential Diagnosis • Cricoarytenoid fixation • Caused by • Joint subluxation/dislocation with ankylosis • Joint fixation by rheumatoid arthritis or gout • Normal EMG • Direct laryngoscopy • Laryngeal malignancy

  26. Treatment • Goal: Improve voice and prevent aspiration. Patient factors affect treatment strategies. • 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

  27. Treatment – Speech and swallow • Provides voice therapy • Teaches vocal hygiene and compensatory strategies • Identifies and eliminates counterproductive compensatory strategies • Pre-operative and post-operative assessment

  28. 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.

  29. 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

  30. Treatment – Injection laryngoplasty Pre-injection Post-injection

  31. Treatment – Injection laryngoplasty • Method: Under general anesthesia via direct laryngoscopy • Adv: Patient comfort, improved precision • Disadv: No voice feedback • Complications: Under-injection, over-injection, improper placement, foreign body reaction

  32. Treatment – Medialization thyroplasty • 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

  33. 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

  34. Treatment – Arytenoid adduction • 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.

  35. 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.

  36. 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

  37. 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.

  38. 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 • 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.

  39. 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

  40. Acknowledgements • Natsha Mirza, M.D. • Lauren Campe, M.S., CCC-SLP

  41. References • 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: 770-779. • 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.

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